Rapid Scale-Up of Antiretroviral Treatment in Ethiopia: Successes and System-Wide Effects

The provision of antiretroviral treatment (ART) has decreased morbidity and mortality in people living with HIV/AIDS [1,2]. However, introducing ART to subSaharan Africa was a topic of hot debate just a few years ago. Concerns about adherence and subsequent development of drug resistance, poor infrastructure, logistic and human capacity, and cost-effectiveness were the major issues [3]. Once pilot projects indicated the feasibility of ART delivery in resource-limited settings, the World Health Organization catalyzed the global effort by declaring lack of access to effective HIV treatment a global emergency. This resulted in the ‘‘3 by 5’’ initiative, which aimed to provide 3 million people in developing countries with ART by the end of 2005 [4]—a 10-fold increase in two years, as in 2003, only 100,000 people living with HIV/AIDS in developing countries were able to access ART [4]. Since the declaration of the ‘‘3 by 5’’ initiative, there have been several enabling factors for the rapid and massive scale-up of ART in resource-limited settings. Some of these are: (1) increased funding, mainly through global initiatives such as the Global Fund To Fight AIDS, Tuberculosis and Malaria and the United States President’s Emergency Plan for AIDS Relief (PEPFAR) [5–7]; (2) a dramatic reduction in prices of antiretroviral drugs through considerable negotiation [7]; and (3) the public health approach to ART delivery [8]. Although the ‘‘3 by 5’’ target was not achieved (only 1.3 million people were able to access ART by the end of 2005) [9], this ambitious plan has served several purposes, including revealing the real challenges for ART scale-up in developing countries [10]. Several developing countries have adopted the public health approach to ART delivery to increase access to treatment [8]. Experiences in ART scale-up using the World Health Organization’s public health approach have been documented in countries with huge geographic, sociocultural, and demographic variations [11]. However, there have been few reports on the system-wide effects of rapid ART scale-up on the overall health system and the HIV epidemic within individual countries. In this paper, we present Ethiopia’s experience in expanding access to ART using the public health approach and highlight the system-wide effects associated with the rapid scale-up of the ART program. Our analysis is based on secondary data sources, mainly (1) official documents from the Ethiopian Ministry of Health, including annual health service coverage reports on health and healthrelated indicators such as HIV/AIDS, tuberculosis, maternal and child health, and human resources for health (HRH); (2) the national ART treatment and implementation guidelines and proceedings of HIV/AIDS program review meetings; and (3) monthly ART reports available on the National AIDS Resource Centre Web site (http://www.etharc.org/). Information gathered through interviews from key informants in the national and regional HIV/AIDS programs was also used to complement the data from secondary sources.