1. "WHO believes that potentially, at least three million people needing care could get ARVs by 2005 - a more than ten-fold increase in the developing world." 3 million HIV/AIDS sufferers could receive anti-retroviral therapy by 2005 – New hope for those in developing world. Press release WHO/58, Barcelona, 9 July 2002.

  2. Untangling the Web of Price Reductions: a Pricing Guide for the Purchase of ARVs for Developing Countries. 2nd edition, MSF Campaign for Access to Essential Medicines, Geneva, June 2002.

  3. "About 55% of the population in low- and middle-income countries had access to DOTS." (Global Tuberculosis Control: Surveillance, Planning and Finance: WHO Report 2002. WHO/CDS/TB/2002.295). Far fewer have access to critical HIV/AIDS related services:
    Availability (%) vs Need (N) in 2001
    RegionBlood safetyDOTSTB cases
    (000)    		VCT VCTPMTCTARTNART
    Africa94%71%6206%100001%1%4400
    Americas93%65%12032%72012%23%200
    E Mediterranean100%65%120–220––56
    Europe100%17%7428%4004%4%44
    SE Asia91%49%44069%19006%4%130
    W Pacific100%67%60010%4903%2%110
    Total96%55%200017%140007%2%4900
    Just four percent of those in need receive isoniazid (INH) prophylaxis for TB, and just one percent receive cotrimoxazole preventive therapy (CPT). The Health Sector Response to HIV/AIDS: Coverage of Selected Services in 2001 – Preliminary Assessment. WHO/HIV/2002.10, July 2002.

  4. Accelerating Access Initiative: Widening access to care and support for people living with HIV/AIDS. Progress report. WHO, June 2002.

  5. The CDC spent $144M on global AIDS programs in FY2002, 14% of the US total. Alagiri P, Summers T, Kates J. Spending on the HIV/AIDS Epidemic – U.S. Spending on Global AIDS. The Henry J. Kaiser Family Foundation, July 2002. http://www.kff.org/content/2002/6050/US_on_Global_July_2002.pdf. Countries involved in the CDC Global AIDS Program (GAP) include Angola, Botswana, Brazil, Cambodia, Côte d'Ivoire, DR Congo, Ethiopia, Guyana, Haiti, India, Kenya, Malawi, Mozambique, Namibia, Nigeria, Rwanda, Senegal, South Africa, Tanzania, Thailand, Uganda, Vietnam, Zambia and Zimbabwe. GAP supports primary prevention, including prevention of sexual and drug-use associated prevention, VCT, MTCT prophylaxis, blood safety, STI prevention and care, youth intervention and behavior change campaigns; surveillance and infrastructure development including support for laboratories, information systems, monitoring & evaluation (M&E) and training programs; and care, support and treatment activities including TB prevention and care, opportunistic infections (OI) prevention and treatment, palliative care, and what it calls "appropriate use of antiretrovirals", which apparently means "not very much". "CDC will assist countries that wish to use ART preventive therapy for prevention of transmission of HIV in occupational and non-occupational settings [and] supports ART as an intervention in preventing MTCT of HIV." In other words, CDC is looking at ART strategies for prevention, but not for treatment as such – though they are working with TASO on a DOT-HAART pilot project in rural Uganda. They are also helping countries integrate isoniazid (INH) prophylaxis for HIV infected people with latent TB, and cotrimoxazole preventive therapy (CPT) for people with HIV, into national programs. http://www.cdc.gov/nchstp/od/gap/strategies.

  6. In 2000-2001 France supported bilateral HIV/AIDS projects in Angola, Benin, Burkina Faso, Burundi, Cambodia, Cameroon, Central African Republic, Congo, Côte d'Ivoire, Djibouti, Gabon, Guinea-Bissau, Madagascar, Mali, Mauritania, Mozambique, Namibia, Niger, Rwanda, Senegal, Togo, Zimbabwe. It was impossible to determine which of these might involve ART programs. In addition they supported 32 million FrF ($4.737 million) in research programs and 46 million FrF ($6.8 million) in assistance to the ISTF/FSTI. http://www.diplomatie.gouv.fr/cooperation/dgcid/publications/reperes/sida_gb.

  7. GTZ supports HIV/AIDS/STI activities in Argentina, Barbados, Brazil, DR Congo, Ghana, Guyana, Honduras, Jamaica, Kenya, Malawi, Mozambique, the Philippines, South Africa, Surinam, Tanzania, Thailand, Trinidad & Tobago, Uruguay and Zimbabwe either bilaterally, regionally, or through cooperation with the European Commission (EU). It is unclear how much effort is being devoted to ART. GTZ has opened pilot MTCT prevention projects in Kenya, Tanzania and Uganda. http://www.gtz.de/aids/english. GTZ worked closely with Daimler-Chrysler South Africa (DCSA), whose comprehensive care program for employees includes "sustained commitment to access to antiviral drugs, treatment according to standard protocols, and appropriate treatment of opportunistic infections within the framework of the company medical aid." http://www.daimlerchrysler.co.za/social/aids/partnership.asp.

  8. Recent HIV/AIDS related World Bank commitments include over $300M in new loans to Benin, Burkina Faso, Burundi, Jamaica, Madagascar and Senegal, as well as $500M in IDA financing for MAP-2 in Africa and $155M for MAP in the Caribbean including Barbados, the Dominican Republic and Jamaica. On the World Bank website, 48 projects have the words AIDS, HIV, STI or tuberculosis in their project titles (thus excluding general health sector projects). Of the 48 AIDS-specific projects, one was funded in 1988 ($8.1M, Zaire) and one in 1992 ($84M, India), two in 1993 ($160M, Brazil; $64.5M, Zimbabwe) and two in 1994 ($76.3, Burkina Faso & Uganda), one each in 1995, 1996, and 1997 ($60.2M for Chad, Indonesia & Argentina), one each in 1998 and 1999 (Brazil, $165M and India, $191M), six in 2000 ($264.7M), ten in 2001 ($335.65M) , and eight (so far) in 2002 ($23.04M), with fifteen in the pipeline. Of the approved projects, 28 are active and seven are closed. http://www4.worldbank.org/sprojects.

  9. As recently as May 2001 DFID bluntly stated, "Prevention remains the priority. Antiretrovirals ... are still unaffordable to most poor people. There are significant equity, cost and sustainability issues... Until safe and equitable systems can be put into place it would be inappropriate to use scarce resources to support wide-scale provision of ARVs for treatment." DFID HIV/AIDS Strategy, http://62.189.42.51/DFIDstage/Pubs/files/hiv_isp.pdf, May 2001, p. The very brief two paragraph treatment and care section recommends just counselling and TB treatment for those unfortunately enough to actually develop AIDS. Despite spending over £200 million on HIV/AIDS related bilateral work in 2001, it appears unlikely that DFID is yet supporting much if any actual antiretroviral treatment in poor countries. http://www.dfid.gov.uk. But DFID may be changing its tune. In the 28 September 2002 Lancet, editor Richard Horton expressed concern that a recent DFID "institutional strategy review" of WHO (http://62.189.42.51/DFIDstage/Pubs/files/dfid_unhcr_isp.pdf) placed excessive emphasis on meeting millennium development goals (MDGs) with regard to HIV, tuberculosis and malaria, to the exclusion of "maternal and child health, nutrition and food safety, non-communicable diseases ... and many other important infections ... and the agency's role in building health programmes and health systems..." R Horton, "WHO's mandate: a damaging reinterpretation is taking place.", The Lancet 360, 960-1, 28 September 2002. There was no evidence in the DFID report that Horton's claim was accurate; the WHO programme budget for 2002-2003 as compared with 2000-2001 shows the greatest percentage increase in support for the following programs:

    		Budget – regular & other sources – US $ 000
    Program area2000-20012002-2003% increase
    Tuberculosis18,682104,650460.2%
    Making pregnancy safer11,03837,157236.6%
    HIV/AIDS55,472129,812134%
    Food safety6,49710,39960.1%
    Tobacco15,99625,20857.6%
    Mental health/substance abuse18,20828,14754.6%
    Evidence for health policy32,46643,22533.1%
    Surveillance, prevention and management of non-communicable diseases15,47420,02929.4%
    Blood safety & clinical technology21,78025,72718.1%
    Organisation of health services51,21257,92313.1%
    WHO – all programs1,939,6542,222,65414.6%
    The priority list includes all of Horton's concerns except for "many other important infections." In any case, even if DFID's new policy is to increase support for WHO activities related to AIDS, TB and malaria, its own position with regard to provision of ART in poor countries does not appear to have changed visibly since May 2001.

  10. USAID spending on global HIV/AIDS was $435M in FY2002 and is slated to rise to $540M (+24%) in FY2003. Of the $435M, $392M (73%) was on USAID bilateral programs, $100M (19%) went to the Global Fund, $18M (3%) to UNAIDS, $15M (3%) to microbicides research and $10M (2%) to IAVI. Approximately 12% of the USAID spending went to care and treatment programs. Alagiri P, Summers T, Kates J. Spending on the HIV/AIDS Epidemic – U.S. Spending on Global HIV/AIDS. The Henry J. Kaiser Family Foundation, July 2002. http://www.kff.org/content/2002/6050/US_on_Global_July_2002.pdf In Barcelona, USAID announced "that it has started antiretroviral treatment programs for HIV-infected people in Ghana, Kenya and Rwanda. These are the first US government-funded programs in these countries to provide comprehensive antiretroviral treatment for people living with HIV and AIDS...
    Ghana: In Ghana, the "Start" program is a comprehensive prevention, care and treatment program that is designed to define, refine and document approaches to HIV/AIDS service delivery in resource-poor settings. This program is being designed and implemented by USAID's partners Family Health International, National AIDS Control Program, Ghana Health Services, and the Ghana AIDS Commission. "Start" will begin in two districts in the Eastern Region of Ghana, where an estimated 18,000 people out of 240,000 are HIV positive.
    Kenya: USAID will start ARV treatment in Mombassa, Kenya, at the Coast Provincial General Hospital, and at two primary health care centers that have ongoing voluntary HIV counseling and testing services. In addition to these services, there is a strong home-based care services system in Mombassa. Family Health International and its collaborators have established networks of community organizations that are working together to serve the needs of people living with HIV and AIDS in these communities.

    Rwanda: USAID is starting a program in Rwanda to provide comprehensive care to people living with HIV/AIDS. Family Health International will build on existing HIV counseling and testing services, and expand the range of medical care and support services that are available to HIV-infected individuals. In this site, a major focus will be on supporting community responses to provide home-based care as a complement to clinic-based services.

    Establishing such sites demonstrates a commitment to sustaining the intervention, and establishing the minimum elements of the comprehensive care and support that can be strengthened and replicated in other resource-constrained settings.
    In all three countries, USAID intends to create models for provision of antiretrovirals that governments and the private sector can expand to a national level. These initial sites will explore a host of issues surrounding the introduction of antiretrovirals into a variety of clinical settings. USAID will rapidly distill lessons learned from these sites." USAID Press Release 2002-069, "USAID Announces Introductory Antiretroviral Treatment Sites", 9 July 2002.

  11. Estimated NIH spending on global HIV/AIDS research activities was $188M in FY2002, 19% of the US total, and eight percent of the NIH AIDS research program. This estimate includes spending on all research outside the US, the majority of which is conducted in developing countries, as well as research training in the US of scientists from other countries. NIH's National Institute of Allergy & Infections Diseases [NIAID] receives approximately 50% of all of NIH's international HIV/AIDS funding... NIH supports more than 250 research projects in approximately 70 countries in Africa, Asia/Western Pacific, Eastern Europe, Latin America and the Caribbean, Western Europe and the Middle East". Alagiri P, Summers T, Kates J. Spending on the HIV/AIDS Epidemic – U.S. Spending on Global AIDS. Kaiser Family Fdn., July 2002. http://www.kff.org/content/2002/6050/US_on_Global_July_2002.pdf. Noteworthy recent and current NIH initiatives include the Comprehensive Program of International Research on AIDS (CIPRA) grants. NIAID awarded $11M over five years to the University of Natal in Durban (UND) to study HIV in KwaZulu-Natal province, South Africa. One important study will look at whether it is better to treat tuberculosis first or treat TB and HIV together in TB/HIV coinfected individuals. China's CDC will receive $14.8M to study pathogenesis, natural history, treatment and vaccines. Smaller planning CIPRA grants were awarded to investigators in Brazzaville, Caxias do Sul (Brazil), Chiang Mai, Cuernavaca, Ho Chi Minh City, Lima, Lusaka, Moshi (Tanzania), New Delhi, Ndola (Zambia) Port of Spain, Puerto Plata (Dominican Republic), Pune, Rio de Janeiro, St. Petersburg and Svay Rieng (Cambodia). The NIAID funded HIV Prevention Trials Network (PTN), Vaccine Trials Network (VTN) and Pediatric AIDS Clinical Trials Group (PACTG) have international sites. The Fogarty International Center (FIC) runs extensive training programs for researchers from developing countries and for US-based researchers in foreign settings. Few of these programs have involved treatment trials; however the Adult AIDS Clinical Trials Group (AACTG) has plans to open an 1,238 subject comparative trial of three protease-sparing regimens as initial therapy in therapy naive HIV+ people with CD4 counts lower than 300/mm3. The study, A5175, will compare AZT+3TC (CombivirTM) plus efavirenz, ddI or tenofovir DF (TDF), and is scheduled to open for enrollment on 1 April 2003 at its twelve recently announced AACTG international units. http://aactg-s3.com.

  12. "WHO re-affirms its commitment to support WTO Members and the Council for TRIPS in finding an expeditious solution to this problem raised in Paragraph 6 of the Declaration. To this end, WHO has published a paper, Implications of the Doha Declaration on the TRIPS Agreement and Public Health, WHO/EDM/PAR/2002.3. This paper describes the features of a solution to the so-called "paragraph 6 problem" which are desirable from a public health perspective. These include: a stable international legal framework; transparency and predictability of the applicable rules in the exporting and importing countries; simple and speedy legal procedures in the exporting and importing countries; equality of opportunities for countries in need of medicines, even for products not patented in the importing country; facilitation of a multiplicity of potential suppliers of the required medicines, both from developed and developing countries; and broad coverage in terms of health problems and the range of medicines. Thus, the basic public health principle is clear: the people of a country which does not have the capacity for domestic production of a needed product should be no less protected by compulsory licensing provisions (or indeed other TRIPS safeguards), nor should they face any greater procedural hurdles, compared to people who happen to live in countries capable of producing the product. Among the solutions being proposed, the limited exception under Article 30 is the most consistent with this public health principle. This solution will give WTO Members expeditious authorization, as requested by the Doha Declaration, to permit third parties to make, sell and export patented medicines and other health technologies to address public health needs." Statement by the representative of the WHO, WTO Council for TRIPS, 17 September 2002.

  13. In an important and thoughtful email sent to the group before the meeting, Ernest Darkoh from the ARV Project Team in Botswana wrote that "Training is going to be the pivotal key capacity growth rate determining step – as important as the number of staff... [T]his issue ultimately determines the feasibility of any implementation plan as well as the speed at which any scale up is possible. We have not had too much of a problem with the development of curricula or materials – there is an abundance of material to draw from. The key challenges associated with training have been:
    1. Identifying the full scope of training needs... Management staff need just as much (if not more) training than the frontline staff. Training needs span the continuum from the mundane to the very complex (e.g., clinician skills). We have often found that some of the most profound bottlenecks are around things generally considered mundane – e.g., skills on how to run a meeting, write a memo, proposal writing, how to refer a patient etc.
    2. Finding the right training model/methods that will deliver a given curriculum rapidly, effectively, and as cheaply as possible (with effectiveness determined by how quickly a health care worker becomes functional).
    3. Sequencing the training so that individuals become functional at the optimal time during the project rollout. Training too early leads to rapid decay of skills and need for retraining. Some training is dependent on arrival of certain equipment/infrastructure (e.g., lab equipment, computers, software, building) and it is a nightmare to get the sequencing right when dependent on the cooperation of numerous functional and administrative units.
    4. Creating a uniform standard and methods of evaluating post training competencies.
    We have experimented with different models and so far, the superior model (speed, cost, effectiveness) seems to be hands-on site based training in the context where the work occurs. This is especially effective in our highly understaffed and overstretched environment. Would be interesting to compare experience of other initiatives.
    Expectations... When the size of the resource requirements is large or seemingly impossible to attain, the information may inadvertently lead to a further sense of helplessness rather than providing an energizing call to action for developing countries. There may even be a tendency for some governments to use the resource requirements data to justify inaction. As much as possible, we should also focus on 'what you can currently do with what you have'." Ernest Darkoh, Operations Manager, ARV Project Team, MOH Botswana (ACHAP Seconded), "Additional thoughts on HR" email to IPA list, 27 September 2002.

  14. "Botswana is putting up substantial money of its own to fight AIDS, roughly $30 million a year... Merck is donating $50 million over five years to support care and treatment programs, and the Bill and Melinda Gates Foundation is donating another $50 million to beef up the health infrastructure... Meanwhile, progress in treating the current victims is agonizingly slow, in part because of a critical shortage of doctors, nurses and other health personnel. Industrialized countries that continue to lure Botswana nurses to meet their own needs have a moral responsibility to stop those recruiting drives. Now that it looks like enough money and medicines will be on hand, international donors need to concentrate on supplying medical personnel. There could be no more vital service to help Botswana survive this threat to its social fabric." "Disaster in Botswana", New York Times editorial reprinted in The International Herald Tribune, 1 October 2002, page 6. Left unaddressed is the impact of the Botswana program on neighboring African countries and their health care staffing levels.

  15. I asked Zackie how many staff run the MSF HIV clinic in Khayelitsha township, Western Cape. He said that three doctors with four to five nurses per clinic take care of 3,000 HIV-infected people with AIDS and 250 people on HAART. They need at least two additional doctors to help manage the opportunistic infections. In addition there are counselors and administrative/clinic staff.
    1. "WHO believes that potentially, at least three million people needing care could get ARVs by 2005 – a more than ten-fold increase in the developing world." 3 million HIV/AIDS sufferers could receive anti-retroviral therapy by 2005 – New hope for those in developing world. Press release WHO/58, Barcelona, 9 July 2002.
    2. Untangling the Web of Price Reductions: a Pricing Guide for the Purchase of ARVs for Developing Countries. 2nd edition, MSF Campaign for Access to Essential Medicines, Geneva, June 2002.
    3. "About 55% of the population in low- and middle-income countries had access to DOTS." (Global Tuberculosis Control: Surveillance, Planning and Finance: WHO Report 2002. WHO/CDS/TB/2002.295). Far fewer have access to critical HIV/AIDS related services:


      		TB casesAvailability (%) vs Need (N) in 2001
      RegionBlood safetyDOTS(000)VCTN VCTPMTCTARTN ART
      Africa94%71%6206%100001%1%4400
      Americas93%65%12032%72012%23%200
      E Mediterranean100%65%120–220-–56
      Europe100%17%7428%4004%4%44
      SE Asia91%49%44069%19006%4%130
      W Pacific100%67%60010%4903%2%110
      Total96%55%200017%140007%2%4900
      Just four percent of those in need receive isoniazid (INH) prophylaxis for TB, and just one percent receive cotrimoxazole preventive therapy (CPT). The Health Sector Response to HIV/AIDS: Coverage of Selected Services in 2001 – Preliminary Assessment. WHO/HIV/2002.10, July 2002.
    4. Accelerating Access Initiative: Widening access to care and support for people living with HIV/AIDS. Progress report. WHO, June 2002.
    5. The CDC spent $144M on global AIDS programs in FY2002, 14% of the US total. Alagiri P, Summers T, Kates J. Spending on the HIV/AIDS Epidemic – U.S. Spending on Global AIDS. The Henry J. Kaiser Family Foundation, July 2002. http://www.kff.org/content/2002/6050/US_on_Global_July_2002.pdf. Countries involved in the CDC Global AIDS Program (GAP) include Angola, Botswana, Brazil, Cambodia, Côte d'Ivoire, DR Congo, Ethiopia, Guyana, Haiti, India, Kenya, Malawi, Mozambique, Namibia, Nigeria, Rwanda, Senegal, South Africa, Tanzania, Thailand, Uganda, Vietnam, Zambia and Zimbabwe. GAP supports primary prevention, including prevention of sexual and drug-use associated prevention, VCT, MTCT prophylaxis, blood safety, STI prevention and care, youth intervention and behavior change campaigns; surveillance and infrastructure development including support for laboratories, information systems, monitoring & evaluation (M&E) and training programs; and care, support and treatment activities including TB prevention and care, opportunistic infections (OI) prevention and treatment, palliative care, and what it calls "appropriate use of antiretrovirals", which apparently means "not very much". "CDC will assist countries that wish to use ART preventive therapy for prevention of transmission of HIV in occupational and non-occupational settings [and] supports ART as an intervention in preventing MTCT of HIV." In other words, CDC is looking at ART strategies for prevention, but not for treatment as such – though they are working with TASO on a DOT-HAART pilot project in rural Uganda. They are also helping countries integrate isoniazid (INH) prophylaxis for HIV infected people with latent TB, and cotrimoxazole preventive therapy (CPT) for people with HIV, into national programs. http://www.cdc.gov/nchstp/od/gap/strategies.
    6. In 2000-2001 France supported bilateral HIV/AIDS projects in Angola, Benin, Burkina Faso, Burundi, Cambodia, Cameroon, Central African Republic, Congo, Côte d'Ivoire, Djibouti, Gabon, Guinea-Bissau, Madagascar, Mali, Mauritania, Mozambique, Namibia, Niger, Rwanda, Senegal, Togo, Zimbabwe. It was impossible to determine which of these might involve ART programs. In addition they supported 32 million FrF ($4.737 million) in research programs and 46 million FrF ($6.8 million) in assistance to the ISTF/FSTI. http://www.diplomatie.gouv.fr/cooperation/dgcid/publications/reperes/sida_gb.
    7. GTZ supports HIV/AIDS/STI activities in Argentina, Barbados, Brazil, DR Congo, Ghana, Guyana, Honduras, Jamaica, Kenya, Malawi, Mozambique, the Philippines, South Africa, Surinam, Tanzania, Thailand, Trinidad & Tobago, Uruguay and Zimbabwe either bilaterally, regionally, or through cooperation with the European Commission (EU). It is unclear how much effort is being devoted to ART. GTZ has opened pilot MTCT prevention projects in Kenya, Tanzania and Uganda. http://www.gtz.de/aids/english. GTZ worked closely with Daimler-Chrysler South Africa (DCSA), whose comprehensive care program for employees includes "sustained commitment to access to antiviral drugs, treatment according to standard protocols, and appropriate treatment of opportunistic infections within the framework of the company medical aid." http://www.daimlerchrysler.co.za/social/aids/partnership.asp.
    8. Recent HIV/AIDS related World Bank commitments include over $300M in new loans to Benin, Burkina Faso, Burundi, Jamaica, Madagascar and Senegal, as well as $500M in IDA financing for MAP-2 in Africa and $155M for MAP in the Caribbean including Barbados, the Dominican Republic and Jamaica. On the World Bank website, 48 projects have the words AIDS, HIV, STI or tuberculosis in their project titles (thus excluding general health sector projects). Of the 48 AIDS-specific projects, one was funded in 1988 ($8.1M, Zaire) and one in 1992 ($84M, India), two in 1993 ($160M, Brazil; $64.5M, Zimbabwe) and two in 1994 ($76.3, Burkina Faso & Uganda), one each in 1995, 1996, and 1997 ($60.2M for Chad, Indonesia & Argentina), one each in 1998 and 1999 (Brazil, $165M and India, $191M), six in 2000 ($264.7M), ten in 2001 ($335.65M) , and eight (so far) in 2002 ($23.04M), with fifteen in the pipeline. Of the approved projects, 28 are active and seven are closed. http://www4.worldbank.org/sprojects.
    9. As recently as May 2001 DFID bluntly stated, "Prevention remains the priority. Antiretrovirals ... are still unaffordable to most poor people. There are significant equity, cost and sustainability issues... Until safe and equitable systems can be put into place it would be inappropriate to use scarce resources to support wide-scale provision of ARVs for treatment." DFID HIV/AIDS Strategy, http://62.189.42.51/DFIDstage/Pubs/files/hiv_isp.pdf, May 2001, p. The very brief two paragraph treatment and care section recommends just counselling and TB treatment for those unfortunately enough to actually develop AIDS. Despite spending over £200 million on HIV/AIDS related bilateral work in 2001, it appears unlikely that DFID is yet supporting much if any actual antiretroviral treatment in poor countries. http://www.dfid.gov.uk. But DFID may be changing its tune. In the 28 September 2002 Lancet, editor Richard Horton expressed concern that a recent DFID "institutional strategy review" of WHO (http://62.189.42.51/DFIDstage/Pubs/files/dfid_unhcr_isp.pdf) placed excessive emphasis on meeting millennium development goals (MDGs) with regard to HIV, tuberculosis and malaria, to the exclusion of "maternal and child health, nutrition and food safety, non-communicable diseases ... and many other important infections ... and the agency's role in building health programmes and health systems..." R Horton, "WHO's mandate: a damaging reinterpretation is taking place.", The Lancet 360, 960-1, 28 September 2002. There was no evidence in the DFID report that Horton's claim was accurate; the WHO programme budget for 2002-2003 as compared with 2000-2001 shows the greatest percentage increase in support for the following programs:

      		Budget – regular & other sources – US $ 000
      Program area2000-20012002-2003% increase
      Tuberculosis18,682104,650460.2%
      Making pregnancy safer11,03837,157236.6%
      HIV/AIDS55,472129,812134%
      Food safety6,49710,39960.1%
      Tobacco15,99625,20857.6%
      Mental health/substance abuse18,20828,14754.6%
      Evidence for health policy32,46643,22533.1%
      Surveillance, prevention and management of non-communicable diseases15,47420,02929.4%
      Blood safety & clinical technology21,78025,72718.1%
      Organisation of health services51,21257,92313.1%
      WHO – all programs1,939,6542,222,65414.6%
      The priority list includes all of Horton's concerns except for "many other important infections." In any case, even if DFID's new policy is to increase support for WHO activities related to AIDS, TB and malaria, its own position with regard to provision of ART in poor countries does not appear to have changed visibly since May 2001.
    10. USAID spending on global HIV/AIDS was $435M in FY2002 and is slated to rise to $540M (+24%) in FY2003. Of the $435M, $392M (73%) was on USAID bilateral programs, $100M (19%) went to the Global Fund, $18M (3%) to UNAIDS, $15M (3%) to microbicides research and $10M (2%) to IAVI. Approximately 12% of the USAID spending went to care and treatment programs. Alagiri P, Summers T, Kates J. Spending on the HIV/AIDS Epidemic – U.S. Spending on Global HIV/AIDS. The Henry J. Kaiser Family Foundation, July 2002. http://www.kff.org/content/2002/6050/US_on_Global_July_2002.pdf In Barcelona, USAID announced "that it has started antiretroviral treatment programs for HIV-infected people in Ghana, Kenya and Rwanda. These are the first US government-funded programs in these countries to provide comprehensive antiretroviral treatment for people living with HIV and AIDS...
      Ghana: In Ghana, the "Start" program is a comprehensive prevention, care and treatment program that is designed to define, refine and document approaches to HIV/AIDS service delivery in resource-poor settings. This program is being designed and implemented by USAID's partners Family Health International, National AIDS Control Program, Ghana Health Services, and the Ghana AIDS Commission. "Start" will begin in two districts in the Eastern Region of Ghana, where an estimated 18,000 people out of 240,000 are HIV positive.
      Kenya: USAID will start ARV treatment in Mombassa, Kenya, at the Coast Provincial General Hospital, and at two primary health care centers that have ongoing voluntary HIV counseling and testing services. In addition to these services, there is a strong home-based care services system in Mombassa. Family Health International and its collaborators have established networks of community organizations that are working together to serve the needs of people living with HIV and AIDS in these communities.
      Rwanda: USAID is starting a program in Rwanda to provide comprehensive care to people living with HIV/AIDS. Family Health International will build on existing HIV counseling and testing services, and expand the range of medical care and support services that are available to HIV-infected individuals. In this site, a major focus will be on supporting community responses to provide home-based care as a complement to clinic-based services.
      Establishing such sites demonstrates a commitment to sustaining the intervention, and establishing the minimum elements of the comprehensive care and support that can be strengthened and replicated in other resource-constrained settings.
      In all three countries, USAID intends to create models for provision of antiretrovirals that governments and the private sector can expand to a national level. These initial sites will explore a host of issues surrounding the introduction of antiretrovirals into a variety of clinical settings. USAID will rapidly distill lessons learned from these sites." USAID Press Release 2002-069, "USAID Announces Introductory Antiretroviral Treatment Sites", 9 July 2002.
    11. Estimated NIH spending on global HIV/AIDS research activities was $188M in FY2002, 19% of the US total, and eight percent of the NIH AIDS research program. This estimate includes spending on all research outside the US, the majority of which is conducted in developing countries, as well as research training in the US of scientists from other countries. NIH's National Institute of Allergy & Infections Diseases [NIAID] receives approximately 50% of all of NIH's international HIV/AIDS funding... NIH supports more than 250 research projects in approximately 70 countries in Africa, Asia/Western Pacific, Eastern Europe, Latin America and the Caribbean, Western Europe and the Middle East". Alagiri P, Summers T, Kates J. Spending on the HIV/AIDS Epidemic – U.S. Spending on Global AIDS. Kaiser Family Fdn., July 2002. http://www.kff.org/content/2002/6050/US_on_Global_July_2002.pdf. Noteworthy recent and current NIH initiatives include the Comprehensive Program of International Research on AIDS (CIPRA) grants. NIAID awarded $11M over five years to the University of Natal in Durban (UND) to study HIV in KwaZulu-Natal province, South Africa. One important study will look at whether it is better to treat tuberculosis first or treat TB and HIV together in TB/HIV coinfected individuals. China's CDC will receive $14.8M to study pathogenesis, natural history, treatment and vaccines. Smaller planning CIPRA grants were awarded to investigators in Brazzaville, Caxias do Sul (Brazil), Chiang Mai, Cuernavaca, Ho Chi Minh City, Lima, Lusaka, Moshi (Tanzania), New Delhi, Ndola (Zambia) Port of Spain, Puerto Plata (Dominican Republic), Pune, Rio de Janeiro, St. Petersburg and Svay Rieng (Cambodia). The NIAID funded HIV Prevention Trials Network (PTN), Vaccine Trials Network (VTN) and Pediatric AIDS Clinical Trials Group (PACTG) have international sites. The Fogarty International Center (FIC) runs extensive training programs for researchers from developing countries and for US-based researchers in foreign settings. Few of these programs have involved treatment trials; however the Adult AIDS Clinical Trials Group (AACTG) has plans to open an 1,238 subject comparative trial of three protease-sparing regimens as initial therapy in therapy naive HIV+ people with CD4 counts lower than 300/mm3. The study, A5175, will compare AZT+3TC (CombivirTM) plus efavirenz, ddI or tenofovir DF (TDF), and is scheduled to open for enrollment on 1 April 2003 at its twelve recently announced AACTG international units. http://aactg-s3.com.
    12. "WHO re-affirms its commitment to support WTO Members and the Council for TRIPS in finding an expeditious solution to this problem raised in Paragraph 6 of the Declaration. To this end, WHO has published a paper, Implications of the Doha Declaration on the TRIPS Agreement and Public Health, WHO/EDM/PAR/2002.3. This paper describes the features of a solution to the so-called "paragraph 6 problem" which are desirable from a public health perspective. These include: a stable international legal framework; transparency and predictability of the applicable rules in the exporting and importing countries; simple and speedy legal procedures in the exporting and importing countries; equality of opportunities for countries in need of medicines, even for products not patented in the importing country; facilitation of a multiplicity of potential suppliers of the required medicines, both from developed and developing countries; and broad coverage in terms of health problems and the range of medicines. Thus, the basic public health principle is clear: the people of a country which does not have the capacity for domestic production of a needed product should be no less protected by compulsory licensing provisions (or indeed other TRIPS safeguards), nor should they face any greater procedural hurdles, compared to people who happen to live in countries capable of producing the product. Among the solutions being proposed, the limited exception under Article 30 is the most consistent with this public health principle. This solution will give WTO Members expeditious authorization, as requested by the Doha Declaration, to permit third parties to make, sell and export patented medicines and other health technologies to address public health needs." Statement by the representative of the WHO, WTO Council for TRIPS, 17 September 2002.
    13. In an important and thoughtful email sent to the group before the meeting, Ernest Darkoh from the ARV Project Team in Botswana wrote that "Training is going to be the pivotal key capacity growth rate determining step – as important as the number of staff... [T]his issue ultimately determines the feasibility of any implementation plan as well as the speed at which any scale up is possible. We have not had too much of a problem with the development of curricula or materials – there is an abundance of material to draw from. The key challenges associated with training have been:
      1. Identifying the full scope of training needs... Management staff need just as much (if not more) training than the frontline staff. Training needs span the continuum from the mundane to the very complex (e.g., clinician skills). We have often found that some of the most profound bottlenecks are around things generally considered mundane – e.g., skills on how to run a meeting, write a memo, proposal writing, how to refer a patient etc.
      2. Finding the right training model/methods that will deliver a given curriculum rapidly, effectively, and as cheaply as possible (with effectiveness determined by how quickly a health care worker becomes functional).
      3. Sequencing the training so that individuals become functional at the optimal time during the project rollout. Training too early leads to rapid decay of skills and need for retraining. Some training is dependent on arrival of certain equipment/infrastructure (e.g., lab equipment, computers, software, building) and it is a nightmare to get the sequencing right when dependent on the cooperation of numerous functional and administrative units.
      4. Creating a uniform standard and methods of evaluating post training competencies.
      We have experimented with different models and so far, the superior model (speed, cost, effectiveness) seems to be hands-on site based training in the context where the work occurs. This is especially effective in our highly understaffed and overstretched environment. Would be interesting to compare experience of other initiatives.
      Expectations... When the size of the resource requirements is large or seemingly impossible to attain, the information may inadvertently lead to a further sense of helplessness rather than providing an energizing call to action for developing countries. There may even be a tendency for some governments to use the resource requirements data to justify inaction. As much as possible, we should also focus on 'what you can currently do with what you have'." Ernest Darkoh, Operations Manager, ARV Project Team, MOH Botswana (ACHAP Seconded), "Additional thoughts on HR" email to IPA list, 27 September 2002.
    14. "Botswana is putting up substantial money of its own to fight AIDS, roughly $30 million a year... Merck is donating $50 million over five years to support care and treatment programs, and the Bill and Melinda Gates Foundation is donating another $50 million to beef up the health infrastructure... Meanwhile, progress in treating the current victims is agonizingly slow, in part because of a critical shortage of doctors, nurses and other health personnel. Industrialized countries that continue to lure Botswana nurses to meet their own needs have a moral responsibility to stop those recruiting drives. Now that it looks like enough money and medicines will be on hand, international donors need to concentrate on supplying medical personnel. There could be no more vital service to help Botswana survive this threat to its social fabric." "Disaster in Botswana", New York Times editorial reprinted in The International Herald Tribune, 1 October 2002, page 6. Left unaddressed is the impact of the Botswana program on neighboring African countries and their health care staffing levels.
    15. I asked Zackie how many staff run the MSF HIV clinic in Khayelitsha township, Western Cape. He said that three doctors with four to five nurses per clinic take care of 3,000 HIV-infected people with AIDS and 250 people on HAART. They need at least two additional doctors to help manage the opportunistic infections. In addition there are counselors and administrative/clinic staff.