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An exploratory analysis of cross-country access to antiretroviral treatment1

CSSR Working Paper No. 117

Nicoli Nattrass

Centre for Social Science Research, University of Cape Town

June 2005

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The past five years have seen a groundswell of public opinion and policy in favour of expanding access to highly active antiretroviral therapy (HAART) in developing countries. Important milestones in this regard have been the launch of the $15 billion United State’s President’s Emergency Plan for AIDS Relief (PEPFAR) and the announcement on World AIDS Day 2003 by the World Health Organisation and UNAIDS of a concrete plan to provide HAART to three million people by the end of 2005. Key elements of this ‘three by five’ strategy include developing country-level support and capacity building, harnessing additional donor funding and ensuring a cost-effective and reliable supply of medication.2

This unprecedented international effort has resulted in dramatic increases in the numbers of people accessing HAART in developing and transitional countries. Between June 2004 and December 2004, the number of people on HAART more than doubled in Sub-Saharan Africa and the developing and transitional country total rose from 400,000 to 700,000 (see Table One). But whilst recognising the centrality of this international mobilisation in favour of greater HAART coverage, UNAIDS and the World Health Organisation are at pains to stress that success will “ultimately depend on continued strong commitment and follow-through by governments”.3

Governments clearly play a central role in determining country-level access to HAART. This is illustrated vividly by the contrasting cases of three high HIV prevalence neighbouring Southern African countries at similar levels of development: Botswana (adult HIV prevalence of 37 percent), Namibia (21 percent) and South Africa (22 percent). Whereas by the end of 2004, Botswana had succeeded in providing HAART to 50 percent of those estimated to need it, and Namibia had reached 28 percent respectively, South Africa had provided HAART to a mere seven percent of those living with AIDS. AIDS prevention and treatment policies are political priorities in Botswana and Namibia, but are mired in confusion and political dissembling in South Africa (Nattrass, 2004; Phororo et al, 2004; WHO, 2005).

Table 1: HAART Coverage in Developing and Transitional Countries

However, political commitment is far from the only reason why AIDS-affected developing countries are likely to differ in terms of HAART coverage. Factors such as resource availability, institutional characteristics and the scale of the epidemic are also likely to be relevant. It is thus instructive to examine the international data to see if empirical regularities exist which might help ‘explain’ the cross-country distribution of HAART coverage.

This paper investigates some possible determinants of HAART coverage through exploratory regression analysis using data from World Health Organisation (2005), UNAIDS and the World Bank.4 Following UNAIDS and the World Health Organisation, HAART coverage is defined as the number of adults on HAART expressed as a percentage of the number estimated to need it in each country. The bulk of the empirical work was conducted using HAART coverage as of December 2004. However, in order to highlight how the international effort to improve access to HAART has changed the situation, regression analysis on HAART coverage as of June 2004 is also included at key points in the paper for comparative purposes.

  1. I am grateful to Jim Levinsohn, Martin Wittenberg and Ali Tasiran for their comments on earlier drafts and to Tom Scott for his research assistance.

  2. Details of the ‘three by five’ initiative’ can be found on

  3. Press release on the December 2004 progress report of the 3 by 5 initiative, available on

  4. Data from the World Bank are available on AIDS-related data are available from the World Health Organisation ( and via links on the UNAIDS website (

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