1. Health PolicyTowards an improved investment approach for an eectiveresponse to HIV/AIDSBernhard Schwartlnder, John Stover, Timothy Hallett, Rifat Atun, Carlos Avila, Eleanor Gouws, Michael Bartos, Peter D Ghys, Marjorie Opuni,David Barr, Ramzi Alsallaq, Lori Bollinger, Marcelo de Freitas, Georey Garnett, Charles Holmes, Ken Legins, Yogan Pillay, Anderson Eduardo Stanciole,Craig McClure, Gottfried Hirnschall, Marie Laga, Nancy Padian, on behalf of the Investment Framework Study Group*Substantial changes are needed to achieve a more targeted and strategic approach to investment in the response to thePublished OnlineHIV/AIDS epidemic that will yield long-term dividends. Until now, advocacy for resources has been done on the basisJune 3, 2011 DOI:10.1016/S0140-of a commodity approach that encouraged scaling up of numerous strategies in parallel, irrespective of their relative6736(11)60702-2eects. We propose a strategic investment framework that is intended to support better management of national and *Members listed at end of paperinternational HIV/AIDS responses than exists with the present system. Our framework incorporates major eciency Joint United Nationsgains through community mobilisation, synergies between programme elements, and benets of the extension ofProgramme on HIV/AIDSantiretroviral therapy for prevention of HIV transmission. It proposes three categories of investment, consisting of (UNAIDS), Geneva, Switzerlandsix basic programmatic activities, interventions that create an enabling environment to achieve maximum eectiveness,(B Schwartlnder MD, C Avila MD, E Gouws PhD,and programmatic eorts in other health and development sectors related to HIV/AIDS. The yearly cost of achievement M Bartos MEd, P D Ghys MD,of universal access to HIV prevention, treatment, care, and support by 2015 is estimated at no less than US$22 billion.M Opuni PhD); FuturesImplementation of the new investment framework would avert 122 million new HIV infections and 74 million Institute, Glastonbury, CT, USAdeaths from AIDS between 2011 and 2020 compared with continuation of present approaches, and result in (J Stover MA, L Bollinger PhD); School of Public Health294 million life-years gained. The framework is cost eective at $1060 per life-year gained, and the additional (T Hallett PhD,investment proposed would be largely oset from savings in treatment costs alone.Prof G Garnett PhD) and Imperial College Business SchoolIntroduction priorities as shown by substantial dierences in resource (Prof R Atun FFPHM), Imperial College London, London, UK;By 2010, extraordinary amounts of political commitment,allocation for national HIV/AIDS responses betweenThe Global Fund to Fight AIDS,social mobilisation, and HIV/AIDS funding had resulted neighbouring countries with equivalent epidemics. Un- Tuberculosis and Malaria,in an unprecedented scale-up of HIV/AIDS prevention, systematic prioritisation and investment were allowed toGeneva, Switzerland (R Atun);treatment, care, and support, a decline in incidence ofpersist9 as interests and stakeholders competed for a pro-International Treatment Preparedness Coalition,new HIV infections in several countries, more than portion of available funding for HIV/AIDS, spreadingNew York, NY, USA (D Barr JD);65 million people receiving antiretroviral therapy, and resources thinly between many objectives.10 International Clinical Researchmillions of orphans able to receive basic education, health, New approaches are needed to achieve universal access Center, Department of Globaland social protection.1,2 Such large-scale investments and the specic targets included in the Joint UnitedHealth, University of Washington, Seattle, WA, USAhelped progress towards more tolerant and enabling Nations Programme on HIV/AIDS (UNAIDS) 201115(R Alsallaq PhD); National AIDSsocial environments.3 However, despite these impressivestrategy and the United Nations Secretary Generals Programme, Brasilia, Brazilgains, universal access to prevention, treatment, care, andReport to the General Assembly in June, 2011.4,11 A change(M de Freitas MD); Oce of thesupport for HIV/AIDS is not available worldwide,4 and is from the commodity approach to a targeted strategic US Global AIDS Coordinator, US Presidents Emergency Planunlikely to be achieved with the present pace of changeinvestment programme driven by the latest evidence is for AIDS Relief, Washington,and with the present approaches to investment. needed to produce substantial and lasting eects on the DC, USA (C Holmes MD,Previously set global targets and associated resourceHIV/AIDS epidemic and make the most of investment inN Padian PhD); The Bill &needs estimates5,6 were eective for mobilisation of the response. Melinda Gates Foundation, Seattle, WA, USA (N Padian);unprecedented resources and driving of major progressWe propose an investment framework to support UNICEF, New York, NY, USAin the HIV/AIDS response, but were based on themanagement of national and international HIV/AIDS (K Legins MPH); Strategicprevailing commodity approach that targeted scale-up ofresponses, encourage transparency in programmeHealth Programmes, Department of Health,discrete interventions rather than overall results, and ledobjectives and results, and enable decision makers and Johannesburg, South Africain many cases to fragmentation of the response.7,8 nanciers to galvanise support for eective action. The (Y Pillay PhD); Global HIV/AIDSThe approach adopted until now has various framework dierentiates between basic programme Unit, Health, Nutrition, andshortcomings. First, estimates of future coverage of activities that aim to directly reduce HIV transmission,Population, The World Bank, Washington, DC, USAintervention programmes were made on the basis of a largemorbidity, and mortality; activities that are necessary to (A E Stanciole PhD); Worldnumber of ambitiousand often aspirationaltargets,support the eectiveness and eciency of theseHealth Organization, Geneva,which were not met. Second, subsequent revisions programmes (critical enablers); and investments inSwitzerland (C McClure PGCE,shortened the timeframe available to meet targets, makingother sectors that can have a positive eect on HIV G Hirnschall MD); and Institute of Tropical Medicine, Antwerp,them further out of reach with increasingly unrealisticoutcomes (synergies with development sectors; gure 1). Belgium (Prof M Laga MD)programmatic and cost assumptions. Third, as the The framework promotes prioritisation of eorts on thecomplexities and costs of a public health response to thebasis of a nuanced understanding of countryHIV/AIDS epidemic and the systemic weaknesses that epidemiology and context, and assumes major eciencyimpeded progress became apparent, the commoditygains as delivery of care evolves from facility-based toapproach was not conducive for countries and donors to set community-based structures.12www.thelancet.com Published online June 3, 2011 DOI:10.1016/S0140-6736(11)60702-2 1

2. Health PolicyCorrespondence to:The framework aims to enhance present eorts to these interventions. The aids 2031 project16 subsequentlyDr Bernhard Schwartlnder,make the most of HIV/AIDS responses, including theused much the same model to develop various scenarios Evidence, Strategy and ResultsDepartment, Joint UnitedGlobal Fund to Fight AIDS, Tuberculosis and Malarias for global HIV/AIDS responses; in their most optimisticNations Programme onnew approach to fund countries on the basis of national scenario all component interventions would be includedHIV/AIDS (UNAIDS), 20 Avenuestrategy applications13 rather than discrete projects.14at full scale and lead to the largest eect, whereas in Apia, Geneva, SwitzerlandEqually, the framework supports improved planning less optimistic scenarios various components were schwartlanderb@unaids.orgfor resource allocation in the largest bilateralexcluded with a corresponding reduction of both costsHIV/AIDS programme, the US Presidents Emergencyand outcomes.Plan for AIDS Relief (PEPFAR), which has a new andThe investment framework that we propose departsexplicit focus on increased country ownership.15 Thefrom these approaches in ve important ways. First,framework will encourage countries to make the most elements are included in the framework on the basis ofof their programmatic responses to the epidemic a graduated assessment of the existing evidence of whatthrough careful targeting and selection of the most works in HIV/AIDS prevention, treatment, care andeective interventions. support and is intended to support systematicIn this Health Policy, we present the investmentstrengthening of the evidence base when needed.framework and apply it in a costing exercise undertaken Second, it applies a rigorous approach to estimation ofto estimate the resources needed to implement a globalthe size of the populations in which new infectionsHIV/AIDS response in the next decade. occur on a country-by-country basis and provides abasis for discontinuation of the inecient applicationInvestment frameworkof programmes to the wrong populations or withoutOutline regard to their outcomes. Third, the framework assumesThe approach previously taken by UNAIDS estimated that major eciency gains are possible through shiftingtotal resource needs on the basis of unit costs and of service provision techniques to place greatercoverage targets for all commonly undertakenemphasis on community mobilisation.17 Fourth, theprevention, treatment, care, and support activities for framework emphasises synergies between programmeHIV/AIDS.5,6 Infections and deaths averted were elements and makes an initial attempt to quantify these See Online for webappendix modelled on the basis of the estimated eect of each of interactions (webappendix pp 2829). Fifth, althoughnot a prescriptive approach to programming, theframework is intended to close the conceptual gap Investment frameworkbetween global resource estimation and large-scaleFor whom? Explicitly identify and prioritise populations on the basis of the epidemic proleprogramming to help shape investment strategies to How? Use the human rights approach to achieve diginity and securityachieve the best outcomes for fewest resources(panel 1). ObjectivesOur modelling of the eectiveness of the investment Basic programme activitiesframework suggests that striking numbers of new Critical enablersinfections and deaths could be averted. For full Reduce risk Social enablers PMTCTeectiveness, all of the activities in the framework Political commitment and advocacyshould be delivered through an approach based on Laws, legal policies, and practices Condom promotion and distribution Community mobilisation human rights20 and that is universal, equitable, and Stigma reductionKey populations (sex work, assures inclusion, participation, informed consent, and Mass mediaMSM, IDU programmes) Reduce Local responses to change risk likelihoodaccountability (gure 1). environment Treatment, care, and support of to people living with HIV/AIDS transmissionBasic programme activities Programme enablers(including facility-based testing) Community centred design Basic programme activities have a direct eect on and deliveryMale circumcision* reduction of transmission, morbidity, and mortality Programme communication Management and incentivesReducefrom HIV/AIDS, and should be scaled up according to Behaviour change programmes mortality Procurement and distribution andthe size of the aected population. Such activities Research and innovation morbidityinclude interventions that directly aect incidence,morbidity, and mortality (such as antiretroviral therapy),and more complex interventions21 for which there isplausible evidence22 of their contribution to reduction ofSynergies withSocial protection, education, legal reform, gender equality, poverty reduction, incidence through a speciable results chain (such asdevelopment sectors gender-based violence, health systems (including STI treatment, blood safety),community systems, and employer practicesbehaviour change programmes). The set of activities werecommend is based on an analysis of programmeFigure 1: Proposed framework for the new investment approacheectiveness and cost-eectiveness reported in the*Applicable in generalised epidemics with a low prevalence of male circumcision. MSM=men who have sex with men. published work supplemented by expert opinion inclu-IDU=injecting drug user. PMTCT=prevention of mother-to-child transmission. STI=sexually transmitted infection.ding a consultation process and a series of meetings2www.thelancet.com Published online June 3, 2011 DOI:10.1016/S0140-6736(11)60702-2 3. Health Policywith international HIV/AIDS experts.23,24 Our recom-mendations build on previously published estimates of Panel 1: Intervention programmes for prevention of HIV/AIDSthe eectiveness of HIV prevention interventions in The eectiveness of HIV/AIDS prevention programmes depends on coverage and ecacychanging sexual behaviours.25 of their constituent interventions and the epidemiological context within which theBasic programme activities in the framework range inprogramme operates. The context (ie, the distribution of risks of transmission andcomplexity and consist of procurement, distribution, andacquisition of HIV infection across the population) determines which groups should be amarketing of male and female condoms; activitiespriority for intervention programmes and the extent to which a risk factor needs todesigned to prevent mother-to-child transmission; change to reduce incidence and approach the tipping point at which infection ispromotion of medical male circumcision; integration ofeliminated from those priority groups. The non-linear relation that exists between theactivities addressing key populations, in particular sexepidemic spread of HIV/AIDS and epidemiological features means that substantialworkers, men who have sex with men, and harm- changes might be possible with a few appropriately targeted ecacious interventions.reduction programmes for injecting drug users;This eect can be noted through modelling of two epidemiological contexts: one in abehaviour change programmes that target reduction ofconcentrated epidemic represented by Karachi, Pakistan,18 where transmission occursthe risk of HIV exposure through changing of peoples mainly through injecting drug use, and the second in a generalised epidemic representedbehaviours and social norms; and antiretroviral therapy by KwaZulu-Natal, South Africa (data not shown), where the main route of transmissionprogrammes. is through heterosexual sex. We compared three scenarios for these regions: rst, aMost scientic evidence about prevention eects comes baseline scenario assuming present interventions continue; second, a broad and shallowfrom biomedical prevention interventions, such as the target assuming moderate increases in treatment coverage and declines in multiplebiomedical aspects of prevention of mother-to-child sexual risk behaviours (and injection risk in Karachi); and third, a narrow and deep targettransmission26 and male circumcision,2729 in part becauseassuming widespread treatment and a high coverage of the most demonstrablythese interventions are less complex, clearly dened, and ecacious interventions (adult male circumcision in KwaZulu-Natal and needle exchangeeasier to assess than are other interventions, especially in Karachi; table 1, gure 2). For every scenario, we assumed antiretroviral therapy wouldwhen they are undertaken within discrete health-carereduce transmission by 92%.19settings or in randomised, controlled trials.Our modelling results suggest that the most targeted approach provides the greatestBehaviour change in key populations is a complexeect, especially in locations where the HIV/AIDS epidemic is most concentrated.intervention but has a major eect on the trajectory ofHowever, any comparison of programmes depends on the costs of combining theconcentrated and low-scale epidemics.30 By denition,dierent interventions within the programmes and the ability of the programmes tokey populations predominate in concentrated epidemicsachieve prespecied intermediate outcomes.but are also present in generalised epidemics, in whichthey contribute an appreciable and in some casessubstantial portion of the epidemic.31,32 In addition toBroad and shallow Narrow and deepgroups that are noted in many epidemics such as sexworkers and clients, men who have sex with men, and Karachi,50% coverage of antiretroviral therapy (CD4 cell count80% coverage of antiretroviralPakistanof