Almost 14 years ago all countries endorsed a set of 8 Millennium Development Goals (or MDGs). 3 of those 8 Goals focus on health – that being child mortality, maternal health, and HIV, malaria and other diseases. After 15 years this Development framework will sunset at the end of 2015. In its place a new global framework is being developed, with the aim of eradicating poverty and ensuring sustainable development by 2030.

OUTLINE Progress towards the MDGs Positioning health in the post-2015 framework Addressing HIV in the new development agenda: Building on the unfinished business of the MDGs Integrating HIV into universal health coverage In this presentation I will provide an update on this post-2015 process. In doing so: Firstly, I will review progress towards achieving the MDGs; Secondly, I will discuss current thinking on how health might be positioned within the post-2015 development framework; and Finally I will consider how HIV could be addressed in the new agenda, with a focus on: Building on the MDGs; and Adopting universal health coverage as an approach to strengthen the HIV response.

MDGs DRIVING ADVANCES IN HEALTH -47% Target: - 66% (1990 – 2015) Child mortality 2012 -53% Target: - 75% (1990 – 2015) Maternal mortality 2010 First, let us consider the progress made towards achieving the MDG targets. As can be seen with this slide, progress has been witnessed across all three health-related MDGs. The HIV response has contributed not only to MDG 6, but has also made a significant contribution to reducing child and maternal mortality . While noting these successes, there is still much to be done to achieve the 2015 targets. For example, despite impressive scale-up of antiretroviral therapy, with a forty-fold increase in the number of people on treatment since 2002, changing treatment criteria means that only 37% of people eligible for treatment are receiving it. Clearly, the targets for most MDGs will not be achieved within the next 18 months, and this unfinished business will need to be tackled as we move beyond 2015. Incidence Mortality -42% -29% -45% -33% +3800% Malaria (2000-2012) TB (1990-2012) New Infections (2001-2012) ART (2002-2013) HIV

BEYOND MDGs - POSSIBLE FOCUS AREAS FOR SDGs 1. End poverty 2. End hunger; food security & nutrition; sustainable agriculture 3. Ensure healthy lives and promote well- being for all at all ages   4. Education and life-long learning 5. Gender equality, empower women & girls 6. Water and sanitation 7. Modern energy services 8 Sustainable economic growth & decent work 9. Sustainable industrialization and innovation 10. Reduce inequality within and among countries 11. Safe, inclusive & sustainable cities and settlements 12. Sustainable consumption and production patterns 13. Climate change 14. Marine resources 15. Terrestrial ecosystems and biodiversity 16. Peaceful and inclusive societies & rule of law 17. Global partnership for sustainable development   So where are we currently placed in formulating a new development framework? A broadly inclusive intergovernmental process has been established to propose a new development framework and a set of sustainable development goals and targets, all to be agreed before the end of 2015. The Open Working Group on Sustainable Development Goals has identified 17 areas in which possible new goals and targets could be developed. You will note that only one of the 17 areas is specific to health, although many other areas are closely linked to health, such as education, nutrition, water and sanitation. With so many other development priorities on the table it appears that health and HIV will not feature as prominently as they have in the MDGs.

POSSIBLE HEALTH GOAL AND SUBGOALS OVERARCHING HEALTH GOAL Ensure healthy lives and promote well-being for all at all ages HEALTH SUB-GOALS: Maternal mortality (build on MDG) Child (<5 years) mortality (MDG) End epidemics of AIDS, TB, malaria and NTDs and combat hepatitis and other communicable diseases NCDs and mental health Alcohol and other substance use Road traffic accidents Sexual and reproductive health Universal Health Coverage incl. financial risk protection Hazardous chemicals, pollution & contamination With the current thinking it is anticipated that there will be one overarching sustainable development goal, with a set of specific goals for different sectors, including health. The health goal is likely to be "Ensure healthy lives and promote well-being for all at all ages', which will include a set of sub-goals and targets. The Open Working Group released a report just yesterday proposing a set of 9 sub-goals for health, including a set of goals building on the health-related MDGs and a goal on universal health coverage, including financial risk protection, access to quality essential health care services and access to quality essential medicines and vaccines. Whereas a number of these sub-goals are relevant to HIV, I would like to focus on those highlighted in red – that is the unfinished business of the MDGs and Universal Health Coverage (or UHC).

BUILD ON MDGs 1. Focus on those MDGs most off-track 2. More ambitious targets for those on track – ending AIDS, TB and malaria epidemics Universal access to HIV prevention, treatment, care and support services Sustain and build on gains in TB – new TB strategy with goal of eliminating TB Sustain and build on gains in the fight against malaria – new strategy in development Let's first consider the unfinished business of the MDGs. Special attention needs to be given to those MDGs that are most off-track, including MDGs 4 and 5 on maternal and child health. Clearly the HIV response can do much to support these efforts through the elimination of mother-to-child transmission of HIV and improving the coverage and quality of HIV treatment and prevention for both children and women. In addition, building on MDG 6, the proposed new sub-goal 3.3 calls for ending the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases by 2030 and combatting hepatitis. Already the goal of eliminating tuberculosis features in the new global tuberculosis strategy endorsed at the World Health Assembly in May this year. And, as you will hear during this conference, UNAIDS is proposing new HIV targets for 2030, calling for a 90% reduction in new HIV infections, a 90% reduction in discrimination and a 90% reduction in HIV-related mortality, as compared with a baseline of 2010.

UNIVERSAL HEALTH COVERAGE – 3 DIMENSIONS The second possible area for a health target is 'universal health coverage' . Universal health coverage is an aspirational goal in which all people receive the health services they need, which are of adequate quality, without incurring financial hardship. UHC has three dimensions, as illustrated by this diagramme: First, people need to be able to access the full range of quality prevention, treatment, care and support services relevant to their specific health needs. Second, services need to be provided equitably to all populations, whoever or wherever they are. And third, all people should have financial protection to minimize out-of-pocket health expenses, through such mechanisms as compulsory health insurance . Each country will need to invest in all three dimensions, to progressively scale up comprehensive programmes as equitably and as quickly as possible while also ensuring that the quality of services is maximized. All people receive the services they need of adequate quality without incurring financial hardship

COMPREHENSIVE QUALITY HEALTH SERVICES Examples of HIV contributions to UHC HIV intervention packages Intervention framework - HIV prevention, care & treatment cascade Research agenda and innovation (basic, clinical, operational, social sciences) For each of the three dimensions of UHC, the HIV response has acted as a trail-blazer in many ways. At the same time, the UHC framework can help reorient HIV programmes to address some of the critical challenges that lie ahead, such as the need to ensure health equity and programme quality and sustainability. For example, under the first dimension of providing comprehensive health services, the HIV response has done much to define comprehensive HIV intervention packages that should be included in national programmes. However, there are areas where major improvements are required, such as improving the quality of services and expanding the scope of HIV intervention packages to link with other critical health areas, such as non-communicable diseases and sexual and reproductive health. Future priorities Better defining core interventions Expand coverage through progressive realization Quality assurance & improvement Linking HIV with other health areas – NCDs, SRH Single framework for national strategic planning and costing

EQUITABLE COVERAGE FOR ALL Examples of HIV contributions to UHC Normative guidance for key populations Models of service delivery to reach marginalized and remote populations Civil society as equal partners Health & community systems strengthening Interventions for enabling environments In the second dimension, that of ensuring equitable coverage of all populations, HIV responses have stimulated the development of highly effective models of decentralized service delivery and promoted community empowerment, critical measures for overcoming pervasive health inequities. On the other hand, HIV programmes in many countries still aren't focusing their efforts on populations and locations most affected by HIV, nor on the interventions that will make the greatest impact. Data from multiple sources, with some sampling limitations Future priorities Improve & disaggregate strategic information Address social determinants Focus on populations and locations most affected Focus on interventions where response is lagging Research and innovation for better service delivery

FINANCING HIV RESPONSE Examples of HIV contributions to UHC Assessing resource needs and programme costing New investments in health New funding approaches Innovative financing (e.g. public-private partnerships) Improved efficiencies in service delivery Access to affordable medicines and other health commodities For the third dimension, that of ensuring financial protection, the HIV response has done much to mobilize huge new investments in health, pioneer innovative financing models and promote treatment access initiatives that have resulted in huge reductions in the prices of medicines and diagnostics. However, much needs to be done to ensure that critical HIV interventions and the associated out-of-pocket expenses are covered through financial protection schemes and that key populations are not excluded from such schemes. Future priorities Continued external development assistance Greater focus on domestic funding Universal financial risk protection schemes Cover associated out-of-pocket expenses Address specific needs of middle-income countries

MDGs: Build on the MDGs with even more ambitious HIV-related targets. WHERE TO FROM NOW? SDGs: Position HIV prominently in the health goal and include HIV-sensitive indicators in other goals. MDGs: Build on the MDGs with even more ambitious HIV-related targets. UHC: Use the HIV experience to achieve UHC and use the UHC framework to accelerate and strengthen the HIV response. Define core HIV interventions to be included in UHC packages Expand HIV links with other health areas to achieve health equity Focus where interventions are needed and responses lagging Emphasize efficiency and quality Ensure universal financial and social protection Therefore, in summary, where do we go now? First, we need to ensure that HIV is prominently represented in any new health goal and targets, and is reflected in other relevant post-2015 goals. Second, we need to build on the momentum of the MDGs and to establish even more ambitious HIV-related targets. And third, we need to ensure that comprehensive HIV interventions are adequately integrated into universal health coverage packages in countries. This coming year will, to a large extent, influence the future of the global HIV response. Therefore, we in the HIV community, will need to actively participate in the post-2015 agenda process, to make certain that the goal of ending the AIDS epidemic will become a reality.