Infectious diseases high on agenda under new WHO leadership

Nathan Ford of MSF cautions that "the three-by-five target must not become another unmet UN target. It is only half the number of people with HIV/AIDS estimated to need treatment today and this number will be much greater in 2 years' time", he warns. For this plan to be realised, Ford says WHO will have to take a much stronger position on the drug price issue.
This article first appeared in the September 1 edition of The Lancet. WHO's new Director-General Jong-Wook Lee says the fight against infectious diseases - especially HIV/AIDS, tuberculosis, and malaria - will be among his "highest priorities" because they affect primarily the poor. Each year these diseases cause about 25% of all deaths worldwide. On his first day in office, Lee appointed Jack Chow , former Special Representative of the US Secretary of State for HIV/AIDS, to lead a new HIV/AIDS, tuberculosis, and malaria cluster. "The [creation of this] new position was necessary", says Elizabeth Corbett (Biomedical Research and Training Institute, Harare, Zimbabwe), because "during the last few years there has been an unprecedented increase in the priority" given to these diseases. In his first speech as the agency's director, Lee announced that by this year's World AIDS Day, December 1, the new HIV/AIDS, tuberculosis, and malaria department will produce a global plan to provide 3 million HIV-infected people in developing countries with antiretroviral drugs by the end of 2005 - what is called the "three-by-five" target. "Setting targets can provide focus and direction: the DOTS [directly observed therapy short-course] strategy for improving tuberculosis control has provided a very clear example of how international targets and leadership can filter down to primary health-care clinic level, resulting in better management for millions of tuberculosis patients. Lee's intentions seem to be that WHO will generate a similar momentum for management of HIV/AIDS", according to Corbett. However, Nathan Ford of Médecins Sans Frontières (MSF) cautions that "the three-by-five target must not become another unmet UN target. It is only half the number of people with HIV/AIDS estimated to need treatment today and this number will be much greater in 2 years' time", he warns. For this plan to be realised, Ford says WHO will have to take a much stronger position on the drug price issue. Although drug prices have come down in recent years, many patented medicines, including many antiretroviral drugs, are still prohibitively expensive. WHO will need to push the pharmaceutical industry to implement a systematic equity pricing policy and charge much less for its drugs and diagnostics. At the same time, WHO must promote generic competition, which has brought the price of triple therapy down to under US$300 per patient per year. Carlos Correa (University of Buenos Aires, Argentina) considers the new initiative "a positive step", but warns that ensured access to all drugs could be overlooked, as recognised by the 2001 Doha declaration on the trade-related intellectual property rights (TRIPS) agreement and public health. According to Correa, actions to improve access to antimalaria, antituberculosis, and antiretroviral drugs should also include technical assistance to developing countries to effectively use the flexibilities allowed by TRIPS and promote competition as far as possible, coupled with efforts to find innovative ways of promoting research in developing countries on new cures and vaccines for the three diseases. Josef Decosas (Health Advisor, Plan International, West Africa Region, Accra, Ghana) adds that the role of WHO should not be to get the drugs to the people who need them, but to strengthen the systems that assure control, quality, and equity of antiretroviral treatment in developing countries. "This is where today's greatest challenge lies, and these are also issues that are squarely within the mandate of WHO", he said. Decosas agrees with Lee that the response to severe acute respiratory syndrome has contributed enormously to building and restoring the reputation of WHO. "The threat of a potentially devastating pandemic of a serious respiratory tract infection appears to have disappeared, and that WHO had a key role in bringing this about. It underlines one of the main remits of WHO, and the Director-General's commitment to strengthening the Global Outbreak Alert and Response Network is entirely appropriate". The WHO also plans to launch a similar initiative for malaria control. However, one of the main challenges the new leadership faces is to find ways in which artemisinin combinations could be included in malaria-treatment protocols at country level. Several donors, including the US Agency for International Aid and the UK Department for International Development, continue to support the use of old drugs to which there are high levels of resistance. The problem is further compounded by lack of funds for all his ambitious plans. The WHO's annual budget is only US$1á1 billion. International aid for malaria control is around $100 million per year but to achieve WHO's goal - to halve malaria deaths by 2010, and to halve them again by 2015 - would alone need $1á5ö$2á5 billion annually, according to a study by Vasant Narasimhan (Harvard Medical School, Boston, MA, USA) and colleagues. Lee also appointed former head of WHO communicable diseases department, David Heymann, to head the WHO effort against polio. "I am committed to an all-out assault on polio. I want to complete the eradication of this disease within my tenure as Director-General", said Lee. India, Nigeria, Pakistan, and Egypt accounted for 99% of new cases last year. So "I am immediately upgrading WHO's capacity to support their efforts to immunise every child against polio".