Drug regimens that control HIV have been around since 1996 and now cost less than a dollar a day. Yet 56,000 people are dying untreated every week, and 6 million of the world’s 40 million HIV-infected people now need immediate care. After years of inaction, governments and relief agencies are racing to address the crisis, but they’re moving in different directions. The 3 by 5 initiative is the boldest effort yet to integrate and streamline their efforts. Kim and the WHO team have spent the past six months sizing up the obstacles to universal AIDS treatment and devising new strategies to confront them. The result–a crisp, 55-page battle plan unveiled on Dec. 1–covers everything from drug delivery to patient care. And unlike your garden-variety committee report, it bristles with innovative ideas.
For starters, it defines AIDS as an acute crisis and approaches treatment as real-time disaster relief. Kim recruited AIDS veterans from several countries to work on the 3 by 5 program, but he also tapped WHO experts schooled in SARS, Ebola and war-related health emergencies. “How do you get help to people within days or weeks instead of months or years?” he asks. “Our model is based on emergency-response work in places like Iraq and Liberia. We invite appeals from countries, they come to us and we dispatch technical teams to help them assess needs and set up standardized training and treatment programs.” More than 20 countries have requested help already, and WHO teams are now working with a half dozen of them.
Kim’s planning group has also developed simple, uniform treatment guidelines, and established a “medicines and diagnostics service” to help poor countries secure steady supplies of high-quality drugs at the lowest possible prices. But its boldest innovation has been in the manpower department. Doctors and labs are scarce to nonexistent in many of the countries most devastated by AIDS. Until recently, experts assumed that antiretroviral drugs would be worthless, perhaps even dangerous, unless highly trained specialists administered them and supervised patients. But recent experience casts doubt on that dogma.
In Haiti, Kim’s longtime collaborator Paul Farmer has shown that community health workers can administer AIDS drugs as effectively as M.D.s once they’ve had a few weeks of training. These accompagnateurs travel the hills on foot, dispensing not only pills but the moral support that patients need to keep taking –them. The cost is minimal and the benefits are immense–both to the patients and to the modestly paid health workers. The 3 by 5 plan builds on that realization, calling on affected countries to train tens of thousands of “community-treatment supporters” in coming months. “These countries are full of resourceful people,” Kim says. “They may lack employment, but look what happens when you give them a chance to make a difference.”
The challenges are still immense. Governments and relief groups will need an estimated $5.5 billion to pay for treatment on the scale envisioned in the 3 by 5 blueprint. The WHO will need an additional $350 million from member states just to fund its own role. Funds are now flowing as never before, but scaling up AIDS treatment poses social and ethics challenges as well as financial ones. If a community can’t treat all of its sick from the outset, who should come first? Children? Parents? Farmers? Teachers? The sickest patients? The civic leaders? Such dilemmas will be thrashed out again and again as medicines become available, and will be resolved in different ways. As Kim puts it, “Those questions can’t be made simple.” The challenge, for now, is to make them relevant.
