a new investment framework for the response to aids
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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
)
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
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