ery systems, the lack of knowledge about treatment, and the threat of drug resistance (McCoy and Loewenson, 2004). In order to meet some of these challenges, several developing countries are engaged in efforts to create national HIV/AIDS programs that steadily expand their public health sector capacity with the long-term goal of providing universal HIV/AIDS treatment.

As countries start or continue to scale up their national antiretroviral (ARV) programs they will encounter difficult ethical decisions, including decisions about who should receive the limited available treatment. These choices will undoubtedly test their moral and ethical values. In the end, because not everyone will have immediate access to life-saving drugs, tragic choices will have to be made. However, if the scale-up programs are successful they will offer a world of hope to millions of people who are in dire need of treatment and have no other means of receiving effective therapy. Because there is a population in immediate and dire need of treatment, decisions must be made with a degree of boldness. But because the process is being scaled-up in an environment of great uncertainty, and because tragic choices will inevitably be made, these decisions must also be approached with a level of humility.

PROGRESS IN ARV SCALE-UP PROGRAMS

In the last two decades, over 30 million people have died of HIV/AIDS. Today, an estimated 40 million people live with HIV/AIDS—approximately 28.5 million of them in sub-Saharan Africa (WHO, 2003a). Outside of Africa, the Caribbean is the region hardest hit by HIV/AIDS (UNAIDS, 2003), but the HIV epidemic is also quickly growing in other areas such as India, Russia, and China. Unfortunately, of the 6 million people in developing countries who currently need ARV therapy, fewer than 8 percent are receiving it, and without rapid access to properly managed treatment these millions of women, children, and men will die (WHO, 2003a). ARVs, especially when used in combinations of three or more, can dramatically improve the health of people living with HIV/AIDS around the world (Wood et al., 2000). Unfortunately, for the vast majority of infected people in need, ARVs have been out of reach—until now.

In a span of about two years, mainly due to pressure from human rights and civil society organizations, we have seen the initiation of new programs such as The Global Fund to Fight AIDS, Tuberculosis, and Malaria, the United States Presidential Emergency Plan for AIDS Relief (United States Aid ), and the World Health Organization’s Three by Five Program, which aims to treat three million people in five years (WHO, 2003b). Global funding for HIV/AIDS in resource constrained countries has, as a result, increased from just over $300 million in 1999 to an unprecedented



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