Latin America/Caribbean State of the Art

HIV/AIDSPart Deux

Paul R. De Lay, M.D.

Chief, HIV/AIDS Division

Global Bureau

USAID

March 13, 2001

HIV/AIDS

• The Expanded Response

• Major Challenges/Issues– PMTCT– Condom supply– OVC– Care and Support

HIV/AIDS and Infectious Disease FundingHIV/AIDS and Infectious Disease FundingFY 1993-2001 FY 1993-2001

($ millions)($ millions)

0

50

100

150

200

250

300

350

1993 1998 1999 2000

HIV/AIDS (all accounts) Infectious Diseases (CSD account)

•FY 2000 LIFE Initiative: An additional $100 million for an Interagency USG program with USAID, CDC, and DoD

•Four Program Elements: Primary prevention Caring for children affected by AIDS Home and community based care and treatment Capacity and infrastructure development

Evolution of the HIV/AIDS Rapid Response

FY 2001: USAID Receives $330 million for HIV/AIDS

Expanded Response Elements target for 2007:

• Reduce HIV Prevalence rates among those 15-24 years of age by 50% in high prevalence countries

• Maintain prevalence below 1% among 15-49 year olds in low prevalence countries

Evolution of the Rapid Response

Targets continued:• Ensure that at least 25% of HIV/AIDS infected mothers in high prevalence countries have access to interventions to reduce HIV transmission to their infants

•Help local institutions provide basic care and support services to at least 25% of HIV infected persons and to provide community support services to at least 25% of children affected by AIDS in high prevalence countries

Evolution of the HIV/AIDS Rapid Response

USAID is Scaling Up HIV/AIDS Activities

Three Country Designations:– Rapid Scale Up– Intensive Focus – Basic Programs

Intensive Focus Countries (20)

Rapid Scale Up Countries (4)

HIV/AIDS Basic Programs Countries (25)

Basic Countries

AFRICA Angola Benin DR of Congo Eritrea Guinea Madagascar Mali Zimbabwe

(LIFE) REDSO/E Sahel Southern Africa

Region (LIFE)

ANE Bangladesh East Timor Indonesia Nepal Philippines E&E Central Asian

Republics Ukraine CEE Regional NIS Regional

LAC Bolivia Dom. Republic El Salvador Guatemala Guyana Haiti Honduras Jamaica Mexico Nicaragua Peru G-CAP

Criteria for Rapid Scale-Up &Intensive Focus Countries

• The relative severity of the epidemic

• The magnitude of epidemic

• The impact on economic and social sectors

• Enabling environment

• The risk of a rapid increase in prevalence

• Availability of other sources of funding

• Return on investment

• Security and safety issues

• National Interest

Intensive Focus Countries

AFRICA

• Ethiopia (LIFE)

• Ghana

• Malawi (LIFE)

• Mozambique (LIFE)

• Namibia

• Nigeria (LIFE)

• Rwanda (LIFE)

• Senegal (LIFE)

• South Africa (LIFE)

• Tanzania (LIFE)

• West Africa Region (LIFE)

ANE• India (LIFE)• ANE Region

LAC• Brazil• Caribbean Sub-Region

E&E

Russia

Rapid Scale-Up

• Cambodia

• Kenya (LIFE)

• Uganda (LIFE)

• Zambia (LIFE)

Rapid Scale-up Rapid Scale-up LIFE

Intensive Focus Intensive Focus LIFE

Basic Basic LIFE

USAID Funding for HIV/AIDS FY 2001USAID Funding for HIV/AIDS FY 2001By AccountBy Account

ACCOUNT USAID HIV/AIDSFUNDING

Child Survival and DiseaseFund

$300

Other Accounts * $15

CSD-Vulnerable Children $15

Total - All Accounts $330 million

* Economic Support Fund, Freedom Support Act, Support for EasternEuropean Democracy

Estimating USG Resources Estimating USG Resources for HIV/AIDSfor HIV/AIDS

FEDERALAGENCY

1999 2000 2001(Estimated)

USAID $142 $190 $330*

Food for Peace $10 $10

CDC $35 $104.5*

Dept. of Defense 0 $10

Dept. of Labor 0 $10

Total $142 $225 $464.5

* Confirmed

Funding Distribution for HIV/AIDS by BureauFunding Distribution for HIV/AIDS by BureauFY 2001 – CSD Account OnlyFY 2001 – CSD Account Only

AFR52%

ANE13%

E&E2%

LAC9%

G16%

BHR2%

UNAIDS6%

Funding Distribution for HIV/AIDS by Program Funding Distribution for HIV/AIDS by Program TypeType

FY 2001 – CSD Account OnlyFY 2001 – CSD Account Only

Intensive Focus37%

Rapid Scale-Up

16%

Basic Programs

21%

UNAIDS6%

USAID/W20%

FY 2001 Legislative Directives on FY 2001 Legislative Directives on USAID’s HIV/AIDS FundingUSAID’s HIV/AIDS Funding

International AIDSVaccine Initiative

$10 million

Microbicides $15 million

World Bank Trust Fund $20 million

UCSF EpidemiologicProfiles

$.5 million

Total $45.5 million* $330 - $45.5 = $284.5 available

FY 2001 Authorization Directives

Directives USAID actions

65% for US and Foreign NGOs includes faith based organizations

-10% AFR to FBOs ->70% to NGO/PVOs -care/MTCT issues

20% for orphans, including AIDS orphans

-18 countries -focus on orphans and vulnerable youth -activities include: direct support, lessons learned, capacity building, policy, collaboration

8.3% for mother to child transmission interventions

-4 countries (Malawi, Kenya, Zambia, Uganda) -activities include VCT, training of HWs, improving ANC care, procuring ARVs -Collaboration (UNICEF, EGF)

New Directions/Confronting Obstacles

• Commodities• Human Capacity Development• Faith Based Organizations• Rapid Response to Unsolicited Proposals• Increased emphasis on research

– HIV vaccines– microbicides

The “Big” Technical Challenges

• Improved targeting

• PMTCT

• Condom supply

• Orphans and vulnerable children

• Care and support

Preventing Mother to Child HIV Transmission

• History– 076 Study (1994)– Short course Thai AZT (1998)– Uganda Nevaripene (1999)

• Breast feeding

Countries Providing Access to ARV HIV Care

• Argentina

• Brazil

• Colombia

• Costa Rica

• Uruguay

The Cost of Care

• In Brazil, > 2/3 of pharmaceutical budget devoted to ARVs covering less than 20% of those infected. This $350 million is $20 million more than the annual USAID budget for HIV/AIDS

• Treating all 36 million infected persons would cost $36 billion at the lowest price frame ($1000/p/y)

Care: What Does It Involve:

• Complex regimens (2 nucleoside reverse transcriptase inhibitors and 1 protease inhibitor)

• Trained HCWs and minimal lab support• Life long intervention (sustainable, role of

drug donations)

• Misuse increases multi-drug resistance• Need for prevention remains• Equity of access ( most vulnerable, lottery,

most productive, core transmitters, ability to pay)

Drug Access/Drug Prices

Advocates• Compulsory

licensing• Parallel importing • Expanded

definition of generics (CIPLA)

Pharmaceuticals• Drug donations• Individual

negotiations• Merck

announcement (Crixovan: $600/yr, Stocrin $500/yr)

Anti-retroviralsOne year course

Drug Trade Name

Class US $ LDC $

Abacavir Ziagen NRTI

Amprenivir Agenerase PI

AZT+3TC Combivir NRTI $7093 $730

Delaviridine Rescriptor Non-NRTI

Didanosine Videx NRTI

Efavirenz Sustiva/

Stocrin

Non-NRTI $4730 $500

Indinavir Crixivan PI $6016 $600

Lamivudine (3TC)

Epivir NRTI $3271 $232

Nevirapine Viramune Non-NRTI $3508 $483

Stavudine Zerit NRTI $3589 $252

The Future:

• New directions?:

• New technologies?: improved condoms, vaccines, microbicides, simpler treatments, better diagnostics

• Websites: www.synergyaids.com

www.census.gov