Take ACTION on the WHO 3 by 5 Strategy

ICW is joining with development NGO VSO (Voluntary Service Overseas) to highlight the need for gender equity in the implementation of the 3 by 5 initiative. Under this initiative, the World Health Organisation (WHO) and UNAIDS aim to get 3 million people on antiretroviral (ARV) treatment by 2005.

What can you do as an ICW member?

Join the campaign to highlight the need for equal treatment for women under the 3 by 5 initiative - write to WHO to express your views:

Take action, write to the WHO

Equal treatment for women?

The importance of the 3 by 5 initiative cannot be underestimated. Help to make sure that women and girls get antiretroviral treatment under this initiative.

The WHO needs to hear how concerned we are about the issue of women and girls’ equal access to care, treatment and support.

By writing to Dr Lee Jong-wook, the Director-General of WHO, you will help ensure WHO does not forget about HIV positive women and girls when planning treatment programmes under 3 by 5.

Write a letter!

Please write your own letter describing in your own words your own experiences related to access to care, treatment and support. (Research shows that original letters are always more effective than copied letters.) Please also make the following points in your letter:

Congratulate Dr Lee for his leadership in taking forward the 3 by 5 initiative and helping to make sure people in developing countries have access to antiretrovirals.

Remind Dr Lee that meeting the target of 3 million people on treatment by 2005 is meaningless unless HIV positive women and girls get equal access to care and treatment.

Give an example from your own experience of how important access to care and treatment is for HIV positive women and girls.

At the end of this article, you will find a sample letter sent by ICW to Dr Lee.

Send it to:

Dr Lee Jong-wook, Director-General, WHO, Avenue Appia 20, 1211 Geneva 27, Switzerland.

Or email your letter to Dr Lee, stating “ICW 3by5” in the subject line of your email. Send it to threebyfive@who.int and copy it to info@icw.org

If you want, also send a copy to your regional WHO office:

If you live in Africa, you could send a copy to: WHO Regional Office for Africa, Cite du Djoue, PO Box 06, Brazzaville, Congo, or WHO Regional Office for Africa Parirenyatwa Hospital, PO Box BE773, Harare, Zimbabwe.

If you live in North or South America, you could send a copy to: WHO Regional Office for the Americas, 525, 23rd Street, N.W. Washington, DC 20037, USA

If you live in Asia, you could send a copy to: WHO Regional Office for SE Asia, World Health House, Indraprastha Estate, Mahatma Gandhi Road, New Delhi 110002, India

If you live in the Pacific Region, you could send a copy to: WHO Regional Office for the Western Pacific, PO Box 2932, 1000 Manila, Philippines

Then let us know!

To help us keep track of how many letters have been sent, please send us a copy of your letter to the ICW office in London, or send us an email to let us know info@icw.org.

If you prefer to retain your confidentiality, you may send your letter anonymously, as an ICW member – or send it to us and we will forward your opinion to WHO in confidence and without giving your name.

ICW has already written an official letter to Dr Lee of WHO:

LETTER FROM ICW on the WHO 3 x 5 Strategy
February 2004.

ICW offers Dr Lee and his staff our warm congratulations for developing the 3 x 5 campaign. This campaign sends a much-needed message to the international political and business community, as well as to religious and other key leaders that millions of women, men and children, from all corners of the world and from all walks of life, are dying needlessly for the want of their political collective will. It also sends a long overdue message of hope to HIV positive people.

ICW fully endorses the launch of this campaign, especially since global access to care, support and treatment for HIV positive women and girls forms one cornerstone of our own human rights agenda. Our own network has suffered greatly over the years, with 43 of our original 56 founder members now dead, and many others of our membership now also lost forever. Those few of us who already have access to a few tablets a day, know what a difference these drugs have made, not only to our own lives, but, through keeping us alive, to those of our children and families. These drugs also mean that we are able to go on working productively on issues such as these.

We have now had the opportunity to read the WHO 3 x 5 strategy and would like to offer WHO some of our initial thoughts on its content. These are set out on the following pages.

We at ICW are willing to offer our knowledge and experience to WHO as we strive together towards our common vision of universal access to care, support and treatment for "everyone" with HIV, irrespective of their gender, age or lifestyle. As HIV positive women, we have built up a wide-spread collective expertise in living positively with HIV and AIDS, as treatment activists and as care-givers. We look forward to collaborating with WHO over the coming months as this campaign develops.

a)Gender
Given the widespread acknowledgement that gender inequities both fuel and fan the flames of this pandemic, it would be important to address the critical and underlying gender dimensions of the 3x5 campaign throughout the document. There is much evidence-based research, as well as practical experience, which repeatedly highlights the challenges facing women and girls in gaining access to treatment of any kind, no matter what the disorder. HIV drugs access will be no easier for women and girls and, due to the constraints of stigma, it is likely to be considerably harder. It is therefore critical that the complex gender issues are analysed and addressed throughout the document itself and incorporated into the campaign strategies.

b) Innovative models of care
Albert Einstein said "you cannot solve problems with the way of thinking that led to their creation", a sentiment echoed in your own opening words to this strategy document. While there is much indication of strong commitment and good intention in the document, this campaign is so urgent that it provides an opportunity for innovative approaches that move away from a paradigm that is centre-led, over-stretched, under-funded and inadequately designed service provision. The plans outlined in the strategy do not appear to be seeking ways of building on innovative and creative programmes of work which are already taking place on the ground in different countries. The overall tone of the document, whilst laudibly promoting a call for “business not as usual”, still suggests a lack of sufficient consultation with and openness to community members and other relevant groups, such as those who work directly with them, in creating “services to fit people” rather than “people to fit services”.

c)Gendered care needs
In addition to this, we suggest that it is also important that HIV positive women and girls often require different treatment and care regimes from men. Our own experiences have repeatedly shown us that women respond to drug regimes differently to men. For example, because of women’s physiological responses during pregnancy and breastfeeding, the drugs can have a very different impact. In addition, the psychological pressures which we face are also often very different to those of men, given women’s and girls’ traditional gender roles as unpaid carers within the household and community. Such differences call for the development of proper gender-equitable research trials, both in relation to drugs and to other aspects of care and treatment. Further, microbicides and vaccine research also has particular gendered dimensions. It would therefore be important to include these aspects in the strategy also.

d)Involvement of HIV positive people
One group which is significant by its absence from the document is HIV positive people ourselves. Whilst the document rightly highlights the lead which organisations of HIV positive people have taken over the years in calling for global access, this appears to be dropped from the plan until page 29. Inclusion of “vulnerable groups of HIV positive people” do not appear to receive a mention until Strategy 8 of Pillar 2, on page 42 of the document. This group includes all HIV positive women and girls, since we are so often ignored by policy makers among others. We find this a great disappointment. We can identify many points in the earlier sections of the document where our own active involvement could make a distinct difference - for instance through being consulted with regard to accessible locations for service provision, or providing our own networks of information exchange, or being trained and employed as service providers. We would argue that it is often the policy makers who maintain and enhance our vulnerable and marginalized status, through continuing to overlook our potential and capacity for involvement in these ways. Our membership has rapidly and repeatedly found that, once positive women and girls are able to gain visibility and have our voices heard, our vulnerability has diminished and the communities to which our members belong have begun to show them more respect. Policy makers have a key responsibility therefore in ensuring that their actions do not exacerbate the marginalized condition of vulnerable groups. We believe that the strategy could benefit greatly from our critical and constructive involvement and integration throughout the process.

e)Promoting community care
Linked closely to the above, this strategy document also fails to emphasise sufficiently the on-going need for programmes which promote care, support and respect for HIV positive people within their own communities and within the health services. Our membership has repeatedly found that we women are most at risk from legal, financial, sexual and reproductive human rights abuses from our own health care providers, social services, families and neighbours.

We have also found that often the hardest groups with whom to be open about our status therefore are our own families and communities. In our roles as mothers we have been especially anxious to protect our children from stigma and discrimination, so have often kept our status the most secret from those adults around us whose support we most need. Until our own communities around us are given the support and training needed to offer us compassion, empathy and understanding, truly equitable access for women and girls especially to care, support and treatment will remain a distant mirage.

f)WHO internal policies
We commend WHO’s plan to develop ARV access for all WHO staff. We believe that this action could be strengthened through an additional proactive workplace policy, which encourages the involvement of HIV positive people in workplace policy development and implementation, which promotes the retention and employment of HIV positive staff, including women, and which ensures that benefits to staff include a range of appropriate care and support, which is not just drug-specific. By being seen to take a lead in this regard, WHO can develop its role as a model employer and can then influence others to follow suit. This should also offer the opportunity to promote a proactive awareness throughout the whole management and staff body, from top to bottom, of the way in which HIV can affect all our lives. There are examples in other organisations where a focus on personalising the issues for management and staff alike, has enabled employers and employees to recognise that HIV forms just one part of the jigsaw of our universal human condition, and has gone a very long way to create a more supportive and caring working environment for everyone, irrespective of their HIV status.

g)WHO acknowledging AIDS
Indeed, such programmes, in promoting leading by doing, will also help WHO and other organisations to recognise that it is not just the front-line staff who are HIV positive and coping with illness but that, as a large international organisation, there are staff at all levels who are living with HIV. Several churches have now started to acknowledge this. It would make a great impact to see WHO also make an explicit statement to this effect.

h)ARV access as a global issue
We also have concerns that this strategy document focuses only on 34 high burden countries in Africa. Whilst we understand the need to begin somewhere, many of our members in Asia and Latin America are also sick and dying, or have already died, through lack of access to ARVs. We would like to encourage WHO to remind the global community that the responsibility to lobby governments for the right to access to ARVs should not lie on the shoulders of the HIV positive community alone. Rather, the global community should actively join forces with the huge efforts which HIV positive people are already making in this regard. Even in countries where access to ARVs is more widely available, indigenous groups, minority groups, drug users and people in prison do not have the access which should be their right. The needs and visions of women and girls in these contexts are especially forgotten about. Once again, then, and in this respect also, WHO can play a key role in Asia and Latin America, and throughout the world by leadership through example.

i)Gender analysis of the initiative and budget
Last not least, ICW would like to call on WHO to conduct an independent gender analysis of the strategy and the budget by a consultant chosen in liaison with ICW and working closely with ICW members. The budget analysis should include a cost/benefit analysis of the figures mentioned, and not just the cost of the drugs. In its present form, ICW believes that without a gendered dimension, without a major paradigmatic shift in approach and, perhaps most of all, without the in-depth insights, experiences and constructive contributions of the HIV positive women and girls around the world who need this strategy to succeed, this important initiative is in grave danger of failure. None of us can afford this outcome.

VSO partners, friends and volunteers will also be writing to WHO – click here to read VSO’s campaign briefing and materials.

Background: Why is this needed?

With a growing international membership from all continents and an international board of trustees, ICW is uniquely placed to share the voices and visions of HIV positive women of all ages from around the world.

ICW congratulates the WHO for developing the 3 by 5 initiative. This sends a much-needed message to the international political and business community, as well as to religious and other key leaders that millions of women, men and children, from all corners of the world and from all walks of life, are dying needlessly for the want of their political collective will. It also sends a long overdue message of hope to HIV positive people.

ICW fully endorses the launch of this initiative, especially since global access to care, support and treatment for HIV positive women and girls forms one cornerstone of our own human rights agenda. Our own network has suffered greatly over the years, with 43 of our original 56 founder members now dead, and many others of our membership now also lost forever. Those of us on antiretrovirals know what a difference these drugs make, not only to our own lives but also - through keeping us alive - to those of our children and families. These drugs also mean that we are able to go on working productively.

However, progress has been extremely slow with very few people able to access the drugs to date. WHO, UNAIDS and the Global Health Fund for AIDS TB and Malaria (GFATM) declared the lack of access to ARVs to be a global health emergency on 22 Sept 2003.

Equal treatment for women?

ICW members know from experience that gender inequities fuel and fan the flames of this pandemic. The Kampala Women’s Declaration (October 2003), developed by HIV positive women attending the International Conference of People Living with HIV/AIDS, calls for world leaders to ACT NOW to ensure human rights and treatment for all. Our practical experience, and participatory projects such as Positive Women: Voices and Choices, and Voces Positivas in Central America, involving ICW members, repeatedly highlight the challenges facing HIV positive women and girls in gaining access to care, treatment and support. It is critical that the WHO 3 by 5 initiative is based on a thorough analysis of these complex gender issues.

There are also concerns that some less economically developed countries will not gain access to ARVs under the 3 by 5 initiative. The hardest hit countries are included automatically, but other countries will have to lobby to be involved. If governments of some countries do not see HIV and AIDS as a priority, their citizens may not be included in the initiative. Given the fact that women are generally less likely to be able to access treatment than men, this will have a particularly severe impact upon them.

Who gets the drugs?

It is estimated that 6 million people in developing countries need ARV treatment. Only about 400,000 of these currently receive any medicine, and the WHO estimates that only 2% of those who need treatment in Africa actually receive any. Eventually, almost all the 40 million people living with HIV and AIDS worldwide will require treatment. Clearly this means that decisions will have to be made about who gets ARVs, particularly in the initial stages of the programme.

WHO and UNAIDS are in the process of producing ethical guidelines about treatment access for national governments. WHO’s strategy for implementing 3 by 5 also states that decisions about treatment will be made on a basis of equality. However, ICW, VSO and many others are concerned that the ultimate decisions about who gets treatment may be guided more by economic efficiency rather than equity.

How will 3 by 5 be funded?

WHO will not be funding the costs of 3 by 5, but will provide the necessary expertise and experience to implement the initiative. It will have to provide $350 million as a contribution for the scaled up work it will do. However, this still leaves an estimated $5 billion funding gap, depending upon drug costs. 35% of the total funding will be spent on ARVs. Clearly, more funds are urgently required through direct contributions and via the Global Fund for AIDS, TB and Malaria (GFATM).

How will 3 by 5 be rolled out?

The WHO aims for 700,000 people to be on ARV therapy by December 2004, 1.6 million by June 2005 and 3 million by December 2005. WHO will not be purchasing and supplying ARVs, but aims to work in partnership with the international community, national governments and NGOs to implement the initiative.

Ways forward?

For 3 by 5 to be a success, women must not be left behind. HIV positive women need treatment appropriate to their needs and must be able to access these services under safe, convenient and affordable conditions.

ICW urges the WHO to involve groups of HIV positive women and girls at every stage of the planning and implementation of the 3 by 5 initiative. Monitoring and evaluation systems need to be set up to give an accurate reflection not only of the total number of people receiving treatment under 3 by 5, but whether they are women or men, girls or boys. Finally, it is essential that all the guidance the WHO provides national governments and other organisations in the implementation of 3 by 5 emphasises the importance of understanding the different realities and needs of women and men affected by HIV and AIDS.