the investment framework - critical enablers are not a luxury! bernhard schwartlander
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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