How can we get to zero?The potential contribution of treatment

Peter Godfrey-Faussett and Bernhard SchwartlanderUNAIDS

WHO Satellite Symposium, Kuala Lumpur30 June 2013

1. Investment thinking and tools

2. New approaches and technologies

3. Impact on new HIV infections

4. Impact on AIDS-related deaths

Going to zero:

Towards an improved investment approach for an effective response to HIV/AIDS Lancet 2011Bernhard Schwartländer, 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, Geoff rey 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*

UNDERSTAND SUSTAIN

1DESIGN

2DELIVER

3 4

Know your epidemic The What:Focus on the right things

The How:Doing things the right

way to go to scale

Sustain for impact

The tool – apply investment thinking to your response:4 simple steps

We are not starting from scratch! Virtually all countries have a national strategy

The tool is meant to support countries to identify - and act upon - opportunities for improvement

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

Programme enablers• Community-centered

design & delivery• Programme

communication• Management & incentives• Operations Research

TreatmentMale circumcision

Keeping people alive

BASIC PROGRAMME ACTIVITIES

Programs for keypopulations PMTCT

Condoms

OBJECTIVES

Stopping new infections

BehaviourChangeProgr.

New investment framework (2011) – focus & simplification

UNDERSTAND SUSTAIN

1DESIGN

2DELIVER

3 4

Where werethe last 1000

infections (Who and Where)?

Are there obvious mismatches?

Cutting cost (cost drivers!) and

efficiency in delivery

Shared responsibility,

innovative financing

The tool – apply investment thinking to your response:4 simple questions

Know your epidemic The What:Focus on the right things

The How:Doing things the right

way to go to scale

Sustain for impact

Spectrum and the Goals Modelwww.futuresinstitute.org

Coverage Targets for 2015 for the Investment Framework (IF) Generalized

EpidemicsConcentrated Epidemics

PMTCT 90% 90%Condoms (discordant couples) 60% 60%

Condoms (medium risk populations)

60% 20%

Condoms (high risk populations)

50% 50%

Sex work 60% 60%MSM 60% 60%IDU outreach 60% 60%IDU needle and syringe exchange

60% 60%

IDU drug substitution 0% 40%ART CD4<200 cells/µl 80% 80%ART CD4 200-250* cells/µl 70% 70%ART CD4 250-350 cells/µl 45% 45%ART CD4 350-500* cells/µl 5% 5%

• IF Investment Framework - as described above• IFE Enhanced IF - with addition of new WHO consolidated

ART guidelines• IFE + UT IFE with Universal Treatment

= Treatment regardless of CD4 count

• IFE + PrEP IFE with pre-exposure prophylaxis• IFE + Vaccine• IFE + UT + PrEP + Vaccine

Scenarios modeled

Scenario Definitions for New Prevention TechnologiesTechnology Population Groups Year of First

AvailabilityYear Target Coverage is Achieved

Target CoverageLow/High Scenarios

Effectiveness

Universal Treatment

All other HIV+ population withCD4 counts > 500 cells/µl

2014 2025 40% / 60% 96%(60%,80% for sensitivity analysis)

Pre-Exposure Prophylaxis

MSM 2013 2025 20% / 60% Before 2018: 44%After 2018: 70%/90%

Female sex workers 2018 2025 10% / 25%

Discordant couples 2020 2025 10% / 30% Adolescents in hyper-

endemics2018 2025 0% / 30%

Vaccine Adult population in generalized epidemics

2025 (high)2030 (low)

2032 (high)2035 (low)

40% / 70% 60% (low)80% (high)

High- risk population in concentrated epidemics

2025 (high)2030 (low)

2032 (high)2035 (low)

30% / 60%

20112014

20172020

20232026

20292032

20352038

20412044

20472050

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

4,500,000

BaseIFIF EnhancedIFE + TasP (high)IFE + PrEP (high)IFE + Vac (high)IFE + TsP + PrEP + Vac (high)

Going to Zero? The 2011 Investment Framework Combination prevention and treatment (current guidelines)

Number of new HIV infections

- Investment Framework

20112014

20172020

20232026

20292032

20352038

20412044

20472050

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

4,500,000

BaseIFIF EnhancedIFE + TasP (high)IFE + PrEP (high)IFE + Vac (high)IFE + TsP + PrEP + Vac (high)

Number of new HIV infections

Going to Zero? The 2011 Investment Framework Combination prevention and treatment (new guidelines)

- Investment Framework

20112014

20172020

20232026

20292032

20352038

20412044

20472050

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

4,500,000

BaseIFIF EnhancedIFE + TasP (high)IFE + PrEP (high)IFE + Vac (high)IFE + TsP + PrEP + Vac (high)

New technologies: critical in reaching zero new infections in both industrialized and LMI countries (e.g. vaccine)

Number of new HIV infections

- Investment Framework

• “All models are wrong – but some are useful”• “Investment thinking” clear that treatment is an

excellent investment and a cornerstone of the response

• New WHO guidelines (IFE) likely to substantially reduce the size of the future epidemic

• Treatment unlikely to be sufficient to achieve our goal of zero new infections

• Continued push for research into vaccines, cures, easier (eg long-acting) treatments and PrEP

Zero new HIV infections?

Resource needs (crude) – different investment scenarios

20112014

20172020

20232026

20292032

20352038

20412044

20472050

0

5

10

15

20

25

30

BaseIFIFE (new WHO guidelines)

Billion US $

- Investment Framework

- Investment Framework Enhanced (new WHO guidelines)

• From cost to investments (in health)• The Investment Framework is not just a case for investment in

HIV, it is about the “HOW” – how to maximise the returns• From “as much as possible” to: how can we invest for greatest

impact; and how we can get the resources to do so• Shared responsibility• Value for money is a core value of country programmes• The GF can be the most powerful instrument to incentivize

and support countries in investing strategically• It is possible to get on the path towards zero

Conclusions: A new paradigm in a replenishment dialogue

Going to Zero: Number of people on ART Different scenarios 2011 to 2050

Number of people on ART

2011 2012 2015 2020 2025 2030 2035 2040 2045 20500

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

Base

Investment Framework

IF Enhanced

IFE + TasP

IFE + TasP + PrEP + Vaccines

Going to Zero: Paths going to 15 by 50

Number of people on ART

2011 2012 2015 2020 2025 2030 2035 2040 2045 20500

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

Base

Investment Framework

IF Enhanced

IFE + TasP

IFE + TasP + PrEP + Vaccines15 million on ART

Going to Zero: Paths going to 15 by 50

Number of people on ART

2011 2012 2015 2020 2025 2030 2035 2040 2045 20500

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

Base

Investment Framework

IF Enhanced

IFE + TasP

IFE + TasP + PrEP + Vaccines15 million on ART

16 million deaths averted

• Millions of lives to be saved by scaling up treatment efficiently

• Immediate gains from prioritising those with advanced HIV

• Access and coverage for all people eligible• Longer term gains from treating earlier – infections

and co-morbidities averted• Impact on non-AIDS morbidity and mortality• Zero AIDS-related deaths

Going to zero.