WHAT IS GOING ON IN HIV AND AIDS IN 2013 AND BEYOND Prof Alan Whiteside RATN MEETING JOHANNESBURG March 2013

Outline 1. Context: Epidemiology Where the epidemic is Hyper-epidemic countries 2. What does this mean For development (and MDGs) Economic growth Donors 3. Responding Prevention (first prize) Treatment Impact mitigation 4. Conclusion Understand your epidemic Prioritize

2009 Global HIV Infection 33.3 million people [31.4–35.3 million] living with HIV 2.2

Exceptional Epidemics: Prevalence in Africa 2009 (Adults 15–49) Source: UNAIDS Global Report 2010 Geneva: UNAIDS (2009data)

HIV prevalence & no of HIV+ people countries with > 1% of SSA HIV+ population. HIV prevalence and number of HIV positive people in countries with 1% or more of the total Sub-Saharan African HIV positive population. Data from: UNAIDS ( demiology/

DHS HIV Prevalence Swaziland 2006

HIV and AIDS CountryNumber of adults living with HIV HIV/AIDS Prevalence rate Swaziland190, % South Africa5,700, % Botswana300, %

Comparison of Epidemics Scale of the epidemic: Southern Africa unbelievably high over 15%, Numbers Mode of transmission: SA - unprotected heterosexual intercourse Ability to respond: a function of wealth and political commitment

What does this mean (more) For development (and MDGs) Economic growth Donors

Demographics: Population Growth Rate

Beyond the MDGs

Responding Prevention (first prize) Treatment Impact mitigation

Epidemic Curves: HIV, AIDS and Impact 27Aug01 -Report I:Epidem’gy & Lit. p.27 T 1 T 2 Time Numbers A 1 A 2 HIV prevalence B 1 A B AIDS - cumulative Impact

Logic for Prevention 1. Growing case load For every two people put on treatment there are five new infections 2. Stretched health systems Lack of buy-in, time for adequate training, intervention that ‘speak to’ individuals 3. Strained human resources 13 providers per 100,000 people in SSA 5,100 new doctors per year in Africa (compared to 173,800 in Europe) 4. Money

AIDS Treatment without prevention is mopping the floor while the tap is running

What Works in Prevention? Currently:  PMTCT  Male circumcision  Male and female condoms Potentially:  Microbicides PREP  Vaccine  Cure  Behaviour change that works

What Should Work in Prevention Behaviour change  Fewer partners  Less concurrency  Later sexual debut What Needs to be Addressed… Poverty/ economic inequalities Gender inequalities Leadership and policy Etc.

Total annual resources available for AIDS in low and middle income countries Source: UNAIDS analysis based on (1) Kaiser Family Foundation and UNAIDS, financing the Response to AIDS in low and middle income countries from the G8, European Commission and other Donor Governments in 2009, July 2010; (2) UNAIDSOECD/DAC online database (last visited on January 05, 2011); (3) Funders Concerned About AIDS (FCAA), 2010; (4) European HIV/AIDS Funders Group (EFG, 2010; (5) UNAIDS Unified Budget of Work (UBW) for 2010 & 2011); (6) Disbursements reports and pledges and contributions reports from the GFATM (last visited on Jan (7) budget review from Donor governments and multilateral organizations. Domestic contribution

Donor funding for Africa flattened, domestic funding increasing (UNAIDS)

African Treatment Programmes aid dependent!

Fiscal Space for Health Spending Health expenditure per capita is predicted by GDP Source: International AIDS Society presentation by van der Gaag, McGreevey & Stimac

National Health Expenditures Source; Don De Savigny & COHRED

Global Positioning 2012 The United States: Terra Nova: How to achieve a successful PEPFAR Transition in South Africa, A report of the CSIS Global Health Policy Centre, December 2011 The Global Fund: Round 11 Cancelled Pledges not met UNAIDS: AIDS Dependency Crisis Sourcing African Solutions

AIDS Dependency Crisis: Sourcing African Solutions (UNAIDS) 1.Strengthen African ownership, exploit & diversifysources Negotiate long-term predicable money from donors Grow African investments Compact for shared differentiated responsibilities Explore sustainable innovative financing 2.Quality Assured Medicines sooner to those in need 3.Establish centres of excellent for local production of medicines in Africa

Men: Prevalence by Age Women: Prevalence by Age 2007 DHS and 2011 SHIMS HIV Prevalence in Swaziland (ages 18-49)

Conclusion The HIV epidemic is no longer on the top of the agenda – it is being overtaken and mainstreamed Understand your epidemic Prioritize Be realistic

THANK YOU