1. An Historic Opportunity to Prevent the Spread of HIV Timothy Hallett Imperial College London Members of The Applied HIV Epidemiology Research Group / HIV Modelling Consortium: Sarah-Jane Anderson, Daniela Fecht, Ide Cremin, Ellen McRobie, Britta Jewell, Jeff Eaton & Nicholas Menzies

2. An Historic Opportunity to Prevent the spread of HIV Epidemiological Intelligence Falling Costs Clear evidence for power of interventions Experience in Getting Results

3. Source: UNAIDS Estimates (www.unaids.org) & Global Burden of Disease 2010 (http://www.healthmetricsandevaluation.org/) (Lozano et al, Lancet 2012)www.unaids.orghttp://www.healthmetricsandevaluation.org/ Some Downward Trends in New HIV Infections in Some Countries… … Set Against a Backdrop of HIV Increasing (by 353%) Share of Global Disease Burden

4. Clear evidence for power of interventions There have been several major breakthroughs for the prevention of HIV through sexual transmission.

5. Falling Costs The Cost of ARV Regimens Reduced by Up to 70% Region: Sub-Saharan Africa Preferred Regimens = Efavirenz (EFV) + Emtricitabine (FTC) + Tenofovir (TDF); Efavirenz (EFV) + Lamivudine (3TC) + Tenofovir (TDF). Source: WHO Price Reporting Mechanism (http://apps.who.int/hiv/amds/price/hdd/) 63% decline since 200370% decline since 2007

6. 11% annual decline The Costs of Delivering ART have Dropped by 11% per year for the Last Decade These plots show the estimated non-drug average cost per-patient year of ART for adults. The estimates control for differences in the countries from which the data were collected. Source: Nicolas Menzies, Harvard Center for Health Decision Science.

7. Experience in Getting Results Achieving High Rates of HIV Testing HIV Prevention in Specific Populations Mode of HIV Testing% population HIV tested House-to-House Testing94% coverage in one round Community Mobilization x4 – x8 increase in testing over 3 years. Provider-initiated testing ~50% after one year Reduced HIV Transmission due to counseling and facilitated disclosure. Source: Tumwesigye AIDS Patient Care and STDs 2010 ;Sweat et al., Lancet ID 2011; Weiser et al, PLoS Med 2006

8. A Hypothetical Scenario: What Would Happen The Totality of Spending on HIV Was Frozen or Cut? Source: Cori, Fraser et al., Forthcoming Zambia Expanded Frozen Cut Expanded Frozen Cut Cut: The ART program is discontinued. Frozen: No need persons are initiated on ART. Expanded: Zambia achieving 80% ART coverage with eligibility at CD4<500. Red line: is "business as usual" -- same policy (350) in place and same patterns of testing/linkage. +700,000 new infections -400,000 new infections +400,000 deaths -200,000 new infections

9. The Investment Framework has Promoted A Carefully Prioritized Approach… Source: UNAIDS

10. The Investment Framework has Promoted A Carefully Prioritized Approach… Source: UNAIDS

11. Epidemiological Intelligence Kenya Geographic and Epidemiological Data Can Now Be Triangulated to Identify Foci of HIV Transmission Average Risk of HIV infection for a “low risk women” estimated to vary 10-fold between counties.

12. Prioritizing Resources To Those Foci Can Radically Improve Efficiency, Generating More Health For the Same Budget Usual Prioritization Strategy + Prioritizing Epidemic Foci No Additional HIV Prevention Spending 21% increase in HIV infections averted Note: Assumes buudget of $600M and uniform across locations. The Specific Example of Kenya & Marginal cost per infection averted of new technologies reduced by 66%.

13. With finer scale data even greater impact may be possible. Variation WITHIN a Small District Source: Tanser et al., CROI 2011 (http://www.retroconference.org/2011/Abstracts/41395.htm) & Stover et al., STI 2010http://www.retroconference.org/2011/Abstracts/41395.htm 5.7% of study area. 1 in 3 new HIV infections Age group Men Women Variation by AGE in populations > 50% of infections occur among men and women aged < 25 years Distribution of New HIV Infections

14. … And Moves The Epidemic Towards a Tipping Point, at which a Foreseeable Vaccine Could Effectively Terminate Epidemics + Vaccine

15. An Historic Opportunity to Prevent the spread of HIV Epidemiological Intelligence Falling Costs Clear evidence for power of interventions Experience in Getting Results