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Treating people seemed relatively easy compared to existing prevention efforts when ARVs emerged on the AIDS scene. Largely due to activist efforts, drugs were quickly produced in large enough quantities and eventually at an affordable price for donors to provide to millions of people in the developing world. Expectations for rapid scale up of treatment programs were hopefully high, but hopelessly unrealistic. WHO's 3x5 initiative failed to meet its goals and now a progress report (.pdf) from WHO, UNAIDS and UNICEF on "Scaling Up Priority Health Interventions in the Health Sector" tells us that the news is still not great. Prevention efforts are behind treatment efforts, but worse still treatment efforts are far behind achieving any true measure of success: only 28% (2 of 7 million) of people with advanced AIDS who require therapy in low and middle income countries were receiving drugs by end of 2006 compared to 2% in 2003 - a "remarkable success" according to Kevin de Cock at WHO (as quoted in the New York Times). What is remarkable is that despite the fact that prices of most first-line ARV drugs decreased by 37% to 53% in low and middle income countries from 2003 to 2006, and that donors are investing heavily in scaling up treatment programs, these results were still short by a million of the 2005 goal at the end of 2006.

There is no question that donors like PEPFAR and the Global Fund are leading the way in putting treatment on the map and improving access to ARVs, and will most definitely reach their newly calibrated treatment goals by 2008-2009, but these will still be low relative to high levels of existing AIDS cases combined with the growing incidence of HIV infection. Lessons we are learning through this massive and not-so-rapid effort to scale up treatment is that it takes more than money and drugs to treat people and save their lives. To begin with, "the global coverage of HIV testing and counseling remains unsatisfactory low," so most people don't even know that they need ARVs. When they find out that they need drugs, many can't get them due to stock outs at clinics or long waits at overburdened and under staffed health clinics. Of the lucky few who receive ARVs, some no doubt benefit, but probably not the poorest; with little access to adequate nutrition and other health interventions the full impact of ARVs is diminished. It takes many carefully orchestrated steps and different investments in health systems, including facilities and human resources, in concert with other development efforts to provide treatment and realize the longer-term outcomes of treatment - i.e. people on ARVs can live productive lives. Commensurate efforts in communities are equally necessary to create the necessary demand for treatment services, and at the same time prevent new infections. Real success - high treatment rates and lives saved, and falling incidence - will always be a moving target, but we can get closer.