The investment framework - Critical enablers are not a luxury!

Bernhard Schwartlander

Good progress towards 15 million people on antiretroviral treatment by 2015

Source: UNAIDS, 2012

Good progress towards elimination of new HIV infections among children (0–14 years) by 2015

Source: UNAIDS, 2012

Maternal access to ARVs needs to be consistent, to boost coverage during breastfeeding

Percentage of eligible mother-child pairs receiving effective prophylaxis to prevent new HIV infections among children, low- and middle-income countries, 2011

Source: UNAIDS, 2012

During pregnancy and delivery During breastfeeding29%

Source: UNAIDS, 2012

HIV incidence: we are NOT on track to achieve the goal of reducing adult HIV infections by half by 2015

AIDS: investing strategically to maximize impact

SYNERGIES WITH DEVELOPMENT SECTORS

CRITICAL ENABLERS

Treatment & care

Male circumcision

Keeping people alive

Keypopulations

OBJECTIVES

Stopping new infections

Behaviourchange

BASIC PROGRAMME ACTIVITIES

• Social

• Programme

Child infections & maternalmortality

Condoms

Current and projected number of new HIV infections

Optimized investment could lead to rapid declines in new HIV infections

Source: UNAIDS 2011

Investment approach

Baseline

Vietnam Nigeria

1990 2015 1990 2015

Cambodia

1990 2015

South Africa

1990 2015

Zimbabwe

1990 2015

Ukraine

1990 2015

Critical enablers and development synergies are distinct, but on a continuum

Developmentsynergies

Criticalenablers

HIV-specific(sole or primaryobjective is anHIV-related outcome)

HIV-sensitive(HIV outcomeis one of many

objectives)

A checklist for applying investment thinking

Source: UNAIDS

Num

ber

of n

ew H

IV in

fect

ions

300 000

-1980 1990 2000 2010

Russian Federation

Brazil

Value for money: doing the right things

Morocco: reallocation to invest where the epidemic is happening

Source: Morocco Ministry of Health, National STI/HIV Programme, HIV modes of transmission in Morocco. August 2010.

Generalpopulation

Sex workersand clients

MSM IDU Key populations (other)

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Per

cen

eta

ge (

%)

80

0

Proposed spending, National Strategic Plan for 2012–2016

People acquiring HIV infection (2009)

Spending on HIV prevention (2008)

Significant reductions in cost for HIV treatment

Ethiopia Zambia0

100

200

300

400

500

600

700

2006 2010/1120062010/11

- 71% - 60%

Costs for facility-level ART including costs for ARVs, personnel, labs, training, etc.

Cos

t per

per

son/

year

US

$

Sources: Menzies et al 2011; CHAI, 2012; Bollinger & Adesina, 2011

Community support keeps people on treatment

Source: Decroo T et al. Distribution of antiretroviral treatment through self-forming groups of patients in Tete province, Mozambique. Journal of Acquired Immune Deficiency Syndromes, 2010 [Epub ahead of print].

Source: Fox MP, Rosen S. Patient retention in antiretroviral therapy programs up to three years on treatment in sub-Saharan Africa, 2007–2009: systematic review. Tropical Medicine and International Health, 2010, 15(Suppl. 1):1–15.

CLINIC-BASED TREATMENT

Sub-Saharan Africa: people receiving ART from specialist clinics

still receiving treatment after two years70%

COMMUNITY TREATMENT MODEL

Mozambique: self-initiated community model

still receiving treatment after two years98%

Sources: Fox MP, Rosen S. Tropical Medicine and International Health, 2010. Decroo T et al. Journal of Acquired Immune Deficiency Syndromes, 2010.

Community mobilization increases effectiveness

Community mobilisation increased HIV testing rates four-fold in Tanzania, Zimbabwe, South Africa and Thailand

Consistent condom use in the past 12 months was 4 times higher in communities with good community engagement (Kenya)

Hypothetical circumcision model KwaZulu-Natal : Core intervention: 240,000 infections averted over ten years With enablers: 420,000 infections averted, with modest marginal

increase in costs

Legal literacy (know your rights and laws)

Legal services

Law reform

Stigma reduction

Police training on non-discrimination, space for outreach, non-harassment, etc.

Health care worker training on non-discrimination, informed consent, confidentiality, duty to treat, infection control

Elimination of violence against women and harmful gender norms

Critical enablers improve the legal and social environment

Source: Gardner E M et al. Clin Infect Dis. 2011;52:793-800

Percentage of people retained in treatment and care after diagnosis, USA

Dignosed Linked to care Retained in care Eligible for ART Iniatiated ART Adherent/undetectable

Tested <30 days

USA

Diagnosedwith HIV

Linked/enrolled in care

Eligiblefor ART

InitiatedART

Adherentor

undetectableRetained

in care

100%

0

Ret

aine

d in

tr

eatm

ent a

nd c

are

Percentage of people retained in treatment and care after diagnosis, USA and Mozambique

Source: Gardner E M et al. Clin Infect Dis. 2011;52:793-800; Micek et al JAIDS 2009

Dignosed Linked to care Retained in care Eligible for ART Iniatiated ART Adherent/undetectable

Tested <30 days

Mozambique

USA

Diagnosedwith HIV

Linked/enrolled in care

Eligiblefor ART

InitiatedART

Adherentor

undetectableRetained

in care

100%

0

Ret

aine

d in

tr

eatm

ent a

nd c

are

Percentage of people retained in treatment and care after diagnosis, USA and Mozambique

Source: Gardner E M et al. Clin Infect Dis. 2011;52:793-800; Micek et al JAIDS 2009

To improve testing: Reduce stigma in the community and in

healthcare settings Strengthen community support and

referral networks Enhance human rights literacy

Dignosed Linked to care Retained in care Eligible for ART Iniatiated ART Adherent/undetectable

Tested <30 days

Mozambique

USA

Diagnosedwith HIV

Linked/enrolled in care

Eligiblefor ART

InitiatedART

Adherentor

undetectableRetained

in care

100%

0

Ret

aine

d in

tr

eatm

ent a

nd c

are

Percentage of people retained in treatment and care after diagnosis, USA and Mozambique

Source: Gardner E M et al. Clin Infect Dis. 2011;52:793-800; Micek et al JAIDS 2009

Improve enrolment in care: Expand community-centred

delivery Overcome cost & transport barriers Enhance treatment & rights literacy

Dignosed Linked to care Retained in care Eligible for ART Iniatiated ART Adherent/undetectable

Tested <30 days

Mozambique

USA

Diagnosedwith HIV

Linked/enrolled in care

Eligiblefor ART

InitiatedART

Adherentor

undetectableRetained

in care

100%

0

Ret

aine

d in

tr

eatm

ent a

nd c

are

Percentage of people retained in treatment and care after diagnosis, USA and Mozambique

Source: Gardner E M et al. Clin Infect Dis. 2011;52:793-800; Micek et al JAIDS 2009

Get more people on treatment: Enhance peer support programmes Reduce costs Overcome transport barriers Ensure adequate nutrition Reduce stigma in healthcare settings

Dignosed Linked to care Retained in care Eligible for ART Iniatiated ART Adherent/undetectable

Tested <30 days

Mozambique

USA

Diagnosedwith HIV

Linked/enrolled in care

Eligiblefor ART

InitiatedART

Adherentor

undetectableRetained

in care

100%

0

Ret

aine

d in

tr

eatm

ent a

nd c

are

Percentage of people retained in treatment and care after diagnosis, USA and Mozambique

Source: Gardner E M et al. Clin Infect Dis. 2011;52:793-800; Micek et al JAIDS 2009

Retain people on treatment: Adherence support programmes Reduce gender inequalities Reduce fear of disclosure Overcome cost and transport barriers Referral and support programmes for

migrants

Dignosed Linked to care Retained in care Eligible for ART Iniatiated ART Adherent/undetectable

Tested <30 days

Mozambique

USA

Diagnosedwith HIV

Linked/enrolled in care

Eligiblefor ART

InitiatedART

Adherentor

undetectableRetained

in care

100%

0

Ret

aine

d in

tr

eatm

ent a

nd c

are