Post on 19-Dec-2015
The Global Response to AIDS: Achievements and Challenges
for the Long Term
Peter PiotInstitute for Global HealthImperial College London
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
2.0
2.2
2.4
2.6
2.8
3.0
end 2002 end 2003 end 2004 end 2005 end 2006 end 2007
Pe
op
le r
ece
ivin
g A
RV
th
era
py (
in M
illio
ns)
North Africa and the Middle East
Europe and Central Asia
East, South and South-East Asia
Latin America and the Caribbean
Sub-Saharan Africa
Global Fund supported programs
Number of people receiving ARV therapy in low- and middle-income countries, 2002—2007
Decline in adult mortality with introduction of ART: Botswana
0
10
20
30
40
50
0
1
2
3
4
5
6
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Pe
rso
ns o
n A
RV
(T
ho
usa
nd
s)
Re
gis
tere
d D
ea
ths (
Th
ou
sa
nd
s)
on ARV
Deaths aged 25-54
Improvements in life expectancy at infection due to the availability of ART: Resource-poor settings
Source: Hallett T B, et al. PLoS Med. 2008 Mar 11;5(3):e53.
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
40M
edia
n H
IV p
reva
lenc
e (%
) 50 BotswanaLesothoMozambiqueNamibiaSouth AfricaSwazilandZimbabwe
1997–1998
1999–2000
2001 2002 2003 2004 2005 2006 2007
West Africa
0
5
10
15
20M
edia
n H
IV p
reva
lenc
e (%
)
0
5
10
15
20
Med
ian
HIV
pre
vale
nce
(%)
Eastern Africa
1997–1998
1999–2000
2001 2002 2003 2004 2005 2006 2007 1997–1998
1999–2000
2001 2002 2003 2004 2005 2006 2007
Ethiopia
Kenya
Burkina FasoCôte d'IvoireGhanaSenegal
Source: National surveillance reports and UNAIDS/WHO/UNICEF, Epidemiological Fact Sheets on HIV and AIDS. July 2008.
1980 1985 1990 1995 2000 2005 20100
10
20
30
40
50
60
Year
HIV
pre
vale
nce
(%
)
1980 1985 1990 1995 2000 2005 20100
2
4
6
8
10
Year
HIV
inci
de
nce
(p
er
10
0p
yar)
Changes in HIV Prevalence and Risk Behaviour:Zimbabwe (urban and semi-urban areas)
Source: Hallett TB, et al. Epidemics 2009;1(2):108-117.
Natural decline in incidence ~1990
Accelerated decline in incidence, due to behaviour change ~2000
Number and percentage of HIV-positive pregnant women receiving antiretroviral prophylaxis, 2004–2007
2004 20062005
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.
AIDS IS NOT OVER
HIV prevalence (%) in adults (15–49) in Africa, 2007
HIV infections among men having sex with men in Asia
Source: Bertozzi SM, et al. Lancet. 2008 Sep 6;372(9641):831-44.http://data.unaids.org/pub/report/2008/thailand_2008_country_progress_report_en.pdf
HIV infections by mode of transmission in Thailand
How did we get there?
Science and rights drivenA global responseFocus on results for peoplePrevention AND treatmentMulti-disciplinary, multi-sectoralCommunity engagement
[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 AIDS1986‒2007
Total annual resources available for AIDS1986‒2007
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
US$ million
2921623
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 BankMAP launch
Global Fund
PEPFAR
257
UNAIDS Gates
Foundation
‘06 2007
10 000
8.9 billion
10 billion
Treatment Action Campaign (TAC), South AfricaTreatment Action Campaign (TAC), South Africa
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
A global response
• Human rights and strategic issue
• Global public good • Role of United Nations• Global civil society and activism• International financing
UNITED NATIONSGENERAL ASSEMBLYSPECIAL SESSION ON HIV/AIDS
25 - 27JUNE2001
United Nations
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)
Prices (US$/year) of first-line antiretroviral regimen in Uganda: 1998-2003
Prices (US$/year) of first-line antiretroviral regimen in Uganda: 1998-2003
Focus on results for people
• Targets• Know your epidemic and the society• Monitor and evaluate• Accountability
Simulated HIV epidemics (A) concentrated (B) in the general population
Source: Boily M-C ,et al. Sex Transm Infect 2007;83:582-589
Need for new evaluation methods
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
• Expand resource base• First genuine business engagement in health
Percentage of countries with sectors included in the national AIDS strategy and earmarked budgets
Source: UNGASS Country Progress Reports 2008.
0 20 40 60 80 100
Public works
Tourism
Trade and industry
Minerals and energy
Agriculture
Transportation
Health
Labour
Military/policeSector included
Earmarked budget present
Percentage of countries (%), N=126
Community engagement
• From planning to implementation• Makes or breaks programmes• National Aids Councils and Global Fund
Country Coordination Mechanisms• Societal sustainability and resilience
TASO, Uganda
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• New blood
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 in 2010
Estimated Resource needs for AIDS, TB and malaria (2009 to 2015)
Estimated resource needs
0
10
20
30
40
50
60
2009 2010 2011 2012 2013 2014 2015
US
$b
n HIV/AIDS
TB
Malaria
Sources: UNAIDS, STB, RBM
Projected AIDS spending needs and per capita GDP, 2030
0.0 2000.0 4000.0 6000.0 8000.0 10000.0 12000.0 14000.00.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
Botswana
Viet NamUkraine
Russia
Nigeria
Kenya
Cameroon
Zambia
MozambiqueUganda
India ChinaThailand
South Africa
Brazil
BrazilSouth AfricaThailandChinaIndiaUgandaMozambiqueZambiaCameroonKenyaNigeriaRussiaUkraineViet NamBotswana
GDP per Capita
AID
S Sp
endi
ng %
of G
DP
The PREVENTION GAPPersons at risk with access to selected prevention
interventions, 2006
Source: Global HIV Prevention: the access and funding gap. June 2007
Effects of Prevention on Future Costs of ART
$0$2$4$6$8
$10$12$14$16
2005 2010 2015 2020 2025 2030
Billion US$
Current Prevention Scaled Up Prevention
Figure 3. Geographical distribution of HIV and tuberculosis infections in South Africa in 1995, 2000, and 2005.Reference: Karim. S, The Lancet, Special Issue: Health in South Africa August 2009 (Data from references 1 and 21.)
Cost Effectiveness
The long term view
• A still evolving epidemic• Sustainability (leadership, funding, treatment) • An all out effort on hiv prevention • Improve programme delivery and capacity• Links and synergies with health services ( ART,
PMTCTC) and community development • To stop aids, need for technological and structural
game changers (but no magic bullet!)• Invest in R&D