HIV/AIDS Challenges and opportunities in the midst of GF funding shortfall GFAN meeting 8-10 Feb 2012, Amsterdam Kerstin Åkerfeldt & Sharonann Lynch, MSF

Have to get ahead of the wave... Will be condemned

USD (Billions) Business as usual Investment framework New HIV Infections (millions) Strategic Investment Framework Costs/returns Total additional investment (over 10 years) US$46.5 Billion Future treatment need averted US$40 Billion Outcomes (millons) Total infections averted > 12 Infant infections averted 1.9 Deaths averted 7.4

Newly eligible for treatment Newly infected For every 1000 patient- years on ART PEPFAR Deaths averted228 Children not orphaned449 Sexual transmission of HIV averted 61 Vertical infections averted26 TB cases averted among HIV+ 9 Life-years gained2, – 90 infec av. / 1000 ART initiation in first year is reasonable ‘rule of thumb’.

6 Accelerated Scale-Up Results in Annual Decline in New HIV Infections in Kenya (CDC) Under the base-case scenario, incident HIV infections remain relatively constant at or above 120,000 new cases per year. With accelerated treatment scale-up, incident HIV infections could be driven down to ~86,500 by Results in Kenya 93 infections averted for every additional 1000 py on ART 31% (n 33K) reduction in HIV incidence in 5 years 59% treatment costs offset through savings (hospitalisations, orphanhood) within 5 years “Accelerated treatment” CD4< 500 (among pre-ART) Discordancy Pregnancy HIV/TB co-infection

Challenges Feasibility: Massively scaling up testing & ART while plugging the leaky cascade Affordability: Triple people on ART without tripling the cost

Approached or offered No HTCHTCNegativePositiveEligible ART workup Started on ART RICLTFRIP Not started LOST Not Eligible Return within 3 months Return within 1 year NOT approached or offered THE CASCADE

What can help: tools, strategies, policies Increased testing – HBCT: 500K participants, 83% offered said yes; 99% of people received their result Increased coverage & higher CD4 count threshold Decentralization & patient self-management – Adherence clubs in Khayelithsa: 97.5% RIC at 2 years – Community ART groups in Mozambique: 98% RIC at 2 years Viral load Pts 58% less likely to die in countries where routine VL available; 53% less likely to be LTF Adherence trigger: 76% UDL Xpert Optimization of ART: – More patient-friendly: fewer pills – More potent – More tolerable

Momentum 15 x 15 Sec Clinton: priority interventions can end AIDS Pres Obama: 2m on ART, 1.5m PMTCT over 2 years 5 countries in negotiation to support “accelerated treatment”

The impact of Round 11 cancellation No new funds for scale up before 2014 (2 years gap) => scale up depending on funds in ongoing grants (phase 2 pipeline) Countries’ R11 preparatory work interrupted – impact on motivation at country level? Transititional funding mechanism (TFM) – only for continuation of essential services => vague defintions and confusion at country level Limited country impact assessment so far… (IAA released, MSF:ongoing - UNAIDS, GF, others?)

Foreseen impact on programmes R11 cancellation cont. 1.Treatment scale up plans being revised/delayed (DRC, Myanmar, Guinea) – Caps on number of new initiations due to funding uncertainty (medical risks) – Risk for loss of benefits for wider health impact, prevention, cost savings, health systems 2.Delayed or rationed implementation of WHO guidelines (Uganda, Malawi, Moz) – Excluded from good practices & promising benefits (3.) Potential risks for low ARV stock levels or stock outs due to funding shortfall – Depleted buffer stocks – Risk of treatment interruption (4.) Donors withdrawing from support and counting on GF R11 – now revising these decisions or already exiting?

Phase 2 renewals and reprogramming – challenges and opportunities >8bn to be disbursed in phase 2 renewals ( )- but available funds far from matching current funding needs in many countries Minus efficiency cuts and savings… Reprogramming: ”facilitate strategic refocusing of existing investments” and ”focus on highest-impact interventions” according to GF strategic objective + UNAIDS investment framework => targeted interventions and increased coverage to reach tipping point where decreased hiv infection rates and mortality reduces costs or Full effect undermined due to filling gaps created by Round 11 cancellation?

Advocacy messages The funding crisis threatens the progress achieved. With new research, tools and innovative approaches coming on line this is not the time to reduce international efforts. In many countries, the lives of patients on ART and those still waiting for treatment depend on increased and continued financial support of donors through the GF. Strategically focusing on high impact interventions, by using existing funding (phase 2 renewals) must move forward to maximise impact, but will not be sufficient to reach the needed level of scale up. It is unacceptable that there will be no new GF funding for scale-up of HIV services until GF caretakers and especially its donors, must ensure the GF is open for business and can ensure countries can apply for new funding by mid-2012 and hold an emergency donor conference to raise the resources needed.