1. STATE OF THE EPIDEMIC AND THE RESPONSE - 2008 PROMISES, PROGRESS AND PROBLEMS DR. ALEX COUTINHO MD MPH Executive Director Infectious Diseases Institute Makerere University Kampala, Uganda

2. FACES OF THE EPIDEMIC HIV+ Grandmother and Grandchild in Tanzania

3. REMOTE AND BEAUTIFUL – PAPUA NEW GUINEA HIV Prevalence in PNG is over 1%

4. GRAND PARENT CARING FOR A VULNERABLE CHILD

5. HEADLINE ACHIEVEMENTS 1,000,000 more individuals were on ART at end of 2007– most of them in Africa, and 3 X 5 was at last achieved against all odds Significantly more mothers and children are now receiving services to prevent transmission to children and to provide paediatric care and ART HIV testing and counseling services have increased substantially through diverse approaches Male Circumcision has been unequivocally demonstrated as an important addition to our combination of proven prevention approaches

6. HEADLINE CHALLENGES Few countries will achieve Universal access by 2010 Most people living with HIV still remain unaware of their HIV status –despite often visiting health facilities New HIV infections significantly outpace the numbers of those started on ART by a ratio of 5 to 2 (2.5 Million new infections – 1.0 Million on Treatment) 69% of people who need treatment are not getting it and often do not even get an essential care package Of those who start treatment 1 in 3 are not in care 2 years later due to early deaths, loss to follow up and drug adherence challenges

7. HEADLINE ACTIONS REQUIRED Leadership, leadership and more leadership! Those countries with passionate sustained leadership are achieving results in both treatment and prevention scale up – Tanzania, Rwanda, Cambodia, Mexico as examples Far more investment in HIV prevention is needed – particularly to scale up Combination Prevention An inclusive Health System that will reach into rural areas as well as hard to reach sites and fully embraces HIV+ as equal players and key catalysts for change Programs that reach out to and support marginalized and at risk communities – MSM, IDU, sex workers, prisoners, migrant workers and increasingly the elderly

8. NUMBER OF PEOPLE RECEIVING ANTIRETROVIRAL THERAPY IN LOW- AND MIDDLE-INCOME COUNTRIES 2002-2007 WHO (2008). Towards Universal Access : Scaling up priority HIV/AIDS interventions in the health sector; progress report 2008

9. ANTIRETROVIRAL THERAPY COVERAGE IN SUB-SAHARAN AFRICA, 2003-2007 WHO (2008). Towards Universal Access : Scaling up priority HIV/AIDS interventions in the health sector; progress report 2008

10. TREATMENT DELIVERY SITES IN ETHIOPIA

11. DOWNSTREAM IMPACTS OF RAPID SCALE-UP OF ART IN AFRICA By 30 June 2006, 2% of ART beneficiaries in Malawi were health care workers. Their combined work-time of more than 1000 staff-days per week was equivalent to the human resources required to provide ART at the national level to over 50,000 ART beneficiaries In Uganda ART and co-trimoxazole achieved a 95% reduction mortality in HIV+ participants, an 81% reduction in mortality in their uninfected children and an estimated 93% reduction in orphan hood

12. HIV AND TB 700,000 people with TB tested in 2006 representing a 30 fold increase from 2002 but only 12% of total TB cases Approx. 50% of people with active TB are HIV+ so 2,200,000 TB/HIV co- infections were missed

13. TB AND HIV  Urgent priority to scale up prevention and treatment of TB in HIV+  700,000 HIV+ with active TB in 2006  TB accounts for 12% of deaths of HIV+ YET  Less than 5% of HIV+ screened for TB  Only 0.1% of HIV+ on Isoniazid preventive therapy

14. HIV COUNSELLING AND TESTING A median of 10.9% of women and 10.3% of men had ever received an HIV test and the test results A median of 20% of people living with HIV knew their HIV status

15. EARLY HIV TESTING PROMOTES DETECTION OF EARLIER STAGE DISEASE Andia et al. 2006: Mbarara University, Uganda

16. NEW HIV TESTING SITE IN PAPUA NEW GUINEA FUNDED BY PRIVATE SECTOR

17. HOME BASED TESTING IN RURAL UGANDA

18. SCALING UP HIV SERVICES FOR WOMEN AND CHILDREN More women than men globally are starting on ART – however only 12% of pregnant HIV+ were assessed for their own treatment needs 33% of pregnant HIV+ women received PMTCT services including ARV in 2007 – up from 10% in 2004 Numbers of children receiving ART increased from 75,000 in 2005 to almost 200,000 in 2007

19. SCALE UP OF PMTCT WHO (2008). Towards Universal Access : Scaling up priority HIV/AIDS interventions in the health sector; progress report 2008

20. SCALING UP PAEDIATRIC ANTIRETROVIRAL TREATMENT WHO (2008). Towards Universal Access : Scaling up priority HIV/AIDS interventions in the health sector; progress report 2008

21. OVC SCALE UP Even the best OVC program cannot replace parents The best way to support children is to keep parents alive and healthy Treatment scale up is estimated to have prevented over 2,000,000 Orphans

22. COMMUNITY RESPONSES HIV and AIDS confront the world with many challenges and far, far more needs to be done, in partnership with governments but also, above all, with communities whose wisdom and resilience offer so much to the HIV response. (World Disaster Report 2008)

24. SCALE-UP OF CLINICAL SERVICES FOR SEX WORKERS UNDER THE AVAHAN INDIA AIDS INITIATIVE WHO (2008). Towards Universal Access : Scaling up priority HIV/AIDS interventions in the health sector; progress report 2008

25. HIV+ SUPPORT GROUP IN ZANZIBAR

26. TASO COMMUNITY ART PROGRAMME

27. WE SHOULD NOT ACCEPT---- That less then 10% of individuals at high risk for HIV like sex workers, IDU, MSM and prisoners in developing countries are receiving appropriate prevention interventions. That PMTCT – a proven effective preventive technology - is not the highest of global and national priorities to reduce HIV transmission to children to below 2% That proven methods of HIV prevention like circumcision are yet to be deployed in most countries that need them including those where the research was carried out!

28. WE SHOULD NOT ACCEPT--- That we cannot provide HIV testing routinely to all who need it That HIV is still being transmitted through unsafe blood and unsafe injections and that only 35% of health facilities have Post Exposure Prophylaxis measures in place That health workers are often not seeking HIV testing and not accessing treatment and care in time to protect their own health

29. PARTING THOUGHTS “Imagination is more important than knowledge” Albert Einstein "Reach for the moon, and even if you miss you will be among the stars." Unknown

30. ACKNOWLEDGMENTS Dr. Andrew Ball – WHO Dr. Yves Souteyrand – WHO All contributors to the Universal Access progress report 2008 UNAIDS, WHO, UNICEF All individuals who gave me permission to use their photographs TASO and IDI