Towards an improved investment approach for an effective response to HIV/AIDS

Substantial changes are needed to achieve a more targeted and strategic approach to investment in the response to the HIV/AIDS epidemic that will yield long-term dividends. Until now, advocacy for resources has been done on the basis of a commodity approach that encouraged scaling up of numerous strategies in parallel, irrespective of their relative effects. We propose a strategic investment framework that is intended to support better management of national and international HIV/AIDS responses than exists with the present system. Our framework incorporates major efficiency gains through community mobilisation, synergies between programme elements, and benefits of the extension of antiretroviral therapy for prevention of HIV transmission.

It proposes three categories of investment, consisting of six basic programmatic activities, interventions that create an enabling environment to achieve maximum effectiveness, and programmatic efforts in other health and development sectors related to HIV/AIDS. The yearly cost of achievement of universal access to HIV prevention, treatment, care, and support by 2015 is estimated at no less than US$22 billion.

Implementation of the new investment framework would avert 12,2 million new HIV infections and 7,4 million deaths from AIDS between 2011 and 2020 compared with continuation of present approaches, and result in 29,4 million life-years gained. The framework is cost effective at $1060 per life-year gained, and the additional investment proposed would be largely offset from savings in treatment costs alone.

Investment framework

The approach previously taken by UNAIDS estimated total resource needs on the basis of unit costs and coverage targets for all commonly undertaken prevention, treatment, care, and support activities for HIV/AIDS. Infections and deaths averted were modelled on the basis of the estimated effect of each of these interventions. The aids 2031 project subsequently used much the same model to develop various scenarios for global HIV/AIDS responses; in their most optimistic scenario all component interventions would be included at full scale and lead to the largest effect, whereas in less optimistic scenarios various components were excluded with a corresponding reduction of both costs and outcomes.

The investment framework that we propose departs from these approaches in five important ways. First, elements are included in the framework on the basis of a graduated assessment of the existing evidence of what works in HIV/AIDS prevention, treatment, care and support and is intended to support systematic strengthening of the evidence base when needed. Second, it applies a rigorous approach to estimation of the size of the populations in which new infections occur on a country-by-country basis and provides a basis for discontinuation of the inefficient application of programmes to the wrong populations or without regard to their outcomes. Third, the framework assumes that major efficiency gains are possible through shifting of service provision techniques to place greater emphasis on community mobilisation. Fourth, the framework emphasises synergies between programme elements and makes an initial attempt to quantify these interactions. Fifth, although not a prescriptive approach to programming, the framework is intended to close the conceptual gap between global resource estimation and large-scale programming to help shape investment strategies to achieve the best outcomes for fewest resources.

The effectiveness of HIV/AIDS prevention programmes depends on coverage and efficacy of their constituent interventions and the epidemiological context within which the programme operates. The context (ie, the distribution of risks of transmission and acquisition of HIV infection across the population) determines which groups should be a priority for intervention programmes and the extent to which a risk factor needs to change to reduce incidence and approach the tipping point at which infection is eliminated from those priority groups. The non-linear relation that exists between the epidemic spread of HIV/AIDS and epidemiological features means that substantial changes might be possible with a few appropriately targeted efficacious interventions. This effect can be noted through modelling of two epidemiological contexts: one in a concentrated epidemic represented by Karachi, Pakistan, where transmission occurs mainly through injecting drug use, and the second in a generalised epidemic represented by KwaZulu-Natal, South Africa (data not shown), where the main route of transmission is through heterosexual sex. We compared three scenarios for these regions: first, a baseline scenario assuming present interventions continue; second, a broad and shallow target assuming moderate increases in treatment coverage and declines in multiple sexual risk behaviours (and injection risk in Karachi); and third, a narrow and deep target assuming widespread treatment and a high coverage of the most demonstrably efficacious interventions (adult male circumcision in KwaZulu-Natal and needle exchange in Karachi). For every scenario, we assumed antiretroviral therapy would reduce transmission by 92%.

Our modelling results suggest that the most targeted approach provides the greatest effect, especially in locations where the HIV/AIDS epidemic is most concentrated. However, any comparison of programmes depends on the costs of combining the different interventions within the programmes and the ability of the programmes to achieve prespecified intermediate outcomes.

Our modelling of the effectiveness of the investment framework suggests that striking numbers of new infections and deaths could be averted. For full effectiveness, all of the activities in the framework should be delivered through an approach based on human rights and that is universal, equitable, and assures inclusion, participation, informed consent, and accountability. (By Dr Bernhard Schwartländer, The Lancet, June 2011)

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