1. © Prof. Rifat Atun. Imperial College London, 2007 The Dublin Declaration Beyond Promises Imperial College London 23 rd November 2007 Professor Rifat Atun MBBS MBA DIC FFPHM FRCGP Professor of International Health Management Director, Centre for Health Management Imperial College London

2. © Prof. Rifat Atun. Imperial College London, 2007 Leadership and Partnership

3. © Prof. Rifat Atun. Imperial College London, 2007 1. Political Leadership Commitments 1, 1, 3, 5, 6, 22, 26, 30, 32, 33 Strengthened political leadership HIV now addressed at national level/leadership Regional efforts and cross-border partnerships Implementation gap: –Resistance to harm reduction programmes –Structural changes in health systems not realised –IDU challenges unlikely to be addressed Need to enhance efforts and M&E 

4. © Prof. Rifat Atun. Imperial College London, 2007 3. Resource availability (Commitments 1, 7, 8, 9, 13, 17, 29) In CIS-10, increased funding US$0.5m in 2001 to US$55m in 2005 Sharp increase 2004-05 : mainly from GFATM Increased out-of-pocket expenditure National contributions variable Funding gaps exist Allocative efficiency questionable 

5. © Prof. Rifat Atun. Imperial College London, 2007 Domestic and International Financing for HIV/AIDS in 10 CIS Countries (2001-06)

6. © Prof. Rifat Atun. Imperial College London, 2007 Domestic vs. International Financing for HIV/AIDS in 10 CIS Countries

7. © Prof. Rifat Atun. Imperial College London, 2007 Prevention

8. © Prof. Rifat Atun. Imperial College London, 2007 4. Injecting drug use and HIV (Commitments 10, 13, 25) Limited progress in scaling up ‘Comprehensive Package’ of Technical Guidance for IDUs –“IDUs remain invisible” –Low NSP and OST coverage in central and eastern Europe –OST not available in six countries –HAART access in Europe increasing but limited for IDUs Need coverage targets for NSPs (60%), OST (40%) and HAART (100%), Monitoring (using WHO/UNODC/UNAIDS Technical Guide) and comparative benchmarking of results 

9. © Prof. Rifat Atun. Imperial College London, 2007 5. Most vulnerable and high-risk populations (Commitments 9, 13, 18, 25) Data remains patchy Stigma, discrimination and inequities persist for sex workers, MSM, prisoners, migrant populations and ethnic minorities Define ‘vulnerable’ and ‘risk’ for M&E of progress Targeted interventions to enhance access with comprehensive surveillance systems Identify and address legal and regulatory barriers 

10. © Prof. Rifat Atun. Imperial College London, 2007 7. Prevention of mother-to-child transmission and paediatric AIDS (Commitments 11, 12, 14) Improved coverage of PMTCT interventions and paediatric HIV Elimination by 2010 needs intensive and accelerated action Prioritise in National Responses –Evidence-based interventions –Strengthen reach and coverage, especially in marginalised groups Eastern Europe and Central Asia –scale up resources for PMTCT and HIV in children –E-W and E-E collaboration –Civil society, national and international partnerships 

11. © Prof. Rifat Atun. Imperial College London, 2007 10. Sexually transmitted infections (Commitment 16) Increasing rates now leveling in some countries but ? Reliability of data Weak/variable surveillance in 2nd generation HIV surveillance that includes STIs No baseline and ascertain progress Many examples of good practice in western Europe Varied integration of HIV-STI services Need to strengthen and harmonise surveillance Evidence based interventions and cross-learning on IEC, prevention and treatment 

12. © Prof. Rifat Atun. Imperial College London, 2007 11. Research and new technologies (Commitments 19, 24, 29) Funding levels increased in the EU but uneven –Larger commitment in FP5-6-7 but execution not clear –Reduced DG Sanco budget for Public Health Programme 2007-13 –Funding gap for PDPs, social sciences and behavioural research –EDCTP commitments not met National level expenditures opaque as no tracking Need to increase funding, address gaps and track resources (absolute and relative to commitments) 

13. © Prof. Rifat Atun. Imperial College London, 2007 Living with HIV/AIDS

14. © Prof. Rifat Atun. Imperial College London, 2007 12. Treatment and care (Commitments 13, 21, 23, 25) HAART coverage rose from 242,000 in 2003 to 389,000 by mid 2006 and 407,000 by 2007 Improved survival Increase of 6x in CEE but coverage still low Inequitable access by IDUs in CEE Lifetime cost €0.5m with total cost for 2.3m persons estimated at €1trillion Resistance to ARVs increasing Co-infection with TB and MDRTB key problem

15. © Prof. Rifat Atun. Imperial College London, 2007 13. Stigma, discrimination and human rights (Commitments 1, 20, 31) “Reality gap” Human rights underpin every aspect of Dublin Declaration, but countries failing to address discrimination and stigma and promote human rights of PLWHA Poor disaggregate data Rights-based approach to monitoring progress 

16. © Prof. Rifat Atun. Imperial College London, 2007 Conclusions

17. © Prof. Rifat Atun. Imperial College London, 2007 Cross Cutting Themes Greater accountability needed Enabling legal and regulatory framework to reduce stigma, exclusion and discrimination Strengthen surveillance M&E with more disaggregate data Greater harmonisation of interventions and M&E Strengthen x-country integration Improve targeting with greater intensity and scale of effort to reduce inequities Increase civil society and private sector involvement Improve use of evidence-based interventions