Implementation at the national and local levels: Revitalize HIV combination prevention in the Eastern and Southern Africa (ESA) region

Transcription

1 UNAIDS 2016 HIGH-LEVEL MEETING REPORT Implementation at the national and local levels: Revitalize HIV combination prevention in the Eastern and Southern Africa (ESA) region Meeting held on the sidelines of the 21 st International AIDS Conference 19 July 2016 at 18:00 Hotel Southern Sun Elangeni Maharani, Durban, South Africa Hosts: The Government of Zimbabwe Co-hosts: UNAIDS, UNFPA and Ford Foundation

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3 High-level meeting Implementation at the national and local levels: Revitalize HIV combination prevention in the Eastern and Southern Africa (ESA) region Meeting held on the sidelines of the 21 st International AIDS Conference 19 July 2016 at 18:00 Hotel Southern Sun Elangeni Maharani, Durban, South Africa

4 MILESTONE 12 Institutionalize regional agenda in regional entities with accountability. ENVISAGED CHANGE IN COUNTRIES Accountability shifts to accelerate implementation and scale-up of HIV combination-prevention services at local level. Increased investments for HIV combination prevention by countries. Result: Reduced new HIV infections to fewer than in the ESA region by MILESTONE 11 By December 2016 Countries document implementation scale-up and increased uptake of HIV-prevention services. July 2016 onwards MILESTONE 10 Countries demonstrate local leadership with accountability shifts and increased investments for HIV prevention. July 2016 onwards MILESTONE 9 Set national targets for reduction of new HIV infections; set targets for each pillar of HIV combination prevention at local level. July 2016 onwards MILESTONE 8 Mobilize more countries to drive regional agenda International AIDS Conference, Durban July and beyond MILESTONE 7 Launch ESA high-level political advocacy platform for revitalizing HIV combination prevention July December 2016 MILESTONE 6 Regional road map for revitalising HIV prevention in ESA region MILESTONE 1 Call brainstorming meeting between selected partners in Harare, Zimbabwe; agree on roadmap and identify r key players from r countries. MILESTONE 2 Govt of Zimbabwe from brainstorming meeting in UNAIDS regional technical consultation towards UN High- Level Meeting on Ending AIDS 4-5 April 2016 MILESTONE 3 Produce strategic products/analysis on combination HIV prevention from 5 champion countries state-of-the-art and promising practices. March June 2017 MILESTONE 4 Chair/co-chair discuss regional agenda with SADC/EAC Health Ministers and obtain buy-in. World Health Assembly, May 2016 MILESTONE 5 Create platform to discuss regional agenda with civilsociety/community organizations for their buy-in. July 2016 Create platform to discuss regional agenda in High-Level Meeting in UN General Assembly June 2016 March 2016

5 Contents Objective 1 Expected result 1 Key messages 1 Meeting details 2 Opening remarks 2 Introductory remarks 2 Welcome remarks 2 Video: Close the tap of new HIV infections: Revitalize HIV combination prevention in the ESA region 4 Actions and strategies for Revitalizing HIV Prevention in the ESA Region 4 Actions for implementation of HIV prevention programmes at national and local levels 4 Leadership level actions to strengthen HIV prevention programme implementation 6 Box: Renewed commitment by stakeholders for HIV combination prevention in the ESA region 7 Summary 7 Vote of thanks and closing 8 Box: Launch of Ten Conversations to End AIDS 8 Annex 1: Programme 9 Annex 2: Concept Note 10

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7 Objective Obtain commitments on actions and strategies to be implemented at the national and local levels to reach specific targets on HIV-combination-prevention services, increased investments and renewed accountability. Expected result Leadership-level and technical-level implementation actions at the local and national levels agreed for revitalizing HIV combination prevention in order to reduce new HIV infections in the Eastern and Southern Africa (ESA) region from (in 2015) to by Key messages In the ESA region there were new HIV infections in 2015, accounting for half of the global total. Reducing HIV incidence in this region is critical, and it can be accomplished only through a renewed focus on HIV combination prevention in addition to continued scale-up of HIV treatment. In the ESA region, adolescent girls and young women are twice as likely to become infected with HIV as adolescent boys and young men, and HIV-combination-prevention programmes targeting them should include tailored HIVprevention education, integrated sexual and reproductive-health services, stigma-reduction messaging, innovative communication channels, and cash transfers. Male sexual partners of adolescent girls and young women also require access to voluntary medical male circumcision (VMMC), HIV testing and HIV treatment in order to reduce HIV transmission. Key and vulnerable populations (including sex workers, men who have sex with men, people who inject drugs, prisoners, migrant workers, truck drivers, workers in the informal sector, and other groups specific to the country context) are a priority target populations for HIV prevention, and require the integration of human rights, legal frameworks, reducing barriers to service uptake, and increasing access to prevention services in ESA countries. Condom programming remains a priority pillar of HIV combination prevention and should be promoted as part of the national-level and local-level prevention response. HIV prevention services, including VMMC, pre-exposure prophylaxis (PrEP) and treatment as prevention, can be scaled up in countries in the ESA region through expanded service delivery and access points, and by increasing demand generated by influential community leaders. Collaboration across sectors, government ministries, communities, civil society and development partners is required for a coordinated and effective prevention response. Implementing HIV-combination-prevention services requires four interconnected approaches: closely engaging community/key audience and civil society in the design, planning and implementation of programmes; collecting and using programme data to tailor HIV-combination-prevention services to the needs of different target groups; leveraging cross learning and sharing of best practices between countries and communities; and innovation in service delivery. Strategic information and the improved availability and use of routine programme and epidemiological data are important for shaping and monitoring the effectiveness of the HIV-prevention response. In order to measure progress in demand creation, implementation and access to service delivery of HIV combination prevention services, establishing specific programme targets for HIV prevention by sub- target population and/or by prevention service is indispensable. In addition to setting specific prevention targets, increasing accountability for the HIV-prevention agenda at the country level requires alignment to one system. This will enable for measuring progress, quality and consistent reporting and tracking with defined indicators specific to the HIV-prevention programme at both the local and national levels. In addition, defined roles and responsibilities of different stakeholders involved in prevention response is key for accountability purposes. Investments for HIV prevention should be increased to 25% of the total budget for the national AIDS response, combining financing from development partners while increasing domestic resources and finding efficiency gains for sustainable HIV prevention. This 25% investment should be for the five high-impact pillars of HIV combination prevention, excluding HIV testing and counselling (HTC) and prevention of mother-to-child transmission (PMTCT) services. 1

8 Meeting details Opening remarks Gerald Gwinji, Permanent Secretary of the Ministry of Health and Child Care, Zimbabwe, opened the meeting and introduced the co-chairs, David Parirenyatwa, Minister of Health and Child Care, Zimbabwe, and Dorcas Makgato, Minister of Health, Botswana. Dr Gwinji indicated that Michel Sidibe, Executive Director of the Joint United Nations Programme on HIV/AIDS (UNAIDS), would join this high-level meeting, and welcomed the attendees, including the Regional Director of the United Nations Population Fund (UNFPA), Julitta Onabanjo; the Director of the Regional Support Team for Eastern and Southern Africa from UNAIDS, Sheila Tlou; the Ministers of Health from the ESA region; and senior government officials, development partners and representatives of civil society. Introductory remarks Shelia Tlou, Director of the UNAIDS Regional Support Team for Eastern and Southern Africa, welcomed and thanked the co-chairs. She extended her welcome to government officials and organizational representatives. She welcomed the Paramount Chief from Botswana and the Executive Director of UNAIDS. Professor Tlou then highlighted that this meeting is what is meant by Delivering as One across UN organizations, with UNFPA, the World Bank, and other co-sponsors of UNAIDS, as well as the Ford Foundation, supporting the meeting. Professor Tlou indicated that this high-level meeting is important because there is an imbalance between HIV prevention and treatment efforts in countries in the ESA region. She illustrated this with the example of scaledup PMTCT services, where 90% of pregnant women in the region are now able to access antiretroviral treatment (ARVs) to prevent HIV transmission to their babies; while at the same time current efforts are not preventing new HIV infections through sexual transmission among adults and young people. She noted therefore that focusing on HIV combination prevention is not an initiative, but should be a comprehensive programme that can be guided by a national/subnational HIV-prevention roadmap through a collaborative approach. Professor Tlou informed participants that the high-level meeting would be broadcast via television in more than 45 countries in sub-saharan Africa and encouraged participants to provide interviews for the broadcast. Following the highlevel meeting, she invited participants to a dinner session, which would feature the launch of a book of poems, Ten Conversations to End AIDS, written by Albert Nyathi and Daniel Low-Beer. Welcome remarks David Parirenyatwa, Minister of Health and Child Care, Zimbabwe, and co-chair of the highlevel meeting, welcomed all participants and invited Michel Sidibe, UNAIDS Executive Director, to speak. Michel Sidibe, Executive Director of UNAIDS, recognized and appreciated the commitment of the Minister of Health and Child Care, Zimbabwe, for his leadership and the Ministers of Health from the ESA region, who are making a huge contribution to changing the paradigm for HIV prevention. He highlighted the report Galvanizing national leadership with accountability to revitalize HIV combination prevention in the eastern and southern Africa (ESA) region from the meeting held in May , which demonstrated these ministers commitment to revitalizing the HIV-prevention agenda. He underscored the critical need for renewed focus on HIV prevention, noting the lack of progress in reducing new HIV infections globally, as outlined in UNAIDS recently released Prevention Gap report. Mr. Sidibe stated that globally, new HIV infections reduced by 35% from mid-1990, when there were approximately 3 million new HIV infections per year. However, in the last five years, 1 Available at: 2

9 although there has been a reduction of new HIV infections among children, new HIV infections among adults have remained the same or are increasing in some countries. Every year since 2000, approximately 1.9 million adults globally have become newly infected with HIV. Lack of continued progress in HIV prevention has focused on three primary reasons: 1. HIV-prevention services are not working for adolescent girls and young women in sub-saharan Africa: 25% of young women will become infected before age 25 in some countries; 75% of adolescents who are newly infected with HIV are girls. 2. Key populations (sex workers, men who have sex with men, transgender people and people who inject drugs) are not being reached by HIVprevention services: 35% of new HIV infections globally are among key populations. 3. Complacency is the new conspiracy: as HIV treatment reduces the number of AIDS-related deaths and increases survival rates, people may become more complacent about the need for HIV prevention services and its promotion and use. In order to close this HIV-prevention gap in the ESA region countries, it is imperative to fast-track the response. Mr. Sidibe highlighted feedback he received during a visit to Kenya, when he was told that the global fasttrack treatment targets of were insufficient, because leaders also required clear targets for measuring whether or not their HIV-prevention response was working. This feedback resonated with Mr. Sidibe, who called for the formation of a scientific committee to clearly define the characteristics of the epidemiological stages of the HIV epidemic in order to enable communities to understand and track the effectiveness of their HIV-prevention programmes. Mr. Sidibe noted that it was essential to have a holistic perspective on how to support and empower young people to start HIV-free, stay HIV-free and remain AIDS-free 4. He highlighted the need for: programming in the region that targets young girls and women; scale-up the five pillars of HIV combination prevention linked to efforts to achieve the treatment targets of ; and advances in reproductive health and sexuality, including early pregnancy and unsafe abortion and human rights. The HIV-prevention response must address social and cultural norms, promote VMMC, provide PrEP to people at higher risk for infection, and reduce age-disparate relationships. Importantly in countries in the ESA region, male sexual partners need to be reached with HIV services, especially blessers 5, who are often in the age range of years, as shown in the data from the Centre for the AIDS Programme of Research in South Africa (CAPRISA), and are a contributing factor to new HIV infections among adolescent girls and young women. A renewed focus on HIV prevention is a key opportunity that, if missed, will prove costly in the long term. In high-hivburden countries, all stakeholders must come together to refocus on HIV prevention to close the tap of new HIV infections. David Parirenyatwa, Minister of Health and Child Care, Zimbabwe, continued the opening remarks by reiterating the need to focus on both HIV prevention and the scale-up of HIV testing and treatment to achieve the targets by He also suggested adding a fourth 90 for HIV prevention to the treatment targets, to capture the critical need to prevent new HIV infections in ESA countries. The co-chair noted that HIV prevention is ongoing throughout a person s life cycle, and that it must be effective from birth, into childhood and through adulthood in order to effectively prevent and control the HIV epidemic. People must be reminded of the need to take action for HIV prevention, rather than becoming complacent as a result of expanded ARV treatment. It is also essential to reach key populations with HIV-prevention programmes and services. Dr. Parirenyatwa noted that countries in the ESA region had previously been reluctant to acknowledge the existence of key populations, such as men who have sex with men. With the recognition of these populations, it is essential to reach them with HIV-prevention services and address barriers that affect the ability of these key populations to access HIV-prevention services and protect themselves from HIV infection. 2 Available at: 3 Fast-track treatment target: By 2020, 90% of all people living with HIV will know their HIV status. By 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy. By 2020, 90% of all people receiving antiretroviral therapy will have viral suppression. More information is available at documents/2014/ More information on Start Free, Stay Free, AIDS Free is available at 5 Blessers is a slang term in the Southern African context, referring to men who provide material support to young women and adolescent girls, often in exchange for sexual relationships. 3

10 Dorcas Makgato, Minister of Health, Botswana, was invited to comment as co-chair. Botswana has been driving a comprehensive approach to HIV prevention, and the Minister noted the importance of UNAIDS and co-sponsor agencies in supporting countries in these efforts. She illustrated the cross-sectoral and collaborative nature of Botswana s HIVprevention response by introducing the diverse members of her delegation, including traditional leaders and officials at various levels of government. She noted that engaging and working with communities is essential, particularly in cases where traditional and religious leaders are more effective than government in calling people to action. The Ministry of Health in Botswana focuses on preventive rather than curative approaches in their work, which is less expensive and more sustainable, and Ms Makgato emphasized that this focus on HIV prevention needs to be at the core of every HIV programme. Video: Close the tap of new HIV infections: Revitalize HIV combination prevention in the ESA region The short video Close the tap of new infections: Revitalize HIV combination prevention in the ESA region was developed in support of the implementation of the 2016 Political Declaration on HIV and AIDS, and to build renewed momentum for HIV combination prevention. It featured evidence on the current status of new HIV infections in the ESA region, and perspectives from government leadership, UNAIDS and UNFPA representatives on the need to revitalize HIV combination prevention in countries in the region. The video demonstrated that the ESA region has been successful in reducing HIV incidence in the past, with declines in HIV incidence of 20% between 2005 and 2015, but that the rate of new HIV infections has recently stabilized in most countries. Effective revitalization of HIV-prevention programmes is required in order to reduce new annual infections in the region to by 2020, the target stated in the 2016 Political Declaration on HIV and AIDS. There were new HIV infections in ESA countries in 2015, accounting for half of the global total. Within the ESA region, approximately 40% of new HIV infections were in South Africa alone. Approximately 4500 adolescent girls and young women aged years are newly infected with HIV in the ESA region each week, double the number of adolescent boys and young men of the same age. The video included commitments from the national leadership from the ESA region to revitalize HIV combination prevention. These policy-makers called for the urgent need to implement and scale up HIV-prevention services to adolescent girls and young women, and their male sexual partners, and key populations. The need for the active engagement of community in service delivery and target setting was reiterated. The engagement of traditional leaders, community leaders, civil society, the private sector and political leaders was highlighted as part of implementing a robust HIV-prevention response. Cross-sectoral collaboration and integration with sexual and reproductive health is essential, as is the need to engage civil society and define its role in HIV-prevention programmes. UNAIDS advocated for increasing investment in HIV-prevention activities to 25% of national HIV budgets, from current levels of 10% in most countries. The video closed with a reminder of support for and commitment to scaling up HIV treatment, and served as a call to action to build similar momentum for HIV combination prevention in countries in the ESA region. David Parirenyatwa, Minister of Health and Child Care, Zimbabwe, summarized the importance of closing the tap of new HIV infections in countries in the ESA region. Actions and strategies for revitalizing HIV prevention in the ESA region David Parirenyatwa, Minister of Health and Child Care, Zimbabwe, led the discussion on revitalizing HIV-combination-prevention programmes in the ESA region, which focused on two main areas: actions for implementation at the national and local levels, and leadership-level actions to enable the HIVprevention response in any given country. 4

11 Actions for the implementation of HIV-prevention programmes at the national and local levels The co-chair invited participants to share their perspective on actions to implement HIV-combination-prevention programmes at the national and local levels. In addition to the detailed actions listed below, four intersecting themes emerged from this high-level meeting: closely engaging community/target audience and civil society in the design, planning and implementation of programmes; collecting and using programme data to tailor the needs of different target population; leveraging cross learning and sharing of best practices between countries and communities; and innovation in service delivery. Adolescent girls and young women, as well as their male sexual partners, are a major priority for HIV prevention. Curriculum transformation in HIV and health education is important to reach young people, with different approaches required for those who are in or out of school. Bernhard Haufiku, Minister of Health and Social Services, Namibia, provided an example of Namibia s cross-ministerial approach to advocate and implement a comprehensive sexual- and reproductive-health curriculum in school from grade four. Nduku Kilonzo, Director, National AIDS Control Council (NACC), Kenya, noted the recent launch of the Maisha County campaign to reach three million young people with information on HIV, and test an additional one million young people. Engaging new voices and partnerships was another approach to reach this target population. Molotsi Monyamane, Minister of Health, Lesotho, suggested building on influential voices in communities, such as the elderly or mothers-in-law, to engage young people and say it straight. Lorna Tumwebaze, Bill and Melinda Gates Foundation, suggested collaboration with the private sector, partnering with adolescent-friendly media, and tapping into role models who can help youth to develop long-term visions. The importance of scaling up adolescent-friendly health and social services was shared by Jane Aceng, Minister of Health, Uganda, and was echoed by civil-society representatives who advocated for improved capacity of health workers to respond to adolescent and young people s needs. The DREAMS initiative of the United States President s Emergency Plan for AIDS Relief (PEPFAR), detailed by Irum Zaidi from PEPFAR, aims to reduce HIV incidence among young women and adolescent girls in the ESA region by 40% by the end of next year, by reducing stigma, expanding cash transfers, improving education, and expanding access of male partners to VMMC and treatment as prevention. Key populations, including sex workers, men who have sex with men, people who inject drugs, prisoners and other target populations specific to the country context, are also a priority for HIV prevention. Sithembile Chiware, Hivos regional office, Zimbabwe, introduced KP Reach, the eight-country regional Global Fundsupported programme targeting key populations in Southern Africa up to and including 2018, which will be an important opportunity for expanding HIV-prevention activities in the region. Carolyne Njoroge, Key Affected Population Health and Legal Rights Alliance, Kenya noted the importance of advancing human rights for key populations, reducing barriers to service uptake, and increasing access to prevention services. Christine Johansson, Regional Team for Sexual and Reproductive Health and Rights (SRHR), Embassy of Sweden, Lusaka, Zambia, emphasized the need to determine what can be achieved through national government s legal frameworks, and how to reach people without discrimination. Kenya and Rwanda were noted by Sheila Tlou, Director, UNAIDS Regional Support Team for Eastern and Southern Africa, as model countries in the ESA region for key-populations programming based on the declining rates of HIV infections among sex workers and men who have sex with men. PEPFAR also announced the key-populations innovation fund, which will be made available as financial support for new and innovative programmes for key populations. Condoms remain a key tool for HIV prevention, and the discussion included opportunities to expand their availability and use. Jane Aceng, Minister of Health, Uganda, noted that the ABC (abstinence, be faithful, and consistent and correct condom use) method worked previously in Uganda and can still work, particularly by expanding condom distribution through a total market approach. Bernhard Haufiku, Minister of Health and Social Services, Namibia, mentioned that condom distribution through civil-society involvement could take place wherever large groups of people gather, such as in churches or at sporting events. Expanded access to Voluntary Medical Male Circumcision (VMMC) and Pre-exposure Prophylaxis (PrEP) for HIV prevention are other areas for increased focus. The DREAMS initiative will support expanded VMMC for the male partners of adolescent girls and young women in the region. Development partners and civil society referred to the continued scale-up of treatment as prevention as an ongoing priority, while Nduku Kilonzo, Director, NACC, Kenya, noted the importance of PrEP and VMMC. 5

12 Bernhard Haufiku, Minister of Health and Social Services, Namibia, advocated for improving access to PMTCT through community-level and expanded pointof-care services. He suggested expanding HIV testing through the use of index patients, such as HIV-positive mothers, to identify children or other members of the community who may require testing, but integrating testing services into primary-care services to prevent stigma. He also noted the opportunity to expand service delivery to high-density-traffic areas, like malls or taxi ranks, or in workplaces for people who are unable to go to a clinic. At the local level, there is a need to engage new stakeholders in HIV-prevention activities. Bernhard Haufiku, Minister of Health and Social Services, Namibia, highlighted the challenges in reaching men with HIV messaging and services, and noted that wives, church leaders and traditional initiation schools may be strong influencers of this group. Nduku Kilonzo, Director, NACC, Kenya, noted the importance of the faith sector in Kenya, where half of the country s 40 million people are reached from Friday to Sunday through religious services. Faith leaders can be engaged by asking them to lead a conversation about HIV once per quarter in every faith to expand the reach of HIV-prevention messages. Kgosi Kgolo ya Ba Ga Malete Kgosi Mosadi Seboko (Paramount Chief from Ramotswa, Botswana) also highlighted the model of Communities Acting Together to Control HIV (CATCH) being implemented in Botswana, which is a grassroots, bottom-up approach that engages key leaders and communities in addressing HIV. In order to measure progress in demand creation, implementation and access to service delivery of HIV combination prevention services, participants noted the importance of establishing specific programme targets for HIV prevention by sub-target target population and/or by prevention service, for example, setting specific targets for young people by country was suggested by Nokhanyo Yolwa, UNFPA Youth Advisory Panel, South Africa. Leadership-level actions to strengthen HIVprevention programme implementation As leadership-level actions, participants highlighted the need to improve accountability with tracking, strategic information, multidisciplinary collaboration, and the need for increased investments in order to further strengthen HIV-prevention programme implementation. Global targets for five prevention pillars Clear HIV prevention targets for national and local levels, alignment to one system, and clearly defined roles and responsibilities across stakeholders can improve accountability for the HIV-prevention response. Sabine Diallo, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), South Africa encouraged alignment around the use of one national system to enhance accountability across multiple participants. This was reinforced by input from Nduku Kilonzo, Director, NACC, Kenya, who discussed the NACC s approach of using a unified system to hold multiple ministries accountable for achieving the various targets that have been allocated to them for combinationprevention activities within their sector. For example, the Ministry of Health is accountable for biomedical approaches like PrEP and VMMC within HIV combination prevention and has non-negotiable targets to reach in these areas. Reports of performance against targets are regularly generated and shared across all stakeholders. Similarly, improved availability and use of data/strategic information is required at the leadership and technical levels. There was a call from Nduku Kilonzo, Director, NACC, Kenya, for UNAIDS to develop a menu of HIV-prevention-related indicators that countries can use to monitor the effectiveness of their national response. Bernhard Haufiku, Minister of Health and Social Services, Namibia, encouraged countries to use data to determine if HIV-prevention responses are working or not, and to share this information with people living with HIV as well as the broader community for further accountability. PEPFAR also places a strong emphasis on the use of granular strategic information for programme design and planning, and the use of indicators to show impact. 6

13 Renewed commitment by stakeholders for HIV combination prevention in the ESA region Following inputs from the various stakeholders present in the high-level meeting, David Parirenyatwa, co-chair of the high-level meeting, called for a joint proposition for a commitment to revitalize HIV prevention in the ESA region. Bernhard Haufiku, Minister of Health and Social Services, Namibia, stated that he, together with colleagues in Eastern and Southern Africa, proposed that they, as leaders, adopt the commitment to revitalize HIV combination prevention in the ESA region. Chamunorwa Mashoko, Zimbabwe AIDS Network, representative from civil society, seconded the motion. HIV combination prevention requires enhanced collaboration across sectors and ministries, and among different stakeholders, for a comprehensive and effective response. Sabine Diallo, GIZ, focused on the need to break down siloes between sectors, institutions and national borders as a key way forward. Participants mentioned cross-ministerial cooperation by the governments of Namibia and Kenya in HIV prevention, while Carolyne Njoroge, Key Affected Population Health and Legal Rights Alliance. Kenya, also expressed appreciation to the Government of Kenya for the active and meaningful inclusion of key populations in developing national policy, strategy and roadmaps. HIV-prevention programmes require adequate investment from global and domestic sources, as well as efficiency gains, in order to be effective and sustainable. Jane Aceng, Minister of Health, Uganda, advocated for sufficient domestic investments in combination prevention, including biomedical approaches as well as advocacy. She noted that it is particularly important to focus investments on combination-prevention activities that yield tangible and measurable results. PEPFAR invests 30% of its total budget in HIV prevention, and Lorna Tumwebaze, Bill and Melinda Gates Foundation, reiterated the importance of replenishing the Global Fund to ensure the availability of global financing. While funding from development partners represents a significant share of HIV-prevention funding in the region, the governments of Namibia and Uganda stated the importance of securing domestic funding commitments for HIV prevention. Casper Erichsen, Positive Vibes Trust, Namibia, expressed appreciation to the Minister of Health of Zimbabwe for his leadership on HIV prevention and recognized the Minister of Health and Social Services from Namibia for committing 30% of the national HIV-response budget for HIV prevention. The use of innovative and cost-effective approaches was referenced as an opportunity to secure efficiency gains to allow available resources to stretch further. Summary Julitta Onabanjo, Regional Director, UNFPA, ESA region, congratulated participants for their commitment to revitalizing HIV-prevention efforts in the region. She noted that while there are country-specific considerations in implementing and leading HIV-prevention programmes, there are also many collective learnings and opportunities across the region. She provided a summary of the discussions from the high-level meeting, as well as the role of the UN system in revitalizing HIV-prevention response. They include: Enhancing accountability at the national level for delivering the HIV-combination-prevention agenda within the broader HIV response. Improving the availability and use of epidemiological data for more granular information, particularly to better understand young people and the diversity of key populations. Translating awareness about HIV-prevention needs into an inclusive plan with specific HIVprevention indicators and targets a prevention roadmap including subnational targets to come together to reduce new HIV infections to by 2020 from in Determining the appropriate response required for the epidemic, and integrating the response at the local level, including linkages to sexual and reproductive health and human rights. 7

14 Refining the approach based on science and what works for HIV prevention. Data, data, data to monitor progress, adjust the prevention programme implementation response and ensure accountability. Continuing to build on opportunities for innovation and financial support from development partners, while increasing the allocation of domestic resources to HIV prevention. Engaging multiple stakeholders from all sectors, building capacity at the community level and among young people, and using the capacity that already exists, for both implementation and scale-up of HIV-prevention services. Continuing to build on the excitement about working together in the region, including south-south platforms and with regional economic communities. Dr Onabanjo reiterated that through joint UN teams, UN agencies can provide support to achieve these priorities at the country and at the regional level, UN agencies will continue to support the regional agenda on revitalizing HIV prevention. David Parirenyatwa, Minister of Health and Child Care, Zimbabwe, stated that all stakeholders must move together to focus on prevention, prevention, prevention to close the tap of new HIV infections, while continuing to scale up HIV treatment in the ESA region. He encouraged countries to work more closely with the UN system to support national and regional efforts. Vote of thanks and closing Dorcas Makgato, Minister of Health, Botswana, reiterated that defined goals are required to support the revitalization of national HIV-prevention programmes, as well as innovative, broad-based, financed and measured approaches that allow stakeholders to be held accountable. She extended thanks to participants for giving their time to the discussion development partners, civil society, community leaders, traditional leaders, UNAIDS, UNFPA, PEPFAR, and the co-chair. Gerald Gwinji, Permanent Secretary of the Ministry of Health and Child Care, Zimbabwe, closed the meeting by thanking the co-chairs, as well as the team that has worked diligently to advance this regional agenda for revitalizing HIV prevention and to obtain buy-in from leadership and other important stakeholders in the region. He invited participants to attend the dinner and the launch of the book Ten Conversations to End AIDS. Launch of Ten Conversations to End AIDS The Minister of Health of Zimbabwe launched the book Ten Conversations to End AIDS by Albert Nyathi and Daniel Low-Beer. He did this jointly with the UNAIDS Secretariat in Geneva, Switzerland, and the Regional Director, UNAIDS Regional Support Team, ESA region. The book of 10 poems focuses on key topics to prompt discussion about HIV within families, relationships, leaders and communities. Ten Conversations to End AIDS is available at Albert Nyathi, David Parirenyatwa and Daniel Low-Beer during the official launch of Ten Conversations to End AIDS 8

15 Implementation at national and local levels: Revitalize HIV combination prevention in eastern and southern Africa (ESA) region Date: 19 July 2016 Time: 18:00 20:00 Venue: Objective: Hotel Southern Sun Elangeni Maharani, Durban Obtain commitments on actions and strategies to be implemented at national and local levels to reach specific targets on HIV combination prevention, increased investments and renewed accountability Programme Time Session Resource persons 18:00 18:15 Introductory remarks and announcements Prof. Sheila Tlou, Director, UNAIDS Regional Support Team, ESA region 18:15 18:20 Welcome remarks Chair Dr. David Parirenyatwa, Honorable Minister of Health, Zimbabwe 18:20 18:30 Video: Close the tap of new HIV infections: Revitalize HIV combination prevention in the ESA region Revitalize HIV Prevention agenda: A snap short What is being done so far? 18:30 18:45 Feedback on actions and way forward on two questions Leadership level actions Shift in accountability national and local level Sufficient investments and resource allocation 18:45 19:00 Feedback on actions and way forward on two questions Technical level actions What needs to be done differently for reaching the targets on adolescents girls and young women, key populations, VMMC, Condoms and PrEP by :00 19:40 Time for renewed commitment for HIV combination prevention: Statements of commitment from political leadership and regional entities Time for renewed commitment for HIV combination prevention: Statements of commitment from civil society, communities and development partners Chair Facilitated discussion Co-chair Dr. Cleopa K. Mailu Honorable Cabinet Secretary of Health, Kenya Facilitated discussion Chair Chair inviting: National political leadership to present statements of commitment Regional entities to present statements of commitment Co-chair inviting: Civil society and communities to present statements of commitment Donors to present statements of commitment UN to present statements of commitment 19:40 19:45 Proposals of actions for consideration Dr. Julitta Onabanjo, Regional Director, UNFPA, ESA region 19:45 19:55 Next steps and key milestones Chair jointly with Dr. Luiz Loures, Deputy Executive Director, UNAIDS and Asst. Secretary General, United Nations 19:55 20:00 Vote of thanks and close Dr. Julitta Onabanjo 20:00 onwards Dinner Launch of Ten Conversations to End AIDS and networking (Invited guests) 9

16 Concept note High-level meeting with Ministers of Health, Gender and Education, civil society, communities and development partners in the 2016 International AIDS Conference, Durban Implementation at the national and local levels: Revitalizing HIV combination prevention in the Eastern and Southern Africa (ESA) region 19 July 2016 at 18:00 at Southern Sun Elangeni Maharani Hotel, Durban Host: Government of Zimbabwe Co-hots: Joint United Nations Programme on HIV/AIDS (UNAIDS), United Nations Population Fund (UNFPA) and Ford Foundation Focal person(s): Dr. Gerald Gwinji (Permanent Secretary, Ministry of Health, Zimbabwe), Jyothi Raja Nilambur Kovilakam (UNAIDS, Regional Support Team, ESA) and Innocent Modisaotsile (UNFPA, Regional Office, ESA) This high-level meeting is part of a series of events/meetings to promote and drive the regional agenda on revitalizing HIV combination prevention in the ESA region. Background The AIDS epidemic continues to disproportionately affect sub-saharan Africa, including Eastern and Southern Africa. Sexual transmission is one of the major modes of HIV transmission in the ESA region, with over 90% of new HIV infections among adults and young people occurring mainly through sexual transmission. Countries in the ESA region have made considerable progress in reducing new HIV infections among adults, with a decline of over 30% between 2005 and 2015, and 4% between 2010 and However, the region has not been able to meet the target set by the 2011 United Nations General Assembly Political Declaration on HIV/AIDS to reduce sexual transmission of HIV by 50% by Over the last several years, countries in the ESA region have made significant and commendable progress in preventing mother-to-child transmission (PMTCT) of HIV and scale-up of HIV treatment. Despite these gains, progress in preventing new HIV infections among adults have stalled, falling to decline for at least 5 years. The ESA region continues to be the hardest-hit by the epidemic, with 46% of the world s new HIV infections and 42% of global AIDS-related deaths in HIV remains the single largest cause of life-years lost in the ESA region. There were approximately new HIV infections among adults and children in the ESA region in 2015 almost half of the global number of new infections (2 million globally). Nearly 40% of new HIV infections in the region in 2015 were in South Africa, and another 50% occurred in eight other countries: Ethiopia, Kenya, Malawi, Mozambique, Uganda, United Republic of Tanzania, Zambia and Zimbabwe. Since 2010, the number of new HIV infections has stalled in the majority of countries in the ESA region, while the number of new infections remains unacceptably high among young girls and women (10-24 years old) and their male sexual partners. There were approximately new HIV infections weekly among adolescent girls and young women in the ESA region, double the rate for adolescent boys and young men. Adolescent girls and young women continue to experience elevated HIV risk and vulnerability. High HIV prevalence also continues to be observed among key populations in countries in the region. Countries in the ESA region are diverse in their HIV-prevention response and huge variations exist in the pace and quality of implementation. Despite the success stories on HIV prevention, significant gaps and shortcomings persist in countries in the region, in particular in primary prevention services. Even as new HIV-prevention tools and approaches have emerged, prevention programmes have weakened in recent years in many countries due to inadequate leadership, poor management, weak accountability, declining funding and complacency. Shortfalls in implementation, with inadequate focus on high-impact interventions, insufficient scale, inconsistent service quality, and inadequate prioritization of geographical locations and target populations may be some of the other contributing factors. Against this backdrop, there is a clear need to revitalize HIV-prevention efforts in the region to reduce new HIV infections. 10

17 Close the tap of HIV new infections in eastern and southern Africa The 2016 Political Declaration on HIV and AIDS: On the Fast-Track to Accelerate the Fight against HIV and to End the AIDS Epidemic by 2030 reaffirmed commitments, and the Member States pledged to intensify efforts towards attaining the goal of comprehensive prevention, treatment and care, and support programmes that will help to significantly reduce new HIV infections, increase life expectancy and quality of life, and promote and protect and fulfill all the human rights and dignity of all people living with, at risk of, and affected by HIV and AIDS, and their families. The 2016 Political Declaration also noted with alarm the slow progress in reducing new infections, and the limited scale of HIV combination-prevention programmes in countries Political Declaration on HIV and AIDS: Regional target for reduction of new HIV infections 65(a): Work towards reducing the number of new infections among young people and adults (aged 15 and older) to (75%) in Eastern and Southern Africa by 2020 Ending the AIDS epidemic as a public health threat by 2030 is within our reach if we fast-track the response. This can be achieved, through embracing the target to reduce new HIV infections globally to fewer than by 2020, and increasing and front-loading investments. To contribute to this global target, the ESA region should work towards its regional target to reduce new HIV infections to fewer than (a 75% reduction) 1 by To attain this regional target, a paradigm shift, with renewed commitment and accountability in the HIV-prevention response by countries, is crucial. The 2016 Political Declaration on HIV and AIDS recognized and called for the commitment of Member States to saturate areas with high HIV incidence with a combination of tailored prevention interventions, and to work towards reaching the global HIV-prevention targets for each of the evidence-based prevention interventions in the context of the fast-track approach. In this context, more than ever, revitalizing HIV prevention should be made a reality, along with the scale-up of HIV treatment in countries in the ESA region in the context of the cascade and the Sustainable Development Goals. This requires a balanced approach, with political and technical shifts and solutions in countries, at both the national and the local level. This realignment of HIV-prevention response in countries needs to happen with key national players from the health and non-health sectors and communities working together Political Declaration on HIV and AIDS by 2020: Global HIV Prevention Targets 62(f): Encourage Member States with high HIV incidence to taking all appropriate steps to ensure that 90% of those at risk of HIV infection are reached by comprehensive prevention services, that 3 million persons at high risk access pre-exposure prophylaxis and an additional 25 million young men are voluntarily medically circumcised by 2020 in high HIV incidence areas and ensure the availability of 20 billion condoms in low-and middle-income countries. 62(g): Commit to ensure that financial resources for prevention are adequate and constitute no less than a quarter of AIDS spending globally on average, and are targeted to evidence-based prevention measures that reflect the specific nature of each country s epidemic by focusing on geographic locations, social networks and populations that are at higher risk of HIV infection according to the extent to which they account for new infections in each setting, in order to ensure that resources for HIV prevention are spent as cost-effectively as possible and to ensure that particular attention is paid to those populations at highest risk, depending on local circumstances. In light of the need for change, leaders are encouraged to translate their political commitment into concrete actions and results in countries. Renewed political and strategic leadership with accountability at the national and local levels is critical, along with technical solutions for revitalizing HIV prevention in countries. National and local accountability for HIV prevention also requires that sufficient investments, both domestic and international, should be allocated to HIV combination prevention, in addition to antiretroviral therapy, including HIV testing and PMTCT, with the specific proportion varying from country to country. In terms of technical shifts and solutions, there is strong evidence that suggests that HIV combination prevention works if implemented smartly at sufficient scale and intensity. At this stage of the epidemic, no single HIV-prevention tool or approach can stop the epidemic. However, a mix of proven, high-impact, evidence-based HIV combination-prevention tools and services 2 would be instrumental in significantly reducing new HIV infections. Addressing the shortfall in implementation, saturation of HIV-prevention programmes in specific geographical locations at the local level for priority populations is desirable. These services need to be delivered at adequate scale with good quality in order for countries to achieve the envisaged results. 1 Secretary-General s Report, On the Fast-Track to End the AIDS Epidemic, 1 April ) Scaling up HIV combination-prevention packages, and access to sexual and reproductive health services for young men, girls and women and their male partners; 2) Scaling up evidence- and human-rights-based prevention programmes for key populations; 3) strengthening national condom programmes; 4) expanding provision of voluntary male medical circumcision; and 5) rapidly incorporating pre-exposure prophylaxis (PrEP). 11

18 Conscious efforts should be made by countries to extensively integrate HIV-prevention services with the prevention services of other diseases such as cancer and tuberculosis, as well as sexual and reproductive health care. Decision-makers need clear, effective and costed HIV combination-prevention packages with specific targets for implementation at the local level, that they can consider for investments. Where are we so far?: Revitalize HIV combination prevention in eastern and southern Africa region Since 2014, a call for regional action to revitalize HIV combination prevention has been rolled out in order to have a comprehensive and balanced AIDS response in countries to reduce new HIV infections. Countries such as Kenya, Zimbabwe, Namibia, Malawi, South Africa and Swaziland are championing revitalizing their HIV-prevention response at the local level. A snapshot of the actions taken thus far in order to drive the regional agenda is presented in the table below. Actions taken since 2014 End of 2014: UNAIDS, UNFPA and World Bank called for reinvigorating/revitalizing HIV combination prevention in ESA region. August 2015: Expert meeting on HIV prevention convened and collectively agreed on actions to be taken for revitalizing HIV prevention in ESA region. December 2015: Leadership session convened at International Conference on AIDS and STIs in Africa (ICASA), Harare, Zimbabwe, where revitalizing HIV prevention was emphasized. March 2016: As follow-up from ICASA, Government of Zimbabwe, under the leadership of Minister of Health, Zimbabwe, called for brainstorming meeting in Harare, and through a consultative process, regional road map was developed. May 2016: Government of Zimbabwe, under the leadership of Minister of Health, Zimbabwe, convened side ministerial meeting on side-lines of 69 th World Health Assembly in Geneva, Switzerland; obtained buy-in from some Health Ministers from ESA region and developmental partners on regional agenda, and regional road map (enclosed) was endorsed by participants. High-level meeting on implementation at the national and local levels: Revitalizing HIV combination prevention Implementation of the agenda to revitalize HIV combination prevention in countries is the next milestone on the regional road map. In order to move forward on this, a high-level meeting is planned to obtain commitments on actions and renewed strategies to reach specific targets on HIV combination prevention, increased investments and renewed accountability by implementing the agenda on revitalizing HIV combination prevention in countries. The high-level meeting is targeted at political leaders from Southern African Development Community (SADC) and East African Community (EAC) countries, representatives of civil society, communities, and representatives from development partners, with the following objective: Obtain commitments on actions and strategies to be implemented at the national and local levels to reach specific targets on HIV combination prevention, increased investments and renewed accountability. The expected results from this high-level meeting include: Agreed actions and strategies as commitments obtained in order to implement the agenda on revitalizing HIV combination prevention at the national and local levels. Technical focal person for further information: Jyothi Raja Nilambur Kovilakam, Senior Strategic Intervention Adviser, UNAIDS Regional Support Team, Rajaj@unaids.org 12

19 MILESTONE 12 Institutionalize regional agenda in regional entities with accountability. ENVISAGED CHANGE IN COUNTRIES Accountability shifts to accelerate implementation and scale-up of HIV combination-prevention services at local level. Increased investments for HIV combination prevention by countries. Result: Reduced new HIV infections to fewer than in the ESA region by MILESTONE 11 By December 2016 Countries document implementation scale-up and increased uptake of HIV-prevention services. July 2016 onwards MILESTONE 10 Countries demonstrate local leadership with accountability shifts and increased investments for HIV prevention. July 2016 onwards MILESTONE 9 Set national targets for reduction of new HIV infections; set targets for each pillar of HIV combination prevention at local level. July 2016 onwards MILESTONE 8 Mobilize more countries to drive regional agenda International AIDS Conference, Durban July and beyond MILESTONE 7 Launch ESA high-level political advocacy platform for revitalizing HIV combination prevention July December 2016 MILESTONE 6 Regional road map for revitalising HIV prevention in ESA region MILESTONE 1 Call brainstorming meeting between selected partners in Harare, Zimbabwe; agree on roadmap and identify r key players from r countries. MILESTONE 2 Govt of Zimbabwe from brainstorming meeting in UNAIDS regional technical consultation towards UN High- Level Meeting on Ending AIDS 4-5 April 2016 MILESTONE 3 Produce strategic products/analysis on combination HIV prevention from 5 champion countries state-of-the-art and promising practices. March June 2017 MILESTONE 4 Chair/co-chair discuss regional agenda with SADC/EAC Health Ministers and obtain buy-in. World Health Assembly, May 2016 MILESTONE 5 Create platform to discuss regional agenda with civilsociety/community organizations for their buy-in. July 2016 Create platform to discuss regional agenda in High-Level Meeting in UN General Assembly June 2016 March 2016

20 UNAIDS Regional Support Team for Eastern and Southern Africa Merafe House 11 Naivasha Road Sunninghill 2192 unaids.org