PowerPoint Presentation

Rosette Kyomuhangi Khiga20th July 2012

1SPENDING ON PREVENTION ACTIVITIES IN THE SADC REGIONAre The Trends and Priorities Within an Investment Framework?AcknowledgementsUNAIDS Geneva & Regional RTS, and Country OfficesAll countries which shared their NASA reports NACs and research teamsTeresa Guthrie who supported the NASA in many SADC countriesSANAC, UNAIDS-SA and the team that was involved in SA NASA

Introduction

HIV PREVENTION IN THE SADC REGIONThe Southern African Development Community (SADC) is the world's most affected region with HIV and AIDS. The combined population of the SADC Member States is about 4% of the world population, yet globally the region accounts for more than 37% of people living with HIV. It is estimated that between 11.7 and 18.8 million people of the region are currently living with HIV (WHO 2010)

Over the past 30 years there have been tremendous gains in the global HIV response, but until now there has been only limited systematic effort to match needs with investments. The result is often a mismatch of the two, and valuable resources are stretched inefficiently across many objectives. To achieve an optimal HIV response, countries and their international partners must adopt a more strategic approach to investments.

4Presentation NamePRESENTATION DATEA new investment framework for HIVSchwartlander et al (2011): Developed by an international group of experts from UNAIDS, GFATM, Bill & Melinda Gates Foundation, The World Bank, WHO and academic and policy institutionsThe framework is based on evidence of what works in HIV prevention, treatment, care and supportModeling the framework's impact shows that its implementation would avert 12.2 million HIV new infections and 7.4 million AIDS-related deaths between 2011 and 2020

5 Key components of the framework include:Basic programme activitiesKey population at higher risk i.e CSW, IDUs & MSMsElimination of new HIV infection among the childrenCondom promotion & distributionVoluntary male circumcisionBehaviour change communicationCare treatment and support for people living with HIVPrioritising the above activities and considering the two indicators below would lead to the desired impact Critical enablers (Social & programme) Synergies with development sectorsA new investment framework for HIV-ContinuedObjectives & Methodology of StudyTo compare the prevention spending in those SADC countries that had undertaken NASAs and/or submitted their GAR financial matrix correctly. To compare with actual spending with the investment framework categories, their costed NSPs, & per capita spending.Method: We reviewed country NASA reports (CEGAA) and GAR data (courtesy of UNAIDS), and examined the breakdown of the spending on prevention activities.The reports varied in the coverage years from 2006 to 2010.

LimitationsThis was a desk study that relied totally on available NASA and GAR data. It did not seek to validate any of the available data. The data is outdated - the most recent being 2009/10 for South Africa 2010 for some few SADC countries before the Investment Model was promoted (2011).Some country data was not well disaggregated between prevention activities and thus may have underestimated spending on specific interventions.Although the investment framework provides unit costs, that still doesn't say how much, or what proportions of the total should be spent on each priority area

9InstitutionalizedImplemented at least once| Implemented in more than 50 countries

UNAIDS, 2011.9SADC HIV Per Capita Spending and Prevalence (2006-2009)

Although South Africa is the biggest spender on HIV in the region, when adjusting for population size, Botswana becomes the highest spender, followed by Swaziland and then SA. This spending appear to reflect the burden of disease in terms of the HIV prevalence in the countries.

10Who are the key funders of HIV prevention activities in the SADC region?

It is evident that on average HIV prevention is mainly funded by development partners (external sources) in the SADC region with the exception of South Africa and Zimbabwe. For such an important response to be funded by the international community as opposed to public funds is a great concern and calls for policy makers to look into issues of sustainability.11HIV prevention spending per capita in the region (US$ per person per annum)

HIV prevention spending per capita is very low in the region with the exception of Botswana12Is HIV prevention prioritized in the SADC region?

It is evident that prevention is not the most prioritized HIV activity in the region in most of these countries. it is mainly ranked third after care & treatment and programme management or OVC13What is the most prioritized prevention activity in the region?

Each country seems to have its own priority but BCC,VCT and PMTCT seem to take large proportions of the prevention component across countries. Of concern is that SOME of the inventions recommended to avert 12.2 million HIV new infections and 7.4 million AIDS-related deaths between 2011 and 2020 were not prioritized. CSW interventions, condom promotion & distribution and voluntary male circumcision are some of the most effective intervention recommended in the investment framework that were not prioritized, in these earlier years before the Investment Framework. More recently MMC has dramatically increased.14HIV prevention spending on investment high impact prevention activities

The missing amounts (to bring the totals to 100%) were for other prevention activities (not in the investmt priorities, but some as critical enablers eg comm.mobilisation). NOTE ALSO THAT THE ART SPENDING WAS NOT INCLUDED HERE AS IT WOULD REDUCE THE PREVENTION ACTIVITIES TO VERY SMALL PROPORTIONS. It is evident that male circumcision and CSW interventions were not common interventions in the region during the time period. Recently MMC has had huge injections of funding and so a more recent analysis would capture this. However, PMTCT, BCC and condom distribution are better implemented across the region. Whether they meet the target of the framework is a question to be answered! The framework does not provide what share (%) the recommended activities should be given when being allocated.15Case study: South Africas provincial HIV spending-2009/10

Generally, South Africa seems to prioritize care and treatment over any other activity. ALTHOUGH ART may now be considered also as a preventative intervention, it is of concern that the spending on other prevention programmes was rather low, and was reducing over time. In addition, more HIV-infected South Africans would live longer as a result of treatment on ARVs and in this way contribute to the increase in the prevalence rate.16Case study: South Africas provincial HIV prevention spending-2009/10

Within South Africa, between different provinces, there are differing and changing prevention priorities, which do not easily ascribe to the available evidence of the most effective interventions. Please note that HCT(VCT) in KZN and GP was classified under care and treatment as PICT17Case study: South Africa- prevention per HIV negative person per capita spending (ZAR) and HIV incidence rates

It is hard to see any trend across provinces. Prevention per capita spending per HIV spending is generally low.18Comparison of (Previous) NSP cost estimates with NASA results-South Africa.

It is clear that general prevention which includes BCC and condom distribution etc as well as PMTCT were under funded/spent in SA in 2009/10. Only care and treatment was funded over 100%, implying that the other five basic programme activities recommended in the investment framework were not implemented to the tune of the required resources.19ConclusionsThe spending on HIV prevention in the SADC region in previous years has not been prioritised, and the chosen prevention activities had not prioritised those thought to be the most impactful within the investment framework. Treatment spending has taken the bulk of the funding, which is likely to increase as more patients are enrolled on ART. This will also reduce the transmission rates and its preventative potential is acknowledged.General HIV spending does not appear to match the greatest burden of the disease among the SADC countriesHIV costed NSPs do not match HIV spending patterns. Eg. In SA, the costed need for HIV prevention was higher than its expenditure

RecommendationsIn order to reduce the number of persons needing treatment, it is vital that budgets & spending are increased for those key prevention interventions that have been shown to have the greatest impact, whilst not ignoring the critical enablers as are suggested in the Investment Framework (UNAIDS).Given funding constraints in recent years, the SADC countries need to increase and carefully align their domestic prevention spending according to the most impactful package of interventions.In order to track the impact of investment framework prioritisation, countries must improve their tracking of HIV expenditure routine resource tracking!Provide guidelines for ideal nominal and proportional spending on investment priorities?A recent comparison of NASA finds and investment framework is recommended for better results

Recommendations (2)The SADC region should attempt to align their HIV expenditure to the National strategic plans & their cost estimates, to avoid wastage or under-spending on national priorities.Costing of the NSPs need to improve in accuracy so as to avoid over- or under-estimating the resource requirements.Impact studies are recommended. For instance countries may consider conducting routine resource tracking exercises and match with output indicators to examine the cost-effectiveness of prevention interventions.Improve financial information systems to enable routine tracking of expenditure linked to outputs to enhance the quality of available data so as to timeously inform policy decisions and programme implementation.

Thank you

Rosette Kyomuhangi KhigaKampala, Ugandarosette@cegaa.org Tel # +256 782 423 085/ 704 818 296

Teresa Gurthrie5th floor, 30 WaterKant street, Cape Town, South Africateresa@cegaa.org Tel # +27 82 872 4694+27 21 425 2852www.cegaa.org23Chart187.451783199924.151.50721547622640.9517.831.986035952423.217.6214016519174.783355346512.54.90.97

Per capita HIV spending (US$)HIV prevalence rate (%)US$/annum%

Sheet1Per capita HIV spending (US$)HIV prevalence rate (%)Series 3Botswana (08/09)87.524.12Swaziland ('06)51.526.05S. Africa (09/10)41.017.8Lesotho ('06)32.023.2Zambia ('06)17.617.02Ug wthout OOPEMozambique4.812.53Mauritius (08/09)4.90.97To resize chart data range, drag lower right corner of range.Check Uganda Pop and HIV prev.334246836.5Check if their figs were in 1'000s