The transformational nature of the aids

response

Peter Piot,MD,PhD

A global view of HIV infection33 million people [30–36 million] living with HIV, 2007

2.2

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

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

Pe

op

le r

ece

ivin

g A

RV

th

era

py (

in M

illio

ns)

North Africa and the Middle East

Europe and Central Asia

East, South and South-East Asia

Latin America and the Caribbean

Sub-Saharan Africa

Global Fund supported programs

Number of people receiving ARV therapy in low- and middle-income countries, 2002—2007

Decline in adult mortality with introduction of ART: Botswana

0

1

2

3

4

5

6

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Re

gis

tere

d D

ea

ths (

Th

ou

sa

nd

s)

0

10

20

30

40

50

Pe

rso

ns o

n A

RV

(T

ho

usa

nd

s)

on ARV

Deaths aged 25-54

HIV prevalence (%) among pregnant women attending antenatal clinics in sub-Saharan Africa, 1997–2007

NOTE: Analysis restricted to consistent surveillance sites for all countries except South Africa (by province) and Swaziland (by region)

Southern Africa

0

10

20

30

40

Med

ian

HIV

pre

vale

nce

(%) 50 Botswana

LesothoMozambiqueNamibiaSouth AfricaSwazilandZimbabwe

1997–1998

1999–2000

2001 2002 2003 2004 2005 2006 2007

West Africa

0

5

10

15

20

Med

ian

HIV

pre

vale

nce

(%)

0

5

10

15

20

Med

ian

HIV

pre

vale

nce

(%)

Eastern Africa

1997–1998

1999–2000

2001 2002 2003 2004 2005 2006 2007 1997–1998

1999–2000

2001 2002 2003 2004 2005 2006 2007

Ethiopia

Kenya

Burkina FasoCôte d'IvoireGhanaSenegal

2.9 Source: National surveillance reports and UNAIDS/WHO/UNICEF, Epidemiological Fact Sheets on HIV and AIDS. July 2008.

Number and percentage of HIV-positive pregnant women receiving antiretroviral prophylaxis, 2004–2007

2004 20062005

Number of HIV-positive pregnant women receiving anti-retrovirals

Year

400 000

500 000

600 000

0

100 000

200 000

300 000

% of HIV-positive pregnant women receiving anti-retrovirals

0

5

30

35

15

20

25

40

10

2007

Source: UNAIDS, UNICEF & WHO, 2008; data provided by countries.4.13

AIDS IS NOT OVER

HIV prevalence (%) in adults (15–49) in Africa, 2007

2.8

HIV infections among men having sex with men in Asia

The aids response is transformational

»Science and rights driven»Political approach»Focus on results for people»Prevention AND treatment»Multi-disciplinary, multi-sectoral»Community engagement»Global response

Good politics, bad politics: the experience of Aids

PPiot, HLarson,SRussell. Am J Publ Health, 2007;97:1934

Recorded female deaths in South Africa and Brazil for ages 15-64 years

Source: Nathan Geffen. Statistics South Africa and Instituto Brasileiro de Geografia e Estatistica.

Brazil, 2004. South Africa, 1997. South Africa, 2004

Median percentage of population reached with HIV prevention serviceswithin the specified legal environment

Sex workers(N=42)

Injecting drugusers (N=17)

Men having sex with men

(N=28)

0

20

40

60

80

100

Median percentage of population reached with HIV prevention services (UNGASS indicator 9)

Countries reporting having non-discrimination laws/regulations with protection for this population

Countries reporting NOT having non-discrimination laws/regulations with protection for this population

Source: UNGASS Country Progress Reports 2008. 3.7

Treatment Action Campaign (TAC), South AfricaTreatment Action Campaign (TAC), South Africa

UN security Council Resolution 1308 (2000) on AIDS

UN security Council Resolution 1308 (2000) on AIDS

[i] 1996-2005 data: Extracted from 2006 Report on the Global AIDS Epidemic (UNAIDS, 2006)[ii] 1986-1993 data: AIDS in the World II. Edited by Jonathan Mann and Daniel J. M. Tarantola (1996)

Notes: [1] 1986-2000 figures are for international funds only [2] Domestic funds are included from 2001 onwards

Total annual resources available for AIDS1986‒2007

Total annual resources available for AIDS1986‒2007

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

US$ million

2921623

8.3 billion

Signing of Declaration of Commitment on HIV/AIDS, UNGASS

‘96 ‘97 ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04 ‘051986 ‘87 ‘88 ‘89 ‘90 ‘91 ‘92 ‘93 ‘94 ‘95

Less than US$ 1 million

59 212

World BankMAP launch

Global Fund

PEPFAR

257

UNAIDS Gates

Foundation

‘06 2007

10 000

8.9 billion

10 billion

Resources available to HIV-related programmes by source and bilateral disbursements, 2006

GSources: UNAIDS analysis based on OECD/DAC online database (last visited on May 6, 2008), Resource availability UNAIDS 2005, Funders Concerned About AIDS (FCAA), European HIV/AIDS Funders Group (EFG) for Philanthropic sector

Bilateral disbursements to HIV-related programmes in 2006

Total Resource availability for HIV-related programmes in 2006 (US$ Billions)

2

5

8

6

7

0

1

3

4

9

10

UN (2%)

GFATM (7%)

Foundations (11%)

Bilaterals (33%)

Domestic Publicand Private (46%)

EC (0.5%)

Canada 2%

Belgium 1%

Netherlands 3%

Other DAC country members 1%

Sweden 3%

Spain 1% Norway 2% Australia 2% Germany 2%

Ireland 3%United Kingdom 9%

United States 71%

(US$

Bill

ions

)

Total resources available: US$8.9 Billion Percentage out of the total bilateral disbursementsTotal Bilateral disbursements 2006: US$ 2.9 Billion

The organizational disbursements are different than commitments or obligations, as well as different from in-country expenditures

Disbursements for HIV per US$ 1 Million GDP, 2006

HSources: UNAIDS and Kaiser Family Foundation analysis, June 2007; Global Fund to Fight AIDS, Tuberculosis and Malaria online data query May 2007; International Monetary Fund, World Economic Outlook Database, April 2007.

Italy 4

Japan 24

Canada 50

Germany 60

France 93

United States 120

United Kingdom 328

Ireland 408

Sweden 462

Netherlands 521

0 100 200 300 400 500 600US$

Prices (US$/year) of first-line antiretroviral regimen in Uganda: 1998-2003

Prices (US$/year) of first-line antiretroviral regimen in Uganda: 1998-2003

Focus on results for people TargetsKnow your epidemic and the

societyMonitor and evaluateInvest in information systems

Know your epidemic

Number of HIV infections each year by route of transmission in Cambodia, 1988-2004

Number of HIV infections each year by route of transmission in Cambodia, 1988-2004

Source: Peerapatanapokin and Brown, using Asia Epidemic Model

Number of new HIV infections each year by route of transmission in Cambodia, 1988-2004 ( Source: Peerapatanapokin and Brown, using Asian Epidemic Model)

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Male clients Sex workers Wife from husband Husband from wife Mother to child

Impotence fears hit polio drive By Ashfaq Yusufzai

BBC News, Peshawar

Health officials in Pakistan say they have failed to immunise over 160,000 children against polio due to rumours the vaccine causes sexual impotence.

Parents in parts of northern Pakistan told the BBC news website they feared an "American conspiracy" to cut the fertility of the next generation.

At least 39 cases of polio were reported in 2006, 15 of them in the North West Frontier Province (NWFP) and the tribal areas in which only 20% of people are immunised. Worldwide 1,902 cases of polio were reported during the year, a recent WHO report said.

A WHO meeting in Geneva last October heard that children paralysed by polio around the world were infected by viruses originating from Pakistan, Afghanistan, India and Nigeria.

Radio rumours The main opposition to the drive in Pakistan came from local clerics who run illegal FM radio

channels in many NWFP districts and the tribal areas, say officials. Amirullah Khan, a resident of NWFP's Swat district, quoted Maulana Fazlullah of a local FM

channel as telling his listeners the vaccination drive was "a conspiracy of the Jews and Christians to stunt the population growth of Muslims".

The PREVENTION GAPPersons at risk with access to selected prevention interventions, 2006

Source: Global HIV Prevention: the access and funding gap. June 2007

Cost Effectiveness

A multi-disciplinary, multi-sectoral response

• Health outcomes determined by multiple factors and interventions

• Particularly key besides health: law, education, work place, trade, armed forces

• Need to expand resource base• First genuine business engagement in health

Percentage of countries with sectors included in the national AIDS strategy and earmarked budgets

6.5 Source: UNGASS Country Progress Reports 2008.

0 20 40 60 80 100

Public works

Tourism

Trade and industry

Minerals and energy

Agriculture

Transportation

Health

Labour

Military/policeSector included

Earmarked budget present

Percentage of countries (%), N=126

Community engagement

• From planning to implementation• Makes or breaks programmes• “Aids literacy”• National Aids Councils and Global Fund

Country Coordination Mechanisms• Societal sustainability and resilience

TASO, Uganda

A global response

• Global public good and strategic issue• Role of United Nations• Global civil society and activism• International financing• Generation WE

UNITED NATIONS GENERAL ASSEMBLYSPECIAL SESSION ON HIV/AIDS

25 - 27JUNE2001

United Nations

New instruments for AIDS financing

• World Bank Multi-country AIDS Program (2000)

• Global Fund to Fight AIDS, TB and Malaria (2002)

• PEPFAR, (2003)

• Unitaid (2005)

• (PRODUCT) Red (2005)

• Debt2Health (2007)

Opportunities for global health Increased funding (ODA and research) Collateral benefits (TB,malaria, health

systems) Culture of accountability Tiered pricing Engagement of non-medical sectors Boost to research Major interest by young peopleBut: how long will the momentum last?

Total health ODA commitments, 2001-2006

$7.2 $7.6

$11.2$13.3

$16.5

$20.1

2001 2002 2003 2004 2005 2006

US$ Billions

Increase in TB financing and new sputum positive cases detected and treated

0.5M

41M

107M 127M

196M

276M

1.4M

0.6M 0.38M

1.9M

-

50,000,000

100,000,000

150,000,000

200,000,000

250,000,000

300,000,000

2002 2003 2004 2005 2006 2007

An

nu

al a

mo

un

t d

isb

urs

ed

(in

US

$)

-

500,000

1,000,000

1,500,000

2,000,000

New

SS

+ c

ases

tre

ated

un

der

D

OT

S (

ann

ual

)

Amount disbursed (US$) New SS+ cases treated under DOTS

Direct funding of health systems through Global Fund grants

Health Systems

35%

Administration10%Other

10%

Commodities, Products, Drugs

45%

Infrastructure and Equipment

9%

Monitoring and Evaluation 3%

Human Resources

23%

Direct Funding of Health Systems through GFGrants (2007)

•Estimates from Global Fund Rounds 2-7 proposals•100% = $5.2 billion USD

Amount (approximately)•Commodities, Products, Drugs - $6.3-billion•Health Systems - $4.9-billion•Administration - $1.4-billion•Other - $1.4-billion

Increasing Coverage of Health Care in Rwanda

300,0007,800900,000

3 million

1,3 million

2 million

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

P rivate healthinsurance

Civilservants/Military

Genocidesurvivors,prisoners

Communityhealth insurance(398 mutuelles)

Num

ber

of b

enef

icia

ries

Global Fundsubsidy

Global Fund co-finance subsidy

Out-of-pocket and/orGovernment subsidy

44%40%

35%

72%

49%

43%

0%

20%

40%

60%

80%

P opulation coveragewith health insurance

P opulation with atleast one

consultation in healthcenter

Utilization rate ofdistrict hospitals

2005 2006

Improving Access to Health CareScaling up Health Insurance

Conclusions• Science AND justice as basis for policy

• Nothing for the people without the people

• Genuine multi-disciplinarity in planning, research and

implementation

• Prevention AND treatment

• Information for accountability and programming

• Think long term and invest in capacity