Australia's domestic and regional response to HIV: shaping the future, learning from the past

Ewen McDonald, Deputy Secretary, Department of Foreign Affairs and Trade

AIDS 2014, 20th International AIDS Conference, Melbourne

22 July 2014

Chairman, Ladies and Gentlemen

Australia is part of a dynamic region. Our neighbours in the Indian Ocean Asia-Pacific region are experiencing rapid economic growth. Burgeoning private sector development is drawing workers and businesses to mega cities such as Jakarta, Mumbai and Shanghai and to boom towns in Papua New Guinea. Two-thirds of Australia’s development partners are now middle-income countries.

Australia’s new development policy reflects this changing context.

The Government’s new development policy, Australian aid: promoting prosperity, increasing stability reducing poverty, and a performance framework for Australia’s aid program, was released on 18 June.

Australia’s aid program will have a stronger focus on private sector development, including aid for trade, in recognition that the private sector is the primary driver of economic growth and poverty reduction. It also recognises that private sector development requires a strong foundation of human development.

Health is a priority under the new policy because improving health, along with education, and gender equality, is essential to building a skilled and competitive workforce, and lifting living standards. Healthier adults have better opportunities to earn an income, and children who are well-nourished and free of disease are able to learn at school and gain the skills needed to break out of poverty.

Communicable diseases, such as tuberculosis, malaria and HIV, continue to pose unacceptable health threats to developing countries - burdening households as well as straining national health systems. Australia is committed to supporting partner governments deliver better health for all, with a focus on cost-effective and socially inclusive interventions to prevent and treat communicable diseases.

Our commitment to HIV

Combatting HIV and communicable diseases continue as priorities for Australia.

However, there have also been major changes to the context of our work on HIV, and I want to touch briefly on these shifts.

First, our understanding of the disease and how to treat it has dramatically improved.  Advances in science and medicine have resulted in the roll out of antiretroviral treatment to almost 10 million people in lower and middle income countries -treatment that saves lives and reduces the possibility of passing the virus to others. This is a major factor in the decline of new infections - by 33 per cent globally and by 26 per cent in Asia and the Pacific since 2001. 

Second, our understanding of the nature of the epidemic has changed.  In the late nineties and early this century we were still operating in crisis mode.  Early evidence of rapidly growing epidemics in places like Papua New Guinea and Cambodia led to fears of HIV epidemics engulfing entire populations in the region. Thankfully, these fears have not been realised.

Research has now revealed that the drivers of the epidemic in Asia were sex work, sex between men and injecting drug use. Improved data shows that HIV is concentrated in these vulnerable and marginalised populations. This is also the case in urban areas in Papua New Guinea. Mark Dybul, the head of the Global Fund to fight AIDS, TB and Malaria, speaks of the need to ensure our efforts target the ‘hot spots’.  I couldn’t agree more.

Third, we understand where we need to target our efforts, and to lower the barriers to accessing services.  Key affected populations need health and HIV services the most. But, paradoxically, it is these populations -  sex workers, men who have sex with men, transgendered people, people who inject drugs and people with HIV-  that are often excluded from these services as a result of stigma and discrimination. Their rights to health care are often overlooked and their human rights are undermined.

Adjusting laws and policies to encourage key populations to adopt safe behaviour and seek treatment has an impact. For example, work with health staff and law enforcement sectors in Indonesia contributed to increases in safe injecting practices among people who inject drugs from 64 per cent in 2009 to 91 per cent in 2013.

Fourth, there needs to be sufficient domestic investment in health to do the job.    

Developing countries spend significantly less on health than developed countries. The average total per capita health spend in low income countries is around $36 compared to an OECD average of around $3500.   Overseas development aid accounts for less than one per cent of health expenditure in these countries, so that cannot fill the gap.  As developing countries’ economies grow, donors can support partner countries to increase their health expenditure and target health resources efficiently and effectively.

Domestic funding for HIV is increasing – accounting for 59 per cent of all HIV funding in our region in 2012.   That’s good news.  But the majority of spending is for HIV treatment and care.   Prevention is relatively cheap and very effective. But prevention is still mainly funded from international sources.  2013 data shows HIV prevention constituted only 14 per cent of domestic spending but 25 per cent of international spending on HIV. Within the prevention category, most spending is still targeted at the general population.

Finally, we need health systems that can deliver.  One of the key enabling factors in Australia’s early success in reducing our new infections was a well-performing health system able to provide a range of clinical services in diverse locations. In many countries, stronger health systems are needed, along with better targeted services.

We are seeing how these developments are changing the response of countries in our region.

Papua New Guinea and Indonesia are encouraging examples of the increasing commitment of governments to addressing HIV and health issues. They are building on earlier successful activities piloted through Australia’s aid program.

In 1992 the Australian aid program was funding HIV awareness-raising for national leaders in PNG. Today, the Government of PNG is on track to achieving their 80 per cent target for antiretroviral treatment under the Medium Term Development Plan. In 2012, 74 per cent of those in need had access to these life-saving drugs, procured and provided free of charge by their Government. 

The steady increases in people testing and accessing treatment are a result of the combined efforts of the health sector and civil society partners like the Catholic HIV/AIDS Services and the Clinton Health Access Initiative, as well as small local organisations like Susu Mamas which DFAT has supported to expand prevention of mother to child transmission services. It is tremendously encouraging to see that Susu Mamas is now receiving core funding from the Government of PNG.

Indonesia is another country where Australia makes a significant contribution to the HIV response though the aid program.  This includes HIV prevention services for people who inject drugs. HIV rates among injectors have fallen from 52 per cent in 2007 to 42 per cent in 2011.  The Government of Indonesia is now taking on many of the harm reduction initiatives started under the aid program, including the funding and staffing of 83 methadone maintenance therapy centres.

We have learnt much from working with PNG and Indonesia, and that has put us on the right track towards sustainable and mutually beneficial partnerships between our governments, and with our civil society, private sector and development partners.

Australia’s policy response

Our policy approach needs to respond to these developments, and so Australia has been considering how we can best contribute to the international HIV response in the future. 

Through a process of review and consultation, including with Australian stakeholders from civil society, research and medical agencies, and development partners in the United Nations and USAID, we have identified priorities for our international HIV response that align with our overall development policy.

We will focus on leadership and advocacy in three key areas: an equitable HIV response, which leaves no one behind, effective evidence-based investments which target key populations and hot spots, and sustainable resourcing

We will continue to promote and demonstrate leadership on health and HIV, with a focus on our neighbours in Asia and Papua New Guinea.

This year Australia is hosting this conference, and the Australian Government is contributing over $4 million. We are also chairing the UNAIDS Board. In these and other global forums we will advocate for support to health and HIV, building on the Millennium Development Goals, the United Nations High Level Meeting on AIDS in 2011 and the Post 2015 development agenda.

In particular we will advocate for a strategic investment in key populations and for changes to laws and policies which prevent marginalised people from accessing services and give rise to stigma and discrimination, including discrimination on the basis of sexuality and HIV status.

Operationalising this will also be a focus of our bilateral HIV programs in Indonesia, Papua New Guinea and Burma.

Through our broader health programs and support for health system reform, we will work to integrate HIV testing and treatment within sexual and reproductive health, TB, maternal and child health and chronic disease care services to maximise opportunities to reach all those in need.

To inform effective programming and innovation in health and HIV, we will support operational research. The Government has committed around $30 million for health research to support this.

But the key issue for an aid program, and one which requires a stronger focus, is sustainability. Our contributions through our aid program are time bound. They cannot substitute for the commitment and political will of a national government. We want to work as partners with national governments, to help where we are needed, to innovate, build capacity, share expertise and lessons learnt.

Australia will supportpartner countries to allocate funding effectively and equitably and increase domestic funding for health and HIV.

Many of the governance and coordination structures set up earlier in our response were designed to manage larger, more generalized epidemics. We will encourage the review of these mechanisms for greater efficiency. We will also look to foster new and innovative partnerships with the private sector and with emerging donors like China and India.

Summary - Going forward

Going forward, Australia will remain a strong advocate for equitable, effective and sustainable HIV responses through health diplomacy in national, regional and global forums.

We will invest strategically in our country programs and more broadly through our support to improve and strengthen national health systems. We will also support regional activities and our multilateral partners, particularly the Global Fund and UNAIDS.  The commitment we made to spend $1 billion in the decade from 2000 has been met and surpassed.  We will continue to invest strategically and plan to spend around $270 million on HIV related activities over the next three years.     

We will continue to build capacity in civil society, enabling these organisations to work productively with government and the private sector in their national HIV responses.  We will work with companies, such as Oil Search and BHP, where there is growing recognition of the need to address HIV more broadly through mechanisms like the Global Fund as well as at workplace level. 

We will build our region’s skills and expertise through Australian Award scholarships for study in Australia and the Government’s New Colombo Plan which will send Australian students to study in the Indo-Pacific region. These initiatives will help to expand our scientific and medical links with the region and be a catalyst for ongoing engagement at a professional and personal level.

In the next year, member states will go through the process of articulating our global vision for the future through the post 2015 development goals. In doing so, we will be building on the progress we have achieved together over decades of hard work, courage and commitment - to step up the momentum and end the  AIDS epidemic. 

Thank you.