Agenda 3: Country experiences and plans towards sustainable AIDS financing AIDS Funding Landscape in Asia and the Pacific J.V.R. Prasada Rao United Nations Secretary-General s Special Envoy for AIDS in Asia and the Pacific 17 September 2014, Hanoi, Viet Nam AHMM Side Meeting: Advocacy on Sustainable Financing for HIV/AIDS Response in ASEAN Member States
Transition time in the HIV and AIDS response in Asia and the Pacific Approaching the target date for the Millennium Development Goals and it is time to look forward to the next 10 years. What is achievable in the context of a shrinking donor pie? How can countries maintain progress and improve efficiency and quality? What are the new goals?
Mixed progress : Declining and rising new infections across countries in Asia and the Pacific 5,000 Cambodia 20,000 Myanmar 5,000 Nepal 0 2005 2013 2,000 Philippines* Number Number Number Number 0 2005 2013 0 2005 2013 100,000 Indonesia 15,000 Pakistan Number Number 0 2005 2013 0 2005 2013 0 2001 2012 *2012 Estimates for UNAIDS Report on the Global Epidemic 2013. Source: Prepared by www.aidsdatahub.org based on UNAIDS 2013 Estimates for UNAIDS. (2014). The Gap Report.
HIV infection estimates and AIDS-related deaths in ASEAN countries, 2013 Rank Country People living with HIV Country New HIV Infections Country AIDS related deaths 1 Indonesia 640,000 Indonesia 80,000 Indonesia 29,000 2 Thailand 440,000 Viet Nam 14,000 Thailand 18,000 3 Viet Nam 250,000 Thailand 8,200 Viet Nam 12,000 4 Myanmar 190,000 Malaysia 8,000 Myanmar 11,000 5 Malaysia 86,000 Myanmar 6,700 Malaysia 5,900 6 Cambodia 75,000 Philippines* 1,800 Cambodia 2,200 7 Philippines* 15,000 Cambodia 1,300 Philippines* <500 8 Lao PDR 5,800 Lao PDR <500 Lao PDR <200 9 Brunei Brunei Brunei... 10 Singapore... Singapore... Singapore... * 2012 estimates Source: Prepared by www.aidsdatahub.org based on UNAIDS. (2014). The Gap Report; and UNAIDS. (2014). HIV Estimates 2013
HIV prevalence (%) HIV prevalence among key populations, ASEAN 2011-2013 50 45 40 35 30 25 20 15 10 5 0 36.4 24.8 8.5 7 4.6 2.1 Men who have sex with men People who inject drugs Female sex workers 46.1 25.2 18.9 18.7 1 12.6 10.4 11.6 8.1 7.1 4.2 3.3 3.7 2.2 0.3 2.6 *Weighted adjusted average for FSW; MSM and FSW 2010 data; PWID 2012 data; **FSW 2011 data; *** PWID 2012 data 5 Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org,hiv Sentinel Surveillance Reports and Integrated Biological and Behavioral Surveillance Reports
National prevalence masks high prevalence geographical areas HIV prevalence among key populations in geographical areas HIV prevalence (%) 40 35 30 25 20 15 10 5 Men who have sex with men 6.5 6.6 14.8 5.5 6.6 Female sex workers 18.6 12.1 10 22 Transgender 30.8 24.7 9.3 0 Note: Countries with national HIV prevalence less than 5% for MSM and FSW. For TG, any available high prevalence geographical locations are included. National HIV prevalence among PWID is higher than 5% in all ASEAN countries that have data *Direct FSW; **Indirect FSW Source: Prepared by www.aidsdatahub.org based on HIV sentinel surveillance reports and integrated biological and behavioral surveillance reports
HIV in Asia and the Pacific region is concentrated among key populations especially in urban areas which is where resources should be spent 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% Cities Female sex workers Viet Nam, 2.7% Hanoi, 23% National Source: Prepared by www.aidsdatahub.org based on HIV sentinel surveillance reports, integrated biological and behavioral surveillance reports and www.aidsinfoonline.org
Source: Prepared by www.aidsdatahub.org based on HIV Sentinel Surveillance Reports and Integrated Biological and Behavioral Surveillance Reports ASEAN countries/cities with rising HIV prevalence trend among MSM, 2002-2013 40% 30 20 10 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Indonesia Philippines (Metro Manila) Indonesia (Jakarta) Philippines (Cebu) Thailand (Bangkok)
HIV prevalence is high among key populations in cities in Asia and the Pacific
Strategic city responses can impact ending AIDS nationally condom promotion in city brothels in Thailand spearheaded a national decline New HIV infections in Thailand, Asian Epidemic Model 1985 2030: 180,000 Clients Male IDU MSW MSM NI FSW Low-risk males Low-risk females 160,000 140,000 120,000 100,000 80,000 60,000 10,000 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 40,000 20,000 0 1985 1990 1995 2000 2005 2010 2015 2020 2025 2030 Prepared by www.aidsdatahub.org based on personal communication from S. Sarkar, UNAIDS
Rising need for treatment- rising need for resources New data analysis demonstrates that for every 10% increase in treatment coverage there is a 1% decline in the percent of new infections among people living with HIV In 2013, 4.8 million people living with HIV in Asia and the Pacific but only 1.56 million people are on treatment, 33% of all people living with HIV in Asia and the Pacific. Source: UNAIDS. (2014). The Gap Report
ASEAN focus: 527,000 people received ART in 2013, expanding but with a slow pace Number of people receiving ART 600,000 500,000 400,000 300,000 200,000 100,000 526,746 13% increase between 2012 and 2013 12% increase between 2011 and 2012 0 2004 2006 2008 2010 2012 2013 Note: Trend data not available for Brunei and Singapore Source: Prepared by www.aidsdatahub.org based on 1) UNAIDS. (2014). The Gap Report; 2) UNAIDS. (2014). HIV Estimates 2013; and 3) www.aidsinfoonline.org;
AIDS Funding Landscape in Asia Assessment and Projections
AIDS Funding Landscape Panel Objective : To understand policy and funding commitments for national HIV/AIDS responses in the region in order to help guide the next decade s response When : First convened in August 2013 to review progress in the regional fight against HIV in the context of the changing global economy Who : Experts and policy leaders Chair : UN Secretary-General s Special Envoy for AIDS in Asia and the Pacific Research team : With support from the World Bank, the panel engaged a team at Kirby Institute, New South Wales University, Australia to conduct background research
Processes Selected countries : Myanmar, Indonesia, Thailand, Papua New Guinea, and Viet Nam Discussion areas : Assess the national funding landscape for HIV prevention and treatment programs Identify economic, institutional, political and other conditions that are required to effectively and efficiently use financial resources for HIV response Identify challenges and strengths of countries capacity to effectively and efficiently use financial resources for national response Generating solutions for a) capacity building, b) leveraging additional fiscal resources and/or sustaining adequate funding for national responses to HIV.
Shared responsibility: ASEAN focus HIV expenditure from domestic sources, ASEAN, latest available year, 2011-2013 % Malaysia (2013) Thailand (2011) Indonesia (2012) 0 25 50 75 100 96 85 42 Philippines (2013) 40 Upper middle income Viet Nam (2012) Cambodia (2012) 10 32 Lower middle income Low income Myanmar (2011) 9 Note: AIDS spending data is not available for Brunei and Singapore Lao PDR (2011) 7 Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org
The Global Fund and PEPFAR are the most important international funders in the region Million US$ $400 $350 $300 $250 $200 $150 $100 $50 International funding for HIV response in Asia Pacific, 2005-2012 Global Fund to Fight AIDS, Tuberculosis and Malaria United States President`s Emergency Plan for AIDS Relief (PEPFAR) Development Banks European governments Other OECD-DAC governments $- 2005 2006 2007 2008 2009 2010 2011 2012 Other sources Source: Countries progress reports, OECD CRS, UNAIDS estimates
The Global Fund provides significant funding to countries in Asia and the Pacific Global Fund country allocations for HIV/AIDS, select countries 600,000,000 $ 450,000,000 300,000,000 2008-2010 2011-2013 2014-2016 150,000,000 0 Indonesia (LMIC) Pakistan (LMIC) Philippines (LMIC) Countries with increasing new HIV infections India (LMIC) Thailand (UMIC) Viet Nam (LMIC) Myanmar (LIC) Countries with decreasing new HIV infections Source: Prepared by www.aidsdatahub.org based on http://web-api.theglobalfund.org/datasets/index/ and UNAIDS. (2013). Global Report: UNAIDS Report on the Global AIDS Epidemic 2013.
International donors are contributing most of the prevention costs ; too much is going toward overhead 400 350 300 AIDS spending by category and financing source in Asia and the Pacific, latest available year, 2009-2012 20% Most domestic contributions go toward care and treatment Million US$ 250 200 150 100 50 0 80% 76% 72% 24% 28% Care and treatment Prevention Programme and administration Domestic (public) International Far too much is spent on programme/administration 68% Incentives and human resources Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org
Most of the targeted programs for key populations are funded by external sources Proportion of funding for programmes targeting key populations by source 5% Domestic resources International donors Men who have sex with men 95% 6% Sex workers and their clients 94% 18% People who use drugs 82% Source: www.aidsdatahub.org
Most countries spend far too much on general prevention Proportion of prevention spending by category, 2009-2011 Philippines (2011) Indonesia (2010) Cambodia (2009) Viet Nam (2010) Lao PDR (2011) Thailand (2011) Malaysia (2011) Myanmar (2011) General prevention and others Youth Prevention mother-to-child People who inject drugs Sex workers and their clients Men who have sex with men 0% 20% 40% 60% 80% 100% Source: www.aidsdatahub.org based on www.aidsinfoonline.org
AIDS spending in ASEAN countries by major spending categories and prevention spending on key populations, latest available year, 2010-2012 160 14% 3% 7% 22% 140 120 Million US$ 100 146 80 54% 60 40 Prevention spending Care and treatment spending Programme management and admin Incentives for human resources Others Total prevention spending 50 Key populations prevention spending 22 17 11 Spending on people who inject drugs Spending on sex workers and clients Spending on men who have sex with men 20 - Note: AIDS spending data is not available for Brunei and Singapore Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org
Total care and treatment and ART spending by financing source in ASEAN countries, latest available year, 2010-2012 Million US$ 400 International 350 71 Domestic public 300 250 200 150 100 50 297 40 182 60% of total care and treatment spending - Total care and treatment spending Spending on ART Note: AIDS spending data is not available for Brunei and Singapore 23 Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org
Potential economic growth of low-and middle-income ASEAN member states; possibility of shifting responsibility for HIV financing to domestic sources GDP per capita US$ 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 11387 Projected economic growth in select Asian countries, in per capita GDP 5450 16,417; Malaysia 7,023 ; Thailand 4,638 ; Philippines 4,638 ; Indonesia 3417 2,780 ; Vietnam 2935 2073 2,493 ; Lao PDR 1567 1,614 ; Cambodia 1088 910 1,325; Myanmar 2014 2015 2016 2017 2018 2019 Upper middle income Lower middle income Low income Source: Prepared by www.aidsdatahub.org based on IMF projections and the World Bank income level classification
The Global Fund s NFM may take resources out of lower middle income countries that have large populations of poor people who are infected and affected by HIV Ability-to-pay factor Ability-to-pay factor Eligible countries as of 2013 Counterpart financing thresholds Indonesia Pakistan Papua New Guinea Philippines Viet Nam LMIC with GNI per capita between 1,300-3,600 GNI per capita, Atlas method Source: The Global Fund. (March 2014). Overview of the allocation methodology (2014-2016) : The Global Fund s new funding model and World Bank
Financial Transition Plans To show their path toward self-sufficiency, or in the case of the low-income countries, their path toward increased use of domestic resources, countries could develop financial transition plans. In order to successfully combat HIV, resources must be directed to the communities not the countries where the virus lives. Global Fund to consider eligibility rules that ensure key populations are not left behind and that community based prevention programmes continue to get assured funding
Financing systems should acknowledge the growing role of cities Innovative financing for cities based response Facilitate twinning and south to south approaches for cities Better and improved systems for tracking epidemic and real time corrective action Improved partnership between civic authorities, communities and private sector for effective delivery
Making human rights work for the AIDS response Countries must commit to ushering in a more friendly legal environment for key populations at higher risk to protect their right to health and well being Critical funding for HIV-related legal and human rights remains insufficient. A UNAIDS survey in 2014 showed that 59% of the civil society organizations implementing human rights programmes are reporting decreases in funding Nearly 70% of the organizations are not accessing domestic funding for their activities Source: UNAIDS. (2014). The Gap Report
Although there is evidence of progress, majority of countries in the region have laws that drive key populations underground Asia- Pacific ASEAN 37 10 11 9 15 8 19 4 criminalize some aspect of sex work compulsory detention centres for people who use drugs provide for the death penalty for drugrelated offences criminalize same-sex relations
Funding gap in ASEAN Regional resource need to reduce new infections and death to attain virtual elimination of MTCT to reduce disease burden among key populations = US $ 1 250 million annually Resources available = US $ 730 million annually Resource gap = US $ 520 million annually Source: Prepared by www.aidsdatahub.org based on Kirby Institute. (2014). AIDS Funding Landscape in Asia and the Pacific (3 rd Sept 2014, unpublished report)
Ending AIDS by 2030 ASEAN countries can substantially reduce new HIV infections and AIDS related mortality by 90% to achieve the goal of ending AIDS by 2030 with smarter investments and effective programming.
Thank you