Supplementary webappendixThis webappendix formed part of the original submission and has been peer reviewed. We post it as supplied by the authors.

Supplement to: Schwartländer B, Stover J, Hallett T, et al, on behalf of the Investment Framework Study Group. Towards an improved investment approach for an effective response to HIV/AIDS. Lancet 2011; published online June 3. DOI:10.1016/S0140-6736(11)60702-2.

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SUPPLEMENTAL MATERIAL

Towards an improved investment approach for an effective response to AIDS; Schwartländer et al. May 2011

Table of Content APPENDIX I SUMMARY........................................................................................................................ 3 BACKGROUND INFORMATION ................................................................................... 3 METHODS FOR ESTIMATING THE COST AND IMPACT OF THE PROPOSED INVESTMENT FRAMEWORK........................................................................................ 4

Impact and effectiveness of interventions....................................................................... 5 Coverage targets.............................................................................................................. 6 Projections of the number of HIV infected people in need and receiving ART............. 8 Estimated cost of programme activities........................................................................ 11

Assumptions about the cost of HIV interventions .................................................... 11 Estimated cost of counseling and testing (C&T) ...................................................... 12 Estimated cost of treatment, care and support .......................................................... 13

Assumptions about the cost and changes in cost of ART..................................... 13 Estimated costs for IDU interventions...................................................................... 15

OST: Coverage targets lower and middle income countries ................................ 16 Unit cost of OST ................................................................................................... 17 NSP: coverage targets lower and middle income countries.................................. 18

Estimated cost of PMTCT ........................................................................................ 19 Screening............................................................................................................... 19 Family Planning .................................................................................................... 19 CD4 Testing .......................................................................................................... 20 Prophylaxis for HIV infected pregnant women.................................................... 20 ART for mothers who need it for their own health............................................... 21 Early infant diagnosis ........................................................................................... 22 Cotrimoxazole Prophylaxis................................................................................... 22

Estimated cost of Behavior Change programmes..................................................... 22 Estimated cost of community mobilization .................................................................. 23 Estimated cost of programme support functions .......................................................... 24 Estimated cost for synergies with development sectors ............................................... 24 Costing Spreadsheets .................................................................................................... 26

APPENDIX II: THE SYNERGISTIC IMPACT OF CRITICAL ENABLERS.............. 28 APPENDIX III: ESTIMATED CONTRIBUTION OF TREATMENT TO REDUCING TRANSMISSION............................................................................................................. 30 APPENDIX IV: INFORMATION ON NEW PREVENTION TECHNOLOGIES......... 32 APPENDIX V: RELEVANT TERMS AND DEFINITIONS......................................... 34

Basic Programme Activities ......................................................................................... 34 Treatment care and support for PLWH (including facility-based testing) ............... 34 Prevention of mother-to-child transmission (PMTCT)............................................. 34

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Male circumcision..................................................................................................... 34 Condom promotion and distribution......................................................................... 35 Behaviour Change Programmes ............................................................................... 35 Component elements of social and behavioural change communication programmes................................................................................................................................... 36 Key populations ........................................................................................................ 37

Sex work interventions ......................................................................................... 37 MSM programmes ................................................................................................ 37 IDU programmes .................................................................................................. 38

Critical enablers ............................................................................................................ 38 Social Enablers.......................................................................................................... 38

Political commitment and advocacy ..................................................................... 38 Laws, legal policies and practices......................................................................... 39 Community Mobilization...................................................................................... 39 Stigma reduction ................................................................................................... 40 Gender based violence .......................................................................................... 41 Local responses to change the risk environment .................................................. 42

Programme Enablers................................................................................................. 43 Community centered design and delivery............................................................. 43 Programme communication .................................................................................. 44 Management and incentives.................................................................................. 44 Procurement and distribution................................................................................ 44 Research and innovation ....................................................................................... 45

REFERENCES ................................................................................................................. 46

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SUMMARY A new investment approach is proposed for the response to HIV. It is simpler and more strategic than current approaches and is intended to support better management of the HIV response, both at national and international levels. The framework proposes three categories of investment: a small number of basic programme activities scaled up to reach the relevant populations; a set of critical interventions that create an enabling environment for achieving maximum impact; and support for programmatic efforts set in wider health and development sectors related to AIDS. In this document we describe in greater detail the methods used for estimating the annual cost of implementing these programmes to achieve universal access to HIV treatment, care and support by 2015, as well as estimating the potential future impact of the new investment strategy.

BACKGROUND INFORMATION Estimating the level of investments required for AIDS is being aligned with the timeline and methods to cost other health-related Millennium Development Goals (MDGs) for a comprehensive response to the epidemic. UNAIDS has conducted several exercises to estimate the resource requirements from all sources, including domestic and international, to respond to the HIV epidemic. The first estimates were prepared for the United Nations General Assembly Special Session on HIV/AIDS (UNGASS) in 20011 and it was inspired by the Secretary General’s call in Abuja for US$ 7-10 billion to fight AIDS, tuberculosis and malaria. It involved estimating the cost of HIV prevention and AIDS care needs in 135 low- and middle- income countries.2

The second exercise was conducted for the UNAIDS Programme Coordinating Board in November 2002.3 Recognising that the global response was less than required to meet the UNGASS goals in many countries by 2005, the achievement of programming levels for a comprehensive response was projected up to 2007. In view of plans for treatment scale-up, two programmes important to health worker retention and morale, namely universal precautions and occupational post-exposure prophylaxis, were added. The medical injection safety4 which had not been specifically included as a prevention measure in the 2001 work was also added.

The third set of estimates, published in the 2004 UNAIDS Report on the Global AIDS Epidemic, benefited from an extensive consultation through 9 regional/sub-regional workshops with over 155 experts drawn from 78 affected countries. It took into account the reduction in treatment costs and the streamlined public health model of service delivery for antiretroviral drugs.5

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In 2005, estimates initiated by a working group of the UNAIDS Reference Group on Economics (URGE), were refined for the High-Level Meeting on “The Global Response to AIDS: Making the Money Work – The Three Ones in Action”.6 These estimates showed global resource requirements of US$ 15 billion in 2006, US$ 18 billion in 2007 and US$ 22 billion in 2008 for prevention, treatment and care, support for orphans and vulnerable children (OVC), as well as programme and human resource costs. Estimates were also reported in 2009 in the UNAIDS publication “What Countries Need: investments needed for 2010 targets in low- and middle-income countries”.7 Estimating resources needed for AIDS represents an ongoing activity aimed to improve the methods and figures by incorporating the most recent data with each cycle in the estimation process. A set of standard definitions, methods and tools has been developed as a common reference for the working groups. The resource needs estimation process is aimed at ensuring the delivery of useful products, and involves coordination, consultation, standardization and estimation. The current investment framework benefits from the experience of the aids2031 international consortium. The aids2031 project modelled long-term funding needs for HIV/AIDS in developing countries with a range of scenarios and substantial variation in costs: ranging from US$397 to $722 billion globally between 2009 and 2031, depending on policy choices adopted by governments and donors.8 The results suggested that countries will move in increasingly divergent directions over the next 20 years; middle-income countries with a low burden of HIV/AIDS will gradually be able to take on the modest costs of their HIV/AIDS response, whereas low-income countries with a high burden of disease will remain reliant upon external support for their rapidly expanding costs.

METHODS FOR ESTIMATING THE COST AND IMPACT OF THE PROPOSED INVESTMENT FRAMEWORK The resource needs and returns on investment of the proposed investment framework were estimated for 139 low- and middle-income countries and summed to a global total. The resource needs estimate is the cost of increasing from current levels of coverage in 2011 to achieve universal access target coverage levels by 2015 and maintain them thereafter. For the baseline scenario we assumed constant coverage at about present funding levels (estimated from analysis of spending data from national and international sources9) except for the reduction in ART drug costs which we assume would decline over time at the same rate as in the investment framework scenario.

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The basic programme activities provided directly to populations in need (such as treatment, male circumcision, or PMTCT) were costed by multiplying the number of people in need of the service by the coverage (to determine the number of people receiving the service) and multiplying the result by the unit cost of providing the service to one individual. The costs of support programs that do not provide a service directly to individuals (such as advocacy, policy reform, stigma reduction, and management and administration) were estimated as a proportion of the total direct costs. Estimates of the number of people in need of services were based on demographic data from the United Nations Population Division10 for services reaching the general population (e.g., PMTCT for pregnant women, male circumcision for men 15-49, testing and counseling for adult males and females). Estimates of the sizes of key populations, including sex workers, men who have sex with men (MSM) and injecting drug users (IDU) were based on national estimates provided to UNAIDS and published reviews of studies of size estimates.11-15

Information on unit costs of providing services were based on published literature and advice from experts from 58 countries participating in four regional workshops on resource needs in 2009.16 Regional or sub-regional averages for coverage levels and unit costs were used for countries where there were no specific data. Coverage was scaled up from current levels to target levels by 2015 with targets for basic programme activities set as maximum plausible coverage level according to size of the relevant population. More information on coverage levels and unit cost is provided elsewhere in the document.

Estimates of the annual number of people in need of treatment were based on an epidemic projection model17 that reproduces at a global level the country-specific estimates of need for treatment, given the assumptions on coverage scale-up reported by national programs.18

The estimated cost for the critical social and programme enablers as well as the synergies with development sectors are described below.

Impact and effectiveness of interventions The Goals model, developed by the Futures Institute,16,19 was used to assess the impact of the selected programme activities on the epidemic. The model considers male and females aged 15-49 years divided into six groups: not sexually active, low risk heterosexual (one partner), medium risk heterosexual (more than 1 partner in the last year), high risk heterosexual (female sex workers and male clients), MSM and IDU. The

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probability of acquiring a new HIV infection is determined by characteristics of the index person (number of partners), the partner (HIV status, stage of infection, ART use) and the partnership (sex acts per partner, condom use, STI prevalence, heterosexual or MSM contact, male circumcision status). Infected persons progress through a primary stage of infection with high infectivity, an asymptomatic stage with low infectivity, and a symptomatic stage with high infectivity, to AIDS death. Infectivity is reduced by ART use. The model includes a component to estimate the effects of prevention interventions on key behaviours based on a summary of the impact literature, described below. The model simulates the effect of biomedical interventions, such as male circumcision and PMTCT, using trial data on effectiveness and simulates the effects of behaviour change interventions using data showing the effect of exposure to these interventions on key behaviour such as condom use, number of partners and age at first sex. Goals models had been prepared for 23 high burden countries, which together account for 77% of the total HIV burden. The models for all these countries were updated with the latest coverage information from the national 2010 UNGASS reports and with unit costs from the latest round of country estimates from the UNAIDS regional Resource Needs workshops and from the AIDS2031 activities.20 Estimates of new HIV infections and AIDS deaths were extracted for the 23 countries and scaled up to obtain global estimates, matching the 2009 UNAIDS estimates.18 An extensive literature review had been conducted to determine the impact of prevention interventions in developing countries. An impact matrix was developed to classify effectiveness results into those prevention intervention categories that UNAIDS use to estimate resource needs,21 with the purpose to harmonize efforts among the various elements of national strategic planning processes. This impact matrix, described in detail by Bollinger in 2008,21 provides the basis for the Goals model. In addition, it is assumed that the probability per act of female to male transmission is reduced by 60% among those men who are circumcised,22-24 and that ART reduces transmission per sexual act by 92% for those on ART.25

Coverage targets Information on current levels of coverage was obtained from country UNGASS reports in 2010 including data from published surveys (such as DHS) and information provided by national programmes. This data can be accessed using AIDSinfo, a data visualization and dissemination tool used by UNAIDS to facilitate the use of AIDS-related data by country and globally (available at:

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http://www.unaids.org/en/dataanalysis/tools/aidsinfo/). Regional averages were used for countries where there were no specific data. Coverage was scaled up from current levels to target levels by 2015, as shown in Table 1. Targets for basic programme activities were set as maximum plausible coverage level according to the size of the relevant population, in many cases resulting in 80% coverage of the relevant activity. Coverage of ART is discussed in detail in the section below. In countries with well established opioid substitution therapy (OST) for injecting drug users (IDU), coverage of about 20-40% can be achieved, and this target is included in internationally endorsed target setting guidance, based on the levels of coverage which have been achieved in countries with established OST programmes.26-29 In countries (e.g. Western Europe and Australia) where these levels of coverage were reached HIV epidemics among IDU’s have stabilized or reversed,30 and a coverage target of 40% of opioid injectors on OST by 2015 would be desirable. Based on historic evidence and country consultation and estimation we assume that we can determine two levels of OST coverage: it is anticipated that countries that have already introduced OST, such as India and China, could arrive at a coverage level of 40% by 2015. However, countries that have not yet introduced (or registered) OST, such as the Russian Federation, may implement OST after 2011 (assuming a coverage of 0% until 2011) and will reach a lower coverage of around 20% by 2015. More information on OST coverage and denominator populations is provided elsewhere in this document. Table 1. Coverage targets for 2015 by epidemic type (*) Hyper-Endemic,

Low Circumcision Generalized, Mixed

Concentrated epidemics

Low level epidemics

Basic Programs PMTCT 90% 90% 90% 90% Condoms (discordant couples)

60% 60% 60% 60%

Condoms (medium risk populations)

60% 60% 20% 20%

Condoms (high risk populations

50% 50% 50% 50%

Sex work 60% 60% 60% 60% MSM 60% 60% 60% 60% IDU outreach 60% 60% 60% 60% IDU needle and syringe exchange

60% 60% 60% 60%

IDU drug substitution 0% 0% 40% 40%* More detailed description of treatment coverage is provided below

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Projections of the number of HIV infected people in need and receiving ART Estimates of ART eligibility are based on the 2010 WHO guidelines,31 using evidence that starting ART earlier (CD4≤350 cells/μL) is cost effective, improves health outcomes, and reduces HIV and tuberculosis transmission. The estimates of the number of people in need of treatment for the investment framework were based on an epidemic projection model that reproduces at a global level the country specific estimates of need for treatment reported by national programs. The model is described elsewhere by Stover et al.17 and estimates are consistent with those produced by UNAIDS using the model developed by the UNAIDS Reference Group on Estimates, Models and Projections.18 The model was used to estimate the number of people needing treatment each year given assumptions about the scale up of coverage. The model tracks the HIV population by CD4 counts, assuming that all newly infected people start with CD4 counts above 500, and that their CD4 cell counts decline over time. People progress from CD4 category to the next, while assumptions are made about the transition probabilities and probability of death from HIV-related or non-HIV related causes. The number starting ART each year is determined by the assumed coverage and the number of people eligible for treatment. The total number of PLHIV eligible for treatment according to the latest WHO guidelines is estimated to be about 18.3 million in 2015. In no society, and for no disease, are 100 percent of those who might benefit from treatment actually treated as some of those eligible remain outside the health system (whether by choice or due to imperfect system coverage), refuse to take treatments, or cannot take treatments due to other conditions. In this light, universal access for ART is described herein as coverage levels of about 80%. If universal access targets are to be treated as serious programme goals and not merely aspirational, modeling and cost assumptions need to better address programme realities. The models used in this analysis assume that 80% will be reached with a very rapid treatment uptake once CD4 cell counts drop to 350, reaching the assumed maximum coverage levels before CD4 counts drop to levels of 200 and below (Figure 1). The total number of people estimated to be on treatment by 2015 will be 13 million. With better treatment models available and a shift to community and primary care delivery over the coming decade, we assume that coverage will be further increased reaching levels of 90 percent and more for those with severe symptoms of HIV disease (Figure 2). By 2020, a total of 18.7 million (86%) of the 22 million eligible under the current guidelines are assumed to be on treatment (Figure 3).

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

>500 350‐499 250‐349 200‐249 100‐199 50‐99 <50

CD4 Count (cells/ml)

Coverage

CD4

350-500 CD4

250-350CD4

200-250 CD4

<200 Treatment coverage 5% 45% 70% 80%

Figure 1. ART coverage in 2015 by CD4 count, as assumed in the Investment Framework

350

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1995 2000 2005 2010 2015 2020 2025

>500

350‐499

250‐349

200‐249

<200

Figure 2. Assumed coverage of ART by CD4 category

0

2

4

6

8

10

12

14

16

18

20

2005 2010 2015 2020

Millions

Figure 3. Projected number of adults receiving ART over time

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Estimated cost of programme activities

Assumptions about the cost of HIV interventions

We assumed that unit costs for some services would decline as programmes expand, due to economies of scale and changes to more efficient service provision modalities in particular through community approaches. Although there is limited information on changes in unit costs over time, recent work indicates that substantial economies of scale are likely to exist.32 Unit costs of providing population-based services were provided by experts from 58 countries participating in four regional workshops on resources needs in 2009.16

Tables 2 provides estimates of the unit costs of key interventions by region in 200916 while assumptions about the ART costs over time are described below. In addition, unit costs for interventions by country are provided in the Excel Spreadsheet (UnitCosts.xlsx) available on-line. Table 2. Median unit costs (US$) of key interventions by region, 2009

PMTCT

Screening** PMTCT

Prophylaxis***

Condom Promotion

and Distribution

Outreach for sex

workers*

Outreach for

MSM*

Per Woman

Screened Per Woman

Receving ARVs Per Condom Distributed

Per Sex Worker Reached

Per MSM Reached

Sub-Sahara Africa 4.48 607 0.18 20.24 25.97 East Asia and the Pacific 3.93 1564 0.09 49.38 62.24 South and South-east Asia 3.92 848 0.08 33.38 41.87

Eastern Europe 3.92 2204 0.23 60.02 69.32 North Africa and Near East 3.90 2265 0.25 71.92 76.17 Latin America and the Caribbean 3.97 1721 0.27 55.26 65.78 * Interventions marked with * have declining unit costs with increasing scale. **Assumes $3.90 per woman screened and found to be HIV-negative and $13 per woman screened and found

to be HIV-positive ***Assumes costs in 22 focus countries in sub-Saharan Africa of $237 for Option A, $705 for Option B, $20

for CD4 counts, $3 for community mobilization, $33 for early infant diagnosis, $5 for Cotrimoxazole. For all other countries costs are adjusted for purchasing power. More information is provided below.

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Cost per client counselled and tested

$0

$10

$20

$30

$40

$50

$60

$70

$80

$90

0%

0.01%

0.03%

0.05%

0.20%

0.40%

0.75% 5% 15

%25%

35%

45%

55%

65%

75%

85%

95%

Coverage

Outreach and needle/syringe exchange for

IDU

Opiod substitution

therapy (2011*)

Male circumcision

Social and behavior change

communications

Counseling and

testing* Community mobilization

Per IDU Reached

Per IDU Reached

Per Person Circumcised

Per National Campaign Per Client

Per Person Reached

Sub-Sahara Africa 23.43 1,008.00 59.10 809,775 14.87 3.38 East Asia and the Pacific 64.77 1,008.00 195,007 26.00 2.27 South and South-east Asia 24.49 1,008.00 3,475,231 14.66 1.31

Eastern Europe 36.37 1,008.00 262,515 15.58 2.62 North Africa and Near East 44.35 1,008.00 479,354 20.15 2.62 Latin America and the Caribbean 71.36 1,008.00 467,342 14.53 3.16

* unit costs for OST ae assumed to decrease by 20 percent by 2015 and 50% by 2020

Estimated cost of counseling and testing (C&T)

The average unit cost of counseling and testing per region is provided in Table 3. These estimates are associated with coverage of C&T and costs generally decline with increasing coverage, as shown in Figure 4.32

Figure 4. Declining cost per client with increasing coverage of counseling and testing

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The following approach is assumed in the investment framework to determine the amount of testing undertaken within the health sector:

1. Provider initiated counseling and testing (PICT): we assume that for each person starting treatment at least three would be tested for differential diagnosis. This approach would most likely identify the patients coming to the clinics with advanced stages of HIV disease (CD4 cell counts below 200/ μL).

2. Pregnant women: It is assumed that all pregnant women in sub-Saharan Africa will be tested for HIV, except those already known to be HIV positive. We assume that 60% of HIV positive women will have CD4 cell counts above 350/μL.

3. STI patients: It is assumed that all people diagnosed with an STI will be tested for HIV. Testing among symptomatic STI patients is assumed to find HIV+ cases at a rate 3 times higher than the HIV prevalence rate.

In addition to the testing in health care settings, there is wider population testing. This can happen as part of VCT or community mobilization, as described elsewhere in the document. With our assumption of gradually moving from VCT modalities to community testing approaches we assume that the number tested through VCT will drop from 230M in 2010 to 60M in 2015. The number tested through community mobilization will increase from 46M in 2010 to 109M in 2015. It is assumed that the overall detection rate of PLWH will increase through more focused testing approaches. Globally, an assumed 316 million people will receive an HIV test in 2015 either in health settings, VCT clinics or community settings, broken down as follows: VCT 60 million, community mobilization 109 million, sex workers 6 million, IDU 7 million, MSM 18.5 million, people with HIV related symptoms 2.5 million, PMTCT 111 million, STI 1.6 million. 

Estimated cost of treatment, care and support

The Investment Framework methodology to estimate resources required for treatment, care and support has been revised to be consistent with the Treatment 2.0 initiative.33 We assume that people who start ART early do not require the treatment and prophylaxis for opportunistic infections (OI) that would be required otherwise. Other OI costs are included in the estimated “end-of-life” costs of $228 per patient. These are estimated at the time of death but reflect both pre-ART and pre-death treatment costs.

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Assumptions about the cost and changes in cost of ART

Based on past trends in ARV prices and the possibilities of new, less expensive drug combinations in the future, we assumed that the average cost per patient on first line ART would decline by about 65% by 2020. We assume that less expensive diagnostic tests that can be used at point-of-care and task shifting of treatment would lead to average reductions of 60% and 40%, respectively, in laboratory and service delivery costs (weighted across low income, lower middle income and upper middle income countries) by 2020. Substantial savings are expected from a reduction in the frequency of visits to facility-based services with the use of more potent, less toxic and resilient antiretroviral schemes. We assumed a reduction in the number of outpatient visits, from published averages to four check-ups per year, most of them based on community support activities. It is also assumed that the service delivery costs in lower-middle and upper middle income countries do not decline at the same rate as these countries are unlikely to switch to a community-based model. The costs in low-income countries decline to $17 per patient per year (assuming reduction from 12 visits per year to 4 plus some migration to task shifting approaches reducing average salary costs by half. The result is that the weighted average service delivery costs decline from $176 in 2010 to $125 by 2020.

We also considered changes in the costs of testing programs as a result of shifting from fixed facilities to community-based approaches. Given recent available data from developing countries these reductions seem plausible. Per-person ART costs in large scale PEPFAR programmes have fallen as implementation experience has grown. In South Africa and Zambia costs fell by half or more over time, and quality was not impaired when services shifted to lower level delivery sites34 and in five other countries (Botswana, Ethiopia, Nigeria, Uganda and Vietnam) median per-patient costs 24-29 months after programme initiation were 37% of their levels in the first 5 months.35 Similarly, large scale ART programmes implemented by Médecins Sans Frontières in Malawi have been delivered at $237 per patient/year, with ARV medicines representing two-thirds of the total cost: a level far below countries with smaller numbers of people receiving ARVs and lower than costs in Malawi when the numbers of persons receiving ARVs was lower.36 The significant majority of the cost savings will occur after 2015 with an increasing shift to primary care and community based approaches and cheaper point of care diagnostics. Average costs and assumed changes over time are provided in Table 3.

Drugs: A weighted average of drug costs for four different first-line regimens and two different second-line regimens is used, weighted by the proportion of patients on each regimen.37,38 Separate prices are available for low-income and middle-income countries. The cost of both 1st and 2nd line drugs for middle-income countries is assumed to increase/decrease at the same rate as the cost for low-income countries.

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Laboratory costs have been calculated as the annual median cost for laboratory tests across countries as obtained from recent literature, including studies from Cote d’Ivoire, Ethiopia, Mexico, Nigeria, Rwanda, South Africa, Thailand, Zambia.39-48 The median cost in 2010 is estimated at $180 (USD) per patient, decreasing to less than $80 by 2020 . Service delivery costs: Studies of service delivery costs conducted by PEPFAR found a range from $79 per patient per year to $345. We used an average cost (weighted across low income, lower middle, and upper middle income countries) of about $180 per patient per year in 2010, declining to $112 by 2020.

Table 3. Average cost of ART (US$) and estimated changes over time   Cost per Patient Per Year 2010 2015 2020

Labs: new patients 180 129 79

Labs: continuing patients 180 128 76

Service delivery: weighted average 176 144 112

Low income countries 103 60 17

Lower middle income countries 181 136 91

Upper middle income countries 332 332 332

Procurement 20% 13% 5%

End of life care 228 228 228

ARV Prices 2009 2015 2020

First Line ARVs

Low income countries 137 130 50

Lower middle income countries 141 134 51

Upper middle Income countries 202 192 74

Weighted average 155  147  57 

Second Line ARVs

Low income countries 853 500 150

Lower middle income countries 1378 808 242

Upper middle Income countries 3638 2,132 640

Weighted average 1678 984 295

Estimated costs for IDU interventions

In addition to responses which apply to other populations (such as HIV testing and counseling and ART) the main interventions for the prevention, treatment and care of HIV/AIDS among injecting drug users (IDUs) are needle and syringe programmes (NSP), and drug dependence treatment including opioid substitution therapy (OST). NSP is a well-established intervention which has been extensively studied and found to reduce HIV incidence and self-reported risk behaviours. Similarly OST is a critical component

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of IDU programmes and has been proven to reduce risk behaviours, stabilize drug users’ lives with consequent improvement in access and adherence to HIV/AIDS treatment and care and to reduce the incidence of HIV.49 The assumed denominator populations used in our estimations are 13.5 million opiate users in low and middle income countries and 10.3 million injecting drug users (all substances) in low and middle income countries. These estimates are based on the UNODC World Drug Reports50 and estimates prepared under the auspices of the UN reference group on HIV and injecting drug use.13 It is assumed that the size of the denominator populations will remain stable at current levels by the year 2015, while coverage levels will be increasing.

OST: Coverage targets lower and middle income countries

Using information from countries with well established OST programmes, approximately 40% of opioid dependent persons can be covered in treatment programmes.26,27 In countries where these levels of coverage have been reached, HIV epidemics among IDUs have generally stabilized.51 We have therefore assumed the desirable target of opioid injectors on OST by 2015 to be 40%, consistent with the WHO/UNODC/UNAIDS target setting guide for injecting drug users. When using a denominator population of 8.1 million opioid injectors in our calculations of coverage and cost estimates for OST, it is assumed that priority is given to scaling up OST to opioid injectors. However, consideration needs to be given to the fact that dependent opioid users who do not inject also benefit from OST and providing OST to them could prevent the transition to starting to inject opioids. Hence 8.1 million is a conservative estimate. Based on historic evidence and (limited) country consultation and estimation we further assume that we can determine two levels of coverage: it is anticipated that countries that have already introduced OST, such as India and China, will arrive at a coverage level of 40% by 2015. However, countries that have not yet introduced (or registered) OST, such as the Russian Federation, may implement OST after 2011 (assuming a coverage of 0% until 2011) and will reach a lower coverage of around 20% by 2015. Countries that have implemented OST with methadone and or buprenorphine and that can be expected to achieve (or have already achieved) 40% coverage by 2015 are shown below in Table 4.

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Based on the above coverage targets for OST in low- and middle-income countries we assume that approximately 2.7 million injectors will be on OST by 2015, a considerable scale up from the approximately 300,000 on OST in 2009.28 Table 4. List of countries that have implemented OST by 2010

Countries in which Methadone maintenance

treatment is available

Countries in which Buprenorpine

maintenance treatment and/or detoxification

is available (including pilot programmes)

Albania, Andorra, Australia, Austria, Azerbaijan,

Belgium, Bosnia and Herzegovina, Bulgaria,

Canada, China, Croatia, Czech Republic,

Denmark, Estonia, Finland, France, Georgia,

Germany, Greece, Hungary, Indonesia, Iran,

Ireland, Israel, Italy, Kyrgyzstan, Latvia,

Liechtenstein, Lithuania, Luxembourg,

Macedonia, Malaysia, Malta, Mexico, Moldova,

Myanmar, the Netherlands, New Zealand,

Norway, Poland, Portugal, Romania, San Marino,

Serbia, Slovak Republic, Slovenia, Spain,

Sweden, Switzerland, Thailand, United Kingdom

(plus overseas territories/dependencies), United

States of America, Ukraine (about to start)

Australia, Austria, Belgium, Bulgaria, China

(Hong Kong), Czech Republic, Denmark,

Estonia, Finland, France, Germany, Greece,

Iceland, India, Indonesia, Iran, Israel, Italy,

Latvia, Lebanon, Lithuania, Luxembourg,

Malaysia, Netherlands, Norway, Portugal,

Singapore, Slovak Republic, Slovenia, South

Africa, Sweden, Switzerland, Ukraine,

United Kingdom, United States of America.

Based on current levels of utilization and assumption that the relatively less expensive methadone will be used in preference to buprenorphine it is assumed that of those receiving OST in low- and middle-income countries, 80% will be on methadone and 20% on buprenorphine.

Unit cost of OST

Unit costs include programme costs directly related to delivery of methadone or buprenorphine and medication costs and not the costs covered elsewhere, such as HIV testing and counselling. Cost of Methadone: USD 1.00 – 2.90 per patient per day (medication costs 33c for 80mg in Iran to $2.06 for 80mg in Indonesia). Range: USD 363.65 – 1,057 per patient per year. Cost of Buprenorphine (only low dose estimates available 4-10mg per day, as compared to recommended doses of 12-24mg) USD 3.39 – 8.68 per patient per day (medication

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costs $2.72 for 10mg in Iran to $7.84 for 8mg in Indonesia). Range: USD 1,236 – 3,166.70 per patient per year. The non medication costs include salaries and to a lesser extent pathology tests (mainly urine drug screens). These estimates do not include the costs of building clinics or training staff. The estimates are based on ongoing maintenance treatment, and do not include the additional costs involved with commencement of treatment and therapeutic withdrawal from treatment. Based on the above, an average current cost of $1,008 per IDU reached per year was assumed in the Investment Framework models. It was further assumed that the costs of OST will be reduced by 20% by 2015 and by 50% by 2020.  

NSP: coverage targets lower and middle income countries

Based on a retrospective analysis of the coverage required to reverse the HIV/AIDS epidemic among IDUs in New York52 and coverage rates typically reached in those European countries that averted or reversed epidemics, coverage of 60% or more of IDUs regularly reached (more than once a month) is considered very good.28 In Odessa in the Ukraine, where prevalence among IDUs had already reach very high levels by 2000, 60% NSP coverage showed a reduction in HIV prevalence by 4% over a 5 year period.42 The projected coverage target for all IDUs in regular reach of NSP in the Investment Framework models have therefore been set at 60% by 2015. A denominator population of 10.3 million IDUs in low and middle income countries (as described above) was used in our calculation of coverage and cost estimation for NSPs. Regular reach is defined as an IDU being in contact with an NSP more than once a month. Our estimated coverage target for IDUs in NSP programmes is therefore estimated at about 6 million by 2015. The unit costs for NSP, which is assumed to decline with increasing coverage levels (see Figure 5), was assumed to be between 7-10 USD per person per year.

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$-

$5.00

$10.00

$15.00

$20.00

$25.00

$30.00

$35.00

$40.00

$45.00

$50.00

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

NSP coverage

Un

it c

ost

Figure 5. Unit cost of NSP by level of coverage

Estimated cost of PMTCT

Screening

The estimation assumes that 90% of pregnant women will be provided with at least one HIV screening test to ascertain her HIV status. However, women who test positive will also be provided with counseling services to help them decide on future courses of action for the benefits of themselves and their unborn children. With PEPFAR estimates of the cost of VCT services in low-income settings ranging between US$3.90 and US$20 per person, we used a weighted average cost of US$ 3.90 for the cost of HIV serological tests per woman for all HIV negative women. For HIV positive women in the population we assumed the cost of testing and counseling to be US$ 13 per woman. An additional 10% was included to take account of other programmatic costs related to the services.

Family Planning

For family planning costing, we used standard published methods. To avoid double counting family planning is included as part of the health systems component in the mayor synergies. However, it is also an important cost item of PMTCT services and a clear distinction is made whenever necessary. Prevention of unintended pregnancies

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among HIV infected women of reproductive age were calculated by multiplying the population of women with unmet need for family planning (15-49 years) by the number of HIV pregnant women in each country. This number is then multiplied by the annual average cost of providing family planning per woman. Family planning was estimated to cost US$ 20 per woman per year.53

CD4 Testing

In line with the 2010 WHO guidelines on PMTCT,54 all women who test positive for HIV should ideally undergo CD4 cell count screening in order to identify those women who require lifelong antiretroviral treatment. The new WHO guidelines stipulate that women whose CD4 counts are below 350cells/μL are to commence lifelong antiretroviral therapy. To ensure that all women who require ART for their own health are identified and treated, it is recommended that CD4 testing should be included in the essential package of care for HIV-infected pregnant women. We assumed that 90% of HIV positive women in the population will have access to CD4 testing at an average cost of US$ 20. This is an average across the high-burden countries and does not include start-up costs, laboratory upgrades or the cost of additional machines. For the purpose of this analysis, we only used the cost of the laboratory tests.

Prophylaxis for HIV infected pregnant women

In the 2010 WHO guidelines on antiretroviral treatment for pregnant women and preventing HIV infection in infants,54 there are two recommended treatment options for women not eligible for ART i.e. women with CD4 counts > 350cells/μL; Option A and Option B. WHO Option A The mother is given ante-partum AZT twice per day starting from as early as 14 weeks of gestation and continued during pregnancy. At the onset of labour, she may be given sd-NVP and initiation of twice daily AZT + 3TC for 7 days postpartum. If maternal AZT was provided for more than 4 weeks antenatally, omission of the sd-NVP and AZT + 3TC tail can be considered; in this case, continue maternal AZT during labour and stop at delivery. For breastfeeding infants, administration of daily NVP from birth for a minimum of 4 to 6 weeks, and until 1 week after all exposure to breast milk has ended. For infants receiving replacement feeding only, administration of daily NVP or sd-NVP + twice-daily AZT from birth until 4 to 6 weeks of age.

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WHO Option B The mother is given triple ARV prophylaxis starting from as early as 14 weeks of gestation and continued until delivery, or, if breastfeeding continued until 1 week after all infant exposure to breast milk has ended. Recommended regimens include: AZT + 3TC + LPV/r or AZT + 3TC + ABC or AZT + 3TC + EFV or TDF + 3TC (or FTC) + EFV Irrespective of the mode of feeding for the infant, the infant is administered daily NVP or twice daily AZT from birth until 4 to 6 weeks of age. Costing of Options A and B In line with WHO guidelines,54 we estimated costs assuming a breastfeeding duration of 12 months. Therefore, if women started receiving antiretroviral prophylaxis at 14 weeks gestational age, it means they will receive the drugs for a period of 18 months in total. We further assumed that on the average, at least 40% of HIV positive women will be eligible for ART for their own health.55 Therefore, 60% of infected women will require antiretroviral prophylaxis using option A or B. As most countries still use a combination of single and dual drug regimens, the 60% of HIV positive women not eligible for ART was split into 36% receiving Option A (dual prophylaxis) and 24% receiving Option B (triple prophylaxis). The total cost for women using Option A used is US$ 237 and consists of $30 for AZT+3TC, $63 for NVP, $54 for laboratory tests and $90 for service delivery. The total cost per women using Option B used is $ 470 which consists of $149 for ARVs, $180 for laboratory tests and $141 for service delivery. When this is multiplied for an 18 month period, we get a total cost of $705 per women.17,56

ART for mothers who need it for their own health

Treatment for mothers is a comprehensive package that includes antiretroviral therapy, laboratory monitoring and delivery cost in health facilities at a cost of US$ 600 per mother per year. We assumed that 40% of the women would have CD4<350 cells//μL and are therefore eligible for full antiretroviral therapy. Women who require ART for their own health are assumed to receive triple therapy according to the WHO Guidelines. The unit costs made for mothers who need treatment for their own health are consistent with the assumptions made for all adults receiving ART as described above. Following 12 months of breastfeeding, it is assumed that HIV-infected women (post-natal) who require ART for their own health are transferred to ART centres for the continuation of treatment. This assumption is to avoid double counting in relation to other estimates for adults receiving ART.

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Early infant diagnosis

All children born to HIV-infected mothers have maternal HIV antibodies which may be detectable in the first six months of life. Therefore, immunological assays performed early in infants may only detect HIV exposure in infants. HIV infection in infants is diagnosed by detecting the presence of viral nucleic acid (viral RNA or viral DNA) or other viral products such as p24 Ag. Polymerase chain reaction (PCR) – based HIV DNA has become the most widely used assays in resource-limited settings for both diagnostic and monitoring purposes. For the purpose of this costing analysis, 90% of all infants exposed to HIV through their mothers are assumed to have access to early infant diagnosis and the cost of PCR-DNA test per infant was assumed to be US$ 32.50.

Cotrimoxazole Prophylaxis

Cotrimoxazole prophylaxis is considered part of an additional package of care for HIV positive women and essential for the postpartum treatment of infected infants. Cotrimoxazole prophylaxis is used to reduce the incidence of opportunistic infections particularly in women with low CD4 counts and to prevent the development of opportunistic infections in infants and it is a proven cost-effective measure for improvement of the quality of life of persons living with HIV/AIDS. Therefore, all the women eligible for treatment for their own health, as well as all infants, are assumed to be given cotrimoxazole prophylaxis for a period of 6-12 months. The cost of cotrimoxazole was assumed to be US$5 per person per year.

Estimated cost of Behavior Change programmes

Behaviour change in generalized epidemics, such as delaying the initiation of sex or partner reduction, affects the likelihood of exposure and it is axiomatic that reducing these behaviours reduces the likelihood of transmission. Furthermore, the importance of behaviour change has been confirmed as a plausible explanation for changes in incidence derived from ecological studies that explain past successes in HIV prevention.57-61 For this reason, behaviour change appears as a discrete basic programme activity – notwithstanding the challenge of amassing consistent, direct and generalizable evidence on the impact of different elements of behaviour change programmes.62,63,64 The most efficacious interventions to accomplish such changes are less well established, but include programs of interpersonal and group communication delivered through the mobilization of civil society, faith based organizations and in the work place.

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Limited information is available on costing of such programmes. For the purpose of this exercise, the cost of workplace programmes have been used as a proxy to arrive at a plausible overall estimate of resource needs for Behavior Change programmes included in Basic Programme Activities of the investment framework. Work place programs typically include services such as the provision of condoms, counseling and testing and STI treatment services either provided on site or through a near by health clinic, as well as health education provided through peer educators. To arrive at an overall estimate of resource needs, we assumed the proxy of workplace programs in 2015 to be scaled up to 50% coverage of the 148 million employees in the formal sector in countries with generalized epidemics, with an average unit cost of US$ 9 per employee per year.

Estimated cost of community mobilization Community mobilization, which underlies many of the critical enablers, has objectives essential to an effective AIDS response. These objectives include: community outreach and engagement, support, advocacy and transparency; community-driven approaches in outreach and engagement activities that successfully connect people facing similar issues and engage them in a broad spectrum of HIV-related interventions thus leading to improved uptake and use of many of the basic programme activities (e.g. HIV-specific education, behavioural change, access to condoms and clean syringes, ART); support activities that target people already engaged in care and enhance quality, adherence and impact in a range of settings such as people who are on treatment, engaged in harm reduction or drug treatment services, or who are already using sexual and reproductive health services; advocacy, transparency and accountability efforts, such as local-level advocacy to ensure that high-quality health services are available and accessible to vulnerable populations. The cost of community mobilization, as one of the critical enablers, was estimated in two ways. First, in generalized epidemics, it was estimated from the number of people in need, coverage levels, and unit costs based on data on community health worker programmes. In the case of concentrated epidemics, the costs of community mobilization were subsumed into the costs of outreach for key populations and thus included under basic activities for these populations. Recent unit cost data, supplied in 2009 by 59 countries in workshops sponsored by UNAIDS, suggest a unit cost for community mobilization in HIV ranging between less than US$ 1 and US$ 14.65 A comprehensive literature search for community-based distribution of various services and commodities, including community-based care, child

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health interventions, and safe water systems, found that the median unit cost, excluding commodities, in 2009 US dollars was US$ 0.88 (mean: US$ 2.06).66-73 This unit cost is consistent with the range described above for community mobilization efforts in HIV. We applied the unit cost for community mobilization as provided by the country experts and applied regionally where no data were available. The country-specific unit costs can be found in the attached models. These unit costs were applied to the total adult population to arrive at an overall cost for community mobilization. The model also assumes that all people reached by community workers receive an HIV test every two years for an additional cost of US$ 1 per test. The framework assumes that major efficiency gains are possible through shifting service provision modalities to place greater emphasis on community mobilization

Estimated cost of programme support functions Assessments of total HIV expenditures and expenditures for program support functions18 indicate that expenditures for program support range from under 10% to over 60% with an average of 12.6%. For this analysis we assume ongoing improvements in efficiency and use 10% of direct expenditure on basic programme activities as the total average for all programme support functions. This includes programs for political commitment and advocacy, legal reform, human rights, stigma reduction, management, research and innovation, monitoring and evaluation, communications, procurement and logistics.

Estimated cost for synergies with development sectors The cost for major synergies is the least specific of the estimates included. For the investment framework we assessed existing expenditure data on systems strengthening activities and made a cost estimate for specific interventions such as blood safety, STI treatment, school based education, support to the most vulnerable populations including orphans, and gender programmes. Unit costs were based on estimates from country reports from the regional UNAIDS Resource Needs workshops, as shown below in Table 5. Total costs for programs to combat gender-based violence and to support AIDS orphans were adopted from previous resource needs estimates. The financing needed to achieve better synergies with development sectors, particularly in gender, health, education and social protection sectors, is estimated at US$ 3.59 billion in 2011, increasing to about US$ 5.43 billion investment by 2020. The estimates comprise gender based violence programmes (increasing from US48.5 million in 2011 to

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nearly US$1 billion in 2020), a number of health sector elements including family planning, STI management, blood safety, post-exposure prophylaxis, safe injections and universal precautions (increasing from a total of US$1.3 billion in 2011 to US$2.7 billion in 2020), youth in schools programmes (US$64 million in 2011 to US$118 million in 2020), and support for children orphaned by AIDS (declining from US$2.1 billion in 2011 to US$1.5 billion in2020).

While this framework does not intend to be prescriptive about spending to support sectoral synergies, this estimate is consistent with current funding approaches to systems strengthening, for example by the Global Fund.

Table 5. Median unit costs (US$) of programs classified as Major Synergies, 2009

Sub-Saharan

Africa

East Asia and the Pacific

South and South-East

Asia Eastern Europe

North Africa and

Middle East

Latin

America and

Caribbean School-based AIDS education (per student) 15.98 27.44 11.33 15.30 18.76

14.53

Family planning (per FP user) 20 20 20 20 20

20

Prevention in prisons (per prisoner) 29.28 35.00 65.39 22.13 27.65

15.83

STI management* (per case treated) 25.69 101.72 66.53 160.26 811.66

68.22

Blood safety (per unit of blood transfused) 8.54 6.32 4.19 13.73 17.41

17.32

Post-exposure prophylaxis (per case) 34.01 94.60 97.48 95.56 125.00

124.69

Safe medical injections (per injection) 0.22 0.16 0.15 0.22 0.03

0.07

Universal precautions (per hospital bed) 303.18 336.86 180.19 66.97 58.98

154.12

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Costing Spreadsheets Excel spreadsheets that were used for the Investment Framework calculations are available from the authors on request. The approach was based on the assumptions that the number reached is estimated by the population times coverage, while resource needs is estimated by the number reached times the unit costs. The spreadsheets include:

PopData.xls : This spreadsheet contains population data. Different worksheets show the different target populations.

Behavior.xls: This spreadsheet includes additional information for calculations including ANC coverage, units of blood needed per 1000 population, % casual sex, coital frequency, injections per person, proportion married.

Coverage.xls : The spreadsheet includes coverage targets and different worksheets are used for the different interventions. The coverage targets for different scenarios are specified in the Goals worksheet.

NumberReached.xls : This spreadsheet provides the numbers reached by each intervention. Different worksheets are used for different interventions. Most of the worksheets simply show the result of population x coverage. The number of people on ART (Figure 3) is drawn from the Goals model applications.

UnitCosts.xls : Different worksheets are used with the unit costs specified for different interventions. Most are constant over time while a few are assumed to change with scale. ART is shown by country type (low / middle income) rather than by individual country.

ResourceNeeds.xlsm : This spreadsheet shows the estimated resources that are required for the investment framework, by intervention. Different worksheets show country estimates for the different interventions. Charts and summary tables are also shown.

To use the spreadsheets, all five spreadsheets should be opened in Excel in order (PopData, Coverage, NumberReached, UnitCosts, ResourceNeeds). The first time this is done the spreadsheets may need to be re-linked if the links are not automatically updated. Warnings

The analysis is intended to provide estimates of resource needs at the global level. Results for individual countries will require further work and confirmation.

Results Results are shown in the spreadsheet “ResourceNeeds.xlsm”. The following worksheets include results:

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Results table. Results for all countries are summed together by intervention. Summary by County. The results by country for all interventions are shown for the 22 countries for which we did Goals applications.

Country by Intervention. The name of a single country can be entered in the yellow cell, B1, to see the resource needs for that country. If it is not one of the 23 Goals countries then resource needs for ART will not be shown.

Summary by Scenario. This worksheet shows the total resources needed for all countries by major component (prevention, treatment, mitigation, support, structural interventions) and by scenario.

Scenarios. The coverage scenarios can be changes in the Coverage spreadsheet, in the Goals worksheet in cell B2. This will change the coverage to the specified scenario, according to the table in the Coverage.xls spreadsheet, Goals worksheet. The region or country can also be changed in the yellow cell B3, but if a country is chosen that is not one of the 23 Goals countries ART costs will not be available.

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APPENDIX II: THE SYNERGISTIC IMPACT OF CRITICAL ENABLERS Critical enabling factors can have a substantial impact on HIV incidence for a low cost if they help change, for the better, the proximate determinants of HIV transmission. Quantifying the link between such enabling activities, implemented at a community level, and individual changes in risk behaviour is difficult, but recent studies provide examples that can be examined in mathematical model projections. Community mobilisation, along with mobile voluntary HIV counselling and testing and post-test support services, increased HIV testing rates four-fold in Tanzania, Zimbabwe, South Africa and Thailand.74 Therefore, increased testing could potentially reduce HIV incidence if more of those who are infected know their status and increased condom use or initiate treatment (on time for clinical need). Furthermore, in Kenya, a four-fold greater odds of reporting consistent condom use over the previous 12 months was associated with living in areas with good engagement of community-based organizations.75 These factors were included in a model representing the population of KwaZulu-Natal to explore how the impact of a hypothetical ‘core’ circumcision intervention might be enhanced by enabling interventions that result in greater HIV testing and condom use (Figure 6). In the model scenario, the core intervention averted 240,000 infections over ten years but key enabling interventions could, for modest marginal increase in costs, avert an additional 180,000 infections.

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0 100 200 300 400 500

Core

Core + Enablers

Number of infections averted, 2012-2022 (1000s)

Inte

rve

ntio

ns

Figure 6: A model of the HIV epidemic in Kwazulu-Natal, South Africa, was used to calculate the number of new HIV infections that would be averted by a “Core” intervention (70% of the uncircumcised men are circumcised over a 5 year period) and the same core intervention in tandem with some key enabling intervention – “Core+Enablers” – (including community mobilization, post-test support) that had the net effect of increasing testing rates (by four-fold) and increasing the odds of condom use across the community by 1.5-fold. Model description can be found (Alsallaq et al, Forthcoming).

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APPENDIX III: ESTIMATED CONTRIBUTION OF TREATMENT TO REDUCING TRANSMISSION The infectiousness of HIV is correlated with the levels of virus in the infected individual, which means that infectiousness increases as disease progresses and viral replication is less constrained. Further, the reductions in viral load associated with ART have been shown to reduce infectiousness in observational studies.25,76 Promptly initiated treatment for clinical need should therefore lead to reductions in transmission. Several mathematical modelling exercises have estimated the proportion of onward transmission that, in the absence of treatment, would come after the point when ART should normally be initiated (Figure 7). These suggest that once an HIV epidemic has matured to near endemic levels approximately 30% of infections are generated by those with CD4 cell counts < 200 cells/µL and approximately 50% of infections are generated by those with CD4 cell counts < 350 cells/µL. During the early stages of an epidemic more infections are recent and therefore contribute a greater proportion of new infections. These estimates provide an upper-limit for the extent to which treatment could reduce infections because, in reality, (i) ART does not perfectly reduce infectiousness, and (ii) individuals for whom ART is failing might become more infectious. New models, accounting for these factors, have estimated that, with 80% able to initiate treatment promptly when they require it, the rate of new infections could be reduced by approximately 20% with treatment starting at CD4<200/μL and 30% with treatment starting at CD4<350 /μL (Eaton et al., personal communication).

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0%

20%

40%

60%

80%

100%

0 2 4 6 8 10 12

Cumulative transm

ission

Years since infection

Hollingsworth et al. (serial partnerships)

Hollingsworth et al. (random mixing)

Eaton et al. (substantial  concurrrency)

Eaton et al. (minimal  concurrrency)

Abu‐Raddad & Longini (Kisumu)

Abu‐Raddad & Longini (Yaoundé)

Goodreau et al.

CD4<350 CD4<200

Figure 7: The number of new infections generated by each HIV-infected individual accumulates over time since infection in published model estimates.77-80 The approximate partition of time spent with CD4 cell counts > 350 cells/µL (pale green), CD4 cell count between 200 and 350 cells/µL (light green) and < 200 cells/µL (dark green) are based on estimate of disease progression in observational cohorts.81,82

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APPENDIX IV: INFORMATION ON NEW PREVENTION TECHNOLOGIES Although considerable progress has yet to be made by expanding the coverage of existing interventions, there will still be a need for new prevention options once existing programs reach maximum scale. Incidence rates have shown to level off even in countries with very high coverage of prevention and treatment programmes at levels of one third to a quarter of peak incidence.83-85 Promising new technologies could contribute to future prevention efforts; including vaginal microbicides, HIV vaccines, and pre-exposure prophylaxis (PrEP) delivered through oral pills. Increased and more efficient research and development spending are needed to speed up the development of HIV vaccines, microbicides, and other new prevention technologies and deliver them to populations most in need.86 Although funding from public and philanthropic agencies for these efforts have more than doubled in recent years, significant resource gaps still remain. Financial resources needed for new technologies are large but the enormous potential benefits of successful products would make these investments worthwhile. Expanding efficacy trial capacity for new HIV vaccine and microbicide candidates will require additional investments between now and 2015. The recent CAPRISA 004 trial conducted in South Africa showed that tenofovir used as a microbicide gel could be effective and safe.87 Tenofovir gel reduced HIV acquisition by an estimated 39% overall, and by 54% in women with high gel adherence, and could potentially fill an important HIV prevention gap. Modelling the potential impact of tenofovir as a microbicide gel showed that up to 2 million new infections and 1 million AIDS deaths could be averted over the next 20 years in South Africa if good adherence is achieved. This new female controlled prevention method could have a significant impact on the HIV epidemic but will depend on the levels of adherence.88 Several other microbicide candidates are currently being tested in clinical trials.89,90 While an effective AIDS vaccine does not currently exist, the results of the ALVAC RV-144 Thai prime-boost vaccine trial91 showed for the first time that it is possible for a vaccine to offer protection against HIV in humans, but more research is needed to understand the immune responses. Several HIV vaccine candidates currently in Phase II trials could move to Phase III efficacy testing over the next decade.90 Recent research into the use of pre-exposure prophylaxis (PrEP) to prevent HIV showed promising results.92 The iPrEx study showed that in gay men, transgender women and

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other men who have sex with men, daily TDF/FTC (tenofovir disoproxyl fumarate plus emtricitabine also known as Truvada) reduced the risk of HIV by 44%. Additional studies are ongoing in other populations. A modelling exercise predicted that the cost-effectiveness of PrEP relative to ART will decrease rapidly as ART coverage increases beyond three times its coverage in 2010, after which the ART program would provide coverage to more than 65% of HIV+ individuals. To have a high relative cost-effective impact on reducing infections in generalized epidemics, PrEP must utilize a window of opportunity until ART has been scaled up beyond this level.93 Although it is unlikely to confer sufficient benefits to justify current TDF/FTC costs, price reductions and/or increases in efficacy could make PrEP a cost-effective option in younger or higher-risk populations94 and further research of using PrEP-based HIV prevention is warranted. Without new innovations, the decrease in the number of new infections is likely to stall, as shown in Figure 8, but potential new technologies developed and implemented at scale over the next decade could enable the downward trajectory of new infections to be continued. As such programmes do not exist to date, costs for possible scale up of new innovations have not been included in our analysis, nevertheless it is useful to bear in mind that innovation is likely and should be anticipated.

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

2011 2013 2015 2017 2019 2021 2023 2025

New

HIV

infe

ctio

ns

Baseline Investment Framework New technologies

Figure 8. New HIV infections in low and middle-income countries expected under the baseline scenario (assuming constant coverage at around present funding rates and approaches), new investment framework approach, and with the potential effect of new technologies (Microbicides, PrEP and Vaccines) introduced starting in 2015.

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APPENDIX V: RELEVANT TERMS AND DEFINITIONS

Basic Programme Activities

Treatment care and support for PLWH (including facility-based testing)

This includes the provision of clinic-based, home-based or community-based services and commodities for the treatment and care of HIV-positive adults and children. Treatment care and support includes several categories: antiretroviral therapy provided to infected adults and children in need of treatment; routine counselling and testing; treatment and care of opportunistic infections; essential illness prevention interventions for PLHIV; nutrition supplements for those on ART; treatment for tuberculosis; and palliative care. This category also includes provider initiated counselling and testing in facilities and utilizing health services. ART significantly reduces viral load and restores immune function, thereby raising the possibility of using ART not only to increase the survival time and quality of life of people infected with HIV, but also to reduce HIV transmission.

Prevention of mother-to-child transmission (PMTCT)

Comprehensive PMTCT programs for pregnant women include pre-test counselling, HIV testing, post-test counselling, drug prophylaxis, initiation of antiretroviral therapy, counselling on infant feeding options and post partum monitoring and interventions for mother and child. Drug prophylaxis may be a single drug regimen (single dose Nevirapine [sd-NVP] or AZT), a combination prophylactic regimen (AZT+sd-NVP with or without 7-day postpartum, AZT+3TC), or a highly active triple drug regimen (AZT + 3TC + NRTI/NNRTI or PI). WHO currently recommends provision of ARVs to all HIV-infected mothers, starting in the second trimester of pregnancy and throughout the breastfeeding period to prevent vertical transmission.54 National authorities should decide on the best infant feeding option (breast feeding with ARV interventions or to avoid all breastfeeding) that will most likely give infants the greatest chance of HIV-free survival. Where breastfeeding is judged the best option, complementary feeding (infant formula) may be introduced at 6 months and continue breastfeeding for at least 12 months.

Male circumcision

Refers to the removal of the prepuce or foreskin covering the tip of the penis for the purpose of reducing the risk of HIV infection. The program includes the operation itself,

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as well as related activities such as counselling, post-operative support, promotion of male circumcision, programme communication, strengthening of necessary medical infrastructure and training. Male circumcision (MC) has been demonstrated to reduce the risk of female-to-male sexual transmission by 60%.22-24 WHO and UNAIDS recommends that male circumcision should now be recognized as an efficacious intervention for HIV prevention. However, MC provides only partial protection against the risk of HIV sexual transmission from women to men and it should therefore always be considered as part of a comprehensive HIV prevention package.

Condom promotion and distribution

Includes programmes to increase the correct and consistent use of male and female condoms by making them more accessible and acceptable. This can involve activities to increase condom availability (such as procurement and distribution) and generate demand (such as social marketing, awareness raising and communication programmes). Evidence from research among heterosexual couples in which one partner is infected with HIV shows that correct and consistent condom use – male and female – significantly reduces the risk of HIV transmission from men to women, from women to men and also from men to men.95 Condoms are an integral and essential part of comprehensive HIV prevention and care programmes, and the promotion thereof must be accelerated. Male and female condom provision, including lubricants, covers mainly the supply side of condom programming including selecting products that appeal to clients, forecasting condom needs, procuring sufficient quantities of high-quality male and female condoms, managing inventories, and distributing condoms.

Behaviour Change Programmes

Behaviour change has had a major impact on the trajectory of concentrated and low level epidemics. In generalized epidemics, behaviour change such as delaying the initiation of sex, increasing condom use or reducing the number of sex partners, affects the likelihood of exposure and reduces the likelihood of HIV transmission. Behavioural change programmes for AIDS includes the strategic use of an integrated programme of advocacy, communication and social mobilization to systematically facilitate and accelerate behaviour change and social change to the underlying drivers of HIV risk, vulnerability and impact. It enables communities and national AIDS programmes to support behaviour change and to tackle underlying structural barriers to effective AIDS responses including inequality and social exclusion. Successful programmes have the capacity to blend participatory methods of community dialogue and empowerment with mass media approaches and other forms of informational and

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motivational communication and advocacy. The goal of such programmes is to act as a catalyst for action at the individual, community and policy levels.

Social and behavioural change communication methods support development of locally owned and implemented solutions that can be measured and tracked over time. Monitoring and evaluation of social and behavioural change communication fosters both local engagement and quality improvement of change activities. They also foster the ability to share results horizontally (i.e. across similar programmes or communities) and vertically (from community to national levels) for learning and accountability. Social and behavioural change communication programmes have been shown to work, although careful evaluation has been the exception rather than the rule in implementing these programmes. Where rigorous evaluation has been conducted these programmes have been shown to make significant and durable change in deeply rooted harmful practices; from domestic violence to police complicity in violence against men who have sex with men; from denial of HIV in rural communities to fear of using condoms in stable couples. Social and behaviour change communication activities should include rigorous impact evaluation to make sure that they are reaching audiences effectively. Key objectives for social and behavioural change communication programmes need to include changing sexual behaviour at both the societal and individual level (including reduction of number of sexual partners, age of sexual onset. Communication for social and behaviour change involves targeting the general population or specific groups through mass media and outreach activities.

Component elements of social and behavioural change communication programmes

Interpersonal communication: face-to-face communication either through a one-on-one exchange or discussions in a small group with a trained facilitator. Several critical components to interpersonal communication could include having a facilitator who is from the same ethnic, cultural and/or linguistic background; having participatory and non-judgmental interactions; ensuring that information shared is factual and based on evidence; and ensuring that exchanges go beyond raising awareness and knowledge building. Interpersonal communication can be delivered through various personal interactions such as individual outreach, small discussion groups, counselling, and client-provider dialogue. The key objectives of interpersonal communication is to address barriers to adopting healthier behaviours, focus on increasing risk perception, increasing use of available services, and improve skills and self-efficacy to enable individuals to be

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responsible for and protect their own health by making healthier behavioural choices. Media communication utilizes one or more channels to transmit the same message to a large audience. Examples include brochures, billboards, posters, newspaper or magazine articles, comic books, television, radio, music videos, Internet, cell phones, songs, dramas, traditional and folk media, and interactive theatre. Media communication includes development of communication messages and materials and their transmission. Media communication seeks to promote positive changes in cognitive and behavioural outcomes such as increasing knowledge of modes of HIV transmission, increasing perceived risk of contracting HIV, reducing high-risk sexual behaviours such as having multiple partners, increasing positive protective behaviours such as condom use, and increasing the utilization of health care services. Media communication can also be utilized to create a supportive environment and often targets social, cultural and gender norms that may hinder behaviour change.

Key populations

Assessing the needs of different population groups and identification and removal of barriers to access services is relevant to planning a programmatic effective response. Community mobilization is often geared towards those who are marginalized from community processes, including young people, women, minorities, sex workers, people who inject drugs (IDU) and men who have sex with men (MSM). A wide range of priority populations have utilized community mobilization in the prevention and mitigation of HIV. Outreach programmes usually include peer education on HIV transmission and risk reduction strategies and HIV testing. Interventions for female and male sex workers and MSM are based on a peer outreach model. These interventions combine one-on-one or small group awareness, group education and access to commodities and services.

Sex work interventions: Programmes to promote risk-reduction measures among commercial sex workers and their clients. Includes STI treatment, peer outreach and counselling, condom promotion, removing stigma and discrimination, elimination of gender-based violence, programmes addressing clients, HIV testing and treatment. MSM programmes: Activities that address men who regularly or occasionally have sex with other men. This includes risk-reduction activities, outreach (including by peers), prevention of sexual transmission of HIV (including condom

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use, prevention and treatment of STIs), voluntary and confidential HIV counselling and testing, and initiatives to ensure that these groups are able to access these services. IDU programmes: Initiatives directed at injecting drug users to reduce the risk of spreading HIV and to mitigate other harmful effects of drug use. This can involve harm reduction programmes, such as sterile needle and syringe programmes, as well as opioid substitution and peer outreach. Needle and syringe programmes aim at reducing the risk of blood borne infection of HIV (and others such as viral hepatitis) transmission associated with using contaminated drug injecting equipment among people who inject drugs. Pogrammes consists of ensuring easy, consistent and safe access to sterile needles and syringes to people who inject drugs. Modalities for needle and syringe programmes include provision of needles and syringes free or for cost; one-for-one exchange, intended to remove used injection equipment from circulation; secondary distribution, where people who inject drugs collect a relatively large number of clean syringes and needles and distribute them to other people who inject drugs with whom they are in contact, aiming to reach users who may not be in touch with services; and provision of other paraphernalia such as alcohol swaps, citric acid, spoons and condoms.

Critical enablers

Social Enablers

Political commitment and advocacy

Political commitment enables AIDS responses at all levels, including through resource allocation, creation of enabling environments where community mobilization and social and behavioural communication can take place, and supporting the realization of rights. Political commitment may be generated through advocacy. Advocacy is the combined effort of a group of individuals or organizations to persuade influential individuals, groups and/or organizations to adopt an effective approach to AIDS as quickly as possible. Advocacy efforts have diverse targets of change: policies, laws, regulations, guidelines, additional funding, and/or programmatic or institutional change. Advocates use a wide variety of organizational techniques and communication channels to bring about political change, including letters, meetings, social networking and internet campaigning, face-to-face interactions, media campaigns, forums and newspaper articles.

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While it is possible to identify advocacy techniques which are applicable across a wide range of settings, the impact of political commitment and advocacy on improving the AIDS response depends greatly on specific context where it takes place. External actors can be enormously influential over political and advocacy outcomes, but can also fail to have any real or lasting impact if they run counter to local needs and understanding of the roots of problem to be addressed.

Laws, legal policies and practices

A supportive legal environment entails having laws in place that protect people living with HIV and key populations from discrimination and having policies that facilitate all populations having access to the HIV programmes and services they require. It also involves removing punitive laws, regulations and policies that block effective HIV responses. These may include: criminalization of same sex sexual activity; laws or police practices which punish possession of condoms or drug paraphernalia and undermine harm reduction measures; inappropriate criminal penalties applied in the context of sex work or to HIV transmission and exposure; laws that preclude importation of generic medicines; policies that impede distribution of sexual health education and information; restrictions on the distribution of condoms, e.g. in prisons; regulations which prevent non-citizens from accessing ART; and the lack of a legal framework for non-governmental organizations to operate effectively. HIV-related legal services include legal information and referral, legal advice, and legal representation. Test cases or ‘strategic litigation’ may also establish a new legal rule, clarify the application of the law or address discriminatory policy or practice. Legal services can also include informal or traditional legal systems (e.g. village courts). HIV-related legal services help improve access to HIV prevention, treatment, care and support services by people living with HIV or other key populations; increase the demand for justice; empower affected populations to advocate for their rights; and provide redress for discrimination.

Community Mobilization

A community becomes mobilized when a particular group of people becomes aware of a shared concern or common need, and together decides to take action in order to create shared benefits. This action may be helped by the participation of an external facilitator—either a person or organization. However, momentum for continued mobilization must come from within the concerned group or it will not be sustained over time. Community mobilization can be conducted through various activities such as group

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discussions, community forums, outreach, and establishing community networks. Community mobilization tries to ensure that people most affected by HIV (including people living with HIV) can play an active and influential role in shaping an effective response to it. It means that community members take responsibility for addressing HIV themselves, with the support of others where necessary, and take a joint responsibility for the outcomes of their actions. Community mobilization within a community can facilitate larger structural changes, which work to empower communities to continually improve their lives. As one of the bases for mobilization is living with HIV, knowledge of HIV status can be an important lever in community mobilization, and thus can be accompanied by HIV testing in various settings (e.g. stand-alone centers, mobile vans, health clinics).

Community mobilization is one of the critical enablers and could be divided into three categories: Outreach and engagement activities; support activities; and advocacy, transparency and accountability. Community mobilization can be supported through community system strengthening which is a systematic approach to promote the development of informed, capable and coordinated communities and community based organisations. Hallmarks of effective community system strengthening include the involvement of a broad range of community actors and enabling them to contribute as equal partners alongside other actors to the long term sustainability of health and other interventions at community level. Community system strengthening aims to improve health outcomes by developing the role of key affected populations, communities and community based organisations in the design, delivery, monitoring and evaluation of services, activities and programmes.

Stigma reduction

HIV-related stigma refers to negative beliefs, feelings and attitudes towards people living with HIV or associated with HIV. It may affect people known to be or suspected of being infected by HIV and their relatives and associates, or those from populations with higher rates of HIV or more at risk, such as people who inject drugs, sex workers, men who have sex with men and transgender people. Stigma is expressed in stigmatizing language and behaviour, such as ostracization and abandonment; shunning and avoiding everyday contact; verbal harassment; physical violence; verbal discrediting, blaming and gossip. HIV-related discrimination refers to the unfair and unjust treatment (act or omission) of an individual based on his or her real or perceived HIV status. Though HIV-related stigma often leads to discrimination, it is important to note that even if a person feels stigma towards another, s/he can decide to not to act in a way that is unfair or discriminatory.

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Stigma and discrimination associated with HIV can be as devastating as the illness itself: abandonment by spouse and/or family, social ostracism, job and property loss, lack of access to or expulsion from school, denial of medical services, lack of care and support, and violence. HIV-related stigma and discrimination undermine HIV prevention efforts by making people afraid to seek out information about how to reduce their risk of exposure to HIV, and to adopt safer behaviour in case this raises suspicion about their HIV status and find out whether or not they are infected. The fear of stigma and discrimination also discourages people living with HIV from disclosing their status, even to family members and sexual partners, and undermines their ability to adhere to treatment. Stigma has been found to be widely prevalent with consequences found to include physical and mental abuse and neglect, deterrence to HIV testing, delays in receiving treatment, low uptake of HIV testing, late presentation with AIDS and reduced adherence to HIV treatment. The impact of stigma on the prevention of mother to child transmission (PMTCT) has been modeled finding that up to 55 percent of cases of mother to child transmission in settings where PMTCT services are readily available may be caused by stigma and discrimination.96 Even where PMTCT services are not as strong, 28 percent of mother to child transmission may be due to stigma.97 Stigma has been addressed through multi-component programmes which include mass communication, participatory education, mobilization of community leaders and a variety of community interaction techniques. Many of these programmes have been found to have significant impacts in reducing stigma.96 Stigma programmes addressing health care providers have been particularly important in addressing stigma produced in these settings, with results obtainable from often modest interventions.98

Gender based violence

Violence and the threat of violence can hamper people’s ability to adequately protect themselves from HIV infection and assert healthy sexual decision-making. In many countries, sex workers, people who use drugs and sexual minorities experience illegal law enforcement in the form of violence, rape, harassment and arbitrary arrest. All forms of gender-based violence—against women and girls, men who have sex with men, transgender people and sex workers—should be recognised as human rights violations and as elements that can increase vulnerability to HIV. Gender based violence is widespread. In a 10-country study on women's health and domestic violence conducted by WHO, between 15% and 71% of women reported

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physical or sexual violence by a husband or partner. Many women said that their first sexual experience was not consensual (24% in rural Peru, 28% in Tanzania, 30% in rural Bangladesh, and 40% in South Africa) and between 4% and 12% of women reported being physically abused during pregnancy.99 The consequences of gender violence are direct and indirect. Violence against women is associated with increased HIV infection as well as unintended pregnancies. Sexual abuse as a child is associated with higher rates of sexual risk-taking (such as first sex at an early age, multiple partners and unprotected sex), substance use, and additional victimization. Each of these behaviours increases HIV risks. Despite the documented negative consequences of gender violence, the evidence-base in relation to its prevention is modest, albeit growing. School-based programmes to prevent violence within dating relationships have demonstrated effectiveness and evidence is emerging of other strategies including microfinance programmes for women combined with gender-equality education; efforts to reduce access to and harmful use of alcohol; and changing social and cultural gender norms. The systematic evaluation and evidence generation around these and other plausible approaches to reducing gender violence is a priority for national and international partners.100

Local responses to change the risk environment

In addition to the targets of the critical enables mentioned above, there exists a range of approaches to addressing the risk of HIV exposure in its local context. These are often termed “structural approaches” and include a wide variety of efforts which aim to change the social, economic, political or environmental factors that underpin HIV risk and vulnerability.101 There are many local examples of successful efforts to reduce the risks of HIV exposure. For example, actions recommended to for local responses especially in rural areas included changing closing hours of local beer shops, restricting youth from drinking establishments, ensuring traditional dances close before darkness falls and establishing a local norms that women only collect firewood after dark when accompanied by men.102 The Asian Development Bank and partners have paid close attention to mitigating the risks of HIV associated with greater road penetration in the Greater Mekong Region and improvement in road surfaces in Myanmar have been credited with reducing HIV risks, through reductions in the need for overnight stops and less indirect sex work.101 Among the first responses to the newly discovered threat of AIDS was to increase lighting in gay bathhouses in an endeavour to reduce the riskiness of the environment.103 Structural approaches proposed to reduce the HIV risks faced by young women in southern Africa

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include: to Reduce dependency on migrant labour; industry standards that seek to provide alternatives to congregate, single-sex dwellings at work sites; transportation alternatives to long distance truck routes; inclusion of workplace AIDS policies and policies promoting gender equity; and programs that provide educational or economic alternatives to sex work for women living in communities surrounding high-risk areas.104 The variety and context-specificity of these local approaches to reducing the risk of HIV exposure restricts the extent to which these programmes can be replicated and defy the creation of a consistent evidence base. Nevertheless, evaluation standards are available to be applied to these local efforts, which should at a minimum assess and document the extent to which they meet their stated objectives.

Programme Enablers

Programme enables are the elements of programme implementation which are critical to the effectiveness and efficiency of HIV responses. Investing in these programme enablers can have dramatic impacts on the uptake, acceleration, and consistency in implementation of activities.

Community centered design and delivery

There are many informal and formal organizations and structures which are involved in community responses to HIV. The documentation of the nature of community involvement is patchy, with informal contributions rarely documented. A major evaluation exercise to assess the results achieved by community responses to HIV is under way by the World Bank’s Global HIV/AIDS Program team, in collaboration with DFID, the UK Consortium on AIDS and International Development, and other partners. While that exercise is ongoing, it does suggest that community responses play a critical role in all aspects of the HIV response and in all contexts.105 Similarly, the Global Fund to Fight AIDS, TB and Malaria together with the International HIV/AIDS Alliance have assess civil society involvement in broad ranging HIV programmes in 9 country settings illustrating both the range and critical impact on programme effectiveness of community centered design and delivery.106 The scope of community action in relation to design and delivery of programmes is considerable. The World Bank’s typology includes the following: advocating for access to services, providing care and support for those most affected by the epidemic, assisting in the development of policy and strategy, and organizing peer efforts among marginalized populations. Community responses can also provide support to government services by encouraging uptake of HIV testing, challenging stigma and discrimination,

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and supporting treatment adherence. In certain circumstances, community responses can also challenge the scope and reach of government actions.

Programme communication

Programme communication is concerned with informing and creating awareness among the general public or specific populations about HIV, and empowering people to take action. It is often principally concerned with communicating a series of messages about the disease or informing the public about what services exist (for diagnosis and treatment). Programme communication also works to create an environment through which communities, particularly affected communities, can discuss, debate, organize, and communicate their own perspectives on HIV. Programme communication is aimed at changing behaviours but can also be used to support community or other communication-for-social-change processes that can spark debate, and other processes to shift social mores and barriers to behaviour change. Programme communication efforts are measured in the reach and comprehension of their messages to intended audiences.

Management and incentives

The efficiency and effectiveness of the management of programmes has a direct impact. Determinants of management quality include both factors relating to inputs (quality and availability of staff, training, organizational capacity) as well as to governance (clarity of objectives, decision-making structures etc.). A key variable in relation to management is the existence of positive or perverse incentives in relation to system functioning. There are many aspects of AIDS programming, including some elements of the global financial architecture of AIDS financing, which have created unintended consequences and perverse incentives. Improving management requires close analysis and concerted action to maximize beneficial incentives.

Procurement and distribution

As AIDS programmes have been scaled-up to more comprehensive, national prevention, care and treatment programs, the range of services offered has increased. In order to support these services, hundreds of commodities are required. The success of these nationwide programs will depend upon the ability to reliably and consistently supply the commodities to facilities and settings at all levels. The consequence of supply interruption can be dire, including drug resistance and condom stock-outs. Many of the commodity supply chains in HIV programmes have large, extended global pipelines, require high levels of product availability and have a high uncertainty in supply and

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demand. It is therefore paramount that supply chain or logistics systems are treated as an important and critical function in getting the products to their destination. In fact, in order to sustain and expand the successful interventions experienced to date, the supply chains will need to be made more robust, agile and flexible through better management and increased investment of resources to achieve supply chain optimization. The term supply chain describes the links and the interrelationships among the many organizations, people, resources, and procedures involved in getting commodities to the customers (in this case, those affected by AIDS). A typical supply chain would include partners from manufacturing, transportation, warehousing and service delivery. Together, these organizations orchestrate the flow of products to the end-consumer, information for better planning and, finances to cover the transaction costs. A key ingredient of a successful supply chain is that partners are focused on improved coordination, information-sharing and, serving the end-customers.107

Research and innovation

Many different strategies for HIV prevention and treatment are now being explored, including topical antiretroviral-containing microbicides, oral/systemic pre-exposure prophylaxis, vaccines, female-initiated barrier methods, herpes simplex virus-2 treatment/suppression, index partner treatment, prevention of mother-to-child transmission and drug substitution/ maintenance for people who inject drugs. The successful development of effective HIV interventions requires that candidate technologies be studied in different populations around the world. This in turn requires a large international cooperative effort, drawing on partners from various health sectors, inter-governmental organisations, government, research institutions, industry, and affected populations. It also requires that these partners adopt best ethical practice in clinical and behavioural trials, including supporting good participatory practice.

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