1.Overview of AIDS Epidemic in Eastern and Southern Africa and progress towards meeting the HLM TargetsPride Chigwedere, MD, PhD, Coordinator for Universal Access, UNAIDS Regional Support Team for Eastern and Southern Africa 25 April 2013, Johannesburg, SA

2. 34 million people living with HIV, 2011 3. International Commitments on HIV/AIDS Global Commitments 2001 UNGASS Declaration of Commitment 2006 Political Declaration - Universal Access 2011 Political Declaration - Elimination Continental Commitments 2001 Abuja Declaration on HIV/AIDS, TB & Other Related IDs 2006 Abuja Call: Common Position on Universal Access 2011 AU Consultative Process: Africa Common Position to HLM 2012 AU Roadmap on Shared Responsibility and Global Solidarity 4. 2015 targets in the UN Political Declaration 201112Halve sexual transmissionHalve infections among injecting drug users6Close the global resource gap and achieve annual investment of US$ 22-24 bn7Eliminate gender inequalities and sexual violence and increase capacities of women and girls3Eliminate new HIV infections among children and halve AIDS-related maternal deaths8Eliminate stigma and discrimination415 million people on HIV treatment9Eliminate travel related restrictions5Halve tuberculosis deaths among people living with HIV10Eliminate parallel systems, for stronger integration 5. Reduce sexual transmission of HIV by 50% In 2011, there were approximately 2.5 million new infections in adults globally; 1,2 million of them were in ESA. Decline in New Infections from 2001 to 2011: 7 countries in ESA achieved over 50%; 4 countries achieved 26-49%; 2 countries achieved 10-25%; 3 countries remained stable; 1 country showed an increase All countries need to achieve 50% decline from 2009 to 2015 6. % Change in Incidence 2001 2011 2001 Prevalence2001 Incidence2011 Prevalence2011 Incidence% Change in Incidence 2001-11Malawi13.81.7410.00.49-72Botswana27.03.4823.41.00-71Namibia15.52.3913.40.77-68Eritrea1.10.080.60.03-67Zambia14.41.8912.50.80-58Rwanda4.10.312.90.15-53Zimbabwe25.02.1114.91.05-50South Africa15.92.4217.31.43-41Swaziland22.24.1126.02.60-37Kenya8.50.666.20.45-32Mozambique9.71.6311.31.13-31Sudan South2.60.413.10.33-21Angola1.70.262.10.21-19Lesotho23.42.6723.32.47-7Tanzania7.20.625.80.59-5Madagascar0.30.040.30.0410Uganda6.90.697.20.8421ComorosnanananandMauritiusnanananandEthiopiananananandSeychellesnanananandCountrySource: UNAIDS Estimate 2012 7. Eliminate new infections among children and reduce AIDS-related maternal deaths Global approximately 330,000 babies were born with HIV in 2011; 55% or 180 000 were in ESA Nearly 90% of all new HIV infections among children globally occur in 22 countries 21 of those countries are in Africa, and 14 are in ESA Global Plan aims to reduce new infections in infants by 90% from 2010 levels, by 2015; requires achieving >90-95% coverage for high quality PMTCT services in priority countries 8. Percentage Coverage of PMTCT Services 2011 (excluding SD Nevirapine) Countries 2 - 49% Countries 50 - 79% Countries >80% ESA coverage for PMTCT services in 2011 was 72% (plus 13% coverage on SD Nevirapine). 9. Reach 15 million PLHIV with ART by 2015 # of persons living with HIV in ESA 2011 17.1m # of persons eligible for ART using CD4 350 guidelines 8.1m # of persons on ART 2011 5.2m (64% coverage) Unmet need for ART 2.9m Epidemiological projection shows that if the 15x15 target is met by 2015, 80% of those in need of ART will be receiving therapy Source: UNAIDS & WHO Estimates, 2012 10. Estimated ART Coverage (CD4 80% coverage 11. Reduce TB deaths in PLHIV by 50% TB is a leading killer of people living with HIV causing one quarter of all deaths. People living with HIV and infected with TB are 21 to 34 times more likely to develop active TB disease, compared to people without HIV. In 2010 there were an estimated 1.1 million new cases of HIVpositive new TB cases globally; approximately 60% occurred in ESA In 2010, about 350 000 people died of HIV-associated TB globally. Almost 250 000 deaths were in ESA, and 85 000 were in SA. 12. HIV Prevalence (Percent Estimate) in New TB Cases, 2009 < 25% 25 50% 50 83%In South Africa, Lesotho, Swaziland, Namibia, Botswana, Zimbabwe, Zambia, Mozambique, Malawi & Uganda, more than 50% of new TB patients are HIV positive 13. Global Investment of US$22-24b / year in low and middle income countries By 2010, Africa had mobilised close to US $ 8bn from both International and Domestic Sources The increase in domestic resources is smaller that that of international resources 14. Share of care and treatment expenditure originating from international assistance, African countries, 20092011 15. THIRD GENERATION NSPs Changed epidemic context: from public health emergency to chronic disease Changed global economic environment: austerity measures in donor capitals, growth in Africa, emphasis on managing for results and value for money. Scientific & technological advances: simpler testing, treatment availability, treatment as prevention, MC, PMTCT Taking AIDS out of isolation: greater national and international interest in integrating AIDS into broader health and development efforts Political Declaration on HIV: Three Zeros, HLM targets and the centrality of NSPs 16. Generations of NSPs 1st generation of NSPs: 1980s/early 90s; mainly GPA times (Medium Term Plans); within the health sector 2nd generation NSPs: mid-90s; multi-sectoral; NACs; increased availability of funding, little prioritization and allocative efficiency 3rd generation NSP: post-2015 and the beginning of the End of AIDS, challenged by signs of donor funding slowdown 17. Lessons from NSP 2G Limited focus on implementation, Low prioritization (high levels of inclusiveness) Large budgets dedicated to low impact interventions Costly and complex processes (heavy on time money & documentation) Weak results orientation (processes, not results) High costs of stand alone coordination with little return in terms of effective management for investment. 18. What is NSP-3G? A new initiative from the UNAIDS family to: Foster a national planning paradigm shift in response to the new environment Prioritize resource allocation and maximize return to investment (Investment Thinking) Respond to country demand and ownership/ leadership (Paris/Accra/Busan) Drive progress towards the UNAIDS vision of the Three Zeros & meeting the HLM targets 19. Universal Principles Country ownership, shared responsibility & global solidarity Scientific evidence public health considerations are integral Full engagement by CSOs and PLHIV Universal and equitable access to AIDS services and eliminating marginalization Advancing human rights and gender justice 20. n Applying Investment Thinking in Lesotho Changing environment : shifting priorities, donor fatigue, economic crisis, national ownership vs. dependency Business as usual is not an option: Prioritization Emphasis on results/ impact Value for Money/efficiency Return on Investment sustainability Investment Cases: How do we maximize the returns on the Investment 21. AIDS: investing strategically to maximize impact CRITICAL ENABLERSBASIC PROGRAMME ACTIVITIES Social Advocacy Laws, policies, and practices Community mobilisation Stigma reduction Mass mediaProgramme Community centred design and delivery Programme communication Management and incentives Procurement and distribution Research and innovationBehaviour changeOBJECTIVESCondoms Stopping new infectionsTreatment & careChild infections & maternal mortality Keeping people aliveKey populationsMale circumcisionSYNERGIES WITH DEVELOPMENT SECTORS 22. Priority Country Actions: Sexual Transmission Assist countries identify who is getting infected / who is at risk of infection (KYE/R) Prioritize relevant, effective, and impactful prevention strategies for different populations (IF) Advocate for the scale up Basic Program Activities: Increase # of people on ARVs (effect on transmission) Scale up male circumcision as a priority Behavior change programmes Programmes for key populations (almost no data for MSM, sex work, IDU in region) Condom promotion & distribution Make smart investments that combine programs with critical enablers to exploit synergies 23. Estimate Number of VMMCs needed to prevent one HIV infection (PEPFAR Data) 24. Estimate of Number of Adults 15-49 yrs. VMMC needed to reach 80% coverage / country (PEPFAR Data) 25. Estimate Number of VMMC done / country as of October 2011 (PEPFAR Data) 26. A checklist for applying investment thinking 27. Returns on investment using the investment approach 20112020Outcomes Total infections avertedMore than 12 millionInfant infections averted1.9 millionDeaths averted7.4 millionLife years gained29.4 million 28. South Africa has significantly reduced the cost of ARVs South African tender prices June 2010 January 2011350International benchmark300 250) d n R ( k a p e c i r P200 150 100 50 0 ABACAVIR 300mgEFAVIRENZ EFAVIRENZ LAMIVUDINE NEVIRAPINE TENOFOVIR 200mg 600mg 150mg 50mg/5ml 300mg 29. Community support keeps people on treatment CLINIC-BASED TREATMENT70%still receiving treatment after two years Sub-Saharan Africa: people receiving ART from specialist clinics Source: Fox MP, Rosen S. Patient retention in antiretroviral therapy programs up to three years on treatment in subSaharan Africa, 20072009: systematic review. Tropical Medicine and International Health, 2010, 15(Suppl. 1):115.COMMUNITY TREATMENT MODEL98%still receiving treatment after two years Mozambique: self-initiated community model 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]. 30. Optimized investment could lead to rapid declines in new HIV infections Current and projected HIV infections CambodiaZimbabweSouth Africa Current & projected HIV infections1990Source: UNAIDS 20112015 19902015 1990Benefit of the investment framework2015 31. Integrated services are more efficientUS$ 40The example of VCT: Costs per client35Stand-alone VCT clinics30Integrated into SRH services25 20 15 10 5 0 Kenya (2002)Kenya (2008)India (2007)Uganda (2009) 32. Lesotho Investment Case? What will the country do differently to maximize returns? Within each of the program activities which critical enablers is the country prioritizing to improve access and scale up, which groups will receive special attention? Which synergies will the country prioritize? How will these be reflected in the investment package? Efficiency gains? Effectiveness? What additional investments are required? Where will they come from? Can they be sustained? 33. VISION ZERO NEW HIV INFECTIONS. ZERO DISCRIMINATION.ZERO AIDS-RELATED DEATHS.16 October 2006UNAIDS 34. AIDS in the Post-2015 Development Agenda Brazey de Zalduondo Sonja Tanaka 24 March 2013 35. UNAIDS overarching messagingInvesting in health. Need a fresh narrative to convince leaders to invest more health reduces inequality; health mobilizes people for building democratic accountability; health cooperation can be a tool for diplomacy; offers entry point for human rights.AIDS is not over. Priority is to ensure HIV is prominently positioned in the post2015 agenda, including ambitious, measurable targets towards the end of AIDS.End of AIDS. With political commitment, community mobilization, adequate funding and the right approaches, the end of AIDS can be a shared triumph of the post-2015 era.Transforming health. Approaches from the AIDS response, including inclusive, people-centred, multi-sectoral action, can be applied to transforming the way countries and their partners do health and development. 36. The Post-2015 House: UN Process towards an agenda P2015 Development AgendaUN General AssemblyP2015 ASG SecretariatRegional, Online, and Other UN Consultations11 Thematic Consultations86 National/Regional ConsultationsOpen Working Group on SDGs (65 Member States)High Level Panel 37. UNAIDS engagement & advocacy targets UNAIDS engaged in 7 / 11 Thematics: Inequalities, Education, Food security and nutrition, Governance, Conflict and fragility, Population dynamics & Health. Joint UNAIDS paper w Cosponsors with key messages on health, human rights and social transformation. UCOs have engaged in Country Consultations (completed or underway, led by UNCT) Global online conversation on worldwewant2015.org and myworld2015.org Civil Society Consultations Lancet Commission UN SGs High Level Panel, chairs: President Yudhoyono (Indonesia), President Johnson Sirleaf (Liberia) and PM Cameron (UK) Open Working Group on Sustainable Development Goals (incl. Algeria, Egypt, Morocco, Tunisia; Benin, Ghana, Congo; Kenya, Tanzania, Zambia & Zimbabwe) 38. 2012-2013 Consultation processes 39. EXD address in Botswana 1. Must recall that where we are today is thanks to the MDGs 2. Our world is entirely different than in was in 2000 3. Opportunity to integrate this transformation into new a narrative for global health smarter argument for why to invest. Example of AU Roadmap: frames health as spurring industrial development, knowledge economy, innovation with SS cooperation. 4. International community must not make same mistake twice. Millennium Declaration gave a central role to inclusiveness, equity, dignity, human rights. But those principles got lost in translation to goals. 5. Global goals demand global solutions we must address global determinants and global responsibility for health and development 6. We have never had better time to disrupt and rebuild a new model to advance global health 7. We should inspire the High Level Panel to be bold and demand new thinking on health governance we can streamline functions into 3 global health institutions (norm setting, financing and accountability) 40. Outcomes of Botswana Health Consultation, 5 March Future health goals need to reflect universal realities be relevant in all countries (HICs as well) and address equity (distribution) and rights Goals must be tracked globally but catalyse progress and monitor success in terms of the reality that each country faces The MDG agenda must be accelerated to 2015 and continued with updated targets - including through target to realise an AIDS-free generation 41. Themes and concerns emerging from the consultations Continued relevance of the MDGs (human development agenda) Need also to incorporate key issues the MDGs left out including Over all: universality, equity, quality In health NCDs (double burden of IDs and NCDs) Address social determinants through policies and investments Need to combat growing inequality disparities within as well as between countries Investment in data, and use of data, at national and sub-national levels. Aim for data disaggregated by sex, age, geography and more. Interconnectedness of goals be smarter, prevent stove-piping Human right are central; need national and regional mechanisms 42. UNAIDS and Lancet Commission: From AIDS to Sustainable Health Hope that Commission will be seen to have legitimacy and influence to drive political movement for AIDS and health High level political Commission with a dynamic programme to produce: o space for systematic analysis of evidence o sharp critique o robust recommendations Co-Chairs: President Joyce Banda; Dr Nkosazana Dlamini Zuma (Chairperson, AUC); Dr Peter Piot (Director, LSHTM) First meeting: Lilongwe, 28-29 June Outcome: Lancet special issue early 2014 43. Commission will address three questions What will it take to bring about the end of AIDS? How can the experience of the AIDS response serve as a transformative force in our approach to global health? If we imagine a more equitable, effective and sustainable global health paradigm, how must the national and global AIDS architecture be similarly modernised? 44. Country and regional consultations in ESA Angola Ethiopia* Kenya* Malawi* Mauritius* Mozambique Rwanda Senegal South Africa Tanzania* Uganda* Zambia* UNECA, with partners, has convened three subregional consultations in Accra, Ghana; Mombasa, Kenya; and Dakar, Senegal.*Consultation reports available 45. Draft African Common Position 4 Pillars 1.Transformative Economic transformation and inclusive growth, 2.Innovative technology transfer and Research development, 3.Human development (incl. UA to quality healthcare and HIV, with focus on treatment and EMTCT) 4.Financing and PartnershipsMarAprilMaySept 46. Role of UCCs and RSTs moving forward ESA must be leading voice for HIV in the next development agenda Ultimately Member States will decide the agenda and framework UCCs and RSTs responsible to identify, target and support: Champions for UNAIDS vision and agenda Government and civil society focal points on P2015 at country level MS members of the Open Working Group MS delegations to Sept UNGA Lancet Commissioners 47. DISCUSSION UCO and RST advocacy strategies Connecting messaging to political priorities for regional political institutions Upcoming political opportunities Internal communication, support from Geneva 48. Impact of ART: Significant Decrease in Mother-toChild Transmission of HIV since 2010Courtesy Birx,UNAIDS Global Report 2012 49. 2001-2011 : Declining incidence 50. New HIV infectionsG8 Okinawa Initiative2006 Political DeclarationAbuja Declaration2011 Political Declaration2001 Declaration of Commitment UNITAIDDoha DeclarationG8 Gleneagles Pledge Gates FoundationPEPFAR5220112010200920082007200620052004200320022001200019991998The Global Fund 1997199619951994199319921991Resources available for HIV in low- and middle-income countriesUS$ 16.8 billionMillenniunm Declaration19903.5 million people2001-2011 : Resources for HIV has shown impact 51. What is driving the change? 52. What is driving the change? 53. The prophecythe realityWall street Journal , 23 July 2012 54. 2015: the 10 Global AIDS targetsREDUCE SEXUAL TRANSMISSIONPREVENT HIV AMONG DRUG USERSCLOSE THEELIMINATERESOURCEGENDER INEQUALITYGAPELIMINATE NEW HIV INFECTIONS AMONG CHILDREN15 MILLION ACCESSING TREATMENTAVOID TB DEATHSELIMINATE ELIMINATE TRAVEL STRENGTHEN HIV STIGMA AND RESTRICTIONS INTEGRATION DISCRIMINATION 55. Supporting countries: what will it take ?Focus Speed with evidence Smart Investments Innovation Human rights 56. HIV Incidence in Countries with Slow or Stalled Scale-Up of Combination Prevention Services Slow or No Decline in HIV Incidence Rates (2001, 2011) - 7%+22% - 5%- 14%- 19%2001 Incidence2009 Incidence2011 IncidenceLesotho2.672.582.47Uganda0.690.740.84Tanzania0.620.450.59Nigeria0.420.380.36Angola0.260.210.21CountriesData source: UNAIDS Global Report 2012 57. Geographic prioritization - KenyaNairobi & NyanzaWestern & CentralRift Valley & CoastEast & North-East 58. Speed: rapid acceleration, but even more is needed 59. Evidence: making the right choices 60. Innovation: current models will not take us to the finish line 61. Community support keeps people on treatment CLINIC-BASED TREATMENT70%still receiving treatment after two years Sub-Saharan Africa: people receiving ART from specialist clinics Source: Fox MP, Rosen S. Patient retention in antiretroviral therapy programs up to three years on treatment in subSaharan Africa, 20072009: systematic review. Tropical Medicine and International Health, 2010, 15(Suppl. 1):115.COMMUNITY TREATMENT MODEL98%still receiving treatment after two years Mozambique: self-initiated community model 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].Sources: Fox MP, Rosen S. Tropical Medicine and International Health, 2010; Decroo T et al. Journal of Acquired Immune Deficiency Syndromes, 2010. 62. Investments: Shared responsibility 63. Implementation compact 64. Activity 3: Next 1000 Infections Where are your next 1000 infections likely to come from? fill out the second thoughts column 65. Low- and middle-income countries are on track to reach 15 million people with antiretroviral treatment by 2015Source: UNAIDS, 2012