Global policy trend of HIV & NCD leveraging the HIV experience by Satoshi Ezoe

Global policy trend of HIV and NCDs: leveraging the HIV experienceInternational Seminar on Socio Economic and Mental Health Burdens of HIV/AIDS in Developing Countries Kuala Lumpur, Malaysia 22nd November 2011 Satoshi Ezoe, MD, MPH, MPA Advisor, Synergies and Systems Joint United Nations Programme on HIV/AIDS (UNAIDS)

Outline1. Introduction2. UN High Level Meeting on HIV/AIDS3. UN High Level Meeting on NCDs4. Discussion on NCD/HIV5. Next steps

What is UNAIDS?Mission: UNAIDS (the Joint United Nations Program on HIV/AIDS), is an innovative United Nations partnership that leads and inspires the world in achieving universal access to HIV prevention, treatment, care and support. 21 Aug 2009 4

VISION ZERO NEW HIV INFECTIONS. ZERO DISCRIMINATION. ZERO AIDS-RELATED DEATHS.

Michel Sidibé Executive Director of UNAIDS Under Secretary-General of the United Nations1952 Born in Mali1987 UNICEF Country Office in Zaire UNICEF Country Representative in Africa2001 UNAIDS Country Support Director2007 UNAIDS Deputy Executive Director2009 UNAIDS Executive Director Taking AIDS out of isolation!!

UNAIDS Cosponsors 21 Aug 2009 Global Stream of HIV/AIDS 7

UNAIDS World AIDS Day Report | 2011Core Epidemiology Slides EMBARGOED FOR TRANSMISSION AND PUBLICATION UNTIL 09:00 GMT, MONDAY 21 NOVEMBER 2011

Global summary of the AIDS epidemic | 2010 < 2009 Number of people Total 34.0 million 33.3 million living with HIV Adults 30.1 million 30.8 million Women 16.8 million 15.9 million Children (<15 years) 3.4 million 2.5 million People newly Total 2.7 million 2.6 million infected Adults 2.3 million 2.2 million with HIV in 2010 Children (<15 years) 390 000 370 000 AIDS deaths in 2010 Total 1.8 million 1.8 million Adults 1.5 million 1.6 million Children (<15 years) 250 000 260 000 www.unaids.org

Global financial trend for HIV/AIDS $17.4 $17,0 17.5 $15.9 $15.6 15.0 $14,3 $14.4 $12,8 12.5 $11.4US$ billion 10.0 Signing of Declaration of Commitment $8.9 on HIV/AIDS UNGASS 2001 $09,9 $8.3 7.5 HIP+ World Bank $6.1 MAP launch UNITAID $5.0 5.0 $3.2 UN AIDS Gates PEPFAR Foundation 2.5 $0.9 $0.5 $0.5 The Global Fund $0.3 $1.4 $1.6 0.0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Outcomes of the2011 UN General Assembly High Level Meeting on AIDS (from NCDs and mental health angle) 8-10 June 2011

The High Level Meeting in numbers 1 Economist cover 2 New York Times editorials 5 Official Panels 27 Heads/ Deputies of State/ Government 30+ First Spouses 43 side events 89 Ministers 100s of civil society, private sector and people living w/ HIV 120 National Delegations 5000+ news articles

Official Panel: Integrating the AIDS response with broader health and development agendasKEY ISSUES:• HIV and health systems• HIV, maternal, newborn and child health and sexual and reproductive health• HIV and TB• HIV and non-communicable diseases• HIV and development

Political Declaration on HIV/AIDS: Intensifying our Efforts to Eliminate HIV/AIDS Recommit to 2006 Political Declaration and 2001 Declaration of Commitment New global targets for 2015 Mobilize funding (US $22-24 billion per year) Shared responsibility Universal access Key populations Trade Related Aspects of Intellectual Property (TRIPS) principles UNAIDS Strategy 2011-2015

Bold new targets for 2015 50% in sexual transmission of HIV 50% of HIV among people who inject drugs 50% TB deaths in people living with HIV Ensure no children are born with HIV and reduction of AIDS-related maternal deaths 15 million on antiretroviral treatment

Commitment to HSS and integrating HIV and AIDS into broader health and development• 98 Commit by 2015 to… direct resources to and strengthen the advocacy, policy and programmatic links between HIV and TB responses, PHC services, SRH, MCH, hepatitis B and C, drug dependence, non-communicable diseases and overall health systems, leverage health-care services to PMTCT of HIV, strengthen the interface between HIV services, related SRH care and services and other health services, including MCH, eliminate parallel systems for HIV-related services and information where feasible……..

Outcomes of the 2011 UN General AssemblyHigh Level Meeting on NCDs (from HIV and mental health angle) 19-20 September 2011

"This is the second health issue ever to be addressed at a specialmeeting of the United Nations General Assembly. We should allwork to meet targets to reduce NCDs. "Ban Ki-moon • UN Secretary-General • 19 September 2011

A clear Message For Heads of States and High-level Policy Makers"You have the power to stop and reverse the NCD disaster. You have the power to protect your people and keep your development efforts on track." Margaret Chan • WHO Director-General • 19 September 2011

Political Declaration on NCDsA challenge of epidemic proportions and its socio-economic anddevelopmental impacts18. Recognize that mental and neurological disorders, including Alzheimer’s disease, are an important cause of morbidity and contribute to the global NCD burden, for which there is a need to provide equitable access to effective programmes and health-care interventions;

Political Declaration on NCDs A challenge of epidemic proportions and its socio-economic and developmental impacts27. Note with concern the possible linkages between NCD and some communicable diseases, such as HIV/AIDS, and call to integrate, as appropriate, responses for HIV/AIDS and NCD and, in this regard, for attention to be given to people living with HIV/AIDS, especially in countries with a high prevalence of HIV/AIDS and in accordance with national priorities;

Political Declaration on NCDs Strengthen national policies and health systems45. Encourage alliances and networks that bring together national, regional and global actors, including academic and research institutes, for the development of new medicines, vaccines, diagnostics and technologies, learning from experiences in the field of HIV/AIDS, among others, according to national priorities and strategies;

Major Outcomes• Consensus and clear positions of NCDs a s priority within the development agenda• A strong call for a whole of government approach to implement the Global Strategy and its action plan and WHOs recommendations on surveillance, prevention and health care• Emphasis on the leading role of WHO in coordinating global action on NCDs• Specific assignments that WHO has to deliver over the coming months and years• Great expectations for WHO to strengthen capacity to support member States(Slide from Dr. Alwan, November 2011)

Official Side Event on NCDs and HIV:Achieving health equity: Uniting around a common agenda to address NCDs and HIV Moderator: Laurie Garrett, Council on Foreign Relations Panel: Margaret Chan, Director-General, WHO Michel Sidibe, Executive Director, UNAIDS Aaron Motsoaledi, Minister of Health, South Africa Eric Goosby, Global AIDS Coordinator, USA Nancy Brinker, WHO Goodwill Ambassador for Cancer Control Tokugha Yepthomi, Civil Society Representative, India

Official Side Event on NCDs and HIV:Aim of the event:• To draw the attention of key policy makers, to ensure that national development/health plans give attention to the NCD and HIV agendas.• To review lessons learned for health systems strengthening that can maximize synergies and efficiencies in HIV and NCD responses.

Discussion paper addressed:• A set of areas for collaborations: - Strengthening understanding on epidemiological linkages - Health systems strengthening - community mobilization

communicable diseases,Global share of Mortality maternal, perinatal and nutritional conditions injuries NCDs after the age of 60 9% 10% 28% 31% 47% 42% 16% 17% Global NCDs before the age of 60 Low- and middle-income countries only (WHO 2008)

Global share of DALYs(Prince M et al, 2007)

Osteopenia/porosis Osteonecrosis Chronic skin Renal insufficiency Hypogonadism conditions Sarcopenia Myopathy Rheumatologic Pulmonary Fibrosis HIV Pulmonary HTN Vitamin D Def Thyroid Diabetes Cognitive impairment GH Def Neuropathy Visceral Fat Chronic diarrhea Atherosclerosis Vascular disease/pulm htn(Slide from Currier J, IAS conference, 2011)

Epidemiological links: NCDs as co-morbidity in PLHIV(1) NCDs as a consequence of long term survival of the HIV/ART cohort(2) Risk of non-AIDS defining cancers as a consequence of the long term immune compromised status(3) NCDs as direct side effect of the ART medicines (e.g. treatment related hyper lipideamia, diabetes). At a median age at death of 60 years, 35% will die of CVD, 26% of cancer, 12% of liver failure and 28 % of other causes (Scott Braithwait et al 2005).

Epidemiological links:

Epidemiological links: Mental health and PLHIV• Evidence base is still weak.• Between 11% and 63% of people living with HIV in LMIC experience depression.• PLHIV are also are prone to anxiety, stress, and panic disorder (Clay, 2006).• Stress impairs immune function (Chandrashekara S et al, 2007)• Depression is linked to poor adherence to ART.

Shared barriers and challenges for HIV and NCDs

Synergies between HIV and NCD programmes

Synergies between HIV and NCD programmesIntegrated HIV, DM and HT services in Cambodia• Chronic disease clinics for HIV, diabetes and hypertension in Cambodia.• A fully integrated model using a patient-centred case management approach• N=9000 (2002-2005), - 5000 living with HIV - 2500 with diabetes - 1500 with hypertension

Synergies between HIV and NCD programmesIntegrated HIV, DM and HT services in CambodiaThis programme demonstrated:• High retention rates of between 70–90% for the various diseases;• Median CD4 count of people living with HIV rising from 53 to 316 per mm3 at 24 months;• Median HbA1c of people with diabetes falling from 11.5% to 8.6%;• 68% of people being treated for hypertension reaching the target blood pressure within six months;• NO difficulties noted from HIV-related stigma.

Advocacy and community mobilization HIV NCDsHigh level political leadership Led by biomedical technicalwas cultivated well beyond groups – not so political untilhealth sector – including HLM 2011UNGASS Success in Tobacco control butStrong civil society led no strong global activism inadvocacy and activism other diseases or risk factorsActivism with high profile global Volunteerism with no publicand local champions and figures across epidemicscelebrity support Almost no linkage between NCDBased on a rights-based and disability advocatesframework

General agreement on the importance of:• Uniting stakeholders around common agendas to address NCDs and HIV;• Identifying synergies for health systems strengthening between HIV and NCDs programmes;• Mobilizing stakeholders, within and beyond the health sector, including civil society;• Leveraging lessons learnt to maximize synergies and efficiencies in dealing with HIV and NCDs.

HIV Next Steps (TBC)

NCDs Next Steps Political Declaration –Timeline (Governing Bodies): 2 Report on the outcomes of the High-level Meeting and the Moscow Conference Progress in implementing 1 the global strategy and the action plan 4 5 Implementation and follow-up 3 plan for the outcomes of the Moscow Conference and the 6 Options for strengthening and High-level Meeting (developed Report on the progress facilitating multisectoral action together with UN agencies and achieved in realizing the for the prevention and control entities) commitments made in the of NCDs through effective partnership Political Declaration Jan-May 2012 Q4 2012 Jan-May 2013 Sep 2014 EB/WHA General Assembly WHA General Assembly(Slide from Dr. Alwan, November 2011)

Preliminary ideas for further collaboration between HIV + NCDsKey tasks:• To work together to promote the issues highlighted at the high-level meeting and discussion paper.• To use every opportunity to strengthen the linkages between HIV and NCDs through individual policies, strategies, plans and programmes as well as in technical norms, standards and guidelines.Opportunities include:• Reportings to WHO EB and WHA in 2012 and beyond• Possible partnership for multisectoral coordination• The World Health Day 2012 publication on ageing• HIV related conferences• Discussions around the post-MDGs development agenda

Possible consideration for mental health• Apply lessons learnt from HIV e.g. multi-sectoral response?, target setting?, advocacy?, community mobilization?, human rights approach?, TRIPS?• Apply lessons learnt from NCDs e.g. regulatory approach?, risk reductions?, Best buy approach?• Strengthen evidence base on MH+HIV, MH+NCDs e.g. Epidemiological links, Service integration, Effect of MH intervention on HIV outcomes• Leverage every opportunity for post HLM processes and post-MDGs discussions

Thank you!Terima kasih! www.unaids.org ezoes@unaids.org

Global policy trend of HIV & NCD leveraging the HIV experience by Satoshi Ezoe

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Global policy trend of HIV & NCD leveraging the HIV experience by Satoshi Ezoe Presentation Transcript