UNAIDS Outcome Framework 2009-2011

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Joint Action for ResultsUNAIDS Outcome Framework2009–2011

UNAIDS/09.13E – JC1713E (English original, May 2009)Updated version March 2010 Joint United Nations Programme on HIV/AIDS (UNAIDS) 2010.All rights reserved. Publications produced by UNAIDS can be obtained from the UNAIDS Content ManagementTeam. Requests for permission to reproduce or translate UNAIDS publications—whether for sale or fornoncommercial distribution—should also be addressed to the Content Management Team at the address below,or by fax, at 41 22 791 4835, or e-mail: publicationpermissions@unaids.org.The designations employed and the presentation of the material in this publication do not imply the expression ofany opinion whatsoever on the part of UNAIDS concerning the legal status of any country, territory, city or area orof its authorities, or concerning the delimitation of its frontiers or boundaries.The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed orrecommended by UNAIDS in preference to others of a similar nature that are not mentioned. Errors and omissionsexcepted, the names of proprietary products are distinguished by initial capital letters.All reasonable precautions have been taken by UNAIDS to verify the information contained in this publication.However, the published material is being distributed without warranty of any kind, either expressed or implied.The responsibility for the interpretation and use of the material lies with the reader. In no event shall UNAIDS beliable for damages arising from its use.Cover photo: UNAIDSWHO Library Cataloguing-in-Publication DataJoint action for results: UNAIDS outcome framework, 2009–2011.“UNAIDS/09.13E / JC1713E”.1.HIV infections – prevention and control. 2.HIV infections – epidemiology. 3.Technical cooperation.4.Interinstitutional relations. I.UNAIDS.ISBN 978 92 9173 780 2UNAIDS20 avenue AppiaCH-1211 Geneva 27Switzerland(NLM classification: WC 503.6)T ( 41) 22 791 36 66F ( 41) 22 791 48 35distribution@unaids.orgwww.unaids.org

Joint Action for ResultsUNAIDS Outcome Framework, 2009–2011Photo UNAIDS / P. Virot“People forget.We are here to act.We are here to deliver results.We are agents ofchange. Our job is to change the UN – and,through it, the world.”Secretary-General Ban Ki-moonTurin, ItalyPhoto UNAIDS / P. VirotPhoto UNAIDS / P. Virot

J O I N T AC T I O N F O R R E S U LT S UNAIDS OUTCOME FRAMEWORK, 2009–2011Photo UNAIDS / P. Virot2Photo UNAIDS / P. Virot

J O I N T AC T I O N F O R R E S U LT S UNAIDS OUTCOME FRAMEWORK, 2009–2011ContextThe global response to the HIV epidemicis at a crossroads. The emergency footing ofthe response over the past 25 years and thebroad social mobilization of stakeholdershave spearheaded remarkable action andresults.Yet the hard-won gains are fragile andcall for a renewed commitment and leadership by the United Nations system. Ourjoint efforts have produced encouragingresults, but many challenges lie ahead.In order to achieve further progress, it isessential to take steps to address specific gapsin the response to the epidemic as well asthe social, political and structural constraintsthat limit results.Progress requires that the UNAIDSSecretariat, the Cosponsors1 and otherpartners protect and build on the gainsalready made and make use of theopportunities for linking specific actionsand broader agendas for reaching theMillennium Development Goals.The challenges facing the response toAIDS are exacerbated by the current globalfinancial and economic crisis. As statedin the April 2009 communiqué from the1Secretariat of the United Nations SystemChief Executives Board for Coordination,the crisis will affect all countries, with aserious and disproportionate impact on thepoorest, and could leave 80% of the world’spopulation without a social safety net.The HIV organizational landscape hasevolved and grown more complex overthe past decade. UNAIDS, donors and civilsociety, including networks of people livingwith HIV, have rightly demanded greaterclarity on the relationships between needs,financing, activities and outcomes. Alsodemanded is greater specificity about therole of UNAIDS and the Secretariat withinthe wider constellation of actors.We are responding through this OutcomeFramework to optimize our partnershipsbetween the UNAIDS Secretariat and theCosponsors. The Outcome Framework,which builds upon the UNAIDS StrategicFramework (2007–2011), will guide futureinvestment. It will also hold the Secretariatand the Cosponsors accountable for makingthe resources of the UN work for results inthe countries.The ten UNAIDS cosponsoring organizations are: Office of the United Nations High Commissioner for Refugees (UNHCR), UnitedNations Children's Fund (UNICEF), World Food Programme (WFP), United Nations Development Programme (UNDP), United NationsPopulation Fund (UNFPA), United Nations Office on Drugs and Crime (UNODC), International Labour Organization (ILO), United NationsEducational, Scientific and Cultural Organization (UNESCO), World Health Organization (WHO), World Bank.3

J O I N T AC T I O N F O R R E S U LT S UNAIDS OUTCOME FRAMEWORK, 2009–2011Keeping the momentumIn 2006, the world made a historic commitment at the United Nations aimed at thegoal of universal access to comprehensiveprevention programmes, treatment, careand support. The achievement of universalaccess will remain the fundamental priorityfor UNAIDS. Universal access goals canbecome a reality. By achieving these goals,we can contribute to the broader development agenda.The multisectoral determinants of theepidemic demand dynamic and multifacetedresponses that must constantly evolve tomeet emerging challenges and priorities. Wehave identified areas in which our collectiveaction can make a difference. Flexibility inplanning and budgeting is critical, as is theability to monitor progress and results.We will continue to strive for increased efficiency and effectiveness in the response toAIDS, and to demonstrate the added valueof coherence in the UN system and itscollective impact at the country level.We will revive the unified forces of theCosponsors and the implementation ofa relevant UN response to the epidemic.Delivering results in priority areas holds theCosponsors and the UNAIDS Secretariataccountable in each area of their respectivecomparative advantage.Photo UNAIDS / J. Wainwright4

J O I N T AC T I O N F O R R E S U LT S UNAIDS OUTCOME FRAMEWORK, 2009–2011Moving forwardUnder the Outcome Framework for theperiod 2009–2011, UNAIDS will continueto advocate for comprehensive nationalresponses, including ramped-up preventionefforts to break the trajectory of the epidemic,and will refocus its efforts on achieving resultsin ten priority areas. These priority areashave been selected because their realizationwill contribute directly to the achievementUnion and the Association of Southeast AsianNations, and coalitions such as Health 8.Substantial progress on a number of theMillennium Development Goals can beachieved by taking the AIDS response outof isolation and integrating it with effortsto achieve broader human developmentand the goals of health and social justice.This Outcome Framework affirms the UNAIDS Secretariat andCosponsors to leverage our respective organizational mandates and resourcesto work collectively to deliver results.of universal access and will simultaneouslyenable advancement towards the relatedMillennium Development Goal outcomes.The response to AIDS should be aboutbuilding bridges and restoring trust inpublic institutions.Our success demands a shift in the development agenda, in which poverty reduction isaccompanied by a growth in dignity, freedomand equality. In this model of development, women and men — including thosepushed to the margins of society — will haveenhanced control over their lives.Future investments in the AIDS response willbe guided by:The AIDS movement has used the powerof human rights to transform society’sapproach to the epidemic. The globalmovement of people living with HIV andthe nearly four million people on treatmentare a force for change.UNAIDS will fully engage partners andstakeholders from all sectors, including civilsociety, networks of people living with HIV,the private sector, governments, regionalintergovernmental groups such as the AfricanThe commitment to stand by peopleliving with and affected by HIV;Measurable impacts on preventing newinfections and on the people mostaffected;The promotion of human rights andgender equality;The best available scientific evidence andtechnical knowledge;Comprehensive responses to AIDS thatintegrate HIV prevention, treatment, careand support;The pursuit of wider results in terms ofdevelopmental outcomes; andProgramme coherence and alignment ofexternal resources to national prioritiesto effectively deliver results.5

J O I N T AC T I O N F O R R E S U LT S UNAIDS OUTCOME FRAMEWORK, 2009–2011Action agenda:Ten priority areas and cross-cutting strategiesPhoto UNAIDSUnder the Outcome Framework for theperiod 2009–2011, UNAIDS will focus itsefforts on achieving results in ten priorityareas. These priority areas have been selectedbased on a series of consultations with theCosponsors, communities, civil society and abroad range of other stakeholders.The realization of these priority areas willaccelerate the achievement of universalaccess. It will require effort and commitmentfrom all stakeholders, and can bring abouteven greater results in terms of widerdevelopmental outcomes and contributeto the attainment of the MillenniumDevelopment Goals.In our continuous efforts to support allcountries to halt and reverse the epidemic,address its drivers and mount an effectiveresponse, major relevant strategies forcombination HIV prevention must bestrengthened, brought to scale and extendedto meet the particular needs of all thoseat risk, including people on the move andpeople in emergency settings.The priority areas are interlinked, andhence progress in one area will contributeto progress in others. In many cases, a singleprogrammatic activity can promote action inmore than one of the priority areas.6We can reduce sexual transmissionof HIV: Sexual transmission accounts formore than 80% of new HIV infectionsworldwide. Reversing the global AIDSepidemic requires a dramatic increase incommunity, national and global action forsexual and reproductive health and rights,and in individual commitment to safersex. We can reduce sexual transmissionof HIV by promoting social norms andindividual behaviours that result in sexualhealth; by supporting the leadership ofpeople living with HIV for ‘positivehealth, dignity and prevention’; andby supporting universal access to keyprevention commodities and services,especially for the most vulnerable.We can prevent mothers fromdying and babies from becominginfected with HIV: By scaling upaccess to and the use of quality servicesfor the prevention of mother-to-childtransmission ( ) as an integral part ofsexual and reproductive health servicesand reproductive rights for women, theirpartners and young people. This includesongoing care and treatment for women,and their partners, and children inaffected families.

J O I N T AC T I O N F O R R E S U LT S UNAIDS OUTCOME FRAMEWORK, 2009–2011HIV prevention key to changing the trajectory of the AIDS epidemicFor every two people who start on HIV treatment, five are newly infected. UNAIDS mustmagnify its focus on HIV prevention while addressing the specific needs of each keypopulation, including youth, women and girls, sex workers and their clients, injecting drugusers, men who have sex with men, prisoners, refugees and migrants. This will help changethe course of the epidemic.UNAIDS advocates for a combination approach to HIV prevention that is tailored to localepidemics. Combination prevention requires action simultaneously both on the immediaterisks and on the underlying drivers of the epidemic.Combination HIV prevention involves choosing the right mix of HIV prevention actions andtactics to suit the unique epidemic in each country and matching the needs of those most atrisk, just as the right combination of drugs and nutritional support is chosen for antiretroviraltreatment.Combination HIV prevention means providing services and programmes for individuals,such as promoting the knowledge and skills necessary to undertake safe behaviours. Theseinclude knowledge of HIV status, knowledge of risks, reducing concurrent and serial sexualpartners, using condoms consistently, scaling-up male circumcision and the prevention ofmother-to-child transmission services. Combination HIV prevention needs investment instructural interventions, including legal reforms to outlaw discrimination against people livingwith HIV and the enforcement of laws that prohibit sexual and gender-based violence. It alsorequires the promotion of a desire for behaviour change while simultaneously acting to shiftcommunity norms and broader social environments. Only in this way can HIV preventionresponses be widespread and sustainable. Combination prevention highlights the synergiesthat can come when these programmes are coordinated and reinforce each other.There is no single ‘magic bullet’ for HIV prevention, but by making the right choices everycountry's HIV prevention efforts can have the power, relevance and scale required to stop newHIV infections.We can ensure that people living withHIV receive treatment: By scaling upand sustaining treatment coverage andbridging the gap between sexual andreproductive health and HIV, integratingnutritional support within treatmentprogrammes and increasing the number ofskilled and equipped health workers.We can prevent people living withHIV from dying of tuberculosis: Byensuring an effective integrated delivery ofservices for HIV and tuberculosis as well asnutritional support in all settings.We can protect drug users frombecoming infected with HIV: Bymaking comprehensive, evidence-informedand human-rights-based interventionsaccessible to all drug users (i.e. harmreduction and demand reduction), includingprogrammes to reduce hepatitis coinfection,7

J O I N T AC T I O N F O R R E S U LT S UNAIDS OUTCOME FRAMEWORK, 2009–2011and by ensuring that legal and policyframeworks serve HIV prevention efforts.We can empower men who havesex with men, sex workers andtransgender people to protectthemselves from HIV infection andto fully access antiretroviral therapy:by ensuring that men who have sex withmen, sex workers and transgender peopleare empowered to both access and delivercomprehensive and appropriate packagesof HIV prevention, treatment, care andsupport services and by ensuring that lawenforcement agencies and the judicialsystem protect their rights. Currently, accessto prevention, treatment, care and supportservices is limited compared with the shareof the burden faced by these populations.We can remove punitive laws, policies,practices, stigma and discriminationthat block effective responses to AIDS:By collaborating with civil society and allstakeholders to uphold non-discriminationin all efforts, countering social judgementand the fear that feeds stigma, delivering onthe broader human rights agenda, includingin the areas of sex work, travel restrictions,homophobia and criminalization of HIVtransmission, ensuring access to justice anduse of the law by promoting property andinheritance rights, protecting access to andthe retention of employment and protectingmarginalized groups and reinforcing thework of UN Plus.We can meet the HIV needs ofwomen and girls and can stopsexual and gender-based violence:by building on the synergies betweenthe gender and AIDS response for8positive change to the lives of womenand girls and by utilizing opportunities tocomprehensively respond to sexual andgender-based violence.We can empower young people toprotect themselves from HIV: By puttingyoung people’s leadership at the centre ofnational responses, providing rights-basedsexual and reproductive health education andservices and empowering young people toprevent sexual and other transmission of HIVinfection among their peers. By ensuringaccess to HIV testing and prevention effortswith and for young people in the contextof sexuality education. And by ensuringenabling legal environments, educationand employment opportunities to reducevulnerability to HIV.We can enhance social protection forpeople affected by HIV: By promotingthe provision of a range of social servicesto protect vulnerable populations,including populations of humanitarianconcern, refugees, internally displacedpersons and migrants, informal-economyworkers, people experiencing hunger, poornutrition and food insecurity and orphanedand vulnerable children. By promotingcorporate social responsibility, workplacepolicies and income generation forpeople affected by HIV. By empoweringgovernments, particularly ministries oflabour, employers and workers to adopt,implement and monitor HIV-relatedpolicies. And by countering discriminationand promoting HIV prevention, treatment,care and support through workplaces,including through UN Cares, and theirlinks with the community.

J O I N T AC T I O N F O R R E S U LT S UNAIDS OUTCOME FRAMEWORK, 2009–2011Photo UNAIDS / P. VirotCross-cutting strategiesThese outcome areas call for joint action. Inorder to address these areas effectively, theSecretariat and the Cosponsors will supportcross-cutting strategies and institutional deliverymechanisms that build on what we know worksand will take steps for change where we needto work differently and work better. We will:Improve country-by-country strategicinformation generation, analysis and use,including through the mobilization ofnovel sources;Assess and realign the management oftechnical assistance programmes;Bring AIDS planning and action intonational development policy and broaderaccountability frameworks;Develop shared messages for sustainedpolitical commitment, leadership development and advocacy; andOptimize UN support for applications to,and programme implementation of, theGlobal Fund to Fight AIDS, Tuberculosisand Malaria;Broaden and strengthen engagement withcommunities, civil society and networksof people living with HIV at all levels ofthe response.9

J O I N T AC T I O N F O R R E S U LT S UNAIDS OUTCOME FRAMEWORK, 2009–2011Translating priority areas into measurableoutcomesThe ultimate impacts of the renewedcommitment to universal access reflected inthe Outcome Framework will be avertingHIV infections and HIV-related deaths andimproving the quality of life of people livingwith HIV. This is in line with the sixthMillennium Development Goal, to halt andreverse the AIDS epidemic.For each of the ten priority areas, as wellas the cross-cutting strategies, specificoutcomes and targets will be established inthe UNAIDS Unified Budget and Workplan(UBW).The UBW brings together the individualand joint efforts of the ten Cosponsorsand the UNAIDS Secretariat to operationalize the Outcome Framework. Thespecific results and corresponding budgetsof the Cosponsors and the Secretariat willbe defined. Clear accountability indicatorswill be developed and used to track progress and to monitor the achievement of theoutcomes and the action agenda.In supporting the implementation of theOutcome Framework, UNAIDS willincreasingly concentrate its human and10financial resources where they can makethe most difference to the epidemic. Jointprogrammes of support will be scaled upsubstantially and will become the norm andnot the exception.UNAIDS country staff will increasinglyfocus their efforts on:Brokering and unifying the managementof relevant technical support for appropriate national AIDS responses;Producing strategic analyses of programmatic quality to improve results-basedimplementation;Enabling political agents to demandchange in governance, legislation andpolicy to support evidence-informedprogrammes;Developing oversight structures toensure mutual accountability to demandresults; andSupporting the Cosponsors, in order tomaximize their comparative advantage atthe country level in support of nationalefforts to achieve universal access.

J O I N T AC T I O N F O R R E S U LT S UNAIDS OUTCOME FRAMEWORK, 2009–2011Measuring progress,promoting accountability, achieving the visionFollowing the historic G20 summit inMarch 2009, UN Secretary-General BanKi-moon made clear the importanceof turning the economic crisis into anopportunity for a sustainable future. TheUN system will actively participate in anew vulnerability monitoring and alertmechanism to track developments andreport on the political, economic, social andenvironmental dimensions of the crisis.Each of the ten priority areas represents adistinct goal. Each priority area requires astrategic combination of specific actions thatshould be tailored to the country’s specificepidemic and that must identify the mosteffective strategies, build local capacity,increase coverage of services, ensure qualityand ensure that services are equitable.If countries were to reach their 2010 targetsfor universal access, a dramatic change in thecourse of the epidemic would follow (seebox below).In order to establish baselines, measureprogress and monitor success or failure,multiple sources of data and methodologiesmust be used. No single indicator cancapture the entire scope of progress towardsany of these outcomes. We will use a mix ofrelevant quantitative indicators, compositeindices and specific qualitative assessments.We will synthesize this information intoa meaningful understanding of whetherIf countries reached their 2010 targets for universal access*, this would dramaticallychange the course of the epidemic.Expected outcomes in 132 low- and middle-income countries (in millions)200720102015Number of new HIV infections (annual)2.71.31.0People on antiretroviral treatment3.06.711.6Workers reached in the workplace11.846.296.7Pregnant women offered comprehensiveprevention of mother-to-child transmissionservices20.074.578.7Men who have sex with men reached3.920.423.3Safe injections provided348.34 2475 742Orphans supported1.56.718.9* Under the country-defined universal access approach countries achieve different programmatic targets at different times and the achievement of universal access by all countries by 2015.11

J O I N T AC T I O N F O R R E S U LT S UNAIDS OUTCOME FRAMEWORK, 2009–2011We can prevent mothers from dying and babies from becoming infectedwith HIV — how to measure progressTo know if a country has achieved this priority area, we need indicators to answerquestions such as:Have the most effective multiple drug combinations for preventing HIVtransmission (according to the latest guidelines), rather than the use of just onedrug (such as nevirapine), been utilized?Were mothers evaluated for initiation of full, ongoing antiretroviral treatment?Have other sexual and reproductive health services been provided (e.g.congenital syphilis screening and treatment)?Were other members of the family provided services, with siblings and spousesbeing tested, counselled and started on therapy as needed?Has counselling taken place on infant feeding and on the future use ofcontraception?Has there been an exploration of the possible social support services that may benecessary, such as for nutrition and education?progress is truly being made and wherebottlenecks are impeding progress.care workers available compared with theestimated needs.By 2010, nearly US 25 billion (US 18.9billion–US 30.5 billion) will be neededannually for low- and middle-incomecountries. To assess access to funds, countrieswill be mapped based on the proportionof available funds from all sources (nationaland international) compared with theestimated resource needs and the number ofcountries with successful HIV-related grantapplications to the Global Fund to FightAIDS, Tuberculosis and Malaria. Countrieswill also be monitored according to thelevel of investment in the strengthening ofthe health sector and the number of health-Each of the ten priority areas will bemonitored and assessed in the samecomprehensive way — outcome byoutcome and country by country. Thecommon dimensions of capacity, coverage,quality, equity and efficiency are neededto provide the framework for assessingthe impact in each country and to enablecomparability across countries.12Ultimately, we are concerned with resultsfor people, whether and why our efforts areeffective at achieving measurable impactson new infections, life expectancy andquality of life.

UNAIDS is an innovative joint venture of the United Nations, bringing together the efforts and resourcesof the UNAIDS Secretariat and ten UN system organizations in the AIDS response. The Secretariat headquarters is in Geneva, Switzerland—with staff on the ground in more than 80 countries. The Cosponsorsinclude UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, ILO, UNESCO, WHO and the World Bank.Contributing to achieving global commitments to universal access to comprehensive interventions for HIVprevention, treatment, care and support is the number one priority for UNAIDS. Visit the UNAIDS websiteat www.unaids.org

UNAIDS20 AVENUE APPIACH-1211 GENEVA 27SWITZERLANDTel.: ( 41) 22 791 36 66Fax: ( 41) 22 791 48 35e-mail: distribution@unaids.orgwww.unaids.orgUniting the world against AIDS

The responsibility for the interpretation and use of the material lies with the reader. In no event shall UNAIDS be liable for damages arising from its use. Cover photo: UNAIDS UNAIDS 20 avenue Appia CH-1211 Geneva 27 Switzerland T ( 41) 22 791 36 66 F ( 41) 22 791 48 35 distribution@unaids.org www.unaids.org WHO Library Cataloguing-in .

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