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Posted: 23 Dec 2011
Journal Club: Novel financing solutions and the end of AIDS

In this week's Journal Club, Andrew Scheibe discusses the difficult road to ending the AIDS epidemic and considers the global economic challenges to UNAIDS’ proposed “Investment Framework.”


   
The End of AIDS. An optimistic thought and a concept which is now the vision of the Joint United Nations Programme on HIV/AIDS (UNAIDS) and AVAC: Global Advocacy for HIV Prevention. This paradigm shift has come about due to the impact and experience of 30 years of work, together with recent developments in HIV related technologies.

HIV prevention efforts reduced the global annual HIV incidence rate by approximately  21% between 1997 and 2010. Furthermore, increased access to ART is believed to be the major contributor to the prevention of an estimated 700,000 AIDS-related deaths during the same period.

The UNAIDS Investment Framework (pdf) proposes three categories of investment to achieve UNAIDS’ vision of zero new HIV infections, zero HIV stigma and zero AIDS related deaths:

  1. investments in six basic programme activities; 
  2. investments in social and programmatic areas to foster enabling environments for effective programme implementation (“critical enablers”); and 
  3. investments to improve synergies between HIV related activities implemented by the health and other development sectors (e.g., HIV programs of the education and business sectors).

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Figure 1. An overview of the UNAIDS Investment Framework. 

This approach re-packages existing interventions and highlights the need to bring a select group of these interventions to scale, supported by efforts to address social and structural factors. The estimated efficiency gains and long-term economic savings of this approach are predicted to prevent 12.2 million HIV infections, avert 7.4 million deaths, result in 29.4 million life years gained and save US $40 billion between 2011 and 2020. Impressive. All this is calculated to cost US $46.5 billion over the next 10 years. In order to reach these goals, annual global contributions would need to increase to US $16 billion in 2012, and increase further to reach a peak of US $22 billion in 2015 (when universal coverage of the programme activities is estimated to be achieved). After 2015, annual contributions are predicted to decrease. Current global HIV contributions amount to just over US $15 billion annually. Clearly, increased contributions (in an equitable manner) would be required from all countries (Schwartländer et al., 2011).  I believe that countries should take ownership of their national HIV responses, and by investing in their own HIV programmes they will be investing in their future. However, I personally doubt the success of mobilizing additional financing for HIV interventions during the current economic climate. 

Nevertheless, I believe that the clear recommendations provided by UNAIDS may help focus global HIV efforts. It is also reassuring to notice the explicit mention of programmes and activities to address the needs of key populations, to foster enabling environments and to increase synergies between the health and other development sectors – areas that have been largely neglected in the past. The proposed streamlined package of proven cost-effective activities seems feasible to implement, as many of these activities have already been deployed in many countries. Many of the barriers to scale-up could be overcome and the expected health gains and cost savings seem tangible.

The exclusion of novel HIV prevention technologies within the Framework is of major concern. Much work still needs to be done before efficacy and cost-effectiveness data on oral and topical Pre-Exposure Prophylaxis (PrEP) is available, and even more work is required to advance HIV vaccine development. Recent advances in biomedical prevention technologies, and their potential benefit, should provide the rationale for increased investment in these strategies. By excluding investments for research and development of novel prevention modalities within the Framework, I fear that even less funding will be directed into interventions with the greatest potential for delivering health gains and for minimizing long term costs.

In agreement with UNAIDS’ Framework, AVAC’s 2011 report, “The End?,” outlines their priorities and goals for 2012. The report also provides a concise overview of recent developments in the HIV prevention field, and contextualizes the contributions various HIV prevention partners have made, and are making, towards reaching “The End” (Figure 2).

AVAC’s proposed agenda includes:

  1. the delivery of proven strategies to scale;
  2. planning for the role out of new prevention tools; and
  3. developing long term solutions, including a vaccine, to end AIDS.

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Figure 2.  AVAC’s three-part agenda for ending AIDS (AVAC, 2011).

I find it reassuring that AVAC has chosen to include the UNAIDS Investment Framework within their agenda for the End of AIDS, as their support will add to the credibility of UNAIDS’ proposal. It is also encouraging that they explicitly mention the need to continue developing long term solutions, specifically an HIV vaccine. AVAC’s timeline is somewhat longer than that of UNAIDS, and seems less well defined, perhaps reflecting their experience with national responses to global recommendations and the low potential for the mobilization of additional funds during periods of economic recession.

UNAIDS and AVAC propose roadmaps which in themselves seem to be feasible, and if performed in concert could result in the rosy end they envision, and I also hope for.  Unfortunately, the UNAIDS Investment Framework does not consider the investments needed to support the development of new prevention technologies. The framework also comes at a time when the Parthenon is shaking, the Coliseum is trembling and the Global Fund to Fight HIV, TB and Malaria (GFATM) announced that it is replacing Round 11 funding with a temporary mechanism designed to maintain only essential services while GFATM is establishing a new model (The Global Fund to Fight AIDS Tuberculsosis and Malaria, 2011).

We do live in trying times. As colleagues working in the fields of basic science, clinical research and policy development, I think that it is important that we remain aware of the great progress that has been made towards overcoming the HIV epidemic, and that we remain optimistic, and believe that the UNAIDS vision will one day become a reality. Until it does, we will need to tighten our belts, continue on paths of discovery and persist to lobby for additional funding and the inclusion of prevention technology development as an essential component of global HIV investments.

About the author: Andrew Scheibe, MBChB, is an Affiliated researcher at the Desmond Tutu HIV Foundation, South Africa.


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