Jamra primary scholl for children affected by HIV/AIDS, drugs or poverty, Senegal (c) Nell Freeman/Alliance Participants in the Photovioce project, Ecuador © Marcela Nievas for the Alliance
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Don’t stop now, finish the job: HIV/AIDS investment framework debated


Aids Alliance

Bernhard Schwartländer, one of the authors of a new paper published in The Lancet that argues that substantial changes are needed to achieve a more targeted and strategic approach to investment in the response to the HIV/AIDS epidemic, was the keynote speaker at a high level panel discussion held in London this week.

The event, co-organised by the Alliance, the UK Consortium on AIDS and International Development and the World Bank at the London School of Hygiene and Tropical Medicine, was attended by an invited audience of civil society, academics and policy makers, including from the UK’s Department for International Development.

The framework

Schwartländer who is Director of Evidence, Strategy and Results at UNAIDS presented the new framework which affirms many ideas about using our knowledge about ‘what works’ to address those most at risk of HIV but presents it in a comprehensive framework that prioritises six programme activities*. Importantly for the Alliance, one of these six programmes is work with key populations, including supporting social solidarity among key population networks.

In the framework, the six programmatic activities sit side-by side with ‘critical enablers’, such as community mobilisation, supportive legal and policy environments and stigma reduction, many of which the Alliance actively promotes as central to the success of any HIV response. The framework argues that by focusing efforts this way, supporting synergies between different HIV programmes and with other development sectors, major efficiency gains will be made that will drastically reduce rates of HIV transmission and AIDS mortality.
The framework also notes that ART treatment plays a critical role in preventing new HIV infections and therefore argues for better and earlier access to ART at a cost that will eventually be offset by HIV infections averted and life years gained.

Key selling points of the framework

For an organisation like the Alliance that has been supporting community action for over 18 years, the key selling point of the framework is the acknowledgment of the importance of community mobilisation, particularly its role in creating demand for services and advocating for enabling environments for effective HIV responses.
Alvaro Bermejo, Executive Director of the Alliance said: ‘We have always seen community mobilisation as an enabler but we have never had a model like this before which shows so clearly the relationship between what Alliance linking organisations and their partners do and their impact on high level HIV response objectives (around reducing risk, reducing the likelihood of transmission and reducing mortality and morbidity).’
The framework is seen as a useful tool for advocating for continued investment in AIDS, when for the first time sector funding has reduced and is likely to continue to fall given the current global economic climate.
The key selling point to investors or donors is how the framework puts forward a case for an incremental increase in investments in up until 2015 in order to deliver exponential growth in the number of new infections reduced and deaths averted in the longer term.  Ultimately, this will enable donors to reduce their future investments – a more attractive proposition than other recent forecasts such as those put forward by the AIDS2031 consortium. 
However, in order to achieve this return on investment, the model requires more money than has already been committed – an additional $6bn. As representatives at the London event commented, the Global Fund to Fight AIDS, TB and Malaria fully embraces the new framework and, in fact, the recently finalised investment guidance is in line with the suggested framework. However, there is no clarity yet as to what extent bilateral donors are committed to shaping their investment along the lines of the framework.

What next?

Questions at the event centred on the lack of published evidence – particularly around the impact of community mobilisation.  Schwartländer said ‘we know it’s true but we need more data.’  Alvaro Bermejo commented, ‘To sell this model effectively, the challenge will be to build the evidence base to support the view that community mobilisation is key to an effective HIV response.  This is not a new issue and the Alliance – through its programmatic evaluations and value for money analyses – will continue to be at the forefront of this debate.’
Concerns were also raised that CBOs and NGOs engaged in activities outside of the six basic programmatic activities might lose out or even reject the framework.  Schwartländer was keen to stress that the framework does not suggest a hierarchy between the critical enablers and the programmatic activities, rather that they are just different types of interventions but that all must be in place as a package for the framework to work.
Concrete suggestions from delegates for taking the debate forward included:

  • How can the framework be translated into national contexts, and be used to influence local funding decisions? 

Many civil society actors are already programming along these lines, so this framework presents a concrete opportunity. Civil society actors were encouraged to discuss the application of the framework within national contexts with DFID country offices, PEPFAR/US government missions and Global Fund Country Coordinating Mechanisms.

  • How can civil society use the framework to make a better case for community mobilisation?

Some of the assumptions in the investment framework need to be unpacked and the Alliance and others must undertake additional research and collate evidence to underpin the basic arguments. Importantly, this needs to include some work on costing of community interventions.

  • What will it mean at country level for those activities not covered in the six basic programmatic activities? 

The key message here is that the critical enablers which are ‘outside of the box’ of programmatic activities are not simply a luxury, but are in fact essential for the framework to operate effectively. More work is needed to create the evidence base to show that the ‘critical enablers’ do deliver reductions in risk, transmission, and mortality and morbidity. Also, caveats need to be created that a ‘one size fits all’ approach will probably not work in all national contexts and work is needed to demonstrate how the framework might be adapted to work in specific countries.

If you would like to partner with the Alliance on its work around the Investment Framework and its wider value for money research, please contact Sam McPherson, Associate Director of Field Programmes at the Alliance.
The Alliance is campaigning for resources to be used more effectively to prevent people becoming infected with HIV.  Read more about our ‘What’s Preventing Campaign?’
* PMTCT, Condom Promotion and Distribution, Key Populations, Treatment, Care and Support to people living with HIV and AIDS, Male Circumcision, Behaviour Change Programmes

    To sell this model effectively, the challenge will be to build the evidence base.