Moving from a commodity approach: “Fund some of everything” or “Fund what is comfortable” to An Investment approach: “Fund evidenced-based activities specific to the needs of your epidemic to get better long term results at lower costs.” A tool for evaluation and reallocation of HIV funding.

 Six basic programmatic activities  Critical interventions that create an enabling environment for achieving maximum impact; and  Programmatic efforts in wider health and development sectors related to AIDS.  Rights-based approach to all services and policies

 Activities that have a direct impact on reducing HIV transmission, morbidity and mortality to be scaled up according to size of relevant affected population

Based on high level evidence of effectiveness.  Treatment, care and support  Vertical Transmission prevention  Condom procurement and distribution  Key populations programs (MSM, IDU, Sex Workers)  Male circumcision  Behavior Change programs

Social Enablers - make possible environments conducive for sound AIDS responses:  outreach for HIV testing  Linkage from testing to care  treatment literacy  stigma reduction  advocacy to protect human rights  monitoring of the equity and quality of programme access and results

Program Enablers - create demand for and help improve the performance of key interventions:  incentives for engagement in health services  methods to improve retention on ART  capacity building for community-based organizational development  strategic planning  communications infrastructure  information dissemination  efforts to improve service integration and linkages from testing to care.

 Health systems and multiple health issues  Gender equality efforts  Education and justice sectors  Social protection and welfare  Food security  Community systems  Housing

 Community-driven outreach and engagement activities that connect people facing similar issues and engage them in HIV-related interventions  Support activities to enhance quality, adherence and impact in a range of settings such as people on treatment, engaged in harm reduction or drug treatment services, or who are using sexual and reproductive health services  Advocacy, transparency and accountability efforts at country and local levels to ensure that high-quality health services are available and accessible to vulnerable populations.

Community support keeps people on treatment Source: Decroo T et al. Distribution of antiretroviral treatment through self-forming groups of patients in Tete province, Mozambique. Journal of Acquired Immune Deficiency Syndromes, 2010 [Epub ahead of print]. Source: Fox MP, Rosen S. Patient retention in antiretroviral therapy programs up to three years on treatment in sub- Saharan Africa, 2007–2009: systematic review. Tropical Medicine and International Health, 2010, 15(Suppl. 1):1–15. CLINIC-BASED TREATMENT Sub-Saharan Africa: people receiving ART from specialist clinics still receiving treatment after two years 70% COMMUNITY TREATMENT MODEL Mozambique: self-initiated community model still receiving treatment after two years 98% Sources: Fox MP, Rosen S. Tropical Medicine and International Health, Decroo T et al. Journal of Acquired Immune Deficiency Syndromes, 2010.

Community mobilization increases effectiveness Community mobilisation increased HIV testing rates four-fold in Tanzania, Zimbabwe, South Africa and Thailand Consistent condom use in the past 12 months was 4 times higher in communities with good community engagement (Kenya) Hypothetical circumcision model KwaZulu-Natal :  Core intervention: 240,000 infections averted over ten years  With enablers: 420,000 infections averted, with modest marginal increase in costs

Percentage of people retained in treatment and care after diagnosis, USA and Mozambique Source: Gardner E M et al. Clin Infect Dis. 2011;52: ; Micek et al JAIDS 2009 Tested <30 days Mozambique USA Diagnosed with HIV Linked/ enrolled in care Eligible for ART Initiated ART Adherent or undetectable Retained in care 100% 0 Retained in treatment and care

Percentage of people retained in treatment and care after diagnosis, USA and Mozambique Source: Gardner E M et al. Clin Infect Dis. 2011;52: ; Micek et al JAIDS 2009 To improve testing:  Reduce stigma in the community and in healthcare settings  Strengthen community support and referral networks  Enhance human rights literacy Tested <30 days Mozambique USA Diagnosed with HIV Linked/ enrolled in care Eligible for ART Initiated ART Adherent or undetectable Retained in care 100% 0 Retained in treatment and care

Percentage of people retained in treatment and care after diagnosis, USA and Mozambique Source: Gardner E M et al. Clin Infect Dis. 2011;52: ; Micek et al JAIDS 2009 Improve enrolment in care:  Expand community-centred delivery  Overcome cost & transport barriers  Enhance treatment & rights literacy Tested <30 days Mozambique USA Diagnosed with HIV Linked/ enrolled in care Eligible for ART Initiated ART Adherent or undetectable Retained in care 100% 0 Retained in treatment and care

Percentage of people retained in treatment and care after diagnosis, USA and Mozambique Source: Gardner E M et al. Clin Infect Dis. 2011;52: ; Micek et al JAIDS 2009 Get more people on treatment:  Enhance peer support programmes  Reduce costs  Overcome transport barriers  Ensure adequate nutrition  Reduce stigma in healthcare settings Tested <30 days Mozambique USA Diagnosed with HIV Linked/ enrolled in care Eligible for ART Initiated ART Adherent or undetectable Retained in care 100% 0 Retained in treatment and care

Percentage of people retained in treatment and care after diagnosis, USA and Mozambique Source: Gardner E M et al. Clin Infect Dis. 2011;52: ; Micek et al JAIDS 2009 Retain people on treatment:  Adherence support programmes  Reduce gender inequalities  Reduce fear of disclosure  Overcome cost and transport barriers  Referral and support programmes for migrants Tested <30 days Mozambique USA Diagnosed with HIV Linked/ enrolled in care Eligible for ART Initiated ART Adherent or undetectable Retained in care 100% 0 Retained in treatment and care

What can we achieve? Universal Access by 2015

 Resource needs and returns on investment were estimated for 139 low- and middle-income countries  Estimates based on the cost of increasing from current levels of coverage in 2011 to achieve universal access target coverage levels by 2015 and maintain them thereafter. (Includes 1 st and 2 nd line treatment.)  Each of the basic programme activities in the framework was applied to relevant populations according to their demographic and epidemiological situation including the distribution of new HIV infections by mode of transmission as detailed in the literature.

Outcomes Total infections averted12.2 million Infant infections averted1.9 million Life years gained29.4 million Deaths averted7.4 million

Basic Programs Critical Enablers Synergies with Development Sectors Total

Cost/Returns Total additional investment (over 10 years) USD 46.5 Billion Future treatment need averted USD 40 Billion Life years gained $1,060 per life year gained