Interview with Dr Jim Yong Kim, WHO HIV/AIDS director

The World Health Organization (WHO) is going to fall short of its ambitious ‘3 by 5’ target - three million people in the developing world on AIDS treatment by 2005. But rather than failure, WHO’s HIV/AIDS director Dr Jim Yong Kim believes that significant gains have been made in the roll out of antiretrovirals (ARVs) in the most unexpected of countries, and important lessons learnt. QUESTION: What went wrong, why couldn't we achieve this target? ANSWER: First of all we need to ask ‘what went right?’. What went right is that countries that everyone was sure would never be able to scale up treatment have in fact done that. So we've seen tremendous activity in places like Swaziland, which reached its target of 50 percent of people on treatment; Uganda reached its target; Botswana - of course we knew that they were going to reach that target. Before 3 by 5, Malawi's target was 5,000 people on treatment by the end of 2008. They're going to have close to 40,000 people on treatment by the end of 2005. Without 3 by 5 they would not have increased their ambition. What went right was that the world needed a global target, the world needed WHO to say: 'Don't fool around anymore, take responsibility'. What went wrong? There are a lot of barriers to scaling up treatment. The money - there's a lot of money, but often it didn't arrive on time and in the right quantities [required]. A lot of countries didn't have good procurement supply management systems and sometimes there were not enough drugs. Human resources; there weren't enough doctors. But the good news is that people are increasingly realising they don't need doctors to manage all aspects of treatment. Doctors have to manage the complicated cases and doctors have to lead the teams, but we know now that clinical officers and nurses are more than capable of starting and monitoring people on treatment … But one of the interesting things to look at is that countries that were predicted to go nowhere have done astoundingly well, and countries that were predicted to get not even 50 percent, but 100 percent of the people on treatment, haven't gotten there: like for instance the 3 countries with the biggest HIV caseload - South Africa, Nigeria and India. These countries have a lot more infrastructure but its been more difficult for a lot of complicated reasons. Nigeria says 2006 is the year they're going to scale up to 250,000 [people receiving ARVs]. If these three countries take off as they say they are going to, and if they do it in the next year, my hope is that we'll get the 3 million before the end of 2006. In that case, we'll call it 3 by 5-and-a-half. Q: A significant barrier you neglected to mention was the health sector infrastructure. How do countries continue scaling up treatment if their health systems are failing them? A: One thing that 3 by 5 shows more than anything else is that you have to be very careful when you make pronouncements about the things that Africans can't do because of the state of the infrastructure. Many development specialists said to me to my face, 'You're crazy, there's no way Africans can do this because they don't have the healthcare systems in place'. But so many African countries have shown us that even with the decrepit state of their health systems, they are able to scale up treatment. So the donors, the bureaucrats and the technicians have to jump in and ... support them with more money and more technical assistance. If you want to build health systems, investing in HIV/AIDS is a great way to do this. Q: In terms of numbers, where are we now, how many people are on treatment? A: We're not going to know until early next year, we're still collecting data. But it's going to be between 750,000 - 1 million in Africa. Q: Beyond 3 by 5 do you see the momentum that's been developing slowing down? A: The momentum [to provide ARVs] is not based on some WHO pronouncement, it's based on fact. Countries and people who felt that this epidemic was just destroying them are now realising that they can fight back. The source of this momentum is people's understanding that they are going to be able to live with this virus. But the real key is that we've got to shift that momentum to prevention because there's not going to be endless money. The money's going to dry up soon and if we're treating people and we're adding new infections at the same high rate, I think the donors will basically drop out. They have every right to demand that we start getting really serious about new infections. Q: But we're still seeing a disconnect between treatment and prevention... A: It doesn't make any sense. Look at what's happening in Lesotho, for example, on just the issue of mother-to-child transmission of HIV. The biggest problem is that we can't identify mothers who are HIV positive because they are not testing. So what should you do? Rapidly expand testing. But how are you going to rapidly expand testing if all a positive result means is that they're going to die soon? So in order to expand testing, you have to expand treatment, and once you've done that, you can really go and be much more proactive about testing. In Lesotho they are going to go house to house to offer voluntary tests. I think that's the right way to go, but you can't do that unless you have treatment and prevention both in place. You can never separate the two. That's the key to this epidemic: doing both things at the same time.