The HIV Response Where are we now? SAMU SUMMARIES JULY 2018 samumsf.org

This presentation To list the scale of the global epidemic and the response To list the global targets we are working towards To list MSF’s response to the HIV epidemic

Summary of global HIV epidemic (2016)

People living with HIV by WHO region (2016)

World Health Organization Summary of global HIV epidemic (2016) 11 November 2018 Number of people living with HIV in 2016 Total Adults Women Men Children (<15 years) 36.7 million [30.8 million – 42.9 million] 34.5 million [28.8 million – 40.2 million] 17.8 million [15.4 million – 20.3 million] 16.7 million [14.0 million – 19.5 million] 2.1 million [1.7 million – 2.6 million] 1.8 million [1.6 million – 2.1 million] 1.7 million [1.4 million – 1.9 million] 160 000 [100 000 – 220 000] 1.0 million [830 000 – 1.2 million] 890 000 [740 000 – 1.1 million] 120 000 [79 000 – 160 000] People newly infected with HIV in 2016 AIDS deaths in 2016 Source: UNAIDS/WHO estimates.

Decline in HIV incidence and mortality over time Source: UNAIDS/WHO estimates.

Remarkable individual and population health benefits 70 World Life Expectancy at birth 60 S.Africa 50 Changes in life expectancy at birth in selected countries in the WHO African Region with a high burden of HIV infection, 1985–2015 40 Zimbabwe 1985 2000 2015

Number of people newly infected with HIV 19% 40% 90% Future targets UNAIDS/WHO estimates

Number of new HIV infections 2015 And 2.1 million new infections in 2015 , 150,000 of which were in children and 46% in eastern and southern africa 2.1 million new infections 150,000 new paediatric infections 960,000 new infections in east and southern Africa

New HIV infections by region, 2015−2016 WHO region Number of new HIV infections 2015 2016 New HIV infections all ages (per 1000 uninfected population) 2015 New HIV infections all ages (per 1000 uninfected population) 2016 Africa   1 200 000 1.34 1.24 Americas 150 000 0.16 South-East Asia 160 000 0.09 0.08 Europe 210 000 220 000 0.23 0.25 Eastern Mediterranean 36 000 37 000 0.06 Western Pacific 97 000 0.05 Global 1 900 000 1 800 000 0.27 0.26

Decrease in eastern and southern Africa New HIV infections 2010-2015 Decrease in eastern and southern Africa Increase in eastern Europe and central Asia Stable in all other regions Although the number of infections remains significantly higher in Africa the number of new infections has declined over the last 5 years This contrasts with eastern Europe and central Asia where there has been a significant rise in the number of new infections

Distribution of new infections by region 2014 Majority of new infections: Africa : General Population Asia and Pacific, Latin America and Middle East and North Africa: combination of key populations Eastern Europe and Central Asia : majority PWID Across the different geographical regions different subpopulations account for the majority of new infections For example in eastern europe and central asia the majority of new infections are occuring in people who inject drugs ( PWID) whilst across Africa the epidemic remains generalised with the majority of new infections occuring in the general population

Number of people receiving antiretroviral treatment Mid-2017 20.9 million 19% 40% 90% Future targets UNAIDS/WHO estimates

HIV testing and care continuum by WHO region (2016) UNAIDS/WHO estimates

Increase in people receiving ART over time 19.5 [17.2–20.3] million on treatment by 2016 20.9 million on treatment by mid-2017 Source: UNAIDS/WHO estimates.

ART coverage over time Source: UNAIDS/WHO estimates.

ART coverage by sex among adults, 2016 Although the numbers on ART have increased significantly there remains wide variations in ART coverage according to region with the middle east , eastern Europe and central Asia and west and central Africa lagging behind in their response Source: UNAIDS/WHO estimates.

Number of people dying from HIV 19% 40% 90% Future targets UNAIDS/WHO estimates

World Health Organization 11 November 2018 Deaths due to HIV by region, 2015−2016 WHO region Number of deaths due to HIV/AIDS 2015 2016 Africa 760 000 720 000 [620 000–930 000] [590 000−890 000] Americas 57 000 54 000 [47 000–69 000] [44 000−65 000] South-East Asia 130 000 [130 000–230 000] [120 000−220 000] Europe 46 000 49 000 [38 000–53 000] [40 000−56 000] Eastern Mediterranean 16 000 17 000 [13 000–22 000] [14 000−24 000] Western Pacific 44 000 39 000 [30 000- 69 000] [25 000−66 000] Global  1 100 000 1 000 000 [880 000-1 300 000] [830 000−1 200 000]

So what are the current global targets ?

The UNAIDs Fast-Track Targets By 2020: Fewer than 500,000 new infections Fewer than 500,000 AIDS related deaths Zero discrimination By 2030 Fewer than 200,000 new infections Fewer than 200,000 AIDS related deaths Zero discrimination UNAIDS has set the global fast track targets – aiming by 2030 for fewer than 200,000 new infections ( 10x less than we currently achieved ) and fewer than 200,000 AIDS related deaths ( 5 x less than was seen in 2015 )

Global Treatment Targets 2000-2030 Global treatment targets have doubled every 5 years since 2000 and with the introduction of treat all will need to double again Global treatment targets have doubled every 5 years since 2000 and need to double again

The 5 “90” Targets 90% of people who know their HIV positive status are accessing treatment 90% of people receiving treatment have suppressed viral loads 90% of people living with HIV know their status 73% of all PLWHIV with suppressed viral loads 90% of all PLWHIV know their status 81% of all PLWHIV on treatment In addition to these fast track global targets the majority of countries have also adopted the UNAIDS 90-90-90 targets which address each step of the HIV continuum of care. The goal is that 90% of people living with HIV know their status , 90% of people who know their status are accessing treatment and 90% of those on treatment have suppressed viral loads Overall this equates to 73% of all people living with HIV A fourth 90 has also been added to address prevention services – stating that 90% of people have access to HIV combination prevention services 90% of people with advanced HIV have access to a package of care to reduce mortality 90% of people have access to HIV combination prevention and sexual and reproductive health services

HIV testing and care continuum (2016) UNAIDS/WHO estimates

The WHO guidelines To support the scale up to these global targets WHO has developed 4 key guidelines , HIV testing services ,the consolidated guidelines for the use of antiretroviral drugs for treating and preventing HIV infection, a guideline specifically for prevention diagnosis and treatment for key populations and guidance for strategic information. They are all available on the WHO website and are included in the relevant resource pages on the SAMU website

What about the resources needed for scale up ? In low and middle income countries: $19.2 billion estimated resources available for AIDS response 2014 $26.2 billion estimate of what is needed by 2020 to reach the fast track targets $19.3 billion peak investment needed in 2017 to achieve the 90-90-90 targets 7.3 billion needed for HIV prevention by 2020 57% of total investments in AIDS response are from domestic funds $7 billion gap in resources available in 2014 and what is needed by 2020 A massive increase in funding is required to meet these ambitious targets $26.2 billion is what is estimated to be needed by 2020 to reach the fast track targets with a 19.3 billion peak investment needed in 2017 Despite an increase in domestic funding to 57% there remains a $7 billion resource gap Calculated in 2016 based on 2015 programme data http://www.unaids.org/sites/default/files/media_asset/HIV_investments_Snapshot_en.pdf

Sources of International Funding Multilateral assistance: The Global Fund to Fight AIDS TB and Malaria, UNITAID and other UN agencies 2015 26% of HIV assistance ($1.9 billion) was provided through multilateral agencies The Global Fund is the worlds largest financier of HIV and AIDS In Sept 2016 the fifth replenishment saw donors commit $12.9 billion between 2017 and 2019 The USA is the largest donor to the Global Fund followed by the UK, France, Germany and Japan Bilateral Assistance The majority of donor government funding was distributed directly to recipient countries in 2015 (74%). ‘Bilateral’ funding fell by US$ 715 million on 2014 levels with the USA accounting for the majority of this fall (57%) One source of bilateral funding is the President's Emergency Plan for AIDS Relief (PEPFAR) Since 2003, PEPFAR has spent US$ 70 billion on programmes globally to combat HIV and AIDS, tuberculosis, malaria and other opportunistic infections. Where multilateral and bilateral funding from USA (66.4%), United Kingdom 13%,France 3.5%,Germany 2.7% , Netherlands 2.3% Since 2006, these five countries have accounted for roughly 80% of all HIV funding from donor governments International HIV funding has traditionally come through both multilateral agencies such as the global fund , UNITAID and other UN agencies and trough bilateral assistance. The largest bilateral funding source is PEPFAR the presidents emergency plan for AIDS relief which has spent to date $70 billion globally on the HIV response Overall the largest contributor to international funding has been the US followed by the UK France Germany and the Netherlands

Source: Financing Global Health Database 2017

Source: PEPFAR report to Congress 2018 pg 89

Source of International Funding Private philanthropic organisations Provided US$ 618 million for global HIV and AIDS programmes in 2014 – an 8% increase on 2013 The Bill & Melinda Gates Foundation is the leading philanthropic funder of international HIV efforts. To date, the foundation has committed more than $3 billion in HIV grants to organisations around the world and has given an additional $1.6 billion to the Global Fund. Additional funding has also been made available through philanthropic organisation with the Bill and Melinda Gates foundation leading these efforts

The Language Focus & prioritisation (high burden, low resources, pops, countries, locations etc) Epidemic control Funding (do more with less, innovation, impact, efficiency, sustainability, shared responsibility) Uptake of WHO policies vs implementation challenges in expanding access Access and quality in- Low Coverage contexts, Key pops, young girls and women, children and adherence Increased competition- SDGs “the kind of global AIDS response policymakers craft when they have one hand tied behind their back”

HIV resource availability by source, 2006–2016, and projected resource needs by 2020, low- and middle-income countries Source: UNAIDS estimates June 2017 on HIV resource availability. Fast-Track update on investments needed in the AIDS response, 2016–2030. Geneva: UNAIDS; 2016. Financing the response to low- and middle-income countries: international assistance from Donor Governments in 2016. The Henry J. Kaiser Family Foundation and UNAIDS (in press). GAM/GARPR reports (2005–2017). Philanthropic support to address HIV/AIDS in 2015. Washington, DC: Funders Concerned about AIDS; 2016. *Estimates for low- and middle-income countries per 2015 World Bank income level classification. All figures are expressed in constant 2016 US Dollars. In UNAIDS report ”Ending AIDS: progress towards the 90-90-90 targets” http://www.unaids.org/sites/default/files/media_asset/Global_AIDS_update_2017_en.pdf “Funding is an additional concern. Trends in resource availability for AIDS responses in low and middle-income countries remained flat for the third consecutive year, at about US$ 19.1 billion. International investment in the AIDS responses of these countries peaked in 2013 at nearly US$ 10 billion (constant 2016 US dollars); it has since declined to around US $8.1 billion in 2016. Meanwhile, although domestic investments increased by an average of 11% a year from 2006 to 2016, the rate of that increase slowed to 5% between 2015 and 2016 (Figure 1.4). This overall stable trend in resource availability is at odds with the resource commitments agreed by the United Nations General Assembly: US$ 26 billion in low- and middleincome countries by 2020. Building on the unprecedented international assistance made by PEPFAR and through the Global Fund to Fight AIDS, Tuberculosis and Malaria, additional domestic and donor investment is needed to achieve the 90–90–90 targets and the other Fast-Track Targets for 2020 within the 2016 United Nations Political Declaration on Ending AIDS.” Source UNAIDS 2017

HIV resource availability by source, 2006–2016, and projected resource needs by 2020, western and central Africa* Source: UNAIDS estimates on HIV resource availability, June 2017. Fast-Track update on investments needed in the AIDS response, 2016–2030. Geneva: UNAIDS; 2016. Financing the response to low- and middle-income countries: international assistance from donor governments in 2016. The Henry J. Kaiser Family Foundation and UNAIDS (in press). GAM/GARPR reports (2005–2017). Philanthropic support to address HIV/AIDS in 2015. Washington, DC: Funders Concerned about AIDS; 2016. *Estimates for low- and middle-income countries per 2015 World Bank income level classification. All figures are expressed in constant 2016 US dollars. “Resources available for AIDS responses in the region increased by 65% from 2006 to 2016 (in constant 2016 US dollars), reaching an estimated US$ 2.1 billion. Investment, however, was far lower than what is needed to achieve Fast-Track Targets by 2020 (Figure 7.10). Domestic investment reached its highest level to date in 2016, but it was still just 35% of the total resources available for the whole region. Most of the countries in the region are highly donor dependent, and sustained support from international donors will be needed for global targets to be met.” Source UNAIDS 2017

Key Messages 21 million on ART of the 36.7 million people living with HIV Wide variations across geographical regions and populations New infections stable or decreased except for eastern Europe and central Asia Mortality remains high at 1 million deaths per year with little decrease Ambitious global targets aim for 73% to have a suppressed viral load and 200,000 new infections by 2030 Decrease in international funding puts the HIV Response and the achievement of Global Targets at risk, despite a significant increase in domestic funding In summary great achievements have been made over the last decade with just under half of all people living with HIV now accessing treatment Despite this there remain large differences between coverage across the regions with west and central africa and eastern europe and central asia lagging behind. In addition eastern europe and central area is the only region to see an ongoing increase in the number of new infections UNAIDS has set ambitious global targets with the 90-90-90 targets aiming overall for 73% of all people living with HIV to have a suppressed viral load To reach where we are today has relied on a significant global and domestic commitment to fight the epidemic. The question remains will ongoing multi and bilateral funding mechanisms be able to contribute enough to reach the $26.2 billion needed by 2020.