1. Overview of AIDS Epidemic in Eastern and
Southern Africa and progress towards meeting the
HLM Targets
Pride Chigwedere, MD, PhD, Coordinator for Universal Access,
UNAIDS Regional Support Team for Eastern and Southern Africa
25 April 2013, Johannesburg, SA

2. 34 million people living with HIV, 2011

3. International Commitments on HIV/AIDS
Global Commitments
2001 UNGASS Declaration of Commitment
2006 Political Declaration - Universal Access
2011 Political Declaration - Elimination
Continental Commitments
2001 Abuja Declaration on HIV/AIDS, TB & Other Related IDs
2006 Abuja Call: Common Position on Universal Access
2011 AU Consultative Process: Africa Common Position to HLM
2012 AU Roadmap on Shared Responsibility and Global Solidarity

4. 2015 targets in the UN Political Declaration 2011
1
2
Halve sexual
transmission
Halve infections
among injecting
drug users
6
Close the global
resource gap and
achieve annual
investment of
US$ 22-24 bn
7
Eliminate gender
inequalities and
sexual violence
and increase
capacities of
women and girls
3
Eliminate new HIV
infections among
children and halve
AIDS-related
maternal deaths
8
Eliminate stigma
and discrimination
4
15 million
people on HIV
treatment
9
Eliminate
travel related
restrictions
5
Halve tuberculosis
deaths among
people living with
HIV
10
Eliminate parallel
systems, for stronger
integration

5. Reduce sexual transmission of HIV by 50%
• In 2011, there were approximately 2.5 million new infections
in adults globally; 1,2 million of them were in ESA.
• Decline in New Infections from 2001 to 2011:
–
–
–
–
–
7 countries in ESA achieved over 50%;
4 countries achieved 26-49%;
2 countries achieved 10-25%;
3 countries remained stable;
1 country showed an increase
• All countries need to achieve 50% decline from 2009 to 2015

6. % Change in Incidence 2001 – 2011
2001 Prevalence
2001 Incidence
2011 Prevalence
2011 Incidence
% Change in
Incidence 2001-11
Malawi
13.8
1.74
10.0
0.49
-72
Botswana
27.0
3.48
23.4
1.00
-71
Namibia
15.5
2.39
13.4
0.77
-68
Eritrea
1.1
0.08
0.6
0.03
-67
Zambia
14.4
1.89
12.5
0.80
-58
Rwanda
4.1
0.31
2.9
0.15
-53
Zimbabwe
25.0
2.11
14.9
1.05
-50
South Africa
15.9
2.42
17.3
1.43
-41
Swaziland
22.2
4.11
26.0
2.60
-37
Kenya
8.5
0.66
6.2
0.45
-32
Mozambique
9.7
1.63
11.3
1.13
-31
Sudan South
2.6
0.41
3.1
0.33
-21
Angola
1.7
0.26
2.1
0.21
-19
Lesotho
23.4
2.67
23.3
2.47
-7
Tanzania
7.2
0.62
5.8
0.59
-5
Madagascar
0.3
0.04
0.3
0.04
10
Uganda
6.9
0.69
7.2
0.84
21
Comoros
na
na
na
na
nd
Mauritius
na
na
na
na
nd
Ethiopia
na
na
na
na
nd
Seychelles
na
na
na
na
nd
Country
Source: UNAIDS Estimate 2012

7. Eliminate new infections among children and
reduce AIDS-related maternal deaths
• Global – approximately 330,000 babies were born with HIV in 2011;
55% or 180 000 were in ESA
• Nearly 90% of all new HIV infections among children globally occur
in 22 countries – 21 of those countries are in Africa, and 14 are in
ESA
• Global Plan aims to reduce new infections in infants by 90% from
2010 levels, by 2015; requires achieving >90-95% coverage for high
quality PMTCT services in priority countries

8. Percentage Coverage of PMTCT Services 2011 (excluding SD Nevirapine)
Countries 2 - 49%
Countries 50 - 79%
Countries >80%
• ESA coverage for PMTCT services in 2011 was 72% (plus 13% coverage on SD Nevirapine).

9. Reach 15 million PLHIV with ART by 2015
• # of persons living with HIV in ESA 2011 – 17.1m
• # of persons eligible for ART using CD4 350 guidelines – 8.1m
• # of persons on ART 2011 – 5.2m (64% coverage)
• Unmet need for ART – 2.9m
• Epidemiological projection shows that if the 15x15 target is met
by 2015, 80% of those in need of ART will be receiving therapy
Source: UNAIDS & WHO Estimates, 2012

10. Estimated ART Coverage (CD4<350) 2011
Countries <50%
Countries 50 - 79%
Countries >80%
• 5 countries Rwanda, Botswana, Namibia, Swaziland and Zambia have achieved > 80% coverage

11. Reduce TB deaths in PLHIV by 50%
• TB is a leading killer of people living with HIV causing one
quarter of all deaths. People living with HIV and infected with
TB are 21 to 34 times more likely to develop active TB disease,
compared to people without HIV.
• In 2010 there were an estimated 1.1 million new cases of HIVpositive new TB cases globally; approximately 60% occurred in
ESA
• In 2010, about 350 000 people died of HIV-associated TB
globally. Almost 250 000 deaths were in ESA, and 85 000 were
in SA.

12. HIV Prevalence (Percent Estimate) in New TB Cases, 2009
< 25%
25 – 50%
50 – 83%
In South Africa, Lesotho, Swaziland, Namibia, Botswana, Zimbabwe, Zambia, Mozambique, Malawi &
Uganda, more than 50% of new TB patients are HIV positive

13. Global Investment of US$22-24b / year in
low and middle income countries
• By 2010, Africa had mobilised close to US $ 8bn from both International and Domestic Sources
• The increase in domestic resources is smaller that that of international resources

14. Share of care and treatment expenditure originating from
international assistance, African countries, 2009–2011

15. THIRD GENERATION NSPs
• Changed epidemic context: from public health emergency to
chronic disease
• Changed global economic environment: austerity measures
in donor capitals, growth in Africa, emphasis on ‘managing for
results’ and ‘value for money’.
• Scientific & technological advances: simpler testing,
treatment availability, treatment as prevention, MC, PMTCT
• Taking AIDS out of isolation: greater national and
international interest in integrating AIDS into broader health
and development efforts
• Political Declaration on HIV: Three Zeros, HLM targets and
the centrality of NSPs

16. Generations of NSPs
• 1st generation of NSPs: 1980s/early 90s; mainly GPA
times (Medium Term Plans); within the health sector
• 2nd generation NSPs: mid-90s; multi-sectoral; NACs;
increased availability of funding, little prioritization
and allocative efficiency
• 3rd generation NSP: post-2015 and the beginning of
the End of AIDS, challenged by signs of donor funding
slowdown

17. Lessons from NSP 2G
•
•
•
•
Limited focus on implementation,
Low prioritization (high levels of inclusiveness)
Large budgets dedicated to low impact interventions
Costly and complex processes (heavy on time
money & documentation)
• Weak results orientation (processes, not results)
• High costs of stand alone coordination with little
return in terms of effective management for
investment.

18. What is NSP-3G?
A new initiative from the UNAIDS family to:
• Foster a national planning paradigm shift in
response to the new environment
• Prioritize resource allocation and maximize return to
investment (Investment Thinking)
• Respond to country demand and ownership/
leadership (Paris/Accra/Busan)
• Drive progress towards the UNAIDS vision of the
Three Zeros & meeting the HLM targets

19. Universal Principles
• Country ownership, shared responsibility & global
solidarity
• Scientific evidence public health considerations are
integral
• Full engagement by CSOs and PLHIV
• Universal and equitable access to AIDS services and
eliminating marginalization
• Advancing human rights and gender justice

20. n Applying Investment Thinking in Lesotho
Changing environment : shifting priorities, donor fatigue, economic crisis,
national ownership vs. dependency
Business as usual is not an option:
Prioritization
Emphasis on results/ impact
Value for Money/efficiency
Return on Investment
sustainability
Investment Cases: How do we maximize the returns on the Investment

21. AIDS: investing strategically to maximize impact
CRITICAL
ENABLERS
BASIC PROGRAMME ACTIVITIES
• Social
Advocacy
Laws, policies, and
practices
Community
mobilisation
Stigma reduction
Mass media
Programme
Community
centred design
and delivery
Programme
communication
Management and
incentives
Procurement and
distribution
Research and
innovation
Behaviour
change
OBJECTIVES
Condoms
Stopping new
infections
Treatment
& care
Child infections
& maternal
mortality
Keeping people
alive
Key
populations
Male
circumcision
SYNERGIES WITH DEVELOPMENT SECTORS

22. Priority Country Actions: Sexual Transmission
• Assist countries identify who is getting infected / who is at risk of
infection (KYE/R)
• Prioritize relevant, effective, and impactful prevention strategies for
different populations (IF)
• Advocate for the scale up Basic Program Activities:
– Increase # of people on ARVs (effect on transmission)
– Scale up male circumcision as a priority
– Behavior change programmes
– Programmes for key populations (almost no data for MSM, sex
work, IDU in region)
– Condom promotion & distribution
• Make smart investments that combine programs with critical
enablers to exploit synergies

23. Estimate Number of VMMCs needed to prevent one HIV
infection (PEPFAR Data)

24. Estimate of Number of Adults 15-49 yrs. VMMC needed to reach
80% coverage / country (PEPFAR Data)

25. Estimate Number of VMMC done / country as of October 2011
(PEPFAR Data)

26. A checklist for applying investment thinking

27. Returns on investment using the investment approach
2011–2020
Outcomes
Total infections averted
More than 12 million
Infant infections averted
1.9 million
Deaths averted
7.4 million
Life years gained
29.4 million

28. South Africa has significantly reduced the cost of ARVs
South African tender prices
June 2010
January 2011
350
International
benchmark
300
250
)
d
n
R
(
k
a
p
e
c
i
r
P
200
150
100
50
0
ABACAVIR
300mg
EFAVIRENZ EFAVIRENZ LAMIVUDINE NEVIRAPINE TENOFOVIR
200mg
600mg
150mg
50mg/5ml
300mg

29. Community support keeps people on treatment
CLINIC-BASED TREATMENT
70%
still receiving treatment after two years
Sub-Saharan Africa: people
receiving ART from specialist
clinics
Source: Fox MP, Rosen S. Patient retention in antiretroviral therapy programs up to three years on treatment in subSaharan Africa, 2007–2009: systematic review. Tropical Medicine and International Health, 2010, 15(Suppl. 1):1–15.
COMMUNITY TREATMENT MODEL
98%
still receiving treatment after two years
Mozambique: self-initiated
community model
Source: Decroo T et al. Distribution of antiretroviral treatment through self-forming groups of patients in Tete province,
Mozambique. Journal of Acquired Immune Deficiency Syndromes, 2010 [Epub ahead of print].

30. Optimized investment could lead to rapid declines in new
HIV infections
Current and projected HIV infections
Cambodia
Zimbabwe
South Africa
Current &
projected HIV
infections
1990
Source: UNAIDS 2011
2015 1990
2015 1990
Benefit of the
investment framework
2015

31. Integrated services are more efficient
US$
40
The example of VCT: Costs per client
35
Stand-alone VCT clinics
30
Integrated into SRH services
25
20
15
10
5
0
Kenya (2002)
Kenya (2008)
India (2007)
Uganda (2009)

32. Lesotho Investment Case?
• What will the country do differently to maximize
returns?
• Within each of the program activities which critical
enablers is the country prioritizing to improve access
and scale up, which groups will receive special
attention?
Which synergies will the country prioritize? How will
these be reflected in the investment package?
• Efficiency gains? Effectiveness?
• What additional investments are required? Where
will they come from? Can they be sustained?

33. VISION
ZERO NEW HIV INFECTIONS.
ZERO DISCRIMINATION.
ZERO AIDS-RELATED DEATHS.
16 October 2006
UNAIDS

34. AIDS in the Post-2015 Development
Agenda
Brazey de Zalduondo
Sonja Tanaka
24 March 2013

35. UNAIDS overarching messaging
•
Investing in health. Need a fresh narrative to convince leaders to invest more –
health reduces inequality; health mobilizes people for building democratic
accountability; health cooperation can be a tool for diplomacy; offers entry point
for human rights.
•
AIDS is not over. Priority is to ensure HIV is prominently positioned in the post2015 agenda, including ambitious, measurable targets towards the end of AIDS.
•
End of AIDS. With political commitment, community mobilization, adequate
funding and the right approaches, the end of AIDS can be a shared triumph of the
post-2015 era.
•
Transforming health. Approaches from the AIDS response, including inclusive,
people-centred, multi-sectoral action, can be applied to transforming the way
countries and their partners do health and development.

36. The Post-2015 House: UN Process towards an agenda
P2015 Development
Agenda
UN General Assembly
P2015 ASG Secretariat
Regional, Online, and
Other UN Consultations
11 Thematic
Consultations
86 National/Regional
Consultations
Open Working Group on SDGs
(65 Member States)
High Level Panel

37. UNAIDS engagement & advocacy targets
 UNAIDS engaged in 7 / 11 Thematics: Inequalities, Education, Food security and
nutrition, Governance, Conflict and fragility, Population dynamics & Health.
 Joint UNAIDS paper w Cosponsors with key messages on health, human rights and
social transformation.
 UCOs have engaged in Country Consultations (completed or underway, led by
UNCT)
 Global online conversation on worldwewant2015.org and myworld2015.org
 Civil Society Consultations
 Lancet Commission
 UN SG’s High Level Panel, chairs: President Yudhoyono (Indonesia), President
Johnson Sirleaf (Liberia) and PM Cameron (UK)
 Open Working Group on Sustainable Development Goals (incl. Algeria, Egypt,
Morocco, Tunisia; Benin, Ghana, Congo; Kenya, Tanzania, Zambia & Zimbabwe)

38. 2012-2013 Consultation processes

39. EXD address in Botswana
1. Must recall that where we are today is thanks to the MDGs
2. Our world is entirely different than in was in 2000
3. Opportunity to integrate this transformation into new a narrative for global health –
smarter argument for why to invest. Example of AU Roadmap: frames health as
spurring industrial development, knowledge economy, innovation – with SS
cooperation.
4. International community must not make same mistake twice. Millennium
Declaration gave a central role to inclusiveness, equity, dignity, human rights. But
those principles got lost in translation to goals.
5. Global goals demand global solutions we must address global determinants and
global responsibility for health and development
6. We have never had better time to disrupt and rebuild a new model to advance
global health
7. We should inspire the High Level Panel to be bold and demand new thinking on
health governance – we can streamline functions into 3 global health institutions
(norm setting, financing and accountability)

40. Outcomes of Botswana Health Consultation, 5 March
 Future health goals need to reflect universal realities –be
relevant in all countries (HICs as well) and address equity
(distribution) and rights
 Goals must be tracked globally but catalyse progress and
monitor success in terms of the reality that each country faces
 The MDG agenda must be accelerated to 2015 and continued
with updated targets - including through target to realise an
AIDS-free generation

41. Themes and concerns emerging from the consultations
 Continued relevance of the MDGs (human development agenda)
 Need also to incorporate key issues the MDGs left out – including
 Over all: universality, equity, quality
 In health – NCDs (“double burden” of IDs and NCDs)
 Address social determinants – through policies and investments
 Need to combat growing inequality – disparities within as well as
between countries
 Investment in data, and use of data, at national and sub-national
levels. Aim for data disaggregated by sex, age, geography – and
more.
 Interconnectedness of goals – be smarter, prevent “stove-piping”
 Human right are central; need national and regional mechanisms

42. UNAIDS and Lancet Commission: From AIDS to
Sustainable Health
 Hope that Commission will be seen to have legitimacy and influence to
drive political movement for AIDS and health
 High level political Commission with a dynamic programme to produce:
o space for systematic analysis of evidence
o sharp critique
o robust recommendations
 Co-Chairs: President Joyce Banda; Dr Nkosazana Dlamini Zuma
(Chairperson, AUC); Dr Peter Piot (Director, LSHTM)
 First meeting: Lilongwe, 28-29 June
 Outcome: Lancet special issue early 2014

43. Commission will address three questions
 What will it take to bring about the end of AIDS?
 How can the experience of the AIDS response serve as a
transformative force in our approach to global health?
 If we imagine a more equitable, effective and sustainable global health
paradigm, how must the national and global AIDS architecture be
similarly modernised?

44. Country and regional consultations in ESA






Angola
Ethiopia*
Kenya*
Malawi*
Mauritius*
Mozambique






Rwanda
Senegal
South Africa
Tanzania*
Uganda*
Zambia*
 UNECA, with partners, has convened three subregional consultations in
Accra, Ghana; Mombasa, Kenya; and Dakar, Senegal.
*Consultation reports available

45. Draft African Common Position
4 Pillars
1.Transformative Economic transformation and inclusive growth,
2.Innovative technology transfer and Research development,
3.Human development (incl. UA to quality healthcare and HIV, with focus
on treatment and EMTCT)
4.Financing and Partnerships
Mar
April
May
Sept

46. Role of UCCs and RSTs moving forward
 ESA must be leading voice for HIV in the next development agenda
 Ultimately Member States will decide the agenda and framework
 UCCs and RSTs responsible to identify, target and support:
 Champions for UNAIDS vision and agenda
 Government and civil society focal points on P2015 at country level
 MS members of the Open Working Group
 MS delegations to Sept UNGA
 Lancet Commissioners

47. DISCUSSION
 UCO and RST advocacy strategies
 Connecting messaging to political priorities for regional political
institutions
 Upcoming political opportunities
 Internal communication, support from Geneva

48. Impact of ART: Significant Decrease in Mother-toChild Transmission of HIV since 2010
Courtesy Birx,
UNAIDS Global Report 2012

49. 2001-2011 : Declining incidence

50. New HIV infections
G8 Okinawa
Initiative
2006
Political
Declaration
Abuja
Declaration
2011
Political
Declaration
2001 Declaration
of Commitment
UNITAID
Doha
Declaration
G8 Gleneagles Pledge
Gates
Foundation
PEPFAR
52
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
The Global Fund
1997
1996
1995
1994
1993
1992
1991
Resources available for HIV in
low- and middle-income countries
US$ 16.8 billion
Millenniunm
Declaration
1990
3.5 million people
2001-2011 : Resources for HIV has shown impact

51. What is driving the change?

52. What is driving the change?

53. The prophecy…the reality
Wall street Journal , 23 July 2012

54. 2015: the 10 Global AIDS targets
REDUCE SEXUAL
TRANSMISSION
PREVENT HIV
AMONG DRUG
USERS
CLOSE THE
ELIMINATE
RESOURCE
GENDER
INEQUALITY
GAP
ELIMINATE NEW
HIV INFECTIONS
AMONG
CHILDREN
15 MILLION
ACCESSING
TREATMENT
AVOID TB
DEATHS
ELIMINATE
ELIMINATE TRAVEL STRENGTHEN HIV
STIGMA AND
RESTRICTIONS
INTEGRATION
DISCRIMINATION

55. Supporting countries: what will it take ?
Focus
Speed with evidence
Smart Investments
Innovation
Human rights

56. HIV Incidence in Countries with Slow or Stalled Scale-Up of
Combination Prevention Services
Slow or No Decline in HIV Incidence Rates (2001, 2011)
- 7%
+22%
- 5%
- 14%
- 19%
2001
Incidence
2009
Incidence
2011
Incidence
Lesotho
2.67
2.58
2.47
Uganda
0.69
0.74
0.84
Tanzania
0.62
0.45
0.59
Nigeria
0.42
0.38
0.36
Angola
0.26
0.21
0.21
Countries
Data source: UNAIDS Global Report 2012

57. Geographic prioritization - Kenya
Nairobi & Nyanza
Western & Central
Rift Valley & Coast
East & North-East

58. Speed: rapid acceleration, but even more is needed

59. Evidence: making the right choices

60. Innovation: current models will not take us to the finish line

61. Community support keeps people on treatment
CLINIC-BASED TREATMENT
70%
still receiving treatment after two years
Sub-Saharan Africa: people
receiving ART from specialist
clinics
Source: Fox MP, Rosen S. Patient retention in antiretroviral therapy programs up to three years on treatment in subSaharan Africa, 2007–2009: systematic review. Tropical Medicine and International Health, 2010, 15(Suppl. 1):1–15.
COMMUNITY TREATMENT MODEL
98%
still receiving treatment after two years
Mozambique: self-initiated
community model
Source: Decroo T et al. Distribution of antiretroviral treatment through self-forming groups of patients in Tete province,
Mozambique. Journal of Acquired Immune Deficiency Syndromes, 2010 [Epub ahead of print].
Sources: Fox MP, Rosen S. Tropical Medicine and International Health, 2010;
Decroo T et al. Journal of Acquired Immune Deficiency Syndromes, 2010.

62. Investments:
Shared
responsibility

63. Implementation compact

64. Activity 3: Next 1000 Infections
• Where are your next 1000 infections likely to
come from?
– fill out the second thoughts column

65. Low- and middle-income countries are on track to reach
15 million people with antiretroviral treatment by 2015
Source: UNAIDS, 2012