The Financial Implications of Reaching Global Treatment and Prevention Goals CHAI slide warehouse Clinton Health Access Initiative (CHAI) October 2, 2015
As we near global consensus toward test and offer it is time to tackle remaining questions on the cost and priorities for HIV programming 1. How strong is the rationale to scale up ART more aggressively? 2. Can we afford to put more people on treatment? 3. What should our priorities be going forward? 2
We already knew that ART can massively reduce the risk of new infections HPTN 052 study New infections amongst sero-discordant couples 100 90 80 70 60 50 40 30 20 10 0 Deferred initiation 96% reduced risk of new infection Immediate initiation 3
Now we have strong evidence that early initiation significantly improves patient outcomes START trial Instances of AIDS, serious non-aids events or death 100 90 80 70 60 50 40 30 20 10 0 Deferred initiation 53% reduced risk of serious illness or death Immediate initiation 4
Patients (Millions) To get these benefits, we would need to scale up ART significantly. At first glance, this appears to be prohibitively costly People eligible for, and on, ART 35 30 25 20 ~2X 15 10 5 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 On ART Eligible Source: UNAIDS, Global AIDS Report 2006-2013.; WHO UNICEF and UNAIDS, Global Update on HIV Treatment 2013.
However, over the past 6 years, we have tripled the number of patients on ART while funding levels increased by only 40% Patients on ART, millions HIV funding levels*, $ billions 16 $20 14 12 10 8 ~3X $18 $16 $14 $12 $10 ~40% 6 4 2 $8 $6 $4 $2 0 $0 * Resources available for HIV programs in low and middle income countries. UNAIDS, Global AIDS Gap Reports, 2012 & 2013.
This was possible because the marginal costs of adding a patient to treatment were far lower than what many people thought Cost estimates of Treatment Per ART Patient-Year (USD) $1,200 $1,000 $800 $600 80% 85% $400 $200 $- General perception PEPFAR costing, 2006/7 CHAI costing, RSA, 2010/11 CHAI costing, LICs/LMICs, 2010/11 PEPFAR costing, Kenya, 2010
Low cost models of ART service delivery are continuing to get more efficient, which are driving down overall costs, particularly in LICs/LMICs $200 $180 $160 $140 $120 $100 $80 $60 Malawi: Total ART Cost PPPY $131 Non ARV costs decreased by 40% $148 Non-ARV ARV In a recent CHAI analysis, facility-level ART costs remained similar between 2010 and 2014, with increases only driven by switch from D4T to TDF. Facilities nearly doubled patient loads between 2010 and 2014, but taskshifting and MMS enabled facilities to maintain similar staffing levels. $40 $20 $- 2010 2014 During the same time period, nationwide retention has increased. 8
and we expect those costs to keep going down particularly in low and lower-middle income countries as a result of three key factors 1 Changing patient mix Projected Patient Mix, 2020 Higher eligibility criteria means more healthy patients, requiring less intensive care 2010 Guidelines 2013 Guidelines <200 200-350 350-500 2 Falling commodities costs Avg. market price for ARVs* ARV, CD4 and VL costs are continuing to come down, though more slowly than in the past 2012 2013 1L Adults 2L Adults 1L Peds 2L Peds 3 Economies of scale/simplified models of care Fixed costs spread over more patients Continuing trends towards differentiated care models for stable patients through task shifting, fewer facility visits etc. Average Non-ARV costs sample of 5 Malawi facilities $65 $37 2010 2014 9 *In generic accessible countries. Source: CHAI - The State of the Antiretroviral Drug Market in Low- and Middle-Income Countries, ISSUE 5, December 2014
3 Differentiated models of service delivery have the potential to drive efficiency gains and maximize resources Determination of Patient Status (ideally through VL) Non-Stable Patients Stable Patients Increased attention to OI screening and care Focused care with higher-level cadres Targeted adherence counseling Linkage to community based services Access to multi-month scripts and/or fast-track refills Care primarily provided through lower level cadres Examples of Differentiated Care Models Multi-Month Prescriptions (Malawi, Zambia, Swaziland); Fast-Track Refills (Malawi); Community ART Distribution Groups (MSF) (Mozambique, Swaziland), etc.
HIV funding (Billions) At current costs, CHAI estimates suggest universal access is affordable, with facility-level ART costs requiring 45-55% of available HIV funding Estimated facility-level ART costs relative to available HIV funding (billion USD) $20 $18 $16 $14 $12 $10 $8 $6 $4 $2 $0 Remaining Funds $1.4 $8.9 Available for other interventions (e.g., VMMC, PrEP, OVC) and management costs HIV Testing 90-90-90 1 Universal Access under 2013 guidelines (80% CD4<500 2 ) The funding required to maintain people on treatment does not appear prohibitive: universal access under 2013 guidelines would require ~46% of available HIV funding Moving to the more aggressive goal of 90-90-90 only adds 1.4B more, reaching ~53% of HIV funding Annual testing costs will vary significantly depending on level of targeting and timeline to reach targets 1. Defined as 81% PLHIV 2. Also includes implementation of Option B+ and treatment for serodiscordant couples. 11
Outside of ART, we also have to be smart about how we invest in identifying new patients through HIV testing The cost of home-based testing in different geographies 8% Prevalence Catchment <1% Prevalence Catchment $955 $1,698 Costs per person added to ART are hugely impacted by both yield and the strength of linkage systems Reaching the first and second 90s will require countries to carefully target testing to carefully optimize coverage and cost $6 $15 Cost Per Person Tested $50 $57 Cost Per HIV+ Person Identified Cost Per HIV+ Person Linked to Care Other interventions, such as VMMC, PrEP, and condoms also need to be carefully targeted
Minimizing the HTC resource needs to reach 90-90-90 will require countries to move from test everyone to prioritized strategies Zimbabwe: Estimated pediatric (0-14 years) yields by entry point TB Malnutrition Growth Inpatient 28.4% 15.5% 15.5% 69.0% 100,000 tests will identify 28,000 peds Index testing 14.0% EPI 6.1% PMTCT 6.1% Outpatient Campaign testing 5.4% 2.1% 100,000 tests will identify 2,000 peds Even the funding were available, few countries have the human resources to reach 90-90-90 without prioritization 13
Targeting is also critical for prevention interventions including VMMC and PrEP; costs could become prohibitive if not rolled out strategically PrEP Example: Cost Per Infection Averted 140,000 $128,205 120,000 100,000 80,000 ~23X 60,000 40,000 20,000 $8,375 $5,593 - Treatment as Prevention PrEP: 3% Incidence (FSW, Kenya) PrEP: 0.1% Incidence (General Population, Kenya) NOTE: These calculations assume 100% adherence to PrEP among client population 14
Once patients are identified, we need to make sure we get the most of ART investments; we currently lose a lot of gains through poor retention TESTED PLWHIV Illustrative $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ LINKED $ $ $ $ $ $ $ $ ON ART $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ SUPPRESSED $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Losses in testing Losses in testing, linkage and care Losses in testing, linkage, care and treatment Investment made, limited/no impact Missed opportunity to have impact Max. return on investment Ongoing infections, morbidity and mortality 15
USD (Millions) MICs/HICs which have more capacity to commit domestic resources to their response account for 77% of total resource needs at 90-90-90 ART Annual Resource Needs and Percent of Global Resource Needs $3,000 80% $2,500 $2,000 $1,500 $1,000 $500 Middle-income or high-income countries 70% 60% 50% 40% 30% 20% 10% $- 0% Annual ART resource needs at 90-90-90 Cumulative % of total resource needs 16
We have clear answers to our key questions: 1. The rationale for scaling up ART is clear, and the evidence is there for both prevention and curative benefits 2. We can afford to maintain as many as 100% of PLHIV on treatment given available resources and low facility-level costs 3. The priorities going forward need to be: a. Further efficiency gains within ART spending through implementation/scale up of differentiated care for stable patients b. Targeted and efficient spending outside of treatment in particular for testing and biomedical prevention that will need to prioritize high yield strategies and populations c. Improved retention along the cascade, so we don t waste the hardwon gains
Thank you!