1. Global policy trend of HIV and NCDs:
leveraging the HIV experience
International Seminar on Socio Economic and Mental Health
Burdens of HIV/AIDS in Developing Countries
Kuala Lumpur, Malaysia
22nd November 2011
Satoshi Ezoe, MD, MPH, MPA
Advisor, Synergies and Systems
Joint United Nations Programme on HIV/AIDS (UNAIDS)

2. Outline
1. Introduction
2. UN High Level Meeting on HIV/AIDS
3. UN High Level Meeting on NCDs
4. Discussion on NCD/HIV
5. Next steps

3. Outline
1. Introduction
2. UN High Level Meeting on HIV/AIDS
3. UN High Level Meeting on NCDs
4. Discussion on NCD/HIV
5. Next steps

4. What is UNAIDS?
Mission:
UNAIDS (the Joint United Nations Program on
HIV/AIDS), is an innovative United Nations
partnership that leads and inspires the world in
achieving universal access to HIV prevention,
treatment, care and support.
21 Aug 2009 4

5. VISION
ZERO NEW HIV INFECTIONS.
ZERO DISCRIMINATION.
ZERO AIDS-RELATED DEATHS.

6. Michel Sidibé
Executive Director of UNAIDS
Under Secretary-General of the United Nations
1952 Born in Mali
1987 UNICEF Country Office in Zaire
UNICEF Country Representative in Africa
2001 UNAIDS Country Support Director
2007 UNAIDS Deputy Executive Director
2009 UNAIDS Executive Director
Taking AIDS
out of
isolation!!

7. UNAIDS Cosponsors
21 Aug 2009 Global Stream of HIV/AIDS 7

8. UNAIDS World AIDS Day Report | 2011
Core Epidemiology Slides
EMBARGOED FOR
TRANSMISSION AND
PUBLICATION UNTIL 09:00 GMT,
MONDAY 21 NOVEMBER 2011

9. Global summary of the AIDS epidemic | 2010 < 2009
Number of people Total 34.0 million 33.3 million
living with HIV Adults 30.1 million 30.8 million
Women 16.8 million 15.9 million
Children (<15 years) 3.4 million 2.5 million
People newly Total 2.7 million 2.6 million
infected Adults 2.3 million 2.2 million
with HIV in 2010 Children (<15 years) 390 000 370 000
AIDS deaths in 2010 Total 1.8 million 1.8 million
Adults 1.5 million 1.6 million
Children (<15 years) 250 000 260 000
www.unaids.org

10. Global financial trend for HIV/AIDS
$17.4
$17,0
17.5
$15.9
$15.6
15.0
$14,3 $14.4
$12,8
12.5
$11.4
US$ billion
10.0 Signing of Declaration of Commitment $8.9
on HIV/AIDS UNGASS 2001 $09,9
$8.3
7.5 HIP+
World Bank $6.1
MAP launch UNITAID
$5.0
5.0
$3.2
UN AIDS Gates PEPFAR
Foundation
2.5
$0.9
$0.5 $0.5 The Global Fund
$0.3
$1.4 $1.6
0.0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
2010

11. Outline
1. Introduction
2. UN High Level Meeting on HIV/AIDS
3. UN High Level Meeting on NCDs
4. Discussion on NCD/HIV
5. Next steps

12. Outcomes of the
2011 UN General Assembly
High Level Meeting on
AIDS
(from NCDs and mental health angle)
8-10 June 2011

13. The High Level Meeting in numbers
1 Economist cover
2 New York Times editorials
5 Official Panels
27 Heads/ Deputies of State/
Government
30+ First Spouses
43 side events
89 Ministers
100s of civil society, private
sector and people living w/ HIV
120 National Delegations
5000+ news articles

14. Official Panel: Integrating the AIDS response
with broader health and development agendas
KEY ISSUES:
• HIV and health systems
• HIV, maternal, newborn and child health and sexual and
reproductive health
• HIV and TB
• HIV and non-communicable diseases
• HIV and development

15. Political Declaration on HIV/AIDS: Intensifying our
Efforts to Eliminate HIV/AIDS
Recommit to 2006 Political Declaration and 2001
Declaration of Commitment
New global targets for 2015
Mobilize funding (US $22-24 billion per year)
Shared responsibility
Universal access
Key populations
Trade Related Aspects of Intellectual Property (TRIPS)
principles
UNAIDS Strategy 2011-2015

16. Bold new targets for 2015
50% in sexual transmission of HIV
50% of HIV among people who inject drugs
50% TB deaths in people living with HIV
Ensure no children are born with HIV and reduction of
AIDS-related maternal deaths
15 million on antiretroviral treatment

18. Commitment to HSS and integrating HIV and
AIDS into broader health and development
• 98 Commit by 2015 to… direct resources to and
strengthen the advocacy, policy and programmatic
links between HIV and TB responses, PHC
services, SRH, MCH, hepatitis B and C, drug
dependence, non-communicable diseases and
overall health systems, leverage health-care
services to PMTCT of HIV, strengthen the interface
between HIV services, related SRH care and
services and other health services, including MCH,
eliminate parallel systems for HIV-related services
and information where feasible……..

19. Outline
1. Introduction
2. UN High Level Meeting on HIV/AIDS
3. UN High Level Meeting on NCDs
4. Discussion on NCD/HIV
5. Next steps

20. Outcomes of the
2011 UN General Assembly
High Level Meeting on NCDs
(from HIV and mental health angle)
19-20 September 2011

21. "This is the second health issue ever to be addressed at a special
meeting of the United Nations General Assembly. We should all
work to meet targets to reduce NCDs. "
Ban Ki-moon • UN Secretary-General • 19 September 2011

22. A clear Message For Heads of States and High-level Policy Makers
"You have the power to stop and reverse the NCD disaster. You have
the power to protect your people and keep your development
efforts on track."
Margaret Chan • WHO Director-General • 19 September 2011

24. Political Declaration on NCDs
A challenge of epidemic proportions and its socio-economic and
developmental impacts
18. Recognize that mental and neurological
disorders, including Alzheimer’s disease,
are an important cause of morbidity and
contribute to the global NCD burden, for
which there is a need to provide equitable
access to effective programmes and
health-care interventions;

25. Political Declaration on NCDs
A challenge of epidemic proportions and its socio-economic and
developmental impacts
27. Note with concern the possible linkages
between NCD and some communicable
diseases, such as HIV/AIDS, and call to
integrate, as appropriate, responses for
HIV/AIDS and NCD and, in this regard, for
attention to be given to people living with
HIV/AIDS, especially in countries with a high
prevalence of HIV/AIDS and in accordance with
national priorities;

26. Political Declaration on NCDs
Strengthen national policies and health systems
45. Encourage alliances and networks that
bring together national, regional and global
actors, including academic and research
institutes, for the development of new
medicines, vaccines, diagnostics and
technologies, learning from experiences in
the field of HIV/AIDS, among others,
according to national priorities and strategies;

27. Major Outcomes
• Consensus and clear positions of NCDs a s priority within
the development agenda
• A strong call for a whole of government approach to
implement the Global Strategy and its action plan and
WHO's recommendations on surveillance, prevention and
health care
• Emphasis on the leading role of WHO in coordinating global
action on NCDs
• Specific assignments that WHO has to deliver over the
coming months and years
• Great expectations for WHO to strengthen capacity to
support member States
(Slide from Dr. Alwan, November 2011)

28. Outline
1. Introduction
2. UN High Level Meeting on HIV/AIDS
3. UN High Level Meeting on NCDs
4. Discussion on NCD/HIV
5. Next steps

29. Official Side Event on NCDs and HIV:
Achieving health equity: Uniting around a common
agenda to address NCDs and HIV
Moderator:
Laurie Garrett, Council on Foreign Relations
Panel:
Margaret Chan, Director-General, WHO
Michel Sidibe, Executive Director, UNAIDS
Aaron Motsoaledi, Minister of Health, South Africa
Eric Goosby, Global AIDS Coordinator, USA
Nancy Brinker, WHO Goodwill Ambassador for Cancer Control
Tokugha Yepthomi, Civil Society Representative, India

30. Official Side Event on NCDs and HIV:
Aim of the event:
• To draw the attention of key policy makers,
to ensure that national development/health
plans give attention to the NCD and HIV
agendas.
• To review lessons learned for health systems
strengthening that can maximize synergies
and efficiencies in HIV and NCD responses.

31. Discussion paper addressed:
• A set of areas for collaborations:
- Strengthening understanding on
epidemiological linkages
- Health systems strengthening
- community mobilization

32. communicable diseases,
Global share of Mortality maternal, perinatal and nutritional
conditions
injuries
NCDs after the age of 60
9% 10%
28% 31%
47% 42%
16% 17%
Global NCDs before the age of 60 Low- and middle-income
countries only
(WHO 2008)

33. Global share of DALYs
(Prince M et al, 2007)

34. Osteopenia/porosis
Osteonecrosis
Chronic skin
Renal insufficiency Hypogonadism conditions
Sarcopenia
Myopathy
Rheumatologic
Pulmonary Fibrosis HIV
Pulmonary HTN
Vitamin D Def
Thyroid
Diabetes
Cognitive impairment
GH Def
Neuropathy
Visceral Fat
Chronic diarrhea
Atherosclerosis
Vascular disease/pulm htn
(Slide from Currier J, IAS conference, 2011)

35. Epidemiological links:
NCDs as co-morbidity in PLHIV
(1) NCDs as a consequence of long term survival of
the HIV/ART cohort
(2) Risk of non-AIDS defining cancers as a
consequence of the long term immune
compromised status
(3) NCDs as direct side effect of the ART medicines
(e.g. treatment related hyper lipideamia, diabetes).
At a median age at death of 60 years, 35% will die
of CVD, 26% of cancer, 12% of liver failure and 28
% of other causes (Scott Braithwait et al 2005).

36. Epidemiological links:

37. Epidemiological links:
Mental health and PLHIV
• Evidence base is still weak.
• Between 11% and 63% of people living with HIV in
LMIC experience depression.
• PLHIV are also are prone to anxiety, stress, and
panic disorder (Clay, 2006).
• Stress impairs immune function (Chandrashekara S
et al, 2007)
• Depression is linked to poor adherence to ART.

38. Shared barriers and challenges for HIV and NCDs

39. Synergies between HIV and NCD programmes

40. Synergies between HIV and NCD programmes
Integrated HIV, DM and HT services in Cambodia
• Chronic disease clinics
for HIV, diabetes and
hypertension in
Cambodia.
• A fully integrated model
using a patient-centred
case management
approach
• N=9000 (2002-2005),
- 5000 living with HIV
- 2500 with diabetes
- 1500 with hypertension

41. Synergies between HIV and NCD programmes
Integrated HIV, DM and HT services in Cambodia
This programme demonstrated:
• High retention rates of between 70–90% for the
various diseases;
• Median CD4 count of people living with HIV
rising from 53 to 316 per mm3 at 24 months;
• Median HbA1c of people with diabetes falling
from 11.5% to 8.6%;
• 68% of people being treated for hypertension
reaching the target blood pressure within six
months;
• NO difficulties noted from HIV-related stigma.

42. Advocacy and community mobilization
HIV NCDs
High level political leadership Led by biomedical technical
was cultivated well beyond groups – not so political until
health sector – including HLM 2011
UNGASS Success in Tobacco control but
Strong civil society led no strong global activism in
advocacy and activism other diseases or risk factors
Activism with high profile global Volunteerism with no public
and local champions and figures across epidemics
celebrity support Almost no linkage between NCD
Based on a rights-based and disability advocates
framework

43. General agreement on the importance of:
• Uniting stakeholders around common agendas
to address NCDs and HIV;
• Identifying synergies for health systems
strengthening between HIV and NCDs
programmes;
• Mobilizing stakeholders, within and beyond the
health sector, including civil society;
• Leveraging lessons learnt to maximize synergies
and efficiencies in dealing with HIV and NCDs.

44. Outline
1. Introduction
2. UN High Level Meeting on HIV/AIDS
3. UN High Level Meeting on NCDs
4. Discussion on NCD/HIV
5. Next steps

45. HIV Next Steps (TBC)

46. NCDs Next Steps
Political Declaration –Timeline (Governing Bodies):
2 Report on the outcomes of
the High-level Meeting and
the Moscow Conference
Progress in implementing
1 the global strategy and the
action plan
4 5
Implementation and follow-up
3 plan for the outcomes of the
Moscow Conference and the 6
Options for strengthening and
High-level Meeting (developed Report on the progress
facilitating multisectoral action
together with UN agencies and achieved in realizing the
for the prevention and control
entities) commitments made in the
of NCDs through effective
partnership Political Declaration
Jan-May 2012 Q4 2012 Jan-May 2013 Sep 2014
EB/WHA General Assembly WHA General Assembly
(Slide from Dr. Alwan, November 2011)

47. Preliminary ideas for further collaboration
between HIV + NCDs
Key tasks:
• To work together to promote the issues highlighted at the
high-level meeting and discussion paper.
• To use every opportunity to strengthen the linkages
between HIV and NCDs through individual policies,
strategies, plans and programmes as well as in technical
norms, standards and guidelines.
Opportunities include:
• Reportings to WHO EB and WHA in 2012 and beyond
• Possible partnership for multisectoral coordination
• The World Health Day 2012 publication on ageing
• HIV related conferences
• Discussions around the post-MDGs development agenda

48. Possible consideration for mental health
• Apply lessons learnt from HIV
e.g. multi-sectoral response?, target setting?, advocacy?,
community mobilization?, human rights approach?,
TRIPS?
• Apply lessons learnt from NCDs
e.g. regulatory approach?, risk reductions?, Best buy
approach?
• Strengthen evidence base on MH+HIV, MH+NCDs
e.g. Epidemiological links, Service integration, Effect of MH
intervention on HIV outcomes
• Leverage every opportunity for post HLM processes and
post-MDGs discussions

49. Thank you!
Terima kasih!
www.unaids.org
ezoes@unaids.org