1. Making smart decisions to end AIDS – an investment approach Mariângela Simão Rights, Gender and Community Mobilization Department

2. 2011 UN Political Declaration: concrete targets for 2015 1 Halve sexual transmission 2 Halve infections among injecting drug users 3 Eliminate new HIV infections among children and halve AIDS-related maternal deaths 4 15 million people on HIV treatment 5 Halve tuberculosis deaths among people living with HIV 10 Eliminate parallel systems, for stronger integration 9 Eliminate travel related restrictions 8 Eliminate stigma and discrimination 7 Eliminate gender inequalities and sexual violence and increase capacities of women and girls 6 Close the global resource gap and achieve annual investment of US$ 22-24 bn

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

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

5. HIV incidence: we are NOT on track to achieve the goal of reducing adult HIV infections by half by 2015

6. International resources for HIV have been flat since 2008 Source: UNAIDS, 2012 International assistance US$ billions

7. Middle-income countries have steadily invested more of their own resources in HIV Source: UNAIDS, 2012 International assistance US$ billions Domestic resources in low- and middle-income countries

8. Total resources continue to grow, but fall short of total needs Source: UNAIDS, 2012 International assistanceTotal resources available, with estimated range US$ billions Domestic resources in low- and middle-income countries

9. Glass half empty or half full?  The evolving resource context is a threat  The evolving resource context is an opportunity “Our programme is already streamlined, but the issue of resources always comes up. We have so many dreams, but will we be able to achieve them?" Senior policy advisor Zimbabwe, March 2012 "The reduction in resources is an opportunity for us to take a step back and review whether we are really doing the right things." NAC Director Tanzania, January 2012

10. 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

11. Returns on investment using the new investment framework 2011–2020 Outcomes Total infections avertedMore than 12 million Infant infections averted1.9 million Deaths averted7.4 million Life years gained29.4 million

12. 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)

13. A checklist for applying investment thinking

14. Source: UNAIDS (2012) Value for money: doing the right things Number of new HIV infections 300.000 0 1980199020002010 Russian Federation Brazil

15. 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 2010. 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)

16. Many countries are now applying an investment approach Eastern and Southern Africa:  Malawi  Namibia  Zimbabwe  Zambia  South Africa  Tanzania  Ethiopia Western and Central Africa:  Benin  Ghana Latin America:  El Salvador  Guatemala Asia-Pacific:  Cambodia

17. Country application: entry points and methods Countries are using a variety of entry points:  Re-programming of Global Fund grants  Joint AIDS programme reviews  Development of new national strategies, and review of existing ones Mix of analysis, advocacy and strategy:  Strategic information (MoT, NASA, SWAPs etc.)  High-level advocacy with NACs, Ministries of Health, Ministries of Finance and Plan, and Parliaments  Focused stakeholder discussion

18. 1. Programs, vs. other 2. Program Areas 3. Unit Costs  Bulk of funding directed towards core programs that directly reduce new infections, morbidity and mortality  Select critical enablers as needed to ensure a robust and sustainable response, but set high bar for impact  Invest in HIV-related interventions that support and have synergies with development goals, without crowding out core prevention and treatment interventions  Ensure the right relative mix of core program interventions for a given context  Demonstrate effective targeting of new infections, morbidity and mortality  Allocations will vary by type of epidemic and country context – benchmark provides a starting point for discussion  Unit cost benchmarks for key interventions, pegged to appropriate economic indicator (e.g. GDP/capita)  Soft benchmarks for overall unit cost  Hard caps for critical commodity costs (e.g. ARVs) Three levels of benchmarks could guide GFATM in investment-related processes ART PMTCT MC Etc.

19. Emerging Lessons and Observations  “Smart investment” is viewed by some as “just another donor- imposed approach”  Some key players exhibit the “we need more studies before we can take decisions” syndrome, which may be counterproductive  Investment approach perceived as a threat by some key partners who see the AIDS response as the road to political patronage, money, and institutional survival

20.  High-level leadership and political commitment to more strategic investment is key: including Ministries of Health, Planning, Finance, and NAC  Importance of a robust KYE/KYR analysis: recent Modes of Transmission study and a resource tracking exercise such as NASA at a minimum  Supplemental analytic work can enhance the investment case: cost-effectiveness studies, sustainable financing analyses, institutional analyses, size estimations for key populations  There is no quick fix, but there is no reason to wait: building an effective investment case requires a systematic and deliberate effort which will take time; the important thing is to begin it Emerging Lessons and Observations

21. To think about….  What are the entry points for a new dialogue around efficiency and investment?  Are there obvious mis-matches between the epidemic and the response?  Which are the factors that make it difficult to scale up basic programme components?  How can partners help in application of the Investment Framework at the country level?