Yogan Pillay 19 April 2012

1. International Multi-stakeholderConsultationon National AIDS Programmes:Enhancing effectiveness, efficiencyand social sustainability – the B, C and D of E2 Yogan Pillay 19 April 2012

5. Global AIDS facts • Progress on treatment and prevention: • The number of people receiving antiretroviral treatment for HIV has increased from 400,000 in 2003 to more than 5 million today. • Globally, the rate of new HIV infections declined 17% from 2001 to 2008. • Progress against AIDS has led to progress on other global health priorities, including tuberculosis and maternal and child health.

6. Global AIDS facts • Remaining challenges: • An estimated 10 million people are in need of HIV treatment, based on current international guidelines, but do not yet receive it. • Prevention efforts must be greatly intensified – for every two people who gain access to HIV treatment, five people become newly infected. The BMG’s HIV Strategy (2010)

11. “African dependency on external sources is destabilizing the AIDS response. Two-thirds of all AIDS expenditures in Africa come from external sources. International investments for AIDS dropped by 13% from 2009 to 2010” (UNAIDS, 2012).

12. Global leadership: will it help? • UN Secretary General Ban Ki-moon said: "Heading into the fourth decade of Aids, we are finally in a position to end the epidemic...Financing will be critical to success. I urge all concerned to act on the investment framework put forward by UNAids and to fully fund the global investment target of up to $24bn annually.“ (Global AIDS Report, 2011) • Bill Gates "called for a continued push to bring down the cost of HIV treatment and urged governments and other funders to continue to back AIDS research, one of the main goals of which he said should be to come up with a 'significantly effective AIDS vaccine‘ (AFP, 2010)

13. Recent reports on aid decline • "The lives of thousands of HIV-positive people in the Democratic Republic of Congo (DRC) are at risk as the country faces declining donor funding and a severe shortage of HIV treatment, according to Medecins Sans Frontieres (MSF),” • "the end of six years of World Bank funding in 2011"; the end of UNITAID funding, which provides for pediatric and second-line ARVs, in December 2012; and "the cancellation of Round 11 funding by the Global Fund to Fight AIDS, Tuberculosis and Malaria" as reasons for the ARV shortage in the DRC. (Feb 4, 2012)

14. Framework for putting health issues on the global agenda • Shiffman and Smith (2007) – health issues gain prominance when: • local and international political leaders publicly and privately express support for the issue; • policies are enacted to address the problem; and • resources appropriate to the disease burden are allocated to the issue

15. Africa’s common position to the high-levelmeeting of the UN General Assembly SpecialSession on AIDS (June 2011) • “Concerned that national responses remain highly dependent on external support, compromising national ownership and sustainability of the response, given the uncertainty of future funding resulting from the global financial crisis and the need to maximize the efficiency and impact of limited financing”

16. Africa’s common position to the high-levelmeeting of the UN General Assembly SpecialSession on AIDS (June 2011) • Leadership, National Ownership & Coordination of the AIDS Response • Stop new HIV infections • Maximizing Efficiency in the Delivery of Treatment, Care and Support • Sustainable Financing for the HIV Response • Accelerate Action for Women, Girls and Gender Equality • Ensure mutual accountability for universal access

17. The equation: B+C+D=E2? • E2: • Effectiveness • Efficiency

18. E2: effectiveness and efficiency • Efficiency is doing things right; effectiveness is doing the right things (Peter Druker) • “The analysis of efficiency and effectiveness is about the relationship between inputs, outputs and outcomes” (Mandl et al, 2008) • The greater the output for a given input the greater the efficiency • Effectiveness depends on the outcomes one seeks to achieve and the success of the utilisation of the resources to achieve these outcomes

19. B, C, D? • Better research • Country ownership • Dedicated health care workers OR/AND (UNAIDS Investment framework) • Basic programme activities • Critical enablers • Development partner support

20. Better research/basic programme activities • What works & under what conditions? • Condoms (but dual protection too!) • VMMC • PMTCT • ARVs (but what regimes, when to switch, pharmacovigilence) • Treatment as prevention: from research to policy • What’s the evidence for behavioural interventions? • What is combination prevention?

23. Key findings from CHAI 5 country study: example of types of studies required • Study focussed on Rwanda, Zambia, Ethiopia, Malawi and South Africa • Facility level costs range from $136-$278 per patient on ARVs per year • Significant efficiencies already achieved (SA high end due to high salaries and additional labs) • Drug costs may increase with more patients on second and third line and switch from D4T to TDF for example • Outcomes improve with early initiation (higher CD4 levels)

24. Within those low costs, ARVs constitute ~50% of total cost in all LIC/LMICs. ARVs and personnel together constitute over 70% of total cost in all countries Cost of treatment per ART patient year by country US Dollars Simple average and median cost of treatment per ART patient year by country US Dollar *Lab category includes consumables only in all countries except SA ** Simple average numbers are not representative of the countries. Weighted average numbers are currently being calculated which will be a better representation of the countries

25. Average annual attrition rates for established patients range from 2% in Rwanda to 8% in RSA, while retention in the first 12 months of treatment is significantly lower Pending Further Analysis Average attrition (at 12 months) for established patients Percent • Sites in the sample have demonstrated an ability to keep patients alive and on treatment However, variation is significant for both new and established patients. • Rwanda stands out for their ability to manage both newly initiated patients as well as those receiving long-term care. • Further analysis is required to better understand the observed differences across the sample. Average retention (at 12 months) for new patients Percent * Transferred patients were excluded from analysis, which may reduce retention rates for sites that transfer stable patients, and increase rates for sites that transfer sicker patients. 25

26. Critical enablers/country ownership • Paris Declaration for AID effectiveness • ownership; • alignment; • harmonisation; • results; and • mutual accountability

27. Critical enablers/country ownership • Accra Agenda for Action • Ownership; • Inclusive partnerships; • Results; and • Capacity development.

28. Dedicated health workers/development partner support • How to get dedicated health workers? • Dr Karamoko Nimaga (left the WHO to work in a rural community) built a health clinic in Markakoungo, Mali, home to 5,000 people. It has a medical unit, a small surgical room, a mother and child's health unit, a hospitalisation unit with 12 beds, and a laboratory. His sole aim for the future is to "continue serving poor people living in rural communities".

29. The Kampala Declaration and Agenda for Global Action (2008) • Leaders to provide the stewardship to resolve the health worker crisis, involving all relevant stakeholders and providing political momentum to the process. • Leaders of bilateral and multilateral development partners to provide coordinated and coherent support to formulate and implement comprehensive country health workforce strategies and plans. • Governments to assure adequate incentives and an enabling and safe working environment for effective retention and equitable distribution of the health workforce.

31. Efficiency in prevention programming • Evidence was found of three distinct sources of inefficiency in the allocation of HIV/AIDS prevention resources: • inefficiency in the mix of interventions selected; • inefficient targeting of key populations; and • technical inefficiency in the production of HIV prevention services. Bautista-Arredondo, Gadsden, Harris, Bertozzi (2008)

32. Recent examples of efficiencies (WHO, 2011) • In South Africa, a new tendering strategy, aimed at increasing competition between drug manufacturers and reducing treatment costs, resulted in a 53% reduction in the cost of antiretrovirals and estimated savings of US$ 685 million over a two-year period. • In Uganda, the use of simplified fixed-dose combination ARVs for children has risen from 17% to 100% of those in need in the past two years, and enabled savings of US$ 2 million.

33. Examples contd • In Mozambique, after the introduction of POC CD4 testing at selected primary health care clinics, the median time taken for CD4 staging was reduced from 27.5 days to one, and & number of patients lost to follow up prior to initiation of ART fell from 64% to 33%. • In Malawi, as a result of shifting treatment delivery from hospitals to health centres and from clinical officers to nurses, patients in one district now start treatment within 3 weeks of diagnosis as opposed to 3 months.

34. Conclusions • Funding for HIV and AIDS is under significant pressure: hence renewed attention on E2 • What’s to be done? • International pressure on both development partners AND LMIC governments • Greater effectiveness and efficiency (we have great examples of what can we done but need scale) • Focus on best buys that are sustainable (we have some research, more needed)

35. Thanks to: • Elly Katabira & IAS • Mats Ahnlund • Emily Blitz • CHAI