Taking Another Look at Condoms Patrick Friel Reproductive Health HIV/AIDS Consultancy 27 April 2006

“Scaling up” condoms? What lessons can we learn from the UNAIDS “Scaling Up to Universal Access” experience? What are some important condom programming challenges and opportunities? What can RHSC/Global Programme do?

Towards Universal Access 2005 World Summit made commitment to scale up with “aim of coming as close as possible to the goal of universal access to treatment by 2010 for all who need it.” G8 Gleneagles Summit expressed support for the same goal At request of UNGA, UNAIDS including its cosponsors and DFID facilitated a global “country-led” process to develop a practical way forward

Towards Universal Access 100 countries, 7 regional consultations and the expert Global Steering Committee including UN, NGOs, foundations, PLHAs and the private sector performed an analysis of the obstacles and made recommendations to overcome them.

Towards Universal Access A fundamental conclusion: HIV prevention needs to integrate with broader health and social services such as programs for PHC, MCH, Sexual and Reproductive Health, TB, nutrition, orphans and vulnerable children, as well as formal and informal education.

Towards Universal Access While people on ART nearly doubled in 2005 from 720,000 to 1.3 million there was an estimated 4.9 million new infections in Therefore, while treatment is vital, a prevention focus is needed to prevent suffering, alleviate impact of AIDS and address ever higher costs for treatment Condoms: a key component of prevention

UNAIDS’ Scaling Up Recommendations 1.Supporting national priorities 2.Predictable and sustainable financing 3.Strengthening human resources and systems 4.Affordable commodities 5.Stigma, discrimination, gender and human rights 6.Accountability

Affordable Commodities Remove barriers to access by June 2007 UNFPA, UNICEF and WHO: lower prices Exempt commodities from taxes by 6/07 Employ TRIPS flexibilities: including local production where feasible by 12/07 Provisional marketing approval for WHO pre-qualified medicines Public-private partnerships: pediatric ARV

In short, we need Support for bottom-up strategies and plans Greater respect for human rights More money More people More commodities and fairer trade Clearer accountability

Policy and Programming Challenges re condoms Weak national policies re human rights and condom stigma persist Inadequate/inequitable resources=many weak programmes Ineffective efforts at country level mirrored by uncoordinated efforts at global level Epidemic proceeds apace

Let’s look at an HIV Model Stover, et al., last month in Science called for stronger political commitment, more money (US$122 billion), more people and better infrastructure. With these inputs we could avert up to 28 million new HIV infections in 125 low- and middle-income countries between 2005 and See next two slides

15 Essential Interventions for an expanded response 1.School-based AIDS education 2.Peer education for out-of-school youth 3.Outreach programmes for commercial sex workers and their clients 4.Public sector condom promotion and distribution 5.Condom social marketing

15 Essential Interventions for an expanded response 6.Treatment for sexually transmitted infections 7.Voluntary counseling and testing 8.Workplace prevention programmes 9.Prevention of mother-to-child transmission 10.Mass media campaigns

15 Essential Interventions for an expanded response 11.Harm reduction programmes 12.Outreach programmes for MSM 13.Community mobilization 14.Prevention programs for people living with HIV 15.Special populations

Role of condoms? Condom programming has a role to play in each intervention area. A comprehensive strategic approach that addresses the 15 essential prevention interventions listed in Stover, et al., Science, 2006, is desirable.

Conclusion Condom Programming is an essential part of HIV prevention and SRH service delivery strategies that should be integrated with all national Health System Strengthening efforts as per the “3 Ones.” “Scaling up to Universal Access” to condoms is a priority for UNAIDS, the World Bank’s MAP and for the GFATM.

Recommendation UNFPA to conduct mini-surveys of a) donor & international agencies and b) country partners (via field offices) to ascertain current status re these interventions and their support levels. Compare current investments by the main donors and international agencies with the reality in these intervention areas. Mobilize the necessary political and additional financial support at global and national levels.

Conclusion Most HIV prevention (and condom programming) guides developed by international agencies provide advice to national governments, NGOs and the private sector. Less common but just as necessary is guidance for the global partners on how to coordinate their work to meet the AIDS epidemic challenge.

Recommendation Identify or develop a guideline for all donors and international agencies that assures: Leadership based on consensus global vision and priorities Coordinated and strategic efforts by each in accord with comparative advantage Adequate long-term financial commitments Monitor for management & accountability

Conclusion International agencies have developed numerous “comprehensive” HIV prevention (and condom programming) guidelines even though most countries do not have access to adequate human, financial and technical resources to implement them.

Recommendation Establish priorities in those areas that are fundamental to effective sustainable programs and assure that they have the necessary human, financial and technical resources.

Finally, can RHSC/Global Programme contribute to UA by: 1.Supporting national priorities 2.Assuring predictable and sustainable financing 3.Strengthening human resources and systems 4.Making commodities more affordable 5.Reducing stigma & discrimination; expanding gender and human rights 6.Being self-critical and accountable?