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December 2005

I have written this "Report from the President" column since 1999, and I always pray that I may, in the last issue of the year, report good news about the state of our world with respect to HIV/AIDS. Sadly, while I may report about good deeds performed by individuals and institutions in the trenches of our collective battle against this insidious disease, it is always punctuated by sobering year-end statistics generated by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO). Regretfully, this year is no exception, as the UNAIDS/WHO "AIDS Epidemic Update: December 2005"1 tells us that:

  • the estimated total number of HIV-positive people worldwide has reached its highest level ever, increasing from 39.4 million in 2004 to 40.3 million in 2005;

  • nearly five million new HIV cases occurred this year and about 3.1 million people died of AIDS-related illnesses in 2005, bringing the total number of deaths from HIV disease to more than 25 million since 1981; and

  • of those who died this year, 500,000 were children and 2.4 million lived in sub-Saharan Africa.

Without question, 2005 has been a year of progress. There has been an unprecedented outpouring of money, significant advances in treatment, an accumulated understanding of how to deliver prevention as well as treatment and care services, along with growing political commitment to stop the spread of HIV disease. Yet, more people will have become infected with HIV and died from AIDS in 2005 than in any previous year.

This year's World AIDS Day theme is "Stop AIDS: Keep the Promise." But just who is accountable when promises are not kept regarding treatment for HIV-positive patients and prevention of further spread of the disease? And for what and how are they accountable? Merriam-Webster's dictionary defines accountability as the "obligation or willingness to accept responsibility or to account for one's actions." Simon Zadek, Chief Executive of the nonprofit watchdog group AccountAbility, reminds us that, "Accountability is the stable core of civilized communities. ... The darker, sadder pockets of our past and present are often terrifying fragments of a world without accountability."2

Rarely have individuals or institutions been willing to accept responsibility for missed opportunities to slow the spread of the AIDS pandemic and to ameliorate the suffering of those living with and affected by HIV disease. The WHO, on the other hand, has recently accepted responsibility for failing to have "moved quickly enough" to meet its target of placing 3 million people in the developing world on antiretroviral therapy by 2005. For so doing, the WHO's self-awareness (sorely lacking in some bureaucracies) should be applauded.

That said, as I read a November 28, 2005, media report entitled, "WHO Sorry for Missing AIDS Target,"3 I was reminded of a fable used to great effect at a lecture I attended not long ago around the problem with utilizing overly simplistic metrics when dealing with complex, urgent, and sometimes long-standing public health emergencies.

Once upon a time in Wonderland, a prestigious national commission declared that the state of health care in that country was abominable. There were so many unhealthy people walking around that "the commission declared the nation "at risk" and called for sweeping reforms. In response, a major hospital decided to measure doctors' performance by patient outcomes and to tie decisions about patient treatment and dismissals to those measures.

The most widely used instrument for assessing health in Wonderland was a simple tool that produced a single score with proven reliability. That instrument, called a thermometer, had the added advantage of being easy to administer and record. No one had to spend a great deal of time trying to decipher doctors' illegible handwriting or soliciting their subjective opinions about patient health. When doctors discovered that they would be held accountable for how many of their patients had thermometer scores above normal, some complained that it was not a comprehensive measure of health. Their complaints were dismissed as defensive and self-serving. The hospital administrators, to ensure that their efforts would not be subverted, then specified that subjective assessments would no longer be used in making decisions. Furthermore, medicines or treatment tools not directly related to thermometer scores would no longer be purchased.

After a year of operating under this new system, more patients were dismissed from the hospital with temperatures at or below normal. Aspirin prescriptions had skyrocketed and the use of other treatments had substantially declined. Some doctors also left the hospital arguing obtusely that their obligations to patients required them to pay attention to other things than to scores on the thermometer. Since thermometer scores were the only measure that could be used to ascertain patient health there was no way to argue whether they were right or wrong.

Some years later during the centennial Wonderland census, the census takers discovered that the population had declined dramatically and mortality rates increased. As people in Wonderland were wont to do, they shook their heads and sighed, "Curiouser and curiouser..." They next appointed another commission.

The real work of battling HIV/AIDS is more difficult and complex than just setting targets and tracking statistics. As with any combat in the arena of infectious diseases, and HIV disease in particular, this global battle is about working and strategizing together as well as using our collective resources to employ the best, most efficient, and effective weapons with an ultimate aim of achieving the optimal outcome for the maximum number of people.

In every country I have visited this year, the myriad individuals and institutions needed to scale up access to antiretroviral therapy have made great strides in implementation of scale-up programs, even with human and organizational infrastructure challenges that have often threatened to cripple their efforts. Nonetheless, they are concerned about and frustrated by the lack of overall leadership required to answer a very basic question: "What next?" There are numerous next steps around which we should be focusing our collective attention, including but not limited to:

  • Increasing the number of people who are aware of their HIV status (which remains a major barrier to antiretroviral therapy scale-up when in some countries less than 10% of the general population is aware of its HIV status);

  • Reassessing data analysis to confirm the estimated number of patients who are clinically eligible for antiretroviral therapy (as with any campaign, statistics evolve and may force course corrections);

  • Augmenting the existing antiretroviral armamentarium to allow for more choices in first- and second-line as well as salvage antiretroviral regimens (this was an explicit goal when the WHO decided to recommend a limited menu of regimen options under the "public health emergency" rubric);

  • Pushing brand-name and generic antiretroviral drug manufacturers, as well as diagnostic technology companies, to continue to reduce their prices and, as important, fulfill their responsibilities as corporate citizens by awarding grants in support of capacity-building activities (this is especially true of generic manufacturers, many of which exhibit robust business acumen but anemic philanthropic leanings);

  • Re-examining the way in which issues and logistics associated with providing effective antiretroviral therapy have been managed (what worked last year may not necessarily work next year);

  • Tackling the thorny issue of which cadres of health care professionals may prescribe antiretroviral therapy and under what conditions (especially as the physician-to-patient ratio in many African countries continues its downward slide); and

  • Integrating the work of traditional and biomedical health practitioners (in some countries, such as Botswana, there are approximately 100 times more traditional healers than physicians).

As important, these next steps must be better integrated -- beyond "lip service" -- into myriad other human development efforts ongoing worldwide. A renewed sense of accountability requires we consider the interconnected, trans-boundary nature of today's issues, impacts, and influences. Other endemic diseases, poverty, sanitation, and civil rights (eg, disability) can no longer be adequately addressed in isolation, as separate causes.

Now that the WHO and, by extension, all WHO partner-institutions, are assuming responsibility for not having done more to achieve the "3 by 5" goal, we must move forward and cease to dwell on the "what ifs." Now that we have collectively affirmed that we are accountable not only to boards or governments, but also to the 40.3 million people living with HIV/AIDS, 6 million of whom are clinically eligible for antiretroviral therapy, we must accept responsibility for the next series of goals that will pave the way toward universal access to antiretroviral therapy.

Zadek argues that, "the increased interconnectedness of both accountability and solutions demands new ways of organizing, mobilizing, and learning. There is a need to join up the dots: to raise awareness of ... how we may most effectively mobilize to shape societal outcomes."3 This argument is in line with the attitude we must all take as we enter the post-"3 by 5" era. Let us catch our breath, regroup, and address the challenges before us with renewed dedication and vigor.

José M. Zuniga is President/CEO of the International Association of Physicians in AIDS Care (IAPAC), and Editor-in-Chief of the IAPAC Monthly.


  1. Joint United Nations Programme on HIV/AIDS (UNAIDS), World Health Organization (WHO). AIDS Epidemic Update: December 2005. Geneva, Switzerland: UNAIDS; 2005.

  2. Zadek, S. Reinventing Accountability for the 21st Century. September 12, 2005. (Accessed December 7, 2005.)

  3. Reuters. WHO sorry for missing AIDS target. November 28, 2005. (Accessed December 9, 2005.)

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This article was provided by International Association of Physicians in AIDS Care. It is a part of the publication IAPAC Monthly.