The State of the Epidemic in 2010 DFID HIV Leaders Meeting The State of the Epidemic in 2010 by Professor Alan Whiteside HEARD House of Lords 9th March 2010

‘Three Threes’ Three exceptional epidemics Three challenges Russia and Ukraine Poor countries with low health spends and mid-range HIV burdens Hyper-endemic countries of Southern Africa Three challenges Prevention Care and treatment (in light of new guidelines) Impact mitigation and looking to the next generation Three critical responses What works Who pays How can it be sustained

The global picture in 2007 Source: UNAIDS Global Report 2008. Geneva: UNAIDS. (2007 data)

Exceptional epidemics: Eastern Europe Low prevalence ; climbing incidence; falling populations; lack of political will Sources: HIV/AIDS Surveillance in Europe. EuroHIV 2007, and World Population Prospects: The 2008 Revision Population database. UN Population Division.

HIV Prevalence in Africa 2007(Adults 15–49) Source: UNAIDS Global Report 2008. Geneva: UNAIDS (2007 data)

Mid-level prevalence in low resourced countries   Malawi Tanzania Uganda Government Health Expenditure Per Capita $62 $72 $71 Average Cost of treatment per person/per year * $257 $850 People living with HIV ** 930,000 1,400,000 940,000 People receiving ARV treatment *** 100, 649 373, 265 111, 232 GDP per capita $800 $1,300 $1,100 Sources: *Rosen, S. and Long, L. ‘How Much Does it Cost to Provide Antiretroviral Therapy for HIV/AIDS in Africa?’ 2006, **UNAIDS Global Report 2008 and ***UNGASS Country Reports 2008.

Exceptional epidemics: the Hyper-endemic Countries Source: Epidemiological Updates. Geneva: UNAIDS 2009.

HIV and AIDS Country Population Numbers living with HIV/AIDS at a 18.8% prevalence rate Swaziland 1,200,000 225,600 UK 60,776,000 11,425,888 EU 492,964,000 92,677,000

Three Challenges: Three Waves Numbers HIV Prevalence AIDS cases Impacts Time Source: Barnett, T. & Whiteside, A. (2006) AIDS in the Twenty-First Century. Palgrave MacMillan

Three Challenges Prevention Impacts Care & Treatment Numbers A A A B B 2 A A 1 Care & Treatment B B 1 T T Time 1 2 Source: Barnett, T. & Whiteside, A. (2006) AIDS in the Twenty-First Century. Palgrave MacMillan

AIDS Treatment without prevention is mopping the floor while the tap is running

AIDS Impacts Sources: Swaziland HIV Estimates and Projections. NERCHA and UNIAIDS Workshop report. 2007 and US Census Bureau International Database

Three Critical Responses What works? Who pays? (and for what) Sustainability

What Works Prevention of Vertical Transmission Combination prevention Male circumcision Social change Leadership Changing Gender Relations Economic Empowerment Community Mobilisation Treatment

Combination HIV Prevention Source: Coates et al. (2008) Behavioural Strategies to Reduce HIV Transmission: How to make them work better. Lancet, 372: 669-684

Adherence to HIV Prevention Technologies Source: Coates et al. (2008) Behavioural Strategies to Reduce HIV Transmission: How to make them work better. Lancet, 372: 669-684

Who Pays? Source: UNAIDS (2009) What Countries Need, Investments Needed for 2010 Targets. Geneva: UNAIDS

Global Resource Needs Source: Estimating the Long-term Global Resource Needs for AIDS through 2031. Draft Working Paper. 2009. AIDS 2031

Sustainability Do we agree on importance of AIDS in the global development context and in global health The rich world needs to keep promises Africa needs to honour the Abuja Declaration (Only Botswana and Gambia have achieved this) Treatment is not sustainable without prevention and international commitment Political and financial commitment are both needed

Conclusions Targets set in 2005 much has been done MDG targets in Southern Africa not sure? Should we change targets (treatment)? Keeping ‘exceptional’ epidemics on the agenda? Moving forward? Who makes decisions? Partnerships?