Jim Kim, here shown visiting with children in Uganda, was recently appointed chair of the Department of Social Medicine at Harvard Medical School, and chief of the Division of Social Medicine and Health Inequalities in the Department of Medicine at Brigham & Women’s Hospital. He also serves on the faculty of the Harvard School of Public Health.

3 by 5 and beyond: Expanding the reach of HIV treatment

In 2003, the World Health Organization (WHO) and UNAIDS declared the global AIDS treatment gap to be a public health emergency. In response, WHO and its partners launched the ambitious “3 by 5” initiative, with the goal to get three million people in resource-limited countries on antiretroviral therapy (ART) by the end of 2005. Jim Yong Kim, MD, PhD, co-founder of Partners In Health, was called upon by WHO to lead this effort as the director of the world body’s HIV/AIDS department. The 3 by 5 program defined AIDS as an acute crisis and approached its treatment as emergency relief, dispatching technical teams to help set up standardized training and treatment programs in communities with very little health infrastructure. Although the program fell short of its target—a total of 1.3 million people were receiving ART by the end of 2005—the program nevertheless resulted in a tremendous expansion of HIV treatment throughout the world, mobilized political and financial commitment to achieving broader access, and provided a foundation for efforts to achieve universal access to ART in the near future.

In an interview with HMI World, Dr. Kim reviewed some of the lessons produced by the 3 by 5 initiative, and talked about his optimism for the future.

HMI WORLD: The 3 by 5 initiative fell short of the target, but a lot of people got on treatment.  Lives were saved.  What do you consider the most important accomplishments of 3 by 5?

KIM: I think the fundamental accomplishment of 3 by 5 was the introduction, along with the PEPFAR [the President’s Emergency Plan for AIDS Relief] program, of the notion of accountability for the deaths of people living with HIV in poor countries. For a long time, those of us who work in global health and with HIV/AIDS particularly had not really been setting for ourselves and for countries specific targets with specific end dates that had to be met. We had been assessing the seriousness of the epidemic and counting the numbers of dead, but we had not really been saying, ‘Here’s what we want to accomplish to fight this epidemic.’ PEPFAR was the first program to set real targets. For 15 countries they set targets for treatment, prevention, and care. And that was a hugely important innovation. Interestingly, the targets were for themselves—for the U.S. government. They weren’t holding national governments to account. They were holding themselves to account, which is one way to tackle the problem.  The World Health Organization can’t do that, so WHO did something else. It said to the countries, ‘We’re going to start counting. We’re not demanding that you do this, that, or the other thing. We think 50 percent of the people who need it should be on treatment by 2005 and we’re going to begin counting.  We’re going to count how many people get on treatment, and every six months we’re going to publish the data.’ We had no idea if that would be a successful strategy for stimulating action, but I think there’s no question now that it was.

Historically, the notion of accountability had been a big part of the response to HIV/AIDS.  We’re sitting in the François-Xavier Bagnoud Center for Health and Human Rights. Jonathan Mann and Albina du Boisrouvray founded the center based on the notion that governments and other powerful people and organizations should be held accountable for what they do or don’t do for people living with HIV/AIDS and for AIDS orphans and other vulnerable children (OVC). So if you fired or shot or imprisoned somebody with HIV/AIDS or ignored the plight of OVCs, you would be accused of human rights violations. The same idea was behind WHO’s decision to publish the numbers. The numbers led to praise, optimism, and a positive assessment of countries that did well, and embarrassment and anger in many of the countries that didn’t do so well. This bully platform—being able to stand up and tell countries what they should do, and then simply count whether they’re doing it or not—is one of the real sources of power of WHO, and I think we used that well. Introducing, along with PEPFAR, the notion of accountability around HIV/AIDS, with real targets and real end dates, was probably the most important accomplishment of 3 by 5.

Now, the next stage is universal access, which was endorsed by the Group of 8 nations.  I applaud this movement enthusiastically but my worry is that access will come to mean something different from real, hard targets and end dates that hold people accountable.

HMI WORLD: The notion of “access” seems a little more slippery than treatment.

KIM: We’re still defining it. It could mean as many as 10 million people on treatment by 2010. But the process of defining it is going to be important, because international bureaucracies often make the mistake of holding no one accountable—especially themselves. That’s why 3 by 5, I think, was so different. WHO said it was going to hold itself accountable in addition to holding countries accountable. This caused a lot of pain and anger but I think it was necessary. Let’s watch universal access. I hope that it’s not going to end up looking like a lot of other global initiatives where there is a lot of agreement and flowery language but no accountability, and no commitment to speaking the truth about failure and success.

HMI WORLD: You have said that one of the key components of a successful government rollout of ART is political will. What does it take to get government leaders to think about the pandemic as something that can be addressed?

KIM: For every country it’s different. Malawi has 40,000 people on treatment, but no one thought they would ever get close to that. But they were losing people right and left. They were losing family members, doctors, teachers, lawyers—the core working people of society. I don’t think there are very many leaders who don’t know that this is happening to their country. But you see in South Africa the real downside of a lack of political will. In places like Malawi, Zambia, and Lesotho, I think you see what extraordinary political will can accomplish. China, for example, once completely lacking in political will around HIV, now has as much as any country around this epidemic and they are going to offer methadone replacement therapy and sterile needle exchange to everybody in the country by 2008. If you don’t have political will from the very top—not just standing up and saying nice things about the importance of HIV, but committing themselves to real targets and end dates—not much will get done.

HMI WORLD: Is the prejudice against the people in these developing countries still an obstacle to rolling out treatment? For instance, you’ve got a very complex, regimented treatment and a lot of people are going to say, ‘Well, that’s too complicated for these people.’

KIM: I think there are really different understandings of how complex it needs to be. At Partners In Health we really rethought HIV treatment in a fundamental way. It’s not innumerable tests and constant drawing of blood, but it’s finding a stable regimen and really working on adherence by hiring and professionalizing community health care workers to help ensure compliance over the long run. What you want is treatment durability, meaning that you can use certain drugs for as long as possible, and then move to the next set and the next set and so forth. I frankly think that, compared to what we did with drug-resistant TB, HIV treatment is not so horribly complicated. And I certainly don’t think it’s so complicated that you should therefore let 25 million people die. I don’t think, in fact, that it’s that much more difficult than setting up distribution networks for Coca-Cola on all the islands of Indonesia or selling Microsoft software all over Nepal. Treatment is important not only because you can save people who are in the prime of their lives and keep them in the workforce, but you also allow them to raise their children to adulthood. So I think there are misconceptions about the complexity. These days, I think most people understand that you don’t have to treat HIV in Malawi exactly the same way you do in Boston. They’re using a different approach there and we know from our experience at Partners In Health in Haiti and Rwanda that intensive attention to community health workers and adherence can actually extend the quality and durability of treatment in a way that we don’t normally try to do here in Boston.

HMI WORLD: You have spoken highly of the use of nurses and community health workers in providing ART. You point out that there are skeptics who still doubt their effectiveness. What is that skepticism about? 

KIM: It comes from a lot of different places. Sometimes, doctors in those countries will say, ‘You guys talk about community health workers, but that’s just poor quality care for poor people,’ and they’ll say, ‘You’re trying to take business away from us.’  We’ve found that there are effective ways of bringing everyone on board but it’s a complicated situation. The evidence for the effectiveness of community health workers is pretty overwhelming though and WHO, in its World Health Report, endorsed the notion of delegating duties to lower level workers who are professionalized and paid. I don’t think it’s any mystery why the WHO is saying this—we don’t have any other choice. We give opportunities to people who are almost always very poor themselves, increase their skill set over time, and then it becomes a great jobs program in countries that are suffering from severe unemployment. Even better are interventions that get people who are on HIV treatment to become those very health workers who support patients who are just starting on treatment. I think it’s a no-brainer. Malawi, for instance, is a really unexpected success story. I hear that they are even allowing community health workers to start people on treatment, and so far, it seems that the program is doing relatively well. There are going to be problems, as with all interventions like these, so we need to invest in continuous training for the community health workers. I think that’s the way to go.

HMI WORLD: Describe the roles that people living with HIV/AIDS have played in the hardest hit communities. What has been their contribution? 

KIM: I think their contribution has been critical. At WHO we worked with groups of people with HIV/AIDS on increasing what we call treatment literacy. Part of the problem of people not coming forward to get tested is that there is a lot of mythology around HIV treatment. But people who are living with HIV and AIDS and are on treatment and understand exactly what it’s like, I believe, are the people best suited to support others who are just beginning treatment. They can educate people about HIV, help them understand the treatment, and eventually become prevention workers.

Many of the people with HIV/AIDS who come in for treatment have not been working for a while, and so they need a job and a long-term future. And being a health worker is not a bad thing. At the point at which they become more than HIV workers, and can help people with all sorts of health and social problems, you get what I call the HIV treatment dividend—that is, by investing in HIV treatment, you are investing in workers to do work beyond that related to HIV, like making sure that children are vaccinated, making sure that people have clean water or bednets to prevent malaria, and making sure that people have treatment for things like pneumonia. There are all kinds of things that these people could do over time, and I think it’s perfectly reasonable to use HIV money to establish these infrastructures.

HMI WORLD: One of the long-discussed barriers to success in HIV/AIDS initiatives has been stigmatization. Do ART rollouts have an impact on reducing the stigmatization of HIV/AIDS patients?

KIM: Once you get people on treatment, other people start seeing the benefits—the so-called Lazarus effect. There’s probably nothing quite so dramatic as seeing a person who looks like they’re almost dead, begin taking antiretrovirals, and progressing so that they’re walking again, gaining weight, and looking well. The Lazarus effect has caused stigma to drop in every single country. Now, stigma isn’t gone even in the United States, so I’m not saying it goes away completely. Stigma is something that you have to constantly work on. But the people who think that the stigma is so bad that they’d rather die, at least in my experience, represent a very, very tiny percentage of the people living with HIV. In fact I’ve never encountered a culture that continues to insist that stigma from HIV is worse than death. On the other hand, when people see the effects of treatment, and understand that although they’re going to have HIV, they’ll be able to live and take care of their children, in the vast majority of cases, people choose life.

HMI WORLD: Although the stigma still exists in the United States, here we have at least advanced to the point where we can consider HIV to be a chronic disease. How far do we have to go in the hardest hit countries of the developing world to get to that point?

KIM: Different lengths in different places. I think Botswana and Zambia are very far down the road to thinking of it that way. I think Lesotho has made huge advances in the last twelve months. You see really fundamental transformations in some of these societies. Others are not doing as well. 

HMI WORLD: For so many people their only knowledge of the HIV/AIDS pandemic and the struggle to address it is what they hear on the news about funding by this or that organization. Can you give us a sense of the bureaucratic and political strings that come attached to that funding, and how those are overcome?

KIM: There are different strings for different pots of money. There are fewer strings attached to money that comes from the Global Fund to Fight HIV, Tuberculosis, and Malaria but the reporting requirements are very tough. But that’s a good thing. I think there are more strings attached to money from the U.S., which has prescriptions about the percentage that can be used for various prevention approaches. I think that’s a mistake. I think prevention programs in any country have to be evidence-based. For example, if the primary risk factor for becoming infected with HIV for women is marriage, then telling people to “be faithful” doesn’t make much sense.

You have to look at the particular dynamics of the epidemic in any given country and use whatever works. For example, the United States won’t pay for needle exchange, but we know that in many countries the epidemic is driven mainly by injection drug use. We know that offering sterile needle exchange is one of the most highly effective prevention mechanisms we’ve ever had. And syringe exchange programs do not seem to increase drug use and they definitely make it safer. Of course we want everyone to quit. But in the meantime while we’re trying to get everyone to quit, we don’t want them to get infected with HIV. And yet the U.S. says no to syringe exchange programs because they oppose it on moral or some other grounds—certainly not based on the evidence for prevention. But I think this epidemic is serious enough that you have to use evidence-based approaches. Look at the contrast between China and Russia. China is doing both methadone replacement and syringe exchange. Russia is doing neither, and they’ve taken the position that injection drug users should simply be prosecuted.  China has taken a very different position because the seriousness of the epidemic has led them to address the problem very aggressively and appropriately in order to prevent more people from being infected. I think that the SARS epidemic helped China understand what it’s like when you try to ignore public health evidence and principles.

HMI WORLD: Do you think of the HIV/AIDS issue as a moral issue, in the sense of the idea that this generation will be judged by its response to the epidemic?

KIM: I think it is a moral issue, in the sense that it really challenges our capacity for solidarity in a most fundamental way. And I think there are groups in our society who are standing up to the challenge and meeting it in a way that will be remembered historically. HIV/AIDS activists in the United States helped to completely change the way that the Food and Drug Administration and National Institutes of Health conduct themselves. They got medicines developed much faster than would have happened without their activism. And these groups took the important step of refusing to allow drug companies to make HIV drugs available only to people who could pay. So I think that the activist community has shown the world the capacity for human solidarity across racial, ethnic, and socioeconomic lines, and brought about a fundamental shift in our humanity. And frankly the rest of us have to catch up. I think we are catching up, especially some of the donor governments, but I think the treatment access movement is going to go down in history as one of the most extraordinary social movements that ever existed. 

HMI WORLD: We talked about stigmatization and it seems that so much of this struggle is a knowledge battle. Do you have a sense of some of the misperceptions that are going to have to be overcome over the next few years?

KIM: Well, there will always be battles to reduce stigmatization and get the real facts out there, but I don’t think that will be the most important misperception that we will have to confront. I think the biggest challenge in the next three years will be to demonstrate that investing in HIV means investing in health systems and in the economic development of a country. If, in three or four years, all we can show is the number treated, the donor community could grow tired of HIV. I think the public health community has to communicate that we have a plan for treatment that includes the development of a primary care health system that can manage a wide variety of problems. That is both a challenge and an opportunity. I’m optimistic. First of all, the activists are going to keep the pressure on, so money, we hope, will continue to flow. Those of us in public health have got to work very hard to get the models of care and the training programs together and make the case that we are and will continue to build health systems that will help lead the way to real and more egalitarian economic development.  

HMI WORLD: Where should we be on the lookout for the big success stories on HIV/AIDS in the next several years?

KIM: I think China is going to be a success story. I think they’re going to contain their epidemic. And I think they’re going to show all of Asia—and I hope central Asia and eastern Europe—the impact of an enlightened policy, at least with drug users. I’m hopeful about pockets of southern Africa, like Zambia, Botswana, Lesotho, Namibia, and Tanzania. I think those countries are really going to advance, and when they do, they’ll put pressure on the bigger countries that are not advancing quite as rapidly. Also, I think you’re going to start hearing about HIV treatment programs that are having a much broader impact on the health of societies as a whole.  HIV treatment can be the pathfinder for development of whole societies—now we just have to make it happen. 

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