This article was written by Keith Alcorn and Theo Smart with contributions from panel members Dr Douglas Wilson (South Africa), Prof. Brian Gazzard (UK), Dr Norman Nyazema (Nigeria) and Chris Green (Indonesia).
- 3 x 5 is the World Health Organisation plan to bring ARV treatment to 3 million by the end of 2005
- The 3 x 5 strategy is intended to catalyse activities within countries that will lead to rapid scale-up of treatment.
- A major underlying assumption is that enough health care workers can be trained to deliver enough medicines to meet demand
- Another important assumption is that capacity can be increased in the community sector to carry out HIV testing and provide post-test counselling for the large numbers of people who will be identified as HIV-positive
- WHO recommends that treatment delivery and monitoring should be devolved to nurses and primary health care facilities, after appropriate training.
- Planning the human resources needed to scale up ARV treatment will also require reliable estimates of the numbers of health care workers and community health workers who have HIV, and what rate of loss will occur from the health service as a result of HIV.
- National training plans are one of the earliest steps that must be taken, along with steps to retain and recruit more health care workers, in order to scale up treatment quickly.
- People involved in providing treatment and care are urged by WHO to link up with the Ministry of Health and press for proper coordination, and feed up information from the ground in order to develop a coherent national treatment plan.
- The 3 x 5 plan depends on mobilising human capacity at country level not just large numbers of doctors and nurses, but also the mobilisation of imagination, courage and determination to move the plans forward during the early stages. Everyone has a part to play.
- Donor coordination will be crucial, together with proactive work by donors to assist people with good ideas and leadership positions to take advantage of opportunities for funding.
What is 3 X 5?
3 x 5, the World Health Organization's initiative to bring antiretroviral treatment to 3 million people living with HIV by the end of 2005 is the most ambitious public health venture ever attempted. And it is only the beginning. WHO sees this first 3 million as only the vanguard of a massive, ongoing programme that the organisation hopes will embrace tens of millions of people within a decade. But it remains to be seen whether the initiatives goals are achievable in the time allotted.
Understandably, 3 x 5 was a matter of much debate in the corridors, at dinners and in particular during a panel discussion at the 1st National HIV and AIDS Conference (NHASORC) last month in Gaborone, Botswana, the first country to attempt to roll-out antiretroviral therapy in sub-Saharan Africa. Botswana too set lofty goals for itself over a year and a half ago antiretroviral treatment for all those who need it (~300,000 persons). While strong leadership in the country may eventually drive the healthcare system close to its goal of providing universal treatment, with a little over 10,000 people on treatment so far (almost two years after the plan commenced), it is clear that their initial timetable was perhaps, optimistic at best.
So the round-table debate naturally drew a large audience at the conference. Dr. J. A Kallilani launched the discussion with an overview of the 3 x 5 initiative. Beyond simply attempting to increase access to ARV treatment in developing countries, the initiative is unique in that it is setting a measurable, fixed target towards the goal of universal access to ART. The stress on large numbers is somewhat understandable.
But the challenge of providing health care where there is little developed health care infrastructure is daunting. Addressing the UN General Assembly, in New York on 22 Sept 2003, WHO Director-General, Dr. Lee Jong-wook said To deliver antiretroviral treatment to the millions who need it, we must change the way we think and change the way we act. Business as usual will not work. Business as usual means watching thousands of people die every single day.
But after years of inaction, why does WHO think that it can now deliver 3 x 5? Dr. Kallilani noted that several unique opportunities exist today: There is increased global political commitment and resources; treatment and testing have become simplified; drugs are cheaper and generic competition [is forcing prices down]; WHO can build on lessons from countries such as Botswana. Furthermore, WHO believes that the use of ART could strengthen national health systems and enhance prevention efforts.
She noted numerous partner organisations have come forward that wish to help in the efforts, including the UN and international agencies, governments, donors, non-governmental organisations including faith based organisations, researchers, people living with HIV/AIDS, the private sector, charitable foundations and communities. Furthermore, WHO has been quick to point out its successful experience managing other diseases such as polio (by vaccine decades ago), SARS (by quarantine) and TB (which in many areas, including Botswana seems to be escaping control).
Pillars of the 3 X 5 strategy
WHO made the 3 x 5 target a part of WHO and UNAIDS core policy in July 2003, began partnership building with stakeholders and held regional consultations with countries in August and September 2003, and launched a WHO/UNAIDS strategy on Dec. 1, 2003.
The pillars of the 3 by 5 strategy, said Dr. Kallilani, are:
- Global leadership, strong partnership and advocacy
- Urgent sustained country support
- Simplified, standardised tools for delivering anti-retroviral therapy
- Effective, reliable supply of medicines and diagnostics
- Learn by doing and rapidly identify and reapply new knowledge and successes.
There is a risk that although 3 x 5 may be a catchy marketing phrase, WHO's efforts could be lambasted as a failure if they do not meet those specific targets (just as Botswana has been criticised for failure to meet targets). Disagreement over the figures could obscure the true organisational goal: to catalyse rapid uptake of ART in communities. They mean to do this by focusing on each individual country, providing them with technical support and leveraged funding, and also by simplification and standardisation of treatment. Nevertheless, it is pretty much a shoot first- (ask questions later) approach.
In the field, WHO has been focusing on counselling and testing centres (if people dont know their status, the Botswana experience has shown that by the time some come in, it is often too late to get any benefit from treatment); working with existing treatment centres, TB clinics, STI and PMTCT services as well as services for IDU (injection drug users). All of these could serve as building blocks for antiretroviral scale up in areas where there is little other infrastructure.
Of course, all these plans depend upon funding. In order to achieve the 3x5 plan not to mention making it sustainable, governments will have to contribute a minimum of $5.5 billion through end 2005 for treatment scale up. WHO can provide some technical support, and approximately $350 million in spending by the end of 2005, 85% of which will be spent by country offices. But in order to deliver treatment to 3 million people by 2005, WHO expects 60 countries to find funding and the will to implement plans in line with their recommendations. At least 100,000 health and community workers will need to be trained in order to roll out treatment, and at least 10,000 treatment outlets established.
The 3x5 initiative places a heavy reliance on community-based organisations and projects, so that about 30,000 partnerships between formal outlets and CBOs will have to be forged.
Another roundtable member at the Botswana conference, Dr. N. V. Ngcongco, pointed out that WHOs initiative is operating on some key underlying assumptions. One is that there will be enough drug (affordable) to provide antiretroviral treatment and treatments for related conditions available for 3 million people. The second is that countries healthcare systems will be strengthened to manage the treatment and comprehensive care required on a sustained basis.
Dr. Ngcongco noted another assumption is that individuals, families and communities will willingly come forward to participate in the initiative. In Botswanas experience, this isnt always true.
Other assumptions include: that there will be the human resource with the requisite knowledge, attitude and skill competence to provide and manage the range of service components considered critical to antiretroviral therapy.
The human resource challenge is possibly the greatest obstacle to swift implementation. Despite two years of developing training programs such as Kitso and mentorship programs with experts from elsewhere in the world, Botswana is still far from having the numbers of adequately trained care providers, technicians and social workers to meet the need for counselling, testing and treatment in the country. Many programs related to HIV care are not yet performing as hoped with clear gaps between programs goals and their actual performance.
In Botswana, Ngcongco believes human resource management issues must be addressed first and foremost. Currently there is a very great demand for trained personnel, doctors, nurses, technicians, social workers and counsellors but the supply cannot keep up with the demand. The planning scenarios for human resource development have to be addressed, reviewing assumptions underlying the countries current forecasting and projection techniques.
One problem with earlier planning scenarios is that they did not adequately factor in the toll of HIV upon the healthcare workforce. HIV has hit healthcare providers and social workers just as hard as other young professionals in sub-Saharan Africa. Community based workers/organisations are suffering even greater attrition. Many of these individuals undergo training only to die shortly thereafter.
Ncongco believes that Botswana needs a better plan to approach the problem of human resource development, using evidence-based information to inform policy on education and development of human resources.
Additionally, if the country wants to avoid further brain drain Botswana must adopt management policies that take into consideration the human rights and development needs of human resources. If this resource feels abused, overused or mistreated, they are more likely to leave the country and pursue work abroad. Botswana needs to put in place efficient and effective management systems with in-built supervision, monitoring and evaluation systems, and for Botswana, read every other country that will take on the 3 x 5 challenge.
The 3 x 5 operational recommendations drawn up at a November expert meeting in Lusaka, Zambia, attempts to bypass the doctor shortage in sub-Saharan Africa by designing a set of recommendations for treatment scale-up that will devolve care to the most local level of the health care system: the primary health facilities largely staffed by medical officers and nurses, often supervised from afar by a single doctor. It is here that most dispensing of antiretrovirals and monitoring of treatment should take place, according to the 3 x 5 strategy.
Early priority actions in the community sector should include:
- developing community awareness of treatment and adherence issues
- developing community-based capacity for treatment of basic problems such as diarrhoea, thrush, pain
- training community health care workers in HIV testing and counselling, patient record keeping, assisting in the storage and distribution of drugs and routine monitoring of antiretroviral side effects, weight, minor infections and coughing
- develop treatment support groups
At primary health care level, nurses and equivalent health care workers should be trained to determine which patients can initiate therapy, and should immediately dispense stavudine/lamivudine and nevirapine to all eligible patients without complications. Patients will only be referred to doctors or clinical/medical officers for starting treatment if they have severe illness or conditions such as peripheral neuropathy, hepatitis or tuberculosis that might complicate the choice of initial treatment. Doctors or clinical officers will also manage all treatment initiation in children.
Training to support a big increase in HIV testing will also be necessary, since primary health care facilities and hospitals will be encouraged to offer the HIV test to all pregnant women and their partners, all people diagnosed with a sexually transmitted infection (and partners), everyone diagnosed with TB if national prevalence exceeds 5% and everyone attending the general outpatient clinic. Eventually testing will be done at community level using rapid tests.
Countries are advised to develop national training plans, both to train existing health care workers and to insert training on HIV treatment and care into the curricula of all courses producing new health care workers. Mentorship systems also need to be put into place, they recommend, like the system used in Botswana, where doctors and nurses from UK hospitals carried out six month training placements in various facilities. Eventually such systems will have to be replicated in-country, since the supply of doctors willing to spend long periods abroad is not infinite!
The operational recommendations also highlight some very basic management issues that will need to be addressed in order to improve staff retention and motivation. Salaries must be paid on time, roles must be clearly defined and staff must be involved in decision-making about service delivery. At the higher level, governments need to look at the workforce policies that may be blocking retention or recruitment of staff. Where is the career path and where is the route back into service for each role within the health service?
There are many other recommendations in the guidelines, but these are the key recommendations relating to human capacity.
However, this model may not be appropriate for all countries, as 3 x 5 technical director Professor Charles Gilks admits.
In India its going to be much more doctor-driven, and the way they are going to approach scale-up is going to be based on centres of excellence which will start training doctors and do curriculum development for undergraduates. It will be very much a doctor-driven service. Their issue is that the status of nurses is much lower in India than it is in Africa, and I think there will inevitably be huge regional differences in approach.
Pushing from the grassroots: moving 3 X 5 forward
WHO country missions have already begun working with nearly twenty countries to devise national plans and technical visits within the next few months to assess the situation and begin work with key stakeholders. WHO awaits approaches from many other seriously affected countries during the course of 2004.
The early success and dynamism of 3 x 5 activities in each country is likely to be critically dependent on the development of a core group that can drive the process forward, says Professor Gilks, and he urged HATIP readers to begin linking up and making themselves known to health ministries and National AIDS Programmes, as key partners in the early scale up of treatment. Simply by subscribing to this email newsletter, HATIP readers have already shown that they have an awareness of antiretroviral therapy, and are therefore amongst the vanguard in their own country.
HATIP: How can individuals working in the front line engage with national AIDS programmes?
Charles Gilks: Were trying to get the countries to set up their own monitoring networks in order to begin assessment of progress towards meeting the 3 x 5 target.
The problem at the moment is that the majority of treatment delivery is through the private sector. Theres no accountability in the private sector and no service quality monitoring and no supervision of the training or background knowledge that people have. Nor are there any national systems for counting the numbers of people on treatment. We need to have an estimate of the baseline and then begin counting accurately&. so people need to begin linking up with the national monitoring service if it exists or as it is set up. We cant do this ourselves at WHO we have to empower the countries and the countries have to take responsibility. This is their treatment problem.
There is now a great deal of resource availability and a great interest in helping countries to close the treatment gap, but at the end of the day the sustainability and the long-term political commitment have to happen in individual countries. So its getting the national systems set up, and the networks for the national systems to work. So really the best way is for people in country to start jumping up and down and to start pushing the national services as they are being set up.
HATIP: In terms of those push activities, what would you say are the priorities for getting things moving at country level in the next six months?
Charles Gilks: There needs to be a target for people to aim at when pushing. The Ministry of Health needs to be strengthened and that central system has to know who to work with the NGOs, the mission hospitals, the individual providers need to have a network and the issues that are occurring at the periphery need to be fed up to the centre for action.
One of the problems is that there are so many different players all doing different things with very poor coordination. Thats one of the first steps to get a group of people within the ministry of health or parallel to the ministry to take on some sort of coordinating role, and that has to be the group that people are `pushing` into, and at the moment that doesnt really exist in many places, which allows the fragmentation and discoordination to continue. Thats one of the reasons why the data about how many people are on treatment have been so difficult to get. Even if you were a quality private sector private physician with good training, theres nothing for you to feed into, youre by yourself. Its not good. You cant maintain your own quality if you work as a single-handed person or a small group youve got to network with a proper group.
Another part of the need for establishment of a central group and establishing a network is the need to establish training standards, keeping people up to date and empowering people to do something with the drugs, and then watching the momentum grow as people realise that. Yes, you can get trained, you can set up a service. And the hope is that that will immediately accelerate prevention activities.
Were just starting. It really is quite different in different areas because of the nature of the partnerships that need to be set up.
3 X 5: Mobilisation at country level critical
Early reporting of the 3 x 5 strategy may have left many with the impression that WHO will be sending in teams of experts to take charge in the worst affected countries. After visiting WHO last week to discuss 3 x 5, its clear how much the plan depends on mobilising human capacity at country level not just large numbers of doctors and nurses, but also the mobilisation of imagination, courage and determination to move the plans forward during the early stages.
In fact the picture that emerges very clearly from discussions with WHO staff is the extent to which the worlds public health guardian will need to beg, cajole and sweet talk dozens of donors, international NGOs, national governments and vested interests in the health care system in order to put together plans in each country.
Reaction to the 3x5 program presentation in Botswana and elsewhere has been mixed. Many in the Gaborone audience wondered how the WHO expected many of poorer countries to contribute so much towards development of the program. Some thought that the timetable was unrealistic given their own experience. Others were gravely concerned about what they perceived to be an over-reliance upon community based organisations, which are only beginning to form in Botswana and many other African nations.
These concerns have been echoed by some of HATIP's panel members but not all. Advocates such as Chris Green welcomed WHO's "turn-around" on dealing with community based organisations.
WHO must be congratulated for their stance on community involvement. This is a huge U-turn for the organization, which up to now in my experience has been uncomfortable in involving the community in the response to any health matter. WHO here in Indonesia has at last shown a willingness to involve the positive community and engage with them. This is major progress!
Yet reliance on minimally trained community workers alarms others, and many will want to see further examples of successful implementation before they back such a radical strategy.
Others fear that 3x5 will go the way of other WHO initiatives in the past. Dr. Norman Nyazema in Zimbabwe told us: "I had a discussion with some collegues in Zimbabwe and the Zimbabwe AIDS Network, about 3x5 strategy. The general consensus was that this was a joke. People do not seem to be serious. In the 1978 we had the Primary Health Care Concept. Where is it now? We also had Health For All By The Year 2000. Where are we now?
He argues: The 3x5 strategy has been adopted without having taken stock of what is on the ground, a view that is likely to be vigourously disputed by the frontline experts who put the plan together. For instance, how many countries have national drug policies in general, and HIV/AIDS drug policies in particular for starters? I am talking about explicit drug policies which are being effectively implemented. There is so much song and dance about the Botswana experience... [but]... Botswana has ACHAP (the Gates Foundation, Merck, Sharp and Dohme,) and diamond money for less than 2 million people."
Yet it has been the Botswana experience that has made many think that the 3x5 plan is worth attempting.
True, start-up may have taken longer than expected but according to Prof. Brian Gazzard while the numbers of patients on antiretroviral therapy remain relatively small, the numbers are growing rapidly and the number of sites now able to enroll patients is rising steeply. Results so far have been extremely good with high adherence rates, relatively low rates of toxicity and excellent overall results.
I believe the provision of antiretroviral care in Botswana has changed attitudes to the HIV epidemic. Of course the introduction of this programme has not been without its problems. But as a model I think Botswana has shown us that if sufficient resources are supplied, antiretroviral treatment can be effectively applied in Africa with very high adherence rates and the logistic difficulties can be overcome.
But in order for 3x5 to succeed in other countries, they may be forced to adopt the Botswana model, which as Prof. Gazzard has pointed out: has two important aspects. They have set up a public/private partnership and secondly they have used a preceptorship programme for training local doctors to provide antiretroviral therapy.
Everyone agrees that human capacity building is one of the immediate critical steps needed to ensure that countries can scale up HIV treatment.
For Dr. Douglas Wilson, presently trying to set up a similar Botswana-like training/preceptorship program for health districts in KwaZulu Natal, South Africa with a population at least 4 or 5 times that of Botswana finding the financial resources to support it is a huge issue for clinicians already overburdened treating patients. We need assistance and 'intellectual resources' to dedicate to writing grant proposals as we are working full-time as clinicians.
His perspective on WHOs plan? "3x5 needs massive financial investment and, most importantly, political will (both locally and internationally) to set up the infrastructure needed to effectively and sustainably deliver ARV's in sub-Saharan Africa.'"
National donor coordination of the kind recently proposed by the British and American governments is likely to prove essential in channeling support to the right places at the right times in order to move the process forward. But this process will need honest brokers to help facilitate the process by aggressively providing local governments, CBOs and clinicians with assistance to navigate the complexities of the application process.
Perhaps the last words on the subject of 3 x 5 should be left to HATIP panel member Chris Green in Indonesia. According to Green "I just know we HAVE to make a go of it. History will judge us very badly if we don't try. It is our last chance."
This newsletter will continue to report on what efforts are likely to make the greatest difference in moving forward national responses in future issues, and the practical steps that are being taken in countries that have been able to move forward quickly.