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  • 1. DISCUSSION PAPERSupporting community action on AIDS in developing countries 12 AUGUST 2011dISCUSSION PAPER: What is the Investment Frameworkfor HIV/AIDS and what does it mean for the Alliance?© Gideon Mendel for the AllianceIntroductionWhat is the investment framework for HIV/AIDS?This discussion paper provides a short introduction to an important new development in global HIVpolicy. A new model, an investment framework for HIV/AIDS,1 was published in The Lancet in June 2011to guide the global response to HIV. The Investment Framework for HIV/AIDS sets out a model for HIVinvestment and HIV programming for the next decade.It is a framework that projects an increase in spending on HIV/AIDS leading up to 2015, followed by adecline in spending from 2015 to 2020.For the first time, a model has been developed that can show a decline in the need for HIV programmesand services, as the effect of current and future targeted investments reach a tipping point. HIVinvestments, and HIV rates, decline.Is this the prediction of the end of AIDS?The framework has proven to be influential and topical already. It was developed by international expertsfrom a range of agencies, including UNAIDS, the Global Fund, WHO and the US Government.2This discussion paper describes some of most important features of the investment framework for theAlliance, along with some actions for us all in making it work for communities affected by HIV/AIDS.1. “Towards an improved investment approach for an effective response to HIV/AIDS” The Lancet Vol. 377 Issue 9782 pp 2031-2041, 11 June 20112. Dr Bernhard Schwartländer MD, John Stover MA, Timothy Hallett PhD, Prof Rifat Atun FFPHM, Carlos Avila MD, Eleanor Gouws PhD, MichaelBartos MEd, Peter D Ghys MD, Marjorie Opuni PhD, David Barr JD, Ramzi Alsallaq PhD, Lori Bollinger PhD, Marcelo de Freitas MD, Prof GeoffreyGarnett PhD, Charles Holmes MD, Ken Legins MPH, Yogan Pillay PhD, Anderson Eduardo Stanciole PhD, Craig McClure PGCE, Gottfried Hirn-schall MD, Prof Marie Laga MD, Nancy Padian PhD, on behalf of the Investment Framework Study Group.a Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerlandb Futures Institute, Glastonbury, CT, USAc School of Public Health, Imperial College London, London, UKd Imperial College Business School, Imperial College London, London, UKe The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerlandf International Treatment Preparedness Coalition, New York, NY, USAg International Clinical Research Center, Department of Global Health, University of Washington, Seattle, WA, USAh National AIDS Programme, Brasilia, Brazili Office of the US Global AIDS Coordinator, US President’s Emergency Plan for AIDS Relief, Washington, DC, USAj The Bill & Melinda Gates Foundation, Seattle, WA, USAk UNICEF, New York, NY, USAl Strategic Health Programmes, Department of Health, Johannesburg, South Africam Global HIV/AIDS Unit, Health, Nutrition, and Population, The World Bank, Washington, DC, USAn World Health Organization, Geneva, Switzerlando Institute of Tropical Medicine, Antwerp, Belgium Page 1
  • 2. © Jenny Mathews for the Alliance DISCUSSION PAPERSupporting community action on AIDS in developing countries Why does the investment framework matter for the Alliance? For four main reasons: 1. It sets out an investment plan that is not primarily aspirational, like the Universal Access by 2010 and 3 by 5 calls were. The difference here is that this plan refers to a specific and scientifically produced calculation of the investment required in order to create a reduction in the trajectory of HIV – both spending, and in terms of HIV/AIDS epidemic dynamics. It is a model, or a calculation, that says that if you invest in these specific ways, then the human and financial costs of AIDS will reduce dramatically by 2020. It provides a model for a highly © Jenny Matthews for the Alliance targeted response. 2. It articulates an approach to the implementation of HIV programmes that reflects and supports our programming. The prioritisation of specific HIV programmes is accompanied by the concept of ‘critical enablers’ that make these programmes work. It endorses working with key populations where they are most affected by HIV/AIDS, there is prominent support for community mobilisation, and for a range of other evidence based interventions that we are implementing, such as HIV testing and counselling, treatment adherence, behaviour change communication, needle and syringe programming, stigma reduction and advocacy. 3. It positions human rights-based programming such as advocacy, stigma reduction and efforts towards supportive laws and practices as critical to the model, not optional or additional but ‘critical’. For example, advocacy to end the criminalisation of sex between men is critical to the implementation of behaviour change communication that reaches a sufficient number of men who have sex with men. 4. It responds to the increasing amounts of new evidence of the significant health improvement and HIV/TB prevention potential of ART. Increases in ART provision are a cornerstone of this model. There are four important features of the way increases in ART provision is conceptualised in this model. • Firstly, increased provision leads to improved health, reduced illness and death as more people living with HIV and tuberculosis receive ART. • Secondly as reduced viral load prevents increased levels of onward HIV transmission. • Thirdly, prevention of mother to child transmission (PMTCT) is a priority intervention. • And finally, from a different perspective, increases in ART provision are conceptualised as producing cost reductions as ART programmes shift from high cost specialist provision to primary care and ‘community-led approaches to delivery’. Page 2
  • 3. DISCUSSION PAPERSupporting community action on AIDS in developing countries Figure 1: Investment frameworkThe investmentThe model calculates theincrease in investmentrequired – such as a$12.9 billion increaseto $22 billion by 2015followed by a decreaseto $10.6 billion by 2020– in order to avert 12.2million new infectionsand to prevent 7.4million deaths due toAIDS.The decrease ininvestment after 2015results from the impactof reaching optimal HIVprogramme coveragelevels, along withcost efficiencies, andimportantly, the declinesin illness and death thatare predicted becauselarger numbers of peopleare receiving ART. Figure 2: Resources requiredSo our calls for moreinvestment in HIV (What’sPreventing Prevention?)for the first time, canbe accompanied bya scientific, modelledprediction of a decline inHIV/AIDS by the end ofthis decade. Page 3
  • 4. DISCUSSION PAPERSupporting community action on AIDS in developing countriesThe investment framework in more detailHIV programming priorities in the Critical enablersframework The framework articulates a very importantWhat is new is that the framework provides an concept for the Alliance, critical enablers. Inevidence based and costed case for doing more this framework, critical enablers are definedof what we do already in order to reach a critical in two categories – social enablers such aspoint where the need for programmes and services community mobilisation, changing laws and stigmawill decline. It argues for, and calculates, the reduction. The second category of critical enablersvalue and potential impact of good quality HIV are programme enablers, or efforts to makeprogramming. Developments in our understanding programmes work, such as community centredof the potential of ART feature here as well - the design and delivery, communication, management,potential of ART to prevent HIV transmission, procurement and research and innovation. Theseand to prevent tuberculosis amongst people are important and familiar concepts in the Alliance.living with HIV. The framework gives prominence to the conceptThe six programme areas that are emphasised are: of community mobilisation – a concept very•  PMTCT close to the Alliance’s heart. We understand how important the mobilisation of communities is to HIV• Condom promotion and distribution programming, but this has rarely been described• Key populations (sex work, MSM, IDU (and described as ‘critical’) in other models. It will programmes) be important to use this opportunity to intensify• Treatment, care and support to people living with efforts at the community level. HIV/AIDS (including facility-based testing)• Male circumcision Looking at the HIV programming priorities, and• Behaviour change programmes. analysing them alongside the critical enablers, essential work at the community level is clear.Male circumcision is specified as being applicable For example, PMTCT is the first of the six HIVin generalised epidemics with a low prevalence of programme priorities outlined. What are the criticalmale circumcision. This is not a blueprint for male enablers for PMTCT? They might include some orcircumcision in every country. all of the following: • advocacy for political commitment to a national How does this list match with HIV PMTCT programme programme efforts in your country? • change in practices such as discrimination by health care providers towards women living with How is progress on each of these HIV, in particular, in the area of family planning programmes in your country? and provision of sexual reproductive health services Does this list of priorities miss something • community mobilisation for PMTCT so that important? local communities know about PMTCT and HIV testing, and can access PMTCT services If funding follows this list, what does it mean • local efforts to incentivise PMTCT programmes for our current work? • design of services so that they meet the needs of communities • research on the best models of delivery. Page 4
  • 5. DISCUSSION PAPERSupporting community action on AIDS in developing countriesThese are examples of potential efforts we might How can we use the framework?highlight in order to make PMTCT more effective.Much of this effort lies outside the clinic and in In our advocacy and resource mobilisation.communities. Using this framework, we can Instead of asking for more money for AIDS witharticulate the need for work at the community level, an implied ever-increasing need, our advocacy forwith community organisations, in order to make the more resources for HIV has more precise goals –investment in PMTCT clinics work optimally. coverage goals that will need to be set nationally and locally – in order to reach a point where the‘Synergies with development sectors’ need for this investment declines. Optimal coverage will be reached, efficiency gains will be realisedAnother area of focus for the Investment Framework and the decrease in new HIV infections will result inis broader development sectors and their links to decreased need for services.HIV programmes and critical enablers. The sectorsreferenced include ‘social protection, education, In our planning. In order to understand thelegal reform, gender equality, poverty reduction , implications of this framework for HIV programminggender-based violence, health systems, community at a country level, we need to answer a set of criticalsystems, and employer practices.’ programming questions: How does the list of development sector synergies match with HIV programme efforts in What are the communities/populations that your country? are most critical to the dynamics of HIV transmission in each country? Is there clarity on what each of these synergies involves? (for example, what are the overlaps What are the critical enablers and how do they between HIV programmes and education?) influence or affect the sexual and injecting practice or health seeking practice of the priority How is progress on each of these synergies in communities/populations? your country? What are the most critical HIV interventions for Does this list of priorities miss something impor- the priority communities/populations? tant? What are the optimal coverage levels for key If funding follows this list, what does it mean for HIV/TB interventions in each country? our current work? What are the critical programmatic enablers? What are our programmes contributing toThinking through the meaning of each aspect of meeting coverage targets in each country? Andthese three areas (programme activities, critical what is their potential?enablers and development sector synergies) at acountry level is important work. This might lead to What is our work in civil society to addressa re-programming of HIV efforts, and we will need the critical enablers? What is the role ofto ensure that we can point to where our HIV/TB government?programming efforts, and our advocacy efforts, are What are the most important synergies for thesesupported in the framework. For many of us, we populations, targets? Social protection? Humanwill need to advocate for changing the investments rights protections? Poverty reduction? Healthin HIV at the national or local level. We might be systems? Community systems? Education?advocating for re-programming, or for the need tobuild capacity in different sectors to make this happen. Page 5
  • 6. DISCUSSION PAPERSupporting community action on AIDS in developing countriesSome of us will have the answers to these know about ART and can see the benefit of it forquestions, some of us will need to work with others themselves and their families? Increased support forto seek or calculate the answers. The answers to community health workers and caregivers to deliverthese questions, and the assumptions contained in ART and support adherence?the framework, should increasingly form the basis ofnational HIV plans, including Global Fund proposals. Left solely to public health planners, some of theseThese questions and their answers are critical for types of questions may not be asked. Increasingour strategic planning and fundraising efforts. We ART provision is a goal for all of us, but gettingare contributing a lot to this national and global the right actions in place in order to achieve this iseffort, but we need to be clearer in defining the HIV more complex. Community activists and communityimpact of this work, and in forecasting the potential based programmers must be part of this analysisof this work to achieve the point, in each country, to ensure that plans go well beyond the provisionwhere HIV is in decline. of more clinical services. And when the goal is to shift more aspects of ART service provision toArticulating the role we play in supporting the communities and their organisations, that this effortcritical enablers will be important work for Alliance is costed and funded properly, not undermined byLinking Organisations – both the social enablers ‘doing it cheaply’, dependent on volunteer labour,and programme enablers. What are our theories unpaid care and the under-funding of communityof change for each critical enabler? It is widely organisations and their staff.acknowledged that defining, planning and costingefforts to address the critical enablers is the weakest Limitations of the frameworkpart of this model. We have to focus attention tothis, and help shape this work. Defining, planning As described above, the ‘critical enablers’ describedand costing the vital pieces of the model such as in the framework are poorly defined, costed andcommunity mobilisation; changing laws, policies tested. They are not universally agreed either, andand practices; stigma reduction; changing risk rest uneasily on an unstable body of evidence.environments; capacity building, management, Further work is required to understand the barriersprocurement, research and innovation. and enablers to effective HIV responses in every context, and to define and demonstrate the value forTesting the assumptions inherent in the model money of key interventions that are enabling.will be important in each country. For example,the model depends heavily on increases in ART The daily struggles to ensure access to HIVprovision. Is that assumption realistic and feasible services to and to protect the human rights of veryfrom the perspective of very marginalised people? marginalised and poor people are well understoodAnd if not, what are the changes, what are the by community organisations. Sometimes a list ofcritical enablers, in order to reach and increase clinical and health promotion interventions fails tothe uptake of ART amongst marginalised people? ‘get at’ the range of needs, struggles and problemsImproved drug procurement and distribution shaping the lives of people who are detained,systems? Reduced discrimination towards key denied services, who are subject to violence,populations in health care settings? ART more breaches of privacy, hate crime, discrimination andaccessible in a wider range of settings? Improvedaccess to opiate substitution treatment for other violations, who live far from health services,injecting drug users? Changes in policy so that who have uncertain immigration status or whopeople without identity cards, or people in prison are poor, young, old or socially isolated. Socialor detention, can access ART? More intensive and behavioural research, political science andcommunity mobilisation so that more people operations research can define HIV and other Page 6
  • 7. DISCUSSION PAPERSupporting community action on AIDS in developing countriesneeds more deeply. They can help to build a bridge populations, programmes and investments. Analysebetween our understanding of the complexity and how these programmes and critical enablersextent of social and personal needs, and a set of are synergising with other development sectors.health programmes that can stop HIV. The science Identify the most important critical enablersthat we bring to the model needs more social to ensure the programmes are of high qualityscience, and more implementation science. and are reaching sufficient numbers of people from specifically targeted populations. SeekThe critical programmatic enablers need to address endorsement for your analysis, including fromcorruption, capacity building, building social government. Analyse the assumptions in thecapital, strengthening community systems and model for your country. What interventions willstrengthening health systems so that health systems make increases in ART most feasible? How dobetter serve all people with HIV needs, including behaviour change communication and condomthose who are criminalised and marginalised. promotion interventions change as a result of increased evidence for treatment as prevention,Acting on the investment framework and male circumcision? What will be the effects on sexual and injecting practice, and how willWe need to act on this investment framework to behaviour change communication respond? Whatmore directly promote effective and community are the community mobilisation efforts for the sixdriven responses to HIV in each country where the programme areas?Alliance operates. There is some critical thinkingto be done. We can use this framework to intensify Advocate for a more high impact, preciselyand improve national planning for HIV. Informed by targeted and costed national HIV programme.the investment framework, some immediate tasks Use this framework to advocate for more precisionarise: in targeting and for a more expanded and nuanced role for communities and their organisations. It willEnsure the framework is on the national agenda. help to analyse current investments in HIV to ensureDo your national planning institutions (NACs, that our best efforts focus on high impact – theCCMs) know about it? Get this framework onto potential to prevent 12.2 million new HIV infectionsthe agenda of these committees. Foster debate and prevent 7.4 million deaths due to AIDS by 2020.about the model. Brief government, civil societyand relevant professional agencies about it. With ABOUT THE ALLIANCEUNAIDS and WHO colleagues, form a working Established in 1993, the International HIV/AIDSgroup made up of relevant specialists to examine Alliance is a global partnership of nationally-the meaning of the framework in your country: based linking organisations working in over 40national HIV government/public health planners, countries, to support community action on AIDSHIV civil society organisations – both key population in developing countries.representatives and HIV programme implementers, International HIV/AIDS AllianceHIV/TB clinicians and social/care providers, HIV (International secretariat)technical agencies, clinical researchers, HIV/TB/ 91-101 Davigdor RoadSRH epidemiologists, HIV social scientists, HIV Hove, East Sussexsocial care experts, HIV human rights specialists. BN3 1RE United KingdomIdentify the key populations, programmes and Tel: +44 1273 718 900 Fax: +44 1273 718 901coverage levels in your country, and analyse Email: mail@aidsalliance.orgassumptions.Work with other experts to identify the most important Registered charity no. 1038860 Page 7