Background In 2009, AIDS financing fell for the first time, reflecting the global financial crisis and shifting health and development priorities. In this context, future international AIDS policy must focus on efficiency, effectiveness and sustainability.

Efficiency The surge of financing for AIDS over the last decade has sometimes led to sub-optimal efficiency. There is an urgent need to improve allocative efficiency, by ensuring resources are allocated for the best proven and most relevant interventions among the right groups in the right geographic areas. AIDS responses globally are beset by mismatches between investments and epidemiological context and program choices. There is also a need to improve technical efficiency, so that selected interventions are delivered at scale, for the lowest cost. Several studies show how the same services in the same context in the same country can vary by several orders of magnitude. In a resource constrained future, such variances must be reduced and technical efficiency constantly improved. Integration of health-related HIV services and other health services may also yield greater efficiencies.

Effectiveness In concentrated epidemics, particularly among sex workers, where we have well validated interventions, our major priorities are to improve allocative and technical efficiency, so we direct our resources towards effective interventions for priority populations. In generalised epidemics, we need to strengthen our evidence of what works. Beyond male circumcision, we have limited proven interventions to reduce general population adult sexual transmission. We also need to move from efficacy to effectiveness, demonstrating that proven approaches can have real world effect at scale. We need to strengthen the middle-ground between randomised control trials and observation, by using quasi-experimental techniques to construct robust counterfactuals—that is, what would have happened without the counterfactual. We also need to make biological end-points, primarily HIV incidence or credible incidence proxy measures.

Sustainability We must move from an emergency response to longer-term sustainability. This will include increasing and diversifying domestic resource mobilisation, especially in middle-income countries and diversifying the sources of international financing. Services that are related to AIDS but also related to other elements of the health sector, such as blood safety and universal precautions will increasingly be financed from overall health sector resources.

Conclusion We must urgently re-position the global AIDS response, guided by the drive for greater efficiency, effectiveness and sustainability—we have no time to lose.