The campaign for global AIDS treatment delivery has reached a defining moment. The first years of programme scale up demonstrated that AIDS treatment can be delivered effectively, even in the poorest settings. But "3 by 5", an initiative by the World Health Organization (WHO) to treat three million people by the end of 2005, is coming to an end and it has fallen at least one million men, women and children short of the target. This leaves at least four million people who urgently need antiretroviral drugs today in order to have any hope of survival. Although progress has been made over the past few years, we cannot call this success.

G8 leaders have pledged a new goal of coming as close as possible to universal AIDS treatment access by 2010. This will be a hollow promise unless governments and international agencies learn the lessons of the early years of treatment delivery and dedicate increased resources, capably address barriers, collaborate more effectively, and hold themselves accountable for steady, measurable progress. The "3 by 5" initiative failed to treat even 50% of people in need of antiretroviral treatment (ART). If the organisations responsible for carrying out this programme are to accomplish an even greater goal in five years time, it will take courageous new leadership from all parties to confront the monumental task ahead. The status quo will not get us there.

Will the international community rise to this challenge? The fate of millions of people around the world hangs in the answer to that question.

The International Treatment Preparedness Coalition (ITPC) is a global alliance of over 600 treatment activists that includes people living with HIV/AIDS (PLWHA) and their advocates. The ITPC AIDS Treatment Report is the first systematic assessment of treatment scale up based on the research of people living in communities in six countries where the epidemic has hit the hardest the Dominican Republic, India, Kenya, Nigeria, Russia and South Africa. The report is based on their experiences and first-hand knowledge of the situation on the ground. Each country used a case study methodology, which emphasizes interviews with carefully selected key informants. Clearly, much more work needs to be done to understand the complexity of this challenge. But what we found tells an important story of individuals exhibiting dedication and courage while caught in desperate situations; and of institutions often struggling to transition, be efficient, and throw off bureaucratic obstacles that stand in the way.

The ITPC AIDS Treatment Report is a prescription for the future. As ART has started to roll out in these six countries, the ITPC research teams have identified barriers that could imperil efforts to make treatment more widely available. The teams have also made concrete recommendations for governments and international institutions.

These recommendations must be taken up with urgency if the goal of universal access by 2010 is to be achieved.

Major roadblocks to success include the following:

• inadequate leadership at the national level that fails to dedicate sufficient resources or mobilize governments;

• a global system that does not collaborate speedily and efficiently to address bottlenecks;

• inadequate and uncertain funding levels for programs and financing mechanisms such as the Global Fund to Fight AIDS, TB and Malaria (GFATM) a situation that keeps countries guessing about the sustainability of services and the meaning of pledges like 'universal access'; bureaucratic delays that prevent urgently needed resources from reaching treatment programs;

• procurement and logistics challenges that demand more comprehensive and effective technical assistance; and

• pervasive stigma against people living with HIV/AIDS that requires moral leadership from national and global communities.

Need for improved leadership at the national level

In every country surveyed there were concerns about inadequate leadership at the national level and the subsequent failure to dedicate sufficient resources or mobilize governments. We heard about the necessity for a well-functioning national AIDS programme that can provide this leadership, implement a comprehensive national AIDS plan, and compel international and domestic organizations to abide by that plan. Sadly, the state of national AIDS programmes in these six countries did not make the grade. Scale up of treatment will not happen unless countries fulfill their responsibilities to those living within their borders and national governments must be the primary engine for increasing access to care.

In addition, in just about every country we saw a failure to link TB and HIV programming effectively, missing opportunities to diagnose and treat these interconnected diseases and establish coordinated systems of health care. We also found that each country has a different constellation of challenges and potential solutions.

In the Dominican Republic bureaucratic delays and power struggles between agencies delayed implementation of a Global Fund grant for months. Many of those initial problems have now been overcome, but delivery of ARVs is still hampered by lack of political leadership; stigma and discrimination; supply problems with ARVs, treatments for opportunistic infections, and CD4 tests; and continued lack of coordination between programs.

In India treatment remains unavailable for the vast majority of the millions of people living with HIV. Although the government has signaled increasing commitment to ART delivery, the national AIDS program has failed to act on several critical issues and national treatment guidelines are underenforced and have several significant gaps. Many people seeking care are forced to travel long distances, and shortfalls in funding and human resources threaten efforts to expand the response.

In Kenya treatment services are being scaled up through new funding from the Global Fund, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), and other programs. Yet people in need of care and service providers from around the country are confronting significant obstacles that include widespread stigma and discrimination against PLWHA and women, misinformation, lack of treatment literacy, and insufficient resources to meet basic nutrition needs or afford travel to health clinics for care.

In Nigeria the government has set new and ambitious targets for treatment delivery, but services remain concentrated in a few'cluster zones' while people in rural areas struggle to get care. Lack of adequate funding and human resources complicate treatment expansion. The high costs of CD4 and viral load tests put these diagnostic tools out of reach of most people in treatment. Stigma and a lack of treatment literacy programs both undermine scale up efforts.

In Russia efforts are underway to significantly scale up ART delivery in response to a fast-growing epidemic concentrated among injection drug users (IDUs). Yet multiple bureaucratic obstacles stand in the way, including a faulty drug procurement system, lack of collaboration among providers, absence of a national treatment protocol, a Global Fund Country Coordinating Mechanism (CCM) that is widely described as ineffective, and lack of leadership from government agencies. Widespread discrimination against IDUs inhibits scale up at an even more fundamental level.

In South Africa activists and providers have forged ahead with treatment delivery even as the national government continues to drag its feet and fails to combat misinformation and pseudo-science. Multilateral agencies have been largely invisible and the CCM is widely criticized. Many practical problems inhibit scale up as well, including a severe shortfall in nurses and other providers, limited access to HIV testing, and inadequate availability of drugs.

Need for a better functioning global system

All implementation is local, but the international community has to do better at identifying and quickly addressing impediments to the flow of resources and delivery of services. Each of the component parts of the multilateral system has strengths that are needed in AIDS treatment scale up, but UNAIDS, WHO, GFATM, and PEPFAR need to work in more efficient partnership both within countries and in Geneva. Countries need additional assistance from the international community in several areas, from logistical problems (like drug procurement) to long-term challenges (like reducing stigma).

What gets measured gets done. A much more systematic approach to setting goals, measuring progress, and assessing and addressing barriers is needed. Rich countries need to stay true to their word and provide increased and sustained support for the Global Fund and other AIDS treatment programmes. The G8 countries cannot defensibly set a goal of universal access and then under-finance the response by billions of dollars. African countries need to live up to their commitment as part of the 2001 Abuja Declaration to devote 15% of their budgets to addressing health priorities, including HIV/AIDS.

UNAIDS, WHO, the Global Fund, and PEPFAR and other bilaterals must keep the world's vision focused on treatment scale up. The operational plan for universal access now under development should emphasize improved collaboration among agencies and include defined countryspecific strategies, with hard timelines and milestones, and clear assignments of responsibility for specific tasks. Incremental targets for treatment delivery to children and marginalized populations are needed, as are action plans for delivery of second- and third-line regimens. In the next six months we want to see concrete evidence of a more collaborative system that more effectively meets the diverse needs of countries. The International Monetary Fund and the World Bank need to end macroeconomic policies that unnecessarily constrain public spending so that countries heavily affected by AIDS can train and hire more doctors, nurses and teachers.

If the international community succeeds in treating the vast majority of people with HIV/AIDS who need it, we will have indeed changed the world. The delivery of antiretroviral therapy will only be possible with a revolution in global public health, which makes primary care available to those who have never had it before. This will pave the way for the treatment of countless other diseases that are now left untreated and unaddressed in most communities around the planet. The goal is before us. We should seize this moment in history together.