Future HIV Financing Direction: Reality Check Brian Rettmann, PEPFAR Country Coordinator

Modeled Impact of New Infections: the Global AIDS Response Scaling up VMMC, Treatment, PMTCT, and Condoms Programs has Drastically Reduced New HIV Infections Source: Stover modeling for the Office of the U.S. Global AIDS Coordinator, 2014

National Epidemiological Context

HIV Prevalence and Total PLHIV 4

Treatment Coverage/Gaps (PEPFAR data only)

Funding Sources PEPFAR – COP13 = $347M – COP14 = $375M (submitted) – PEPFAR Central funding Global Fund – $384 M ($191M new) NMSF Grant pool-funded – Canada DFATD $45M CAD – DANIDA: $38 USD ended – No secure funding post-2016 UN – ~ $9M Health Basket Fund – New MOU post-2015 under development – Decreased funding trend AIDS Trust Fund – TBD Big Results Now Health Health and HIV/AIDS sectors as a share of total GoT budget continue to diminish – This trend is not sustainable

Focusing on Right Things: Core Activities to Maximize Epidemic Impact Combination Prevention (PMTCT, ART, Condoms, VMMC) Effective/targeted other prevention interventions Holistic services for families including OVCs Strengthening Health Systems as specifically required to support the core activities – Human resources for health, financing, procurement & supply chain, lab, and strategic information Appropriate resources for disproportionately effected, neglected & hard to reach populations – Young women and children – Key populations: MSM, FSW, PWID

Focusing on Right Places Symmetric geographic alignment of program investment and epidemiology Saturation in the highest burden areas (regions, districts, hotspots) based on: – prevalence and number of PLHIV – greatest unmet need for services o Among general population/specific neglected populations Withdrawal from zero and very low volume facilities – Discontinue (HTC) or maintain (treatment and PMTCT) in order to prioritize support to higher volume facilities and communities with greatest need

Measuring Program Efficiency: HTC Preliminary Analysis Undergoing Review and Revisions

Program Efficiency: PMTCT Preliminary Analysis Undergoing Review and Revisions

Total GF Allocation (3 years) DiseaseExisting Funding Additional Funding Total Allocation HIV$193,133,430$191,306,621$384,440,050 TB$13,068,691$13,369,851$26,438,541 Malaria$182,422,697$2,913,151$185,335,848 HSS$36,333,124$0$36,333,124 Total$424,957,942$207,589,623$632,547,563

HIV/TB Concept Note Allocation

Within and Above Allocation Requests ModuleAllocation ($)Allocation %Above Allocation ($)Full Request ($) Prev-Gen Pop$9,214,8044%$8,000,000$17,214,804 Prev-MSM/TG$1,100,0000.5%$840,000$1,940,000 Prev-SW$3,400,0001%$1,800,000$5,200,000 PMTCT$34,091,61115%$34,124,980$68,216,591 HIV C&T$144,407,16263%$204,712,793$248,119,954 TB C&T$15,555,2847%$9,151,800$20,040,931 TB/HIV$2,959,2311%$3,998,152$6,105,376 MDR-TB$4,287,9182%$6,318,381$8,797,952 PSM$2,248,8931%$1,540,000$3,788,893 HMIS/M&E$5,032,0572%$15,252,950$20,285,008 CSS$1,900,0001%$1,554,000$3,454,000 Program Mgmt$5,351,5532%$0$5,351,553 Total$229,548,513$287,293,056 (> 50%)$516,841,568

Commodity Funding Gap Above Allocation request for key commodities: $193,117,348 Key commodities ARVsRTKsHEID Lab reagents for testing

Modeling Analysis of Investment Options for HIV Program in Tanzania Draft, October 1, 2014 Futures Institute, Johns Hopkins School of Public Health, UNAIDS, TACAIDS

Scenarios Base: Coverage of all interventions constant at 2013 levels NMSF: Targets of National Multi-Sectoral Strategic Framework (NMSF) 2013/ /18). Assumes WHO 2013 treatment guidelines adopted in 2014 and all HIV+ children <15 become eligible for treatment in 2015 PMTCT: Only PMTCT is scaled up. Coverage is constant for all other interventions ART: Only ART is scaled up. Coverage is constant for all other interventions Strategic: Full scale up of most cost-effective interventions: ART, PMTCT, female sex worker empowerment, VMMC, condom promotion. Coverage is constant for all other interventions. FSW moderate: FSW empowerment program scaled up to 35% by 2019 and 55% by FSW optimistic: FSW empowerment program scaled up to 50% by 2019 and 80% by 2024 Optimal: Resources available capped at $600 million by Most cost effective interventions are scaled up (ART, PMTCT, FSW, VMMC, condoms) others have reduced coverage to constrain costs increases (mass media, community mobilization, workplace)

Optimal Scenario The Optimal scenario is designed to maximize impact within a resource constraint of < $600 million per year by – It fully scales up the most cost-effective interventions: ART, PMTCT, FSW, condoms, VMMC. – It reduces coverage by ½ to ¾ for the least cost-effective interventions: mass media, workplace, community mobilization.

ScenarioInfections Averted ( ) Co NMSF1.2 M PMTCT0.2 M ART0.7 M Strategic0.9M FSW mod0.1 M FSW opt0.2 M Optimal0.9M

ScenarioResources Needed (Billions of US$) ( ) Base$11.4 NMSF$18.7 PMTCT$11.7 ART$13.9 Strategic$14.5 FSW mod $11.6 FSW opt$11.7 Optimal$12.4

Ending AIDS Scenario: New HIV Infections Total number of people living with HIV/AIDS (PLWHA) 35M PLWHA 52M PLWHA 44M PLWHA 79M PLWHA 48M PLWHA $8B in additional Treatment cost/year $31B in additional Treatment cost/year

Defining the unmet ART need CD4 count less than 350 (WHO 2010 guideline) CD4 count less than 500 (WHO 2013 guideline) HIV+ persons (36m globally) regardless of CD4 count Source: UNAIDS 2013 Global Fact Sheet

Advancing a legacy by increasing country capacity to self-finance and sustain HIV epidemic control efforts 24 AIDS-free Generation Impact Agenda – Increase resources for prevention, care and treatment Application of analytics help ensure intended use Impact Agenda – Increase resources for prevention, care and treatment Application of analytics help ensure intended use Efficiency Agenda Gains from improved organization of health financing Identification and application of efficient tax and financial practices Efficiency Agenda Gains from improved organization of health financing Identification and application of efficient tax and financial practices Sustainability Agenda Increased domestic financing and country ownership of needed reforms Data drives accountability and political will Sustainability Agenda Increased domestic financing and country ownership of needed reforms Data drives accountability and political will Partnership Agenda Working with public sector on reform Working with the private sector on innovative financing Partnership Agenda Working with public sector on reform Working with the private sector on innovative financing Human Rights Agenda Risk pooling to reach the bottom quintiles Coverage of HIV/AIDS services reaching specific target populations Human Rights Agenda Risk pooling to reach the bottom quintiles Coverage of HIV/AIDS services reaching specific target populations

Low income countries (n=7) Low/middle income countries (n=6) As economies grow, the local share of HIV funding also grows Source: FY2014 COP

NHA Report 2014 Total Health Spending: 71,428 Tsh (~45 USD) per capita, Main sources of health sector financing: – Donors: 48% of total health expenditure (up from 40%, 2010 NHA report) – Households (largely out of pocket): 27% – Government: 21% Spending by disease HIV: 20% Other: 18% Malaria: 15% RCH: 11%TB :10% Vaccine preventable : 7% Respiratory: 5% Diarrheal: 4% Other Parasitic: 3% NCD: 3% nutritional deficiency: 2% Injury: 1%

Modelling Study: Maximising the effect of combination HIV prevention through prioritisation of the people and places in greatest need: a modelling study Lancet 2014, 384:

Findings Uniformly distributed combination of HIV prevention interventions: Could reduce the total number of new HIV infections by 40% during a 15-year period. With focused approach: This effect could be increased by 14% (almost 100,000 extra infections) and result in 33% fewer new HIV infections occurring every year by the end of the 15-year period Lancet 2014, 384:

Closing Considerations $287 Million Gap for : – GF Incentive Funds – Other international donors are unlikely – Government and private sector domestic resources – AIDS Trust Fund and BRN eventually As Tanzania moves toward middle income status, domestic financing will need to increase. We also need to be strategic with the right interventions in the right places at the right scope/scale. Join planning and governance between Global Fund, PEPFAR, and ATF is essential for greater efficiency

ASANTENI SANA! Thank you!