Mozambique Test and Start Cost Analysis

Transcription

1 Mozambique Test and Start Cost Analysis

2 Background WHO released new treatment guidelines (2015) Initiate ART in children, adolescents and adults with HIV regardless of CD4 count or clinical stage. HP+ approved workplan January 28, 2016 HP+ traveled to Maputo from February 26 to March 13, 2016 Subsequent Trips June 26 to July 9, 2016 September 30 to October 16, 2016 November 18 to November 27, 2016 MISAU adopted Test and Start on March 6, 2016 HP+ meetings with the TWG (MOH, UNAIDS, USAID, and GF) March 2016 May 2016 July 2016 October 2016 November 2016 MISAU started implementing Test and Start in August 2016

3 Background Health benefits for Mozambique of rapid scale-up Mortality and morbidity among PLHIV is reduced Sexual and vertical transmission of HIV is suppressed with successful treatment Importance to MISAU of Test and Start Increase coverage Adults on ART from 63% (2014) to 90% by 2020 Children on ART from 36% (2014) to 90% by 2020 Reduce the number of new infections by 50% Improve retention and follow-up of patients on ART Improve ART access (especially in the North and Central regions) Rapid scale-up will require more resources upfront, but should lead to cost savings over time

4 Objective (Original SOW) To provide cost analysis that will contribute as key evidence needed for the GoM to make critical decisions to achieve by 2020

5 Objectives (Consultation with Costing TWG) Determine the incremental costs through 2020 of a change in ART initiation eligibility to test and start (T&S) Determine the incremental costs through 2020 of a change in prevention interventions Determine the costs for modifying monthly scripting standards for ART in Mozambique from the current practice to multimonth scripts (MMS) (3 or 6 month visits)

6 Methodology Unit Costs Unit costs for drugs and consumables obtained from MISAU/DNAM and/or PSM (Chemonics) Programmatic Costs Training Monitoring and evaluation Mass media and facility-based IEC Quality control National planning, coordination and program management Human Resources Updated salaries, benefits, and number of staff obtained from FORSSAS (Deloitte) Infrastructure costs Obtained from CMAM (MOH) Logistics costs Assumed as 9% per year on top of drugs and consumables

7 Methodology Treatment Scenarios Constant Coverage Moderate Scale-up Fast Track Treatment Eligibility CD4 < 500 T&S T&S T&S Treatment Coverage (2020) Multi Month Scripting (MMS) 63% 81% 81% 81% No Fast Track Treatment and Prevention Laboratory No viral load 25% viral % viral % viral 2020 Prevention No change PEN IV targets No change UNAIDS Fast Track targets

8 Methodology: Targets Regions C = Central (Manica, Sofala, Tete and Zambezia) N = North (Cabo Delgado, Nampula and Niassa) S = South (Inhambane, Gaza, Maputo, Maputo City) Intervention Region Constant PEN IV Fast Track ( ) (2020 Targets) (2020 Targets) C 1.8% 15% 15% Community mobilization N 3.3% S 9.5% 30% 30% N 20% Mass media C 31% 80% 80% S 45% N 19% 58% 58% VCT C 26% 33% 35% S 36% 48% 48% N 17% 27% Condoms C 25% 36% 90% S 29% 36% N 1.8%/5.7% Youth in school/out of school C 3.0%/3.0% 20%/30% 20%/30% S 3.0%/19% N 13% 60% SW (outreach) C 14% 85% S 21% 80% N 35% MSM (outreach) C 0 26% 85% S 0.5% IDU (outreach) All 0 50% 85% N 91% 91% Male circumcision C 45% 44% 90% S 68% 75% PrEP: Medium risk, high risk, MSM All %

9 Results Total Costs Photo Courtesy of Photoshare

10 People on ART (Adults and Pediatric) 1,400,000 Increased prevention spending and the benefits of treatment as prevention reduces the number of people on ART 1,200,000 1,000, , , , , Constant Prevention Moderate Scale-up Fast Track Treatment Fast Track Treatment and Prevention

11 Total Costs Millions $400 $350 $300 Substantial resources are still needed to achieve $250 $200 $150 $100 $50 $ Constant Coverage Moderate Scale-up Fast Track Treatment Fast Track Treatment and Prevention

12 Cost Per Person $148 $146 $144 $142 $140 $138 $136 $134 $132 $130 $ Constant Coverage Fast Track Treatment Moderate Scale-up Fast Track Treatment and Prevention

13 Total Costs (Treatment vs Prevention) Treatment Prevention Millions $200 $180 $160 $140 $120 $100 $80 $60 $40 $20 $ Millions $200 $180 $160 $140 $120 $100 $80 $60 $40 $20 $ Constant Coverage Moderate Scale-up Constant Coverage Moderate Scale-up Fast Track Treatment Fast Track Treatment and Prevention Fast Track Treatment Fast Track Treatment and Prevention

14 Photo Courtesy of Rossino Drugs and Supplies

15 Drug and Supply Costs Millions $250 $200 $150 $100 $50 $ Constant Coverage Moderate Scale-up Fast Track Treatment Fast Track Treatment and Prevention

16 Drugs and Supplies Highest decrease (6%) in ART as a % of drugs and supplies in the FT Treatment & Prevention scenario when compared with FT Treatment (5%) Moderate Scale-up 11% 7% 68% 4% 14% 6% 64% The Moderate Scale-up scenario also showed a decrease (5%) in ART as a % of drugs and supplies Fast Track Treatment 11% 7% 4% 16% 6% 69% 64% ART (First-Line Treatment) for Adults (drugs and consumables only) 6% 6% 5% Pediatric ART (First-Line Treatment) (drugs and consumables only) Diagnostic/Lab Costs (drugs and consumables only) HIV Counseling and Testing (consumables only) Fast Track Treatment and Prevention 12% 67% 15% 61% Condoms (consumables)

17 Program Costs Photo Courtesy of Andre Moore

18 Program Costs $70 $60 $50 $40 $30 $20 $10 $ Constant Coverage Moderate Scale-up Fast Track Treatment Fast Track Treatment and Prevention

19 Photo Courtesy of PBS News Hour Service Delivery: Human Resources

20 Human Resources New guideline recommendations for medicine dispensing 6 months 3 months Analysis for HR: Looking at cost changes from switching all patients to dispensing for 3 months and 6 months For dispensing at 3 months and 6 months, looked at the areas with most impact on HR: Adult ART first and second line Pediatric ART first and second line Cadres of staff analyzed Generalists/primary care doctors Nurses Pharmaceutical technicians/assistants Clinical officers Additional concerns Task shifting has been maximized Hiring freeze of staff is in place Not all staff want to move to rural areas

21 Human Resources: Scripting Scenarios Comparison (2016 to 2020) HR cost savings are achievable due to efficiencies gained via MMS $5,000,000 $4,500,000 $4,000,000 $3,500,000 $3,000,000 $2,500,000 $2,000,000 $1,500,000 $1,000,000 $500,000 $ Constant Coverage Moderate Scale-up Fast Track Treatment Fast Track Treatment and Prevention

22 Limitations Photo Courtesy of Rosinio

23 Limitations ART Costs Unit costs for ARVs has continued to decrease over the years The rapid scale-up of ART should further reduce unit costs; however, the degree of this reduction is unknown at this time, thus ARV unit costs were maintained from 2016 to 2020 Equipment MOH/DNAM is opting for renting equipment rather than purchase Costs of equipment will be included in the tests The unit cost over time is not yet known HR Analysis Scenarios assume that all patients will have the same number of visits per year for dispensing of ARVs (adult and pediatric). Additional system limitations Infrastructure Warehousing space is limited/poor maintenance Logistics Rural locations still face challenges of access to meds Need to store and supply large quantities of meds at once

24 Photo Courtesy of Andre Moore Summary

25 Key Findings Substantial resources are still needed to achieve In this study achieving 81% coverage for T&S will require: US$134 million (2020) for treatment in the constant scenario US$177 million (2020) for treatment in the moderate scale-up scenario US$182 million (2020) for treatment in the fast track treatment scenario US$173 million (2020) for treatment in the fast track treatment and prevention scenario Despite the resources needed, cost savings are still possible Initiation of early therapy and improved prevention efforts Should decrease the number of new infections Should decrease the number of people on ART Increased efficiency gains through multi-month scripting from standard to 3-month and 6-month regimens Constant prevention scenario in 2020: US$4.6 million Fast track treatment scenario in 2020: US$3.7 million (cost reduction of US$2 million over 5 years)

26 Thank You!! Muito Obrigado!!

27 Health Policy Plus (HP+) is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A , beginning August 28, The project s HIV activities are supported by the U.S. President s Emergency Plan for AIDS Relief (PEPFAR). HP+ is implemented by Palladium, in collaboration with Avenir Health, Futures Group Global Outreach, Plan International USA, Population Reference Bureau, RTI International, ThinkWell, and the White Ribbon Alliance for Safe Motherhood. This presentation was produced for review by the U.S. Agency for International Development. It was prepared by HP+ with critical support from MISAU, UNAIDS/Mozambique, PSM/Mozambique, and FORSSAS. The information provided in this presentation is not official U.S. Government information and does not necessarily reflect the views or positions of the U.S. Agency for International Development or the U.S. Government.

28 Breakdown of Pediatric ART Percentage of Pediatric Patients on First Line ART Regimens AZT+3TC+ABC 1.0% 1.0% 1.0% 1.0% 1.0% AZT+3TC+EFV 1.0% 1.0% 1.0% 1.0% 1.0% AZT+3TC+LPV/r 4.0% 4.0% 4.0% 4.0% 4.0% AZT+3TC+NVP 83.0% 83.0% 83.0% 83.0% 83.0% ABC+3TC+NVP 3.0% 3.0% 3.0% 3.0% 3.0% ABC+3TC+EFV 3.0% 3.0% 3.0% 3.0% 3.0% TDF+3TC+EFV 5.0% 5.0% 5.0% 5.0% 5.0% Percentage of Pediatric Patients on Second Line ART Regimens ABC+3TC+LPV/r 97.0% 97.0% 97.0% 97.0% 97.0% TDF+3TC+LPV/r 3.0% 3.0% 3.0% 3.0% 3.0%

29 Breakdown of Adult ART Percentage of Adult Patients on First Line ART Regimens AZT+3TC+ABC 0.101% 0.101% 0.101% 0.101% 0.101% AZT+3TC+EFV 0.806% 0.806% 0.806% 0.806% 0.806% AZT+3TC+LPV/r 0.152% 0.152% 0.152% 0.152% 0.152% AZT+3TC+NVP % % % % % d4t 30+3TC+EFV 0.086% 0.086% 0.086% 0.086% 0.086% TDF+3TC+EFV % % % % % TDF+3TC+NVP 0.003% 0.003% 0.003% 0.003% 0.003% ABC+3TC+EFV 0.013% 0.013% 0.013% 0.013% 0.013% Percentage of Adult Patients on Second Line ART Regimens ABC+3TC+LPV/r 5.4% 5.4% 5.4% 5.4% 5.4% ABC+AZT+LPV/r 6.5% 6.5% 6.5% 6.5% 6.5% TDF+3TC+LPV/r 84.7% 84.7% 84.7% 84.7% 84.7% TDF+ABC+3TC+LPV/r 0.2% 0.2% 0.2% 0.2% 0.2% TDF+ABC+LPV/r 0.7% 0.7% 0.7% 0.7% 0.7% TDF+AZT+LPV/r 2.5% 2.5% 2.5% 2.5% 2.5%

30 Breakdown of Weighted Costs for ART Weighted Costs for Adults First Line ART ( ) Regimens Weighted Cost per year (USD) AZT+3TC+ABC $ 0.21 AZT+3TC+EFV $ 0.93 AZT+3TC+LPV/r $ 0.45 AZT+3TC+NVP $ d4t 30+3TC+EFV $ 0.07 TDF+3TC+EFV $ TDF+3TC+NVP $ 0.00 ABC+3TC+EFV $ 0.02 $ 97.21* Weighted Costs for Pediatric First Line ART ( ) Regimens Weighted Cost per year (USD) AZT+3TC+ABC $ 2.09 AZT+3TC+EFV $ 1.16 AZT+3TC+LPV/r $ AZT+3TC+NVP $ d4t 30+3TC+EFV $ 5.47 TDF+3TC+EFV $ 5.83 TDF+3TC+NVP $ 4.80 $ * Weighted Costs for Adults Second Line ART ( ) Regimens Weighted Cost per year (USD) AZT+3TC+ABC $ AZT+3TC+EFV $ AZT+3TC+LPV/r $ AZT+3TC+NVP $ 0.90 d4t 30+3TC+EFV $ 2.75 TDF+3TC+EFV $ 8.40 $ * Weighted Costs for Pediatric Second Line ART ( ) Regimens Weighted Cost per year (USD) AZT+3TC+ABC $ AZT+3TC+EFV $ 8.29 $ * * Costs used in calculations

31 Drugs and Supplies Test Unit Cost (USD) Viral Load CD4 FACS Count 7.96 FACS Calibur 6.83 PIMA 8.28 Hematology 1.15 Biochemistry 1.68