The investment framework - Critical enablers are not a luxury! Bernhard Schwartlander

Good progress towards 15 million people on antiretroviral treatment by 2015 Source: UNAIDS, 2012

Good progress towards elimination of new HIV infections among children (0–14 years) by 2015 Source: UNAIDS, 2012

Maternal access to ARVs needs to be consistent, to boost coverage during breastfeeding Percentage of eligible mother-child pairs receiving effective prophylaxis to prevent new HIV infections among children, low- and middle-income countries, 2011 Source: UNAIDS, 2012 During pregnancy and delivery During breastfeeding 29%

Source: UNAIDS, 2012 HIV incidence: we are NOT on track to achieve the goal of reducing adult HIV infections by half by 2015

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

Current and projected number of new HIV infections Optimized investment could lead to rapid declines in new HIV infections Source: UNAIDS 2011 Investment approach Baseline Vietnam Nigeria Cambodia South Africa Zimbabwe Ukraine

Critical enablers and development synergies are distinct, but on a continuum Development synergies Critical enablers HIV-specific (sole or primary objective is an HIV-related outcome) HIV-sensitive (HIV outcome is one of many objectives)

A checklist for applying investment thinking

Source: UNAIDS Number of new HIV infections Russian Federation Brazil Value for money: doing the right things

Morocco: reallocation to invest where the epidemic is happening Source: Morocco Ministry of Health, National STI/HIV Programme, HIV modes of transmission in Morocco. August General population Sex workers and clients MSM IDU Key populations (other) Font size!!!!!! Percenetage (%) 80 0 Proposed spending, National Strategic Plan for 2012–2016 People acquiring HIV infection (2009) Spending on HIV prevention (2008)

Significant reductions in cost for HIV treatment Costs for facility-level ART including costs for ARVs, personnel, labs, training, etc. Cost per person/year US$ Sources: Menzies et al 2011; CHAI, 2012; Bollinger & Adesina, 2011

Community support keeps people on treatment Source: Decroo T et al. Distribution of antiretroviral treatment through self-forming groups of patients in Tete province, Mozambique. Journal of Acquired Immune Deficiency Syndromes, 2010 [Epub ahead of print]. Source: Fox MP, Rosen S. Patient retention in antiretroviral therapy programs up to three years on treatment in sub- Saharan Africa, 2007–2009: systematic review. Tropical Medicine and International Health, 2010, 15(Suppl. 1):1–15. CLINIC-BASED TREATMENT Sub-Saharan Africa: people receiving ART from specialist clinics still receiving treatment after two years 70% COMMUNITY TREATMENT MODEL Mozambique: self-initiated community model still receiving treatment after two years 98% Sources: Fox MP, Rosen S. Tropical Medicine and International Health, Decroo T et al. Journal of Acquired Immune Deficiency Syndromes, 2010.

Community mobilization increases effectiveness Community mobilisation increased HIV testing rates four-fold in Tanzania, Zimbabwe, South Africa and Thailand Consistent condom use in the past 12 months was 4 times higher in communities with good community engagement (Kenya) Hypothetical circumcision model KwaZulu-Natal :  Core intervention: 240,000 infections averted over ten years  With enablers: 420,000 infections averted, with modest marginal increase in costs

 Legal literacy (know your rights and laws)  Legal services  Law reform  Stigma reduction  Police training on non-discrimination, space for outreach, non-harassment, etc.  Health care worker training on non- discrimination, informed consent, confidentiality, duty to treat, infection control  Elimination of violence against women and harmful gender norms Critical enablers improve the legal and social environment

Source: Gardner E M et al. Clin Infect Dis. 2011;52: Percentage of people retained in treatment and care after diagnosis, USA Tested <30 days USA Diagnosed with HIV Linked/ enrolled in care Eligible for ART Initiated ART Adherent or undetectable Retained in care 100% 0 Retained in treatment and care

Percentage of people retained in treatment and care after diagnosis, USA and Mozambique Source: Gardner E M et al. Clin Infect Dis. 2011;52: ; Micek et al JAIDS 2009 Tested <30 days Mozambique USA Diagnosed with HIV Linked/ enrolled in care Eligible for ART Initiated ART Adherent or undetectable Retained in care 100% 0 Retained in treatment and care

Percentage of people retained in treatment and care after diagnosis, USA and Mozambique Source: Gardner E M et al. Clin Infect Dis. 2011;52: ; Micek et al JAIDS 2009 To improve testing:  Reduce stigma in the community and in healthcare settings  Strengthen community support and referral networks  Enhance human rights literacy Tested <30 days Mozambique USA Diagnosed with HIV Linked/ enrolled in care Eligible for ART Initiated ART Adherent or undetectable Retained in care 100% 0 Retained in treatment and care

Percentage of people retained in treatment and care after diagnosis, USA and Mozambique Source: Gardner E M et al. Clin Infect Dis. 2011;52: ; Micek et al JAIDS 2009 Improve enrolment in care:  Expand community-centred delivery  Overcome cost & transport barriers  Enhance treatment & rights literacy Tested <30 days Mozambique USA Diagnosed with HIV Linked/ enrolled in care Eligible for ART Initiated ART Adherent or undetectable Retained in care 100% 0 Retained in treatment and care

Percentage of people retained in treatment and care after diagnosis, USA and Mozambique Source: Gardner E M et al. Clin Infect Dis. 2011;52: ; Micek et al JAIDS 2009 Get more people on treatment:  Enhance peer support programmes  Reduce costs  Overcome transport barriers  Ensure adequate nutrition  Reduce stigma in healthcare settings Tested <30 days Mozambique USA Diagnosed with HIV Linked/ enrolled in care Eligible for ART Initiated ART Adherent or undetectable Retained in care 100% 0 Retained in treatment and care

Percentage of people retained in treatment and care after diagnosis, USA and Mozambique Source: Gardner E M et al. Clin Infect Dis. 2011;52: ; Micek et al JAIDS 2009 Retain people on treatment:  Adherence support programmes  Reduce gender inequalities  Reduce fear of disclosure  Overcome cost and transport barriers  Referral and support programmes for migrants Tested <30 days Mozambique USA Diagnosed with HIV Linked/ enrolled in care Eligible for ART Initiated ART Adherent or undetectable Retained in care 100% 0 Retained in treatment and care