Introduction

Uncertainty in HIV treatment

‘AIDS is not over’, warn Michel Sidibé, Peter Piot and Mark Dybul, representatives of the principal organizations of global health, in a commentary published in the Lancet (Sidibé, Piot and Dybul 2012). A lot is contained in their short claim. The authors explain that 8 million people world-wide were receiving antiretroviral medicines by 2011. AIDS-related deaths have been decreasing as a result of the large-scale provision of antiretroviral therapy. Most of these global health achievements were made in sub-Saharan African countries, which bear the brunt of the global burden of disease. Despite this ‘good news’, one of the reasons why these authors refrain from an optimistic view of the future of the AIDS epidemic is that today, still too many HIV positive people lack access to these medicines.

Currently, the most important global framework to articulate such claims to access to antiretroviral therapy is the Millennium Development Goals (MDGs) project, which defines a set of targets and indicators to measure progress toward the most important development goals of the twenty-first century. Under this project, ‘universal access to treatment’ is defined as one of the targets to ‘combat HIV/AIDS, Malaria and other diseases’. The official list of indicators promoted by UN organizations posits that universal access to treatment is reached when at least 80 percent of the ‘population with advanced HIV infection [have] access to antiretroviral drugs’. The attribute ‘universal’ refers not to all people with HIV, but only to those who, according to official treatment guidelines, are in an advanced stage of HIV infection and thus need treatment. Even with this definition, 8 million is only half of the target to reach 15 million people with access to antiretroviral therapies by 2015 (see also United Nations 2014: 36). Yet, the global prevalence of HIV is actually much higher, currently estimated to be 34 million, as the authors remind us in their review of these indicators (Sidibé, Piot and Dybul 2012: 2058). However, current funding levels of donor aid are not sufficient to cover the 15 million. Health economic models projecting the long-term costs of antiretroviral therapy demand an annual US$22 billion to run treatment programs world-wide, of which US$12 billion alone would be earmarked for the purchasing of antiretrovirals (e.g. Schwartländer et al. 2011; UNAIDS 2012).