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Three Categories of Investment:

“Towards an improved investment approach for an effective response to HIV “ The Lancet, June 3, 2011 www.thelancet.com.

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Three Categories of Investment:

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  1. “Towards an improved investment approach for an effective response to HIV “The Lancet, June 3, 2011www.thelancet.com

  2. Moving from a commodity approach:“Fund some of everything” or“Fund what is comfortable”toAn Investment approach:“Fund evidenced-based activities specific to the needs of your epidemic to get better long term results at lower costs.”A tool for evaluation and reallocation of HIV funding.

  3. Three Categories of Investment: • Six basic programmatic activities • Critical interventions that create an enabling environment for achieving maximum impact; and • Programmatic efforts in wider health and development sectors related to AIDS. • Rights-based approach to all services and policies

  4. Basic programme activities • Activities that have a direct impact on reducing HIV transmission, morbidity and mortality to be scaled up according to size of relevant affected population

  5. Basic Program Activities Based on high level evidence of effectiveness. • Treatment, care and support • Vertical Transmission prevention • Condom procurement and distribution • Key populations programs (MSM, IDU, Sex Workers) • Male circumcision • Behavior Change programs

  6. Critical Enablers Social Enablers - make possible environments conducive for sound AIDS responses: • outreach for HIV testing • Linkage from testing to care • treatment literacy • stigma reduction • advocacy to protect human rights • monitoring of the equity and quality of programme access and results

  7. Critical Enablers Program Enablers - create demand for and help improve the performance of key interventions: • incentives for engagement in health services • methods to improve retention on ART • capacity building for community-based organizational development • strategic planning • communications infrastructure • information dissemination • efforts to improve service integration and linkages from testing to care.

  8. Synergies with other development sectors • Health systems and multiple health issues • Gender equality efforts • Education and justice sectors • Social protection and welfare • Food security • Community systems • Housing

  9. What is the Role of Community Mobilization in this Framework? • Community-driven outreach and engagement activities that connect people facing similar issues and engage them in HIV-related interventions • Supportactivities to enhance quality, adherence and impact in a range of settings such as people on treatment, engaged in harm reductionor drug treatment services, or who are using sexual and reproductive health services • Advocacy, transparency and accountability efforts at country and local levels to ensure that high-quality health services are available and accessible to vulnerable populations.

  10. Community support keeps people on treatment CLINIC-BASED TREATMENT 70% still receiving treatment after two years Sub-Saharan Africa: people receiving ART from specialist clinics Source: Fox MP, Rosen S. Patient retention in antiretroviral therapy programs up to three years on treatment in sub-Saharan Africa, 2007–2009: systematic review. Tropical Medicine and International Health, 2010, 15(Suppl. 1):1–15. COMMUNITY TREATMENT MODEL 98% still receiving treatment after two years Mozambique: self-initiated community model Source: Decroo T et al. Distribution of antiretroviral treatment through self-forming groups of patients in Tete province, Mozambique. Journal of Acquired Immune Deficiency Syndromes, 2010 [Epub ahead of print]. Sources: Fox MP, Rosen S. Tropical Medicine and International Health, 2010. DecrooT et al. Journal of Acquired Immune Deficiency Syndromes, 2010.

  11. Community mobilization increases effectiveness Community mobilisation increased HIV testing rates four-fold in Tanzania, Zimbabwe, South Africa and Thailand Consistent condom use in the past 12 months was 4 times higher in communities with good community engagement (Kenya) Hypothetical circumcision model KwaZulu-Natal : • Core intervention: 240,000 infections averted over ten years • With enablers: 420,000 infections averted, with modest marginal increase in costs

  12. Percentage of people retained in treatment and care after diagnosis, USA and Mozambique 100% USA Mozambique Retained in treatment and care 0 Diagnosedwith HIV Eligiblefor ART InitiatedART Adherentor undetectable Linked/enrolled in care Tested <30 days Retained in care Source: Gardner E M et al. Clin Infect Dis. 2011;52:793-800; Micek et al JAIDS 2009

  13. Percentage of people retained in treatment and care after diagnosis, USA and Mozambique • To improve testing: • Reduce stigma in the community and in healthcare settings • Strengthen community support and referral networks • Enhance human rights literacy 100% USA Mozambique Retained in treatment and care 0 Diagnosedwith HIV Eligiblefor ART InitiatedART Adherentor undetectable Linked/enrolled in care Tested <30 days Retained in care Source: Gardner E M et al. Clin Infect Dis. 2011;52:793-800; Micek et al JAIDS 2009

  14. Percentage of people retained in treatment and care after diagnosis, USA and Mozambique • Improve enrolment in care: • Expand community-centred delivery • Overcome cost & transport barriers • Enhance treatment & rights literacy 100% USA Mozambique Retained in treatment and care 0 Diagnosedwith HIV Eligiblefor ART InitiatedART Adherentor undetectable Linked/enrolled in care Tested <30 days Retained in care Source: Gardner E M et al. Clin Infect Dis. 2011;52:793-800; Micek et al JAIDS 2009

  15. Percentage of people retained in treatment and care after diagnosis, USA and Mozambique • Get more people on treatment: • Enhance peer support programmes • Reduce costs • Overcome transport barriers • Ensure adequate nutrition • Reduce stigma in healthcare settings 100% USA Mozambique Retained in treatment and care 0 Diagnosedwith HIV Eligiblefor ART InitiatedART Adherentor undetectable Linked/enrolled in care Tested <30 days Retained in care Source: Gardner E M et al. Clin Infect Dis. 2011;52:793-800; Micek et al JAIDS 2009

  16. Percentage of people retained in treatment and care after diagnosis, USA and Mozambique • Retain people on treatment: • Adherence support programmes • Reduce gender inequalities • Reduce fear of disclosure • Overcome cost and transport barriers • Referral and support programmes for migrants 100% USA Mozambique Retained in treatment and care 0 Diagnosedwith HIV Eligiblefor ART InitiatedART Adherentor undetectable Linked/enrolled in care Tested <30 days Retained in care Source: Gardner E M et al. Clin Infect Dis. 2011;52:793-800; Micek et al JAIDS 2009

  17. What can we achieve?Universal Access by 2015

  18. Projections and Estimates • Resource needs and returns on investment were estimated for 139 low- and middle-income countries • Estimates based on the cost of increasing from current levels of coverage in 2011 to achieve universal access target coverage levels by 2015 and maintain them thereafter. (Includes 1st and 2nd line treatment.) • Each of the basic programme activities in the framework was applied to relevant populations according to their demographic and epidemiological situation including the distribution of new HIV infections by mode of transmission as detailed in the literature.

  19. Returns for InvestmentMore than 12 million Infections averted

  20. Return on investment of the new investment framework (2011-2020)

  21. What will it cost?What are the returns?

  22. Financial requirements (Billions of US$)

  23. Economic returns between 2011 to 2020

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