1. Manoela Manova
Regional Support Team for Eastern
Europe and Central Asia

2. Outline
• Fast Track
• Rationale for investment approach
• Key messages in applying the Investment approach
• What is Investment Approach and Investment case
• What did we learn from IC implemented so far?
• What’s the meaning of transition funding

3. • Reaching 90/90/90 target - HIV Testing and treatment
delivery
• Intensified Combination Prevention
• Focus on Cities/ location and population programming
• Human Rights and Zero Discrimination
• Global Plan/EMTCT
• Focus, Innovation, Cost savings
• Ownership, accountability, leadership

4. «90-90-90» - ambitious target aimed at ending AIDS
In 2020
90% of all people
living with HIV will
know their HIV status
In 2020
90% of all people
diagnosed with HIV will
receive sustained
antiretroviral therapy
.
In 2020
90% of all people receiving
antiretroviral therapy will be
virally suppressed

5. 15
Benefits of fast-tracking the AIDS response in low- and middle-income countries

6. A SHORT FIVE-YEAR WINDOW

7. CHOOSE THE WORLD YOU WANT TO SEE IN 2030
BUSINESS AS USUAL ACCELERATED RESPONSE
2.5 million new adult HIV infections 0.2 million new adult HIV infections

8. What does it take?

9. Fast-Track the AIDS Response by 2020
Unprecedented Opportunity for HIV Prevention
5 BILLION
CONDOMS EVERY YEAR
3 MILLION
PEOPLE ON PrEP
2 MILLION YOUNG
PEOPLE
CASH TRANSFERS
20 MILLION KEY
POPULATIONS
HIV SERVICES
10 MILLION MEN
(ADDITIONAL) MALE
CIRCUMCISIONS
25 MILLION
PEOPLE ON ART
(90-90-90)

10. Title Slide: title in 24 point Arial
regular
Estimating resource needs for 90-90-90 in Low and Middle Income Countries
Resource Needs for Care and Treatment
Service Uptake is Linked to KP Outreach Targets;
Treatment Coverage and Quality depends on Programme and Social Enablers
$0
$5,000
$10,000
$15,000
$20,000
Resource Needs Millions of US$
ART
PreART
Testing
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
Resource Needs Millions of US$
Health Systems Strengthening
Community Mobilization
Social Enablers
Program Enablers
PrEP
Prisoners
OST
PWID
Transgenders
MSM
SW
ART
PreART
Testing

11. Resource Needs for Ending AIDS by 2030 are the sum of resources to maintain
coverage rates as in 2013 and the additional funding to attain ambitious targets.
0.9 0.9 0.9 0.9
0.6
1.0
1.3
1.5
0.0
0.5
1.0
1.5
2.0
2.5
3.0
2015 2017 2020 2030
Billions
Eastern Europe and Central Asia
Constant Coverage Resource Gap

12. -
2.0
4.0
6.0
8.0
10.0
12.0
14.0
$-
$100
$200
$300
$400
$500
$600
$700
2015 2020 2030
Sex Workers
Resource needs (millions)
Persons to reach (millions)
-
5.0
10.0
15.0
20.0
$-
$200
$400
$600
$800
$1,000
2015 2020 2030
Men who have sex with men
Resource needs (millions)
Persons to reach (millions)
-
2.0
4.0
6.0
8.0
10.0
12.0
14.0
$-
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
$4,000
$4,500
2015 2020 2030
People who inject drugs
Persons on Therapy
(millions)
Persons to reach
(millions)
Resource needs: OST
(millions)
Resource needs:
outreach (millions)
-
2.0
4.0
6.0
8.0
10.0
12.0
$-
$200
$400
$600
$800
$1,000
$1,200
$1,400
$1,600
$1,800
$2,000
2015 2020 2030
Pre-Exposure Prophylaxis
for MSM, FSW and Adolescents
Persons to reach
Adolescents
Persons to reach KP
Resource needs (millions)
Reaching out for Key Populations
Global targets for key populations
The key to attain 90-90-90 is effectively engaging key populations and communities

13. 1.13
3.60
2.41
1.50
0.69
0.10
3.97
12.39
10.10
6.58
2.67
1.09
Children
SDC
Multiple partners
FSW+clients
MSM
PWID
New infections by Group (Millions)
2015 - 2030
Constant Targets
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000
450,000
New HIV Infections in Key Populations
Ambitious Targets 2015 - 2030
FSW+clients MSM PWID
The impact of ambitious targets
A sharp reduction in new infections for all risk groups

14. 0 5 10 15 20 25
Total R. Need
Total Expenditure
Million USD
Total resource need and expenditure for CSW, MSM and PWID for a group of 6 countries in 2012 -
Armenia, Georgia, Kazakhstan, Kyrgyzstan, Moldova and Uzbekistan. Source: UNAIDS Investment
framework ,GARPR 13.
Underinvestment in Key Populations
Financing Gap for CSW, MSM and PWID in 6 selected
Eastern European countries, 2012

15. Investment approach and Investment case

16. SYNERGIES WITH DEVELOPMENT SECTORS
Social protection; Education; Legal Reform; Gender equality; Poverty reduction; Gender-based violence;
Health systems (incl. treatment of STIs, blood safety); Community systems; Employer practices.
CRITICAL
ENABLERS
Social enablers
• Political commitment &
advocacy
• Laws, policies &
practices
• Community
mobilization
• Stigma reduction
• Mass media
• Local responses, to
change risk
environment
Programme enablers
• Community-centered
design & delivery
• Programme
communication
• Management & incentives
• Production & distribution
• Research & innovation
Care &
treatment
Male
circumcision
Keeping more
people alive
BASIC PROGRAMME ACTIVITIES
Key
populations
Children &
mothers
Condoms
RETURN
Less new
infections
Behaviour
change
The Case for Optimized Investments

17. Investment Aproach as Key Opportunity to Optimize for
Impact
1. Correct the mismatches between the epidemic and response
2. Focus – geographic, key populations, human rights, etc.
3. Look for allocative efficiencies and efficiencies in the
implementation – e.g. avoid systems duplications, scale
constraints, service delivery configuration (community
services), parallel systems (procurement)
4. Sustainability – manage fiscal space, and domestic and
international finance flows for predictability and sustained
results.

18. International resources for HIV have been flat since 2008
Source: UNAIDS, 2012
0
2
4
6
8
10
12
14
16
18
20
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
International assistance
US$billions

19. Middle-income countries have steadily invested more
of their own resources in HIV
Source: UNAIDS, 2012
0
2
4
6
8
10
12
14
16
18
20
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
International assistance
US$billions
Domestic resources in low-
and middle-income countries

20. Total resources continue to grow, but fall short of total needs
Source: UNAIDS, 2012
0
2
4
6
8
10
12
14
16
18
20
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
International assistance Total resources available,
with estimated range
US$billions
Domestic resources in low-
and middle-income countries

21. Key message 1:
Every dollar spent on AIDS is an investment not
expenditure and countries can make important gains if
they invest wisely, now

22. Key message 2:
Focus on what makes a difference - Investing
resources strategically for greater impact

23. Using a geographic approach to prioritize
investment – Thailand - location
• Thailand: Thailand intends to scale up
combination prevention , including the
strategic use of antiretroviral medicines, with
enhanced focus on the 27 provinces that
represent 70% of all new HIV
infections among key populations

24. Morocco: Reallocating to invest where the epidemic is
Source: Morocco Ministry of Health, National STI/HIV Programme, HIV modes of transmission in Morocco. August 2010.
General
population
Sex workers
and clients
MSM IDU Key populations
(other)
Percentage(%)
80
0
Proposed spending, National
Strategic Plan for 2012–2016
People acquiring HIV
infection (2009)
Spending on HIV
prevention (2008)

25. Source: UNAIDS
Number of new HIV infections
300 000
1980 1990 2000 2010
Russian Federation
Brazil
Investing smart is a choice

26. Eastern Europe and Central Asia
Concentrated HIV epidemics, in particular in PWID
HIV prevalence in selected
populations in
Eastern Europe and
Central Asia, 2011
Source: UNAIDS 2012

27. Spending on harm reduction for IDUs of total response
(International & Public/ domestic Funding without private)
Country Year
% spending on harm reduction
for IDUs of total response
(International & Public/
domestic Funding without
private)
Armenia 2011 8%
Azerbaijan 2011 4%
Belarus 2011 9%
Georgia 2011 23%
Kazakhstan 2011 7%
Kyrgyzstan 2011 7%
Republic of Moldova 2011 8%
Russian Federation 2008 1%
Tajikistan 2011 9%
Ukraine 2010 5%
Uzbekistan 2011 5%

28. Key message 3:
Address service delivery, cost drivers and bottlenecks to
scale up

29. Successful country initiatives to lower ARV costs
Country Action Savings
South Africa • Revised tender process to increase competition
• Pooled procurement across provinces to achieve
economies of scale
• Improved price transparency
$640 million over 2 years
Uganda • Ring-fenced ARV funds
• Regularly monitored ARV market prices
• Promptly switched to approved generics
$1.3 million between 2006 and
2007
Swaziland • Revised ARV tender process, included ceiling prices,
supplier performance and more reliable quantification
methods
$12 million between January
2010 and March 2012
Nigeria • Coordinated with PEPFAR implementing partners for
ARV planning, purchase, shipping and distribution of
ARVs.
• Transferred ARVs between partners to avoid stock-
outs, costly emergency orders and wastage due to
expired drugs
$2.8 million in drug costs since
May 2010
Brazil • Implemented compulsory license for the manufacture
of efavirenz
$95 million

30. Practical Quick Savings that can be made
Number of Patients on
ART in Russia
Average Cost of ART drugs
per patient per year in USD
paid by Russia
TOTAL costs of ART drugs
per year (in USD)
160,000 2,500 400,000,000
Number of Patients on
ART in Russia
Cipla Cost of ART drugs per
patient per year in USD
TOTAL costs of ART drugs
per year (in USD)
160,000 225 36,000,000
What could be yearly
savings for the Government
of Russia
364,000,000
How many patients could
the Government treat
with the same yearly
allocation if using Cipla
prices
Cipla Cost of ART drugs per
patient per year in USD
TOTAL costs of ART drugs
per year (in USD)
1,777,778 225 400,000,000

31. Practical Quick Savings that can be made
Number of Patients on
ART in Russia
Number of VL per
patient per year
Approximate Price paid
by Russian Government
for one VL (in USD)
TOTAL costs of VL paid by
Russia per year (in USD)
160,000
4
69 44,160,000
Number of Patients on
ART in Russia
Number of VL per
patient per year
Reduced VL price
For e.g. Roche Global
Access initiative price (in
USD)
TOTAL costs of VL paid by
Russia per year (in USD)
160,000
2
10 3,200,000
What could be yearly
savings for the
Government of Russia 40,960,000

32. Unit expenditure benchmarking: PEPFAR: Use of Expenditure
Analysis Results for Partner Management to Improve Efficiency
Goal to ensure IPs that are providing similar services/support are adopting best
practices and using PEPFAR resources optimally
Step 1: Identify outliers
Step 2: In–depth analysis
to identify cost drivers
Step 3: Agreement to
lower UE by $X in
coming year by
decreasing
expenditures or
increasing targets
Source: PEPFAR Finance and Economics Work Group

33. Regional averages of Unit Costs for Prevention Interventions
in EECA: much higher than projected global costs
0.0
20.0
40.0
60.0
80.0
100.0
120.0
2009 2015 2009 2015 2009 2015 2009 2015 2009 2015
Sex Worker
Outreach
Counseling & Testing IDU Outreach &
NSEP
MSM Outreach STI Treatment
Eastern Europe Global Average
Source: Bollinger & Stover, 2009
USD

34. Integrated services are more efficient
USD
0
5
10
15
20
25
30
35
40
Kenya (2002) Kenya (2008) India (2007) Uganda (2009)
stand-alone C&T (e.g. HIV clinics)
C&T integrated (e.g. SRH/FP or PHC clinics)
The example of VCT: Costs per client
Stand-alone VCT clinics
Integrated into SRH services

35. Key message 4:
Making HIV responses sustainable is a shared responsibility

36. OECD countries can afford to do more
2010 overseas development assistance as a share of Gross National Income
0.12%
0.15%
0.17%
0.20%
0.21%
0.26%
0.29%
0.32%
0.32%
0.33%
0.38%
0.41%
0.43%
0.50%
0.53%
0.55%
0.56%
0.64%
0.81%
0.90%
0.97%
1.09%
1.10%
0.0% 0.7%
Korea
Italy
Greece
Japan
United States
New Zealand
Portugal
Australia
Austria
Canada
Germany
switzerland
Spain
France
Ireland
Finland
United Kingdom
Belgium
Netherlands
Denmark
Sweden
Luxembourg
Norway
0.12%
0.15%
0.17%
0.20%
0.21%
0.26%
0.29%
0.32%
0.32%
0.33%
0.38%
0.41%
0.43%
0.50%
0.53%
0.55%
0.56%
0.64%
0.81%
0.90%
0.97%
1.09%
1.10%
0.0% 0.7%
Korea
Italy
Greece
Japan
United States
New Zealand
Portugal
Australia
Austria
Canada
Germany
switzerland
Spain
France
Ireland
Finland
United Kingdom
Belgium
Netherlands
Denmark
Sweden
Luxembourg
Norway

37. Middle-income countries will provide more HIV resources
Note: Based on ability to pay, by income category, and allocation to HIV in line with disease
burden. Data sourced from the IMF and including UNAIDS projections.
0
5
10
15
20
25
2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
International
contribution
Low income
countries
Lower middle
Upper middle
(non-BRICS)
BRICS
US$billion

38. HIV investment case:

39. What Investment Approach (IA) and Investment case (IC) mean?
• Investment Approach is a process of rigorous examination of HIV
responses in terms of effectiveness, efficiency, and sustainability
• Investment case is the application of the HIV investment approach. IC is a
document based on investment logic and reviews of HIV responses in
terms of effectiveness, efficiency, and sustainability to estimate returns of
investments - new HIV infections averted and Deaths averted.
• IC is aimed to answer specific policy questions that are of high priority for
the country.
• IC provides different scenarios that allow the decision makers to weigh
various options and make informed decisions on funding for specified
outcomes.

40. Same Same, but Different – NSP -IC
• While there is significant overlap
between robust NSPs and
investment cases in the sense that
investment cases are also evidence-
based documents providing essential
information on the epidemiological
context, the current response, and
other key areas, a sound investment
case quantifies the returns on HIV
investments. NSPs rarely include
such an assessment. Investment
cases also have a longer-term
perspective (typically 10+ years),
which is crucial, as returns of
investments often occur beyond the
5-year horizon of a NSP.

41. An investment case answers 8 critical questions
UNDERSTAND
DESIGN
DELIVER
SUSTAIN
▪ Introduction: Why an investment case now?0
▪ What is the current state of the epidemic? And how is that
expected to change?
1
▪ Where are we focusing our efforts and resources today? What is
the current impact? And where does the money come from?
2
▪ What programme elements are required and at what scale for an
optimal response?
3
▪ What would the impact of this optimal programme be?4
▪ How much money will be needed for HIV in the future and what
are the net savings over time?
6
▪ What bottlenecks and inefficiencies can be addressed and how?5
▪ What financing options are available to close any remaining
financing gap once efficiency gains are achieved?
7
▪ How will you guarantee stakeholder buy-in and operational
excellence required?
8
INVESTMENT CASE TOOL

42. Your investment case should allow
you to complete this summary pageExample output: Improved HIV response
WHAT IS AN INVESTMENT CASE?
Net savings
(through treatment and
hospitalization costs
averted)
$600 million
Current programme
85,000
Resource needs for
business as usual over
the next decade (based
on current plan)
Total
number of
new
infections
averted
$600 million
98,000
Total
number of
deaths
averted
Optimal programme
Costs required over the next
decade for optimal investment
of resources (accounting for
enhanced investments and
efficiency gains)
$900 million
deaths averted
135,000
Total number
of new
infections
averted
176,000
Total number
of deaths
averted
1,165
Cost /
infection
averted
ILLUSTRATIVE

43. Optimal allocation
o Depends on objective
o Minimizing new infections is only one objective
o Different objectives = different allocations
o Universal access to HIV services and Equality in access
to prevention services and health care across all groups
is a different objective
o Other governing principles and strategies are important
that achieve different objectives

44. What we do in the region to improve the value for
money
• We promote the Investment approach and develop
investment cases
• We conduct Allocative Efficiency Analysis
• We plan technical efficiency studies to identify the most cost
efficient service delivery models
• We engage in ART and VL tests price reduction negotiations
• We estimate resource and service gaps to scale up to 90-90-
90 targets in the region

45. Kazakhstan Allocative Efficiency Findings
Optimize spending towards national and ambitious targets
National targets - keep the HIV new infections/deaths in 2020 at 2014 level
Ambitious targets - reduce HIV new infections/deaths by 2020 to 50% of 2014 levels

46. New HIV infections under different
investment scenarios

47. Total number of AIDS-related deaths over time

48. Number people receiving treatment

49. Kazakhstan Allocative Efficiency Findings
With current ART prices Kazakstan cannot achieve
national targets with current funding, even if
optimally allocated
However, reducing ART three-fold would allow to
achieve the ambitious targets with existing
funding (and 20% efficiency gains

50. Countries can achieve more with less – example of Armenia
Expected impact of different resource allocations
75 additional
HIV infections
124 averted
HIV infections
20% reduction in infections would occur
with a 22.2% decrease in overall funding
if allocated optimally

51. Conclusion: What did we learn?

52. Challenges, emerging lessons and recommendations
for moving forward
• IC - Inherently political process that requires difficult decisions
regarding resource allocations.
• Vested interests that have previously leveraged their political
power to capture a share of resources may resist efforts to re-
think resource allocations or expose decisions about allocations
to rigorous examination.
• The measure for success - ensuring that tough decisions are
actually implemented.

53. Challenges, emerging lessons and recommendations
for moving forward
• Capacity challenges - Most countries are currently relying on
external experts for modelling, estimation, projections and economic
analysis: an approach that is clearly not sustainable over the long
run.
• Moreover, decentralisation, strengthening community systems and
eliminating parallel service systems – while beneficial from the
standpoint of the long-term return on investment – will often
require considerable start-up costs and will not be achieved
overnight.
• Currently, a major gap in available evidence in many countries
concerns the actual costs of HIV services.

54. Transition funding possibilities

55. What’s the meaning of transition?
• From a context in which central/local governments and
the Fund supply jointly a predominant majority of funding
for the national AIDS response
• To a context in which central/local governments alone
supply a predominant majority of funding for the national
AIDS response.
• The key risk that the transition plan is meant to mitigate
maintain the variety, scope, and scale of HIV prevention
and treatment programs and that the implementation
capacity that delivers the services funded by the Fund is
used by the governments.

56. Romania’s fate!?
• Ineligible since Round 7. Disbursements
stopped in 2010.
• Coverage of PWID fell from 76% in 2009 to
49% in 2011. Nearly all NEPs had to close by
mid-2013.
ROMANIA 2010 2011 2012 2013
New HIV cases in IDU 9 116 170 149
New HIV cases in MSM 45 78 69 72
HIV rate per 100,000 general
population
1.4 2.1 2.4 2.5
Source: ERHN, ECDC

57. Why not Russia’s fate!?
• Applied under NGO rule in 2014
• As of 1 January 2015, previously funded by
GFATM programs, i.e., 30 NSP prog. (27,000
clients), 5 CSW prog. (3,350 clients), 5 MSM
prog. (4,200 clients) will cease to receive
commodities and funds.
• As of 1 November 2014:
• 864 394 registered HIV cases
• 63 863 newly registered in 2014
• 58,4% due to injecting drug use
Source: GFATM, Russian Federal AIDS Centre

58. What the transition plan is meant to?
• Rules are different for GFATM and public funds
• Parallel systems
• Not necessarily bad, if both can deliver
complimentary services, have two different
sources of funding that cannot be unified
• Collapse if one cannot do what the other can,
and should one of the two disappear
• To help public health systems learn to fund
what GF funds

59. Critical leverage point
• Transition is a tailor-made process
• Critical leverage point: counterpart financing
• Ability to spend public monies on the same
program as the Global Fund – a true stress
test of recipient countries’ readiness to
graduate.
• Graduation is not optional

60. Pillars of graduation
• Legislative acts & normative documents
that enable central/local governments
spend public funds:
• on HIV prevention in key populations
& settings
• to purchase services of NGOs to
prevent HIV in key populations

61. Government & International funding
for ART & Prevention in 2012
$0
$5,000,000
$10,000,000
$15,000,000
$20,000,000
$25,000,000
Prevention
ART
Prevention
ART
Prevention
ART
Prevention
ART
Prevention
ART
Prevention
ART
Uzbekistan Belarus Moldova Kazakhstan Romania Turkey
international
public
Source: GARPR 2013

62. Public funds to purchase services of
NGOs
• Laws and implementation mechanisms exist in
many countries but:
–May not apply to HIV prevention (Belarus)
–No implementation mechanism (Moldova)
–Will need constant modification during
“learning” period (Kazakhstan)

63. In order to make a breakthrough
in AIDS response we need to
“Maximize the effectiveness of existing tools
to virtually eliminate progression to AIDS,
premature death and HIV transmission, and
thereby transform the HIV/AIDS pandemic into a
low level sporadic endemic.”