There is a strong likelihood that the World Health Organization's 3 x 5 target to get three million people onto antiretroviral treatment by the end of 2005 could fail unless governments in South Africa, India and Nigeria show greater commitment to reaching treatment targets, according to Dr Jim Kim of the World Health Organization. He was speaking on the opening day of the Twelfth Annual Retroviruses conference, held this year in Boston, USA.

Only two countries - Botswana and Brazil - have met their targets for scale up, he said. Mozambique, Malawi, Burundi and Uganda have made good progress, and in each case the 3 x 5 target has been an important spur to expand treatment. On the other hand, South Africa, India and Nigeria "have to start moving". Countries such as Zambia, Swaziland and Lesotho will meet their targets, which could be "quite embarrassing for South Africa if they only reach 10% of their target by the end of 2005."

Dr Kim identified four factors considered critical for scale up: political will, access to affordable drugs, accelerated prevention through the scale up of treatment and a public health approach to treatment scale-up.

Securing the supply of generic drugs through the prequalification programme must continue and the programme must be defended, said Dr Kim. However, procurement and supply chain management is the major bottleneck in the view of the Global Fund to Fight AIDS.

Dr Kim appealed to the audience at the Twelfth Annual Retroviruses conference to support the public health approach to antiretroviral therapy. The public health approach is designed to work in settings where doctors are in short supply and the health care infrastructure is poor, and provides standardised regimens for use in large numbers of patients where hi-tech monitoring is lacking.

The DART trial, which uses a public health approach to treatment, shows significantly better outcomes than the historical Entebbe cohort; after 1.25 years on treatment, less than 5% of the DART participants had died, compared to around 50% of the untreated Entebbe cohort.

Dr Kim appealed for three forms of help from the audience and the wider international research community.

• "Support 3 x 5 - don't get caught up in theorising about whether we will make it or not. It's a focused effort to make the people who can take action take action. Please stop speculating and simply do what you can to make it happen."

• "Please support the public health approach - we know there will be opposition to the public health approach here, but we have no choice but to go forward and do the best we can now."

• "We are screaming for the research that you do to go on being funded, but there is almost no money for the kind of operational research that will help us do what we do better. Tell Tony Fauci that you care about research that may not lead to increased tenure in universities, but will lead to increased tenure of mothers and fathers, of families."

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