Transcript Modelling course DIDE 10Sept09 (FINAL) - Workspace

The Global Response to AIDS:
Achievements and Challenges
for the Long Term
Peter Piot
Institute for Global Health
Imperial College London
Number of people receiving ARV therapy in low- and
middle-income countries, 2002—2007
People receiving ARV therapy (in Millions)
3.0
North Africa and the Middle East
Europe and Central Asia
East, South and South-East Asia
Latin America and the Caribbean
2.8
2.6
2.4
Sub-Saharan Africa
2.2
Global Fund supported programs
2.0
1.8
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0.0
end 2002
end 2003
end 2004
end 2005
end 2006
end 2007
Decline in adult mortality with introduction of ART:
Botswana
6
on ARV
Deaths aged 25-54
40
4
30
3
20
2
10
1
0
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Persons on ARV (Thousands)
Registered Deaths (Thousands)
5
50
Improvements in life expectancy at infection due to
the availability of ART: Resource-poor settings
Source: Hallett T B, et al. PLoS Med. 2008 Mar 11;5(3):e53.
HIV prevalence (%) among pregnant women attending
antenatal clinics in sub-Saharan Africa, 1997–2007
Southern Africa
Median HIV prevalence (%)
50
Botswana
Lesotho
Mozambique
Namibia
South Africa
Swaziland
Zimbabwe
40
30
20
10
0
1997– 1999– 2001 2002 2003 2004 2005 2006 2007
1998 2000
Eastern Africa
West Africa
20
15
Ethiopia
10
0
Kenya
1997– 1999– 2001 2002 2003 2004 2005 2006 2007
1998 2000
Median HIV prevalence (%)
Median HIV prevalence (%)
20
5
NOTE: Analysis
restricted to
consistent
surveillance sites for
all countries except
South Africa (by
province) and
Swaziland (by
region)
15
Burkina Faso
Côte d'Ivoire
Ghana
Senegal
10
5
0
1997– 1999– 2001 2002 2003 2004 2005 2006 2007
1998 2000
Source: National surveillance reports and UNAIDS/WHO/UNICEF, Epidemiological Fact Sheets on HIV and AIDS. July 2008.
Changes in HIV Prevalence and Risk Behaviour:
Zimbabwe (urban and semi-urban areas)
Natural decline in
incidence ~1990
60
Accelerated decline in
incidence, due to
behaviour change ~2000
10
50
HIV incidence (per 100pyar)
HIV prevalence (%)
8
40
30
20
6
4
2
10
0
1980
1985
1990
1995
Year
2000
2005
2010
0
1980
1985
1990
1995
Year
Source: Hallett TB, et al. Epidemics 2009;1(2):108-117.
2000
2005
2010
Number and percentage of HIV-positive pregnant women receiving
antiretroviral prophylaxis, 2004–2007
40
600 000
35
500 000
30
Number of HIV-positive 400 000
pregnant women
receiving anti-retrovirals
300 000
25
20
15
200 000
10
100 000
5
0
0
2004
2005
2006
Year
Source: UNAIDS, UNICEF & WHO, 2008; data provided by countries.
2007
% of HIV-positive
pregnant women
receiving anti-retrovirals
AIDS IS NOT OVER
HIV prevalence (%) in adults (15–49) in Africa, 2007
HIV infections among men having sex with men in Asia
HIV infections by mode of transmission in Thailand
Source: Bertozzi SM, et al. Lancet. 2008 Sep 6;372(9641):831-44.
http://data.unaids.org/pub/report/2008/thailand_2008_country_progress_report_en.pdf
How did we get there?
 Science and rights driven
 A global response
 Focus on results for people
 Prevention AND treatment
 Multi-disciplinary, multi-sectoral
 Community engagement
Total annual resources available for AIDS
1986‒2007
US$ million
10 billion
10 000
8.9 billion
9000
Signing of Declaration of
Commitment on HIV/AIDS, UNGASS
8000
8.3 billion
7000
6000
World Bank
MAP launch
5000
4000
3000
2000
UNAIDS
Less than
US$ 1 million
1000
PEPFAR
1623
292
257
212
59
Gates
Foundation
Global Fund
0
1986 ‘87
Notes:
‘88
‘89
‘90
‘91
‘92
‘93
‘94
‘95
‘96
‘97
[1] 1986-2000 figures are for international funds only
[2] Domestic funds are included from 2001 onwards
[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)
‘98
‘99
‘00
‘01
‘02
‘03
‘04
‘05
‘06
2007
Treatment Action Campaign (TAC), South Africa
Recorded female deaths in South Africa and Brazil
for ages 15-64 years
Brazil, 2004.
South Africa, 1997.
Source: Nathan Geffen. Statistics South Africa and Instituto Brasileiro de Geografia e Estatistica.
South Africa, 2004
A global response
•
•
•
•
•
Human rights and strategic issue
Global public good
Role of United Nations
Global civil society and activism
International financing
UNITED NATIONS GENERAL ASSEMBLY
SPECIAL SESSION ON HIV
/AIDS
25 - 27 JUNE2001
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)
Prices (US$/year) of first-line antiretroviral regimen in
Uganda: 1998-2003
Focus on results for people
• Targets
• Know your epidemic and the society
• Monitor and evaluate
• Accountability
Need for new evaluation methods
Simulated HIV epidemics (A) concentrated (B) in the general population
Source: Boily M-C ,et al. Sex Transm Infect 2007;83:582-589
A multi-disciplinary, multi-sectoral
response
• Health outcomes determined by multiple
factors and interventions
• Particularly key besides health: law, education,
work place, trade, armed forces
• Expand resource base
• First genuine business engagement in health
Percentage of countries with sectors included
in the national AIDS strategy and earmarked budgets
Military/police
Sector
included
Labour
Health
Earmarked
budget
present
Transportation
Agriculture
Minerals and energy
Trade and industry
Tourism
Public works
0
20
40
60
80
Percentage of countries (%), N=126
Source: UNGASS Country Progress Reports 2008.
100
Community engagement
• From planning to implementation
• Makes or breaks programmes
• National Aids Councils and Global Fund
Country Coordination Mechanisms
• Societal sustainability and resilience
TASO, Uganda
Opportunities for global health
• Health diplomacy
• Increased funding (ODA and research)
• Collateral benefits (TB, malaria, health
systems)
• Culture of accountability
• Tiered pricing
• Engagement of non-medical sectors
• New blood
aids2031
• Taking a long term view- stretching planning and
funding horizons to achieve sustainability
• Multi-disciplinary – bringing together bio-medical,
social and political scientists, economists and activists
to look at what should we do differently – or more of
the same – now to change the future of AIDS
• Key aids2031 report “Agenda for the Future” to be
launched in 2010
Estimated Resource needs for AIDS, TB and malaria
(2009 to 2015)
Estimated resource needs
60
50
US$bn
40
HIV/AIDS
TB
30
Malaria
20
10
0
2009
2010
2011
2012
2013
Sources: UNAIDS, STB, RBM
2014
2015
Projected AIDS spending needs and per capita GDP, 2030
3.50
Zambia
3.00
Brazil
South Africa
2.50
AIDS Spending % of GDP
Kenya
Thailand
Mozambique
China
Uganda
2.00
India
Uganda
Mozambique
Zambia
1.50
Cameroon
Kenya
Cameroon
Nigeria
1.00
Russia
Ukraine
Nigeria
South Africa
0.50
Viet Nam
Botswana
Botswana
Viet Nam
Ukraine Brazil
India
China
Russia
Thailand
0.00
0.0
2000.0
4000.0
6000.0
8000.0
GDP per Capita
10000.0
12000.0
14000.0
The PREVENTION GAP
Persons at risk with access to selected prevention
interventions, 2006
Source: Global HIV Prevention: the access and funding gap. June 2007
Effects of Prevention on Future Costs of ART
$16
$14
$12
$10
Billion US$ $8
$6
$4
$2
$0
2005
2010
Current Prevention
2015
2020
Scaled Up Prevention
2025
2030
Figure 3. Geographical distribution of HIV and tuberculosis infections in South Africa in 1995, 2000, and 2005.
Reference: Karim. S, The Lancet, Special Issue: Health in South Africa August 2009 (Data from references 1 and 21.)
Cost Effectiveness
The long term view
•
•
•
•
•
A still evolving epidemic
Sustainability (leadership, funding, treatment)
An all out effort on hiv prevention
Improve programme delivery and capacity
Links and synergies with health services ( ART,
PMTCTC) and community development
• To stop aids, need for technological and structural
game changers (but no magic bullet!)
• Invest in R&D