AIDS: the long term view Peter Piot Prince Mahidol Award in Public Health 30.1.2014

% Condom use at last sex among FSW Thai Working Group on HIV/AIDS Projection Higher FSW =82% Lower FSW =70% %condom used with clients จากกราฟเป็น % condom use with RP & non RP ส่วนเส้นประเป็น % การใช้ condom กับ FSW ใน BSS ของชายกลุ่มต่าง ๆ ใน AEM เดิม %condom used with clients of DSW = 82% คิดว่าน่าจะใช้ตัวนี้ได้ต่อ เพราะจากการพิจารณาข้อมูลแนวโน้มของ BSS trend ค่อนข้าง stable และไม่แตกต่างจากเดิม บวกกับเป็นค่ากึ่งกลางของแต่ละกลุ่ม ซึ่ง %condom used with clients of ISW น่าจะต่ำกว่า DSW ~ 10% >> 70%

Non-viral resistance Experts: in public health and health services, essential medicines, international development Institutions: development agencies, World Bank, European Commission, WHO, Unicef Politicians: Ministers of Health and of Finance Denial about HIV : e.g. President Mbeki

Resources available for HIV in low- and middle-income countries, 1986-2010 Preliminary data suggest that global financing in 2010, $ 15.3 billion were available for HIV and AIDS in low and middle income countries from all sources. Still, 6.5 million people to access ART UNAIDS Source: UNAIDS, 2010 6 November 14, 2018 6

Prices (US$/year) of antiretroviral regimen in Uganda: 1998-2003

Source: UNAIDS

Current business model will NOT get us to 2015 treatment targets Estimate 2015: 1.6 million Target 2015: 2.3 million FALLS SHORT OF TARGET BY ~700 000 Estimate 2012: 1.25 million ART – improving but lagging behind global averages Global increasing trend from 38% in 2009 to 61% in 2012 Regional increasing trend from 35% in 2009 to 51% in 2012. Adults ART coverage is better in South and South-East Asia than in East Asia WE need to scale up at rate of 350,000 new people on treatment per year for next 2 years. – within reach. Between 2010 – 2011 increased by about 200,000 (between 2011 and 2012 about 145,000) Source: Prepared by www.aidsdatahub.org based on UNAIDS HIV Estimates 2012 for UNAIDS.(2013). Global Report: UNAIDS Report on the Global AIDS Epidemic 2013.

The Treatment Cascade

Current business model will NOT get us to 2015 targets for reductions in new infections Estimate in 2015 based on trend of last five years: 350 000 FALLS SHORT OF TARGET BY ~175 000 The next flew slides look at progress and reaching the new infections targets at the REGIONAL level Hence we are unlikely to reach the 2015 target with current response 2015 Target is based on 50% reduction in new infections in 2010 = ½ of 350,000 = 175,000 Source: Prepared by www.aidsdatahub.org based on UNAIDS HIV Estimates 2012 for UNAIDS.(2013). Global Report: UNAIDS Report on the Global AIDS Epidemic 2013.

Number of people newly infected with HIV, Uganda, 1990-2011 1995 2000 2005 2011 Estimate Low and high estimates Uganda National Aids Commission, 2012

HIV incidence and deaths England, 1981-2010 (PHE,2012)

Projected HIV prevalence by sub population Thailand, 1985 - 2030 Thai Working Group on HIV/AIDS Projection % Male IDU Male sex workers MSW MSM

Projected number of new infections by sub population, Thailand, 1985 – 2030 Thai Working Group on HIV/AIDS Projection

HIV testing coverage among men who have sex with men, 2007-2012 FOR RMM Arrange in epi profile groups * Programme data It is not strictly comparable across countries since methods and sampling varied. In addition, many surveys were conducted in a few urban areas and it might not necessarily reflect prevailing conditions at the national level. Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org and Ministry of Health Indonesia.(2013). Recalculated HIV Testing Coverage for the Global AIDS Response Progress Report Online Reporting using IBBS 2011 Data.

A renewed AIDS Response Combination prevention and sustained ART Address multiple micro-epidemics with own dynamics Working with other programmes Renewed leadership Counter stigma & discrimination, including through legal reform R&D on vaccine & cure

Contributions of AIDS response Disrupted divide between disease prevention and treatment. New forms of disease advocacy and activism New global commitments in the funding of health Attracted private philanthropy. Debate about the cost of essential medicines. Recognition of basic human rights and social justice. Source: Brandt, How AIDS Invented Global Health, N Engl J Med 2013

Empowerment Development Science Politics Systems Empowerment Development Science can and must inform health policy decisions in several ways, including by identifying emerging problems. For example, the discovery of new types of influenza virus, or of smoking as a cause of cancer made policy makers aware of grave threats to health. However, as we all know from Science also has limits in health policy decision making since other factors play a key role. The decision to form policy in response to evidence of effectiveness is made politically, not least by voters who selected particular individuals to lead their countries. We should remember that progress in public health has been as much driven by politics as by scientific and technological innovation. Without constructive politics, historical progress in public health would have been far more limited, as the example of AIDS illustrates more recently. None of this is to deny that policy decisions made without scientific advice can be ineffective (such as, restrictions on people with HIV entering a country). This is why the unique system of chief scientific advisers to inform (though not control) policy making in nearly all UK government departments is so important and an example for other countries. (Based on your paper in the BMJ)