A new Investment Framework for the Response to AIDS

More Value for the Money within a Framework of Shared Responsibility

Resources available for HIV in low and middle income countries, 1986-2010

We have done a lot…

Unprecedented scale up of HIV prevention, treatment, care and support

Decline in rate of new HIV infections in many countries

More than 6.6 million people on ART

Millions of orphans receiving basic education, health, social protection

But we can do better

Scale up to date guided by a “commodity approach”

Unsystematic prioritisation and investment with limited basis in country epidemiology and context

Resources spread thinly across many parallel interventions

Focus on discrete interventions rather than overall results leading to a fragmented response

New Investment Framework

SYNERGIES WITH DEVELOPMENT SECTORSSocial protection; Education; Legal Reform; Gender equality; Poverty reduction; Gender-based violence; Health systems (incl. treatment of STIs, blood safety); Community systems; Employer practices.

CRITICAL ENABLERS

Social enablers• Political commitment &

advocacy• Laws, policies &

practices• Community

mobilization• Stigma reduction• Mass media• Local responses, to

change risk environment

Programme enablers• Community-centered

design & delivery• Programme

communication• Management & incentives• Production & distribution• Research & innovation

Care & treatment

Male circumcision

Keeping people alive

BASIC PROGRAMME ACTIVITIES

Keypopulations

Children &mothers

Condoms

OBJECTIVES

Stopping new infections

Behaviourchange

0

5

10

15

20

25

30

35

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Three investment scenariosImpact on the epidemic

USD

(Bill

ions

)

- 2.5- 2.0- 1.5- 1.0- 0.5- 0 N

ew H

IV In

fecti

ons

(mill

ions

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Business as usual- 2.5- 2.0- 1.5- 1.0- 0.5- 0 N

ew H

IV In

fecti

ons

(mill

ions

)

0

5

10

15

20

25

30

35

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

USD

(Bill

ions

)

Business as usual

Investment framework

- 2.5- 2.0- 1.5- 1.0- 0.5- 0 N

ew H

IV In

fecti

ons

(mill

ions

)

Three investment scenariosImpact on the epidemic

0

5

10

15

20

25

30

35

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

USD

(Bill

ions

)

Rapid scale upprevious projections

Business as usual

Investment framework

- 2.5- 2.0- 1.5- 1.0- 0.5- 0 N

ew H

IV In

fecti

ons

(mill

ions

)

Three investment scenariosImpact on the epidemic

0

5

10

15

20

25

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

USD (Billions)

The new investment frameworkFocus on what makes a difference

Basic Programme Activities

Critical Enablers

Synergies

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

>500 350-499 250-349 200-249 100-199 50-99 <50

CD4 Count (cells/ml)

Cove

rage

ART coverage in 2015 by CD4 count

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

>500 350-499 250-349 200-249 100-199 50-99 <50

CD4 Count (cells/ml)

Cove

rage

13.1 million (health)

CD4 350

15 million

T4P

Returns on investment of new investment framework (2011-2020)

Outcomes

Total infections averted More than 12 million

Infant infections averted 1.9 million

Deaths averted 7.4 million

Life years gained 29.4 million

New investment framework: the tipping point

Newly eligible for treatment

Newly infected

New infections, behaviour change and treatment coverage in Botswana

Behaviour change

New infections and treatment coverage

Cost and economic returns 2011 to 2020

Cost/Returns

Total additional investment (over 10 years)

US$46.5 Billion

Future treatment need averted

US$40 Billion

Life years gainedUS$1,060

per life year gained

Investment framework projections for new HIV infections

Optimized investment will lead to rapid declines in new HIV infections in many countries

Community mobilization assumptions in the investment framework Cost envelope: community mobilisation component of the

critical enablers

2011 $0.3bn 2015 $0.6 bn 2020 $1.0 bn

Assumptions:• Increased community capacity • increased community service delivery • need for remuneration of community and lay workers • need for training, guidance, supervision• participation of people living with HIV

Community mobilization: makes scale up possible

• Number of people tested through community mobilization 2010: 46 million (VCT) 2015: 109 million

• Service delivery costs (treatment) 2010: $179 per year 2020: $125 per year ($17 in low income countries)

• Driving costs down: fewer outpatient visits, community support service modalities

• Better Health Outcomes

Community mobilization: increases effectiveness• Community mobilisation increased HIV testing rates four-

fold in Tanzania, Zimbabwe, South Africa and Thailand. • Consistent condom use in past 12 months 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

Investement framework allocation in 2015

Resources available for HIV in low and middle income countries, globally, 2002-2010

Percentage of care and treatment expenditure from international sources

Few donors meet the development assistance targets

Net development assistancein 2001 as % of grossnational income

NorwayLuxembourg

SwedenDenmark

NetherlandsBelgium

United KingdomFinlandIrelandFrance

SpainSwitzerland

GermanyCanadaAustria

AustraliaPortugal

New ZealandUnited States

JapanGreece

ItalyKorea

1.10%1.09%

0.97%0.90%

0.81%

0.50%0.43%0.41%

0.38%0.33%0.32%0.32%

0.29%0.26%

0.21%0.20%

0.17%0.15%

0.12%

0.64%0.56%

0.55%0.53%

0% 0.3% 0.5% 1% 1.2%0.7%

Measuring national commitment to AIDS:the Domestic Investment Priority Index

SOURCE: UNAIDS expenditure data; WHO data on the burden disease; and economic data from the International Monetary Fund World Economic Outlook database

Economic growth in Africa, 1970–2010Third-fastest growing region in the World

Three options for increasing domestic public HIV investment in Africa

Projected resource needs (in USD billion)Assumed increases of domestic contributions by BRICS and others within “ability to pay” (economic growth and towards Abudja targets)

LI

9.711.3

11.913.0

13.6 13.5 12.7 11.8 10.7 9.4 8.0

LMI

UMI

Deve

lop

me

nt A

ssistance

Dom

estic fin

ancin

g

BRICS

The beginning of the end of The beginning of the end of AIDS is in our handsAIDS is in our hands

Reaching people with services:Examples for 2015

Coverage(population reached)

Condoms (discordant couples) 60%Condoms (high risk pop) 50%Sex work 60%MSM programmes 60%IDU programmes 60%

MillionHIV testing 320ART (CD4 350, T4P) towards 15

Cost per patient per year (weighted average in US$)

2010 20152020

Lab (new patients) 180 129 79

Lab (cont patients) 180 128 76

Service delivery 176 144 112

1st Line ARVs 155 147 57

2nd Line ARVs 1678 984 295

Testing and CounselingCoverage and cost per person

Cost per client counselled and tested

$0

$10

$20

$30

$40

$50

$60

$70

$80

$90

0%0.01%

0.03%0.05%

0.20%0.40%

0.75% 5%15%

25%35%

45%55%

65%75%

85%95%

Coverage

OST Cost Assumptions

Cost of Methadone: • 33c for 80mg in Iran to $2.06 for 80mg in

Indonesia

• About USD 1000 per person year

• Going down by 20% in 2015 and by half in 2020

• Little evidence for effectiveness• Little information on cost• As a proxy: cost workplace programs (by 2015,

50% coverage of the 148 million employees in the formal sector in countries with generalized epidemics, average unit cost of US$ 9 per employee per year)

Behavior Change Programmes

• Little information on cost

• Country reviews (USD 1 to 14 per adult population)

• Community Health Workers (@ USD 2 per adult population)

Community Mobilization