1. Strategic information for a sustainable response Panama, November 2012 Cero nuevas infecciones por el VIH Cero discriminación Cero muertes relacionadas con el sida

2. 2015 targets in the UN Political Declaration 2011 1 Halve sexual transmission 2 Halve infections among injecting drug users 3 Eliminate new HIV infections among children and halve AIDS-related maternal deaths 4 15 million people on HIV treatment 5 Halve tuberculosis deaths among people living with HIV 10 Eliminate parallel systems, for stronger integration 9 Eliminate travel related restrictions 8 Eliminate stigma and discrimination 7 Eliminate gender inequalities and sexual violence and increase capacities of women and girls 6 Close the global resource gap and achieve annual investment of US$ 22-24 bn

3. 2011 Political Declaration on HIV/AIDS: resources for the HIV response  Programmes must become more cost-effective and evidence-based and deliver better value for money  Break the upward trajectory of costs through the efficient utilization of resources (simplification and integration)  Close the global resource gap by 2015 (USD 24 billion by 2015)  Support and strengthen existing financial mechanisms  Expand voluntary and additional innovative financing mechanisms

4. What we are doing quite well?

5. Low- and middle-income countries are on track to reach 15 million people with antiretroviral treatment by 2015 Source: UNAIDS, 2012

6. 54% of all people eligible were receiving antiretroviral therapy in low- and middle-income countries in 2011 Percentage receiving ART in 2011. Legend Source: UNAIDS, 2012 Number of people eligible for antiretroviral therapy.

7. Low- and middle-income countries are on track to eliminate new HIV infections among children (0–14 years) Source: UNAIDS, 2012

8. We are not doing as well at preventing sexual transmission…and ensuring a sustainable response

9. Source: UNAIDS, 2012 The world is NOT on track to halve adult HIV infections

10. New adult HIV infections are declining, particularly in Africa Source: UNAIDS, 2012

11. New adult HIV infections are rising in Eastern Europe and Central Asia, and in the Middle East and North Africa Source: UNAIDS, 2012

12. International resources for HIV have been flat since 2008 Source: UNAIDS, 2012 International assistance US$ billions

13. Middle-income countries have steadily invested more of their own resources in HIV Source: UNAIDS, 2012 International assistance US$ billions Domestic resources in low- and middle-income countries

14. Total resources continue to grow, but fall short of total needs Source: UNAIDS, 2012 International assistanceTotal resources available, with estimated range US$ billions Domestic resources in low- and middle-income countries

15. New HIV infections (millions) Schwartländer et al. Lancet 2011 Business as usual will lead to stagnation HIV investment US$ (billions) Investment

16. Schwartländer et al. Lancet 2011 Business as usual will lead to stagnation HIV investment US$ (billions) New HIV infections (millions) Investment New HIV Infections

17. Schwartländer et al. Lancet 2011 Better investments can achieve large gains HIV investment US$ (billions) New HIV infections (millions)

18. Pay now or pay forever Schwartländer et al. Lancet 2011 HIV investment US$ (billions) New HIV infections (millions) 2015 gap: US$ 7 billion

19. AIDS: investing strategically to maximize impact SYNERGIES WITH DEVELOPMENT SECTORS CRITICAL ENABLERS Treatment & care Male circumcision Keeping people alive OBJECTIVES Stopping new infections BASIC PROGRAMME ACTIVITIES Social Programme

20. Which strategic information do we need to develop sustainable investment plans ? Cero nuevas infecciones por el VIH Cero discriminación Cero muertes relacionadas con el sida

21. A checklist for applying investment thinking

22. Which are priority needs regarding treatment and prevention? HIV – STI prevalence studies KAP Studies (Knowledge, attitudes and practices) Estimates Programme Data – Service coverage MoT – incidence studies Key population size estimates National AIDS Spending Assessment - NASA Financial sustainability analysis Program cost-effectiveness evaluation Analysis Understand your epidemic and response Steps to develop investment plans for maximum impact on HIV epidemic

23. Has the basic package of services been optimized according to needs? Unitary costs studies Quality of care / treatment studies Bottle-necks studies Actors and services mapping Barriers to treatment and prevention studies Stigma and Discrimination studies Violence, Gender and HIV studies MOT X NASA MOT X prevention strategies Steps to develop investment plans for maximum impact on HIV epidemic

24. Is program implementation efficient and effective? Cost monitoring Effectiveness monitoring Input provision monitoring Evaluation of service models Steps to develop investment plans for maximum impact on HIV epidemic

25. What resources are needed and which are available in the long term? Economic studies of several traditional and innovative mechanisms Studies of several purchase – production options related to strategic inputs Studies of Human resources requirements Steps to develop investment plans for maximum impact on HIV epidemic

26. Guías disponibles

27. Available guidelines & Studies

28. Hacer las cosas mejor! Implementation of the investment framework in the Caribbean

29. 29 20012009 $91m IMPACT IN HEALTH 21,000 Funding 12,000 deaths $1.6 Billion 18,000 new infections Progress made in Caribbean HIV response

30. VIH investment and national ownership Year Investment Public US$ % Haiti 2011 209 m <1% Trinidad 2009 90.3 m 84% Dom. Rep. 2008 31.3 m 25% Guyana 2010 28.9 m 8% Jamaica 2011 16.2 m 25%

31. WB projects begin GF-HAITI MoT GF Changes in eligibility criteria 31 Most World Bank Projects close GF Changes in eligibility criteria GF Phase II proposals for Haiti & Guyana rejected Source: UNAIDS Caribbean RST, 2011 External resources for HIV in the Caribbean 2001 – 2011

32. 32 Source: IMF 2005 -2010 variations in Real GDP in the Caribbean

33. Guyana: HIV finacing sources, 2010 PEPFAR ends in 2015 $18.7m 2010 to $0m in 2015 GF largest funding source in 2015 (68%) Ends in 2016 33 Sources: Sustainability Analysis of HIV/AIDS Services HAPSAT Guyana, July 2011.

34. Data tracking history in Jamaica ] HIV expenditure per funding source Jamaica 2009/2010 - 2010/2011 Source 2009/102010/11 Amount (Millions US$) % % Public 3.521%4.125% International 13.479%12.175% Private 0.05<1%0.05<1% Total 16.9100%16.2100%

35. ARV Financial dependency Low ( 0-5% ARV covered with external funding) Moderate ( 20-75% ARV covered with external funding) High ( 70-100% ARV covered with external funding) Bahamas, Belize, Suriname, Trinidad y Tobago Barbados, Cuba, St. Lucia Source: Antiretroviral Treatment in the Spotlight: A public health Analysis in Latin America and the Caribbean, PAHO, 2012 Antigua, Dominica, Dominican Republic, Guyana, Grenada, Haiti, Jamaica, St Kitts, St Vincent

36. Investment Framework Experience in Jamaica NASA - 2009/2010 financial year Sustainability Study – 2011 & MoT - 2012 Organization of a high level team – Ministry of Health, Finance, Planning, WB, UNAIDS In process – moving beyond our “conform zones”: new language and audiences

37. Investment Framework Experience in Jamaica Priorities, costs, gaps identification / prioritization Community – based participatory research Web-based M&E platform (Jam, TNT, DOR) CVC Increased emphasis in HIV testing Prevention, > key populations

38. Investment Framework Experience in Jamaica Development of Sustainability Plan Country ownership of HIV response Service Integration Decentralization Transaction cost reductions

39. Hacer las cosas mejor! Application of the Investment thinking in Central America: ASAP MCR Guatemala

40. UNAIDS ASAP: Evidence informed strategic planning for a more cost effective budgeting ASAP Results Strategy Cycle To develop a costed and evidence-based strategy Establish the complete process Step 1 Analyze the epidemic & evaluate nat. response Step 2 Identify NSF results Step 3 Select strategic programmes Step 4 Identify critical interventions Step 5 Estimate intervention costs and available resources Step 6 Establish NSF results monitoring Step 7 Plan to evaluate NSF results Step 8Use evidence to formulate following strategies The approach Source: Rodriguez-Garcia, R., & Kusek, J. World Bank, 2007. Note “NSP” refers to Nat. Strategic Framework

41. El Salvador plan to improve ‘value for money’ in HIV prevention for key populations HIV prevalence Planned changes in budget 2008-2010

42. Increase in budget allocation for HIV prevention for MSM and SW. Insufficient in relation to the distribution of new HIV infection? El Salvador MOT 2011 versus MEGAS 2010

43. UNAIDS Comparison of the distribution of new HIV infections 2011 (MOT) with HIV expenditures in prevention per beneficiary population (NASA 2010) in El Salvador Others % Incidence % of spending in MoT populations Intravenous drug users & their couples Sex workers & their clients MSM General Population

44. UNAIDS MCR: Analysis of financial vulnerability of the HIV response in Central America (MEGAS 2010)

45. Financial gap to cover the National Strategic Plan financial needs in selected countries

46. Sustainability and dependency: in average 30% of HIV expenditure in Central America are from international sources.

47. Effective allocation of financial resources: In concentrated epidemies It is necessary to invest more in key populations and other key populations. In CA, 10% of HIV expenditures are allocated to these populations

48. 1 st Line ARV: % of potential economies in ARV expenditures in relation to total costs of ARV, if treatment schemes would be optimized. 2010 48

49. MCR: HIV Sustainable response strategy in Central America and Dominican Republic 2012-2015 Progress made could be lost in Central American Integration System countries regarding the HIV response, if there is an abrupt reduction of external funding for HIV. 2010 Central American NASA evidenced the most vulnerable countries, activities and populations in case of a reduction of external funding. The Central American Health Ministers’ Council, in its XXXVI meeting, appointed the Regional Coordination Mechanisms (MCR) and the Secretariat of the C.A. Health Ministers’ Commission (SE-COMISCA) to establish a multidisciplinary, intersectoral technical group, with participation of technical cooperation, to prepare an action plan. The Sustainability Strategy Action Plan for the Comprehensive HIV Response was prepared by teams organized within the MCR.

50. Guatemala Applying the investment framework 2012 Conditions that favor and urge IF introduction Reduction of international funding Guatemala declared a High Impact country by UNAIDS Government oriented towards Results-Based Management In preparation of Global Fund Phase II Renovation Dependency of external funding 46 millions (2010) AIDS expenditure 28% external funding in the following components: a) MARP b) Management c) Research and environment

51. NASA 2010 comparison with NSP 2011 – 2015 and Investment Framework for LAC

52. Value for Money: Why does Guatemala spend so much in ARV? Product Nicaragua (VPP purchases) Strategic Fund PAHO Guatemala (local purchases) Abacavir 300mg17.5014.47160.28 Efavirenz 600mg4.454.1053.32 Tenofovir 300mg + Emtricitabina 200mg 11.509.4954.74 Lopinavir 200mg + Ritonavir 50mg 36.7532.65109.65 Tenofovir 300mg7.507.4530.91

53. Value for money : Why does Guatemala spend so much in ARV?

54. USD$ 16.7 MM for prevention/ 46 MM. Type of interventions 1.Behavioral change 2.PMTCT 3.Testing and counseling 4.Condoms and safe blood 0.47% prevention targeted to sexual diversity populations 60% of new infections will result from these groups ( MoT 2012). Value for Money: How does Guatemala spend on HIV prevention?

55. Value for money: To ensure a pertinent response in Guatemala Proportion of spending in BCC and condom promotion In Guatemala, 2008 Interventions in specially accessible vulnerable populations Interventions in most exposed populations Interventions in people living with HIV Interventions in general population Behavioral change programmes Condom promotion programmes

56. Guatemala: Applying the investment framework 2012 Conclusions y recommendations More efficient use of resources taking into consideration funding reductions Excessive Care expenditure, limiting preventive expenditure in most-at-risk populations (only external funding) Promote political dialogue among CONASIDA, CCM-G, international cooperation and civil society for re-distribution of resources and identification of funding sources to achieve sustainability Revise normative frameworks that limit ARV purchase at international level at low cost and quality assured (care resources for prevention) Advocacy to cover the financial gap with tax contributions, private enterprise, social security and municipalities

57. Show most cost effective interventions and monitor performance of implementers NSP Annual Operational Plan aligned with Investment Framework Strategy to optimize treatment schemes Ensure pertinence of MARP interventions and investment for those that have proved scientific effectiveness Annual ARV purchase planning, prioritizing those with PAHO, UNITAID, WHO, VPP etc. Strategy to develop national response synergies (NAC / CONASIDA) Evaluate feasibility, cost, cultural pertinence, of new prevention technologies Guatemala: Applying the investment framework 2012 Conclusions y recommendations

58. Together we can end the AIDS epidemic