According to the World Health Organization (WHO), six million people living with HIV/AIDS need treatment today. Yet, as of July 2002, only 230,000 people in the developing world have had access to antiretroviral therapy (ART). Half of these people live in Brazil. In Africa, there are fewer than 50,000 people estimated to be currently receiving ART. WHO has bravely targeted 50% coverage of ART by 2005. That means 3 million people could be on HAART in 3 years, a more than 10-fold increase in the current figures. Bob Huff, in this issue of Treatment Issues, has called this WHO's "moonshot challenge".

The year 2002 has thus become a pivotal point when the fate of millions of people living with HIV is decided. Will we collectively take up this challenge or will we ignore it? I think we have no choice but to answer WHO's call. Without immediate action, the six million who need treatment today will be dead soon enough, and 70 million will die of AIDS by 2022. Challenges like this can only be made once; such dramatic goals do not stand up well to failure -- we won't be able to say "let's try it again" in 2005, if we haven't made substantial progress by then.

Unlike many of the moonshot challenges that have been made during the AIDS epidemic such as the call for a vaccine by 2010 or a Manhattan Project to develop a cure for AIDS, this task doesn't depend on the serendipity of science to offer us our "holy grail." We are facing a logistical problem, albeit a massive one: how do we get the existing drugs to the people who need them? With enough resources and a gigantic mobilization of people and expertise, we can treat 3 million people in 3 years.

According to the Congressional Budget Office, the war in Afghanistan probably will cost $10.2 billion this year. I am mentioning the war in Afghanistan not to make a guns-into-butter appeal to the U.S. government, but to just document the scale of what we need to have happen, and a current example of a successful mobilization of this size.

We need to get busy. Before the end of this year, there must be a roadmap in hand for getting us to our goal of treating 3 million in 3 years. This roadmap needs to offer a comprehensive plan for action: from procurement and delivery of drugs and associated products (e.g. diagnostic tests), to technical assistance; from financing options, to education and mobilization efforts for people with HIV/AIDS; from resistance surveillance to recruitment, training and retention of health-care workers... the list goes on and on.

We also desperately need leadership. While the Barcelona AIDS conference was notable for the emergence of a new, unequivocal consensus on the urgency of delivering treatment to the millions of those who need it, a plethora of different efforts and initiatives have now been launched or are in the planning stages. An effort on the scale of what the WHO is suggesting needs a "general," or at least someone with experience and expertise in large public health initiatives to push this forward. We should look to individuals with experience in scaling up public health programs for other diseases, including TB, river blindness, trachoma, polio, smallpox and malaria or even to people who have experience outside of the health field in large-scale mobilizations, yes, including military leaders -- real generals.

Finally, while the resources for treating 3 million people in 3 years will come from a variety of sources, including the Global Fund for AIDS, TB and Malaria, the United States will have to pony up a significant chunk of the resources for this task. So far, the Bush Administration has done almost nothing towards promoting access to treatment in the developing world. With a new global consensus on treatment, it's time for President Bush to step up and lead. It can be his "Nixon in China" moment, where the unlikeliest of characters can make history, and in this case save millions of lives.

In his speech during the opening plenary at the Barcelona conference, Bernhard Schwartlander, the new chief of WHO's AIDS program, made a plea to the assembled audience: "The time for excuses has run out. Challenges remain -- that's why we're here. But the pieces are finally coming together. Two years from now, when we meet again in Bangkok, let this presentation look not simply at the number of new infections, but how many lives we have saved."

We need to answer WHO's rallying cry and run forward to join this fight.