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Supporting community action on AIDS in developing countries

Don’t Stop Now!

CALLING FOR A UK BLUEPRINT TO ACHIEVE AN HIV-FREE GENERATION

The International HIV/AIDS Alliance The International HIV/AIDS Alliance (the Alliance) supports communities in developing countries to play a full and effective role in the global response to HIV and AIDS. It is a partnership of 39 Linking Organisations (national, independent, locally governed and managed NGOs) around the world that supports approximately 2,300 community organisations delivering HIV prevention, treatment and care services to nearly three million people a year. www.aidsalliance.org What’s Preventing Prevention? is a campaign of the Alliance. It calls on donors and governments to guarantee a more effective HIV prevention response that enables groups that are at higher risk of being infected or affected by HIV to access prevention services and realise their rights. www.whatspreventingprevention.org

Acknowledgements This policy report was developed as part of the Alliance’s What’s Preventing Prevention? campaign activity around World AIDS Day 2012. It calls on the UK government, the world’s second largest bilateral HIV donor, to develop a detailed blueprint to map out the UK’s role in achieving an HIV-free generation.

The report is based on a longer paper authored by Mike Podmore, Policy Manager. It was edited by David J Olson. The Alliance managed the production of the report and commissioned nef (the new economics foundation) to undertake specific financial data analysis and forecasting to support the report findings.

For further information, contact the authors of this report at mail@aidsalliance.org International HIV/AIDS Alliance (International secretariat) Telephone: +44 (0)1273 718900 Fax: +44 (0)1273 718901 © International HIV/AIDS Alliance, 2012 Design by Progression Design Any parts of this publication may be reproduced without permission for educational and non-profit purposes if the source is acknowledged.

Registered British charity number 1038860

FOREWORD Despite economically challenging times, and urgent humanitarian crises, research has shown that the British people continue to think it is important to maintain spending on HIV programmes.

The understandable tendency would be to focus entirely on domestic concerns and deep-freeze our humanitarian impulses until a stronger economy permits us to think big again.

But if we do that, we may miss out on one of the greatest opportunities of our times – achieving an HIV-free generation – a world with no new infections, no AIDS related deaths and where HIV positive people are healthy and realise their rights. With scientific advances and robust evidence of what works, that goal is no longer a distant dream but a realistic objective.

This report, issued on World AIDS Day 2012, makes the case for the UK government, a world leader in fighting HIV, to develop a UK blueprint for achieving an HIV-free generation. The UK has already committed to increasing its overseas development assistance to 0.7% of its Gross National Income of which 7.1% already goes to fighting HIV. The International HIV/AIDS Alliance is calling on the UK to simply maintain that proportion as its contribution to that goal.

This is the moral thing to do, but it also makes economic sense. The most knowledgeable minds on HIV have determined that if we increase HIV investments over the next three years, we will achieve universal access to HIV services by 2015, at which point infections, AIDS-related deaths and costs will all start to fall.

The role of UK leadership in supporting an evidence-informed response to HIV — and backing it up with sufficient resources — is absolutely critical to this global mission. And there are few global development issues where the UK is a global leader and which the public strongly supports. HIV is one of those areas.

Alvaro Bermejo Executive Director, International HIV/AIDS Alliance

CONTENTS Executive Summary 1. The Political Commitment: A UK blueprint for an HIV-free generation Investment Framework for HIV

2 4-7 8

2. The Financial Investment: 7.1% of 0.7% = UK share of an HIV-free generation

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3. Being smarter in the allocation of resources

12-15

Recommendations

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EXECUTIVE SUMMARY

This report calls on the UK government, the world’s second largest bilateral HIV donor, to develop a detailed blueprint by June 2013 which maps out the UK’s role in achieving an HIV-free generation,1 and is based on the Investment Framework developed by leaders of the HIV response in 2011. The blueprint would build on the role the UK government has played in the global HIV response for the last 30 years, from the landmark HIV awareness campaigns and the introduction of harm reduction in the UK in the 1980s through to the impressive global political and HIV funding leadership of the 2000s.

Indeed, one purpose of this report is to shine a light on the essential role the UK government has played in funding the HIV response in low and middle income countries. But it also proposes a role the UK government can and, we believe, should play in realising the end of the HIV pandemic.

become known) that can be used by countries to ensure that resources are used strategically, where they are needed, for maximum impact.

Of course, implementing the Investment Framework to achieve its promise will not be easy. The significant global mobilisation of funding for the HIV response has faltered recently due to the global economic recession and shifting development priorities. An additional challenge is that the nature and location of the HIV pandemic has shifted in recent years: the majority of people living with HIV now live in middle income countries, and serious questions have emerged about whether donor priorities, funding and delivery mechanisms have responded appropriately.

In this report, we make the case why the UK government should deliver: Political Commitment: A UK blueprint for an HIV-free generation • Create a detailed blueprint based on the Investment Framework by June 2013 that maps out the UK’s role in achieving an HIV-free generation and use the political opportunities it will have in 2013 to secure a global commitment to achieve an HIVfree generation.

This is the perfect time for the UK to exert high profile, high level leadership on HIV once again, an opportunity reminiscent of the historic leadership the UK government seized at the G8 Gleneagles Summit in 2005, which led to unprecedented progress on HIV. There will never be a better opportunity to do that than 2013, when the UK once again hosts the G8 Summit, Prime Minister David Cameron co-chairs a UN panel on replacing the Millennium Development Goals (MDGs), and Secretary of State for International Development Justine Greening continues working to demonstrate results for poor people and value for money in Britain’s foreign aid budget.

Financial Investment: 7.1% of 0.7% = UK share of an HIV-free generation • Simply maintain the current 7.1% of UK overseas development assistance (ODA) that goes to HIV as overall ODA increases to 0.7% of GNI.

Game-changing research and scientific breakthroughs added to the evidence of what works have led HIV practitioners and advocates to believe that we finally have enough information and tools to get the pandemic under control. This knowledge has been moulded by global HIV leaders into a framework for strategic investment (or ‘Investment Framework’ as it has

Smarter allocation of resources • Use the blueprint to deploy smart strategies to ensure that the right level of funding is directed at the right programmes for the right populations at the right scale, particularly in middle income countries, where the majority of people living with HIV now reside.

1

‘HIV-free generation’ refers to our goal of achieving a world with no new infections, no AIDS-related deaths and where HIV-positive people are healthy and realise their rights

UNAIDS, Together we will end AIDS (2012) pg 19

2

NEW BREAKTHROUGHS SHOW US AN

HIV-FREE GENERATION IS WITHIN OUR GRASP

For the first time in 30 years, it is realistic to talk about achieving an HIV-free generation and keeping HIV-positive people healthy.

The number of new infections is declining, and; The number of people on treatment is increasing2

“30 years ago an HIV diagnosis was a death sentence but today for millions in countries around the world that’s just not the case. Working together we will continue to prevent and treat HIV so that many more can live long, fulfilling and happy lives.”

Prime Minister David Cameron on World AIDS Day 2011

NEW SCIENTIFIC ADVANCES • Antiretroviral therapy: Quality has increased while cost has decreased • Prevention of mother to child transmission: Improved prevention options can help reduce the risk 3 of transmission to less than 1% • Treatment as prevention: Early treatment can prevent HIV transmission between heterosexual couples 4 by 96%; and PREP (pre-exposure prophylaxis) can protect HIV-negative people at high risk of infections • Home-testing kits: The first over the counter self-test kit has been approved. This has the potential to lead to increased uptake of HIV testing if made widely available

“Now is the time to take even more bold action, inspired by true global solidarity to achieve an AIDS-free world.”

Ban-Ki Moon Secretary-General of the United Nations, 2011

These game-changing scientific advances, while exciting, do not offer a complete solution.

They must be combined with context specific programmes, based on what works.

By basing a blueprint on the Investment Framework, the UK government can make smart investments at the right scale, in the right places to contribute to a tipping point to an HIV-free generation.

2

UNAIDS, Together we will end AIDS, 2012, pg 19

3

UNAIDS, Countdown to Zero: Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive, 2011-2015 (2012)

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Alliance, Policy briefing: treatment as prevention, 2012

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1. The Political Commitment: A UK Blueprint for an HIV-free generation

Two beneficiaries of an ARV treatment programme join hands Š Gideon Mendel for the Alliance

DFID’s standing in Zimbabwe has led to increased donor collaboration and value for money

DFID must leverage the leadership shown at national level through global, high level political commitment.

Visit our website www.aidsalliance.org/blueprint to read a case study from Zimbabwe in full

The Political Commitment: A UK Blueprint for an HIV-free generation

The UK government has been a global leader of the HIV response for much of the last 30 years (see timeline on cover). This is something for which the government and the British people should feel proud and want to continue.5 This report calls on the UK government to produce a detailed blueprint that maps out the UK’s role in achieving an HIV-free generation based on the Investment Framework for HIV (see page 8).

In 2011, there was a paradigm shift in the HIV response when, for the first time, it became realistic to imagine an HIV-free generation.

A series of game-changing scientific and research breakthroughs (shown on page 3) have added to the existing body of proven HIV interventions to give us the tools we need for an effective HIV response. In June 2011, global HIV experts drew together this evidence and published a ‘targeted strategic investment programme’ that would ultimately deliver an HIV-free generation that has since become known as the Investment Framework.

The UK is the second largest bilateral HIV donor6 and has continued to provide considerable political leadership, although largely behind the scenes in the last few years7.

The time has come for the UK to reveal its high level political leadership on HIV once more.

There will never be a better time to do so than 2013, when the UK hosts the G8 Summit, Prime Minister David Cameron co-chairs at the UN High Level Panel that will oversee the development of the global framework that will replace the Millennium Development Goals (MDGs) and Secretary of State for International Development Justine Greening works to

demonstrate results for poor people and value for money in Britain’s foreign aid budget. These opportunities are reminiscent of the historic political leadership the UK government seized at the G8 in 2005 to Make Poverty History and secure global commitment to ‘Universal Access to HIV Treatment, Prevention, Care and Support’ (see cover). Renewed UK leadership now is critical because of the clear correlation between the commitment to global targets, the mobilisation of resources and the resulting impact on lives saved.

“In the coming year we have unprecedented opportunities to help shape the international consensus on development.”

Secretary of State for International Development, Justine Greening BOND Annual General Meeting, October 2012

5

Bill and Melinda Gates Foundation. Building Support for International Development: Results from multi-country research on understanding and communicating with key policy constituencies. Dec 2011. p.8

6

Kaiser Family Foundation and UNAIDS. Financing the response to AIDS in low and middle income countries: International assistance from the G8, European Commission and other donor governments. 2004-2012

7

While UK leadership has been critical in the Global Fund to Fight AIDS, TB and Malaria and in negotiations for the UN High Level Meeting on HIV/AIDS in 2011, the UK has not made any high level political statements on HIV in recent years.

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The Political Commitment: A UK Blueprint for an HIV-free generation

In order for the UK government to have the confidence to play its role in shaping international consensus on development and creating an HIV-free generation we call on Justine Greening to: • Develop a UK blueprint for an HIV-free generation to guide the UK government’s HIV leadership into 2013 and beyond. The blueprint must be a strategy that describes how the UK will apply the Investment Framework to all its own work and support global implementation to achieve an HIV-free generation. The blueprint must be published

by June 2013 so it can guide the UK position in key global development policy discussions.

It should run from 2013 and be reviewed in 2015 following the conclusion of the current MDGs and the beginning of the new postMDG framework.

• Inform this blueprint through a comprehensive review of the Department for International Development’s (DFID) current support to the global HIV response in early 20138. The review of DFID’s HIV work should be structured around the Investment Framework9 to ensure the UK government is making strategic investment choices around programming priorities that will have the greatest impact and reach the poorest and most marginalised wherever they are.

“With a resourced UK blueprint for an HIV-free generation, based on the Investment Framework, the UK government will have the tools it needs to champion the HIV response in 2013 and beyond.”

• Use the blueprint to leverage global political and financial commitment for the goal of achieving an HIV-free generation. Up until 2015, David Cameron and Justine Greening should use the blueprint to drive efforts to reach the current MDGs and meet the targets in the 2011 UN Political Declaration on HIV and AIDS; and embed the aim of an HIV-free generation in the post-MDG framework with an internationally agreed accountability mechanism for monitoring global progress towards this goal.

The new UK blueprint is essential because DFID is currently basing its HIV work on a position paper from May 201110. So much has changed since then – the UN High Level Meeting on HIV/AIDS11, the Investment Framework and major scientific findings have dramatically changed the landscape and highlighted the critical role of the UK government.

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DFID has committed to conduct a review of its HIV work in early 2013 in its 2011 position paper Towards zero infections: The UK’s position paper on HIV in the developing world, May 2011

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The review should analyse the findings of the DFID Business Case ‘Strategic Investment Framework - Developing country-level HIV planning and budgeting tools to improve effectiveness and efficiency of HIV investments’. This was a DFID-funded one-year pilot testing of the Investment Framework through funding for UNAIDS which came to an end in November 2012

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DFID, Towards zero infections: The UK’s position paper on HIV in the developing world, May 2011, this replaces the previous strategy produced in 2008 Achieving Universal Access

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UN, Political Declaration on HIV and AIDS: Intensifying Our Efforts to Eliminate HIV and AIDS, July 2011

The Political Commitment: A UK Blueprint for an HIV-free generation

“73% of the UK public thinks it is important to maintain spending on HIV programmes.”

The response to HIV has an impact across all aspects of society and places a spotlight on the enduring structural challenges that have a negative impact to fully achieve equality and democracy and the fulfillment of human rights for all in society. Right now, the HIV response makes critical contributions to most of the MDGs beyond the specific goal on combating HIV and AIDS, particularly on ending poverty, achieving gender equality and child and maternal health.

There is no doubt the world has changed significantly since 2000 when the current MDGs were formulated. We now operate in a more complex environment and the world is evolving at an even more rapid pace. The blueprint should be the guiding tool with which to address what David Cameron calls the ‘golden thread’ of development.12 In this context, tackling HIV contributes to addressing issues of property rights for women; human rights for the vulnerable and marginalised; accountability of government for delivering services; and the role of civil society in delivering services to the hardest to reach. The UK has an impressive track record in supporting such areas of work and a blueprint will ensure this continues.

The blueprint will serve as a benchmark for guiding and assessing the effectiveness of DFID in addressing some of its own stated priorities.13 These include achieving faster

progress on the MDGs in low income and fragile states, combating global public challenges such as the disease pandemics and working out a new offer of engagement and assistance to middle income countries to build the skills, expertise and institutions they need to thrive – all of which are central to contributing to an effective HIV response.

Surveys show that the UK public would welcome the UK government publicly championing the HIV response again - both for the iconic opportunity of achieving an HIV-free generation but also for the wider developmental impact it can bring.

We commissioned an Ipsos MORI poll in November 2011 which found that 73% of the UK public thinks it is important to maintain spending on HIV programmes overall and 60% are keen for the UK government to give aid to help women in developing countries give birth to children born free of HIV14. In addition, a poll in UK, France, Germany, China and the US commissioned by Bill & Melinda Gates Foundation in 201115 found that amongst the engaged public16 in the UK, “HIV/AIDS is widely regarded as the most urgent health-related challenge.” There are few global development areas where the UK continues to be both a global leader and where the public exhibit such ongoing concern - HIV is one of those areas.

12

David Cameron in an article in the Wall Street Journal: “And that means a radical new approach to what I see as “the golden thread” of conditions that enable open economies and open societies to thrive: the rule of law, the absence of conflict and corruption, and the presence of property rights and strong institutions.”

13

DFID civil servant Mark Lowcock in a speech in India, October 2012

14

Ipsos MORI. Public Perceptions of HIV. For the International HIV/AIDS Alliance. 25 November 2011

15

Bill and Melinda Gates Foundation. Building Support for International Development: Results from multi-country research on understanding and communicating with key policy constituencies. Dec 2011. p.8

16

Ibid. The ‘engaged public’ is defined as ‘members of the general public age 16+ living in urban areas, who are interested in national and international affairs, in international development and/or global health issues, and have reported social or political engagement in the past six months.” p.5

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The Investment Framework for HIV…

A highly targeted response

The Investment Framework refers to a specific and scientifically produced calculation of the global investment required in order to create a reduction in the trajectory of HIV – both spending, and in terms of HIV/AIDS epidemic dynamics. It is a model that says that if you invest in these specific ways, then the human and financial costs of AIDS will reduce dramatically by 2020. It provides a model for a highly targeted response.

The global investment

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If governments, donors and others implemented the Investment Framework, an estimated additional 12.2 million new infections could be averted and 7.4 million AIDSrelated deaths prevented between now and 2020, and the following targets set at the 2011 United Nations High Level Meeting on AIDS would become reality by 2015: • • • • • •

15 million more people living with HIV on treatment Sexual transmission reduced by half Injecting drug use transmission reduced by half New infections in children eliminated AIDS-related maternal mortality reduced by half Tuberculosis deaths reduced by half.

As these two graphs show, when short-term investment is increased in line with the Investment Framework, the logic of taking action seems irresistible. Any delay in implementation of the Investment Framework - even by three years - would result in an additional 3 million lives lost to AIDS and 5 million new HIV infections.

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Number of Cases

Latest UNAIDS estimates18 suggest that by applying the Investment Framework and increasing global HIV investment to $24 billion a year by 2015, universal access to HIV services is achievable. After 2015 the cost is projected to steadily decline as a result of the impact of reaching optimal HIV programme coverage levels, along with cost efficiencies, and importantly, the declines in illness and death that are predicted because larger numbers of people are receiving life-saving anti-retroviral treatment.

Towards an HIV-free generation

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...sets out a model for HIV investment and HIV programming for the next decade.17 It is a framework that projects an increase in spending on HIV/AIDS leading up to 2015, followed by a decline in spending from 2015 to 2020. For the first time, a model has been developed that can show a decline in the need for HIV programmes and services, as the effect of current and future targeted investments reach a tipping point. HIV investments, and HIV rates, decline.

The Investment Framework emphasises six specific evidencebased HIV programming priorities19 which are accompanied by the concept of ‘critical enablers’ that make these programmes work: social enablers such as community mobilisation and programme enablers such as community centred design and delivery. It also positions human rights-based programming such as advocacy, stigma reduction and efforts towards supportive laws and practices as critical to the model, not optional or additional but ‘critical’. The programme areas and critical enablers are complemented crucially by a third area of interventions called ‘development synergies’ relating to the links between HIV and other sectors, such as social protection, education, sexual reproductive health and gender equality.

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Figure 1. Without the Investment Framework

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Figure 2. With the Investment Framework

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Towards an improved investment approach for an effective response to HIV/AIDS” The Lancet, 2011

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UNAIDS, Breaking news supplement: Meeting the investment challenge, tipping the dependency balance, (2012)

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Prevention of mother to child transmission (PMTCT), condom promotion and distribution, key populations (sex workers, men who have sex with men, people who inject drugs and transgender people) programmes, treatment, care and support to people living with HIV/AIDS, male circumcision and behaviour change programmes

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2. The Financial Investment: 7.1% of 0.7% = UK share of an HIV-free generation

Peer educator in Ecuador © Gideon Mendel for the Alliance

A consequence of stigma in Latin America is HIV prevalence as high as 35% among some key populations DFID’s (now-discontinued) Latin American Programme Partnership Agreement played a critical role in addressing inequality in middle-income countries – a role many national governments are not currently equipped or willing to take over from.

Visit our website www.aidsalliance.org/blueprint to read a case study from Latin America in full

The Financial Investment: 7.1% of 0.7% = UK share of an HIV-free generation

11000 10000 9000 8000 7000 GBP (millions)

This report calls on the UK government, the world’s second largest bilateral HIV donor, to continue its historic leadership on HIV. It can do this financially simply by maintaining its HIV investment as a proportion of overseas development assistance (ODA) at the current level of 7.1%, while total ODA increases as already planned to 0.7% of Gross National Income20.

6000 5000 4000 3000 2000

If the UK maintains 7.1% of ODA on HIV, our calculations confirm that the UK will deliver its share of investment needed to implement the Investment Framework globally21. Implementation of the Investment Framework will result in a tipping point being reached in 2015, followed by a fall in HIV infections and AIDS-related deaths and a corresponding decrease in needed funding.

Over the last 12 years the HIV response has transformed into one of the most successful investment stories in development. Global HIV funding dramatically increased from just over US $1 billion in 2000 to almost $17 billion in 201122.

An indication of the significant impact of the political and financial commitment shown by the UK is that 8 million people living with HIV in low and middle income countries are now receiving life-saving antiretroviral therapy23, as well as the wider impact of tackling the root causes of poverty, such as the enduring challenges of equality, democracy and human rights.

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Figure 3. UK spending on HIV as a percentage of UK ODA from 2004 to 2011

However, despite that success, funding has not yet been sufficient to meet the needs of a fully funded global HIV response. While G8 governments, including the UK, led the way in delivering funding for HIV, the economic crisis of 2008 prompted many donors to flatline or reduce their ODA for HIV24, pushing down the trajectory of global HIV funding. The result has been that international donor funding for HIV has not increased over the last four years, leading to the cancellation in November 2011 of the latest round of funding by the Global Fund to Fight AIDS, TB and Malaria.25

“FOR THE UK GOVERNMENT this means simply maintaining 7.1% of ODA (at 0.7% of GNI) to deliver the UK’s share of creating an HIV-free generation.”

20

7.1% of UK GNI (based on IMF economic forecasts) would amount to £760,192,252 in 2012. £789,333,854 in 2013, £825,827,034 in 2014, and £869,052,491 in 2015

21

Specific data analysis conducted for this report by the new economics foundation (nef)

22

Kaiser Family Foundation, Financing the Response to AIDS in Low- and Middle- Income Countries: International Assistance from the G8, European Commission and Other Donor Governments in 2011, July 2012

23

UNAIDS, Together we will end AIDS, 2012

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Germany, Japan and the Netherlands have reduced significantly in the last four years

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Alliance, DON’T STOP NOW: how underfunding the Global Fund impacts on the HIV response, 2012

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The Financial Investment: 7.1% of 0.7% = UK share of an HIV-free generation

However, at the same time, domestic funding in low and middle income countries reached $8.6 billion and for the first time surpassed the $8.2 billion contributions of international donors.26 Between 2006 and 2011, 81 countries increased their national HIV funding by more than 50%.

Brazil, Russian Federation, India, China and South Africa (BRICS) now cover 80% or more of their own HIV responses (making up over 50% of the $8.6 billion). And low income countries also increased their investments by at least 70% and lower middle income countries by nearly 100%.

UNAIDS believes that this domestic funding in low and middle income countries can be increased a further $2.1 billion each year up to 2015 just based on economic growth projections ($1 billion), matching health spending to disease burden and allocating at least 15% of national budget to health ($1.1 billion)27. Emerging donors such as the BRICS could begin to make a sizable additional contribution through international development assistance28. And, there is also significant scope for innovative financing mechanisms at national and international level (such as the Financial Transaction Tax for international development and the UNITAID airline levy) many of which are, or are about to be, implemented.

However, it would be a grave mistake to see these recent increases as reason to reduce UK funding for HIV. In the crucial period between now and 2015 UK financial leadership means maintaining our current funding share of the global HIV response so that we can leverage others to contribute their share and ensure that we meet the full investment needed to implement the Investment Framework. The UK government will also need to use its planned review of its HIV work to analyse which funding mechanisms are best able to deliver impact and build on the UK’s comparative advantage

in the HIV response. This includes; funding high performing multilaterals, and fulfilling its commitment to increase its contribution to the Global Fund; and assessing whether its planned reduction of HIV bilateral aid will support or hinder progress; and further utilise other effective mechanisms, such as funding civil society and business partnerships.

Universal access targets to prevention, treatment, care and support29 cannot be met unless we and others fully fund an effective HIV response as mapped out in the Investment Framework. For the UK government this means: • Contribute 7.1% of ODA (at 0.7% of GNI) to deliver the UK’s share of creating an HIVfree generation. It also means using these resources effectively: ensuring they have the most impact, and achieve the best value for money for those people directly affected by HIV and AIDS, and for UK taxpayers.

• As part of the above, also deliver on the UK government’s commitment to ‘up to double’30 the UK’s contribution to the Global Fund for 2013 and 2014 as well as announce a substantial long-term commitment to the Global Fund for 2015 and beyond.

• Reassess their planned reduction to bilateral support31 and examine how this can be better utilised to deliver the Investment Framework.

• Utilise funding mechanisms such as civil society and business partnerships as well as joint DFID and Foreign and Commonwealth Office funding instruments such as Regional Programme Partnership Agreements.

26

UNAIDS, Meeting the Investment Challenge: Tipping the Dependency Balance, 2012

27

UNAIDS, Together we will end AIDS, 2012 p.118

28

UNAIDS estimate that if the BRICS apportion 0.1% of their GDP to international development, it would raise $10 billion. Ibid. p.117

29

UN Political Commitment on HIV/AIDS, June 2011

30

House of Commons International Development Committee, DFID’s contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria First Report of Session 2012–13, May 2012 p.19

31

DFID plans to reduce the share of HIV funding as a percentage of health bilateral aid from 16% in 2010-11 to less than 6% in 2014-15

11

3. Being smarter in the allocation of resources

Peer educator in Viet Nam collects used needles to reduce risk to other people © Pham Hoai Thanh/SCDI

DFID, with the World Bank, fund vietnam’s largest, and very successful, harm reduction programme If DFID support ends in 2013 as planned without ensuring the programme’s continuity, it risks not just leaving a void, but undoing the progress made on reducing the number of new infections.

Visit our website www.aidsalliance.org/blueprint to read a case study from Vietnam in full

Being smarter in the allocation of resources

Once the UK government has delivered the political and financial commitments, it must apply the right strategies smartly, to ensure that it can help achieve an HIVfree generation in line with the UK’s strong leadership on transparency, accountability, human rights and most importantly, results for poor people.

That’s what the Investment Framework is all about – an approach for strategic investment that can be used by countries to ensure that the right level of funding is directed at the right programmes for the right populations at the right scale.

It’s imperative that the UK government uses simple monitoring systems to measure its contribution to achieving an HIV-free generation and uses its influence to call on relevant international bodies to monitor and publish annual reports that demonstrate global progress on smart and targeted programmes.

Using the Investment Framework to guide programme and policy choices is not only smart for an effective HIV response but it’s also smart for the UK government and taxpayers, because it will translate into better and faster results for less money, and help address David Cameron’s ‘golden thread’ in which progress in HIV also addresses broader development issues like property rights for women, human rights for marginalised people, government accountability and the role of civil society.

“Once we have secured the political and financial commitments, we have to apply the right strategies smartly, by reaching those most at risk of HIV where the majority of people with HIV now live, to have the greatest impact.”

(MSM), sex workers, people who inject drugs and transgender populations and ensuring that the human rights of all people living with HIV, including the right to health and to non-discrimination are protected and fulfilled.

• Ensure that the UK develops a clearer package of economic, social and political assistance constructed to support the HIV response that particularly targets the poorest and most marginalised in middle income countries, where a majority of people living with HIV now live.

Championing human rights

We recommend two key approaches – based on the Investment Framework – for achieving smarter allocation of resources:

There are a range of marginalised groups within societies, many of whom are disproportionately affected by HIV, but three populations in particular were recognised in the 2011 UN Political Declaration on HIV/AIDS as having the highest risk of infection – MSM, sex workers and people who inject drugs. To this group we would add transgender people.

• Use a human rights approach informed by evidence that directly reaches those most at risk of HIV infection, particularly marginalised populations like men who have sex with men

For these groups, HIV prevalence is significantly higher and rates of infection are increasing32. Yet the little data that can be gathered shows that, for example, only

32

Worldwide, adults have an HIV prevalence of 0.4%, sex workers 3%, men who have sex with men 6% and people who inject drugs 13%. This data is from The Foundation for AIDS Research: The shifting Global Health Landscape: Implications for HIV/AIDS and Vulnerable Populations, 2010

13

Being smarter in the allocation of resources HIGH INCOME COUNTRIES

2,134,620 (6%)

MIDDLE INCOME COUNTRIES

19,345,060 (58%) LOW INCOME COUNTRIES

12,216,600 (36%)

Where do people living with HIV and AIDS live?

10-20% of MSM have access to targeted or tailored HIV prevention services. Research we commissioned in 201033 showed that, across all the countries reporting for the 2008 UNAIDS National AIDS Spending Assessments, less than 5% was invested in HIV prevention services and programmes targeting key populations.34 Of course, one of the key reasons that services are so minimal is because of stigma, discrimination and criminalisation of these groups. At least 41 of the 54 Commonwealth Member States have not repealed colonial sodomy laws criminalising homosexuality. In many, punishments are severe, including life imprisonment and even the death penalty35.

Championing the human rights of key populations is a priority for the UK that it should be proud to continue. For example, speaking out during discussions of the ‘aggravated homosexuality bill’ in Uganda that proposes the death penalty for being gay. Elsewhere the criminalisation of people who use drugs is fuelling the HIV epidemic and UK aid has been instrumental in providing access to and championing of harm reduction services for people who use drugs. In Vietnam, a UK/World Bank funded harm reduction programme has provided an alternative to arbitrary detention centres. The UK’s global technical leadership on HIV is under threat as UK aid is rapidly withdrawn from middle income countries. UK leadership will become increasingly harder to deliver unless the UK develops innovative strategies for continuing to influence work in middle income countries.

Source: Country Income Status World Bank; PLHIV Country estimates - UNAIDS, Report on the Global AIDS Epidemic, 2010

Ensuring HIV services reach the most vulnerable in middle income countries Many are unaware that the majority of people living with HIV live in countries that are now classified as middle income – not low income – countries (see chart above) with the greatest number living in India, Nigeria and South Africa.36 This is a reflection of the changing economic status of many countries with high prevalence rates. As of 2011, there were only 35 low income countries left, compared to 110 middle income countries. However, while many countries are transitioning from low to middle income, poverty and inequality remains pervasive in middle income countries. In fact, three-quarters of the world’s poorest now live in countries now classified as middle income and 60% of the world’s poorest live in just five of the most populous middle income countries: Pakistan, India, Nigeria, China and Indonesia37.

While a continued focus of international assistance for the HIV response in low income countries is critical (particularly in basic infrastructure), the role of donor governments’ support to middle income countries must be addressed in a way that doesn’t punish the poorest and most marginalised.

33

Alliance, Don’t Stop Now, Finish the Job: Making HIV prevention funding work, 2010

34

The term ‘key populations’ or ‘key populations at higher risk of HIV exposure’ refers to those most likely to be exposed to HIV or to transmit it – their engagement is critical to a successful HIV response i.e. they are key to the epidemic and key to the response. In all countries, key populations include people living with HIV. In most settings, men who have sex with men, transgender persons, people who inject drugs, sex workers and their clients, and seronegative partners in serodiscordant couples are at higher risk of HIV exposure to HIV than other people.

35

Alliance, Enabling Legal Environments: an effective HIV response, 2010

36

UNAIDS 2009 data

37

IDS, In Focus Policy Briefing Issue 26: Where will the World’s Poor Live?, August 2012

14

Being smarter in the allocation of resources

Secretary of State Justine Greening recently stated concerning India: While middle income country governments are increasingly taking financial responsibility for their national health and HIV responses, many have not yet prioritised sufficient resources for effective health services or simply cannot afford to cover the whole cost. In either case, most are reluctant to spend limited resources on services for politically unpopular groups such as key populations and this will certainly not be encouraged by donors disengaging.

Therefore, there remains an essential role for the UK to construct a ‘golden thread’ of economic, social and political assistance to support the majority of people living with HIV, who now live in middle income countries. We are pleased that Secretary of State Justine Greening still includes health as being a key area of focus in DFID’s support to middle income countries. However, we ask DFID to more clearly explain in the new blueprint what the UK’s global HIV response in middle income countries will be. For example, it could commit to:

“From now, all new programmes will focus on sharing skills and expertise in priority areas such as growth, trade and investment, skills and health ... That work will see a ‘hub’ of specialists ... working alongside the Foreign Office, UK Trade and Investment and other government departments to share advice and skills with the government.”

• Specifically address the areas of UK expertise and comparative advantage around human rights and the inclusion and support particularly for LGBT communities, sex workers, people who inject drugs and transgender communities.

• Explain more clearly the role that the Foreign and Commonwealth Office, UK Trade and Investment and other government departments can play in delivering the UK’s blueprint for an HIVfree generation.

• Map out clearly a process to ensure that the poorest and most marginalised are not the ones who pay the price when specific HIV bilateral programmes are ending and explain how HIV can be addressed as a cross-cutting theme across the remaining DFID bilateral programmes.

• Recognise the key role of the international and national civil society organisations as being the key mechanism for scaling up HIV services for the most marginalised38 and explore increased funding for those that have proven themselves to have impact.

• Exert UK influence in UK-funded multilateral programmes (such as the Global Fund) to ensure that they stay global in reach and target the poorest and most marginalised people living with HIV or at risk of HIV infection, wherever they are.

38

World Bank, DFID, Evaluating the Community Response to HIV, 2012

15

a uk blueprint to achieve an hiv-free generation A UK BLUEPRINT TO ACHIEVE AN HIV-FREE GENERATION “With the progress we are making together, we can look ahead to a historic goal: creating an AIDS-free generation.”

dn e goo ews... h T

...but

decline in HIV-related deaths between 2005-2011

There were

24%

Hillary Clinton

Millennium Development Goal 6 To have halted by 2015 and begun to reverse the spread of HIV and AIDS and achieve by 2010 universal access to treatment for HIV/AIDS for all those who need it.

2.5 million new infections in 2011

In 2011, more than 8 million people had access to treatment for HIV, up

20%

from 2010

The wider impact of tackling AIDS

Labour

Education

Sexual & reproductive health

Nutrition

Water & sanitation

Social protection

Human rights

Trade

A changing epidemic x 1m

19 million people with HIV living in middle income countries x 1m

12 million people with HIV living in low income countries

THREE QUARTERS of the world’s poor live in middle income countries, so do the majority of people living with HIV

What will it take to end AIDS? With the right inv estment we can reach a tipping point in the epidemic wh ich...

“Britain will meet our obligation to spend 0.7% of our gross national income on aid from next year.”

David Cameron

16

...would avert 12 .2 million more new infections and 7.4 million more AIDS-relat ed deaths between now an d 2020

What we spend on bottled water worldwide in a year would cover the cost of universal access to HIV services by 2015

The UK simply needs to maintain its HIV spend at the current level of overseas aid

7.1%

“We call on the international community, which was so tremendous in its fight against another epidemic, apartheid, to show the same commitment to deal with TB and HIV/AIDS.” Desmond Tutu

UK blueprint for action, focusing

We need a

on all people affected

by HIV and AIDS regardless of where they live

Alliance recommendations The Alliance calls on the UK government to do three things – as described in more detail elsewhere in this report — to increase its chances of making a significant contribution to achieving an HIV-free generation:

1

The Political Commitment: Provide a UK blueprint for an HIV-free generation

The Investment Framework and UNAIDS estimates suggest that by applying the Investment Framework and increasing global HIV investment to $24 billion a year by 2015, universal access to HIV services is achievable.

After 2015 the cost is projected to steadily decline thanks to continuing coverage of services, efficiency gains and a steady decline in infections and deaths. The UK government must use the blueprint to leverage global political commitment to use the Investment Framework to achieve an HIV-free generation and this smart approach should be embedded within the post MDG framework.

2

3

The UK government should publish a detailed blueprint by June 2013 that maps out the UK’s role in achieving an HIV-free generation. The Department for International Development (DFID) should conduct a comprehensive review of its global HIV work using the Investment Framework developed by HIV experts in 2011 and use the results to inform the blueprint.

We have analysed the data. If the UK does this, it will deliver its share of investment needed to implement the Investment Framework which will result in a tipping point being reached in 2015, followed by a fall in HIV infections and AIDS-related deaths and a corresponding decrease in needed funding.

The Financial Investment: 7.1% of 0.7% = UK share of an HIV-free generation

The UK, the world’s second largest bilateral HIV donor, must simply maintain its HIV investment at the current level of 7.1% of overseas development assistance (ODA), while total ODA increases to 0.7% of GNI as is already planned, with investments guided by the Investment Framework.

Be smarter in the allocation of resources

In line with the UK’s strong leadership on transparency, accountability, human rights and, most importantly, results for poor people, the UK blueprint will deploy smart strategies using existing aid instruments to ensure that the right level of funding is directed at the right programmes for the right populations at the right scale, by: • Applying a human rights approach that directly reaches those most at risk of HIV infection, particularly marginalised populations like men who have sex with men, sex workers, people who inject drugs and transgender people and ensuring that the human rights of all people living with HIV, including the right to health and to nondiscrimination are protected and fulfilled.

• Ensuring that the UK delivers a clearer package of economic, social and political assistance to support the HIV response that targets the poorest and most marginalised people in middle income countries, where the majority of people living with HIV now reside.

Being smarter in the allocation of resources is not only good for an effective HIV response but also for the UK government and taxpayers, because the Investment Framework will help deliver greater measurable results at lower costs.

“Delaying the Investment Framework - even by three years - would result in an additional 3 million lives lost to AIDS and 5 million new infections.”

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A global partnership:

International HIV/AIDS Alliance Supporting community action on AIDS in developing countries

39

The UK’s Call to Action called for stronger political action on HIV, better funding, better donor co-ordination and better HIV programmes

40

One agreed HIV and AIDS Action Framework, one national AIDS Coordinating Authority, and one agreed country level monitoring and evaluation system in each country.