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

Summary

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.

Introduction

By 2010, extraordinary amounts of political commitment, social mobilisation, and HIV/AIDS funding had resulted in an unprecedented scale-up of HIV/AIDS prevention, treatment, care, and support, a decline in incidence of new HIV infections in several countries, more than 6·5 million people receiving antiretroviral therapy, and millions of orphans able to receive basic education, health, and social protection.1, 2 Such large-scale investments helped progress towards more tolerant and enabling social environments.³ However, despite these impressive gains, universal access to prevention, treatment, care, and support for HIV/AIDS is not available worldwide,⁴ and is unlikely to be achieved with the present pace of change and with the present approaches to investment.

Previously set global targets and associated resource needs estimates5, 6 were effective for mobilisation of unprecedented resources and driving of major progress in the HIV/AIDS response, but were based on the prevailing commodity approach that targeted scale-up of discrete interventions rather than overall results, and led in many cases to fragmentation of the response.7, 8

The approach adopted until now has various shortcomings. First, estimates of future coverage of intervention programmes were made on the basis of a large number of ambitious—and often aspirational—targets, which were not met. Second, subsequent revisions shortened the timeframe available to meet targets, making them further out of reach with increasingly unrealistic programmatic and cost assumptions. Third, as the complexities and costs of a public health response to the HIV/AIDS epidemic and the systemic weaknesses that impeded progress became apparent, the commodity approach was not conducive for countries and donors to set priorities as shown by substantial differences in resource allocation for national HIV/AIDS responses between neighbouring countries with equivalent epidemics. Unsystematic prioritisation and investment were allowed to persist⁹ as interests and stakeholders competed for a proportion of available funding for HIV/AIDS, spreading resources thinly between many objectives.¹⁰

New approaches are needed to achieve universal access and the specific targets included in the Joint United Nations Programme on HIV/AIDS (UNAIDS) 2011–15 strategy and the United Nations Secretary General's Report to the General Assembly in June, 2011.4, 11 A change from the commodity approach to a targeted strategic investment programme driven by the latest evidence is needed to produce substantial and lasting effects on the HIV/AIDS epidemic and make the most of investment in the response.

We propose an investment framework to support management of national and international HIV/AIDS responses, encourage transparency in programme objectives and results, and enable decision makers and financiers to galvanise support for effective action. The framework differentiates between basic programme activities that aim to directly reduce HIV transmission, morbidity, and mortality; activities that are necessary to support the effectiveness and efficiency of these programmes (critical enablers); and investments in other sectors that can have a positive effect on HIV outcomes (synergies with development sectors; figure 1). The framework promotes prioritisation of efforts on the basis of a nuanced understanding of country epidemiology and context, and assumes major efficiency gains as delivery of care evolves from facility-based to community-based structures.¹²

The framework aims to enhance present efforts to make the most of HIV/AIDS responses, including the Global Fund to Fight AIDS, Tuberculosis and Malaria's new approach to fund countries on the basis of national strategy applications¹³ rather than discrete projects.¹⁴ Equally, the framework supports improved planning for resource allocation in the largest bilateral HIV/AIDS programme, the US President's Emergency Plan for AIDS Relief (PEPFAR), which has a new and explicit focus on increased country ownership.¹⁵ The framework will encourage countries to make the most of their programmatic responses to the epidemic through careful targeting and selection of the most effective interventions.

In this Health Policy, we present the investment framework and apply it in a costing exercise undertaken to estimate the resources needed to implement a global HIV/AIDS response in the next decade.