EXECUTIVE BOARD 138th session Provisional agenda item 9.2
EB138/29 18 December 2015
Draft global health sector strategies HIV, 2016–2021 Report by the Secretariat
1. In May 2011, the Sixty-fourth World Health Assembly endorsed the global health sector strategy on HIV/AIDS, 2011–2015,1 in resolution WHA64.14, and affirmed, inter alia, the vision and strategic directions of the global health sector strategy on HIV/AIDS, 2011 –2015 and that the global strategy aimed to guide the health sector’s response to HIV/AIDS, including recommended actions at country and global levels, as well as contributions to be made by WHO. In the resolution, the Director-General was requested, inter alia, to monitor and evaluate progress in implementing that global health sector strategy on HIV/AIDS, 2011–2015, and to report on that progress, aligned with the reporting of other United Nations agencies, through the Executive Board, to the Sixty-fifth, Sixty-seventh and Sixty-ninth World Health Assemblies. 2. In May 2014, the Sixty-seventh World Health Assembly reviewed progress on the implementation of the strategy.2 There was a call by Member States for the development of a new strategy in the post-2015 development agenda, and a request that HIV continue to be a priority for WHO.3 3. The global health sector strategy on HIV/AIDS, 2011–2015 played a key role in the achievement of global HIV targets outlined in the Millennium Development Goals. In addition, the strategy was closely aligned with the UNAIDS multisectoral strategy 2011 –20154 and guided by the Political Declaration on HIV and AIDS adopted by the United Nations General Assembly in 2011.5 At the end of 2015, over 15 million people were on antiretroviral therapy. Since 2000, it has been estimated that as many as 7.8 million HIV-related deaths and 30 million new HIV infections have been averted.
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Document WHA64/2011/REC/1, Annex 4. Document A67/40 progress report A.
See the summary records of the Sixty-seventh World Health Assembly of Committee A, twelfth meeting, section 9 (document WHA67/2013/REC/3). 4 Getting to zero: 2011–2015 strategy: joint United Nations Programme on HIV/AIDS (UNAIDS), at: http://www.unaids.org/sites/default/files/en/media/unaids/contentassets/documents/unaidspublication/2010/20101221_JC203 4E_UNAIDS-Strategy_en.pdf (accessed 1 December 2015). 5 Political Declaration on HIV and AIDS: Intensifying Our Efforts to Eliminate HIV and AIDS, United Nations General Assembly resolution 65/277, see: http://www.unaids.org/sites/default/files/sub_landing/files/20110610_UN_A-RES65-277_en.pdf (accessed 5 November 2015).
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4. In September 2014, the Secretariat initiated a process to develop a draft global health sector strategy on HIV for the period 2016–2021, in association with the development of the draft global health sector strategies on viral hepatitis and on sexually transmitted infections.1 5. In September 2015, the United Nations General Assembly adopted the 2030 Agenda for Sustainable Development,2 which endorsed the Sustainable Development Goals, including the target of particular relevance here, target 3.3: “By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases.” 6. The goal of the Secretariat’s draft strategy on HIV (see the Annex of the present report for a summary of the draft strategy) is to end the AIDS epidemic as a public health threat by 2030, within the context of ensuring healthy lives and promoting well-being for all at all ages. Furthermore, it is aligned with the 2030 Agenda for Sustainable Development: its focus is on ensuring financial security and health equity through its commitment to universal health coverage. 7. The draft strategy provides a framework for WHO and Member States for joint action at the global, regional and country levels. It is based on existing good practices and available evidence on the effectiveness of HIV-related approaches and interventions in the health sector. 8. The broad consultative process that led to the draft strategy involved all key partners, including Member States, organizations of the United Nations system and other multilateral agencies, donor and development agencies and initiatives, civil society, nongovernmental organizations, scientific and technical institutions and networks, and the private sector. Numerous stakeholder consultations were held, and more than 90 Member States participated in consultations held in all WHO regions in the period April–July 2015. To supplement these consultations and ensure the broadest participation, the Secretariat hosted a widely-promoted public online consultation for six weeks in the period April–June 2015. An official technical briefing on the three strategies (viral hepatitis, HIV and sexually transmitted infections) was held during the Sixty-eighth World Health Assembly. 9. As referred to previously, the process of developing the draft global health sector strategy on HIV, 2016–2021 was managed together with two other draft health sector strategies for the same period. The universal health coverage framework provided a common structure for the three draft strategies. For the draft strategy on HIV, substantial input was provided by the Secretariat, in particular from areas with significant involvement in HIV-related activities, and from all regional offices and some country offices. The process was enhanced by input from the WHO civil society
The full draft strategies on HIV, hepatitis, and sexually transmitted infections, which include priority actions proposed for WHO and for countries, are available at: http://www.who.int/hiv/strategy2016-2021/en/ (accessed 17 December 2015); http://www.who.int/reproductivehealth/ghs-strategies/en/ (accessed 3 December 2015); and http://www.who.int/hepatitis/news-events/strategy2016-2021/en/ (accessed 5 November 2015). See document EB138/30, Annex for a summary of the draft strategy on hepatitis; and see document EB138/31, Annex for a summary of the draft strategy on sexually transmitted infections. United Nations General Assembly, resolution 70/1, see: http://www.un.org/ga/search/view_doc.asp?symbol= A/RES/70/1&Lang=E (accessed 5 November 2015). 2
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reference group on HIV and the WHO Scientific and Technical Advisory Committee on HIV. The consultation process was extensive.1 10. The draft global health sector strategy on HIV, 2016–2021 articulates WHO’s commitments to achieving internationally-agreed HIV and development goals and targets. The goals, targets and priorities articulated in the UNAIDS multisectoral strategy for 2016–2021 and the health-related Goals and targets identified in the 2030 Agenda for Sustainable Development are reflected in the proposed strategy on HIV. 11. Impressive gains were made in the multisectoral response to date, which are recognized in the draft global health sector strategy on HIV, 2016–2021. Importantly, the proposed strategy also emphasizes the need to fast-track the response to prevent a rebound in new HIV infections and HIV-related deaths. Proceeding at the current pace will not be enough to end an epidemic that is constantly evolving. New HIV infections will increase and more people will require HIV treatment and care. The costs of prevention, care and treatment will continue to expand. By the end of 2014, the number of people living with HIV worldwide had reached an estimated 36.9 million (range 34.3 million–41.4 million). 12. To guide actions by Member States and by the Secretariat, the draft strategy proposes five strategic directions, which are provided in the summary (see the Annex), and are explained in more detail in the full draft strategy. 13. The draft global health sector strategy on HIV, 2016–2021 is closely aligned with the UNAIDS 2016–2021 strategy,2 which has been developed in parallel – including through joint consultations in several regions. It recognizes that an effective HIV response requires action across many sectors, and aims to describe the specific health sector contribution to a multisectoral response and the multisectoral UNAIDS strategy. It supports and reinforces the agreed division of labour among UNAIDS cosponsors.3
ACTION BY THE EXECUTIVE BOARD 14. The Executive Board is invited to consider the draft global health sector strategy on HIV, 2016–2021, which is on the website,4 and to make a recommendation on its possible endorsement by the Sixty-ninth World Health Assembly.
1 For more information on the consultative process and on a variety of supporting draft strategy documents and summary reports, see http://www.who.int/hiv/pub/hep-strategy-background/en/ (accessed 30 November 2015).
UNAIDS 2016–2021 strategy: on the fast-track to end AIDS, is available at: http://www.unaids.org/sites/default/ files/media_asset/20151027_UNAIDS_PCB37_15_18_EN_rev1.pdf (accessed 1 December 2015). 3 As a cosponsor of UNAIDS, WHO is responsible for the health sector response to HIV, taking the lead on HIV treatment and care and on HIV/tuberculosis coinfection. WHO shares responsibility with UNICEF for the prevention of mother-to-child transmission of HIV, and collaborates with other cosponsors in supporting actions in all other priority areas.
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The full draft strategy on HIV is available at: http://www.who.int/hepatitis/news-events/strategy2016-2021/en/ (accessed 5 December 2015).
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ANNEX SUMMARY OF THE DRAFT GLOBAL HEALTH SECTOR STRATEGY ON HIV, 2016–2021
1. The international community has committed to ending the AIDS epidemic as a public health threat by 2030 – an ambitious target of the 2030 Agenda for Sustainable Development, which was adopted by the United Nations General Assembly in September 2015.1 Interim targets have been established for 2020. This draft strategy describes the health sector contribution towards the achievement of these targets. It outlines what countries need to do and what WHO will do. If implemented, these fast-track actions by countries and by WHO will accelerate and intensify the HIV response in order for the “end of AIDS” to become a reality.
WHY THE WORLD MUST STEP UP THE HIV RESPONSE QUICKLY 2. Large declines in new HIV infections and HIV-related deaths in the past decade attest to the commitment, resources and innovations that have already been directed at the global HIV epidemic. In 2014, new HIV infections were estimated at 2.0 million (range of 1.9 million – 2.2 million), which is 41% lower than the peak in 1997. Fewer people are dying of HIV-related causes, with an estimated 1.2 million (range of 0.980 million – 1.6 million) deaths in 2014, down 42% from the peak in 2004, largely the result of increased access to antiretroviral therapy. 3. Despite major progress in the response, HIV epidemics continue to pose serious public health threats in all regions. The current coverage of services is inadequate and the rate of expansion is too slow to achieve global targets. Success is distributed unevenly and inequitably. While HIV incidence is declining overall, it is increasing in some countries and regions. With changing donor priorities, many countries, particularly middle-income countries, will need to transition to domestic funding of their HIV programmes. Many national HIV programmes fail to focus interventions on the populations and locations most in need. HIV programmes worldwide have seen rapid expansion. It is essential, however, that the quality of services is ensured, without which the effectiveness of such programmes is at risk. AIDS deaths are declining with expanding access to antiretroviral therapy, however, investments in treatment are being challenged by increasing morbidity and mortality associated with coinfections, such as hepatitis B and hepatitis C, and other comorbidities. The global epidemic has reached a point where a steady-state response – that is, maintaining coverage at current levels or gradual expansion – will soon see a rebound in new HIV infections and HIV-related deaths.
United Nations General Assembly resolution 70/1 – Transforming our world: the 2030 Agenda for Sustainable Development, see http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E (accessed 30 October 2015).
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Figure. Outline of the draft global health sector strategy on HIV, 2016–2021
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4. An immediate, fast-tracked global response that achieves the targets set out in this strategy will effectively end the epidemic as a global public health threat. Modelling undertaken by UNAIDS shows that implementation of high-impact prevention packages and accelerated testing and treatment effort would: • Reduce new adult HIV infections from 2.1 million in 2010 to 500 000 in 2020; • Avert 28 million HIV infections between 2015 and 2030; • Avert almost 6 million infections in children by 2030; • Avert 21 million AIDS-related deaths between 2015 and 2030; • Avoid US$ 24 billion of additional costs for HIV treatment; • Enable countries to reap a 15-fold return on their HIV investments.
FRAMING THE STRATEGY 5. The strategy is designed to contribute to the attainment of the Goal on health of the 2030 Agenda for Sustainable Development – Goal 3. It describes how the health sector response to HIV can contribute to the achievement of the “ending AIDS” target, universal health coverage, and other key health and development targets. The HIV draft strategy is also aligned with other relevant health strategies, notably the End TB Strategy,1 the UNAIDS strategy mentioned previously, and other HIV strategies (those of key partners, and those that are sectoral and multisectoral in nature). The strategy draws on three organizing frameworks: universal health coverage; the continuum of HIV services; and the public health approach (see Figure).
VISION, GOAL AND TARGETS Global vision 6. Zero new HIV infections, zero HIV-related deaths and zero HIV-related discrimination in a world where people living with HIV are able to live long and healthy lives.
Goal 7. To end the AIDS epidemic as a public health threat by 2030, within the context of ensuring healthy lives and promoting well-being for all at all ages.
Targets for 2020 8. Countries have an opportunity to take a decisive leap towards ending their AIDS epidemics – if they act swiftly and with enough resolve to reach ambitious targets for 2020. These targets apply to everyone: children, adolescents and adults; rich and poor; women and men; and all key populations. 1
The End TB Strategy is available at: http://www.who.int/tb/strategy/en/ (accessed 2 December 2015).
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HIV-related deaths 9. The targets include: • reduce global HIV-related deaths to below 500 000; • reduce tuberculosis deaths among people living with HIV by 75%; • reduce hepatitis B and C deaths among people coinfected with HIV by 10%, in line with mortality targets for all people with chronic hepatitis B and C infection. Testing and treatment 10. The targets include: • ensure that 90% of people living with HIV know their HIV status; • ensure that 90% of people diagnosed with HIV receive antiretroviral therapy; • ensure that 90% of people living with HIV, and who are on treatment, achieve viral load suppression. Prevention 11. The targets include: • reduce new HIV infections to below 500 000; • zero new infections among infants. Discrimination 12. The targets include: • zero HIV-related discriminatory laws, regulations and policies, and zero HIV-related discrimination in all settings, especially health settings; • 90% of people living with HIV and key populations report no discrimination in the health sector. Financial sustainability 13. The targets include: • ensure financial risk protection for 90% of all people living with HIV; • ensure domestic investments in upper middle-income countries of 95% of national AIDS resource needs and annual international HIV investment of US$ 12 700 million in lower middle-income countries;
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• ensure all countries have integrated essential HIV services into national health financing arrangements. Innovation 14. The targets include: • increase research into and development of HIV-related vaccines and medicines for use in treatment and prevention; • provision of access by 90% of countries to integrated health services covering HIV, tuberculosis, hepatitis B and C, reproductive health and sexually transmitted infections.
STRATEGIC DIRECTIONS AND PRIORITY ACTIONS 15. To achieve the 2020 and 2030 targets, action is required in five areas, referred to as “strategic directions”. Under each of the strategic directions, specific actions need to be taken by countries, WHO and partners. 16. Strategic direction 1 – Information for focused action. A robust and flexible strategic information system that can generate high-quality data is the cornerstone for advocacy, national strategic planning, and ensuring accountability for the best and fairest use of resources. High-quality “‘granular” data enable national HIV strategies to be developed that can focus investments where they are needed to achieve greatest impact and ensure equitable access. 17. Strategic direction 2 – Interventions for impact. Each country should review its package of essential HIV services in light of changing epidemics, new knowledge and innovations, and define a set of essential HIV interventions, services, medicines and commodities to be included in its national health-benefit package. The package of interventions should cover the full continuum of HIV services, including: male and female condom programming; harm reduction for people who use drugs; the use of antiretroviral drugs for pre-exposure prophylaxis and post-exposure prophylaxis of HIV infection; prevention of HIV infection in infants; voluntary medical male circumcision in high-HIV prevalence settings in sub-Saharan Africa; injection and blood safety; behaviour change communication; prevention of gender-based and sexual violence; HIV testing; antiretroviral therapy; prevention and management of major coinfections, including tuberculosis and viral hepatitis; chronic care for people living with HIV; and prevention and management of HIV drug resistance. 18. Strategic direction 3: Delivering for equity. The efficient delivery of the continuum of HIV services to different populations and in different locations requires a strong health system. HIV services need to be adapted to the local context to deliver person-centred care. Decentralization and integration of HIV services with strong community engagement should aim to improve their reach, efficiency, acceptability, quality and impact. The expansion of HIV services will place unprecedented demands on the health workforce, requiring new models of service delivery, including greater emphasis on task shifting. To ensure the uninterrupted provision of HIV services, the procurement and supply management of HIV medicines, diagnostics and other commodities should be integrated into the broader national procurement and supply management system. An effective HIV response requires a supportive social, legal and policy environment that encourages and enables people to access and use services.
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19. Strategic direction 4: Financing for sustainability. Implementing fast-track actions to end the AIDS epidemic will require major new global and domestic investments, from both the public and private sectors. It will also require integrating essential HIV interventions and services into the national health benefit package, minimizing the financial burden for individuals and households through prepayment and pooling of health funds, achieving programme savings and avoiding wastage, and using available funds efficiently and equitably. 20. Strategic direction 5: Innovation for acceleration. Research and innovation provide the tools and knowledge that can change the trajectory of the HIV response, improve efficiency and quality, achieve equity and maximize impact. Innovation is required along the continuum of HIV services to develop new medicines, diagnostics and other technologies, to implement new models of service delivery and to use existing tools more efficiently and to adapt them for different populations, settings or purposes.
STRATEGY IMPLEMENTATION 21. Effective implementation of the strategy depends on concerted action from all stakeholders in the health sector response to HIV. Strong partnerships are required with civil society, donor and development agencies, and technical partners. The Joint United Nations Programme on HIV/AIDS (UNAIDS) provides the framework for multisectoral action within the United Nations system, with WHO taking the lead on the health sector response. 22. Implementation of the strategy will be monitored at four levels, using existing mechanisms: monitoring and reporting progress towards global goals and targets; monitoring and evaluating the response at regional and country levels; applying WHO’s framework for results-based management; and applying the UNAIDS accountability framework. 23. Costing of implementation of the strategy has been undertaken based on the costing of the UNAIDS 2016–2021 strategy. The total costs of the draft global health sector strategy are estimated to rise from about US$ 20 000 million in 2016 to just over US$ 27 000 million in 2020, before declining somewhat to US$ 26 000 million in 2021. Antiretroviral therapy requires the largest amount of resources, about 36% of the total. Prevention for people who inject drugs is the next largest component at 13%, and HIV testing services are next at 11%.
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