This 98-page report, published by the International Treatment Preparedness Coalition (ITPC) in November 2005, looks at the status of anti-retroviral treatment provision in low income countries around the world.

Researched and written by treatment advocates on the frontlines in six of the countries considered to be hardest hit by AIDS - Dominican Republic, India, Kenya, Nigeria, Russia, and South Africa - the report identifies barriers to AIDS treatment and offers concrete recommendations to overcome them. Among the roadblocks identified are:

• inadequate leadership at the national level in several countries,
• a global system that does not collaborate speedily and efficiently to address bottlenecks,
• a severe shortage of health care workers,
• lack of necessary funding,
• bureaucratic delays that prevent resources from reaching treatment programmes, and
• pervasive stigma against people living with HIV/AIDS.

The World Health Organization's (WHO) "3 by 5" target was missed in part because of these roadblocks, and at least four million men, women and children around the world are still in need of treatment. The G8 countries have committed to coming as close as possible to universal treatment access by 2010, but according to this report, the world will not come anywhere near this goal unless changes are made at the national and global level.

The report found:

• 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 antiretrovirals (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 programmes.
• In India 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 there is widespread stigma and discrimination against women and people living with HIV/AIDS, misinformation, lack of treatment literacy, and insufficient resources to meet basic nutrition needs or afford travel to health clinics for care.
• In Nigeria lack of adequate funding and human resources complicate treatment expansion, and 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 programmes both undermine scale up efforts.
• In Russia treatment is hampered by 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. Further, widespread discrimination against intravenous drug users inhibits scale up at an even more fundamental level.
• In South Africa the 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 criticised. Many practical problems inhibit scale up as well, including a severe shortfall of health providers, limited access to HIV testing, and inadequate availability of drugs.

The on-the-ground experience documented by ITPC's country research teams offers potential insights for organisations working to provide treatment access, and the report includes overarching recommendations for national and international programmes, as well as detailed recommendations for each country, including:

• UN agencies should work more collaboratively and play a more active role in identifying national problems and marshalling their strengths to address these challenges.
• National governments need to honestly assess the problems with treatment delivery and develop local strategies for resolving them.
• Every level - from individuals to village leaders to national legislators and international policymakers - must work systematically to end stigma.

"Missing the Target: A Report on HIV/AIDS Treatment Access from the Frontlines" marks the first time that treatment activists have come together from every affected continent to publicly address national and international barriers to universal treatment access. According to this report, ITPC's 600 "activists without borders" have pledged to work together and with governments, international agencies, non-governmental organisations, the pharmaceutical industry, and others to find solutions to the problems of lack of treatment access.