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    2 supplementary-webappendix-if-lancet-paper 2 supplementary-webappendix-if-lancet-paper Document Transcript

    • Supplementary webappendixThis webappendix formed part of the original submission and has been peer reviewed.We post it as supplied by the authors.Supplement to: Schwartländer B, Stover J, Hallett T, et al, on behalf of the InvestmentFramework Study Group. Towards an improved investment approach for an effectiveresponse to HIV/AIDS. Lancet 2011; published online June 3. DOI:10.1016/S0140-6736(11)60702-2.
    • SUPPLEMENTAL MATERIAL Towards an improved investment approach for an effective response to AIDS; Schwartländer et al. May 2011Table of ContentAPPENDIX ISUMMARY........................................................................................................................ 3BACKGROUND INFORMATION ................................................................................... 3METHODS FOR ESTIMATING THE COST AND IMPACT OF THE PROPOSEDINVESTMENT FRAMEWORK ........................................................................................ 4 Impact and effectiveness of interventions....................................................................... 5 Coverage targets.............................................................................................................. 6 Projections of the number of HIV infected people in need and receiving ART............. 8 Estimated cost of programme activities........................................................................ 11 Assumptions about the cost of HIV interventions .................................................... 11 Estimated cost of counseling and testing (C&T) ...................................................... 12 Estimated cost of treatment, care and support .......................................................... 13 Assumptions about the cost and changes in cost of ART..................................... 13 Estimated costs for IDU interventions...................................................................... 15 OST: Coverage targets lower and middle income countries ................................ 16 Unit cost of OST ................................................................................................... 17 NSP: coverage targets lower and middle income countries.................................. 18 Estimated cost of PMTCT ........................................................................................ 19 Screening............................................................................................................... 19 Family Planning .................................................................................................... 19 CD4 Testing .......................................................................................................... 20 Prophylaxis for HIV infected pregnant women .................................................... 20 ART for mothers who need it for their own health............................................... 21 Early infant diagnosis ........................................................................................... 22 Cotrimoxazole Prophylaxis................................................................................... 22 Estimated cost of Behavior Change programmes..................................................... 22 Estimated cost of community mobilization .................................................................. 23 Estimated cost of programme support functions .......................................................... 24 Estimated cost for synergies with development sectors ............................................... 24 Costing Spreadsheets .................................................................................................... 26APPENDIX II: THE SYNERGISTIC IMPACT OF CRITICAL ENABLERS.............. 28APPENDIX III: ESTIMATED CONTRIBUTION OF TREATMENT TO REDUCINGTRANSMISSION ............................................................................................................. 30APPENDIX IV: INFORMATION ON NEW PREVENTION TECHNOLOGIES ......... 32APPENDIX V: RELEVANT TERMS AND DEFINITIONS......................................... 34 Basic Programme Activities ......................................................................................... 34 Treatment care and support for PLWH (including facility-based testing) ............... 34 Prevention of mother-to-child transmission (PMTCT)............................................. 34 1 26/05/2011
    • Male circumcision..................................................................................................... 34 Condom promotion and distribution......................................................................... 35 Behaviour Change Programmes ............................................................................... 35 Component elements of social and behavioural change communication programmes ................................................................................................................................... 36 Key populations ........................................................................................................ 37 Sex work interventions ......................................................................................... 37 MSM programmes ................................................................................................ 37 IDU programmes .................................................................................................. 38 Critical enablers ............................................................................................................ 38 Social Enablers.......................................................................................................... 38 Political commitment and advocacy ..................................................................... 38 Laws, legal policies and practices......................................................................... 39 Community Mobilization...................................................................................... 39 Stigma reduction ................................................................................................... 40 Gender based violence .......................................................................................... 41 Local responses to change the risk environment .................................................. 42 Programme Enablers................................................................................................. 43 Community centered design and delivery............................................................. 43 Programme communication .................................................................................. 44 Management and incentives.................................................................................. 44 Procurement and distribution................................................................................ 44 Research and innovation ....................................................................................... 45REFERENCES ................................................................................................................. 46 2 26/05/2011
    • SUMMARYA new investment approach is proposed for the response to HIV. It is simpler and morestrategic than current approaches and is intended to support better management of theHIV response, both at national and international levels. The framework proposes threecategories of investment: a small number of basic programme activities scaled up toreach the relevant populations; a set of critical interventions that create an enablingenvironment for achieving maximum impact; and support for programmatic efforts set inwider health and development sectors related to AIDS. In this document we describe ingreater detail the methods used for estimating the annual cost of implementing theseprogrammes to achieve universal access to HIV treatment, care and support by 2015, aswell as estimating the potential future impact of the new investment strategy.BACKGROUND INFORMATIONEstimating the level of investments required for AIDS is being aligned with the timelineand methods to cost other health-related Millennium Development Goals (MDGs) for acomprehensive response to the epidemic. UNAIDS has conducted several exercises toestimate the resource requirements from all sources, including domestic and international,to respond to the HIV epidemic. The first estimates were prepared for the United NationsGeneral Assembly Special Session on HIV/AIDS (UNGASS) in 20011 and it wasinspired by the Secretary General’s call in Abuja for US$ 7-10 billion to fight AIDS,tuberculosis and malaria. It involved estimating the cost of HIV prevention and AIDScare needs in 135 low- and middle- income countries.2The second exercise was conducted for the UNAIDS Programme Coordinating Board inNovember 2002.3 Recognising that the global response was less than required to meetthe UNGASS goals in many countries by 2005, the achievement of programming levelsfor a comprehensive response was projected up to 2007. In view of plans for treatmentscale-up, two programmes important to health worker retention and morale, namelyuniversal precautions and occupational post-exposure prophylaxis, were added. Themedical injection safety4 which had not been specifically included as a preventionmeasure in the 2001 work was also added.The third set of estimates, published in the 2004 UNAIDS Report on the Global AIDSEpidemic, benefited from an extensive consultation through 9 regional/sub-regionalworkshops with over 155 experts drawn from 78 affected countries. It took into accountthe reduction in treatment costs and the streamlined public health model of servicedelivery for antiretroviral drugs.5 3 26/05/2011
    • In 2005, estimates initiated by a working group of the UNAIDS Reference Group onEconomics (URGE), were refined for the High-Level Meeting on “The Global Responseto AIDS: Making the Money Work – The Three Ones in Action”.6 These estimatesshowed global resource requirements of US$ 15 billion in 2006, US$ 18 billion in 2007and US$ 22 billion in 2008 for prevention, treatment and care, support for orphans andvulnerable children (OVC), as well as programme and human resource costs. Estimateswere also reported in 2009 in the UNAIDS publication “What Countries Need:investments needed for 2010 targets in low- and middle-income countries”.7Estimating resources needed for AIDS represents an ongoing activity aimed to improvethe methods and figures by incorporating the most recent data with each cycle in theestimation process. A set of standard definitions, methods and tools has been developedas a common reference for the working groups. The resource needs estimation process isaimed at ensuring the delivery of useful products, and involves coordination,consultation, standardization and estimation.The current investment framework benefits from the experience of the aids2031international consortium. The aids2031 project modelled long-term funding needs forHIV/AIDS in developing countries with a range of scenarios and substantial variation incosts: ranging from US$397 to $722 billion globally between 2009 and 2031, dependingon policy choices adopted by governments and donors.8 The results suggested thatcountries will move in increasingly divergent directions over the next 20 years; middle-income countries with a low burden of HIV/AIDS will gradually be able to take on themodest costs of their HIV/AIDS response, whereas low-income countries with a highburden of disease will remain reliant upon external support for their rapidly expandingcosts.METHODS FOR ESTIMATING THE COST AND IMPACT OF THEPROPOSED INVESTMENT FRAMEWORKThe resource needs and returns on investment of the proposed investment frameworkwere estimated for 139 low- and middle-income countries and summed to a global total.The resource needs estimate is the cost of increasing from current levels of coverage in2011 to achieve universal access target coverage levels by 2015 and maintain themthereafter. For the baseline scenario we assumed constant coverage at about presentfunding levels (estimated from analysis of spending data from national and internationalsources9) except for the reduction in ART drug costs which we assume would declineover time at the same rate as in the investment framework scenario. 4 26/05/2011
    • The basic programme activities provided directly to populations in need (such astreatment, male circumcision, or PMTCT) were costed by multiplying the number ofpeople in need of the service by the coverage (to determine the number of peoplereceiving the service) and multiplying the result by the unit cost of providing the serviceto one individual. The costs of support programs that do not provide a service directly toindividuals (such as advocacy, policy reform, stigma reduction, and management andadministration) were estimated as a proportion of the total direct costs.Estimates of the number of people in need of services were based on demographic datafrom the United Nations Population Division10 for services reaching the generalpopulation (e.g., PMTCT for pregnant women, male circumcision for men 15-49, testingand counseling for adult males and females). Estimates of the sizes of key populations,including sex workers, men who have sex with men (MSM) and injecting drug users(IDU) were based on national estimates provided to UNAIDS and published reviews ofstudies of size estimates.11-15Information on unit costs of providing services were based on published literature andadvice from experts from 58 countries participating in four regional workshops onresource needs in 2009.16 Regional or sub-regional averages for coverage levels and unitcosts were used for countries where there were no specific data. Coverage was scaled upfrom current levels to target levels by 2015 with targets for basic programme activities setas maximum plausible coverage level according to size of the relevant population. Moreinformation on coverage levels and unit cost is provided elsewhere in the document.Estimates of the annual number of people in need of treatment were based on anepidemic projection model17 that reproduces at a global level the country-specificestimates of need for treatment, given the assumptions on coverage scale-up reported bynational programs.18The estimated cost for the critical social and programme enablers as well as the synergieswith development sectors are described below.Impact and effectiveness of interventionsThe Goals model, developed by the Futures Institute,16,19 was used to assess the impact ofthe selected programme activities on the epidemic. The model considers male andfemales aged 15-49 years divided into six groups: not sexually active, low riskheterosexual (one partner), medium risk heterosexual (more than 1 partner in the lastyear), high risk heterosexual (female sex workers and male clients), MSM and IDU. The 5 26/05/2011
    • probability of acquiring a new HIV infection is determined by characteristics of the indexperson (number of partners), the partner (HIV status, stage of infection, ART use) and thepartnership (sex acts per partner, condom use, STI prevalence, heterosexual or MSMcontact, male circumcision status). Infected persons progress through a primary stage ofinfection with high infectivity, an asymptomatic stage with low infectivity, and asymptomatic stage with high infectivity, to AIDS death. Infectivity is reduced by ARTuse. The model includes a component to estimate the effects of prevention interventionson key behaviours based on a summary of the impact literature, described below.The model simulates the effect of biomedical interventions, such as male circumcisionand PMTCT, using trial data on effectiveness and simulates the effects of behaviourchange interventions using data showing the effect of exposure to these interventions onkey behaviour such as condom use, number of partners and age at first sex.Goals models had been prepared for 23 high burden countries, which together account for77% of the total HIV burden. The models for all these countries were updated with thelatest coverage information from the national 2010 UNGASS reports and with unit costsfrom the latest round of country estimates from the UNAIDS regional Resource Needsworkshops and from the AIDS2031 activities.20 Estimates of new HIV infections andAIDS deaths were extracted for the 23 countries and scaled up to obtain global estimates,matching the 2009 UNAIDS estimates.18An extensive literature review had been conducted to determine the impact of preventioninterventions in developing countries. An impact matrix was developed to classifyeffectiveness results into those prevention intervention categories that UNAIDS use toestimate resource needs,21 with the purpose to harmonize efforts among the variouselements of national strategic planning processes. This impact matrix, described in detailby Bollinger in 2008,21 provides the basis for the Goals model. In addition, it is assumedthat the probability per act of female to male transmission is reduced by 60% amongthose men who are circumcised,22-24 and that ART reduces transmission per sexual act by92% for those on ART.25Coverage targetsInformation on current levels of coverage was obtained from country UNGASS reports in2010 including data from published surveys (such as DHS) and information provided bynational programmes. This data can be accessed using AIDSinfo, a data visualization anddissemination tool used by UNAIDS to facilitate the use of AIDS-related data by countryand globally (available at: 6 26/05/2011
    • http://www.unaids.org/en/dataanalysis/tools/aidsinfo/). Regional averages were used forcountries where there were no specific data. Coverage was scaled up from current levelsto target levels by 2015, as shown in Table 1. Targets for basic programme activitieswere set as maximum plausible coverage level according to the size of the relevantpopulation, in many cases resulting in 80% coverage of the relevant activity. Coverage ofART is discussed in detail in the section below.In countries with well established opioid substitution therapy (OST) for injecting drugusers (IDU), coverage of about 20-40% can be achieved, and this target is included ininternationally endorsed target setting guidance, based on the levels of coverage whichhave been achieved in countries with established OST programmes.26-29 In countries (e.g.Western Europe and Australia) where these levels of coverage were reached HIVepidemics among IDU’s have stabilized or reversed,30 and a coverage target of 40% ofopioid injectors on OST by 2015 would be desirable. Based on historic evidence andcountry consultation and estimation we assume that we can determine two levels of OSTcoverage: it is anticipated that countries that have already introduced OST, such as Indiaand China, could arrive at a coverage level of 40% by 2015. However, countries that havenot yet introduced (or registered) OST, such as the Russian Federation, may implementOST after 2011 (assuming a coverage of 0% until 2011) and will reach a lower coverageof around 20% by 2015. More information on OST coverage and denominatorpopulations is provided elsewhere in this document.Table 1. Coverage targets for 2015 by epidemic type (*) Hyper-Endemic, Generalized, Concentrated Low level Low Circumcision Mixed epidemics epidemicsBasic Programs PMTCT 90% 90% 90% 90% Condoms (discordant 60% 60% 60% 60%couples)Condoms (medium risk 60% 60% 20% 20%populations) Condoms (high risk 50% 50% 50% 50%populations Sex work 60% 60% 60% 60% MSM 60% 60% 60% 60% IDU outreach 60% 60% 60% 60% IDU needle and syringe 60% 60% 60% 60%exchange IDU drug substitution 0% 0% 40% 40%* More detailed description of treatment coverage is provided below 7 26/05/2011
    • Projections of the number of HIV infected people in need andreceiving ARTEstimates of ART eligibility are based on the 2010 WHO guidelines,31 using evidencethat starting ART earlier (CD4≤350 cells/μL) is cost effective, improves health outcomes,and reduces HIV and tuberculosis transmission.The estimates of the number of people in need of treatment for the investment frameworkwere based on an epidemic projection model that reproduces at a global level the countryspecific estimates of need for treatment reported by national programs. The model isdescribed elsewhere by Stover et al.17 and estimates are consistent with those producedby UNAIDS using the model developed by the UNAIDS Reference Group on Estimates,Models and Projections.18 The model was used to estimate the number of people needingtreatment each year given assumptions about the scale up of coverage.The model tracks the HIV population by CD4 counts, assuming that all newly infectedpeople start with CD4 counts above 500, and that their CD4 cell counts decline over time.People progress from CD4 category to the next, while assumptions are made about thetransition probabilities and probability of death from HIV-related or non-HIV relatedcauses. The number starting ART each year is determined by the assumed coverage andthe number of people eligible for treatment.The total number of PLHIV eligible for treatment according to the latest WHO guidelinesis estimated to be about 18.3 million in 2015. In no society, and for no disease, are 100percent of those who might benefit from treatment actually treated as some of thoseeligible remain outside the health system (whether by choice or due to imperfect systemcoverage), refuse to take treatments, or cannot take treatments due to other conditions. Inthis light, universal access for ART is described herein as coverage levels of about 80%.If universal access targets are to be treated as serious programme goals and not merelyaspirational, modeling and cost assumptions need to better address programme realities.The models used in this analysis assume that 80% will be reached with a very rapidtreatment uptake once CD4 cell counts drop to 350, reaching the assumed maximumcoverage levels before CD4 counts drop to levels of 200 and below (Figure 1). The totalnumber of people estimated to be on treatment by 2015 will be 13 million. With bettertreatment models available and a shift to community and primary care delivery over thecoming decade, we assume that coverage will be further increased reaching levels of 90percent and more for those with severe symptoms of HIV disease (Figure 2). By 2020, atotal of 18.7 million (86%) of the 22 million eligible under the current guidelines areassumed to be on treatment (Figure 3). 8 26/05/2011
    • 100% 90% 80% 70% 60% Coverage 50% 40% 30% 20% 10% 0% >500 350‐499 250‐349 200‐249 100‐199 50‐99 <50 350 CD4 Count (cells/ml) CD4 CD4 CD4 CD4 350-500 250-350 200-250 <200 Treatment coverage 5% 45% 70% 80%Figure 1. ART coverage in 2015 by CD4 count, as assumed in the Investment Framework 9 26/05/2011
    • 100% 90% 80% 70% 60% >500 350‐499 50% 250‐349 40% 200‐249 30% <200 20% 10% 0% 1995 2000 2005 2010 2015 2020 2025Figure 2. Assumed coverage of ART by CD4 category 20 Millions 18 16 14 12 10 8 6 4 2 0 2005 2010 2015 2020 Figure 3. Projected number of adults receiving ART over time 10 26/05/2011
    • Estimated cost of programme activitiesAssumptions about the cost of HIV interventionsWe assumed that unit costs for some services would decline as programmes expand, dueto economies of scale and changes to more efficient service provision modalities inparticular through community approaches. Although there is limited information onchanges in unit costs over time, recent work indicates that substantial economies of scaleare likely to exist.32 Unit costs of providing population-based services were provided byexperts from 58 countries participating in four regional workshops on resources needs in2009.16Tables 2 provides estimates of the unit costs of key interventions by region in 200916while assumptions about the ART costs over time are described below. In addition, unitcosts for interventions by country are provided in the Excel Spreadsheet (UnitCosts.xlsx)available on-line. Table 2. Median unit costs (US$) of key interventions by region, 2009 Condom Promotion Outreach Outreach PMTCT PMTCT and for sex for Screening** Prophylaxis*** Distribution workers* MSM* Per Sex Per Woman Per Woman Per Condom Worker Per MSM Screened Receving ARVs Distributed Reached Reached Sub-Sahara Africa 4.48 607 0.18 20.24 25.97 East Asia and the Pacific 3.93 1564 0.09 49.38 62.24 South and South-east Asia 3.92 848 0.08 33.38 41.87 Eastern Europe 3.92 2204 0.23 60.02 69.32 North Africa and Near East 3.90 2265 0.25 71.92 76.17 Latin America and the Caribbean 3.97 1721 0.27 55.26 65.78 * Interventions marked with * have declining unit costs with increasing scale. **Assumes $3.90 per woman screened and found to be HIV-negative and $13 per woman screened and found to be HIV-positive ***Assumes costs in 22 focus countries in sub-Saharan Africa of $237 for Option A, $705 for Option B, $20 for CD4 counts, $3 for community mobilization, $33 for early infant diagnosis, $5 for Cotrimoxazole. For all other countries costs are adjusted for purchasing power. More information is provided below. 11 26/05/2011
    • Outreach and Opiod Social and needle/syringe substitution behavior Counseling exchange for therapy Male change and Community IDU (2011*) circumcision communications testing* mobilization Per IDU Per IDU Per Person Per National Per Person Reached Reached Circumcised Campaign Per Client ReachedSub-Sahara Africa 23.43 1,008.00 59.10 809,775 14.87 3.38East Asia and thePacific 64.77 1,008.00 195,007 26.00 2.27South and South-east Asia 24.49 1,008.00 3,475,231 14.66 1.31Eastern Europe 36.37 1,008.00 262,515 15.58 2.62North Africa andNear East 44.35 1,008.00 479,354 20.15 2.62Latin America andthe Caribbean 71.36 1,008.00 467,342 14.53 3.16* unit costs for OST ae assumed to decrease by 20 percent by 2015 and 50% by 2020Estimated cost of counseling and testing (C&T)The average unit cost of counseling and testing per region is provided in Table 3. Theseestimates are associated with coverage of C&T and costs generally decline withincreasing coverage, as shown in Figure 4.32 Cost per client counselled and tested $90 $80 $70 $60 $50 $40 $30 $20 $10 $0 0% 5% % % % % % % % % % % % % % % % 01 03 05 20 40 75 15 25 35 45 55 65 75 85 95 0. 0. 0. 0. 0. 0. Coverage Figure 4. Declining cost per client with increasing coverage of counseling and testing 12 26/05/2011
    • The following approach is assumed in the investment framework to determine the amountof testing undertaken within the health sector: 1. Provider initiated counseling and testing (PICT): we assume that for each person starting treatment at least three would be tested for differential diagnosis. This approach would most likely identify the patients coming to the clinics with advanced stages of HIV disease (CD4 cell counts below 200/ μL). 2. Pregnant women: It is assumed that all pregnant women in sub-Saharan Africa will be tested for HIV, except those already known to be HIV positive. We assume that 60% of HIV positive women will have CD4 cell counts above 350/μL. 3. STI patients: It is assumed that all people diagnosed with an STI will be tested for HIV. Testing among symptomatic STI patients is assumed to find HIV+ cases at a rate 3 times higher than the HIV prevalence rate. In addition to the testing in health care settings, there is wider population testing. This can happen as part of VCT or community mobilization, as described elsewhere in the document. With our assumption of gradually moving from VCT modalities to community testing approaches we assume that the number tested through VCT will drop from 230M in 2010 to 60M in 2015. The number tested through community mobilization will increase from 46M in 2010 to 109M in 2015. It is assumed that the overall detection rate of PLWH will increase through more focused testing approaches. Globally, an assumed 316 million people will receive an HIV test in 2015 either in health settings, VCT clinics or community settings, broken down as follows: VCT 60 million, community mobilization 109 million, sex workers 6 million, IDU 7 million, MSM 18.5 million, people with HIV related symptoms 2.5 million, PMTCT 111 million, STI 1.6 million. Estimated cost of treatment, care and supportThe Investment Framework methodology to estimate resources required for treatment,care and support has been revised to be consistent with the Treatment 2.0 initiative.33 Weassume that people who start ART early do not require the treatment and prophylaxis foropportunistic infections (OI) that would be required otherwise. Other OI costs areincluded in the estimated “end-of-life” costs of $228 per patient. These are estimated atthe time of death but reflect both pre-ART and pre-death treatment costs. 13 26/05/2011
    • Assumptions about the cost and changes in cost of ARTBased on past trends in ARV prices and the possibilities of new, less expensive drugcombinations in the future, we assumed that the average cost per patient on first line ARTwould decline by about 65% by 2020. We assume that less expensive diagnostic tests thatcan be used at point-of-care and task shifting of treatment would lead to averagereductions of 60% and 40%, respectively, in laboratory and service delivery costs(weighted across low income, lower middle income and upper middle income countries)by 2020. Substantial savings are expected from a reduction in the frequency of visits tofacility-based services with the use of more potent, less toxic and resilient antiretroviralschemes. We assumed a reduction in the number of outpatient visits, from publishedaverages to four check-ups per year, most of them based on community support activities.It is also assumed that the service delivery costs in lower-middle and upper middleincome countries do not decline at the same rate as these countries are unlikely to switchto a community-based model. The costs in low-income countries decline to $17 perpatient per year (assuming reduction from 12 visits per year to 4 plus some migration totask shifting approaches reducing average salary costs by half. The result is that theweighted average service delivery costs decline from $176 in 2010 to $125 by 2020.We also considered changes in the costs of testing programs as a result of shifting fromfixed facilities to community-based approaches. Given recent available data fromdeveloping countries these reductions seem plausible. Per-person ART costs in largescale PEPFAR programmes have fallen as implementation experience has grown. InSouth Africa and Zambia costs fell by half or more over time, and quality was notimpaired when services shifted to lower level delivery sites34 and in five other countries(Botswana, Ethiopia, Nigeria, Uganda and Vietnam) median per-patient costs 24-29months after programme initiation were 37% of their levels in the first 5 months.35Similarly, large scale ART programmes implemented by Médecins Sans Frontières inMalawi have been delivered at $237 per patient/year, with ARV medicines representingtwo-thirds of the total cost: a level far below countries with smaller numbers of peoplereceiving ARVs and lower than costs in Malawi when the numbers of persons receivingARVs was lower.36 The significant majority of the cost savings will occur after 2015 withan increasing shift to primary care and community based approaches and cheaper point ofcare diagnostics. Average costs and assumed changes over time are provided in Table 3.Drugs: A weighted average of drug costs for four different first-line regimens and twodifferent second-line regimens is used, weighted by the proportion of patients on eachregimen.37,38 Separate prices are available for low-income and middle-income countries.The cost of both 1st and 2nd line drugs for middle-income countries is assumed toincrease/decrease at the same rate as the cost for low-income countries. 14 26/05/2011
    • Laboratory costs have been calculated as the annual median cost for laboratory tests across countries as obtained from recent literature, including studies from Cote d’Ivoire, Ethiopia, Mexico, Nigeria, Rwanda, South Africa, Thailand, Zambia.39-48 The median cost in 2010 is estimated at $180 (USD) per patient, decreasing to less than $80 by 2020 . Service delivery costs: Studies of service delivery costs conducted by PEPFAR found a range from $79 per patient per year to $345. We used an average cost (weighted across low income, lower middle, and upper middle income countries) of about $180 per patient per year in 2010, declining to $112 by 2020.Table 3. Average cost of ART (US$) and estimated changes over time   Cost per Patient Per Year 2010 2015 2020 Labs: new patients 180 129 79 Labs: continuing patients 180 128 76 Service delivery: weighted average 176 144 112 Low income countries 103 60 17 Lower middle income countries 181 136 91 Upper middle income countries 332 332 332 Procurement 20% 13% 5% End of life care 228 228 228 ARV Prices 2009 2015 2020First Line ARVs Low income countries 137 130 50 Lower middle income countries 141 134 51 Upper middle Income countries 202 192 74 Weighted average 155  147  57 Second Line ARVs Low income countries 853 500 150 Lower middle income countries 1378 808 242 Upper middle Income countries 3638 2,132 640 Weighted average 1678 984 295 Estimated costs for IDU interventions In addition to responses which apply to other populations (such as HIV testing and counseling and ART) the main interventions for the prevention, treatment and care of HIV/AIDS among injecting drug users (IDUs) are needle and syringe programmes (NSP), and drug dependence treatment including opioid substitution therapy (OST). NSP is a well-established intervention which has been extensively studied and found to reduce HIV incidence and self-reported risk behaviours. Similarly OST is a critical component 15 26/05/2011
    • of IDU programmes and has been proven to reduce risk behaviours, stabilize drug users’lives with consequent improvement in access and adherence to HIV/AIDS treatment andcare and to reduce the incidence of HIV.49The assumed denominator populations used in our estimations are 13.5 million opiateusers in low and middle income countries and 10.3 million injecting drug users (allsubstances) in low and middle income countries. These estimates are based on theUNODC World Drug Reports50 and estimates prepared under the auspices of the UNreference group on HIV and injecting drug use.13It is assumed that the size of the denominator populations will remain stable at currentlevels by the year 2015, while coverage levels will be increasing.OST: Coverage targets lower and middle income countriesUsing information from countries with well established OST programmes, approximately40% of opioid dependent persons can be covered in treatment programmes.26,27 Incountries where these levels of coverage have been reached, HIV epidemics among IDUshave generally stabilized.51 We have therefore assumed the desirable target of opioidinjectors on OST by 2015 to be 40%, consistent with the WHO/UNODC/UNAIDS targetsetting guide for injecting drug users.When using a denominator population of 8.1 million opioid injectors in our calculationsof coverage and cost estimates for OST, it is assumed that priority is given to scaling upOST to opioid injectors. However, consideration needs to be given to the fact thatdependent opioid users who do not inject also benefit from OST and providing OST tothem could prevent the transition to starting to inject opioids. Hence 8.1 million is aconservative estimate.Based on historic evidence and (limited) country consultation and estimation we furtherassume that we can determine two levels of coverage: it is anticipated that countries thathave already introduced OST, such as India and China, will arrive at a coverage level of40% by 2015. However, countries that have not yet introduced (or registered) OST, suchas the Russian Federation, may implement OST after 2011 (assuming a coverage of 0%until 2011) and will reach a lower coverage of around 20% by 2015. Countries that haveimplemented OST with methadone and or buprenorphine and that can be expected toachieve (or have already achieved) 40% coverage by 2015 are shown below in Table 4. 16 26/05/2011
    • Based on the above coverage targets for OST in low- and middle-income countries weassume that approximately 2.7 million injectors will be on OST by 2015, a considerablescale up from the approximately 300,000 on OST in 2009.28Table 4. List of countries that have implemented OST by 2010Countries in which Methadone maintenance Countries in which Buprenorpinetreatment is available maintenance treatment and/or detoxification is available (including pilot programmes)Albania, Andorra, Australia, Austria, Azerbaijan, Australia, Austria, Belgium, Bulgaria, ChinaBelgium, Bosnia and Herzegovina, Bulgaria, (Hong Kong), Czech Republic, Denmark,Canada, China, Croatia, Czech Republic, Estonia, Finland, France, Germany, Greece,Denmark, Estonia, Finland, France, Georgia, Iceland, India, Indonesia, Iran, Israel, Italy,Germany, Greece, Hungary, Indonesia, Iran, Latvia, Lebanon, Lithuania, Luxembourg,Ireland, Israel, Italy, Kyrgyzstan, Latvia, Malaysia, Netherlands, Norway, Portugal,Liechtenstein, Lithuania, Luxembourg, Singapore, Slovak Republic, Slovenia, SouthMacedonia, Malaysia, Malta, Mexico, Moldova, Africa, Sweden, Switzerland, Ukraine,Myanmar, the Netherlands, New Zealand, United Kingdom, United States of America.Norway, Poland, Portugal, Romania, San Marino,Serbia, Slovak Republic, Slovenia, Spain,Sweden, Switzerland, Thailand, United Kingdom(plus overseas territories/dependencies), UnitedStates of America, Ukraine (about to start)Based on current levels of utilization and assumption that the relatively less expensivemethadone will be used in preference to buprenorphine it is assumed that of thosereceiving OST in low- and middle-income countries, 80% will be on methadone and 20%on buprenorphine.Unit cost of OSTUnit costs include programme costs directly related to delivery of methadone orbuprenorphine and medication costs and not the costs covered elsewhere, such as HIVtesting and counselling.Cost of Methadone: USD 1.00 – 2.90 per patient per day (medication costs 33c for 80mgin Iran to $2.06 for 80mg in Indonesia). Range: USD 363.65 – 1,057 per patient per year.Cost of Buprenorphine (only low dose estimates available 4-10mg per day, as comparedto recommended doses of 12-24mg) USD 3.39 – 8.68 per patient per day (medication 17 26/05/2011
    • costs $2.72 for 10mg in Iran to $7.84 for 8mg in Indonesia). Range: USD 1,236 –3,166.70 per patient per year.The non medication costs include salaries and to a lesser extent pathology tests (mainlyurine drug screens). These estimates do not include the costs of building clinics ortraining staff. The estimates are based on ongoing maintenance treatment, and do notinclude the additional costs involved with commencement of treatment and therapeuticwithdrawal from treatment.Based on the above, an average current cost of $1,008 per IDU reached per year wasassumed in the Investment Framework models. It was further assumed that the costs ofOST will be reduced by 20% by 2015 and by 50% by 2020.  NSP: coverage targets lower and middle income countriesBased on a retrospective analysis of the coverage required to reverse the HIV/AIDSepidemic among IDUs in New York52 and coverage rates typically reached in thoseEuropean countries that averted or reversed epidemics, coverage of 60% or more of IDUsregularly reached (more than once a month) is considered very good.28 In Odessa in theUkraine, where prevalence among IDUs had already reach very high levels by 2000,60% NSP coverage showed a reduction in HIV prevalence by 4% over a 5 year period.42The projected coverage target for all IDUs in regular reach of NSP in the InvestmentFramework models have therefore been set at 60% by 2015.A denominator population of 10.3 million IDUs in low and middle income countries (asdescribed above) was used in our calculation of coverage and cost estimation for NSPs.Regular reach is defined as an IDU being in contact with an NSP more than once amonth. Our estimated coverage target for IDUs in NSP programmes is thereforeestimated at about 6 million by 2015. The unit costs for NSP, which is assumed to declinewith increasing coverage levels (see Figure 5), was assumed to be between 7-10 USD perperson per year. 18 26/05/2011
    • $50.00 $45.00 $40.00 $35.00 $30.00 Unit cost $25.00 $20.00 $15.00 $10.00 $5.00 $- 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% NSP coverageFigure 5. Unit cost of NSP by level of coverageEstimated cost of PMTCTScreeningThe estimation assumes that 90% of pregnant women will be provided with at least oneHIV screening test to ascertain her HIV status. However, women who test positive willalso be provided with counseling services to help them decide on future courses of actionfor the benefits of themselves and their unborn children. With PEPFAR estimates of thecost of VCT services in low-income settings ranging between US$3.90 and US$20 perperson, we used a weighted average cost of US$ 3.90 for the cost of HIV serological testsper woman for all HIV negative women. For HIV positive women in the population weassumed the cost of testing and counseling to be US$ 13 per woman. An additional 10%was included to take account of other programmatic costs related to the services.Family PlanningFor family planning costing, we used standard published methods. To avoid doublecounting family planning is included as part of the health systems component in themayor synergies. However, it is also an important cost item of PMTCT services and aclear distinction is made whenever necessary. Prevention of unintended pregnancies 19 26/05/2011
    • among HIV infected women of reproductive age were calculated by multiplying thepopulation of women with unmet need for family planning (15-49 years) by the numberof HIV pregnant women in each country. This number is then multiplied by the annualaverage cost of providing family planning per woman. Family planning was estimated tocost US$ 20 per woman per year.53CD4 TestingIn line with the 2010 WHO guidelines on PMTCT,54 all women who test positive for HIVshould ideally undergo CD4 cell count screening in order to identify those women whorequire lifelong antiretroviral treatment. The new WHO guidelines stipulate that womenwhose CD4 counts are below 350cells/μL are to commence lifelong antiretroviraltherapy. To ensure that all women who require ART for their own health are identifiedand treated, it is recommended that CD4 testing should be included in the essentialpackage of care for HIV-infected pregnant women. We assumed that 90% of HIVpositive women in the population will have access to CD4 testing at an average cost ofUS$ 20. This is an average across the high-burden countries and does not include start-upcosts, laboratory upgrades or the cost of additional machines. For the purpose of thisanalysis, we only used the cost of the laboratory tests.Prophylaxis for HIV infected pregnant womenIn the 2010 WHO guidelines on antiretroviral treatment for pregnant women andpreventing HIV infection in infants,54 there are two recommended treatment options forwomen not eligible for ART i.e. women with CD4 counts > 350cells/μL; Option A andOption B.WHO Option AThe mother is given ante-partum AZT twice per day starting from as early as 14 weeks ofgestation and continued during pregnancy. At the onset of labour, she may be given sd-NVP and initiation of twice daily AZT + 3TC for 7 days postpartum. If maternal AZTwas provided for more than 4 weeks antenatally, omission of the sd-NVP and AZT +3TC tail can be considered; in this case, continue maternal AZT during labour and stop atdelivery. For breastfeeding infants, administration of daily NVP from birth for aminimum of 4 to 6 weeks, and until 1 week after all exposure to breast milk has ended.For infants receiving replacement feeding only, administration of daily NVP or sd-NVP +twice-daily AZT from birth until 4 to 6 weeks of age. 20 26/05/2011
    • WHO Option BThe mother is given triple ARV prophylaxis starting from as early as 14 weeks ofgestation and continued until delivery, or, if breastfeeding continued until 1 week after allinfant exposure to breast milk has ended. Recommended regimens include: AZT + 3TC + LPV/r or AZT + 3TC + ABC or AZT + 3TC + EFV or TDF + 3TC (or FTC) + EFVIrrespective of the mode of feeding for the infant, the infant is administered daily NVP ortwice daily AZT from birth until 4 to 6 weeks of age.Costing of Options A and BIn line with WHO guidelines,54 we estimated costs assuming a breastfeeding duration of12 months. Therefore, if women started receiving antiretroviral prophylaxis at 14 weeksgestational age, it means they will receive the drugs for a period of 18 months in total.We further assumed that on the average, at least 40% of HIV positive women will beeligible for ART for their own health.55 Therefore, 60% of infected women will requireantiretroviral prophylaxis using option A or B. As most countries still use a combinationof single and dual drug regimens, the 60% of HIV positive women not eligible for ARTwas split into 36% receiving Option A (dual prophylaxis) and 24% receiving Option B(triple prophylaxis). The total cost for women using Option A used is US$ 237 andconsists of $30 for AZT+3TC, $63 for NVP, $54 for laboratory tests and $90 for servicedelivery. The total cost per women using Option B used is $ 470 which consists of $149for ARVs, $180 for laboratory tests and $141 for service delivery. When this ismultiplied for an 18 month period, we get a total cost of $705 per women.17,56ART for mothers who need it for their own healthTreatment for mothers is a comprehensive package that includes antiretroviral therapy,laboratory monitoring and delivery cost in health facilities at a cost of US$ 600 permother per year. We assumed that 40% of the women would have CD4<350 cells//μLand are therefore eligible for full antiretroviral therapy. Women who require ART fortheir own health are assumed to receive triple therapy according to the WHO Guidelines.The unit costs made for mothers who need treatment for their own health are consistentwith the assumptions made for all adults receiving ART as described above. Following12 months of breastfeeding, it is assumed that HIV-infected women (post-natal) whorequire ART for their own health are transferred to ART centres for the continuation oftreatment. This assumption is to avoid double counting in relation to other estimates foradults receiving ART. 21 26/05/2011
    • Early infant diagnosisAll children born to HIV-infected mothers have maternal HIV antibodies which may bedetectable in the first six months of life. Therefore, immunological assays performedearly in infants may only detect HIV exposure in infants. HIV infection in infants isdiagnosed by detecting the presence of viral nucleic acid (viral RNA or viral DNA) orother viral products such as p24 Ag. Polymerase chain reaction (PCR) – based HIV DNAhas become the most widely used assays in resource-limited settings for both diagnosticand monitoring purposes. For the purpose of this costing analysis, 90% of all infantsexposed to HIV through their mothers are assumed to have access to early infantdiagnosis and the cost of PCR-DNA test per infant was assumed to be US$ 32.50.Cotrimoxazole ProphylaxisCotrimoxazole prophylaxis is considered part of an additional package of care for HIVpositive women and essential for the postpartum treatment of infected infants.Cotrimoxazole prophylaxis is used to reduce the incidence of opportunistic infectionsparticularly in women with low CD4 counts and to prevent the development ofopportunistic infections in infants and it is a proven cost-effective measure forimprovement of the quality of life of persons living with HIV/AIDS. Therefore, all thewomen eligible for treatment for their own health, as well as all infants, are assumed tobe given cotrimoxazole prophylaxis for a period of 6-12 months. The cost ofcotrimoxazole was assumed to be US$5 per person per year.Estimated cost of Behavior Change programmesBehaviour change in generalized epidemics, such as delaying the initiation of sex orpartner reduction, affects the likelihood of exposure and it is axiomatic that reducingthese behaviours reduces the likelihood of transmission. Furthermore, the importance ofbehaviour change has been confirmed as a plausible explanation for changes in incidencederived from ecological studies that explain past successes in HIV prevention.57-61 Forthis reason, behaviour change appears as a discrete basic programme activity –notwithstanding the challenge of amassing consistent, direct and generalizable evidenceon the impact of different elements of behaviour change programmes.62,63,64 The mostefficacious interventions to accomplish such changes are less well established, butinclude programs of interpersonal and group communication delivered through themobilization of civil society, faith based organizations and in the work place. 22 26/05/2011
    • Limited information is available on costing of such programmes. For the purpose of thisexercise, the cost of workplace programmes have been used as a proxy to arrive at aplausible overall estimate of resource needs for Behavior Change programmes includedin Basic Programme Activities of the investment framework. Work place programstypically include services such as the provision of condoms, counseling and testing andSTI treatment services either provided on site or through a near by health clinic, as wellas health education provided through peer educators. To arrive at an overall estimate ofresource needs, we assumed the proxy of workplace programs in 2015 to be scaled up to50% coverage of the 148 million employees in the formal sector in countries withgeneralized epidemics, with an average unit cost of US$ 9 per employee per year.Estimated cost of community mobilizationCommunity mobilization, which underlies many of the critical enablers, has objectivesessential to an effective AIDS response. These objectives include: community outreachand engagement, support, advocacy and transparency; community-driven approaches inoutreach and engagement activities that successfully connect people facing similar issuesand engage them in a broad spectrum of HIV-related interventions thus leading toimproved uptake and use of many of the basic programme activities (e.g. HIV-specificeducation, behavioural change, access to condoms and clean syringes, ART); supportactivities that target people already engaged in care and enhance quality, adherence andimpact in a range of settings such as people who are on treatment, engaged in harmreduction or drug treatment services, or who are already using sexual and reproductivehealth services; advocacy, transparency and accountability efforts, such as local-leveladvocacy to ensure that high-quality health services are available and accessible tovulnerable populations. The cost of community mobilization, as one of the critical enablers, was estimated in twoways. First, in generalized epidemics, it was estimated from the number of people inneed, coverage levels, and unit costs based on data on community health workerprogrammes. In the case of concentrated epidemics, the costs of community mobilizationwere subsumed into the costs of outreach for key populations and thus included underbasic activities for these populations.Recent unit cost data, supplied in 2009 by 59 countries in workshops sponsored byUNAIDS, suggest a unit cost for community mobilization in HIV ranging between lessthan US$ 1 and US$ 14.65 A comprehensive literature search for community-baseddistribution of various services and commodities, including community-based care, child 23 26/05/2011
    • health interventions, and safe water systems, found that the median unit cost, excludingcommodities, in 2009 US dollars was US$ 0.88 (mean: US$ 2.06).66-73 This unit cost isconsistent with the range described above for community mobilization efforts in HIV.We applied the unit cost for community mobilization as provided by the country expertsand applied regionally where no data were available. The country-specific unit costs canbe found in the attached models. These unit costs were applied to the total adultpopulation to arrive at an overall cost for community mobilization. The model alsoassumes that all people reached by community workers receive an HIV test every twoyears for an additional cost of US$ 1 per test. The framework assumes that majorefficiency gains are possible through shifting service provision modalities to place greateremphasis on community mobilizationEstimated cost of programme support functionsAssessments of total HIV expenditures and expenditures for program support functions18indicate that expenditures for program support range from under 10% to over 60% withan average of 12.6%. For this analysis we assume ongoing improvements in efficiencyand use 10% of direct expenditure on basic programme activities as the total average forall programme support functions. This includes programs for political commitment andadvocacy, legal reform, human rights, stigma reduction, management, research andinnovation, monitoring and evaluation, communications, procurement and logistics.Estimated cost for synergies with development sectorsThe cost for major synergies is the least specific of the estimates included. For theinvestment framework we assessed existing expenditure data on systems strengtheningactivities and made a cost estimate for specific interventions such as blood safety, STItreatment, school based education, support to the most vulnerable populations includingorphans, and gender programmes. Unit costs were based on estimates from countryreports from the regional UNAIDS Resource Needs workshops, as shown below in Table5. Total costs for programs to combat gender-based violence and to support AIDSorphans were adopted from previous resource needs estimates.The financing needed to achieve better synergies with development sectors, particularlyin gender, health, education and social protection sectors, is estimated at US$ 3.59 billionin 2011, increasing to about US$ 5.43 billion investment by 2020. The estimatescomprise gender based violence programmes (increasing from US48.5 million in 2011 to 24 26/05/2011
    • nearly US$1 billion in 2020), a number of health sector elements including familyplanning, STI management, blood safety, post-exposure prophylaxis, safe injections anduniversal precautions (increasing from a total of US$1.3 billion in 2011 to US$2.7 billionin 2020), youth in schools programmes (US$64 million in 2011 to US$118 million in2020), and support for children orphaned by AIDS (declining from US$2.1 billion in2011 to US$1.5 billion in2020).While this framework does not intend to be prescriptive about spending to supportsectoral synergies, this estimate is consistent with current funding approaches to systemsstrengthening, for example by the Global Fund.Table 5. Median unit costs (US$) of programs classified as Major Synergies, 2009 North Latin East Asia South and Africa and America Sub-Saharan and the South-East Eastern Middle and Africa Pacific Asia Europe East CaribbeanSchool-based AIDSeducation (per student) 15.98 27.44 11.33 15.30 18.76 14.53Family planning (per FPuser) 20 20 20 20 20 20Prevention in prisons (perprisoner) 29.28 35.00 65.39 22.13 27.65 15.83STI management* (percase treated) 25.69 101.72 66.53 160.26 811.66 68.22Blood safety (per unit ofblood transfused) 8.54 6.32 4.19 13.73 17.41 17.32Post-exposure prophylaxis(per case) 34.01 94.60 97.48 95.56 125.00 124.69Safe medical injections(per injection) 0.22 0.16 0.15 0.22 0.03 0.07Universal precautions (perhospital bed) 303.18 336.86 180.19 66.97 58.98 154.12 25 26/05/2011
    • Costing SpreadsheetsExcel spreadsheets that were used for the Investment Framework calculations areavailable from the authors on request. The approach was based on the assumptions thatthe number reached is estimated by the population times coverage, while resource needsis estimated by the number reached times the unit costs.The spreadsheets include:  PopData.xls : This spreadsheet contains population data. Different worksheets show the different target populations.  Behavior.xls: This spreadsheet includes additional information for calculations including ANC coverage, units of blood needed per 1000 population, % casual sex, coital frequency, injections per person, proportion married.  Coverage.xls : The spreadsheet includes coverage targets and different worksheets are used for the different interventions. The coverage targets for different scenarios are specified in the Goals worksheet.  NumberReached.xls : This spreadsheet provides the numbers reached by each intervention. Different worksheets are used for different interventions. Most of the worksheets simply show the result of population x coverage. The number of people on ART (Figure 3) is drawn from the Goals model applications.  UnitCosts.xls : Different worksheets are used with the unit costs specified for different interventions. Most are constant over time while a few are assumed to change with scale. ART is shown by country type (low / middle income) rather than by individual country.  ResourceNeeds.xlsm : This spreadsheet shows the estimated resources that are required for the investment framework, by intervention. Different worksheets show country estimates for the different interventions. Charts and summary tables are also shown.To use the spreadsheets, all five spreadsheets should be opened in Excel in order(PopData, Coverage, NumberReached, UnitCosts, ResourceNeeds). The first time this isdone the spreadsheets may need to be re-linked if the links are not automatically updated.Warnings  The analysis is intended to provide estimates of resource needs at the global level. Results for individual countries will require further work and confirmation.ResultsResults are shown in the spreadsheet “ResourceNeeds.xlsm”. The following worksheetsinclude results: 26 26/05/2011
    •  Results table. Results for all countries are summed together by intervention. Summary by County. The results by country for all interventions are shown for the 22 countries for which we did Goals applications.  Country by Intervention. The name of a single country can be entered in the yellow cell, B1, to see the resource needs for that country. If it is not one of the 23 Goals countries then resource needs for ART will not be shown.  Summary by Scenario. This worksheet shows the total resources needed for all countries by major component (prevention, treatment, mitigation, support, structural interventions) and by scenario.Scenarios. The coverage scenarios can be changes in the Coverage spreadsheet, in theGoals worksheet in cell B2. This will change the coverage to the specified scenario,according to the table in the Coverage.xls spreadsheet, Goals worksheet. The region orcountry can also be changed in the yellow cell B3, but if a country is chosen that is notone of the 23 Goals countries ART costs will not be available. 27 26/05/2011
    • APPENDIX II: THE SYNERGISTIC IMPACT OF CRITICALENABLERSCritical enabling factors can have a substantial impact on HIV incidence for a low cost ifthey help change, for the better, the proximate determinants of HIV transmission.Quantifying the link between such enabling activities, implemented at a community level,and individual changes in risk behaviour is difficult, but recent studies provide examplesthat can be examined in mathematical model projections. Community mobilisation, alongwith mobile voluntary HIV counselling and testing and post-test support services,increased HIV testing rates four-fold in Tanzania, Zimbabwe, South Africa andThailand.74 Therefore, increased testing could potentially reduce HIV incidence if moreof those who are infected know their status and increased condom use or initiatetreatment (on time for clinical need). Furthermore, in Kenya, a four-fold greater odds ofreporting consistent condom use over the previous 12 months was associated with livingin areas with good engagement of community-based organizations.75 These factors wereincluded in a model representing the population of KwaZulu-Natal to explore how theimpact of a hypothetical ‘core’ circumcision intervention might be enhanced by enablinginterventions that result in greater HIV testing and condom use (Figure 6). In the modelscenario, the core intervention averted 240,000 infections over ten years but key enablinginterventions could, for modest marginal increase in costs, avert an additional 180,000infections. 28 26/05/2011
    • Core + EnablersInterventions Core 0 100 200 300 400 500 Number of infections averted, 2012-2022 (1000s) Figure 6: A model of the HIV epidemic in Kwazulu-Natal, South Africa, was used to calculate the number of new HIV infections that would be averted by a “Core” intervention (70% of the uncircumcised men are circumcised over a 5 year period) and the same core intervention in tandem with some key enabling intervention – “Core+Enablers” – (including community mobilization, post-test support) that had the net effect of increasing testing rates (by four-fold) and increasing the odds of condom use across the community by 1.5-fold. Model description can be found (Alsallaq et al, Forthcoming). 29 26/05/2011
    • APPENDIX III: ESTIMATED CONTRIBUTION OF TREATMENTTO REDUCING TRANSMISSIONThe infectiousness of HIV is correlated with the levels of virus in the infected individual,which means that infectiousness increases as disease progresses and viral replication isless constrained. Further, the reductions in viral load associated with ART have beenshown to reduce infectiousness in observational studies.25,76 Promptly initiated treatmentfor clinical need should therefore lead to reductions in transmission. Severalmathematical modelling exercises have estimated the proportion of onward transmissionthat, in the absence of treatment, would come after the point when ART should normallybe initiated (Figure 7). These suggest that once an HIV epidemic has matured to nearendemic levels approximately 30% of infections are generated by those with CD4 cellcounts < 200 cells/µL and approximately 50% of infections are generated by those withCD4 cell counts < 350 cells/µL. During the early stages of an epidemic more infectionsare recent and therefore contribute a greater proportion of new infections. Theseestimates provide an upper-limit for the extent to which treatment could reduce infectionsbecause, in reality, (i) ART does not perfectly reduce infectiousness, and (ii) individualsfor whom ART is failing might become more infectious. New models, accounting forthese factors, have estimated that, with 80% able to initiate treatment promptly when theyrequire it, the rate of new infections could be reduced by approximately 20% withtreatment starting at CD4<200/μL and 30% with treatment starting at CD4<350 /μL(Eaton et al., personal communication). 30 26/05/2011
    • 100% Cumulative transmission Hollingsworth et al. (serial partnerships) Hollingsworth et al. (random mixing) 80% Eaton et al. (substantial  concurrrency) 60% Eaton et al. (minimal  concurrrency) Abu‐Raddad & Longini (Kisumu) 40% Abu‐Raddad & Longini (Yaoundé) Goodreau et al. 20% CD4<350 CD4<200 0% 0 2 4 6 8 10 12 Years since infectionFigure 7: The number of new infections generated by each HIV-infected individual accumulates over timesince infection in published model estimates.77-80 The approximate partition of time spent with CD4 cellcounts > 350 cells/µL (pale green), CD4 cell count between 200 and 350 cells/µL (light green) and < 200cells/µL (dark green) are based on estimate of disease progression in observational cohorts.81,82 31 26/05/2011
    • APPENDIX IV: INFORMATION ON NEW PREVENTIONTECHNOLOGIESAlthough considerable progress has yet to be made by expanding the coverage of existinginterventions, there will still be a need for new prevention options once existing programsreach maximum scale. Incidence rates have shown to level off even in countries withvery high coverage of prevention and treatment programmes at levels of one third to aquarter of peak incidence.83-85 Promising new technologies could contribute to futureprevention efforts; including vaginal microbicides, HIV vaccines, and pre-exposureprophylaxis (PrEP) delivered through oral pills.Increased and more efficient research and development spending are needed to speed upthe development of HIV vaccines, microbicides, and other new prevention technologiesand deliver them to populations most in need.86 Although funding from public andphilanthropic agencies for these efforts have more than doubled in recent years,significant resource gaps still remain. Financial resources needed for new technologiesare large but the enormous potential benefits of successful products would make theseinvestments worthwhile.Expanding efficacy trial capacity for new HIV vaccine and microbicide candidates willrequire additional investments between now and 2015. The recent CAPRISA 004 trialconducted in South Africa showed that tenofovir used as a microbicide gel could beeffective and safe.87 Tenofovir gel reduced HIV acquisition by an estimated 39% overall,and by 54% in women with high gel adherence, and could potentially fill an importantHIV prevention gap. Modelling the potential impact of tenofovir as a microbicide gelshowed that up to 2 million new infections and 1 million AIDS deaths could be avertedover the next 20 years in South Africa if good adherence is achieved. This new femalecontrolled prevention method could have a significant impact on the HIV epidemic butwill depend on the levels of adherence.88 Several other microbicide candidates arecurrently being tested in clinical trials.89,90While an effective AIDS vaccine does not currently exist, the results of the ALVAC RV-144 Thai prime-boost vaccine trial91 showed for the first time that it is possible for avaccine to offer protection against HIV in humans, but more research is needed tounderstand the immune responses. Several HIV vaccine candidates currently in Phase IItrials could move to Phase III efficacy testing over the next decade.90Recent research into the use of pre-exposure prophylaxis (PrEP) to prevent HIV showedpromising results.92 The iPrEx study showed that in gay men, transgender women and 32 26/05/2011
    • other men who have sex with men, daily TDF/FTC (tenofovir disoproxyl fumarate plusemtricitabine also known as Truvada) reduced the risk of HIV by 44%. Additional studiesare ongoing in other populations. A modelling exercise predicted that the cost-effectiveness of PrEP relative to ART will decrease rapidly as ART coverage increasesbeyond three times its coverage in 2010, after which the ART program would providecoverage to more than 65% of HIV+ individuals. To have a high relative cost-effectiveimpact on reducing infections in generalized epidemics, PrEP must utilize a window ofopportunity until ART has been scaled up beyond this level.93 Although it is unlikely toconfer sufficient benefits to justify current TDF/FTC costs, price reductions and/orincreases in efficacy could make PrEP a cost-effective option in younger or higher-riskpopulations94 and further research of using PrEP-based HIV prevention is warranted.Without new innovations, the decrease in the number of new infections is likely to stall,as shown in Figure 8, but potential new technologies developed and implemented at scaleover the next decade could enable the downward trajectory of new infections to becontinued. As such programmes do not exist to date, costs for possible scale up of newinnovations have not been included in our analysis, nevertheless it is useful to bear inmind that innovation is likely and should be anticipated. 3,000,000 2,500,000 New HIV infections 2,000,000 1,500,000 1,000,000 500,000 0 2011 2013 2015 2017 2019 2021 2023 2025 Baseline Investment Framework New technologies Figure 8. New HIV infections in low and middle-income countries expected under the baseline scenario (assuming constant coverage at around present funding rates and approaches), new investment framework approach, and with the potential effect of new technologies (Microbicides, PrEP and Vaccines) introduced starting in 2015. 33 26/05/2011
    • APPENDIX V: RELEVANT TERMS AND DEFINITIONSBasic Programme ActivitiesTreatment care and support for PLWH (including facility-basedtesting)This includes the provision of clinic-based, home-based or community-based servicesand commodities for the treatment and care of HIV-positive adults and children.Treatment care and support includes several categories: antiretroviral therapy provided toinfected adults and children in need of treatment; routine counselling and testing;treatment and care of opportunistic infections; essential illness prevention interventionsfor PLHIV; nutrition supplements for those on ART; treatment for tuberculosis; andpalliative care. This category also includes provider initiated counselling and testing infacilities and utilizing health services. ART significantly reduces viral load and restoresimmune function, thereby raising the possibility of using ART not only to increase thesurvival time and quality of life of people infected with HIV, but also to reduce HIVtransmission.Prevention of mother-to-child transmission (PMTCT)Comprehensive PMTCT programs for pregnant women include pre-test counselling, HIVtesting, post-test counselling, drug prophylaxis, initiation of antiretroviral therapy,counselling on infant feeding options and post partum monitoring and interventions formother and child. Drug prophylaxis may be a single drug regimen (single doseNevirapine [sd-NVP] or AZT), a combination prophylactic regimen (AZT+sd-NVP withor without 7-day postpartum, AZT+3TC), or a highly active triple drug regimen (AZT +3TC + NRTI/NNRTI or PI). WHO currently recommends provision of ARVs to all HIV-infected mothers, starting in the second trimester of pregnancy and throughout thebreastfeeding period to prevent vertical transmission.54 National authorities should decideon the best infant feeding option (breast feeding with ARV interventions or to avoid allbreastfeeding) that will most likely give infants the greatest chance of HIV-free survival.Where breastfeeding is judged the best option, complementary feeding (infant formula)may be introduced at 6 months and continue breastfeeding for at least 12 months.Male circumcisionRefers to the removal of the prepuce or foreskin covering the tip of the penis for thepurpose of reducing the risk of HIV infection. The program includes the operation itself, 34 26/05/2011
    • as well as related activities such as counselling, post-operative support, promotion ofmale circumcision, programme communication, strengthening of necessary medicalinfrastructure and training. Male circumcision (MC) has been demonstrated to reduce therisk of female-to-male sexual transmission by 60%.22-24 WHO and UNAIDS recommendsthat male circumcision should now be recognized as an efficacious intervention for HIVprevention. However, MC provides only partial protection against the risk of HIV sexualtransmission from women to men and it should therefore always be considered as part ofa comprehensive HIV prevention package.Condom promotion and distributionIncludes programmes to increase the correct and consistent use of male and femalecondoms by making them more accessible and acceptable. This can involve activities toincrease condom availability (such as procurement and distribution) and generate demand(such as social marketing, awareness raising and communication programmes). Evidencefrom research among heterosexual couples in which one partner is infected with HIVshows that correct and consistent condom use – male and female – significantly reducesthe risk of HIV transmission from men to women, from women to men and also frommen to men.95 Condoms are an integral and essential part of comprehensive HIVprevention and care programmes, and the promotion thereof must be accelerated. Maleand female condom provision, including lubricants, covers mainly the supply side ofcondom programming including selecting products that appeal to clients, forecastingcondom needs, procuring sufficient quantities of high-quality male and female condoms,managing inventories, and distributing condoms.Behaviour Change ProgrammesBehaviour change has had a major impact on the trajectory of concentrated and low levelepidemics. In generalized epidemics, behaviour change such as delaying the initiation ofsex, increasing condom use or reducing the number of sex partners, affects the likelihoodof exposure and reduces the likelihood of HIV transmission.Behavioural change programmes for AIDS includes the strategic use of an integratedprogramme of advocacy, communication and social mobilization to systematicallyfacilitate and accelerate behaviour change and social change to the underlying drivers ofHIV risk, vulnerability and impact. It enables communities and national AIDSprogrammes to support behaviour change and to tackle underlying structural barriers toeffective AIDS responses including inequality and social exclusion. Successfulprogrammes have the capacity to blend participatory methods of community dialogue andempowerment with mass media approaches and other forms of informational and 35 26/05/2011
    • motivational communication and advocacy. The goal of such programmes is to act as acatalyst for action at the individual, community and policy levels.Social and behavioural change communication methods support development of locallyowned and implemented solutions that can be measured and tracked over time.Monitoring and evaluation of social and behavioural change communication fosters bothlocal engagement and quality improvement of change activities. They also foster theability to share results horizontally (i.e. across similar programmes or communities) andvertically (from community to national levels) for learning and accountability.Social and behavioural change communication programmes have been shown to work,although careful evaluation has been the exception rather than the rule in implementingthese programmes. Where rigorous evaluation has been conducted these programmeshave been shown to make significant and durable change in deeply rooted harmfulpractices; from domestic violence to police complicity in violence against men who havesex with men; from denial of HIV in rural communities to fear of using condoms in stablecouples. Social and behaviour change communication activities should include rigorousimpact evaluation to make sure that they are reaching audiences effectively.Key objectives for social and behavioural change communication programmes need toinclude changing sexual behaviour at both the societal and individual level (includingreduction of number of sexual partners, age of sexual onset. Communication for socialand behaviour change involves targeting the general population or specific groupsthrough mass media and outreach activities.Component elements of social and behavioural changecommunication programmes Interpersonal communication: face-to-face communication either through a one-on-one exchange or discussions in a small group with a trained facilitator. Several critical components to interpersonal communication could include having a facilitator who is from the same ethnic, cultural and/or linguistic background; having participatory and non-judgmental interactions; ensuring that information shared is factual and based on evidence; and ensuring that exchanges go beyond raising awareness and knowledge building. Interpersonal communication can be delivered through various personal interactions such as individual outreach, small discussion groups, counselling, and client-provider dialogue. The key objectives of interpersonal communication is to address barriers to adopting healthier behaviours, focus on increasing risk perception, increasing use of available services, and improve skills and self-efficacy to enable individuals to be 36 26/05/2011
    • responsible for and protect their own health by making healthier behavioural choices. Media communication utilizes one or more channels to transmit the same message to a large audience. Examples include brochures, billboards, posters, newspaper or magazine articles, comic books, television, radio, music videos, Internet, cell phones, songs, dramas, traditional and folk media, and interactive theatre. Media communication includes development of communication messages and materials and their transmission. Media communication seeks to promote positive changes in cognitive and behavioural outcomes such as increasing knowledge of modes of HIV transmission, increasing perceived risk of contracting HIV, reducing high-risk sexual behaviours such as having multiple partners, increasing positive protective behaviours such as condom use, and increasing the utilization of health care services. Media communication can also be utilized to create a supportive environment and often targets social, cultural and gender norms that may hinder behaviour change.Key populationsAssessing the needs of different population groups and identification and removal ofbarriers to access services is relevant to planning a programmatic effective response.Community mobilization is often geared towards those who are marginalized fromcommunity processes, including young people, women, minorities, sex workers, peoplewho inject drugs (IDU) and men who have sex with men (MSM). A wide range ofpriority populations have utilized community mobilization in the prevention andmitigation of HIV. Outreach programmes usually include peer education on HIVtransmission and risk reduction strategies and HIV testing. Interventions for female andmale sex workers and MSM are based on a peer outreach model. These interventionscombine one-on-one or small group awareness, group education and access tocommodities and services. Sex work interventions: Programmes to promote risk-reduction measures among commercial sex workers and their clients. Includes STI treatment, peer outreach and counselling, condom promotion, removing stigma and discrimination, elimination of gender-based violence, programmes addressing clients, HIV testing and treatment. MSM programmes: Activities that address men who regularly or occasionally have sex with other men. This includes risk-reduction activities, outreach (including by peers), prevention of sexual transmission of HIV (including condom 37 26/05/2011
    • use, prevention and treatment of STIs), voluntary and confidential HIV counselling and testing, and initiatives to ensure that these groups are able to access these services. IDU programmes: Initiatives directed at injecting drug users to reduce the risk of spreading HIV and to mitigate other harmful effects of drug use. This can involve harm reduction programmes, such as sterile needle and syringe programmes, as well as opioid substitution and peer outreach. Needle and syringe programmes aim at reducing the risk of blood borne infection of HIV (and others such as viral hepatitis) transmission associated with using contaminated drug injecting equipment among people who inject drugs. Pogrammes consists of ensuring easy, consistent and safe access to sterile needles and syringes to people who inject drugs. Modalities for needle and syringe programmes include provision of needles and syringes free or for cost; one-for- one exchange, intended to remove used injection equipment from circulation; secondary distribution, where people who inject drugs collect a relatively large number of clean syringes and needles and distribute them to other people who inject drugs with whom they are in contact, aiming to reach users who may not be in touch with services; and provision of other paraphernalia such as alcohol swaps, citric acid, spoons and condoms.Critical enablersSocial EnablersPolitical commitment and advocacyPolitical commitment enables AIDS responses at all levels, including through resourceallocation, creation of enabling environments where community mobilization and socialand behavioural communication can take place, and supporting the realization of rights.Political commitment may be generated through advocacy. Advocacy is the combinedeffort of a group of individuals or organizations to persuade influential individuals,groups and/or organizations to adopt an effective approach to AIDS as quickly aspossible. Advocacy efforts have diverse targets of change: policies, laws, regulations,guidelines, additional funding, and/or programmatic or institutional change. Advocatesuse a wide variety of organizational techniques and communication channels to bringabout political change, including letters, meetings, social networking and internetcampaigning, face-to-face interactions, media campaigns, forums and newspaper articles. 38 26/05/2011
    • While it is possible to identify advocacy techniques which are applicable across a widerange of settings, the impact of political commitment and advocacy on improving theAIDS response depends greatly on specific context where it takes place. External actorscan be enormously influential over political and advocacy outcomes, but can also fail tohave any real or lasting impact if they run counter to local needs and understanding of theroots of problem to be addressed.Laws, legal policies and practicesA supportive legal environment entails having laws in place that protect people livingwith HIV and key populations from discrimination and having policies that facilitate allpopulations having access to the HIV programmes and services they require. It alsoinvolves removing punitive laws, regulations and policies that block effective HIVresponses. These may include: criminalization of same sex sexual activity; laws or policepractices which punish possession of condoms or drug paraphernalia and undermineharm reduction measures; inappropriate criminal penalties applied in the context of sexwork or to HIV transmission and exposure; laws that preclude importation of genericmedicines; policies that impede distribution of sexual health education and information;restrictions on the distribution of condoms, e.g. in prisons; regulations which preventnon-citizens from accessing ART; and the lack of a legal framework for non-governmental organizations to operate effectively.HIV-related legal services include legal information and referral, legal advice, and legalrepresentation. Test cases or ‘strategic litigation’ may also establish a new legal rule,clarify the application of the law or address discriminatory policy or practice. Legalservices can also include informal or traditional legal systems (e.g. village courts). HIV-related legal services help improve access to HIV prevention, treatment, care and supportservices by people living with HIV or other key populations; increase the demand forjustice; empower affected populations to advocate for their rights; and provide redress fordiscrimination.Community MobilizationA community becomes mobilized when a particular group of people becomes aware of ashared concern or common need, and together decides to take action in order to createshared benefits. This action may be helped by the participation of an externalfacilitator—either a person or organization. However, momentum for continuedmobilization must come from within the concerned group or it will not be sustained overtime. Community mobilization can be conducted through various activities such as group 39 26/05/2011
    • discussions, community forums, outreach, and establishing community networks.Community mobilization tries to ensure that people most affected by HIV (includingpeople living with HIV) can play an active and influential role in shaping an effectiveresponse to it. It means that community members take responsibility for addressing HIVthemselves, with the support of others where necessary, and take a joint responsibilityfor the outcomes of their actions. Community mobilization within a community canfacilitate larger structural changes, which work to empower communities to continuallyimprove their lives. As one of the bases for mobilization is living with HIV, knowledgeof HIV status can be an important lever in community mobilization, and thus can beaccompanied by HIV testing in various settings (e.g. stand-alone centers, mobile vans,health clinics).Community mobilization is one of the critical enablers and could be divided into threecategories: Outreach and engagement activities; support activities; and advocacy,transparency and accountability. Community mobilization can be supported throughcommunity system strengthening which is a systematic approach to promote thedevelopment of informed, capable and coordinated communities and community basedorganisations. Hallmarks of effective community system strengthening include theinvolvement of a broad range of community actors and enabling them to contribute asequal partners alongside other actors to the long term sustainability of health and otherinterventions at community level. Community system strengthening aims to improvehealth outcomes by developing the role of key affected populations, communities andcommunity based organisations in the design, delivery, monitoring and evaluation ofservices, activities and programmes.Stigma reductionHIV-related stigma refers to negative beliefs, feelings and attitudes towards people livingwith HIV or associated with HIV. It may affect people known to be or suspected of beinginfected by HIV and their relatives and associates, or those from populations with higherrates of HIV or more at risk, such as people who inject drugs, sex workers, men who havesex with men and transgender people. Stigma is expressed in stigmatizing language andbehaviour, such as ostracization and abandonment; shunning and avoiding everydaycontact; verbal harassment; physical violence; verbal discrediting, blaming and gossip.HIV-related discrimination refers to the unfair and unjust treatment (act or omission) ofan individual based on his or her real or perceived HIV status. Though HIV-relatedstigma often leads to discrimination, it is important to note that even if a person feelsstigma towards another, s/he can decide to not to act in a way that is unfair ordiscriminatory. 40 26/05/2011
    • Stigma and discrimination associated with HIV can be as devastating as the illness itself:abandonment by spouse and/or family, social ostracism, job and property loss, lack ofaccess to or expulsion from school, denial of medical services, lack of care and support,and violence. HIV-related stigma and discrimination undermine HIV prevention effortsby making people afraid to seek out information about how to reduce their risk ofexposure to HIV, and to adopt safer behaviour in case this raises suspicion about theirHIV status and find out whether or not they are infected. The fear of stigma anddiscrimination also discourages people living with HIV from disclosing their status, evento family members and sexual partners, and undermines their ability to adhere totreatment.Stigma has been found to be widely prevalent with consequences found to includephysical and mental abuse and neglect, deterrence to HIV testing, delays in receivingtreatment, low uptake of HIV testing, late presentation with AIDS and reduced adherenceto HIV treatment. The impact of stigma on the prevention of mother to child transmission(PMTCT) has been modeled finding that up to 55 percent of cases of mother to childtransmission in settings where PMTCT services are readily available may be caused bystigma and discrimination.96 Even where PMTCT services are not as strong, 28 percent ofmother to child transmission may be due to stigma.97Stigma has been addressed through multi-component programmes which include masscommunication, participatory education, mobilization of community leaders and a varietyof community interaction techniques. Many of these programmes have been found tohave significant impacts in reducing stigma.96 Stigma programmes addressing health careproviders have been particularly important in addressing stigma produced in thesesettings, with results obtainable from often modest interventions.98Gender based violenceViolence and the threat of violence can hamper people’s ability to adequately protectthemselves from HIV infection and assert healthy sexual decision-making. In manycountries, sex workers, people who use drugs and sexual minorities experience illegal lawenforcement in the form of violence, rape, harassment and arbitrary arrest. All forms ofgender-based violence—against women and girls, men who have sex with men,transgender people and sex workers—should be recognised as human rights violationsand as elements that can increase vulnerability to HIV.Gender based violence is widespread. In a 10-country study on womens health anddomestic violence conducted by WHO, between 15% and 71% of women reported 41 26/05/2011
    • physical or sexual violence by a husband or partner. Many women said that their firstsexual experience was not consensual (24% in rural Peru, 28% in Tanzania, 30% in ruralBangladesh, and 40% in South Africa) and between 4% and 12% of women reportedbeing physically abused during pregnancy.99The consequences of gender violence are direct and indirect. Violence against women isassociated with increased HIV infection as well as unintended pregnancies. Sexual abuseas a child is associated with higher rates of sexual risk-taking (such as first sex at an earlyage, multiple partners and unprotected sex), substance use, and additional victimization.Each of these behaviours increases HIV risks.Despite the documented negative consequences of gender violence, the evidence-base inrelation to its prevention is modest, albeit growing. School-based programmes to preventviolence within dating relationships have demonstrated effectiveness and evidence isemerging of other strategies including microfinance programmes for women combinedwith gender-equality education; efforts to reduce access to and harmful use of alcohol;and changing social and cultural gender norms. The systematic evaluation and evidencegeneration around these and other plausible approaches to reducing gender violence is apriority for national and international partners.100Local responses to change the risk environmentIn addition to the targets of the critical enables mentioned above, there exists a range ofapproaches to addressing the risk of HIV exposure in its local context. These are oftentermed “structural approaches” and include a wide variety of efforts which aim to changethe social, economic, political or environmental factors that underpin HIV risk andvulnerability.101There are many local examples of successful efforts to reduce the risks of HIV exposure.For example, actions recommended to for local responses especially in rural areasincluded changing closing hours of local beer shops, restricting youth from drinkingestablishments, ensuring traditional dances close before darkness falls and establishing alocal norms that women only collect firewood after dark when accompanied by men.102The Asian Development Bank and partners have paid close attention to mitigating therisks of HIV associated with greater road penetration in the Greater Mekong Region andimprovement in road surfaces in Myanmar have been credited with reducing HIV risks,through reductions in the need for overnight stops and less indirect sex work.101 Amongthe first responses to the newly discovered threat of AIDS was to increase lighting in gaybathhouses in an endeavour to reduce the riskiness of the environment.103 Structuralapproaches proposed to reduce the HIV risks faced by young women in southern Africa 42 26/05/2011
    • include: to Reduce dependency on migrant labour; industry standards that seek to providealternatives to congregate, single-sex dwellings at work sites; transportation alternativesto long distance truck routes; inclusion of workplace AIDS policies and policiespromoting gender equity; and programs that provide educational or economic alternativesto sex work for women living in communities surrounding high-risk areas.104The variety and context-specificity of these local approaches to reducing the risk of HIVexposure restricts the extent to which these programmes can be replicated and defy thecreation of a consistent evidence base. Nevertheless, evaluation standards are available tobe applied to these local efforts, which should at a minimum assess and document theextent to which they meet their stated objectives.Programme EnablersProgramme enables are the elements of programme implementation which are critical tothe effectiveness and efficiency of HIV responses. Investing in these programme enablerscan have dramatic impacts on the uptake, acceleration, and consistency inimplementation of activities.Community centered design and deliveryThere are many informal and formal organizations and structures which are involved incommunity responses to HIV. The documentation of the nature of communityinvolvement is patchy, with informal contributions rarely documented. A majorevaluation exercise to assess the results achieved by community responses to HIV isunder way by the World Bank’s Global HIV/AIDS Program team, in collaboration withDFID, the UK Consortium on AIDS and International Development, and other partners.While that exercise is ongoing, it does suggest that community responses play a criticalrole in all aspects of the HIV response and in all contexts.105 Similarly, the Global Fundto Fight AIDS, TB and Malaria together with the International HIV/AIDS Alliance haveassess civil society involvement in broad ranging HIV programmes in 9 country settingsillustrating both the range and critical impact on programme effectiveness of communitycentered design and delivery.106The scope of community action in relation to design and delivery of programmes isconsiderable. The World Bank’s typology includes the following: advocating for accessto services, providing care and support for those most affected by the epidemic, assistingin the development of policy and strategy, and organizing peer efforts amongmarginalized populations. Community responses can also provide support to governmentservices by encouraging uptake of HIV testing, challenging stigma and discrimination, 43 26/05/2011
    • and supporting treatment adherence. In certain circumstances, community responses canalso challenge the scope and reach of government actions.Programme communicationProgramme communication is concerned with informing and creating awareness amongthe general public or specific populations about HIV, and empowering people to takeaction. It is often principally concerned with communicating a series of messages aboutthe disease or informing the public about what services exist (for diagnosis andtreatment). Programme communication also works to create an environment throughwhich communities, particularly affected communities, can discuss, debate, organize, andcommunicate their own perspectives on HIV. Programme communication is aimed atchanging behaviours but can also be used to support community or other communication-for-social-change processes that can spark debate, and other processes to shift socialmores and barriers to behaviour change.Programme communication efforts are measured in the reach and comprehension of theirmessages to intended audiences.Management and incentivesThe efficiency and effectiveness of the management of programmes has a direct impact.Determinants of management quality include both factors relating to inputs (quality andavailability of staff, training, organizational capacity) as well as to governance (clarity ofobjectives, decision-making structures etc.). A key variable in relation to management isthe existence of positive or perverse incentives in relation to system functioning. Thereare many aspects of AIDS programming, including some elements of the global financialarchitecture of AIDS financing, which have created unintended consequences andperverse incentives. Improving management requires close analysis and concerted actionto maximize beneficial incentives.Procurement and distributionAs AIDS programmes have been scaled-up to more comprehensive, national prevention,care and treatment programs, the range of services offered has increased. In order tosupport these services, hundreds of commodities are required. The success of thesenationwide programs will depend upon the ability to reliably and consistently supply thecommodities to facilities and settings at all levels. The consequence of supplyinterruption can be dire, including drug resistance and condom stock-outs. Many of thecommodity supply chains in HIV programmes have large, extended global pipelines,require high levels of product availability and have a high uncertainty in supply and 44 26/05/2011
    • demand. It is therefore paramount that supply chain or logistics systems are treated as animportant and critical function in getting the products to their destination. In fact, in orderto sustain and expand the successful interventions experienced to date, the supply chainswill need to be made more robust, agile and flexible through better management andincreased investment of resources to achieve supply chain optimization.The term supply chain describes the links and the interrelationships among the manyorganizations, people, resources, and procedures involved in getting commodities to thecustomers (in this case, those affected by AIDS). A typical supply chain would includepartners from manufacturing, transportation, warehousing and service delivery. Together,these organizations orchestrate the flow of products to the end-consumer, information forbetter planning and, finances to cover the transaction costs. A key ingredient of asuccessful supply chain is that partners are focused on improved coordination,information-sharing and, serving the end-customers.107Research and innovationMany different strategies for HIV prevention and treatment are now being explored,including topical antiretroviral-containing microbicides, oral/systemic pre-exposureprophylaxis, vaccines, female-initiated barrier methods, herpes simplex virus-2treatment/suppression, index partner treatment, prevention of mother-to-childtransmission and drug substitution/ maintenance for people who inject drugs. Thesuccessful development of effective HIV interventions requires that candidatetechnologies be studied in different populations around the world. This in turn requires alarge international cooperative effort, drawing on partners from various health sectors,inter-governmental organisations, government, research institutions, industry, andaffected populations. It also requires that these partners adopt best ethical practice inclinical and behavioural trials, including supporting good participatory practice. 45 26/05/2011
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