Introduction

Access to good quality antiretroviral treatment has transformed the prognosis for people with AIDS in the developed world. Although it is feasible and desirable to deliver antiretroviral drugs in resource poor settings,1 ^{w1 w2} few of the 95% of people with HIV and AIDS who live in developing countries receive them. The World Health Organization has launched a programme to deliver antiretroviral drugs to three million people with AIDS in the developing world by 2005, the “3 by 5” initiative.2 ^w3 We identify some of the challenges faced by the initiative, focusing on delivery of care.

Continuum of care

Ideally, care for people with AIDS should start with voluntary counselling and HIV testing. However, only 10% of people who need testing in low and middle income countries have access to services, and therefore most are unaware of their serological status.^w5 Care should include psychological, social, and economic support as well as broad based medical care incorporating nutritional advice, prevention and treatment of opportunistic infections, and palliative care.3 ^w6 In many countries, this continuum remains to be set up.

The 3 by 5 initiative considers access to antiretroviral drugs as an opportunity to improve care and enhance prevention efforts.4 However, the focus on antiretroviral drugs risks distracting resources and attention from a broader model of health care. A recent survey of palliative care for people with AIDS in developing countries showed that services were often inadequate.5 Pain management was especially poor. India's decision to rapidly provide free antiretroviral drugs to 100 000 people with AIDS in the six states with the highest HIV prevalence created considerable debate, partly …