- 1. UNAIDS ISSUES BRIEF | 2011 A NEWINVESTMENTFRAMEWORKFOR THE
GLOBAL HIVRESPONSE
2. Copyright 2011Joint United Nations Programme on HIV/AIDS
(UNAIDS)All rights reservedThe designations employed and the
presentation of the material in this publication do not imply
theexpression of any opinion whatsoever on the part of UNAIDS
concerning the legal status of any country,territory, city or area
or of its authorities, or concerning the delimitation of its
frontiers or boundaries.UNAIDS does not warrant that the
information published in this publication is complete and correct
andshall not be liable for any damages incurred as a result of its
use.UNAIDS/JC2244E (English original, October 2011) 3. UNAIDS
ISSUES BRIEF A NEW INVESTMENTFRAMEWORK FOR THE GLOBALHIV
RESPONSEOver the past 30 years there havebeen tremendous gains in
the globalHIV response, but until now therehas been only limited
systematic effortto match needs with investments. Theresult is
often a mismatch of the two,and valuable resources are
stretchedinefficiently across many objectives.To achieve an optimal
HIV response,countries and their internationalpartners must adopt a
more strategicapproach to investments. 4. A new investmentframework
for HIVThe investment framework offersa realistic, achievable road
mapto decisively accelerate progress inthe global HIV responseIn
June 2011 a policy paper was publishedAims of the investmentin The
Lancet (Schwartlnder et al) that laidframeworkout a new framework
for investment for theglobal HIV response. The new framework
Maximize the benefits of the HIVis based on existing evidence of
what worksresponsein HIV prevention, treatment, care and Support
more rational resourcesupport. It is intended to facilitate more
allocation based on countryfocused and strategic use of scarce
resources. epidemiology and context Encourage countries to
prioritizeModelling of the frameworks impact showsand implement the
most effectivethat its implementation would avertprogrammatic
activities12.2 million new infections and 7.4 millionIncrease
efficiency in HIV prevention,AIDS-related deaths between 2011 and
2020. treatment, care and support programmingThis modelling also
indicates thatimplementation of the investment Though much has been
achieved in theframework is highly cost-effective, with global HIV
response over the last 30 years,additional investment largely
offset byimportant gaps remain. Currently, strategiessavings in
treatment costs alone, andare often implemented in parallel,
regardlessenabling the HIV response to reach anof how they might
overlap or leave criticalinflection point in both investments and
gaps in coverage. Through a simplificationrates of HIV
infection.and clarification of the different elements of HIV
efforts, as well as better support forThe framework was developed
by an countries to prioritise HIV programmesinternational group of
experts from the Joint and assess the synergies between them,
theUnited Nations Programme on HIV/AIDS framework presents a
radical departure from(UNAIDS), The Global Fund to Fights AIDS,
existing approaches to HIV investment andTuberculosis and Malaria,
the US Presidents programming.Emergency Plan for AIDS Relief, The
Bill& Melinda Gates Foundation, The WorldBank, the World Health
Organization andacademic and policy institutions.2UNAIDS | A new
investment framework for the global HIV response 5. Proposed
Investment FrameworkFIGURE 1: Proposed Investment
FrameworkCRITICALBASIC PROGRAMME ACTIVITIESOBJECTIVESENABLERSKey
populations atSocial enablers higher riskEliminate new
HIVinfections advocacy among children drugs) practices mobilization
Stopping new infectionsreductionmediaBehaviour changerprogrammes
Condom promotionand distribution environmentProgramme
enablerscenterdeliveryKeeping people alive Pr
communicationVoluntarymedical male incentives circumcision Procur
distribution pr Treatment, Researc care and circumcision)
innovationsupport for people living with HIV SYNERGIES WITH
DEVELOPMENT SECTORSprrefor equalityr Genderviolence, trpractices.
Key components of theBasic programme activities investment
framework Just six basic programme activities are essential toan
adequate HIV response and need to be deliveredBasic programme
activitiesat scale according to the size of the relevantCritical
enablers population. These activities work together forSynergies
with development sectorsmaximum impact and should therefore be
deliveredas a package, where each element reinforces the other. The
investment framework takes as its starting point a human rights
approach to theThey are: HIV response, to ensure that it is
universal,1. Focused programmes for key populations equitable,
inclusive, and fosters participation,at higher risk (particularly
sex workers and informed consent and accountability.their clients,
men who have sex with men, and people who inject drugs); The
framework makes a distinction between2. Elimination of new HIV
infections in children; basic programme activities that have a
direct3. Programmes that focus on the reduction of risk effect on
HIV risk, transmission, morbidity of HIV exposure through changing
peoples and mortality; the critical enablers that are behaviour and
social norms; crucial to the success of HIV programmes;4.
Procurement, distribution and marketing of and synergies with
development sectorsmale and female condoms; (Figure 1).5.
Treatment, care and support for people living with HIV;6. Voluntary
medical male circumcision in countries with high HIV prevalence and
low rates of circumcision. A new investment framework for the
global HIV response | UNAIDS3 6. Implementing the framework will
avert 12.2 million new infections and 7.4 million AIDS-related
deaths between 2011 and 2020.The evidence base for the basic
programmesamenable to generic description, vary greatlyis strongest
in relation to biomedical inter- according to context and are
underpinned byventions such as voluntary medical male a weaker
evidence base.circumcision and the biomedical aspectsHowever, they
increase the impact ofof eliminating new HIV infections amongbasic
programme activities by overcomingchildren. Although behaviour
changebarriers to the adoption of evidence-basedprogrammes tend to
be more complex andHIV policies and the factors that adverselyless
clearly defined, changes in behaviouraffect HIV programmes by
distortinghave been associated with declines in HIVtheir
priorities, including social stigma,prevalence. Key populations, by
definition,poor health literacy and a punitive legalpredominate in
concentrated epidemics.environment.However, they also contribute to
generalized(where HIV prevalence among pregnantExamples of social
enablers are outreach forwomen consistently exceeds 1%)
epidemicsHIV testing, stigma reduction, human rightsand in some
cases account for a substantial advocacy, and community
mobilization.proportion of the epidemic. Basic activitiesProgramme
enablers include strategicfor key populations include focused
commu-planning, programme management andnication, education and
condom program- capacity building for community-basedming tailored
to each populations needs. organizations. Community mobilization
isa key element of the investment frameworkAccess to antiretroviral
therapy is a keybecause it leads to improved uptake ofprogramme
activity of the HIV response.HIV programmes and promotes
local-levelNot only does ART reduce morbidity andadvocacy,
transparency and accountability.mortality among people infected
with HIV,Community mobilization has been recognizedit also reduces
the incidence of AIDS-as a cornerstone of HIV programmes.related
tuberculosis, and has public healthbenefits in terms of reducing
the onwardSynergies with developmenttransmission of HIV.
Community-ledsectorsdelivery approaches to treatment are
animportant component of the framework. HIV programmes are not
implementedin isolation. The investment frameworkCritical enablers
recognizes the need for the HIV response tobe aligned to country
development objectivesUnderlying the success of basic programmeand
to support the strengthening of social,activities are the enablers
which makelegal and health systems.programme access possible and
success morelikely and respond to local context. Critical Social
protection, increasing access toenablers can be divided into two
categories:education, legal reform, poverty reduction,social
enablers that create environmentsreducing gender-based violence,
andconducive to rational HIV responses, andimproving health,
community andprogramme enablers that create demand employment
systems are all key areas wherefor programmes and improve
theirthere are synergies between HIV-specificperformance. Critical
enablers are not always efforts and development.4 UNAIDS | A new
investment framework for the global HIV response 7. TABLE 1: RETURN
ON INVESTMENT IN THE PROPOSED FRAMEWORK2011-20152011-2020Total
infections averted 4 200 000 12 200 000 (US$ 2450 each)Infant and
child infections averted 680 000 1 900 000 (US$ 2180 each)Life
years gained3 700 00029 400 000 ( US$ 1060 each)Deaths averted 1
960 0007 400 000 (US$ 4090 each)Resources needed to implementthe
investment frameworkModelling of the frameworks impact There will
also be efficiency gains such asand cost demonstrates how it can
lead cost-saving on treatment commodities andto universal access to
HIV prevention,a shift to community-based treatment andtreatment,
care and support, and create testing.a tipping point in both the
rate ofHIV infection and investment in HIV Whereas basic programme
costs in 2011programmes. stand at US$7 billion, in the model
theyare US$12.9 billion in 2015, dropping toImplementation of the
investmentUS$10.9 billion in 2020 (Table 2, Figure 2).framework is
estimated to avert 12.2 millionnew HIV infections including 1.9
millionThe single largest cost is treatment, care andHIV infections
among children, 7.4 millionsupport, accounting for 38% of the
increaseAIDS-related deaths between 2011 and 2020,in resources
(Figure 2). Other contributorsand result in a gain of 29.4 million
life-years to the cost increase include doubling(Table 1). At
US$1060 per life-year gained, the coverage of outreach and needle
andthe additional investment required would be syringe programmes
and a 10-fold increaselargely offset by savings in future treatment
in provision of drug substitution forcosts alone.injecting drug
users, as well as increasedcoverage of prevention of
mother-to-childCosts are based on what is needed totransmission to
reach 90% of all child-increase present rates of coverage to
bearing women living with HIV, so thatachieve universal access to
HIV prevention, new HIV infections among children can betreatment,
care and support by 2015 and eliminated by 2015.to maintain it at
that level of access. Theinvestment framework model requires a
Costs for critical enablers would fall fromscaling-up of HIV
programme funding US$5.9 billion in 2011 to US$3.4 billionfrom
US$16.6 billion in 2011 to US$22.0 in 2015 before increasing
slightly tobillion in 2015, before declining to US$19.8US$3.7
billion in 2020 due to a shift frombillion in 2020 (Table 2, Figure
2).comparatively expensive facility-basedvoluntary HIV counselling
and testing to lessFewer resources will be needed becauseexpensive
and more focused community-coverage will have reached target rates
and based programmes (Table 2, Figure 2). In thethere will be fewer
new HIV infectionsmodel 316 million people will receive
HIVrequiring treatment and other services. testing in 2015.A new
investment framework for the global HIV response | UNAIDS 5 8.
TABLE 2: RESOURCES REQUIRED FOR THE INVESTMENT FRAMEWORK OVER
TIME(billions of US$)20112015 2020Basic programmes (total) 7.0 12.9
10.6Key populations at higher risk 1.0 3.32.5Elimination of new
infections in children0.9 1.51.3Behaviour change programmes0.1
0.70.7Condom promotion and distribution0.4 0.50.6Treatment, care
and support for people living with 4.5 6.75.5HIVVoluntary medical
male circumcision0.1 0.20.1Critical enablers5.9 3.43.7Synergies
with development sectors 3.6 5.85.4TOTAL16.622.0 19.8Synergies with
development sectors require programme elements are effective andan
increase in funding from US$3.6 billion ineffective. This, in turn,
empowers the HIVin 2015 to US$5.8 billion in 2015 and US$5.4
response to be based on fewer things done atbillion in 2020 (Table
2, Figure 2). These a deeper level, and it offers clear
incentivesestimates are based on the costs of a rangeto maximise
the synergies between theof programmes such as those focussed
ondifferent elements of HIV programmes.gender-based violence, youth
in schools,workplace education and caring for childrenOne of the
limitations of the investmentorphaned by HIV. framework is that it
lays out a defined set of evidence-based basic programmes, but
doesStrengths andnot explore what delivery models deliver optimum
results when interventions arelimitations of the combined and
expanded. It is crucial toinvestment framework identify the best
ways to scale up bundled HIV interventions.The investment framework
offers a realistic, Another shortcoming of the investmentachievable
road map to decisively accelerate framework is that while there is
an everprogress in the global HIV response. One growing body of
evidence on the effectivenessof its major strengths is that it is
based on and cost-effectiveness of basic programmes,the best
available evidence on what works there is more limited evidence
availablein HIV prevention, treatment, care and for critical
enablers and synergies withsupport. Moreover, the framework allows
development sectors. Further research isadaptation as new evidence
emerges,especially if new technologies or approaches needed to
better understand the barriers toshow that they directly affect HIV
incidence,effective HIV responses and factors enablingmorbidity and
mortality and can be them; to quantify key enabling
interventions;consistently scaled up.and to demonstrate their
cost-effectiveness. In particular, improved evidence is neededThe
framework enables countries to respond on the best approaches to
communityto HIV based on their own priorities. It mobilisation and
community-led delivery ofsimplifies the process of determining what
programmes, as well as their costs.6 UNAIDS | A new investment
framework for the global HIV response 9. FIGURE 2: ESTIMATED COST
OF THE INVESTMENT FRAMEWORK, 2011-20Synergies with development
sectorsCritical enablersVoluntary medical male
circumcisionTreatment, care and support for people living with
HIVCondom promotion and distributionBehaviour change
programmesElimination of new infections in childrenKey populations
at higher risk2520Cost (billions US$)15105020112012 20132014
201520162017 201820192020 Year Implementing the of existing HIV
prevention, treatment, careand support programmes as well as their
investment framework costs, enabling factors and potential
barriersto implementation. With this information, In countries,
governments and their partners countries can then prioritize
activities and can apply the investment framework toimplement a
carefully focused and more guide HIV responses and make the most of
effective response. In most countries this will their
programmes.mean changing investments in HIV and a To implement the
investment framework, re-programming of HIV efforts. policy makers
must make use of informationAt the global level, the investment on
HIV incidence and prevalence as well asframework will enhance
present efforts to the populations at highest risk of acquiringmake
the most of HIV responses, including HIV, the geographic
distribution of HIV andthe Global Funds new approach to fund the
proximate and structural determinants ofcountries on the basis of
national strategy transmission.applications rather than discrete
projects, They must also have a nuancedand PEPFARs new and explicit
focus on understanding of the scope and coverageincreased country
ownership.A new investment framework for the global HIV response |
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