WGHA Discovery Series: Peter Piot

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Washington Global Health Alliance Discovery Series

Peter Piot, MD, PhD
March 2, 2009
'The Transformational Nature of the AIDS Response: Opportunities for Global Health'

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WGHA Discovery Series: Peter Piot

  1. 1. The transformational nature of the aids response Peter Piot,MD,PhD
  2. 2. A global view of HIV infection 33 million people [30–36 million] living with HIV, 2007 2.2
  3. 3. Number of people receiving ARV therapy in low- and middle-income countries, 2002—2007 3.0 North Africa and the Middle East 2.8 Europe and Central Asia People receiving ARV therapy (in Millions) East, South and South-East Asia 2.6 Latin America and the Caribbean 2.4 Sub-Saharan Africa 2.2 Global Fund supported programs 2.0 1.8 1.6 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0 end 2002 end 2003 end 2004 end 2005 end 2006 end 2007
  4. 4. Decline in adult mortality with introduction of ART: Botswana 6 50 on ARV 5 Deaths aged 25-54 Registered Deaths (Thousands) 40 Persons on ARV (Thousands) 4 30 3 20 2 10 1 0 0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
  5. 5. HIV prevalence (%) among pregnant women attending antenatal clinics in sub-Saharan Africa, 1997–2007 Southern Africa 50 Botswana Median HIV prevalence (%) Lesotho 40 Mozambique 30 Namibia NOTE: Analysis 20 South Africa restricted to Swaziland consistent 10 surveillance sites for Zimbabwe all countries except 0 1997– 1999– 2001 2002 2003 2004 2005 2006 2007 South Africa (by 1998 2000 province) and Swaziland (by region) Eastern Africa West Africa 20 20 Median HIV prevalence (%) Median HIV prevalence (%) 15 15 Ethiopia Burkina Faso 10 10 Côte d'Ivoire Ghana 5 5 Kenya Senegal 0 0 1997– 1999– 2001 2002 2003 2004 2005 2006 2007 1997– 1999– 2001 2002 2003 2004 2005 2006 2007 1998 2000 1998 2000 Source: National surveillance reports and UNAIDS/WHO/UNICEF, Epidemiological Fact Sheets on HIV and AIDS. July 2008. 2.9
  6. 6. Number and percentage of HIV-positive pregnant women receiving antiretroviral prophylaxis, 2004–2007 40 600 000 35 500 000 30 Number of HIV-positive 400 000 % of HIV-positive 25 pregnant women pregnant women receiving anti-retrovirals receiving anti-retrovirals 300 000 20 15 200 000 10 100 000 5 0 0 2004 2005 2006 2007 Year Source: UNAIDS, UNICEF & WHO, 2008; data provided by countries. 4.13
  7. 7. AIDS IS NOT OVER
  8. 8. HIV prevalence (%) in adults (15–49) in Africa, 2007 2.8
  9. 9. HIV infections among men having sex with men in Asia
  10. 10. The aids response is transformational »Science and rights driven »Political approach »Focus on results for people »Multi-disciplinary, multi-sectoral »Community engagement »Global response
  11. 11. 27 years of responding to AIDS First cases of unusual immune Global Fund to fight AIDS, 50 deficiency identified Tuberculosis and Malaria US$10 billion for Millions AIDS in 45 HIV identified as The UN General Assembly Special developing cause of AIDS Session on HIV/AIDS countries 40 Four Frees and WHO launches the One Care Global Programme Highly Active 35 on AIDS Antiretroviral Treatment 30 First HIV First regimen to 3 million antibody test 25 reduce mother-to-child on ART in becomes transmission of HIV President Bush developing available 20 announces PEPFAR world 15 UNAIDS created 10 5 0 1980 ‘81 ‘82 ‘83 ‘84 ‘85 ‘86 ‘87 ‘88 ‘89 ‘90 ‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 2000 ‘01 ‘02 ‘03 ‘04 ‘05 ’06 2007 People living with HIV
  12. 12. Good politics, bad politics: the experience of Aids PPiot, HLarson,SRussell. Am J Publ Health, 2007;97:1934
  13. 13. Recorded female deaths in South Africa and Brazil for ages 15-64 years Brazil, 2004. South Africa, 1997. South Africa, 2004 Source: Nathan Geffen. Statistics South Africa and Instituto Brasileiro de Geografia e Estatistica.
  14. 14. Median percentage of population reached with HIV prevention services within the specified legal environment 100 Countries reporting having 80 non- discrimination laws/regulations Median percentage with protection 60 of population for this reached with population HIV prevention services Countries 40 (UNGASS indicator 9) reporting NOT having non- discrimination laws/regulations 20 with protection for this population 0 Sex workers Injecting drug Men having (N=42) users (N=17) sex with men (N=28) Source: UNGASS Country Progress Reports 2008. 3.7
  15. 15. Treatment Action Campaign (TAC), South Africa
  16. 16. UN security Council Resolution 1308 (2000) on AIDS
  17. 17. Total annual resources available for AIDS 1986‒2007 US$ million 10 billion 10 000 8.9 billion 9000 Signing of Declaration of 8000 Commitment on HIV/AIDS, UNGASS 8.3 billion 7000 6000 World Bank 5000 MAP launch 4000 Gates PEPFAR 3000 UNAIDS Foundation Less than 2000 US$ 1 million 1623 1000 Global Fund 292 257 212 59 0 ‘06 2007 1986 ‘87 ‘88 ‘89 ‘90 ‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04 ‘05 Notes: [1] 1986-2000 figures are for international funds only [2] Domestic funds are included from 2001 onwards [i] 1996-2005 data: Extracted from 2006 Report on the Global AIDS Epidemic (UNAIDS, 2006) [ii] 1986-1993 data: AIDS in the World II. Edited by Jonathan Mann and Daniel J. M. Tarantola (1996)
  18. 18. Resources available to HIV-related programmes by source and bilateral disbursements, 2006 Total Resource availability for HIV-related Bilateral disbursements to HIV-related programmes in 2006 (US$ Billions) programmes in 2006 10 (US$ Billions) 9 Other DAC country members 1% EC (0.5%) Belgium 1% 8 Spain 1% UN (2%) 7 Norway 2% 6 Australia 2% GFATM (7%) Germany 2% 5 Foundations (11%) Canada 2% 4 Sweden 3% Bilaterals (33%) Netherlands 3% 3 Domestic Public Ireland 3% 2 and Private (46%) United Kingdom 9% 1 United States 71% 0 Total resources available: US$8.9 Billion Percentage out of the total bilateral disbursements Total Bilateral disbursements 2006: US$ 2.9 Billion The organizational disbursements are different than commitments or obligations, as well as different from in-country expenditures Sources: UNAIDS analysis based on OECD/DAC online database (last visited on May 6, 2008), Resource availability UNAIDS 2005, Funders Concerned About G AIDS (FCAA), European HIV/AIDS Funders Group (EFG) for Philanthropic sector
  19. 19. Disbursements for HIV per US$ 1 Million GDP, 2006 Netherlands 521 Sweden 462 Ireland 408 United Kingdom 328 United States 120 France 93 Germany 60 Canada 50 Japan 24 Italy 4 0 100 200 300 400 500 600 US$ Sources: UNAIDS and Kaiser Family Foundation analysis, June 2007; Global Fund to Fight AIDS, Tuberculosis and Malaria online data query May 2007; H International Monetary Fund, World Economic Outlook Database, April 2007.
  20. 20. Prices (US$/year) of first-line antiretroviral regimen in Uganda: 1998-2003
  21. 21. Focus on results for people Targets Know your epidemic and the society Monitor and evaluate Invest in information systems
  22. 22. Know your epidemic
  23. 23. Number of HIV infections each year by route of transmission in Cambodia, 1988-2004 Number of new HIV infections each year by route of transmission in Cambodia, 1988-2004 (Source: Peerapatanapokin and Brown, using Asian Epidemic Model) 45000 40000 35000 30000 25000 20000 15000 10000 5000 0 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Male clients Sex workers Wife from husband Husband from wife Mother to child Source: Peerapatanapokin and Brown, using Asia Epidemic Model
  24. 24. Impotence fears hit polio drive By Ashfaq Yusufzai BBC News, Peshawar Health officials in Pakistan say they have failed to immunise over 160,000 children against polio due to rumours the vaccine causes sexual impotence. Parents in parts of northern Pakistan told the BBC news website they feared an quot;American conspiracyquot; to cut the fertility of the next generation. At least 39 cases of polio were reported in 2006, 15 of them in the North West Frontier Province (NWFP) and the tribal areas in which only 20% of people are immunised. Worldwide 1,902 cases of polio were reported during the year, a recent WHO report said. A WHO meeting in Geneva last October heard that children paralysed by polio around the world were infected by viruses originating from Pakistan, Afghanistan, India and Nigeria. Radio rumours The main opposition to the drive in Pakistan came from local clerics who run illegal FM radio channels in many NWFP districts and the tribal areas, say officials. Amirullah Khan, a resident of NWFP's Swat district, quoted Maulana Fazlullah of a local FM channel as telling his listeners the vaccination drive was quot;a conspiracy of the Jews and Christians to stunt the population growth of Muslimsquot;.
  25. 25. The PREVENTION GAP Persons at risk with access to selected prevention interventions, 2006 Source: Global HIV Prevention: the access and funding gap. June 2007
  26. 26. Cost Effectiveness
  27. 27. A multi-disciplinary, multi-sectoral response • Health outcomes determined by multiple factors and interventions • Particularly key besides health: law, education, work place, trade, armed forces • Need to expand resource base • First genuine business engagement in health
  28. 28. Percentage of countries with sectors included in the national AIDS strategy and earmarked budgets Military/police Sector Labour included Health Earmarked Transportation budget present Agriculture Minerals and energy Trade and industry Tourism Public works 0 20 40 60 80 100 Percentage of countries (%), N=126 Source: UNGASS Country Progress Reports 2008. 6.5
  29. 29. Community engagement • From planning to implementation • Makes or breaks programmes • “Aids literacy” • National Aids Councils and Global Fund Country Coordination Mechanisms • Societal sustainability and resilience
  30. 30. TASO, Uganda
  31. 31. A global response • Global public good and strategic issue • Role of United Nations • Global civil society and activism • International financing • Generation WE
  32. 32. UNITE D N ATION S GENERA L ASSEMB LY /AIDS SPECIA L SESSIO N O N HIV 25 - 27 JUNE 2001 United Nations
  33. 33. New instruments for AIDS financing • World Bank Multi-country AIDS Program (2000) • Global Fund to Fight AIDS, TB and Malaria (2002) • PEPFAR, (2003) • Unitaid (2005) • (PRODUCT) Red (2005) • Debt2Health (2007)
  34. 34. Opportunities for global health  Increased funding (ODA and research)  Collateral benefits (TB,malaria, health systems)  Culture of accountability  Tiered pricing  Engagement of non-medical sectors  Boost to research  Major interest by young people But: how long will the momentum last?
  35. 35. Total health ODA commitments, 2001-2006 $20.1 US$ Billions $16.5 $13.3 $11.2 $7.6 $7.2 2001 2002 2003 2004 2005 2006
  36. 36. Increase in TB financing and new sputum positive cases detected and treated Amount disbursed (US$) New SS+ cases treated under DOTS 1.9M 300,000,000 2,000,000 New SS+ cases treated under Annual amount disbursed 276M 250,000,000 1,500,000 1.4M DOTS (annual) 200,000,000 196M (in US$) 150,000,000 1,000,000 127M 107M 100,000,000 0.38M 0.6M 500,000 41M 50,000,000 0.5M - - 2002 2003 2004 2005 2006 2007
  37. 37. Direct Funding of Health Systems through GF Grants (2007) Direct funding of health systems through Global Fund grants Administration 10% Other Monitoring and 10% Evaluation 3% Infrastructure and Equipment Health 9% Systems 35% Human Resources 23% Commodities, Products, Drugs 45% Amount (approximately) • Estimates from Global Fund Rounds 2-•Commodities, Products, Drugs - $6.3-billion 7 proposals •Health Systems - $4.9-billion •Administration - $1.4-billion • 100% = $5.2 billion USD •Other - $1.4-billion
  38. 38. Increasing Coverage of Health Care in Rwanda Scaling up Health Insurance Improving Access to Health Care 80% 7,000,000 72% 6,000,000 Global Fund 2005 2006 subsidy 60% 2 m illion Number of beneficiaries 5,000,000 Global Fund co- 49% finance subsidy 44% 43% 4,000,000 40% Out-of-pocket and/or 1,3 m illion 40% 35% Government subsidy 3,000,000 2,000,000 20% 3 million 1,000,000 900,000 300,000 0 7,800 0% P rivate health Civil Geno cide Co mmunity P o pulatio n co verage P o pulatio n with at Utilizatio n rate o f insurance servants/M ilitary survivo rs, health insurance with health insurance least o ne district ho spitals priso ners (398 mutuelles) co nsultatio n in health center
  39. 39. Basics • Science AND justice as basis for policy • Nothing for the people without the people • Genuine multi-disciplinarity • Information for accountability and programming • Think long term

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