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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