1. Title NAME HERE Financial Resources Required to Achieve Universal Access to HIV Prevention, Treatment, Care and Support 2009-2015

2. Outline Background What is new? Findings Challenges Key issues Next steps

3. Resource Needs estimates by UNAIDS since 2001 June 2001- Prepared for UNGASS – $10 billion by 2005 ($5 prevention, $4.8 treatment) Nov 2002- Prepared for Barcelona AIDS Conference –$10.5 in 2005 and $15.2 in 2007 –Estimates to 2007 (includes new interventions UP, PEP, med injections Julio 2004- Prepared for Bangkok AIDS Conference –$11.6 2005 and $19.9 in 2007 –Used 3X5 public health model, decrease in ARV prices, OI Rx, PEP, nutritional support, increased T&C Agosto 2005- Prepared for G-8 –$15 in 2006, $18 in 2007 and $22 in 2008 –Used increased rate of scale up consistent with reaching UA by 2010, now includes investments in human resources, physical infrastructure, community mobilization Septiembre 2007- Prepared for the MDGs price tag –Financial requirements to attain the health-related Millennium Development Goals

4. Global Resource Needs 2009-2015: main features of the estimation process A critical review of the current method and analysis of alternative and innovative methods was conducted The process is build-up to ensure that adequate consideration is given to the concerns/advice from the different constituencies Consultation and involvement of low- and middle-income country representatives is underway to validate and incorporate current data Two different bodies supervise and guide the estimation process Technical Working Group Advisory Board

5. What is new about these estimates Additional activities included Prevention Selected services to reduce violence against women Male Circumcision Opioid substitution treatment for Injecting Drug Users Treatment Provider Initiated Testing and Counselling (extended targeted population and new coverage ) Modification of the definition of the persons in need of Antiretroviral treatment which results in starting treatment at an earlier stage Program support costs Global advocacy Policy development, framing of HIV services within a human rights framework and addressing of stigma 3.Provision of Technical Support was made a separate intervention within Programme Costs Three scenarios

6. Financing Universal Access 1.What’s committed? 2.What’s needed? 3.What would this money buy?

7. What is Universal Access? “ Requests... that the UNAIDS Secretariat and its Cosponsors assist in facilitating inclusive, country-driven processes...for scaling up HIV prevention, treatment, care and support, with the aim of coming as close as possible to the goal of universal access to treatment by 2010” UN General Assembly resolution (December 2005) “Commit ourselves to setting, in 2006… ambitious national targets…that reflect the commitment of the present Declaration and the urgent need to scale up significantly towards the goal of universal access to comprehensive prevention programmes, treatment, care and support by 2010” UN High Level Meeting on AIDS, 2006

8. Three approaches for the response: scenarios Universal access by 2010 scale-up scenario envisions significant increases in available resources and an urgent and dramatic expansion of coverage in all countries, achieving universal access by 2010 in accordance with globally agreed goals and nationally set targets.

9. Three approaches for the response: scenarios Projected trends based on current scale-up Assumes that the pace at which HIV services are now being expanded will continue into the foreseeable future. An empirical projection of trend is one logical scenario for the future –Reflecting current logistical constraints This continued scale up requires increases in financial resources, although it would not achieve universal access targets in 2010 nor in 2015

10. [Table 5] Treatment and ART coverage Universal access by 2010Projected trends based on current scale-up Coverage rate Year Adults on ART (millions) 3-Year need a (%) 2-Year need b (%) Adults on ART (millions) 3-Year need a (%) 2-Year need b (%) 20073.033 45 2.72931 20085.254 65 3.434 20097.470 80 4.038 20109.682 93 4.74241 201110.982 89 5.345 201211.982 86 6.049 201312.882 86 6.75352 201413.582 87 7.35755 201514.083 88 8.06258

11. [Table 6 ] Treatment and care components Universal access by 2010200820092010 Adult first-line antiretroviral drugs1,6652,4073,232 Child first-line antiretroviral drugs48102189 Adult second-line antiretroviral drugs7731,1581,492 Tuberculosis antiretroviral co-treatment282319 First-line laboratory testing9321,3261,728 Second-line laboratory testing76127180 Nutrition supplements968985 First-line service delivery555767988 Second-line service delivery5179109 Opportunistic infection – treatment and palliative care288260194 Cotrimoxazole323642 Opportunistic infection – prophylaxis111 Provider-initiated testing and counselling5378891,233 Screening for sexually transmitted infection183144 Counseling for people with HIV and families/partners4884120 Total for treatment and care5,1487,3799,656

12. [Table 3] Global prevention Universal access by 2010200820092010 Communication for social and behavioural change210298386 Community mobilization4789133 Voluntary counselling and testing8821,1131,349 Youth in school103124145 Youth out of school237434633 Programmes focused on sex workers and their clients8481,1721,542 Programmes focused on men who have sex with men4978361,183 Harm reduction for injecting drug users (including opioid substitution treatment)1,0802,1313,181 Workplace298554835 Programmes focused on prisoners148204261 Other vulnerable populations252 Condom provision (male and female condoms)502699900 Management of sexually transmitted infections8171,4142,001 Prevention of mother-to-child transmission350499668 Male circumcision (in countries with generalized epidemics)150153157 Blood safety (HIV-screening)352355359 Post-exposure prophylaxis (health care setting and post-rape)134 Safe medical injections866 Universal precautions (low-income sub-Saharan African countries)99186277 Total for prevention7,73911,38115,131

13. AIDS programme costs by activity [Figure 6] Universal access by 2010200820092010 Health facility development41227550 Management (prevention)170259388 Management (treatment, care and palliative care)1,5832,6974,108 Information, education, communication [SK1] and advocacy [SK1]5180112 Monitoring and evaluation including operations research244398502 Training339604797 Logistics and supply, including transportation825378 Upgrading of laboratory and other infrastructure883854 Supervision of personnel and patient tracking107176361 Drug resistance surveillance118234375 Civil society strengthening40 Human resources1,0431,2691,327 Technical assistance119 Global advocacy and coordination419 Policy, human rights and stigma264 Total4,7076,8779,494

14. AIDS Resource Needs * The totals have been rounded to the first decimal place with the result that there may be small differences with the figures for sub-totals because of rounding. [Table 1] Universal access by 2010200920102015 Prevention11.415.115.4 Treatment and care (including palliative care)7.49.715.4 Orphans and vulnerable children 2.44.4 Programme costs*6.99.510.1 Prevention of violence against women0.61.3 Total28.640.146.6

15. Adults on ART10 million VCT clients60 million Pregnant women offered PMTCT services80 million Orphans supported19 million Scenarios towards “Universal Access” in 132 low- and middle-income countries, 2007 ‒ 2015 (US$ billion) Adults on ART4.6 million VCT clients24 million Pregnant women receiving PMTCT21 million Orphans supported2.3 million US$B

16. Is this realistic? Targets and coverage levels Obstacles to reach UA Investments for human resources, systems, physical infrastructure Resource needed: not only money

17. Three approaches for the response: scenarios Phased scale-up scenario envisions that each country will reach universal access at different times. This scenario assumes different rates of scale- up for each country based on current service coverage and capacity, with essentially all countries reaching universal access by 2015 at the latest. Priority would be given to the most effective programmatic services as dictated by data derived from national efforts to ‘know and act on your epidemic’.

18. Scenarios towards “Universal Access” in 132 low- and middle-income countries, 2007 ‒ 2015 (US$ billion)

19. Funding of health services will not stop AIDS Social change: tackle the structural drivers of the epidemic HIV prevention largely outside health services Tackle drivers of epidemic Gender HIV related stigma and discrimination (IVDU) Sexuality, including homosexuality Social and economic inequalities directly related to AIDS

20. AIDS Resource Needs by activity area [Table 1] Universal Access by 2010200820092010 HIV specific health services10,060 15,068 20,807 Health system strengthening and cross-cutting activities*4,9386,0207,228 Non-health services5,2099,08114,211 Total20,20730,16842,245

21. AIDS Resource Needs: programmes to prevent violence against women (US$ million) [Table 1] Universal access by 2010200820092010 Workplace1650102 Community mobilization1870158 Education and sensitivity training for adolescents68259573 Enabling environment (sex workers)3183153 Gender perspective in health services012 Mass media29100214 Comprehensive post-rape services, including post- exposure prophylaxis kits72656 Strengthening of nongovernmental organizations61218 Total1766001,276

22. Potential contribution by AIDS to broader health and social sector issues Orphans and vulnerable children –All double orphans, near orphans, half of single orphans, who are living below poverty line in SSA, –Proportion of AIDS orphans elsewhere Provision of “Universal Precautions” in health facilities Recruitment, incentives and salaries of additional health care staff Refurbishment of health centres and hospitals Construction of additional health centers.

23. Costing the health related MDGs Produce information to support scaling-up of national responses and to contribute to the achievements of Millennium Development Goals (MDGs) Child survival (pneumonia, diarrhoea, malaria, measles) Maternal health Tuberculosis HIV/AIDS Malaria

24. Challenges Are the investments in capacity sufficient to address the “implementation gap?” What are the diversions, enhancements and synergies? What is a “fair share” for AIDS funding for improving health and social sectors? Where will this funding come from?

25. Global Resource Needs 2009-2015: where the additional money is likely to come from Middle-income countries Governments –Use of own revenues –Reimbursable loans from Development banks Official Development Assistance –G8, other DAC member countries and Non-DAC governments Direct bilateral, e.g. PEPFAR Budget Support Through Multilaterals, e.g. increased funding through GF and others Innovative approaches –New ways of delivering services –Efficiencies, synergies and scale economies –International taxation systems UNITAID

26. Next Steps Review the current normative package of HIV services Compile national RNE and validate UNAIDS country estimates Extension of the current model: impact Provide TA: costing NSP Estimate financing gaps

27. http://www.unaids.org/en/KnowledgeCentre/HIVData/Tracking/Default.asp