Paper for Civil Society Congress Access to Anti-Retroviral Treatment Where are we and where should we be going?

Transcription

1 Paper for Civil Society Congress Access to Anti-Retroviral Treatment Where are we and where should we be going? Introduction The government is reviewing its National Strategic Plan (NSP) on HIV/AIDS and developing a new NSP for The NSP will include all aspects of the response to HIV, notably HIV prevention, treatment and care and will incorporate the Operational Plan on Comprehensive HIV and AIDS Care, Management and Treatment for South Africa (the Operational Plan), the policy document that makes provision for antiretroviral (ARV) treatment in the public health sector. This paper focuses on the implementation of the Operational Plan in the last three years, in particular the rollout of ARV treatment and linked services. However, at the outset it is necessary to say that information is difficult to access. In some provinces this is because systems for collecting data are not yet fully operational. In other provinces Health departments do not share information with civil society. Despite this the Joint Civil Society Monitoring Forum (JCSMF) 1 consisting of more than 20 civil society organizations - has endeavoured to collate all available information on the programme. The assessment and recommendations contained in this report are largely based on its findings. Implementation of the Operational Plan Quantative Assessment By October 2006, three years after the cabinet adopted the Operational Plan, the total number of people on treatment in both the public and private sector stood at approximately About people are accessing ART in the public sector and approximately ,000 are receiving it in the private and not-for-profit sectors. Although this is a significant number it is estimated by UNAIDS that at the end of December 2005 that the overall number of people who need treatment in SA is This means that about people are still in need of treatment. Actuaries estimate that only about 20% of people who need treatment are getting it (Nattrass 2006). 3 As a result the rise in adult and infant mortality due to AIDS has not been reversed. 1 The JCSMF is an ad-hoc body made up of a range of non-governmental organizations. It was set up in 2004 to monitor and assist with the effective and efficient implementation of the Operational Plan from a public health and human rights perspective. It has since hosted nine meetings in eight provinces to share information on various aspects of implementation. After each meeting it has compiled recommendations to provincial and national authorities. SOUTH AFRICA JOINT CIVIL SOCIETY MONITORING FORUM: RESOLUTIONS AND MINUTES 2 Report on the Global AIDS Epidemic, A UNAIDS 10 th anniversary special edition. UNAIDS See Natrass N (2006) South Africa s Rollout of Highly Active Antiretroviral Therapy: A Critical Assessment CSSR Working Paper Natrass reports that a recent econometric analysis of the determinants of HAART coverage suggests that SA s performance is relatively poor given its economic, institutional and epidemiological characteristics.. In other words, although South Africa comprises a large share (25%) of the total number of Sub-Saharan Africans on HAART (whether in the public,

2 Linked to the numbers on treatment, several important trends are now discernable, and require recognition and action: Women make up about 60% of those on treatment. Relatively few men are seeking and accessing treatment. In most provinces paediatric numbers are very low. 4 Huge inter-provincial disparities exist. This means that in many parts of the country, thousands of people are not accessing treatment. For example the table below illustrates that almost half of the total number of patients on treatment are in four provinces: Gauteng, Western Cape, KZN and North West. Numbers on ART by Province and Event (smoothed out) Numbers GT NW NC EC W C KZN LP MP FS Total Provinces TAC/ALP July st JCSMF Sep nd JCSMF Nov rd JCSMF Dec 2004/Jan 05 4th JCSFM March 2005 SA AIDS conf. June th JCSMF Aug - 05 TAC 3rd Cong TAC NEC Jan - 06 TAC NEC Sept Number on ART by Province and Event (smoothed out excl. total) Numbers on ART TAC/ALP July st JCSMF Sep nd JCSMF Nov rd JCSMF Dec 2004/Jan 05 4th JCSFM March 2005 SA AIDS conf. June th JCSMF Aug - 05 TAC 3rd Cong TAC NEC Jan - 06 TAC NEC Sept GT NW NC EC WC KZN LP MP FS Province private or not-for profit sectors), it should be performing a lot better than it is with respect to coverage. 4 At the end 2005, about children were estimated to be living with HIV. Some experts suggest that based on these figures, about 50-60% need immediate access to ARVs. At present we estimate that only about children are receiving ARV treatment. The additional sting is that even where children are being treated, they are found mostly in urban centres where specialist paediatric centres exist

3 There are also intra-provincial disparities. For example, at Mahatma Gandhi hospital in KZN 5 waiting lists are running into mid 2007 and in Umtata, there is a waiting list of more than 1000 patients. This is mainly because hospitals cannot bear the burden of HIV/AIDS unless treatment is decentralised to primary health clinics. A few days ago the Department of Health admitted that about patients whose CD4 counts are below 200 are waiting for treatment across the country. In all parts of SA there is a shortage of nurses, pharmacists and doctors. In rural areas there are problems with electricity and running water. In many clinics and hospitals there is simply not enough space. Most public sector patients on ARV treatment are receiving care at academic hospitals and the so-called main sites, with very few patients accessing ARV treatment at rural, remote or primary health care sites. The key challenge is to ensure that the programme now becomes nurse driven with the primary health care setting taking the lead in service delivery. Implementation of the Operational Plan Qualitative Assessment Available cohort studies show good patient outcomes of people on ARVs in SA. High levels of adherence have been publicly reported by the Western Cape and Free State 6 as well as by many individual sites. But in addition to the trends identified there are a number of problems, which will further hinder the programme if they are not dealt with soon, including: Inadequate forward planning for a sustainable supplies of affordable drugs, especially of newer drugs; Limited availability of key diagnostic and monitoring laboratory services; The continued use of sub-optimal treatment protocols; Confusion and fear amongst patients because of inaccurate messages about treatment options and the use of ARVs; Poor integration of HIV and TB care, as well as HIV and maternal health, reproductive health etc; Insufficient availability of HIV testing and counseling services, and confusion about HIV testing policy among health providers; Inadequate social security support networks; and Low morale amongst health care workers. In the section below we identify aspects of the plan where (a) urgent action is needed (b) a policy change is needed or (c) work needs to be urgently undertaken to avoid difficulties: 5 See also ALP Field Monitoring Report on KZN, October Western Cape Antiretroviral Programme Monitoring Report, June Available at: and Free State Department of Health Implementation of the Comprehensive Care, Management and Treatment of HIV and AIDS Programme Fourth Quarter Report, Released June 2006.

4 Issues for Urgent Action: Under this heading we deal with the following: a. Action plan to improve PMTCT and children s access to treatment b. Improving access by increasing availability Accreditation c. Monitoring and Evaluation d. An emergency plan for Human Resources CHILDREN The national programme to prevent mother to child HIV transmission is not being managed, monitored or implemented properly. Although the programme exists on paper, in practice it is non-existent in many parts of the country. Consequently there are still thousands of avoidable infant infections although the antenatal survey no longer estimates the numbers. The lack of human resources, and in particular paediatricians and health care workers trained to administer paediatric treatment, have been cited as reasons for the low number of children on treatment. Children constitute about 10% on average of the total number of patients on treatment. According to the Operational Plan, an accredited site must treat both adults and children. But access for children has not enjoyed the same level of attention as access for adults. Most messaging still targets adults and often ignores children. The unwillingness, fear and/or inability to treat children are factors that have contributed to fewer children being put on ARV treatment. In addition, limited availability of child-appropriate medicines (for example, syrups or smaller tablets or appropriate drug combinations) makes it difficult for health care providers to treat children. Offer HIV testing to all pregnant women as a standard part of antenatal care. Integrate HIV prevention and care into routine antenatal, obstetric and childcare. Improve PMTCT programme; set targets for reduction of infant infections Paediatric treatment targets are necessary so that sites can measure their performance against identifiable objectives. HIV PCR testing, at four weeks, should be included as part of the Integrated Management of Childhood Illnesses (IMCI) and linked to immunisation coverage. 7 This way, children will not be lost to follow up and can be identified easily. o Where the NHLS does not have sufficient capacity, partnerships with laboratories in the private sector should be considered. In addition, provincial and national permission for mobile laboratories such as the laboratory container in Gugulethu (through the Desmond Tutu Foundation) must be expedited so that settings that do not have meaningful access to laboratory services can develop their own capacity 8 7 PCR tests for early paediatric diagnosis are not widely used in all provinces even though it is part of the national protocol. 8 In the event that the private sector can perform essential diagnostic and monitoring at a price less than the NHLS tariff provinces must be allowed to use those services despite the NHLS being a designated preferred laboratory provider (this will save money and boost

5 The urgent finalisation and distribution of the national paediatric guidelines to all provinces and the amalgamation of provincial guidelines with the national protocol is required. The latter must with a sense of urgency be brought in line with the WHO Revised 2006 Paediatric and MTCT Treatment Guidelines. Education and advocacy concerning the treatment of children with HIV/AIDS within the medical profession and communities must be improved. ACCESS AND AVAILABILITY TO CARE AND TREATMENT In October 2006 the Government estimated that about 177,000 people were on treatment and that were on waiting lists. This indicates not only that the majority of people with AIDS are not accessing treatment, but also that they are not accessing all the other components of care included in the programme. Tragically, many people who are sick with AIDS are in the ambit of health services (receiving treatment for TB or other HIV related illnesses), but not of the ARV programme. There are two problems here: 1. The process for accreditation 2. The policy on HIV testing Justifiably, the Operational Plan requires a health facility to be accredited before it can commence with its ARV programme. But the formal process of accreditation limits access to health care services unreasonably. Since 2004 the process of accreditation of treatment sites has been carried out nationally. While provinces may identify potential sites for purposes of assessment by the NDoH, they are not permitted to accredit sites themselves, despite the fact that the Operational Plan provided for provinces to be entrusted with the function of accreditation. In addition the 23 items set out in the Operational Plan, necessary for accreditation, reflect a gold standard that many facilities are not in a position to meet. 9 This delays the accreditation of primary health clinics and undermines attempts by hospitals to refer patients to sites closest to their home. The rigid accreditation criteria coupled with the failure to assist facilities with infrastructure strengthening is undermining the development and expansion of service points that are more accessible to more people. 10 laboratory capacity). The Clinton Foundation has negotiated lower costs for CD4 monitoring as well as viral load testing. SA has to date not made use of these price reductions it should. 9 The following should be sufficient for accreditation: provision of basic HIV/AIDS services including VCT; possession of national treatment guidelines and protocols; someone to draw blood; access to laboratory facilities; a clinical nurse practitioner or a professional nurse licensed to dispense or a pharmacist assistant supported by a district pharmacist; 24 hour access to care, treatment and support; access to expert consultation and appropriate trained staff. There is a need to devolve treatment to clinic level, to overcome treatment bottlenecks in hospitals and academic sites. Paediatric treatment must be strengthened at primary care level.

6 Decentralise HIV/AIDS prevention and treatment services so that provinces are entrusted with the function of accreditation Adopt a more flexible accreditation paradigm and ensure that the criteria for accreditation does not remain an artificial barrier for accessing treatment Assist provinces with facility strengthening so that over time all facilities can meet the gold standard. HIV Testing: See the section on policy change below. MONITORING AND EVALUATION Despite the ARV programme commencing in 2004, there is no coherent or uniform M&E system in place. This has resulted in provinces now adopting a range of different solutions and approaches. While revised M&E indicators are now available many of these are not feasible without a facility-based system through which data can be aggregated. The indicators themselves are often confusing and do not follow principles of collecting a few things well that are likely to be used, and they request cohort type outcomes on a monthly basis which clinicians argue are inappropriate. M&E experts also warn that there has never been a proper starting point for example, provincial paper based registers and structured clinical record keeping would enhance patient management, as would the adequate provision of clerical staff. There is also a shortage of mid-level management that oversees routine reporting. Experts also warn that IT heavy systems are appropriate for some of the bigger sites or where there are dedicated pharmacies, but they are not appropriate for all settings. Without proper M&E it is difficult to assess the clinical impact of the Operational Plan or that of the PMTCT programme. A coherent M&E system must be put in place. Information about site details, patient numbers, gender/age breakdown as well as adherence rates and reported side effects should be disseminated on a monthly basis and made publicly accessible. A national qualitative analysis of outcomes in both the public and private sector must be commissioned and completed by early Provincial reports must be made publicly available. It is important to note that at both the African Union and United Nations has agreed to set targets in relation to

7 all aspects of the response to HIV. We support this. However, without a proper system for monitoring and evaluation this will not be possible. THE SHORTAGE OF ESSENTIAL HEALTH CARE WORKERS The national HR plan released in April 2006 does not go far enough in addressing the crisis. Worryingly, it does not address short-term needs of the health system. Both the pace and quality of implementation is hampered by the lack of trained doctors, nurses, pharmacists and other health care providers. Without addressing the crisis in human resources for health including poor working conditions, low salaries, concerns about career-pathing, the lack of incentives and the international poaching of HR all health programmes will suffer. Largely because of HR shortages, several sites are placing caps on patient numbers arguing that they cannot take on additional patients. This places an additional burden on other treatment sites. The biggest crisis is amongst nurses. In many provinces, nurses complain that they are overworked, underpaid and undervalued. They report that at many sites, the appointment of a clerk, porter and low level nurses would alleviate their burden, freeing up their time to provide a better service. In their view, the scare skills allowance and rural allowances are insufficient mechanisms to resolve the crisis of staff shortages in remote areas. In other words, working and living conditions must also be addressed in conjunction with the evaluation of scare skills and rural allowances. A national HR meeting should be called to address the crisis of vacancies, morale, as well as attrition, retention and training strategies; o A plan to ensure that bursaries for matriculants are available; o Ensure that sufficient nursing colleges stay open and are not closed; o Nursing unions and federations as well as the SANC must agree on a crisis plan to ensure that more nurses stay in the public sector and receive the necessary training to work at ARV sites; The scope of practice of nurses must be urgently reviewed in order to successfully implement a nurse based ARV programme; Steps have to be taken to improve that patient: nurse ratio including the use of private sector and retired nurses; The confusion about any legal constraints that prohibit lay counsellors from doing HIV testing must be dealt with. This would free up the time burden experienced by nurses at present. In addition, the issue of compensation and basic labour rights of lay workers needs to be resolved as a matter of urgency; Mechanisms to encourage retention and promotion in the public health sector must be reviewed;

8 There needs to be a plan for addressing HIV/AIDS within the health workforce given the prevalence and incidence of HIV amongst HCWs; and A list of the emergency HR needs of all provinces as well as the number of unfilled posts should be made public. NUTRITIONAL SUPPORT Poverty and the lack of food security are major national challenges. There is a clear link between employment, access to income and food and nutrition security. The World Health Organization (WHO) Consultation on Nutrition and HIV/AIDS in Africa (co-hosted by the NDoH) confirmed that everyone requires good nutrition, including people living with HIV/AIDS. However, there are serious shortcomings in the nutrition programme. These have arisen at individual facility level because of a shortage of social workers, dieticians and nutritionists. The lack of proper guidelines and the confusion that has been created and exploited around nutrition has compounded the problem. In addition, logistical delays in getting food parcels to facilities (administered by the Department of Social Development) have also added to the weaknesses of the programme. 11 The administrative burden of processing hundreds of applications for food parcels also results in limited access. Additional studies are needed, including operational studies, to establish how nutritional support can best be integrated into existing care programmes. Clear entry and exit criteria are needed to guide health workers as to when family food support should be provided (when a family does not have enough food to meet normal requirements) as opposed to nutritional supplements/ therapeutic feeding. Improved regulation of companies and the claims they make by the NDoH and MCC about nonregistered so called nutritional products is necessary. Issues for Policy change: Under this heading we deal with the following: (a) An expanded model for the offer of HIV counseling and testing. (b) Revision of treatment protocols. We strongly recommend that in making the changes proposed the NDoH fully consult and listen to health care workers. In addition, whilst these changes are overdue there must be caution that they must not be introduced in a manner that disrupts or confuses existing interventions. 11 In for order for the national department to comply with its mandate, better collaboration between it (responsible for providing fortified maize meal, milk formula, nutritional supplements and nutritional information and counselling), the Department of Social Development (responsible for food parcels and social assistance grants) and the Department of Education (responsible for school feeding schemes) is required.

9 HIV TESTING AND COUNSELLING SA has not evaluated or changed its policy on HIV Testing since Consequently the only model currently sanctioned is the traditional approach to VCT. Although there is evidence that the number of people accessing VCT has increased, there is a widespread feeling that the availability of HIV testing and counseling particularly in health settings need to be increased. But this means that the routine availability of testing, information and counseling including public messaging about the benefits of testing early is crucial. Significantly, the increased availability of testing in all settings including all health settings could assist with identifying TB/HIV patients much sooner than current models. Given the recent outbreak of XDR TB, it is vital that testing includes both active TB screening and HIV testing. The national testing policy should be changed so that active TB screening and HIV testing is offered and made available as a standard part of TB, STI, youth, family planning and antenatal services; A cost effective, humane approach to identifying which clients are most in need of HIV care, including anti retroviral therapy, is to provide some form of counseling and testing in high prevalence HIV settings such as TB clinics. This may take the form of group counseling, provider initiated testing as well as voluntary counseling and testing. Furthermore, the availability or of counseling and testing services need to be advertised at these clinics and should in fact become standard of care. In some TB clinics, the commonest reason given for refusal to test is that patients want to deal with their TB first. The City of Cape Town experience with the repeated offering of counseling and testing is an excellent idea and perhaps should be offered in a more structured way at specific time points in TB care such as on diagnosis of TB, after the intensive phase of TB treatment and at the 5th month of TB treatment. Another compelling reason for offering counseling and testing is the emergence of drug resistant TB including XDR amongst HIV infected individuals who have not been exposed to TB treatment previously, as well as the additional infection control procedures that should be implemented to reduce this risk. The scope of practice of counselors and lay counsellors must be revised so that they are permitted to do HIV tests that require a finger prick, sputum and dried blood sample; In addition, the workplace, learning institutions including schools, cultural and religious institutions must also be given the responsibility of making testing and counseling services available; Messaging and details about testing services and facilities must be made more prominent and regular; and

10 REVISE TREATMENT PROTOCOLS IN CONSULTATION WITH HEALTH PROVIDERS The national adult, paediatric and MTCT treatment protocols have not been revised since They are no longer line with international best practice. This has undermined the ability of doctors and nurses to provide patients with a standard of care recommended by the WHO even for resource poor settings. In other words, our current national treatment protocols are below the WHO minimum standard of care. Given the side effect profile of the drug d4t, clinicians agree that it should be removed as a first line drug and replaced. For this reason the registration of tenofovir by the MCC, which has now been subject to a lengthy process, must be expedited - clinicians have warned that this delay is undermining the possibility of using optimal treatment regimens in the public sector. 12 Single does nvp for pregnant mothers to prevent the risk of maternal HIV transmission during pregnancy, birth or breastfeeding must be replaced with a more optimal multi drug ARV regimen at the very least AZT should be added to the current regimen; A plan to implement the recommendations of the Committee of Inquiry into maternal deaths is needed. In particular, the recommendation that pregnant women with low CD4 counts and where the mother is WHO defined symptomatic be commenced on ART where appropriate. Issues for Integrated Planning: AFFORDABILITY AND SUPPLY OF ESSENTIAL DRUGS The award of the ARV drug tender, announced on 2 March 2005, was to seven pharmaceutical groups two generic and five innovator companies. However, for reasons set out below the tender process has locked government into higher prices than necessary and has limited flexibility of procurement. The tender did not secure lower prices than that ordinarily available to the state through a simple quotation system. Further, it locked the state into inflexible agreements that were unable to take advantage of subsequent price reductions or drug registrations. 13 For example: 12 The WC is recommending using only 30mg D4T. This might reduce the impact of adverse events by 50%. The WC is also recommending that all women who have a BMI of over 28 be treated with AZT and not D4T. This will reduce the chances of toxicity. 13 A limited number or absolute lack of licensees means that prices are not subject to the downward pressure of competition. It also threatens sustainability of supply, particularly when the number of people on ARV treatment risesin particular, it precluded the state from procuring the recently registered fixed-dose combination (FDC) of stavudine/lamivudine/nevirapine, which is one of the two first-line regimens used in the public sector.

11 At the time of the award only five of the ten ARV medicines used in the public sector could be procured from generic companies. 14 Since then, no generic company has managed to secure a voluntary licence to import and/or produce any of four of the remaining medicines. 15 In respect of the fifth ARV medicine, MSD s efavirenz, only Aspen Pharmacare has been licensed. 16 Its product has yet to be registered for use. Given the limited number of potential suppliers for each ARV medicine, 17 the publication of companies best international offers to public sector programmes and the generic pricing agreements facilitated by the Clinton Foundation, in future, a formal tender does not appear to be appropriate. Finally, the slow pace of drug registration by the Medicines Control Council (MCC) effectively blocks access to new ARV medicines (with better efficacy and side-effect profiles) and generic versions of existing ones (limiting competitive pressure and ensuring sustainability of supply). Shift to a quotation system, especially where there are insufficient competitors in respect of any ARV medicine; Where there is no generic competition in respect of any HIV-related medicine, make use of the Medicine Pricing regulations to investigate whether the prices charged are reasonable; In respect of HIV-related medicines that are still under patent (where the patents are enforced), negotiate with the exclusive rights holders MSD and Abbott in particular to ensure that multiple licenses are issued on reasonable terms 18 ; Ensure that contracts allow the state to procure FDCs (when available) and new ARV medicines in accordance with revised treatment protocols; and Ensure that all ARV, TB and other essential medicine dossiers placed before the MCC are in fact fasttracked, which may require additional financial and human resources. Set Targets for Treatment, Care and Prevention In May 2006 the African Union, including South Africa, agreed that by December 2006 countries would include revised, quantified national targets (both interim for2008 and for 2010) for prevention, PMTCT, AIDS treatment and care and support that are consistent with and contribute to the Africa wide targets (see below). 14 The medicines are abacavir (syrup), didanosine (25mg, 50mg and 100mg tablets), efavirenz (50mg and 200mg capsules and 600mg tablets), indinavir (400mg capsules), lamivudine (solution and 150mg tablets), lopinavir/ritonavir (solution and 133/33mg capsules), nevirapine (solution and 200mg tablets), ritonavir (solution and 100mg capsules), stavudine (solution and 20mg, 30mg and 40mg capsules) and zidovudine (syrup, 100mg capsules and 300mg tablets). 15 These four are GlaxoSmithKline s abacavir, MSD s indinavir and Abbott Laboratories lopinavir/ritonavir and ritonavir. 16 Prior to licensing Aspen, MSD licensed Thembalami Pharmaceuticals, a joint venture between an Indian and a South African company. When Thembalami collapsed (as did its licence), Aspen was licensed. MSD has made it plain that it is only prepared to license a single company at this stage. 17 Only zidovudine is no longer under patent. While the exclusive rights in didanosine and stavudine are not enforced in South Africa, only a handful of generic companies have taken advantage. In respect of lamivudine and nevirapine, only two licensees have managed to bring products to market. 18 Where companies are unwilling to negotiate in good faith, threaten to make use of section 4 of the Patents Act, 57 of 1978 to issue licences

12 In June 2006, South Africa signed the UN Political Declaration on HIV/AIDS following the UN High Level meeting. Paragraph 49 stated that: We commit ourselves to setting, in 2006, through inclusive, transparent processes, ambitious national targets, including interim targets for 2008 in accordance with the core indicators recommended by the Joint United Nations Programme on HIV/AIDS, that reflect the commitment of the present Declaration and the urgent need to scale up significantly towards the goal of universal access to comprehensive prevention programmes, treatment, care and support by 2010, and to setting up and maintaining sound and rigorous monitoring and evaluation frameworks within their HIV/AIDS strategies; 19 According to the African Union, the targets to be met by 2010 include the following: i. Reduce HIV prevalence in young people between 15 and 24 years, by at least 25% in ALL African countries ii. Protect and support in 2010, 5 million children orphaned by AIDS and ensure that 80% of orphans and vulnerable children have access to basic services. iii. At least 80% of pregnant women have access to Prevention of Mother-To-Child Transmission (PMTCT), and treatment for HIV-positive women and children. iv. At least 80% access of those in need, particularly children, have access to HIV/AIDS treatment, especially antiretroviral, as well as care and support. Supported by the following: i. At least 80% of target populations access Voluntary Counseling and Testing (VCT) ii. 100% of blood and blood products are safe to reduce the rate of transmission of HIV/AIDS iii. 100% injection safety is ensured iv. At least 80% of target populations have access to prevention and treatment of Sexually Transmitted Infections (STI) v. At least 80% of target population use condoms for HIV prevention ensured vi. 100% of refugees and other displaced persons have access to HIV/AIDS prevention, treatment, care and support when these are available to surrounding host populations vii. 100% of all clients accessing HIV care and support services are screened for TB to ensure early detection and treatment viii. 100% of TB patients have access to HIV testing and counseling services ix. 100% of HIV-positive TB patients access antiretroviral treatment x. 100% access to sexual and reproductive health services including antenatal care We recommend discussion and endorsement of all these targets. ENDS 19 Resolution adopted by the General Assembly 60/262. Political Declaration on HIV/AIDS 87th plenary meeting, 2 June 2006

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