“Towards an improved investment approach for an effective response to HIV “

The Lancet, June 3, 2011www.thelancet.com

Moving from a commodity approach:“Fund some of everything” or“Fund what is comfortable”toAn Investment approach:“Fund evidenced-based activities specific to the needs of your epidemic to get better long term results at lower costs.”

A tool for evaluation and reallocation of HIV funding.

Three Categories of Investment:

Six basic programmatic activities Critical interventions that create

an enabling environment for achieving maximum impact; and

Programmatic efforts in wider health and development sectors related to AIDS.

Rights-based approach to all services and policies

Basic programme activities Activities that have a direct impact

on reducing HIV transmission, morbidity and mortality to be scaled up according to size of relevant affected population

Basic Program Activities

Based on high level evidence of effectiveness.

Treatment, care and support Vertical Transmission prevention Condom procurement and

distribution Key populations programs (MSM,

IDU, Sex Workers) Male circumcision Behavior Change programs

Critical Enablers

Social Enablers - make possible environments conducive for sound AIDS responses:

outreach for HIV testing Linkage from testing to care treatment literacy stigma reduction advocacy to protect human rights monitoring of the equity and quality of

programme access and results

Critical Enablers

Program Enablers - create demand for and help improve the performance of key interventions:

incentives for engagement in health services methods to improve retention on ART capacity building for community-based

organizational development strategic planning communications infrastructure information dissemination efforts to improve service integration and

linkages from testing to care.

Synergies with other development sectors

Health systems and multiple health issues

Gender equality efforts Education and justice sectors Social protection and welfare Food security Community systems Housing

What is the Role of Community Mobilization in this Framework?

Community-driven outreach and engagement activities that connect people facing similar issues and engage them in HIV-related interventions

Support activities to enhance quality, adherence and impact in a range of settings such as people on treatment, engaged in harm reduction or drug treatment services, or who are using sexual and reproductive health services

Advocacy, transparency and accountability efforts at country and local levels to ensure that high-quality health services are available and accessible to vulnerable populations.

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

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

Reta

ined in

treatm

ent

and 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

Reta

ined in

treatm

ent

and 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

Reta

ined in

treatm

ent

and 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

Reta

ined in

treatm

ent

and 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

Reta

ined in

treatm

ent

and c

are

What can we achieve?

Universal Access by 2015

Projections and Estimates Resource needs and returns on investment were

estimated for 139 low- and middle-income countries Estimates based on the cost of increasing from

current levels of coverage in 2011 to achieve universal access target coverage levels by 2015 and maintain them thereafter. (Includes 1st and 2nd line treatment.)

Each of the basic programme activities in the framework was applied to relevant populations according to their demographic and epidemiological situation including the distribution of new HIV infections by mode of transmission as detailed in the literature.

Returns for InvestmentMore than 12 million Infections averted

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

New

HIV

infe

ctio

ns

Baseline Investment Framework

New infections averted between 2011 and 2020: 12.2 million

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

AID

S de

aths

Baseline Investment Framework

AIDS deaths averted between 2011 and 2020: 7.4 million

Return on investment of the new investment framework (2011-2020)

Outcomes

Total infections averted 12.2 million

Infant infections averted 1.9 million

Life years gained 29.4 million

Deaths averted 7.4 million

What will it cost?

What are the returns?

Financial requirements (Billions of US$)

2011 2015 2020

Basic Programs 7.0 12.9 10.6

Critical Enablers 5.9 3.4 3.7Synergies with Development Sectors 3.6 5.8 5.4

Total 16.6 22.0 19.8

0

5

10

15

20

25

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Cos

t (bi

llion

s U

S$)

Baseline

Investment Framework

Economic returns between 2011 to 2020

Cost/Returns

Total additional investment (over 10 years) USD 46.5 Billion

Future treatment need averted USD 40 Billion

Life years gained $1,060 per life year gained