The Global Response to AIDS: Achievements and Challenges

for the Long Term

Peter PiotInstitute for Global HealthImperial College London

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0.4

0.6

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1.4

1.6

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end 2002 end 2003 end 2004 end 2005 end 2006 end 2007

Pe

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ivin

g A

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th

era

py (

in M

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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

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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

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IV p

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Med

ian

HIV

pre

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(%)

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

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(%

)

1980 1985 1990 1995 2000 2005 20100

2

4

6

8

10

Year

HIV

inci

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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

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2.50

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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