Ending the AIDS epidemic by 2030

Ending the AIDS epidemic by 2030 Steven J. Kraus Director UNAIDS Regional Support Team, Asia and the Pacific for the UNAIDS Regional Management Meeting 25 th October 2014

Number Regional overview of trends in HIV infections and AIDS-related deaths 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 0 HIV and AIDS in Asia and the Pacific 1990-2013 4,800,000 1,700,000 610,000 350,000 250,000 210,000 2013 zoom-in People living with HIV 4.8 million Women living with HIV 1.7 million Young people living with HIV 610 000 New HIV infections 350 000 People living with HIV (Estimate) Children living with HIV (Estimate) New HIV infections Women living with HIV (Estimate) Young people living with HIV (Estimate) AIDS-related deaths (Estimate) Children living with HIV 210 000 Deaths 250 000 Source: Prepared by www.aidsdatahub.org based on UNAIDS 2013 Estimates for UNAIDS. (2014). The Gap Report.

New HIV infections have declined since 2001, but remain largely unchanged in last 5 years Number of new HIV infections 500,000 400,000 30% decline Estimate 2013: 350 000 2015 estimate based on trend of last five years: 355 000 300,000 200,000 FALLS SHORT OF TARGET BY 190 000 100,000 Target 2015: 165 000 0 2001 2004 2007 2010 2013 2015 New HIV infections Estimated trend to 2015 (current trend) 50% reduction by 2015 Source: Prepared by www.aidsdatahub.org based on UNAIDS 2013 Estimates for UNAIDS. (2014). The Gap Report.

New HIV infections among children PMTCT coverage Region lags behind the global average in eliminating new HIV infections among children Estimated new HIV infections among children in Asia and the Pacific, 2001-2013 40000 Elimination of mother-to-child transmission in Asia and the Pacific, 2011-2013 100 30000 29% decline since 2005 Global average 67% 20000 22,000 50 10000 New HIV infections among children 18% 19% 30% 0 2001 2005 2009 2013 0 2011 2012 2013 Source: Prepared by www.aidsdatahub.org based on UNAIDS 2013 Estimates for UNAIDS. (2014). The Gap Report.

Number of people receiving ART Treatment has accelerated, but still only half the people living with HIV likely to access treatment by 2015 Source: Prepared by www.aidsdatahub.org based on 1)UNAIDS. (2013). Global Report: UNAIDS Report on the Global AIDS Epidemic 2013.; 2) www.aidsinfoonline.org; and 3) UNAIDS.(2014). The Gap Report. 3,000,000 2,500,000 Estimated 2.4 million PLHIV will receive ART in 2015 at current pace of scale up 2,000,000 1,500,000 2013 estimate: 1.56 million 1,000,000 500,000 0 25% increase between 2012 and 2013 13% increase between 2011 and 2012 2003 2007 2011 2013 2015 Number of people receiving ART by 2013 Number of people receiving ART by 2015 (with current pace)

People on ART AIDS-related deaths (Number) Treatment saves lives: AIDS-related deaths are declining in Asia and the Pacific People receiving ART AIDS-related deaths, Asia and the Pacific, 2001-2013 1,560,000 400,000 26% decline since 2005 9 x increase since 2005 1.56 million 200,000 AIDS-related deaths [Estimate] 0 2005 2013 0 2001 2005 2009 2013 Source: Prepared by www.aidsdatahub.org based on UNAIDS 2013 Estimates for UNAIDS. (2014). The Gap Report.

Legal barriers to the HIV response remain in the 38 UN Member States in Asia and the Pacific 10 impose some form of HIV-related restriction on entry, stay or residence 37 criminalize some aspect of sex work 11 compulsory detention centres for people who use drugs 15 impose the death penalty for drug-related offences 18 criminalize same-sex relations

US$ million Domestic funding has increased to make up for leveling off of international financing $2,500 $2,000 Resources available for AIDS response in Asia and the Pacific, low-and middle-income countries (LMIC) $2.2 billion $1,500 $1.3 billion, 59% $1,000 $500 $0.7 billion $ 0.4 billion $0.9 billion $- $ 0.3 billion 2005 2006 2007 2008 2009 2010 2011 2012 Domestic sub-total International sub-total Resources available to LMICs in Asia and the Pacific Source: UNAIDS estimates 2012

Regional priorities to end the AIDS epidemic by 2030 No one left behind Key populations: PWID, MSM, SWs, TG, prison populations, migrants, women and girls, other (country-specific) City focus Reach the 90-90-90 Treatment Targets by 2020 Investment approach Enabling environment AIDS in the post-2015 development agenda

No one left behind

Countries that account for >90% PLHIV and new infections and high HIV prevalence in key populations = Yes New HIV infections (2013) People living with HIV (2013) India* 130,000 2,100,000 Indonesia 80,000 640,000 China* 48,000 780,000 Viet Nam 14,000 250,000 Pakistan 14,000 68,000 Thailand 8,200 440,000 Malaysia 8,000 86,000 Myanmar 6,700 190,000 Philippines 3,400 22,000 Papua New Guinea 2,200 32,000 Cambodia 1,300 75,000 Nepal 1,300 39,000 National HIV prevalence > 5 % among MSM National HIV prevalence > 5% among PWID National HIV prevalence > 5% among FSW Regional size estimates 11 million 3.5 million 4.4 million * 2011 estimates Source: Prepared by www.aidsdatahub.org based on UNAIDS Estimates 2013; Philippines HIV Estimations and Projections 2014 (Unpublished document); National HIV Sentinel Surveillance Surveys; and Integrated Biological and Behavioural Surveys

National prevalence masks high prevalence in localized geographical areas

HIV in Asia and the Pacific is concentrated among key populations, especially in cities HIV prevalence (national, %) HIV prevalence (city, %) 60 40 20 0 20 40 60 People who inject drugs Indonesia, 36% Jakarta, 56% Men who have sex with men Thailand, 7% Bangkok, 24% Female sex workers Viet Nam, 2.7% Hanoi, 23% Source: Prepared by www.aidsdatahub.org based on HIV sentinel surveillance reports, integrated biological and behavioral surveillance reports and www.aidsinfoonline.org

Prevention services are reaching key populations but are not scaling up fast enough to reverse the epidemic Prevention coverage (%) Number of needles /syringes per PWID per year 100 HIV prevention coverage among key populations (regional median trend*) 250 80 200 60 40 57 58 55 51 116 41 98 36 37 37 37 64 54 131 54 150 100 20 51 50 0 2010 2012 2013 2014 MSM MSW FSW PWID 0 * latest available data from UNGASS/ Global AIDS Response Progress Reporting (GARPR) 2010 to 2014 Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org

Ambitious, but achievable, new targets by 2020

The result 3 72% of all people living with HIV will be virally suppressed three-fold increase over current estimates

HIV testing is the entry point for treatment, but only around 1/3 of key populations know their HIV status HIV testing coverage (%) 100 HIV testing coverage among key populations, regional median, 2007-2013 80 60 40 35 34 40 20 24 0 Female sex workers Men who have sex with men Male sex workers People who inject drugs Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org

Treatment is expanding, but still only 1 in 3 PLHIV are on ART and most start late 67 57 49 46 45 Source: Prepared by www.aidsdatahub.org based on UNAIDS 2013 Estimates for UNAIDS. (2014). The Gap Report, and information provided by UNAIDS country offices for UNAIDS regional management meeting (RMM) 2014 CD4 count at ART initiation ART coverage among countries in Asia and the Pacific, 2013 Regional median CD4 at ART initiation 100% 80% 60% 40% 500 CD4 cells/mm 3 350 CD4 cells/mm 3 500 400 300 200 20% 0% 36 35 33 32 29 23 20 20 19 18 14 11 8 6 5 33 185 Regional median CD4 at ART initiation 100 0 Treatment gap ART coverage

% of estimated PLHIV on ART There are huge opportunities in cities to scale up treatment 100 90 80 70 60 50 40 30 20 10 0 ART coverage in cities Cities <5 million population Cities >5 million population R² = 0.0018 R² = 0.2228 0 2 4 6 8 10 12 14 16 18 City population size (millions) R-squared measures the degree of correlation between X and Y axes ART coverage = number of people on ART Total PLHIV Source: Prepared by www.aidsdatahub.org based on city posters prepared by the Data Hub and UNAIDS country offices as part of preparation for UNAIDS Management Meeting 2014.

Progress on laws since 2010 At least 11 punitive laws have been lifted, including: criminalization of same sex practices; of HIV transmission, exposure or non-disclosure; HIV-related discrimination in employment; HIV-related restrictions on entry, stay and residence; and compulsory detention of sex workers. At least 6 countries have increased legal protections for PLHIV or key populations: legal recognition of transgender persons; protection against discrimination on grounds of HIV status or sexual orientation; and protection of labour rights and freedom from violence for sex workers.

19 countries have conducted national reviews and/or consultations on legal barriers to access to services, resulting in prioritized action plans. WHO Guidelines for key populations now recommending decriminalization and protective laws Improved data on stigma and violence, including GBV Programmes to reduce stigma and discrimination and increase access to justice receiving increased attention through Global Fund NFM

Growing evidence: gender-based violence against SW, MSM and TG % Key populations who were forced to have sex, 2008-2012 50 40 Ever Last 6 months Last 12 months 41 30 29 28 22 20 13 15 16 10 0 Herat, Afghanistan (2012) Lao PDR (2008) 16 Terai Port Moresby, Highway PNG (2010) Districts, Nepal (2012) Port Moresby, PNG (2010) Fiji (2010-11) Kabul, Afghanistan (2008) FSW forced to have sex MSW forced to have sex TG SW forced to have sex MSM forced to have sex Source: Prepared by www.aidsdatahub.org based on IBBS 2008 (Lao PDR); IBBS 2012 (Afghanistan); IBBS 2012 (Nepal); Kelly, A., Kupul, M., Man, W. Y. N., Nosi, S., et al. (2011). Askim Na Save (Ask and Understand): People Who Sell and Exchange Sex in Port Moresby; Bavinton, B., Singh, N., Naiker, D. S., et al. (2011). Secret Lives, Other Voices: A Community-Based Study Exploring Male-to-Male Sex, Gender Identity and HIV Transmission Risk in Fiji.; Khan S., et al., Rapid assessment of male vulnerabilities to HIV and sexual exploitation in Afghanistan, March 2009 23

Prevention spending on key populations is heavily dependent on international financing sources Distribution of prevention spending by financing source in Asia and the Pacific, latest available year, 2009-2012 100% Total prevention spending Prevention spending on Sex workers and clients MSM PWID 80% International 60% 40% 20% Domestic public 0% Spending by service category is not available for India and China Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org

US$ million About half of AIDS spending is on care and treatment, mostly domestically sourced 24% 47% US$ 77 million International Domestic public 400 350 300 7% 250 4% 18% Prevention spending Care and treatement spending Programme management and admin US$ 300 million (80%) 60% of total care and treatment spending US$ 42 million US$ 184 million (80%) 200 150 100 50 Incentives for human resources Others Total care and treatment spending Spending on ART 0 Spending by service category is not available for India and China Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org

Investment cases on AIDS are guiding the response

Evidence-based investment cases have influenced AIDS responses in the region Thailand: Triggered paradigm shift from controlling AIDS to ending AIDS by 2030 Influenced priorities for GF NFM HIV grant; essential package of services in Thailand s Universal Health Coverage scheme National policy on ART for All regardless of CD4 count (1 Oct 2014) Myanmar: Set new targets for revised NSP for HIV/AIDS, 2011-2016 Treatment gap identified which helped mobilize US $ 5 million from Government the first time such a substantial allocation made Indonesia: Approval of $110 million Phase II GF HIV grant, Nov 2012-Jun 2015 Geographical prioritization of interventions in 30 major cities in National AIDS Strategy, 2015-2019 Being used to help country develop investment case for Ending AIDS ; integrate HIV into UHC schemes; explore funding opportunities at district level using local government funds

Post 2015 Agenda

Key processes feeding into the post-2015 development agenda Source: IPPF. (2014). Post-2015 made simple Shaping the future of sexual and reproductive health rights

Now is the time to influence and make a difference in the post-2015 development agenda Securing strong political commitment for ending AIDS by 2030 will spur progress on a range of development, gender equality and human rights challenges. Situating ending AIDS as critical to advancing global health in the post-2015 development agenda Ending AIDS: a beneficiary of and catalyst for human rights Leaving no one behind is critical to ending AIDS by 2030 Ending AIDS can be a catalyst for gender-transformative action which puts people at the centre of development

Ours can be the first region to end AIDS by 2030... but strategic actions are required NOW Innovation: let's put new science and knowledge to practice (e.g. early treatment initiation, community-based testing, PrEP for MSM) Implementation: prevention and treatment scale up to have a synergistic impact treatment coverage is still below 1 in 3 PLHIV SimpliCity: Over 1 million PLHIV live in 20 Asian cities the region's cities must be engines of progress, change and rapid scale up Managing transition: the region's transition to domestic financing will require us to invest resources wisely, or we may lose all our gains to date Human rights: new WHO guidance is very clear no rights is all wrong! Urgency: nearly 1000 people get infected every day in our region! Emerging epidemics in "stable" countries such as India demand immediate action

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