The Global Response to AIDS: Achievements and Challenges for the Long Term Peter Piot Institute for Global Health Imperial College London

Number of people receiving ARV therapy in low- and middle-income countries, 2002—2007

Decline in adult mortality with introduction of ART: Botswana

Improvements in life expectancy at infection due to the availability of ART: Resource-poor settings Source: Hallett T B, et al. PLoS Med Mar 11;5(3):e53.

HIV prevalence (%) among pregnant women attending antenatal clinics in sub-Saharan Africa, 1997–2007 NOTE: Analysis restricted to consistent surveillance sites for all countries except South Africa (by province) and Swaziland (by region) Southern Africa Median HIV prevalence (%) 50 Botswana Lesotho Mozambique Namibia South Africa Swaziland Zimbabwe 1997– – West Africa Median HIV prevalence (%) Median HIV prevalence (%) Eastern Africa 1997– – – – Ethiopia Kenya Burkina Faso Côte d'Ivoire Ghana Senegal Source: National surveillance reports and UNAIDS/WHO/UNICEF, Epidemiological Fact Sheets on HIV and AIDS. July 2008.

Changes in HIV Prevalence and Risk Behaviour: Zimbabwe (urban and semi-urban areas) Source: Hallett TB, et al. Epidemics 2009;1(2): Natural decline in incidence ~1990 Accelerated decline in incidence, due to behaviour change ~2000

Number and percentage of HIV-positive pregnant women receiving antiretroviral prophylaxis, 2004– Number of HIV-positive pregnant women receiving anti-retrovirals Year % of HIV-positive pregnant women receiving anti-retrovirals Source: UNAIDS, UNICEF & WHO, 2008; data provided by countries.

AIDS IS NOT OVER

HIV prevalence (%) in adults (15–49) in Africa, 2007

HIV infections among men having sex with men in Asia

Source: Bertozzi SM, et al. Lancet Sep 6;372(9641): HIV infections by mode of transmission in Thailand

How did we get there?  Science and rights driven  A global response  Focus on results for people  Prevention AND treatment  Multi-disciplinary, multi-sectoral  Community engagement

[i] data: Extracted from 2006 Report on the Global AIDS Epidemic (UNAIDS, 2006) [ii] data: AIDS in the World II. Edited by Jonathan Mann and Daniel J. M. Tarantola (1996) Notes:[1] figures are for international funds only [2] Domestic funds are included from 2001 onwards Total annual resources available for AIDS 1986‒ US$ million billion Signing of Declaration of Commitment on HIV/AIDS, UNGASS ‘96‘97‘98‘99‘00‘01‘02‘03‘04‘051986‘87‘88‘89‘90‘91‘92‘93‘94‘95 Less than US$ 1 million World Bank MAP launch Global Fund PEPFAR 257 UNAIDS Gates Foundation ‘ billion 10 billion

Treatment Action Campaign (TAC), South Africa

Recorded female deaths in South Africa and Brazil for ages years Source: Nathan Geffen. Statistics South Africa and Instituto Brasileiro de Geografia e Estatistica. Brazil, 2004.South Africa, 1997.South Africa, 2004

A global response Human rights and strategic issue Global public good Role of United Nations Global civil society and activism International financing

New instruments for AIDS financing World Bank Multi-country AIDS Program (2000) Global Fund to Fight AIDS, TB and Malaria (2002) PEPFAR, (2003) Unitaid (2005) (PRODUCT) Red (2005) Debt2Health (2007)

Prices (US$/year) of first-line antiretroviral regimen in Uganda:

Focus on results for people Targets Know your epidemic and the society Monitor and evaluate Accountability

Simulated HIV epidemics (A) concentrated (B) in the general population Source: Boily M-C,et al. Sex Transm Infect 2007;83: Need for new evaluation methods

A multi-disciplinary, multi-sectoral response Health outcomes determined by multiple factors and interventions Particularly key besides health: law, education, work place, trade, armed forces Expand resource base First genuine business engagement in health

Percentage of countries with sectors included in the national AIDS strategy and earmarked budgets Source: UNGASS Country Progress Reports Public works Tourism Trade and industry Minerals and energy Agriculture Transportation Health Labour Military/police Sector included Earmarked budget present Percentage of countries (%), N=126

Community engagement From planning to implementation Makes or breaks programmes National Aids Councils and Global Fund Country Coordination Mechanisms Societal sustainability and resilience

TASO, Uganda

Opportunities for global health Health diplomacy Increased funding (ODA and research) Collateral benefits (TB, malaria, health systems) Culture of accountability Tiered pricing Engagement of non-medical sectors New blood

aids2031 Taking a long term view- stretching planning and funding horizons to achieve sustainability Multi-disciplinary – bringing together bio-medical, social and political scientists, economists and activists to look at what should we do differently – or more of the same – now to change the future of AIDS Key aids2031 report “Agenda for the Future” to be launched in 2010

Estimated Resource needs for AIDS, TB and malaria (2009 to 2015) Sources: UNAIDS, STB, RBM

Projected AIDS spending needs and per capita GDP, 2030

The PREVENTION GAP Persons at risk with access to selected prevention interventions, 2006 Source: Global HIV Prevention: the access and funding gap. June 2007

Effects of Prevention on Future Costs of ART

Figure 3. Geographical distribution of HIV and tuberculosis infections in South Africa in 1995, 2000, and Reference: Karim. S, The Lancet, Special Issue: Health in South Africa August 2009 (Data from references 1 and 21.)

Cost Effectiveness

The long term view A still evolving epidemic Sustainability (leadership, funding, treatment) An all out effort on hiv prevention Improve programme delivery and capacity Links and synergies with health services ( ART, PMTCTC) and community development To stop aids, need for technological and structural game changers (but no magic bullet!) Invest in R&D