How Universal will Universal Access be in Europe by 2010? Eddy Beck Evaluation Department UNAIDS, Geneva

The introduction of combination antiretroviral therapy has had a profound impact on mortality and morbidity patterns of people living with HIV….. …and scaling up services, which countries are involved with as part of the Universal Access process. This was agreed at the High Level Meeting in New York in June 2006 and is described in the 2006 Political Declaration on HIV/AIDS

Scaling up of HIV prevention, treatment, care and support services; Country driven process, in which countries set own ambitious but realistic targets To make this happen needs to be country owned process involving all stakeholders, especially people living with HIV and other members of civil society Universal Access, 2006 Political Declaration on HIV/AIDS

Build on the momentum of scaling up treatment and care programs, including Universal Access, 2006 Political Declaration on HIV/AIDS

Introduction of combination antiretroviral therapy has reduced the mortality and morbidity of people living with HIV….. but the irony is, that the momentum generated by scaling up treatment and care programs, has also highlighted the need for improved prevention services…………….

*Per 100,000 US Population; MMWR. 2005;54(46):1188.

HIV and AIDS diagnoses and deaths, UK Numbers will rise, for recent years, as further reports are received. Clinician reports of new HIV/AIDS diagnosis

HIV diagnoses by exposure category, UK Numbers will rise, for recent years, as further reports are received. Clinician reports of new HIV/AIDS diagnosis

Review of Newly Diagnosed People with HIV, UK ,523 newly diagnosed heterosexuals 74% Black Africans, 11% White & 4% black Caribbeans 42% diagnosed late: 43% of Black Africans, 36% of Whites and Black Caribbeans. Most Black Africans infected in Africa 20% of Black Africans infected in the UK diagnosed late, compared with 44% of those infected in Africa. Chadborn et al, AIDS 2006,20:

Global number of people newly infected with HIV and AIDS deaths

Economics of providing health services Cost of providing services Cost-effectiveness of interventions, programs or services

Cost of providing health services What does it cost to run an HIV service?; Is the service affordable? Are additional resources required to provide services in a particular manner? What is the gap between the cost of services and the financial resources spent on services?

Cost-effectiveness of interventions, programs or services what does it cost to achieve a certain outcome or impact?; does a new intervention add value?

Cost-effectiveness of HAART? Canada South Africa UK

Cost-effectiveness of HAART in Canada

Clinical Progression for non-AIDS Patients in Quebec, Canada 1991 – 1995 vs

Clinical Progression for AIDS patients in Quebec, Canada 1991 – 1995 vs

Incremental cost per life-year-gained by stage of HIV infection US $14,587 for non-AIDS patients US $12,813 for AIDS patients Beck EJ, Mandalia S, Gaudreault M, et al The Cost-effectiveness of HAART, Canada AIDS, 2004; 18:

Cost-effectiveness of HAART in South Africa

Clinical Progression for non- AIDS patients, P< Badri M, Maartens G, Mandalia S, et al. Cost-effectiveness of Highly Active Antiretroviral Therapy in South Africa. Plos Medicine January 2006; 3: e4

Clinical Progression for AIDS patients, P< Badri M, Maartens G, Mandalia S, et al. Cost-effectiveness of Highly Active Antiretroviral Therapy in South Africa. Plos Medicine January 2006; 3: e4

Cost-effectiveness of HAART in non-AIDS and AIDS patients, Cape Town Cost saving at annual HAART Cost of US$730 or US$ 181 US$2506 LYG at annual cost HAART of US$730 and US$ 327 LYG at US$181 per annum Non-AIDSAIDS

Cost-effectiveness of different HAART regimens in the UK

Time to treatment failure for people on different first-line HAART regimens

The cost-effectiveness per life year gained (LYG) for first line HAART 2NRTIs+NNRTI versus 2NRTIs+ PI boosted US$19,577 per LYG 2NRTIs+NNRTI versus 2NRTIs + PI US$19,659 per LYG 2NRTIs+NNRTI versus 2NRTIs+ 2PI US$ 8,571 per LYG

Conclusions HAART enables people living with HIV to remain socially and economically active HAART a cost-effective intervention in a number of high- and middle-income countries, despite differences in health care systems Evidence that viral load levels reflect levels of infectivity, so HAART reduces the infectivity of individuals living with HIV

Rationale for treating People living with HIV with HAART Human Rights Argument – the Joint UNAIDS Program is based on the premise that access to services and treatment is a basic human right Public Health Argument: treating people with HAART, reduces their infectivity and exposes them to prevention services for themselves and people within their social environment

Requirements For optimal treatment people living with HIV need to be followed up regularly and attend for follow up Drug combinations will eventually fail: if not under regular supervision may fail earlier, develop resistance etc. This provides opportunities to regularly reinforce prevention messages and practices

Realities in many countries However, irregular migrants may be less likely to regularly attend health services, in fear of coming into contact with government officials, with potential consequences including deportation Even regular migrants, especially those who belong to ethnic minorities, often access services late and services may be of lesser quality than those used by non-migrants

Realities in many countries Most vulnerable populations - women, youth, prisoners etc. – and most at risk populations – MSMs, IDUs, sex workers etc – may be socially marginalized, be migrants themselves or members of ethnic minorities, all resulting in reduced access to appropriate services

For Universal Access to become a reality, even in Europe……… …. all these populations need to be reached and constructively engaged...

Thank you!