The Dublin Declaration
Beyond Promises
Imperial College London
23rd November 2007
Professor Rifat Atun MBBS MBA DIC FFPHM FRCGP
Professor of International Health Management
Director, Centre for Health Management
Imperial College London
© Prof. Rifat Atun. Imperial College London, 2007
Leadership and Partnership
© Prof. Rifat Atun. Imperial College London, 2007
1. Political Leadership


Commitments 1, 1, 3, 5, 6, 22, 26, 30, 32, 33
•
•
•
•
Strengthened political leadership
HIV now addressed at national level/leadership
Regional efforts and cross-border partnerships
Implementation gap:
– Resistance to harm reduction programmes
– Structural changes in health systems not realised
– IDU challenges unlikely to be addressed
• Need to enhance efforts and M&E
© Prof. Rifat Atun. Imperial College London, 2007
3. Resource availability

(Commitments 1, 7, 8, 9, 13, 17, 29)
• In CIS-10, increased funding US$0.5m in 2001 to
US$55m in 2005
• Sharp increase 2004-05 : mainly from GFATM
• Increased out-of-pocket expenditure
• National contributions variable
• Funding gaps exist
• Allocative efficiency questionable
© Prof. Rifat Atun. Imperial College London, 2007

Millions
Domestic and International Financing for
HIV/AIDS in 10 CIS Countries (2001-06)
$70
$60
$50
$40
$30
$20
$10
$0
2001
2002
2003
Domestic Public Expenditures
© Prof. Rifat Atun. Imperial College London, 2007
2004
2005
2006
International Financing
Domestic vs. International Financing for
HIV/AIDS in 10 CIS Countries
Domestic versus Global funds 2005
100%
75%
50%
25%
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Domestic05
Global05
© Prof. Rifat Atun. Imperial College London, 2007
Prevention
© Prof. Rifat Atun. Imperial College London, 2007
4. Injecting drug use and HIV
(Commitments 10, 13, 25)
• Limited progress in scaling up ‘Comprehensive
Package’ of Technical Guidance for IDUs
–
–
–
–
“IDUs remain invisible”
Low NSP and OST coverage in central and eastern Europe
OST not available in six countries
HAART access in Europe increasing but limited for IDUs
• Need coverage targets for NSPs (60%), OST (40%)
and HAART (100%),
• Monitoring (using WHO/UNODC/UNAIDS Technical
Guide) and comparative benchmarking of results
© Prof. Rifat Atun. Imperial College London, 2007

5. Most vulnerable and high-risk populations
(Commitments 9, 13, 18, 25)
• Data remains patchy
• Stigma, discrimination and inequities persist for sex
workers, MSM, prisoners, migrant populations and
ethnic minorities
• Define ‘vulnerable’ and ‘risk’ for M&E of progress
• Targeted interventions to enhance access with
comprehensive surveillance systems
• Identify and address legal and regulatory barriers
© Prof. Rifat Atun. Imperial College London, 2007

7. Prevention of mother-to-child
transmission and paediatric AIDS
 
(Commitments 11, 12, 14)
• Improved coverage of PMTCT interventions and
paediatric HIV
• Elimination by 2010 needs intensive and accelerated
action
• Prioritise in National Responses
– Evidence-based interventions
– Strengthen reach and coverage, especially in marginalised groups
• Eastern Europe and Central Asia
– scale up resources for PMTCT and HIV in children
– E-W and E-E collaboration
– Civil society, national and international partnerships
© Prof. Rifat Atun. Imperial College London, 2007
10. Sexually transmitted infections
(Commitment 16)
 
• Increasing rates now leveling in some countries but ?
Reliability of data
• Weak/variable surveillance in 2nd generation HIV
surveillance that includes STIs
• No baseline and ascertain progress
• Many examples of good practice in western Europe
• Varied integration of HIV-STI services
• Need to strengthen and harmonise surveillance
• Evidence based interventions and cross-learning on
IEC, prevention and treatment
© Prof. Rifat Atun. Imperial College London, 2007
11. Research and new technologies
(Commitments 19, 24, 29)

• Funding levels increased in the EU but uneven
–
–
–
–
Larger commitment in FP5-6-7 but execution not clear
Reduced DG Sanco budget for Public Health Programme 2007-13
Funding gap for PDPs, social sciences and behavioural research
EDCTP commitments not met
• National level expenditures opaque as no tracking
• Need to increase funding, address gaps and track
resources (absolute and relative to commitments)
© Prof. Rifat Atun. Imperial College London, 2007
Living with HIV/AIDS
© Prof. Rifat Atun. Imperial College London, 2007
12. Treatment and care
(Commitments 13, 21, 23, 25)

• HAART coverage rose from 242,000 in 2003 to 389,000
by mid 2006 and 407,000 by 2007
• Improved survival
• Increase of 6x in CEE but coverage still low
• Inequitable access by IDUs in CEE
• Lifetime cost €0.5m with total cost for 2.3m persons
estimated at €1trillion
• Resistance to ARVs increasing
• Co-infection with TB and MDRTB key problem
© Prof. Rifat Atun. Imperial College London, 2007
13. Stigma, discrimination and human rights
(Commitments 1, 20, 31)

• “Reality gap” Human rights underpin every
aspect of Dublin Declaration, but countries failing
to address discrimination and stigma and
promote human rights of PLWHA
• Poor disaggregate data
• Rights-based approach to monitoring progress
© Prof. Rifat Atun. Imperial College London, 2007
Conclusions
© Prof. Rifat Atun. Imperial College London, 2007
Cross Cutting Themes
• Greater accountability needed
• Enabling legal and regulatory framework to reduce
stigma, exclusion and discrimination
• Strengthen surveillance
• M&E with more disaggregate data
• Greater harmonisation of interventions and M&E
• Strengthen x-country integration
• Improve targeting with greater intensity and scale of
effort to reduce inequities
• Increase civil society and private sector involvement
• Improve use of evidence-based interventions
© Prof. Rifat Atun. Imperial College London, 2007