USAID Satellite, Washington Where the tide will turn: How is community level participation most effective in turning the tide? Eddy Beck Senior Technical Advisor, Office of the Deputy Executive Director Programme Branch, UNAIDS, Geneva, Switzerland Community Participation: necessary engagement but are community services necessarily cheaper?

Contributors to this work Olufunke Fasawe Patricia Ongpin Carlos Avilla Peter Ghys Paul De Lay UNAIDS Secretariat, Geneva, Switzerland

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.

Resources available 2011 Total resources: $16.8billion International community: $8.2billion Countries: $8.6billion ………..shared responsibility in action…….

The Investment Framework Conceptual framework for country policymakers to focus their national response to their country’s HIV epidemic Identified critical aspects of HIV response within the broader country context Was used at global level to estimate resources required to turn the HIV pandemic around Main focus now on in-country use

AIDS investment framework SYNERGIES WITH DEVELOPMENT SECTORS Social protection; Education; Legal Reform; Gender equality; Poverty reduction; Gender-based violence; Health systems (incl. treatment of STIs, blood safety); Community systems; Employer practices. CRITICAL ENABLERS Social enablers Political commitment & advocacy Laws, policies & practices Community mobilization Stigma reduction Mass media Local responses, to change risk environment Programme enablers Community-centered design & delivery Programme communication Management & incentives Production & distribution Research & innovation Care & treatment Male circumcision Keeping people alive BASIC PROGRAMME ACTIVITIES Key populations OBJECTIVES Stopping new infections

Importance ‘critical enablers’ and ‘development synergies’ (1) they support and increase the effectiveness, efficiency and reach of basic programme activities; (2) they can act directly to reduce or exacerbate susceptibility to HIV; (3) some protect and promote human rights; and (4) some support achieving other health and development goals, including the MDGs, and encourage sustainability of national AIDS responses.

Projected resource needs under the investment framework Development Assistance Domestic financing US$ billions

At country level the insights obtained from such a conceptual framework than need to be implemented through National Strategic Programmes…..which where the ‘rubber hits the road’ because in many countries the robust and contemporary strategic information required to develop and implement effective and efficient NSPs often do not exist.

Review published cost and cost-effectiveness studies of HIV community services Period of review was 1986 – 2011 Literature search through the various data bases and also following up referenced material not cited 74 studies identified covering 23 countries. 33 (45%) performed in Africa, 25 (34%) performed in North America + Caribbean, 9 Asia, 4 in Europe, 2 South America and 1 Australia.

OECD Income Classification High-income countries - 28 studies (38%), Upper- middle-income countries 15 studies (20%) ; Lower-middle-income countries 12 studies (16%); Low-income countries 16 studies (22%)

Specific Countries 5 countries generated 66% of the published studies USA - 23 (31%) studies; South Africa 9 (12%), Uganda and India each 6 (16%) Zambia 5 (7%); the remainder of the countries each had fewer than 5 studies published during the study period.

General Findings Substantial variation was observed in the costs and cost-effectiveness reported, related to variation in the methods used across the studies as well as the range of services studied, inputs covered and outcomes used. More consistent and standardized costing methods and more comprehensive coverage – both by country and type of service – are needed in order for policymakers and other stakeholders to be able to have access to robust and contemporary strategic information to be able to monitor and evaluate the cost and efficiency of HIV community services in countries

Investment Framework can assist countries to make their response more. Effective…………. Efficient………….. Equitable………… Acceptable………. …. but needs to be focused on the conditions operative within countries and National Strategic Plans need to be based on robust and contemporary country data…

VISION ZERO NEW HIV INFECTIONS. ZERO DISCRIMINATION. ZERO AIDS-RELATED DEATHS.