UNAIDS ISSUES BRIEF A NEW INVESTMENTFRAMEWORK FOR THE GLOBAL HIV RESPONSEOver the past 30 years there havebeen tremendous gains in the globalHIV response, but until now therehas been only limited systematic effortto match needs with investments. Theresult is often a mismatch of the two,and valuable resources are stretchedinefficiently across many objectives.To achieve an optimal HIV response,countries and their internationalpartners must adopt a more strategicapproach to investments.
A new investmentframework for HIV The investment framework offers a realistic, achievable road map to decisively accelerate progress in the global HIV responseIn June 2011 a policy paper was published Aims of the investmentin The Lancet (Schwartländer et al) that laid frameworkout a new framework for investment for theglobal HIV response. The new framework Maximize the benefits of the HIVis based on existing evidence of what works responsein HIV prevention, treatment, care and Support more rational resourcesupport. It is intended to facilitate more allocation based on countryfocused and strategic use of scarce resources. epidemiology and context Encourage countries to prioritizeModelling of the framework’s impact shows and implement the most effectivethat its implementation would avert programmatic activities12.2 million new infections and 7.4 million Increase efficiency in HIV prevention,AIDS-related deaths between 2011 and 2020. treatment, care and support programmingThis modelling also indicates thatimplementation of the investment Though much has been achieved in theframework is highly cost-effective, with global HIV response over the last 30 years,additional investment largely offset by important gaps remain. Currently, strategiessavings in treatment costs alone, and are often implemented in parallel, regardlessenabling the HIV response to reach an of how they might overlap or leave criticalinflection point in both investments and gaps in coverage. Through a simplificationrates of HIV infection. and clarification of the different elements of HIV efforts, as well as better support forThe framework was developed by an countries to prioritise HIV programmesinternational group of experts from the Joint and assess the synergies between them, theUnited Nations Programme on HIV/AIDS framework presents a radical departure from(UNAIDS), The Global Fund to Fights AIDS, existing approaches to HIV investment andTuberculosis and Malaria, the US President’s programming.Emergency Plan for AIDS Relief, The Bill& Melinda Gates Foundation, The WorldBank, the World Health Organization andacademic and policy institutions.2 UNAIDS | A new investment framework for the global HIV response
Proposed Investment FrameworkFIGURE 1: Proposed Investment Framework CRITICAL BASIC PROGRAMME ACTIVITIES OBJECTIVES ENABLERS Key populations at Social enablers higher risk Eliminate new HIV infections advocacy among children drugs) practices mobilization Stopping new infections reduction media Behaviour change r programmes Condom promotion and distribution environment Programme enablers center delivery Keeping people alive Pr communication Voluntary medical male incentives circumcision Procur distribution pr Treatment, Researc care and circumcision) innovation support for people living with HIV SYNERGIES WITH DEVELOPMENT SECTORS pr refor equality r Gender violence, tr practices. Key components of the Basic programme activities investment framework Just six basic programme activities are essential to an adequate HIV response and need to be delivered Basic programme activities at scale according to the size of the relevant Critical enablers population. These activities work together for Synergies with development sectors maximum impact and should therefore be delivered as a package, where each element reinforces the other. The investment framework takes as its starting point a human rights approach to the They are: HIV response, to ensure that it is universal, 1. Focused programmes for key populations equitable, inclusive, and fosters participation, at higher risk (particularly sex workers and informed consent and accountability. their clients, men who have sex with men, and people who inject drugs); The framework makes a distinction between 2. Elimination of new HIV infections in children; basic programme activities that have a direct 3. Programmes that focus on the reduction of risk effect on HIV risk, transmission, morbidity of HIV exposure through changing people’s and mortality; the critical enablers that are behaviour and social norms; crucial to the success of HIV programmes; 4. Procurement, distribution and marketing of and synergies with development sectors male and female condoms; (Figure 1). 5. Treatment, care and support for people living with HIV; 6. Voluntary medical male circumcision in countries with high HIV prevalence and low rates of circumcision. A new investment framework for the global HIV response | UNAIDS 3
Implementing the framework will avert 12.2 million new infections and 7.4 million AIDS-related deaths between 2011 and 2020.The evidence base for the basic programmes amenable to generic description, vary greatlyis strongest in relation to biomedical inter- according to context and are underpinned byventions such as voluntary medical male a weaker evidence base.circumcision and the biomedical aspects However, they increase the impact ofof eliminating new HIV infections among basic programme activities by overcomingchildren. Although behaviour change barriers to the adoption of evidence-basedprogrammes tend to be more complex and HIV policies and the factors that adverselyless clearly defined, changes in behaviour affect HIV programmes by distortinghave been associated with declines in HIV their priorities, including social stigma,prevalence. Key populations, by definition, poor health literacy and a punitive legalpredominate in concentrated epidemics. environment.However, they also contribute to generalized(where HIV prevalence among pregnant Examples of social enablers are outreach forwomen consistently exceeds 1%) epidemics HIV testing, stigma reduction, human rightsand in some cases account for a substantial advocacy, and community mobilization.proportion of the epidemic. Basic activities Programme enablers include strategicfor key populations include focused commu- planning, programme management andnication, education and condom program- capacity building for community-basedming tailored to each population’s needs. organizations. Community mobilization is a key element of the investment frameworkAccess to antiretroviral therapy is a key because it leads to improved uptake ofprogramme activity of the HIV response. HIV programmes and promotes local-levelNot only does ART reduce morbidity and advocacy, transparency and accountability.mortality among people infected with HIV, Community mobilization has been recognizedit also reduces the incidence of AIDS- as a cornerstone of HIV programmes.related tuberculosis, and has public healthbenefits in terms of reducing the onward Synergies with developmenttransmission of HIV. Community-led sectorsdelivery approaches to treatment are animportant component of the framework. HIV programmes are not implemented in isolation. The investment frameworkCritical enablers recognizes the need for the HIV response to be aligned to country development objectivesUnderlying the success of basic programme and to support the strengthening of social,activities are the enablers which make legal and health systems.programme access possible and success morelikely and respond to local context. Critical Social protection, increasing access toenablers can be divided into two categories: education, legal reform, poverty reduction,social enablers that create environments reducing gender-based violence, andconducive to rational HIV responses, and improving health, community andprogramme enablers that create demand employment systems are all key areas wherefor programmes and improve their there are synergies between HIV-specificperformance. Critical enablers are not always efforts and development.4 UNAIDS | A new investment framework for the global HIV response
TABLE 1: RETURN ON INVESTMENT IN THE PROPOSED FRAMEWORK 2011-2015 2011-2020Total infections averted 4 200 000 12 200 000 (US$ 2450 each)Infant and child infections averted 680 000 1 900 000 (US$ 2180 each)Life years gained 3 700 000 29 400 000 ( US$ 1060 each)Deaths averted 1 960 000 7 400 000 (US$ 4090 each)Resources needed to implementthe investment frameworkModelling of the framework’s impact There will also be efficiency gains such asand cost demonstrates how it can lead cost-saving on treatment commodities andto universal access to HIV prevention, a shift to community-based treatment andtreatment, care and support, and create testing.a tipping point in both the rate ofHIV infection and investment in HIV Whereas basic programme costs in 2011programmes. stand at US$7 billion, in the model they are US$12.9 billion in 2015, dropping toImplementation of the investment US$10.9 billion in 2020 (Table 2, Figure 2).framework is estimated to avert 12.2 millionnew HIV infections including 1.9 million The single largest cost is treatment, care andHIV infections among children, 7.4 million support, accounting for 38% of the increaseAIDS-related deaths between 2011 and 2020, in resources (Figure 2). Other contributorsand result in a gain of 29.4 million life-years to the cost increase include doubling(Table 1). At US$1060 per life-year gained, the coverage of outreach and needle andthe additional investment required would be syringe programmes and a 10-fold increaselargely offset by savings in future treatment in provision of drug substitution forcosts alone. injecting drug users, as well as increased coverage of prevention of mother-to-childCosts are based on what is needed to transmission to reach 90% of all child-increase present rates of coverage to bearing women living with HIV, so thatachieve universal access to HIV prevention, new HIV infections among children can betreatment, care and support by 2015 and eliminated by 2015.to maintain it at that level of access. Theinvestment framework model requires a Costs for critical enablers would fall fromscaling-up of HIV programme funding US$5.9 billion in 2011 to US$3.4 billionfrom US$16.6 billion in 2011 to US$22.0 in 2015 before increasing slightly tobillion in 2015, before declining to US$19.8 US$3.7 billion in 2020 due to a shift frombillion in 2020 (Table 2, Figure 2). comparatively expensive facility-based voluntary HIV counselling and testing to lessFewer resources will be needed because expensive and more focused community-coverage will have reached target rates and based programmes (Table 2, Figure 2). In thethere will be fewer new HIV infections model 316 million people will receive HIVrequiring treatment and other services. testing in 2015.A new investment framework for the global HIV response | UNAIDS 5
TABLE 2: RESOURCES REQUIRED FOR THE INVESTMENT FRAMEWORK OVER TIME(billions of US$) 2011 2015 2020Basic programmes (total) 7.0 12.9 10.6 Key populations at higher risk 1.0 3.3 2.5 Elimination of new infections in children 0.9 1.5 1.3 Behaviour change programmes 0.1 0.7 0.7 Condom promotion and distribution 0.4 0.5 0.6 Treatment, care and support for people living with 4.5 6.7 5.5 HIV Voluntary medical male circumcision 0.1 0.2 0.1Critical enablers 5.9 3.4 3.7Synergies with development sectors 3.6 5.8 5.4TOTAL 16.6 22.0 19.8Synergies with development sectors require programme elements are effective andan increase in funding from US$3.6 billion ineffective. This, in turn, empowers the HIVin 2015 to US$5.8 billion in 2015 and US$5.4 response to be based on fewer things done atbillion in 2020 (Table 2, Figure 2). These a deeper level, and it offers clear incentivesestimates are based on the costs of a range to maximise the synergies between theof programmes such as those focussed on different elements of HIV programmes.gender-based violence, youth in schools,workplace education and caring for children One of the limitations of the investmentorphaned by HIV. framework is that it lays out a defined set of evidence-based basic programmes, but doesStrengths and not explore what delivery models deliver optimum results when interventions arelimitations of the combined and expanded. It is crucial toinvestment framework identify the best ways to scale up bundled HIV interventions.The investment framework offers a realistic, Another shortcoming of the investmentachievable road map to decisively accelerate framework is that while there is an everprogress in the global HIV response. One growing body of evidence on the effectivenessof its major strengths is that it is based on and cost-effectiveness of basic programmes,the best available evidence on what works there is more limited evidence availablein HIV prevention, treatment, care and for critical enablers and synergies withsupport. Moreover, the framework allows development sectors. Further research isadaptation as new evidence emerges,especially if new technologies or approaches needed to better understand the barriers toshow that they directly affect HIV incidence, effective HIV responses and factors enablingmorbidity and mortality and can be them; to quantify key enabling interventions;consistently scaled up. and to demonstrate their cost-effectiveness. In particular, improved evidence is neededThe framework enables countries to respond on the best approaches to communityto HIV based on their own priorities. It mobilisation and community-led delivery ofsimplifies the process of determining what programmes, as well as their costs.6 UNAIDS | A new investment framework for the global HIV response
FIGURE 2: ESTIMATED COST OF THE INVESTMENT FRAMEWORK, 2011-20 Synergies with development sectors Critical enablers Voluntary medical male circumcision Treatment, care and support for people living with HIV Condom promotion and distribution Behaviour change programmes Elimination of new infections in children Key populations at higher risk 25 20Cost (billions US$) 15 10 5 0 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Year Implementing the of existing HIV prevention, treatment, care and support programmes as well as their investment framework costs, enabling factors and potential barriers to implementation. With this information, In countries, governments and their partners countries can then prioritize activities and can apply the investment framework to implement a carefully focused and more guide HIV responses and make the most of effective response. In most countries this will their programmes. mean changing investments in HIV and a To implement the investment framework, re-programming of HIV efforts. policy makers must make use of information At the global level, the investment on HIV incidence and prevalence as well as framework will enhance present efforts to the populations at highest risk of acquiring make the most of HIV responses, including HIV, the geographic distribution of HIV and the Global Fund’s new approach to fund the proximate and structural determinants of countries on the basis of national strategy transmission. applications rather than discrete projects, They must also have a nuanced and PEPFAR’s new and explicit focus on understanding of the scope and coverage increased country ownership. A new investment framework for the global HIV response | UNAIDS 7
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