PEPFAR 3.0 Vision for an AIDS-Free Generation. Ambassador Deborah L. Birx, M.D. U.S. Department of State June 2015

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1 PEPFAR 3.0 Vision for an AIDS-Free Generation Ambassador Deborah L. Birx, M.D. U.S. Department of State June 2015

2 PEPFAR s Evolution From Emergency Response to Sustainable Impact for an AIDS-free Generation : PEPFAR I Emergency response Delivering prevention, care, & treatment services Building & strengthening health systems to deliver HIV services : PEPFAR 2 Shift from emergency to sustainable response Shared responsibility & country-driven programs Scaling up core interventions (ART, PMTCT & VMMC) for impact : PEPFAR 3 Sustainability & shared responsibility Quality, oversight, transparency, & accountability for impact Accelerating core interventions for epidemic control

3 THE HIV/AIDS EPIDEMIC Dissecting & disaggregating data

4 : Peak of the Pandemic Before PEPFAR & Global Response Nearly 30 million people living with HIV and 10,000 new HIV infections daily globally (2001) <1M on treatment globally and <50,000 on treatment in Sub-Saharan Africa (2001) Health systems overwhelmed by the epidemic Life expectancy declines of over 20 years in high burden countries Loss of working age population reversing decades of development progress Stigma and discrimination pervasive Source: UNAIDS, 2015

5 Celebrating PEPFAR s Remarkable Success PEPFAR has saved millions of lives since M people on life-saving ART More than 1M babies born HIV-free 6.5 M men received VMMC services Care and support for >5 M OVC 21 M people in priority and key populations reached with prevention interventions Under the Obama Administration, unprecedent ed progress has been made, building on the strong foundation laid under the Bush Administration. The U.S. government has committed more than $60 billion through PEPFAR, the Global Fund, and bilateral TB programs since 2004.

6 HIV Prevalence & PLHIV Cartograph, 2013

7 Dramatic reductions in HIV Incidence Rates Maintaining momentum is key to achieving epidemic control HIV Incidence Rate (%) 1 Trends in HIV Incidence Rates, Caribbean 0.9 Asia & the Pacific Eastern Europe & Central Asia Latin America Middle East & North Africa Sub-Saharan Africa Source: UNAIDS, 2013

8 GLOBAL IMPACT NEW INFECTIONS 10,000 new infections/day globally ,000 new infections/day globally 2014 DEATH 8000 deaths/day globally deaths/day globally 2014 Stigma and discrimination remains pervasive

9 Angola Uganda Lesotho Kenya DRC Mozambique Cameroon Swaziland Namibia Zimbabwe Nigeria South Africa Botswana Zambia Cote divoire Tanzania Rwanda Ethiopia Ghana Malawi Burundi Progress has been unequal Percent Change in Total HIV Incidence, % 40% 20% 0% -20% -40% -60% -80% Source: UNAIDS, 2013

10 Change in HIV incidence among children Change in HIV incidence among children % -10% -20% -30% -40% -50% -60% -70% -80% -90% -100% Source: UNAIDS, 2013

11 Angola Uganda Kenya Lesotho Ethiopia Mozambique DRC Namibia Zimbabwe Cameroon Swaziland Cote divoire South Africa Tanzania Zambia Botswana Nigeria Rwanda Malawi Ghana Burundi Change in HIV incidence among adults 60% 40% Change in Adult HIV Incidence, % 0% -20% -40% -60% -80% -100% Source: UNAIDS, 2013

12 Change in HIV Incidence Countries with an increase or <10% decline in new adult infections 60% Percent Change in HIV Incidence Adult, child, & total, Countries with <10% decline in adult incidence 40% 20% 0% -20% Angola Ethiopia Kenya Lesotho Uganda -40% -60% -80% -100% Source: UNAIDS, 2013 Children Adults Total

13 Change in HIV Incidence Countries with slow decline in new adult infections 0% Percent Change in HIV Incidence Adult, child, & total, Countries with 10-29% decline in adult HIV incidence Cameroon DRC Mozambique Namibia Swaziland Zimbabwe -10% -20% -30% -40% -50% Children Adults Total -60% -70% -80%

14 Change in HIV Incidence Countries with moderate decline in new adult HIV infections Percent Change in HIV Incidence Adult, child, & total, Countries with 30-50% decline in adult HIV incidence 0% Botswana Cote divoire Nigeria Rwanda South Africa Tanzania Zambia -10% -20% -30% -40% -50% -60% Children Adults Total -70% -80% -90% -100%

15 Change in HIV Incidence Countries with rapid decline in new adult HIV infections 0% Percent Change in HIV Incidence Adult, child, & total, Countries with 60-80% decline in adult HIV incidence Burundi Ghana Malawi -10% -20% -30% -40% -50% Children Adults Total -60% -70% -80% -90%

16 THE CHALLENGE Ending AIDS within current resource envelope

17 Business as usual : escalating costs year over year Source: UNAIDS, MILLION NEW ADULT HIV INFECTIONS PER YEAR

18 Fast Track Strategy : Program costs decline in out years Source: UNAIDS, MILLION NEW ADULT HIV INFECTIONS PER YEAR

19 We have a 5-YEAR WINDOW Busine ss as usual Fast Track Strate gy Source: UNAIDS, 2015

20 Demographic shift in RSA: year olds

21 New HIV infections Estimated new HIV infections in 2030 in LMIC with achievement of Fast Track Targets compared to continuation of 2013 coverage

22 PEPFAR & GF Funding Has Plateaued PEPFAR annual funding ($USD Millions) $6,031 $6,680 $6,867 $6,725 $6,639 $6,528 $6,833 $6,542 $3,290 $2,704 $2, $4, Bilateral TB programs Global Fund Bilateral HIV/AIDS programs Indivs on PEPFAR-supported treatment (millions) 2016 Request

23 Achieving epidemic control with the current global budget will require delivering the Right Things in the Right Places Right Now In the Right Way Do we have the collective will?

24 FOCUSING ON HIGHEST BURDEN AREAS Use of site-level data to prioritize and focus evidence-based interventions

25 The Right Things Defining Core, Near Core, & Non Core Activities CORE Activities central to HIV/AIDS, critical to saving lives & preventing new infections grounded in science NEAR CORE Activities that directly support HIV/AIDS goals and cannot yet be done well by other partners or host government NON CORE Activities that do not directly impact HIV/AIDS goals and/or can be taken on by other partners or host government

26 Uganda: Focus on Core (Treatment) 350,000, ,000, ,000,000 PEPFAR Uganda Budget and Adults & Children on ART, Uganda Program Review 700, , , ,000, , ,000, , ,000, ,000 50,000, , Budget 276,262,3 287,113,7 286,258,3 323,388,3 298,388,3 323,388,3 320,000,0 ART 130, , , , , , ,458 0

27 Uganda: Focus on Core (PMTCT) B+ Acceleration 1,800,000 1,600,000 1,400,000 1,200,000 1,000, , , , ,000 PEPFAR Uganda PMTCT: Testing of Pregnant Women & Lifelong ART for Mothers Uganda Program Review PMTCT Test 594, , ,615 1,136,884 1,231,115 1,508,404 1,647,818 PMTCT B ,083 17,138 75,566 88, ,000 90,000 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0

28 Uganda: Focus on Core (VMMC) 350,000,000 Uganda Program Review 300,000, ,000, ,000, ,000, ,000,000 50,000, budget 276,262,3 287,113,7 286,258,3 323,388,3 298,388,3 323,388,3 320,000,0 VMMC ,052 57, , ,615 1,000, , , , , , , , , ,000 0

29 Right Places - Focusing Programs Highest burden countries Prevalence & number of PLHIV Countries with greatest unmet need for services Among general population Among specific neglected populations Sub-national regions/districts with highest burden Analyzing data to target programming geographically & among neglected populations; OVC programming should align with the epidemic Highest volume facilities Analyzing site-level data to prioritize support to facilities and communities with greatest need

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34 0% 3% 5% 8% 10% 12% 15% 17% 20% 22% 25% 27% 30% 32% 35% 37% 39% 42% 44% 47% 49% 52% 54% 57% 59% 62% 64% 67% 69% 71% 74% 76% 79% 81% 84% 86% 89% 91% 94% 96% 98% 101% Total # on ART Uganda ART Volume : Do we have the right service delivery model ART Volume by Site and Cumulative Number of Patients on ART 100% 90% 80% 70% 60% 12,000 10,000 8,000 50% 40% 30% 20% 10% 1,461 sites 643,458 on treatment 80% of patients at 19% of sites 6,000 4,000 2,000 0% - Total # on ART Cumulative % Patients Data submitted March 10, 2015

35 Using Program Data to Refine Prevalence Kenya: Spectrum & PMTCT Site Prevalence

36 Using Geospatial Mapping to Define Site Density

37 People living with HIV Nairobi Kenya County HIV burden & ART coverage Kisumu Migori Nakuru Mombasa Turkana Machakos Bomet Busia Narok Trans Nzoia Meru Nyeri Kwale Kericho Kirinyaga Vihiga Baringo Tharaka Nithi Samburu Mandera Isiolo Marsabit Wajir HIV Prevalence 1,301,716 PLHIV 328,422 PLHIV 225, , ,000 43% PLHIV (5 Counties) 80% PLHIV (20 Counties) 20% PLHIV (27 Counties) 1% PLHIV (7 Counties) , , Unmet Need Current on ART (APR 14) HIV Prevalence 339,700 on ART 246,072 on ART 148,058 on ART 6,667 on ART

38 Nairobi Kisumu Migori Nakuru Mombasa Turkana Machakos Bomet Busia Narok Trans Nzoia Meru Nyeri Kwale Kericho Kirinyaga Vihiga Baringo Tharaka Nithi Samburu Mandera Isiolo Marsabit Wajir People living with HIV HIV Prevalence 225, ,000 Kenya County HIV burden & ART coverage Accelerating Scaling 43% PLHIV (5 Counties) 80% PLHIV (20 Counties) Sustained Scaling Sustained Commodities 20% PLHIV (27 Counties) , ,000 1% PLHIV (7 Counties) , Unmet Need Current on ART (APR 14) HIV Prevalence 8 counties: Scale up to saturation by FY17 12 counties: Scale up to saturation by FY18 20 counties: Sustained high 7 counties: Sustained low

39 11% increase in HIV Testing Millions Targets with targeting of highest burden populations to maximize positive yield HIV Testing 50 HTC for 10M additional high risk people 0 Total 2014 Total 2015

40 Millions 30% Increase in Current on Treatment Massive increase in the number of people receiving lifesaving ART Current on Treatment 14 30% overall increase 0 Total 2014 Total 2015

41 Millions 113% Increase in New on ART Unprecedented acceleration & scale-up of treatment services for adults and children 4 New on Treatment More than twice last year s new on ART 0 Total 2014 Total 2015

42 Millions Maintaining & Focusing OVC Services To ensure the most vulnerable receive services tailored to their needs Services for Orphans & Vulnerable Children 6 3% increase in OVC services 0 Total 2014 Total 2015

43 Millions 9% Increase in VMMC Focusing on highest prevalence areas & populations 3 Voluntary Medical Male Circumcision (VMMC) 0 Total 2014 Total 2015

44 Millions Thousands PMTCT: gradual decline as more women are on lifelong ART through Option B+ PMTCT HTC 16 1,000 PMTCT ARVs 0 Total 2014 Total Total 2014 Total 2015

45 FOCUS ON YOUNG WOMEN & ADOLESCENT GIRLS Preventing new HIV infections

46 Key Populations Vary by Location Source: UNAIDS, 2014 Young women are the biggest key population in Sub-Saharan Africa

47 Heterosexual relationships continue to be the main sources of new infections in Africa Estimated new HIV infections in 2030 in Africa with continuation of 2013 coverage Heterosexual (incl. young women, excl. sex work) 1,350,000 Children 400,000 Female sex workers and their clients 200,000 Source: UNAIDS, 2014 Men who have sex with men People who inject drugs 25,000 7,500

48 HIV in pregnant women in rural South Africa ( ), N=4,818 HIV Prevalence 60.00% 50.00% 49.50% 51.90% 40.00% 30.00% 20.00% 10.00% 11.50% 21.30% 30.40% 39.40% 0.00% >25 Age Group (years) Source: Abdool Karim Q, 2014

49 Stark Disparity in HIV Prevalence in male and female high school students in rural South Africa 50.00% 45.00% 40.00% HIV Prevalence in Male and Female High School Students, KwaZulu-Natal, South Africa, % 30.00% 25.00% 20.00% Male (n=1,252) 13.60% 24.70% 15.00% 10.00% 5.00% 2.60% 6.10% 0.00% Source: Abdool Karim Q,

50 The DREAMS Partnership Launched on WAD 2014, $210 million partnership between PEPFAR, the Bill & Melinda Gates Foundation, and the Nike Foundation to reduce new HIV infections in adolescent girls and young women in up to 10 countries. DREAMS aims to ensure that girls have an opportunity to live Determined, Resilient, Empowered, AIDS-free, Mentored and Safe lives. Provide a country determined core package of evidence-based interventions that have successfully addressed HIV risk behaviors, HIV transmission, and gender-based violence

51 Determine d Resilient Empowere d AIDS-free Mentored Safe DREAMS Eligible Countries: Kenya Lesotho Malawi Mozambique South Africa Swaziland Tanzania Uganda Zambia

52 FOCUSING ON CHILDREN Scaling up ART services for children & adolescents

53 Adults & children currently on ART 2013 Percent of adults and children eligible for ART that are receiving it Source: UNAIDS, 2015

54 Without lifesaving antiretroviral therapy for HIV-infected children, 50% will die before their 2 nd birthday. 80% will die before age 5.

55 Partnering to save children PEPFAR & Children s Investment Fund Foundation (CIFF) Accelerating Children s HIV/AIDS Treatment (ACT) $200M partnership Doubling the number of children receiving life saving ART FY 2017 Target: 500,000 on treatment Interim FY 2016 Target: 400,000 on treatment Countries : Cameroon, Cote d Ivoire, DRC, Kenya, Lesotho, Malawi, Mozambique, Tanzania, Zambia, Zimbabwe

56 FOCUS ON KEY POPULATIONS Preventing new HIV infections

57 Source: WHO, 2014 Disparate Burden of HIV among Female Sex Workers versus General Population of Women Pooled HIV Prevalence among Female Sex Workers by Region,

58 Source: WHO, 2014 Disproportionate Burden of HIV among MSM Pooled HIV Prevalence among Men who have Sex with Men by Region,

59 Discriminatory Cultural & Legal Environments Nearly 80 countries have laws that persecute same-sex sexual relations Source: ILGA, May 2013

60 Enacted Stigma in Jamaica Reported by Health Care Staff FHI360/USAID/PEPFAR study done in 2012 Refused health care services Status (HIV, MSM, SW) gossiped about by health care provider HIV tested without consent Assigned by senior provider to junior provider SW MSM PLHIV Received less care than other patients

61 MSM and SW Experiences with Health Services and Programs (Last Six Months) FHI360/USAID/PEPFAR study done in 2012

62 Key Points Across most examined scenarios, the desire to avoid interactions with MSM was greater than it was with SW Across both health facility and social services respondents, the highest stigma levels were found for MSM HIV positive then SW HIV positive and the non-msm HIV positive which again, demonstrated layered stigma from both HIV and MSM/SW Gossip towards those suspected to be PLHIV, MSM, or SW was the most predominant report among health facility and social service staff FHI360/USAID/PEPFAR study done in 2012

63 TRUE PARTNERSHIP FOR AN AIDS-FREE GENERATION

64 In order to achieve the FAST TRACK Strategy : We will need to continue to evolve and improve our engagement with Host Governments, Civil Society, WHO, UNAIDS and Global Fund COP COP 2015 COP 2016

65 Together True partnership for an AIDS-free generation We have the opportunity to control the HIV/AIDS epidemic in countries by doing the right things in the right places at the right now in partnership with host country and GF Do we have the collective will to make the hard choices to reach more in need by focusing resources and efforts? Can we increase impact with innovations to increase the effectiveness of our programming to decrease HIV transmission? USG accountability will continue to be enhanced to ensure achievement of the targets and ensuring HIV/AIDS epidemic control; PEPFAR data will be

66 Our work is not done. This week alone Over 3600 children died this week from HIV Over 25,000 adults died this week from HIV Over 4,600 babies were infected with HIV Over 36,500 adults were infected of which more than 7000 were young women

67 There is a window of opportunity before us, a window through which we can very clearly see the end of AIDS within my lifetime...

68 THANK YOU!

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