It was a breath of fresh air to read Mark's piece ("Comments on Problems in the Current Draft World Health Organization (WHO) Antiretroviral Treatment Guidelines for Resource Limited Settings," March 2002). I have been saying for a long time that a big piece of this puzzle is the failure of UNAIDS/WHO/(PAHO in Latin America, Pan American Health Organization) to provide an effective and coherent response to issues relating to access to treatment, but I have felt that this was an issue that others didn't pay too much attention to.
Although it sounds paradoxical, I would rather see the Global Fund give $50 million to WHO/UNAIDS so they can scale up to provide an international infrastructure, than to give the money to country programs that will find a way to waste it (with the exception of funds that go directly to the purchase of antiretrovirals that will be delivered directly to people, under adequate medical supervision). Of course, providing additional funding for WHO/UNAIDS implies holding them accountable for quality outcome in terms of their reports, programs, and interventions. Mark has made many good recommendations.
Ironically, in most countries in Latin America that I have knowledge of, the Global Fund application process was supported by UNAIDS/WHO staffers who had the technical ability to help a Country Coordinating Mechanism write an intelligent application. But who is going to help the country carry out programs once they are approved? Understaffed national AIDS program staff are used to working with budgets [with] numbers in four figures (like $8,000 a year)! How are they suddenly going to "scale up" intelligently to carry out a program that provides a million dollars or more?
The UNAIDS "Accelerated Access" program, which can be effective where it has been carried out, muddles along like a lost turtle. Latin America has the infrastructure and some economic resources to take advantage of this program, but only in Trinidad, Chile, and now Honduras, has the program been carried out. The much praised Peter Piot has not asked for the resources he needs to do a good job with UNAIDS. By now, it's apparent that his well-intended rhetoric is not getting the job done, but he is strangely silent on the treatment access issue and [on] providing recommendations as to what it takes to create a really meaningful response.
UNGASS [a Special Session of the United Nations General Assembly -- on HIV/AIDS] in most parts of the world is just lip service. The life of the average person [infected with HIV] has not changed at all. Those who are alive in 2002 are not going to benefit from UNGASS's (unenforceable) target dates of 2005 or 2010. The Global Fund remains an open question, as far as funding for treatment access and purchase of generics is concerned. Basic issues such as getting accurate price information to health ministries, getting generic products registered, (plus all the other issues that Mark raises) and getting an adequate assessment of who needs what kind of care in what country, could be addressed by international agencies which could provide quality level consultation to governments.
On a small scale, Médecins Sans Frontières (MSF) has put together all the ingredients that it takes to deliver antiretroviral medications in resource poor settings with, of course, very small numbers of patients in selected programs. If MSF staff could just replace WHO staff, we would already be light years ahead. I would challenge this list-serv to devote some attention to trying to figure out if there are effective advocacy actions that could be taken in support of the issues that Mark is raising. This is a tricky issue, but a few demonstrations outside of WHO offices in Washington might not be a bad idea.
Richard Stern, Director
Agua Buena Human Rights Association
PO Box 366-2200
Coronado, Costa Rica