AIDS campaign signals new WHO priorities and approach
Authors: Clare Kapp
Journal: The Lancet (2003)

Lee promises to focus on real targets and improving WHO'S effectiveness WHO Director-General Lee Jong-wook is unapologetic about the UN health agency's revolutionary goal of getting 3 million people in poor countries on antiretroviral treatment by 2005—an ambitious target even by the standards of idealists. But the South Korean infectious disease specialist says it was hard-nosed realism rather than dreams that prompted him to adopt the “3 by 5” campaign—which is expected to need US$5·5 billion in new funds over the next 2 years—as the centerpiece of his leadership of the UN health agency. “For us to inject some sense of urgency we have to choose a target that is real, and 2005 is real”, he told The Lancet. “The key question is not whether we can afford to do this, but whether we can afford not to do this.” “If you see that 8000 people die every day of HIV/AIDS, 2010 and 2015 is not enough”, he said in an interview at WHO headquarters. “In many countries on the African continent, the health system is not collapsing, it has collapsed. One bed is shared by three or four people. There are people lying between beds, under the beds, on the corridor. Clearly something has to be done.” The 3 by 5 campaign, launched in a blaze of publicity on World AIDS Day, Dec 1, is meant to restore WHO's leadership role in the fight against HIV/AIDS, and signifies a marked shift away from the priorities established by former WHO Director-General Gro Harlem Brundtland. Brundtland—a former Norwegian prime minister—used her 5-year term in office to catapult health on to the global political agenda through the Commission on Macroeconomics and Health and the Framework Convention on Tobacco Control (FCTC). Lee—who began his WHO career in 1983 as a leprosy consultant in the South Pacific—now wants to translate the political declarations into practical results on the ground, especially on AIDS, tuberculosis, malaria, and the final defeat of polio. He cites the example of the containment of the SARS (severe acute respiratory syndrome) epidemic within 120 days as proof of the results that can be achieved by a united and global health strategy. In a bid to improve WHO's effectiveness at grass-roots level, Lee has begun to implement his campaign promise of shifting resources away from WHO's glass headquarters in Geneva, with the aim of allocating three-quarters of budgetary resources to country and regional level by 2007. “It's happening”, he said. “It's not really that difficult to do it in a phased manner.” He said he wants to increase two-way traffic between headquarters and country and regional operations, starting with those who are willing to be rotated. Excuses of having bought houses and having children in schools around Geneva will not wash. “If I face resistance there won't be an open war but there will be a guerilla war”, he warned. Unsurprisingly, there is unease in the ranks at the prospect of stricter rotation. There is also nervousness that the emphasis on 3 by 5 may be at the expense of WHO's standard-setting work, and some smaller programmes, such as mental health, are feeling vulnerable. WHO's Tobacco-Free Initiative—the flagship of the Brundtland era—has fallen silent. This is largely because the FCTC has been agreed, and it is now down to countries to sign it (about 80 have so far) and implement it. But there is also an apparent shift away from the vocal criticism of tobacco manufacturers that characterised the Brundtland administration in line with, what some insiders say, a more cooperative approach to industry in general. WHO's forthcoming strategy paper on diet and nutrition is thus awaited with bated breath, not least to see how Lee will tackle potential antagonism from influential industry sectors and possibly the US government. None of Lee's critics are willing to be named. And on the whole, Lee is enjoying a honeymoon period sweetened by his own impressive capabilities, his dynamism, and amiable hands-on approach. In stark contrast to his predecessor, Lee rushes out personally to greet visitors—paper cup of coffee in hand—and shuns the “minders” that usually shadow senior UN staff. One of his first acts upon taking office on July 21 was to order a Toyota Prius, a small, slow, hybrid electric and gasoline car, instead of the usual Mercedes. He said it was intended to send a message to the staff who drive “fancy, powerful cars”. “When I go to attend diplomatic receptions as head of agency, mine is always the smallest car”, he smiles. “That's fine by me.” “We are talking about clean air, clean water, and the environment, and this is my small contribution.” He wants to build a gym on WHO's top floor and is trying to persuade the Finnish embassy to donate a sauna. “We promote all this healthy lifestyle but if we look at what we do in our daily life, it's an unhealthy job with meetings and travel”, he said of the planned fitness drive. Other changes are afoot. WHO's old cinema is being converted into a “situation room” to try to improve the organisation's information technology capabilities. The aim is to give member states online access to information about outbreaks, health emergencies, and progress towards health targets. He has demolished the glass cubicles on the seventh floor, which houses the top executives, to provide an open-plan environment where status no longer depends on “how many windows you have in the office”. This is intended to encourage team spirit to replace the competition that was rife in the Brundtland era. He has retained Denis Aitken—a political survivor who predated the Brundtland administration—to direct his office, as well as bringing in new advisers including Jim Yong Kim, a visionary academic from Harvard Medical School, and Ian Smith, who worked with Lee at Stop TB. Jack Chow, President Bush's former deputy assistant secretary for health and science, heads the new HIV/AIDS, tuberculosis, and malaria cluster. In a careful balancing act, Paulo Teixeira, the driving force behind Brazil's promotion of generic medicine and its push to provide all AIDS patients with antiretroviral treatment, is director of the HIV/AIDS department. Some high-profile figures of the Brundtland administration such as David Heymann (communicable diseases) and Derek Yach (tobacco) have been moved to less pivotal positions. But Lee insists that he doesn't want change purely for the sake of change, “otherwise we will be in the business of reinventing wheels, again and again”. “I try to remind myself that I am responsible—initially—for 5 years but that the organisation has a future, and also a past”, he said. “It is not as if I own the organisation. I was just entrusted with it.” WHO strategy focuses on simpler regimens and cheaper drugsPlans unveiled by WHO and UNAIDS aim to provide antiretroviral treatment to 3 million AIDS patients in poor countries by the end of 2005 and focus on simplified regimens and cheaper drugs—including a wider embrace of generics.The formal launch of the “3 by 5” strategy came as UNAIDS estimated that 3 million people died of AIDS this year and 5 million were infected with HIV, bringing total infections to 40 million. Less than 5% of infected people have access to antiretroviral drugs, credited with slashing mortality rates in rich countries by 70%.“We firmly believe that we stand no chance of halting this epidemic unless we dramatically scale up access to HIV care”, said Peter Piot, UNAIDS Executive Director.The new strategy cuts the number of WHO-recommended treatment regimens to four, from 35, in a bid to simplify treatment in developing countries. It recommends the use of quality-assured “fixed-dose combinations” or easy-to-use blister packs of medicine if available.At the launch of 3 by 5, WHO also certified three new generic fixed-dose triple therapy combinations containing lamivudine, stavudine, and nevirapine from Indian generic producers Cipla and Ranbaxy.“Their introduction in the list of quality medicines will increase choice and competition, thus contributing to make AIDS treatment progressively more affordable”, said WHO.It said there would be a global AIDS Medicines and Diagnostics Service (AMDS), operated by WHO, UNICEF, and other partners, designed to give poor countries access to quality medicines and diagnostic tools at the best prices by helping them forecast and manage supply and delivery of necessary products. It includes a Prequalification Project to ensure that manufacturers, procurement agencies, and laboratories meet basic international standards. Another key element is the simplification of monitoring, so that easy- to-use tests such as bodyweight and colour-scale blood tests are used if more complicated tests for viral load and white cell (CD4) count are unavailable.The new strategy recommends intensive training for tens of thousands of community health workers to support the delivery and monitoring of HIV/AIDS treatment and to boost community-based prevention programmes.WHO said that more than 20 poor countries have requested help from WHO, UNAIDS, and other partners for the 3 by 5 programmes and that teams had already travelled to Kenya, Burkina Faso, Malawi, and Zambia to try to identify and remove obstacles to the speedy and effective supply of antiretrovirals.Médecins Sans Frontiéres, which has spearheaded the fight for cheaper medicines, welcomed the WHO move. The Health GAP coalition of activists also hailed 3 by 5, while noting that its launch came as the Global Fund to fight AIDS, Tuberculosis, and Malaria was “entering its second year of severe underfunding” and that the US$15 billion AIDS programme announced last January by President George Bush still had not got off the ground. Plans unveiled by WHO and UNAIDS aim to provide antiretroviral treatment to 3 million AIDS patients in poor countries by the end of 2005 and focus on simplified regimens and cheaper drugs—including a wider embrace of generics. The formal launch of the “3 by 5” strategy came as UNAIDS estimated that 3 million people died of AIDS this year and 5 million were infected with HIV, bringing total infections to 40 million. Less than 5% of infected people have access to antiretroviral drugs, credited with slashing mortality rates in rich countries by 70%. “We firmly believe that we stand no chance of halting this epidemic unless we dramatically scale up access to HIV care”, said Peter Piot, UNAIDS Executive Director. The new strategy cuts the number of WHO-recommended treatment regimens to four, from 35, in a bid to simplify treatment in developing countries. It recommends the use of quality-assured “fixed-dose combinations” or easy-to-use blister packs of medicine if available. At the launch of 3 by 5, WHO also certified three new generic fixed-dose triple therapy combinations containing lamivudine, stavudine, and nevirapine from Indian generic producers Cipla and Ranbaxy. “Their introduction in the list of quality medicines will increase choice and competition, thus contributing to make AIDS treatment progressively more affordable”, said WHO. It said there would be a global AIDS Medicines and Diagnostics Service (AMDS), operated by WHO, UNICEF, and other partners, designed to give poor countries access to quality medicines and diagnostic tools at the best prices by helping them forecast and manage supply and delivery of necessary products. It includes a Prequalification Project to ensure that manufacturers, procurement agencies, and laboratories meet basic international standards. Another key element is the simplification of monitoring, so that easy- to-use tests such as bodyweight and colour-scale blood tests are used if more complicated tests for viral load and white cell (CD4) count are unavailable. The new strategy recommends intensive training for tens of thousands of community health workers to support the delivery and monitoring of HIV/AIDS treatment and to boost community-based prevention programmes. WHO said that more than 20 poor countries have requested help from WHO, UNAIDS, and other partners for the 3 by 5 programmes and that teams had already travelled to Kenya, Burkina Faso, Malawi, and Zambia to try to identify and remove obstacles to the speedy and effective supply of antiretrovirals. Médecins Sans Frontiéres, which has spearheaded the fight for cheaper medicines, welcomed the WHO move. The Health GAP coalition of activists also hailed 3 by 5, while noting that its launch came as the Global Fund to fight AIDS, Tuberculosis, and Malaria was “entering its second year of severe underfunding” and that the US$15 billion AIDS programme announced last January by President George Bush still had not got off the ground.