Joint letter on universal access to Dr Piot, Director of UNAIDS and Dr Chan, Director of the WHO

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Dear Drs. Piot and Chan:

We are writing to you to express grave and urgent concerns by civil society and people living with HIV/AIDS that the forthcoming draft document "Financial requirements for scaling up towards universal access" (1) if issued in its current form, will have a significant and lasting negative impact on the global response to AIDS by legitimizing the abandonment by the world governments of the goal of universal access by 2010.

We view this as a critical issue, and we write to you with a sense of urgency. We urge you to attend to this matter personally because the success of the global response to AIDS, and the position of UNAIDS and WHO as leading global advocates for combating HIV/AIDS and improving public health are at stake, along with -- more importantly -- millions of lives.

We acknowledge that the draft "Financial requirements" and background documentation (1, 2, 3) contain
elements of a more strategic and comprehensive assessment of the essential elements of national response to AIDS. Our chief concern, however, is that "Financial requirements" abandons the goals set by the 2006 G8 and UNGASS political declaration, which committed the world's governments to:

[20] Commit ourselves to pursuing all necessary efforts to scale up nationally driven, sustainable and comprehensive responses to achieve broad multisectoral coverage for prevention, treatment, care and support, with full and active participation of people living with HIV, vulnerable groups, most affected communities, civil society and the private sector, towards achieving the goal of universal access to comprehensive prevention programmes, treatment, care and support by 2010 [emphasis added] (4)

The current draft document formally announces the death of the G8/UN-endorsed goals of coming
close to universal access by 2010.

Since May 2007 the drafters of the "Financial requirements" for universal access documentation have explicitly abandoned a scenario which modeled universal access by 2010/12. The report on the Program Advisory Board Meeting in Glion on 3-4 May 2007 noted [see ref. 3, Annex 7, p. 35] that

"Three scenarios are currently presented:

a. Historical growth [now called the 'current scale-up scenario'];
b. Universal access by 2015 [now called 'the strategic scale-up scenario'];
c. Universal access by 2010/12 (UA by 2010 for prevention and 2012 for care and treatment)" [now abandoned and not contained in the August 16 and 24 draft documents]

Moreover [ref. 3, Annex 7, p. 36], it is noted that the incremental cost on resource needs in 2015 compared with the current scenario is +$18 billion for the UA15 scenario and just an additional +$5 billion for the UA10/12 scenario, which is now abandoned.

To save $5 billion in 2015, millions are condemned to die because UNAIDS and WHO refuse to publish
accurate financial assessments of how much it would cost to achieve universal access by 2010/12.
Therefore we have three urgent over-arching and non-negotiable demands to UNAIDS and your international partners in this exercise:

1. Restore the Universal Access by 2010/12 scenario which was included in presentations to the Program Advisory Board in Glion on 3-4 May 2007, thus presenting all three scenarios: a) Historical
growth/current scale-up [which will not achieve UA until at least 2025]; b) UA15/strategic scale-up
[which you include in the current draft]; and c) UA10/12, which was available earlier this year and has
now disappeared from the draft.

2. Provide clear figures for us to understand how many infections will be averted, how many
people will be treated with ART, and how many lives will be saved or lost with each of the three
scenarios.

3. Explicitly address the fact that the previous estimated need for people with HIV needing ART
was based on the number of people who would die within two years, whereas under current
WHO guidelines (CD4<200 and/or WHO stage III/IV disease) about 50% more people will need
treatment. If the currently evolving standard of care for treating HIV moves to higher CD4 levels such
as CD4<350 regardless of symptoms, about 1/3 of the overall HIV positive population may need
treatment. These numbers must be included in the summary.
Since you must have developed these numbers in order to run the scenario models in the drafts it should be possible to publish them. They should show:

• How many people are infected with HIV at the start of each year;
• How many new infections will take place each year;
• How many people will start ART each year;
• How many people will die each year;
• How will the different scenarios affect the overall numbers of people infected and dying each year?

We are also concerned that the model system used by UNAIDS, WHO, and partners does not account for the fact that more rapid scale-up of ART as part of a comprehensive response may significantly reduce HIV transmission; other models may more accurately incorporate the impact of widespread ART on HIV transmission (5).

There is no question that more rapid scale up of both prevention and treatment towards UA will both prevent many more new infections and prolong many more lives through accelerated treatment and care.
The document fails to mention how many millions of people will die in the next few years if the international community does not keep its word. It fails to mention the lost opportunities to build health systems by living up to global commitments.

As putative global advocacy leaders on HIV and public health, the role of UNAIDS and WHO is to tell the world how much is needed in financial, human, and technical resources to achieve international commitments -- not to dismiss these international commitments as unreasonable when the response to date has been insufficient. Of course, it is possible this promise by the international community will not be realized. But it is not for UNAIDS and WHO to block world leaders’ commitments. Rather, show the world the options before us, the benefits of keeping our promises, the cost of achieving international commitments, and the terrible human and social costs of failing to do so.

We also ask that UNAIDS and WHO share all their data sources used to develop these scenarios. Such
transparency of information is important for everyone to understand your assumptions and collaborate fully with you to refine scenarios. (The 24 August draft document refers to background documentation at
www.unaids.org/resourceneeds/methods, see ref. 1 footnote 46, that is not accessible on the UNAIDS
website.)

We would also like to raise several specific concerns about the draft plan; these concerns are listed below and will be addressed in more detail in follow-up memos to you and the costing teams; they include

• Adequately addressing resource needs for harm reduction, palliative care, VCT, human resources,routine testing, TB services, compensation for community health workers, gender and violence against women programs, orphans and vulnerable children programs, and technical support
• Taking into account clinical advances in treatment
• Clarifying total need for services and regimens to be utilized

It is imperative that UNAIDS and WHO's forthcoming guidance documents on how to achieve universal access provide a clear roadmap for achieving international commitments and for transparently costing the
comprehensive response.

Due to the urgency of these issues we request the courtesy of a reply by Monday 10 September 2007. Please reply to Greg Gray at itpc@apnplus.org or Asia Russelll at asia@healthgap.org.

Sincerely,

Greg Gray
International Coordinator
International Treatment Preparedness Coalition ITPC

Asia Russell
Director, International Policy
Health GAP (Global Access Project), USA

For and on behalf of the following individuals and organisations:

Organisations:

AIDS and Rights Alliance for Southern Africa (ARASA)
ActionAid International, Johannesburg, South Africa
Action Against AIDS Germany
Act Up-Paris, France
Africa Public Health Rights Alliance, 15% Now! Campaign
African Services Committee, New York, USA
AGIHAS, Latvia
Agua Buena Human Rights Association Costa Rica
AIDES, France
AIDS ASIA e FORUM
AIDS Policy Project, USA
AIDS Vaccine Advocacy Coalition (AVAC), USA
ACTWID KONGADZEM NGO Network, Cameroon
All-Ukrainain Network PLWH
Asia Pacific Network of People Living with HIV and AIDS APN+
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Asian Harm Reduction Network
Association “Pozityvus gyvenimas,” Lithuania
Association Marocaine de Solidarité et Développement (AMSED)
Bangladesh Manobadhikar Sangbadik Forum-BMSF
Caribbean Vulnerable Communities Coalition
Church World Service, Pakistan
Communities Living with HIV, TB and Affected by Malaria Delegation to the Board of the Global Fund to Fight
AIDS, TB and Malaria,
Coalition of HIV Infected and Affected Community Service Organizations (CHIACSOK), Kenya
Czech AIDS Help Society
Delhi Network of Positive People (DNP+), India
East European & Central Asian Union of PLWH
Eastern European & Central Asian Union of PLWH, Ukraine
Ecumenical Advocacy Alliance
Empower, India
Estonian Network of PLWH
European AIDS Treatment Group (EATG), Brussels, Belgium
Foundation for Integrative AIDS Research, USA
Franciscans International
Gestos- Soropositividade, Comunicação e Gênero
Global Aids Alliance
Grupo de Trabajo sobre Tratamientos del VIH (gTt) Barcelona, Spain
Guyana Human Rights Association
Health GAP, USA
Health Center "Hope of Life" NGO AIDS Information and Support Center, Estonia
Health is not Commerce Campaign
Health Rights Advocacy Forum, Kenya
Health Unlimited, UK
Health Triangle Trust, Kabwe, Zambia
HIV/AIDS Task Force, Africa Japan Forum (AJF)
HOYWIK PROGRAMMES--Humanity for Orphans,Youth and Widows Initiatives, Kenya
Interagency Coalition on AIDS and Development (ICAD), Canada
International Civil Society Support
International Council of AIDS Service Organizations (ICASO)
International Planned Parenthood Federation
International Treatment Preparedness Coalition
International HIV/AIDS Alliance, UK
Japanese Network of PLHIV JaNP+
Kazakhstan’s Union of PLWH
Kenya AIDS NGOs Consortium (KANCO)
KETAM
Kenya Network of HIV Positive Teachers
Latin American and Caribbean Council of AIDS Service Organizations (LACCASO)
League of PLWH of the Republic of Moldova
Loving Hand Organisation Zimbabwe
Medecins du Monde
National AIDS Committee, Guyana
National Association of PLHA in Nepal (NAP+N)
NGO "Real World, Real People," Armenia
NGO “Guli Surkh," Tajikistan
NGO LIGO, LIfe Is Going On, Estonian Association of Women Against HIV and AIDS
Norwegian Church Aid
Open Society Institute
Organisation Panafricaine de Lutte Contre le Sida (OPALS)
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Pan African Treatment Access Movement (PATAM).
PCF “Positive initiative,” Kyrgyzstan
Public Association of People Living with HIV and Their Close Ones "ISHONCH VA HAYOT" ("Hope and Live"),
Uzbekistan
Pinoy Plus Association Philippines
Positive Action Foundation Philippines
PHILIPPINE HIV/AIDS NGO SUPPORT PTOGRAM, INC. (PHANSuP)
Physicians for Human Rights (USA)
Positive Life, Mongolia
Positive Malaysian Treatment Access & Advocacy Group (MTAAG+), Malaysia
Project RING, Japan AIDS and Society Association (JASA)
Public Organization on the AIDS Fight, Azerbaijan
Public Union "Positive Movement," Byelorussia
Recovering Nepal
RESULTS Educational Fund, USA
RESULTS, UK
Russian Harm Reduction Network
Sensoa, Belgium
SIEC+, Poland
Social Help & Research Organization (SHRO), Pakistan
Seven Sisters Coalition
SKUC Magnus, Ljubljana, Slovenia
Southern Africa Treatment Access Movement (SATAMo)
Social AIDS Committee, Poland
Stop AIDS Campaign (UK network of over 80 NGOs)
Student Global AIDS Campaign, USA
Student Partnerships Worldwide, UK
TB People Pakistan
TB Survival Project
Terve Eesti NGO
The Alliance South Sudan
The Centre, Zimbabwe
Treatment Action Group (TAG)
Uganda Treatment Access Movement
Ukrainian AIDS Response
World AIDS Campaign
World Student Christian Federation
YouAct, European Youth Network on Sexual and Reproductive Rights, The Netherlands
Youth Incentives, The Netherlands
Individuals:
Anastasia Agafonova
Brook Baker
Snehansu Bhaduri
Andrew Doupe
Believe Dhliwayo
Alick Makiyi
Rafa Valente Machava
Robert Carr
Chris Collins
Vitaly Djuma, Russian Harm Reduction Network
Mark Harrington
Rafa Valente Machava
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John Rock
Lorena Di Giano
James Kamau
Lillian Mworeko
Nenet Ortega
Gregory Vergus
Vladimir Osin
Sergey Kovalevsky
Paul Moses
Katsha Nomsa Sibanda
Fr. Jesudason Thomas.
Pervaiz Tufail
Elena Traicu
Nicoli Nattrass, AIDS and Society Research Unit, University of Cape Town
Dr Tokugha Yepthomi, HIV/AIDS Physician and Researcher Chennai India
Tomczynski, Wojciech
Tajikistan: Kamilova, Sevara NGO “GULI SURKH”
Kazakhstan: Amanzholov, Nurali Kazakhstan’s Union of PLWH
Uzbekistan: Uchaev, Sergey Public Union of PLWH “Ishonch va Hayot”
Kyrgyzstan: Bidayshiev, Ruslan PCF “Positive initiative”
Ukraine: Zhovtyak, Vladimir All-Ukrainain Network PLWH
Moldova: Kilchevskiy, Igor League of PLWH of Republic Moldova
Azerbaijan: Sharifov, Nofal Public organization on AIDS fight
Armenia: Azaryan, Eleena NGO “Real world, real people”
Mongolia: Tsevendendev, Pervjav Positive Life
Poland: Tomczynski, Wojciech SIEC+
Estonia: Sobolev, Igor Estonian Network of PLWH
Lithuania: Andriushka, Jurgis Association “Pozityvus gyvenimas”
Latvia: Klavins, Sandris AGIHAS
Byelorussia: Spevak, Yeugeniy Byelorussian public union “Positive Movement”
Mark Platt, Ukrainian AIDS Response
Paul Thorn, TB Survival Project
Terry White, All-Ukrainian Network PLWH
Natasha Leonchuk, All-Ukrainian Network PLWH
Paul Zeitz

References

1. UNAIDS, Financial requirements for scaling-up towards Universal Access to HIV-related programmes
and services in 132 low- and middle-income countries. 24 August 2007 Embargoed draft.
2. UNAIDS. Strategic Scale-Up Towards Universal Access by 134 low- and middle-income countries:
2009-2015 financial requirements. PowerPoint presentation accompanying ref. 1, no date, Embargoed
draft.
3. UNAIDS. Resource needs for AIDS in low- and middle-income countries: Preliminary Results 2009-
2015. Presented to the Advisory Board, 16 August 2007. Embargoed -- Draft.
4. UN General Assembly 2006 High-Level Meeting on AIDS, Political Declaration on HIV/AIDS, adopted 2
June 2006, Political Declaration on HIV/AIDS; http://www.un.org/ga/aidsmeeting2006/declaration.htm.
5. Nicoli Nattrass, Modelling the relationship between antiretroviral treatment and HIV prevention:
limitations of the Spectrum AIDS Impact Model in a changing policy environment. In press, African
Journal of AIDS Research

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