The transformational nature of the aids response Peter Piot,MD,PhD

A global view of HIV infection 33 million people [30–36 million] living with HIV,

Number of people receiving ARV therapy in low- and middle-income countries, 2002—2007

Decline in adult mortality with introduction of ART: Botswana

HIV prevalence (%) among pregnant women attending antenatal clinics in sub-Saharan Africa, 1997–2007 NOTE: Analysis restricted to consistent surveillance sites for all countries except South Africa (by province) and Swaziland (by region) Southern Africa Median HIV prevalence (%) 50 Botswana Lesotho Mozambique Namibia South Africa Swaziland Zimbabwe 1997– – West Africa Median HIV prevalence (%) Median HIV prevalence (%) Eastern Africa 1997– – – – Ethiopia Kenya Burkina Faso Côte d'Ivoire Ghana Senegal 2.9 Source: National surveillance reports and UNAIDS/WHO/UNICEF, Epidemiological Fact Sheets on HIV and AIDS. July 2008.

Number and percentage of HIV-positive pregnant women receiving antiretroviral prophylaxis, 2004– Number of HIV-positive pregnant women receiving anti-retrovirals Year % of HIV-positive pregnant women receiving anti-retrovirals Source: UNAIDS, UNICEF & WHO, 2008; data provided by countries. 4.13

AIDS IS NOT OVER

HIV prevalence (%) in adults (15–49) in Africa,

HIV infections among men having sex with men in Asia

The aids response is transformational » Science and rights driven » Political approach » Focus on results for people » Prevention AND treatment » Multi-disciplinary, multi-sectoral » Community engagement » Global response

Good politics, bad politics: the experience of Aids PPiot, HLarson,SRussell. Am J Publ Health, 2007;97:1934

Recorded female deaths in South Africa and Brazil for ages years Source: Nathan Geffen. Statistics South Africa and Instituto Brasileiro de Geografia e Estatistica. Brazil, 2004.South Africa, 1997.South Africa, 2004

Median percentage of population reached with HIV prevention services within the specified legal environment Sex workers (N=42) Injecting drug users (N=17) Men having sex with men (N=28) Median percentage of population reached with HIV prevention services (UNGASS indicator 9) Countries reporting having non- discrimination laws/regulations with protection for this population Countries reporting NOT having non- discrimination laws/regulations with protection for this population Source: UNGASS Country Progress Reports

Treatment Action Campaign (TAC), South Africa

UN security Council Resolution 1308 (2000) on AIDS

[i] data: Extracted from 2006 Report on the Global AIDS Epidemic (UNAIDS, 2006) [ii] data: AIDS in the World II. Edited by Jonathan Mann and Daniel J. M. Tarantola (1996) Notes:[1] figures are for international funds only [2] Domestic funds are included from 2001 onwards Total annual resources available for AIDS 1986‒ US$ million billion Signing of Declaration of Commitment on HIV/AIDS, UNGASS ‘96‘97‘98‘99‘00‘01‘02‘03‘04‘051986‘87‘88‘89‘90‘91‘92‘93‘94‘95 Less than US$ 1 million World Bank MAP launch Global Fund PEPFAR 257 UNAIDS Gates Foundation ‘ billion 10 billion

Resources available to HIV-related programmes by source and bilateral disbursements, 2006 G Sources: UNAIDS analysis based on OECD/DAC online database (last visited on May 6, 2008), Resource availability UNAIDS 2005, Funders Concerned About AIDS (FCAA), European HIV/AIDS Funders Group (EFG) for Philanthropic sector Bilateral disbursements to HIV-related programmes in 2006 Total Resource availability for HIV-related programmes in 2006 (US$ Billions) UN (2%) GFATM (7%) Foundations (11%) Bilaterals (33%) Domestic Public and Private (46%) EC (0.5%) Canada 2% Belgium 1% Netherlands 3% Other DAC country members 1% Sweden 3% Spain 1% Norway 2% Australia 2% Germany 2% Ireland 3% United Kingdom 9% United States 71% (US$ Billions) Total resources available: US$8.9 BillionPercentage out of the total bilateral disbursements Total Bilateral disbursements 2006: US$ 2.9 Billion The organizational disbursements are different than commitments or obligations, as well as different from in-country expenditures

Disbursements for HIV per US$ 1 Million GDP, 2006 H Sources: UNAIDS and Kaiser Family Foundation analysis, June 2007; Global Fund to Fight AIDS, Tuberculosis and Malaria online data query May 2007; International Monetary Fund, World Economic Outlook Database, April Italy 4 Japan 24 Canada 50 Germany 60 France 93 United States 120 United Kingdom 328 Ireland 408 Sweden 462 Netherlands US$

Prices (US$/year) of first-line antiretroviral regimen in Uganda:

Focus on results for people  Targets  Know your epidemic and the society  Monitor and evaluate  Invest in information systems

Know your epidemic

Number of HIV infections each year by route of transmission in Cambodia, Source: Peerapatanapokin and Brown, using Asia Epidemic Model Number of new HIV infections each year by route of transmission in Cambodia, (Source: Peerapatanapokin and Brown, using Asian Epidemic Model) Male clientsSex workersWife from husbandHusband from wifeMother to child

Impotence fears hit polio drive By Ashfaq Yusufzai BBC News, Peshawar Health officials in Pakistan say they have failed to immunise over 160,000 children against polio due to rumours the vaccine causes sexual impotence. Parents in parts of northern Pakistan told the BBC news website they feared an "American conspiracy" to cut the fertility of the next generation. At least 39 cases of polio were reported in 2006, 15 of them in the North West Frontier Province (NWFP) and the tribal areas in which only 20% of people are immunised. Worldwide 1,902 cases of polio were reported during the year, a recent WHO report said. A WHO meeting in Geneva last October heard that children paralysed by polio around the world were infected by viruses originating from Pakistan, Afghanistan, India and Nigeria. Radio rumours The main opposition to the drive in Pakistan came from local clerics who run illegal FM radio channels in many NWFP districts and the tribal areas, say officials. Amirullah Khan, a resident of NWFP's Swat district, quoted Maulana Fazlullah of a local FM channel as telling his listeners the vaccination drive was "a conspiracy of the Jews and Christians to stunt the population growth of Muslims".

The PREVENTION GAP Persons at risk with access to selected prevention interventions, 2006 Source: Global HIV Prevention: the access and funding gap. June 2007

Cost Effectiveness

A multi-disciplinary, multi-sectoral response Health outcomes determined by multiple factors and interventions Particularly key besides health: law, education, work place, trade, armed forces Need to expand resource base First genuine business engagement in health

Percentage of countries with sectors included in the national AIDS strategy and earmarked budgets 6.5 Source: UNGASS Country Progress Reports Public works Tourism Trade and industry Minerals and energy Agriculture Transportation Health Labour Military/police Sector included Earmarked budget present Percentage of countries (%), N=126

Community engagement From planning to implementation Makes or breaks programmes “Aids literacy” National Aids Councils and Global Fund Country Coordination Mechanisms Societal sustainability and resilience

TASO, Uganda

A global response Global public good and strategic issue Role of United Nations Global civil society and activism International financing Generation WE

New instruments for AIDS financing World Bank Multi-country AIDS Program (2000) Global Fund to Fight AIDS, TB and Malaria (2002) PEPFAR, (2003) Unitaid (2005) (PRODUCT) Red (2005) Debt2Health (2007)

Opportunities for global health  Increased funding (ODA and research)  Collateral benefits (TB,malaria, health systems)  Culture of accountability  Tiered pricing  Engagement of non-medical sectors  Boost to research  Major interest by young people  But: how long will the momentum last?

Total health ODA commitments, US$ Billions

Increase in TB financing and new sputum positive cases detected and treated

Direct funding of health systems through Global Fund grants Amount (approximately) Commodities, Products, Drugs - $6.3-billion Health Systems - $4.9-billion Administration - $1.4-billion Other - $1.4-billion

Conclusions Science AND justice as basis for policy Nothing for the people without the people Genuine multi-disciplinarity in planning, research and implementation Prevention AND treatment Information for accountability and programming Think long term and invest in capacity