1. Achievements and future of the global aids response Peter Piot Imperial College London

2. Number of people receiving ARV therapy in low- and middle-income countries, 2002—2007

3. Decline in adult mortality with introduction of ART: Botswana

4. HIV prevalence (%) among pregnant women attending antenatal clinics in sub-Saharan Africa, 1997–2007 NOTE: Analysis restricted to consistent surveillance sites for all countries except South Africa (by province) and Swaziland (by region) Southern Africa 0 10 20 30 40 Median HIV prevalence (%) 50 Botswana Lesotho Mozambique Namibia South Africa Swaziland Zimbabwe 1997– 1998 1999– 2000 2001200220032004200520062007 West Africa 0 5 10 15 20 Median HIV prevalence (%) 0 5 10 15 20 Median HIV prevalence (%) Eastern Africa 1997– 1998 1999– 2000 2001200220032004200520062007 1997– 1998 1999– 2000 2001200220032004200520062007 Ethiopia Kenya Burkina Faso Côte d'Ivoire Ghana Senegal 2.9 Source: National surveillance reports and UNAIDS/WHO/UNICEF, Epidemiological Fact Sheets on HIV and AIDS. July 2008.

5. Number and percentage of HIV-positive pregnant women receiving antiretroviral prophylaxis, 2004–2007 200420062005 Number of HIV-positive pregnant women receiving anti-retrovirals Year 400 000 500 000 600 000 0 100 000 200 000 300 000 % of HIV-positive pregnant women receiving anti-retrovirals 0 5 30 35 15 20 25 40 10 2007 Source: UNAIDS, UNICEF & WHO, 2008; data provided by countries. 4.13

6. AIDS IS NOT OVER

7. HIV prevalence (%) in adults (15–49) in Africa, 2007 2.8

8. HIV infections among men having sex with men in Asia

9. How did we get there? » Science and rights driven » Political approach » A global response » Focus on results for people » Prevention AND treatment » Multi-disciplinary, multi-sectoral » Community engagement

10. People living with HIV 2007‘01‘02‘03‘04‘05’06‘94‘95‘96‘97‘98‘992000‘87‘88‘89‘90‘91‘92‘93 Millions 1980‘81‘82‘83‘84‘85‘86 50 45 40 35 30 25 20 15 10 5 0 First cases of unusual immune deficiency identified HIV identified as cause of AIDS First regimen to reduce mother-to-child transmission of HIV First HIV antibody test becomes available Highly Active Antiretroviral Treatment WHO launches the Global Programme on AIDS Global Fund to fight AIDS, Tuberculosis and Malaria US$10 billion for AIDS in developing countries UNAIDS created President Bush announces PEPFAR 3 million on ART in developing world The UN General Assembly Special Session on HIV/AIDS Four Frees and One Care

11. [i] 1996-2005 data: Extracted from 2006 Report on the Global AIDS Epidemic (UNAIDS, 2006) [ii] 1986-1993 data: AIDS in the World II. Edited by Jonathan Mann and Daniel J. M. Tarantola (1996) Notes:[1] 1986-2000 figures are for international funds only [2] Domestic funds are included from 2001 onwards Total annual resources available for AIDS 1986‒2007 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 US$ million 292 1623 8.3 billion Signing of Declaration of Commitment on HIV/AIDS, UNGASS ‘96‘97‘98‘99‘00‘01‘02‘03‘04‘051986‘87‘88‘89‘90‘91‘92‘93‘94‘95 Less than US$ 1 million 59 212 World Bank MAP launch Global Fund PEPFAR 257 UNAIDS Gates Foundation ‘062007 10 000 8.9 billion 10 billion

12. Treatment Action Campaign (TAC), South Africa

13. Recorded female deaths in South Africa and Brazil for ages 15-64 years Source: Nathan Geffen. Statistics South Africa and Instituto Brasileiro de Geografia e Estatistica. Brazil, 2004.South Africa, 1997.South Africa, 2004

14. A global response Human rights and strategic issue/smart power Global public good Role of United Nations Global civil society and activism International financing Generation WE

16. UN security Council Resolution 1308 (2000) on AIDS

17. New instruments for AIDS financing World Bank Multi-country AIDS Program (2000) Global Fund to Fight AIDS, TB and Malaria (2002) PEPFAR, (2003) Unitaid (2005) (PRODUCT) Red (2005) Debt2Health (2007)

18. Disbursements for HIV per US$ 1 Million GDP, 2006 H Sources: UNAIDS and Kaiser Family Foundation analysis, June 2007; Global Fund to Fight AIDS, Tuberculosis and Malaria online data query May 2007; International Monetary Fund, World Economic Outlook Database, April 2007. Italy 4 Japan 24 Canada 50 Germany 60 France 93 United States 120 United Kingdom 328 Ireland 408 Sweden 462 Netherlands 521 0100200300400500600 US$

19. Prices (US$/year) of first-line antiretroviral regimen in Uganda: 1998-2003

20. Focus on results for people  Targets  Know your epidemic and the society  Monitor and evaluate  Invest in information systems

21. Know your epidemic

22. A multi-disciplinary, multi-sectoral response Health outcomes determined by multiple factors and interventions Particularly key besides health: law, education, work place, trade, armed forces Need to expand resource base First genuine business engagement in health

23. Percentage of countries with sectors included in the national AIDS strategy and earmarked budgets 6.5 Source: UNGASS Country Progress Reports 2008. 0 20406080100 Public works Tourism Trade and industry Minerals and energy Agriculture Transportation Health Labour Military/police Sector included Earmarked budget present Percentage of countries (%), N=126

24. Community engagement From planning to implementation Makes or breaks programmes “Aids literacy” National Aids Councils and Global Fund Country Coordination Mechanisms Societal sustainability and resilience

25. TASO, Uganda

26. Opportunities for global health  Health diplomacy  Increased funding (ODA and research)  Collateral benefits (TB,malaria, health systems)  Culture of accountability  Tiered pricing  Engagement of non-medical sectors  Boost to research  Major interest by young people

27. Challenges: the long term view A still changing epidemic Sustainability (leadership, funding, treatment) An all out effort on hiv prevention Links and synergies with health and development Improve programme delivery and capacity R&D

28. Number of HIV infections each year by route of transmission in Cambodia, 1988-2004 Source: Peerapatanapokin and Brown, using Asia Epidemic Model Number of new HIV infections each year by route of transmission in Cambodia, 1988-2004 (Source: Peerapatanapokin and Brown, using Asian Epidemic Model) 0 5000 10000 15000 20000 25000 30000 35000 40000 45000 19881989199019911992199319941995199619971998199920002001200220032004 Male clientsSex workersWife from husbandHusband from wifeMother to child

29. Estimated Resource needs for AIDS, TB and malaria (2009 to 2015) Sources: UNAIDS, STB, RBM

30. Annual resources available 2000–2007 and funding gap between projected financial resources if current scale-up continues and a phased scale-up scenario to reach universal access between 2010 and 2015 (US$ billion) I US$ Billion 20002001200220032004200520062007200820092010 5 15 25 35 45 0 10 20 30 40 1.4 1.6 3.2 5.0 6.1 8.3 8.9 10.0 Resources available for HIV services Resource Needs: if current scale-up continues Resource Needs for phased scale-up to Universal Access

31. Total health ODA commitments, 2001-2006 US$ Billions

32. The PREVENTION GAP Persons at risk with access to selected prevention interventions, 2006 Source: Global HIV Prevention: the access and funding gap. June 2007

35. Direct funding of health systems through Global Fund grants Amount (approximately) Commodities, Products, Drugs - $6.3-billion Health Systems - $4.9-billion Administration - $1.4-billion Other - $1.4-billion

36. Cost Effectiveness

37. aids2031 Taking a long term view- stretching planning and funding horizons to achieve sustainability Multi-disciplinary – bringing together bio-medical, social and political scientists, economists and activists to look at what should we do differently – or more of the same – now to change the future of AIDS Key aids2031 report “Agenda for the Future” to be launched end of 2009

38. CONCLUSIONS Science AND justice as basis for policy Nothing for the people without the people Genuine multi-disciplinarity Information for accountability and programming Think long term No magic bullet!