- 1. DISCUSSION PAPERSupporting community action on AIDS in
developing countries 12 AUGUST 2011dISCUSSION PAPER: What is the
Investment Frameworkfor HIV/AIDS and what does it mean for the
Alliance? Gideon Mendel for the AllianceIntroductionWhat is the
investment framework for HIV/AIDS?This discussion paper provides a
short introduction to an important new development in global
HIVpolicy. A new model, an investment framework for HIV/AIDS,1 was
published in The Lancet in June 2011to guide the global response to
HIV. The Investment Framework for HIV/AIDS sets out a model for
HIVinvestment and HIV programming for the next decade.It is a
framework that projects an increase in spending on HIV/AIDS leading
up to 2015, followed by adecline in spending from 2015 to 2020.For
the first time, a model has been developed that can show a decline
in the need for HIV programmesand services, as the effect of
current and future targeted investments reach a tipping point.
HIVinvestments, and HIV rates, decline.Is this the prediction of
the end of AIDS?The framework has proven to be influential and
topical already. It was developed by international expertsfrom a
range of agencies, including UNAIDS, the Global Fund, WHO and the
US Government.2This discussion paper describes some of most
important features of the investment framework for theAlliance,
along with some actions for us all in making it work for
communities affected by HIV/AIDS.1. Towards an improved investment
approach for an effective response to HIV/AIDS The Lancet Vol. 377
Issue 9782 pp 2031-2041, 11 June 20112. Dr Bernhard Schwartlnder
MD, John Stover MA, Timothy Hallett PhD, Prof Rifat Atun FFPHM,
Carlos Avila MD, Eleanor Gouws PhD, MichaelBartos MEd, Peter D Ghys
MD, Marjorie Opuni PhD, David Barr JD, Ramzi Alsallaq PhD, Lori
Bollinger PhD, Marcelo de Freitas MD, Prof GeoffreyGarnett PhD,
Charles Holmes MD, Ken Legins MPH, Yogan Pillay PhD, Anderson
Eduardo Stanciole PhD, Craig McClure PGCE, Gottfried Hirn-schall
MD, Prof Marie Laga MD, Nancy Padian PhD, on behalf of the
Investment Framework Study Group.a Joint United Nations Programme
on HIV/AIDS (UNAIDS), Geneva, Switzerlandb Futures Institute,
Glastonbury, CT, USAc School of Public Health, Imperial College
London, London, UKd Imperial College Business School, Imperial
College London, London, UKe The Global Fund to Fight AIDS,
Tuberculosis and Malaria, Geneva, Switzerlandf International
Treatment Preparedness Coalition, New York, NY, USAg International
Clinical Research Center, Department of Global Health, University
of Washington, Seattle, WA, USAh National AIDS Programme, Brasilia,
Brazili Office of the US Global AIDS Coordinator, US Presidents
Emergency Plan for AIDS Relief, Washington, DC, USAj The Bill &
Melinda Gates Foundation, Seattle, WA, USAk UNICEF, New York, NY,
USAl Strategic Health Programmes, Department of Health,
Johannesburg, South Africam Global HIV/AIDS Unit, Health,
Nutrition, and Population, The World Bank, Washington, DC, USAn
World Health Organization, Geneva, Switzerlando Institute of
Tropical Medicine, Antwerp, Belgium Page 1
2. Jenny Mathews for the AllianceDISCUSSION PAPERSupporting
community action on AIDS in developing countries Why does the
investment framework matter for the Alliance? For four main
reasons: 1. It sets out an investment plan that is not primarily
aspirational, like the Universal Access by 2010 and 3 by 5 calls
were. The difference here is that this plan refers to a specific
and scientifically produced calculation of the investment required
in order to create a reduction in the trajectory of HIV both
spending, and in terms of HIV/AIDS epidemic dynamics. It is a
model, or a calculation, that says that if you invest in these
specific ways, then the human and financial costs of AIDS will
reduce dramatically by 2020. It provides a model for a highly Jenny
Matthews for the Alliance targeted response. 2. It articulates an
approach to the implementation of HIV programmes that reflects and
supports our programming. The prioritisation of specific HIV
programmes is accompanied by the concept of critical enablers that
make these programmes work. It endorses working with key
populations where they are most affected by HIV/AIDS, there is
prominent support for community mobilisation, and for a range of
other evidence based interventions that we are implementing, such
as HIV testing and counselling, treatment adherence, behaviour
change communication, needle and syringe programming, stigma
reduction and advocacy. 3. It positions human rights-based
programming such as advocacy, stigma reduction and efforts towards
supportive laws and practices as critical to the model, not
optional or additional but critical. For example, advocacy to end
the criminalisation of sex between men is critical to the
implementation of behaviour change communication that reaches a
sufficient number of men who have sex with men. 4. It responds to
the increasing amounts of new evidence of the significant health
improvement and HIV/TB prevention potential of ART. Increases in
ART provision are a cornerstone of this model. There are four
important features of the way increases in ART provision is
conceptualised in this model. Firstly, increased provision leads to
improved health, reduced illness and death as more people living
with HIV and tuberculosis receive ART. Secondly as reduced viral
load prevents increased levels of onward HIV transmission. Thirdly,
prevention of mother to child transmission (PMTCT) is a priority
intervention. And finally, from a different perspective, increases
in ART provision are conceptualised as producing cost reductions as
ART programmes shift from high cost specialist provision to primary
care and community-led approaches to delivery.Page 2 3. DISCUSSION
PAPERSupporting community action on AIDS in developing countries
Figure 1: Investment frameworkThe investmentThe model calculates
theincrease in investmentrequired such as a$12.9 billion increaseto
$22 billion by 2015followed by a decreaseto $10.6 billion by 2020
in order to avert 12.2million new infectionsand to prevent
7.4million deaths due toAIDS.The decrease ininvestment after
2015results from the impactof reaching optimal HIVprogramme
coveragelevels, along withcost efficiencies, andimportantly, the
declinesin illness and death thatare predicted becauselarger
numbers of peopleare receiving ART. Figure 2: Resources requiredSo
our calls for moreinvestment in HIV (WhatsPreventing
Prevention?)for the first time, canbe accompanied bya scientific,
modelledprediction of a decline inHIV/AIDS by the end ofthis
decade.Page 3 4. DISCUSSION PAPERSupporting community action on
AIDS in developing countriesThe investment framework in more
detailHIV programming priorities in the Critical
enablersframeworkThe framework articulates a very importantWhat is
new is that the framework provides an concept for the Alliance,
critical enablers. Inevidence based and costed case for doing more
this framework, critical enablers are definedof what we do already
in order to reach a criticalin two categories social enablers such
aspoint where the need for programmes and servicescommunity
mobilisation, changing laws and stigmawill decline. It argues for,
and calculates, thereduction. The second category of critical
enablersvalue and potential impact of good quality HIVare programme
enablers, or efforts to makeprogramming. Developments in our
understandingprogrammes work, such as community centredof the
potential of ART feature here as well - thedesign and delivery,
communication, management,potential of ART to prevent HIV
transmission, procurement and research and innovation. Theseand to
prevent tuberculosis amongst peopleare important and familiar
concepts in the Alliance.living with HIV.The framework gives
prominence to the conceptThe six programme areas that are
emphasised are:of community mobilisation a concept very PMTCTclose
to the Alliances heart. We understand howimportant the mobilisation
of communities is to HIV Condom promotion and
distributionprogramming, but this has rarely been described Key
populations (sex work, MSM, IDU (and described as critical) in
other models. It will programmes)be important to use this
opportunity to intensify Treatment, care and support to people
living withefforts at the community level. HIV/AIDS (including
facility-based testing) Male circumcisionLooking at the HIV
programming priorities, and Behaviour change programmes. analysing
them alongside the critical enablers,essential work at the
community level is clear.Male circumcision is specified as being
applicableFor example, PMTCT is the first of the six HIVin
generalised epidemics with a low prevalence of programme priorities
outlined. What are the criticalmale circumcision. This is not a
blueprint for male enablers for PMTCT? They might include some
orcircumcision in every country.all of the following: advocacy for
political commitment to a national How does this list match with
HIV PMTCT programmeprogramme efforts in your country? change in
practices such as discrimination by health care providers towards
women living with How is progress on each of theseHIV, in
particular, in the area of family planning programmes in your
country? and provision of sexual reproductive health servicesDoes
this list of priorities miss something community mobilisation for
PMTCT so thatimportant? local communities know about PMTCT and HIV
testing, and can access PMTCT servicesIf funding follows this list,
what does it mean local efforts to incentivise PMTCT programmes for
our current work? design of services so that they meet the needs of
communities research on the best models of delivery.Page 4 5.
DISCUSSION PAPERSupporting community action on AIDS in developing
countriesThese are examples of potential efforts we mightHow can we
use the framework?highlight in order to make PMTCT more
effective.Much of this effort lies outside the clinic and inIn our
advocacy and resource mobilisation.communities. Using this
framework, we can Instead of asking for more money for AIDS
witharticulate the need for work at the community level,an implied
ever-increasing need, our advocacy forwith community organisations,
in order to make themore resources for HIV has more precise goals
investment in PMTCT clinics work optimally. coverage goals that
will need to be set nationallyand locally in order to reach a point
where theSynergies with development sectorsneed for this investment
declines. Optimal coveragewill be reached, efficiency gains will be
realisedAnother area of focus for the Investment Frameworkand the
decrease in new HIV infections will result inis broader development
sectors and their links todecreased need for services.HIV
programmes and critical enablers. The sectorsreferenced include
social protection, education, In our planning. In order to
understand thelegal reform, gender equality, poverty reduction
,implications of this framework for HIV programminggender-based
violence, health systems, communityat a country level, we need to
answer a set of criticalsystems, and employer practices.
programming questions: How does the list of development
sectorsynergies match with HIV programme efforts in What are the
communities/populations that your country? are most critical to the
dynamics of HIV transmission in each country?Is there clarity on
what each of these synergies involves? (for example, what are the
overlapsWhat are the critical enablers and how do they between HIV
programmes and education?) influence or affect the sexual and
injecting practice or health seeking practice of the priority How
is progress on each of these synergies in
communities/populations?your country?What are the most critical HIV
interventions forDoes this list of priorities miss something impor-
the priority communities/populations? tant? What are the optimal
coverage levels for keyIf funding follows this list, what does it
mean forHIV/TB interventions in each country?our current work? What
are the critical programmatic enablers?What are our programmes
contributing toThinking through the meaning of each aspect
ofmeeting coverage targets in each country? Andthese three areas
(programme activities, critical what is their potential?enablers
and development sector synergies) at acountry level is important
work. This might lead to What is our work in civil society to
addressa re-programming of HIV efforts, and we will needthe
critical enablers? What is the role ofto ensure that we can point
to where our HIV/TB government?programming efforts, and our
advocacy efforts, are What are the most important synergies for
thesesupported in the framework. For many of us, we populations,
targets? Social protection? Humanwill need to advocate for changing
the investmentsrights protections? Poverty reduction? Healthin HIV
at the national or local level. We might be systems? Community
systems? Education?advocating for re-programming, or for the need
tobuild capacity in different sectors to make this happen. Page 5
6. DISCUSSION PAPERSupporting community action on AIDS in
developing countriesSome of us will have the answers to these know
about ART and can see the benefit of it forquestions, some of us
will need to work with others themselves and their families?
Increased support forto seek or calculate the answers. The answers
tocommunity health workers and caregivers to deliverthese
questions, and the assumptions contained in ART and support
adherence?the framework, should increasingly form the basis
ofnational HIV plans, including Global Fund proposals.Left solely
to public health planners, some of theseThese questions and their
answers are critical fortypes of questions may not be asked.
Increasingour strategic planning and fundraising efforts. WeART
provision is a goal for all of us, but gettingare contributing a
lot to this national and globalthe right actions in place in order
to achieve this iseffort, but we need to be clearer in defining the
HIV more complex. Community activists and communityimpact of this
work, and in forecasting the potential based programmers must be
part of this analysisof this work to achieve the point, in each
country, to ensure that plans go well beyond the provisionwhere HIV
is in decline.of more clinical services. And when the goal isto
shift more aspects of ART service provision toArticulating the role
we play in supporting the communities and their organisations, that
this effortcritical enablers will be important work for Alliance is
costed and funded properly, not undermined byLinking Organisations
both the social enablersdoing it cheaply, dependent on volunteer
labour,and programme enablers. What are our theories unpaid care
and the under-funding of communityof change for each critical
enabler? It is widely organisations and their staff.acknowledged
that defining, planning and costingefforts to address the critical
enablers is the weakest Limitations of the frameworkpart of this
model. We have to focus attention tothis, and help shape this work.
Defining, planningAs described above, the critical enablers
describedand costing the vital pieces of the model such as in the
framework are poorly defined, costed andcommunity mobilisation;
changing laws, policies tested. They are not universally agreed
either, andand practices; stigma reduction; changing riskrest
uneasily on an unstable body of evidence.environments; capacity
building, management,Further work is required to understand the
barriersprocurement, research and innovation. and enablers to
effective HIV responses in everycontext, and to define and
demonstrate the value forTesting the assumptions inherent in the
model money of key interventions that are enabling.will be
important in each country. For example,the model depends heavily on
increases in ART The daily struggles to ensure access to
HIVprovision. Is that assumption realistic and feasibleservices to
and to protect the human rights of veryfrom the perspective of very
marginalised people? marginalised and poor people are well
understoodAnd if not, what are the changes, what are theby
community organisations. Sometimes a list ofcritical enablers, in
order to reach and increase clinical and health promotion
interventions fails tothe uptake of ART amongst marginalised
people?get at the range of needs, struggles and problemsImproved
drug procurement and distributionshaping the lives of people who
are detained,systems? Reduced discrimination towards keydenied
services, who are subject to violence,populations in health care
settings? ART morebreaches of privacy, hate crime, discrimination
andaccessible in a wider range of settings? Improvedaccess to
opiate substitution treatment for other violations, who live far
from health services,injecting drug users? Changes in policy so
that who have uncertain immigration status or whopeople without
identity cards, or people in prisonare poor, young, old or socially
isolated. Socialor detention, can access ART? More intensiveand
behavioural research, political science andcommunity mobilisation
so that more peopleoperations research can define HIV and other
Page 6 7. DISCUSSION PAPERSupporting community action on AIDS in
developing countriesneeds more deeply. They can help to build a
bridgepopulations, programmes and investments. Analysebetween our
understanding of the complexity and how these programmes and
critical enablersextent of social and personal needs, and a set of
are synergising with other development sectors.health programmes
that can stop HIV. The scienceIdentify the most important critical
enablersthat we bring to the model needs more socialto ensure the
programmes are of high qualityscience, and more implementation
science. and are reaching sufficient numbers of peoplefrom
specifically targeted populations. SeekThe critical programmatic
enablers need to addressendorsement for your analysis, including
fromcorruption, capacity building, building socialgovernment.
Analyse the assumptions in thecapital, strengthening community
systems andmodel for your country. What interventions
willstrengthening health systems so that health systems make
increases in ART most feasible? How dobetter serve all people with
HIV needs, including behaviour change communication and condomthose
who are criminalised and marginalised.promotion interventions
change as a result ofincreased evidence for treatment as
prevention,Acting on the investment frameworkand male circumcision?
What will be the effectson sexual and injecting practice, and how
willWe need to act on this investment framework tobehaviour change
communication respond? Whatmore directly promote effective and
community are the community mobilisation efforts for the sixdriven
responses to HIV in each country where the programme areas?Alliance
operates. There is some critical thinkingto be done. We can use
this framework to intensifyAdvocate for a more high impact,
preciselyand improve national planning for HIV. Informed bytargeted
and costed national HIV programme.the investment framework, some
immediate tasksUse this framework to advocate for more
precisionarise:in targeting and for a more expanded and nuancedrole
for communities and their organisations. It willEnsure the
framework is on the national agenda. help to analyse current
investments in HIV to ensureDo your national planning institutions
(NACs, that our best efforts focus on high impact theCCMs) know
about it? Get this framework ontopotential to prevent 12.2 million
new HIV infectionsthe agenda of these committees. Foster debate and
prevent 7.4 million deaths due to AIDS by 2020.about the model.
Brief government, civil societyand relevant professional agencies
about it. With ABOUT THE ALLIANCEUNAIDS and WHO colleagues, form a
working Established in 1993, the International HIV/AIDSgroup made
up of relevant specialists to examine Alliance is a global
partnership of nationally-the meaning of the framework in your
country:based linking organisations working in over 40national HIV
government/public health planners,countries, to support community
action on AIDSHIV civil society organisations both key populationin
developing countries.representatives and HIV programme
implementers,International HIV/AIDS AllianceHIV/TB clinicians and
social/care providers, HIV (International secretariat)technical
agencies, clinical researchers, HIV/TB/ 91-101 Davigdor RoadSRH
epidemiologists, HIV social scientists, HIVHove, East Sussexsocial
care experts, HIV human rights specialists. BN3 1RE United
KingdomIdentify the key populations, programmes and Tel: +44 1273
718 900 Fax: +44 1273 718 901coverage levels in your country, and
analyse Email: [email protected] with other
experts to identify the most important Registered charity no.
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