This World AIDS Day, one year after the end of '3 by 5,' all of us engaged in the response to AIDS have a decision to make. Will we launch the full-scale, coordinated, deadline-driven mobilization envisioned just two years ago by such leaders as the late WHO Director-General Jong-wook Lee? Or are we willing to live with incremental gains that fall millions of lives short of the 'universal access' goal?

This monitoring project from the International Treatment Preparedness Coalition (ITPC) has found that despite pockets of progress, efforts as a whole are stagnating.

The international community has reaffirmed the abstract goal of coming as close as possible to universal access to HIV treatment, but most major players have refused to define what this means. Imagine where the smallpox and polio immunization campaigns would have gotten had they focused on coming 'as close as possible'€ rather than on bringing those diseases to an end. The May 2006 UNAIDS annual report actually does quantify universal access as 9.8 million people on antiretroviral treatment (ART) by 2010. Yet at the current rate—600,000 more people receiving ART each year in addition to the 1.6 million on treatment as of June 2006 we are on course to miss that goal by over five million people.

With no clear targets to work against and diminishing public attention and accountability, urgency is being replaced by gradualism. Ultimately, we need to be building health systems that can deliver HIV treatment and prevention, as well as TB and other services. We need to reach people in rural as well as urban areas; the marginalized as well as the privileged; and children as well as adults. Yet we are at risk of forfeiting what is perhaps our best opportunity to build sustainable health systems through accelerated treatment delivery.

To ensure that stagnation in HIV treatment scale up does not become a permanent condition, this report calls for six specific action points by June 2007:

• The incoming director-general of WHO, Dr. Margaret Chan, should reassert that agency's profile and leadership in the fight for treatment access and declare a '3 by 5'€-like campaign to reach universal access by 2010.

• The Global Fund, PEPFAR and other agencies should put clear systems, lines of accountability and guidelines in place to avoid country-level failures to meet goals associated with their programs.

• Multilateral agencies and country governments should agree on a consensus statement on what “universal access” to treatment means quantitatively for the world.

• National governments should complete ambitious costed national plans in consultation with people living with HIV/AIDS with specific targets to reach universal access by 2010.

• Donors should commit to specific year-over-year increases in funding for the Global Fund and other programs to finance the agreed-upon targets.

• Governments, donors and multilaterals should negotiate lower prices for HIV treatments, particularly newer and second-line drugs.

This is ITPC's third report based on its monitoring of the state of AIDS treatment delivery in six heavily affected countries. As in previous reports, ITPC members based in each country used a standard questionnaire to interview and collect data from government officials, multilateral agency staff, health care providers, activists, and people living with HIV and AIDS (PLWHA) in their countries. For each country we have recommended specific areas where we want to see substantial progress by June 2007. This report finds that:

• In the Dominican Republic, treatment delivery has expanded by several thousand in two years and diagnostics are now more accessible. However, fewer than half of those who need ART have access; women and marginalized people receive substandard care; and a proposed new health insurance scheme explicitly excludes PLWHA and the disabled.

• In India, the increasing number of people receiving treatment represents only one in 14 of those in need; more treatment sites opened this year (though the number of sites is still insufficient); action is needed to secure access to second-line drugs; pediatric ARV formulations are not widely available; and marginalized groups face significant barriers in accessing ART at government-supported centers.

• In Kenya, although national treatment targets are said to be achievable and the PEPFAR program has been praised, the country is grappling with an acute shortage of health care workers, a Global Fund grant at risk, limited ART access for children, and an increasing need for expensive second-line drugs.

• In Nigeria, a free treatment policy is being implemented and more treatment centers are open. Yet costs associated with treatment are keeping many from care; the availability of treatment and voluntary testing is not well publicized; care centers remain concentrated in urban areas; and stigma is a significant barrier to access.

• In Russia, a rapidly expanding epidemic is being met with increasing government commitment. Yet major access barriers persist, such as a lack of support services for treatment uptake among vulnerable groups, including injecting drug users who represent the majority of those in need. Other barriers include lack of an approved national treatment protocol; poor coordination of provider training; and limited inclusion of civil society input.

• In South Africa, activists have persuaded the government to pledge dramatic improvements in its response to AIDS. Public-sector officials must now follow through with swift action to establish widely supported treatment targets; address severe human resources shortfalls; revise national pediatric and other treatment guidelines; and greatly accelerate the pace of treatment scale up.

TB is the leading cause of death among PLWHA, yet in every country ITPC researchers found inadequate linkage of HIV and TB programs, with numerous reports of HIV and TB clinics that do not provide appropriate testing, treatment or referral for the other disease; limited awareness of TB/HIV drug interactions; and lackluster attention to the escalating epidemics of multidrug-resistant (MDR) and extreme drug-resistant (XDR) tuberculosis.

While each country profiled in this report is unique, their end stories are similar: treatment coverage is rising, yet the modest gains are dwarfed by the number of people who need ART, are not getting it, and thus face imminent death. Governments rich and poor and the global institutions they support must rediscover the urgency of addressing AIDS comprehensively. To do less is to lose a vast opportunity to advance humane systems of care and needlessly allow millions to perish.