1. The future of the global AIDS response: Implications for HIV Professionals and Civil Society Organisations Robin Gorna Executive Director International AIDS Society

2. 2 Outline of Presentation I.Unprecedented success story made possible by donor assistance II.These achievements are now under threat III.Monitoring of global crisis: what does it tell us? IV.Need for a new focus of the HIV and AIDS response

3. Booming International Assistance for AIDS (US$ billions) 3

4. Made Possible Great Progress in Prevention 4

5. As well as for Treatment (Number of People on Treatment) 5 Towards Universal Access UNAIDS 2009 5

6. Regional Differences in Coverage Adults receiving ART Adults in Need of ART ART coverage (Adults) ART Coverage (Children) Sub-Sahara Africa 2 700 0006 100 00044%35% Latin America and Caribbean 429 000800 00054%76% Asia537 0001 500 00036%52% Eastern and Central Europe 80 000370 00032%85% North Africa and Middle- East 10 00062 00015%6% Total3 755 0008 800 00043%38% 6 Towards Universal Access UNAIDS 2009

7. Treatment Coverage for Women (Actual versus Expected) 7 Towards Universal Access UNAIDS 2009

8. II. These Achievements are now Under Threat  New emerging priorities  Impact of the Global Crisis on developing countries is spreading.  This affects government’s ability to provide services  History suggests that the recovery of developed economies will be protracted.  This affects the capacity of these countries to continue to provide increasing amounts of aid 8

9. 9 New Emerging Priorities  Competing priorities (1990s and early 2000s)  Debt relief  War on terrorism (Afghanistan, Iraq)  Recent priorities  Health sector (International Health Partnership)  Education for all Initiative  Climate change  Food security  Global crisis

10. Global Crisis: Impact on Regional Growth 10

11. Protracted Recovery  History indicates:  Recovery takes time  Lost output is a permanent loss  Risk for HIV epidemic: Long lasting impact  eg. Loss of access to ART: would affect family welfare, education, etc.  Loss of prevention services for most-at-risk prevention groups: likely to affect course of the epidemic  Costly to reverse the consequences which extend over the long- term Decision to monitor the impact of the epidemic 11

12. III. Monitoring of Impact  Monitoring:  First survey of respondents (March 2009): 71 countries  Second survey (July 2009): 63 countries  Survey of civil society organizations: 458 answers  12 specific country studies  Key result:  Impact is getting worse for nearly all HIV-affected countries 12

13. Worse Impact on ART as of Today  These countries are home to:  430,000 people on treatment (March)  1.3 million people on treatment (July) 13

14. Impact Expected to Worsen (During next 12 months) Expected impact next 12 months 14

15. Adverse Impact on Key Prevention Programs 15 APCaribbeanESAFECALAMENAWCAF VCT18%67%36%20% 33% 67%25% Condoms18%67%27%50% 33% 67%23% AIDS education18%67%27% 30%33% 19% IDUs programmes18%33%9%60.017%67%17% MSM programmes36% 100% 18% 30% 50%67%24% SWs programmes46% 100% 36% 30%33% 67% 28% Human rights and advocacy 18% 100% 18% 30% 50% 33% 24% Programmes to reduce stigma and discrimination 27% 100% 18%50% 27% Violence against women 18% 100%9% 20%17%15% Programmes to empower young people 36% 67%27%40%17% 33% 26%

16. Universal Access Challenge (Coverage of ART) Expected outcomes Trend for universal access 16

17. Towards Universal Access UNAIDS 200917

18. Change in Treatment Guidelines to CD4 below 350 18

19. Main Issue: High Uncertainty about Future Resources 19

20. IV. New Focus of the HIV and AIDS Response I.Reduce funding uncertainty II.Improve allocation of resources and efficiency III.Plan for the long-term not the immediate future 20

21. Reduce Funding Uncertainty  Clarify donor funding for the short-term  Set up regular coordination mechanisms among major donors  Establish sustainable funding mechanism  Mobilize domestic resources  Bring ART under health insurance  Innovative funding mechanisms 21

22. Improve Allocation of Resources and Efficiency  Maintain link between interventions and the epidemic  Remember: prevention interventions for the most-at-risk populations are the ones most-at risk of a budget cut  Do not cut funding for critical interventions  Invest in high impact evidence based interventions for maximun cost effectiveness  Reduce the huge variation in unit cost  Take advantage of existing health interventions  Strengthen research 22

23. Source: Steff Bertozzi, National Health Institute of Mexico23

24. Take Advantage of other Health Intervention s  Integrate HIV better into health and other sectoral programs  Inefficient use of resources when:  Family planning programs are not addressing HIV  TB and HIV don’t coordinate  VCT programs focus on identifying HIV positive individuals without testing couples,  Etc. 24

25. HIV Programmes leverage substantial health gains  In Botswana adult deaths dropped from 15,500 in 2003 to 7,400 in 2008; infant mortality declined; life expectancy increased  83% reduction in non-HIV infant mortality in Eastern Uganda  57% reduction in under 2 child mortality in KwaZulu Natal Province in South Africa  Malaria incidence declined from 591 cases per 100 person years to 476 cases (after 1 year ART) to 476 cases (after 2 years) to 259 cases (after 3 years) to 153 cases (after 4 years ART)  Substantial impact on TB prevalence, morbidity and mortality

26. Tuberculosis among HIV-infected patients receiving HAART: long term incidence and risk factors in a South African cohort. Lawn, Badria and Wood, AIDS 2005, 19:2109–2116 TB-free survival on HAART and baseline status Total Cohort n =346 WHO III/IV CD4 <100 WHO I,II vs III,IV CD4 >100 vs <100 Priority: Integrating Services – the Major Co-Infections 26

27. 27 Conclusion: a Long-Term Agenda  Plan for the future, beyond 3 to 5 years  Invest in evidence-informed strategies  Empower people living with HIV to help lead national response  Maximise the synergies between HIV and other health (& development) programmes  Put in place innovative mechanisms to sustain long-term financing  We cannot afford for the momentum of scale up to slip:  Essential for the response to AIDS – to care and treat, to prevent HIV  Proves that “Yes We Can” mount an effective response to health in developing countries