Major Challenges to HIV/AIDS Prevention and Treatment Universal Access and Sustaintability

1. Major Challenges to HIV/AIDS Prevention and Treatment Universal Access and Sustaintability Pedro Chequer UNAIDS Regional Advisor, Latin America Regional Support Team

2. .Challenges to HIV Prevention Challenges to ART Sustainability Common Challenges Some strategies to cope with these challenges Major Challenges to HIV/AIDS Prevention and Treatment

3. Challenges to HIV Prevention 1) Limited information about the market of prevention supplies, including condoms, may lead to over-demand, under-supply and systemic failures

5. Challenges to HIV Prevention 1) Limited information about the market of prevention supplies, including condoms, may lead to over-demand, under-supply and systemic failures 2) Limited availability of HIV counselling and testing services

7. 3) Mixed and conflicting messages from donors and international partners The ABC D isaster The criticism of the content of AB is simple: the messages cannot be implemented by substantial parts of the population, they are not geared at real life. Abstinence is not an option for many (poor) women and being faithful does not protect against HIV/AIDS infection Over the years, the A and B of the ABC tend to get a lot more emphasis than the C Uganda case Recent studies from Southern African Countries

8. Challenges to HIV Prevention 4) Forgotten (or neglected) areas: - blood supply - HIV transmission in health-care settings - hard-to-reach and vulnerable populations, including sex workers, men who have sex with men and intravenous drug users 5) Scale up from small pilot projects with little impact and geographic coverage 6) Financial Gap 2005(Prevention): US$ 3.2 /5.7 (bi) Prevention/Care needs: 15 bi/ 2006, 18 bi 2007, 22 bi/ 2008

9. Challenges to HIV Prevention Some facts and wrong concepts Alcohol consumption is linked to unprotected sex The use of condom at sexual debut is infrequent, with females consistently less likely to report practice than males Condom use is typically irregular, and very few youth report consistent and correct use of it Sexually active youth express a preference for traditional methods, such as withdrawal and rhythm

10. Challenges to HIV PreventionSome facts and wrong concepts Prevention targets difficult Multisectoral and many partners Prevention not as appealing Stigma and Discrimination "STIs/HIV can be prevented by good personal hygiene, and AIDS cured by medication" "Condoms are unsafe"

11. Preventing HIV: What works • Preventing Sexual Transmission: • Behaviour change programs that encourage the use of condoms; • HIV testing and counselling; • Treatment of other STIs • HIV education • Circumcision (?)

12. Preventing HIV: What works Preventing Blood Borne Transmission Harm reduction programs for IDU including needle and syringe programs Blood supply safety Infection control in health care settings Preventing mother-to-child transmission Antiretroviral drugs Breastfeeding alternatives Cesarean delivery

13. Preventing HIV: What works It is estimated that increasing access to effective hiv prevention could avert half of the 62 million new hiv infections projected to occur worldwide between 2005 and 2015

14. New prevention paradigms • Paradigms that move from behavioral and individual approaches and focus on collective processes. • That promote multisectorial responses through alliances and partnerships and establishes coresponsibility of actions. • That have a health and human rights perspective - that promote nondiscrimination of persons living with HIV, non discrimination of persons due to sexual diversity, ethnicity, gender, age or drug use. Cristina Pimenta, Toronto 2006

15. New prevention paradigms That promote and provide access to scientifically proven preventive measures. That addresses the importance of linking prevention to treatment and care as part of an integral and integrated approach to prevention and health care. • That promotes the combat of stigma and discrimination through provision of national legislature and implementation of local protective policies. Cristina Pimenta, Toronto 2006

16. Challenges to HIV Treatment Universal Access and Sustainability

17. Antiretroviral therapy coverage in low- and middle-income countries, June 2006 Some numbers do not add up due to rounding - Source WHO

18. 20 low- and middle-income countries in sub-Saharan Africa, Asia, Latin America and the Caribbean treated more than 50% of those in need, June 2006

19. Unmet need 70% of the total unmet need 5 Receiving ARV therapy (Number of people in millions) 4 3 2 1 Latin America and the Caribbean East, South and South-East Asia Europe and Central Asia North Africa and the Middle East Sub-Saharan Africa ARV Therapy: global need, June 2006

20. Challenges to ART sustainability 1) Poor attention to ARV treatment follow up and transition to more complex regimens– we may not get a second chance! • 2) Burden of success: lower political engagement due to initial positive results from • - national governments AND • - civil society

21. Challenges to ART sustainability 3) Apparent affordability of antiretrovirals – pricing continues to be an issue: • Countries will increasingly switch to 2nd line drugs • Current 2nd line drugs may become 1st line regimens • Prices of “3rd-line” drugs may skyrocket (e.g., T-20) 4) Short-sighted perception that intellectual property right issues are no longer relevant

22. An example from Brazil Apparent Affordability Intellectual Property Rights

23. Average cost of ARV per patient/year (US$) 7000 6240 6000 5486 5000 4603 Introduction of expensive new ARVs 4000 3464 3000 • Prices of second-line, patented drugs have stopped falling substantially • Number of people using them has increased dramatically Thousands (US$) 2500 2210 2000 1500 1359 1336 1000 0 1997 1998 1999 2000 2001 2002 2003 2004 2005* Year

24. Total expenditure (in US$ mi) in ARV procurement and average number of patients on antiretrovirals 450 200 395 180 400 336 160 350 305 303 140 300 120 232 250 224 203 Number of patients (thousands) 100 Expenditures (US$ mi) 181 179 200 80 150 60 100 40 50 20 0 0 1997 1998 1999 2000 2001 2002 2003 2004 2005* Total expenditures (US$mi) Average n. of patients (thousands) Source: PN DST-AIDS/SVS/MS * Data subject to revisions and modifications

25. Challenges to ART sustainability 5) Lack of long-term financial commitment from donors and recipients 6) Current mono/oligopolistic configuration of the market of active principle ingredients (API’s) 7) Lack of publicly-available, internationally-validated monographs and accredited laboratories for quality control

26. 8-Prevention better than "cure” Ensure prevention is not left behind 9-Chronic disease management Beyond the numbers starting Quality of care for life/Adherence Person-centred care in the community Challenges to ART universal coverage and sustainability

27. 10-Treatment of Opportunistic Infections 11- Children: Neglected patients 12-ARV Treatment for pregnant women 13-Tb x HIV 14-ITS x HIV 15-Counseling & Testing Challenges to ART universal coverage and sustainability

28. S T R A T E G I C I N F ORMA T I ON Expanding testing and counselling Maximising prevention Accelerating treatment scale up Strengthening health systems The health sector's contribution to achieving Universal Access (WHO)

29. Common Challenges • 1) Development of new technologies and systems Technologies: • Prevention (e.g., microbicides, etc) • Treatment and care (e.g., new FDCs) • Vaccine Systems: • Monitoring and Evaluation and Operational Research • Personnel (health and management) • Management 2) In a global resource-constrained environment, Latin America may be given ‘lower preference’

30. Some strategies to cope with these challenges 1 – South-South cooperation in technology-intensive areas 2 – Collective price negotiations 3-Clinton Foundation Approach 4-International Drug Purchase Facility (IDPF-UNITAID))) 5 – Local Production (TRIPS)