Transcript Commonwealth….

Combination Prevention in the
Response to HIV and STIs
Prof. Sheila Tlou
Director, UNAIDS, Regional Support
Team for Eastern and Southern Africa
ICASA, 4-8 December 2011
VISION
ZERO NEW HIV INFECTIONS.
ZERO DISCRIMINATION.
ZERO AIDS-RELATED DEATHS.
UNAIDS Strategy 2011-2015,
Three Strategic Directions
Revolutionising HIV
prevention
Political commitment to why
people are getting infected
Communities demand
transformative change
Resources directed to
hotspots and what works
Catalysing the next phase
of treatment, care & support
 Access to effective treatment
when people need it
 Strong national & community
systems
 Access to care, support &
social protection
Advancing human rights &
gender equality
 Protective social & legal
environments enable access
 Equitable service provision
reaches people most in need
 HIV-related needs and rights
women and girls addressed
•
High Level Meeting Targets
•
Combination Prevention to Revolutionize
Prevention / Investment framework
•
Conclusions
Bold global targets for 2015, HLM, June 2011
50%  in sexual transmission of HIV
50%  of HIV among people who inject drugs
50%  TB deaths in people living with HIV
Ensure no children are born with HIV and reduction of
AIDS-related maternal deaths
 15x15 (15 million people on ART by 2015)
 Mobilize funding (US $22-24 billion per year)
 55 Operative Paragraphs in the Political Declaration
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


Security Council Resolution 1983
 Reaffirms significance of epidemic to individual, national and
global security
 Respects and promotes human rights in conflict/post-conflict
 Recognizes link between HIV and violence against women
 Recognizes contribution of UN peacekeeping operations to
integrated response to HIV
Africa Common Position Targets
• Halve the number of HIV infections by 2015 (SADC and EAC
resolutions)
• Eliminate mother-to-child transmission of HIV, and in so doing
keep mothers and children alive (SADC resolution)
• Double the number of people on treatment by 2015 (SADC
resolution)
• Significantly increase domestic resources for the response
including but not limited to the Abuja Declaration targets of
allocating at least 15% of national budget for health (SADC,
ESA Consultation resolution)
• Establish legal, political and social environments that enable
effective HIV responses… especially for vulnerable and key
populations (SADC, ESA Consultation resolution)
• Resource interventions that empower women and girls (SADC,
EAC & COMESA meeting resolution)
Target: Reduce HIV sexual transmission by 50%
• In 2010, there were approximately 2.7 million
new infections in adults; 1,2 million of them or
46% were in ESA.
• While new infections have declined in the
region, Africa still needs a Prevention
Revolution if Global Targets are to be met
Countdown to Zero: Global Plan Towards Elimination of
New Infections Among Children by 2015 and Keeping
their Mothers Alive
 A global plan to deliver on UNAIDS goal
 Builds on progress in many countries
 Additional pledges in answer to Call to Action
Target: Eliminate new infections among
children and keep their mothers alive
• Global – approximately 390,000 babies were born
with HIV in 2010; 56% or 220,000 were in ESA
• Nearly 90% of all new HIV infections among
children globally occur in 22 countries – 21 of those
countries are in Africa
• Global Plan aims to bring down new infections in
infants by 90% from 2010 levels, by 2015; this is
achievable only if countries achieve >90-95%
coverage for high quality PMTCT services
CONTENTS
•
High Level Meeting Targets
•
Combination Prevention to Revolutionize
Prevention / Investment framework
•
Conclusions
Combination prevention addresses biomedical,
behavioural and structural causes of
risk and vulnerability
Features of combination prevention
1. tailored to national and local needs and contexts,
2. a combination of biomedical, behavioural and structural
elements—to reduce both the immediate risks and the underlying
vulnerabilities;
3. full engagement of affected communities, promoting human rights
and gender equality;
4. operates synergistically, consistently over time, on multiple
levels—individual, family and society;
5. invests in decentralized and community responses and enhances
coordination and management;
6. flexible—adapt to changing epidemic patterns and can rapidly
deploy innovations.
The KYE/KYR Synthesis process – rights based and evidence informed
analysis to define the needed combinations
Analysis of social,
economic, cultural,
legal and political
context
Scientific research
and programme
evaluations
SYNTHESIS
process
Review of
combination
prevention
response – policies,
programmes, costs
Gap analysis
process
National Prevention
Consultation/Summit and ReProgramming processes
To FOCUS effort where the need is
and ensure strategic mix of structural,
biomedical and behavioural strategies
Epidemiological
Review and
Incidence
modelling: HIV,
behaviour, risk
factors
Review of
resources
expended and
available for
prevention
Time for a better
focused response
Scale up to date guided by a
“commodity approach”
 Unsystematic prioritisation and
investment with limited basis in
country epidemiology and context
 Resources spread thinly across
many parallel interventions
 Focus on discrete interventions
rather than overall results leading
to a fragmented response
The new investment framework focuses on
the combination that makes a difference
USD (Billions)
25
20
6 Basic Programme
Activities
15
10
5
0
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
• Behavior Change
Programmes
• Male Circumcision
• Treatment (ART) and Care
• Programmes for Key
Populations
• Condom Promotion
• Prevention of Mother to
Child Transmission
The new investment framework focuses on
the combination that makes a difference
USD (Billions)
25
20
Critical Enablers, incl:
15
•Community mobilization
•Stigma reduction
•Legal environment
•Programme management
10
5
Basic Programme
Activities
0
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
The new investment framework focuses on
the combination that makes a difference
USD (Billions)
25
Synergies with broader
development sectors, incl:
20
•Gender
•Health Systems
•Education
•Social Protection
15
10
Critical Enablers
5
Basic Programme
Activities
0
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Regional variation in estimated investment
allocation requirements in 2015
Proportional allocation to investment framework
basic programme activities,
2011-2015, sub-Saharan Africa
UNAIDS: checklist for helping countries
get to the HLM targets
 Where are the next 1000 sexually transmitted infections
going to happen?
 What are the target numbers to halve them by 2015?
 Is the national programme focussed on halving these
new infections?
 Are the basic programme activities to scale, and critical
enablers in place?
 What is the specific contribution of UNAIDS to achieving
this focus?
 What are the entry points (e.g. NSP review, GF grant)?
•
High Level Meeting Targets
•
Combination Prevention to Revolutionize
Prevention / Investment framework
•
Conclusions
Conclusions
• Combine biomedical prevention with social and behaviour
change; services are important but not enough
• Direct resources to epidemic hotspots, prioritise prevention
programmes and set bold targets based on KYE/KYR
• Involve affected communities and mobilise demand for
social and legal change, including change for gender
equality
• Enlist leaders through greater recognition and incentives
• Country ownership for HIV responses which create
resilient, equitable and inclusive societies that demand
prevention and human rights
Working together, spiders can tie up
a lion! (Tanzanian proverb)
Moroto wa o esi ga o ele (Botswana
Proverb)
More than 34 million people living with HIV, 2010
• ESA is the epicentre of the Global HIV Epidemic with just under 50% of all persons living with HIV
• ESA’s share or contribution to the Global Response should be at least 50%
Generalized Epidemic
Source: Schwartlander, B
For Whom?: explicitly identify and prioritize on populations, geography, Age, Sex…
Outcomes
Basic programme
activities
CRITICAL ENABLERS
Political commitment /Advocacy
Management, M&E, Procurement
Research and innovation
Community mobilisation
Testing , counselling and referral
Stigma reduction
Gender violence/
local response impacting exposure
Laws, legal policies and practices
Incentives
MAJOR
SYNERGIES
Condom procurement,
promotion and distribution
Risk
reduction
PMTCT
Male Circumcision
Sex Work Interventions
Likelihood of
transmission
Treatment and care
(incl. facility–based testing)
Behaviour change
communication
Mortality
and
morbidity
Social Protection, Education, Health Systems , STI treatment, Blood
safety, Gender, Legal reform, Poverty reduction, Employer practices