Show Me the Money: A Discussion about Investments Needed to Change STD Rates in the United States

Show Me the Money: A Discussion about Investments Needed to Change STD Rates in the United States Harrell Chesson Health Economist Centers for Disease Control and Prevention National Coalition of STD Directors Annual Meeting Alexandria, VA November 17, 2017 National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of STD Prevention

64 percent of all the world's statistics are made up right there on the spot. -Todd Snider Statistician s Blues

64 percent of all the world's statistics are made up right there on the spot. 84 percent of all statisticians truly hate their jobs. -Todd Snider Statistician s Blues

CDC Budget, Fiscal Year 2016 Budget Category * Budget Funding per capita ($ per person) Total $11.5 billion $35.49 HIV/AIDS $0.8 billion $2.47 STDs $0.16 billion $0.49 * CDC budget estimates (overall and HIV/STD components) adapted from CDC s FY 2016 Justification of Estimates for Appropriation Committees. Assumes US population of 324 million (www.census.gov).

CDC Budget, Fiscal Year 2016 Budget Category * Budget Funding per capita ($ per person) Total $11.5 billion $35.49 HIV/AIDS $0.8 billion $2.47 STDs $0.16 billion $0.49 Consumption Category ** Annual spending Spending per capita (dollars per person) Taco Bell $6.0 billion $18.52 Bottled water $11.8 billion $36.42 Lotteries $69.0 billion $212.96 * * CDC budget estimates (overall and HIV/STD components) are approximated and were adapted from CDC s FY 2016 Justification of Estimates for Appropriation Committees. ** Spending estimates Taco Bell and Lotteries (2012) were obtained from:http://www.washingtonexaminer.com/sixthings-that-americans-spend-more-on-than-the-2014-midterm-elections/article/2555534; Taco Bell estimates are from 2013, and Lottery estimates are for 2012. Spending estimates for bottled water are for 2012 and were obtained from: http://www.businessinsider.com/bottled-water-costs- 2000x-more-than-tap-2013-7. Per capita calculations based on population of 324 million.

Outline What has been the impact of STD programs? Illustration of STD rates with and without prevention efforts User-friendly tool for programs to estimate the economic benefits of their teams with high chances of winning prevention activities What investment is needed to make an appreciable change in national STD rates? Illustration of future STD rates under different funding scenarios What is the effect of budget changes? User-friendly tool for programs to estimate the health and medical cost impact of budget cuts, budget increases 6

Outline What has been the impact of STD programs? Illustration of STD rates with and without prevention efforts User-friendly tool for programs to estimate the economic benefits of their prevention activities What investment is needed to make an appreciable change in national STD rates? Illustration of future STD rates under different funding scenarios What is the effect of budget changes? User-friendly tool for programs to estimate the health and medical cost impact of budget cuts, budget increases 7

Summary of studies examining impact of STD/HIV prevention funding on STD/HIV-related health outcomes Data examined Main findings State-level CDC funding allocations for STD and HIV prevention and state-level gonorrhea rates, 1981-1998 1 Greater amounts of prevention funding in a given State-level syphilis rates and state-level CDC allocation for syphilis elimination activities, 1997-2005 2 National-level HIV prevention allocations and national-level HIV incidence estimates, 1978-2006 4 County-level public health spending and county-level gonorrhea and syphilis rates in California, 2003-2012 5 State-level CDC HIV prevention funding (1996-2003) and HIV testing data from the Behavioral Risk Factor Surveillance System (2003) 3 year were associated with lower STD/HIV incidence rates in subsequent years Greater amounts of public health spending in a given year were associated with lower gonorrhea and syphilis incidence rates in subsequent years The odds of having been tested for HIV were higher in states with greater amounts of HIV prevention funding 1 Chesson HW et al., Eval Rev 2005.; 2 Chesson & Owusu-Edusei, Soc Sci Med 2008 ; 3 Linas BP et al., AJPH 2006; 4 Holtgrave & Kates,, Am J Prev Med 2007. 5 Gallet C. Int Adv Econ Res 2017.

Analysis of state-level gonorrhea rates and STD/HIV prevention funding Data: State-level data 1981 to 1998 918 observations (18 annual data points for all 50 states and DC) Funding amounts Reported gonorrhea rates Methods: Regression analysis Findings: Greater amounts of prevention funding in a given year were associated with reductions in gonorrhea incidence rates in subsequent years Each dollar of prevention funding per capita was associated with reductions in gonorrhea of about 2% to 20% Results consistent over a variety of robustness tests Chesson et al., Eval Rev 2005

Includes explanatory variables: AIDS mortality rate Percent of population aged 15 to 24 Robbery rate Per capita cigarette consumption Per capita income Poverty rate

Reported gonorrhea rate (new cases per 100,000) 1970-2005 1200 Number of reported cases 1000 800 600 400 200 Reported gonorrhea rate 0 1970 1975 1980 1985 1990 1995 2000 2005 Chesson, Sex Trans Dis (2006)

Reported gonorrhea rate (new cases per 100,000) 1970-2005 1200 Number of reported cases 1000 800 600 400 200 Estimated gonorrhea rate without CDC prevention funding Reported gonorrhea rate 0 1970 1975 1980 1985 1990 1995 2000 2005 Chesson, Sex Trans Dis (2006)

Annual percentage change in reported rate of early syphilis in states that were and were not initially targeted for syphilis elimination 50% 40% 30% States not targeted 20% Percentage change 10% 0% -10% -20% -30% Targeted states -40% -50% 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year Chesson & Owusu-Edusei, Soc Sci Med 2008. 17

25,000 Reported cases of P&S syphilis Number of reported cases 20,000 15,000 10,000 5,000 Reported syphilis cases 0 1994 1996 1998 2000 2002 2004 2006 Year P&S: Primary and secondary 18

25,000 Reported cases of P&S syphilis With and without syphilis elimination Number of reported cases 20,000 15,000 10,000 5,000 Reported syphilis cases w/o syphilis elimination funding Reported syphilis cases 0 1994 1996 1998 2000 2002 2004 2006 Year P&S: primary and secondary. Calculated by extrapolation of estimates published by Chesson & Owusu-Edusei, Soc Sci Med 2008. 19

Outline What has been the impact of STD programs? Illustration of STD rates with and without prevention efforts User-friendly tool for programs to estimate the economic benefits of their prevention activities What investment is needed to make an appreciable change in national STD rates? Illustration of future STD rates under different funding scenarios What is the effect of budget changes? User-friendly tool for programs to estimate the health and medical cost impact of budget cuts, budget increases 20

Outline What has been the impact of STD programs? Illustration of STD rates with and without prevention efforts User-friendly tool for programs to estimate the economic benefits of their prevention activities What investment is needed to make an appreciable change in national STD rates? Illustration of future STD rates under different funding scenarios What is the effect of budget changes? User-friendly tool for programs to estimate the health and medical cost impact of budget cuts, budget increases 29

Combined reported cases of chlamydia, gonorrhea, and P&S syphilis 3,000,000 Combined number of reported cases 2,500,000 2,000,000 1,500,000 1,000,000 500,000 0 2010 2015 2020 2025 Year 30

Combined reported cases of chlamydia, gonorrhea, and P&S syphilis 3,000,000 Combined number of reported cases 2,500,000 2,000,000 1,500,000 1,000,000 500,000 Flat funding Assuming recent increases level off over 10 years 0 2010 2015 2020 2025 Year 31

Combined reported cases of chlamydia, gonorrhea, and P&S syphilis 3,000,000 Combined number of reported cases 2,500,000 2,000,000 1,500,000 1,000,000 500,000 Flat funding +$162 million annually 0 2010 2015 2020 2025 Year 32

64 percent of all the world's statistics are made up right there on the spot. -Todd Snider Statistician s Blues

Outline What has been the impact of STD programs? Illustration of STD rates with and without prevention efforts User-friendly tool for programs to estimate the economic benefits of their prevention activities What investment is needed to make an appreciable change in national STD rates? Illustration of future STD rates under different funding scenarios What is the effect of budget changes? User-friendly tool for programs to estimate the health and medical cost impact of budget cuts, budget increases 37

S.P.A.C.E. MONKEY 1.0 STD Prevention Allocation Consequence Estimator Click to Begin TD) prevention programs to estimate the impact of changes in their budget. roduced by, this spreadsheet reflect the views of the authors and do not nters for Disease Control and Prevention. 38

To begin, we need a little information about your program Enter information in the white boxes Size of population served by STD program (all ages) Reported number of chlamydia cases Reported number of gonorrhea cases Reported number of syphilis cases (Primary, secondary, and early latent) Previous screen Next screen 39

This tool estimates the effect of a permanent change in your budget. Please enter the change in your budget in the appropriate box below. Enter information in one of the two white boxes below Amount of budget decrease Amount of budget increase Previous screen Next screen 40

Would you like to enter information about Disease Intervention Specialists (DIS) in your program, such as: Number of DIS in your program Average annual salary per DIS Number of STD patients interviewed per DIS per year Percentage of STD cases interviewed by DIS YES N0 41

For each row in the table below, you can: Enter your own value in the white box, OR Leave the white box blank to use the default value. Input Default value Number of Disease Intervention Specialists (DIS) employed 0 Annual cost per DIS (salary plus fringe benefits) * 73,600 Annual number of STD cases interviewed per DIS 400 Percentage of chlamydia cases interviewed 12% Percentage of gonorrhea cases interviewed 17% Percentage of syphilis cases interviewed (Primary, secondary, and early latent) 89% Your value Leave blank to use the default value Previous screen Next screen 42

Results: Estimated impact of change in STD prevention funding Year Percentage decrease in STDs due to budget increase Reduction in number of syphilis infections Reduction in number of gonorrhea infections Reduction in number of chlamydia infections Reduction in number of STDattributable HIV infections Reduction in STD costs Reduction in HIV costs Reduction in total costs (STD + HIV) Year 1 0.00% 0 0 0 0.0 $0 $0 $0 Year 2 0.00% 0 0 0 0.0 $0 $0 $0 Year 3 0.00% 0 0 0 0.0 $0 $0 $0 Year 4 0.00% 0 0 0 0.0 $0 $0 $0 Year 5 0.00% 0 0 0 0.0 $0 $0 $0 Year 6 0.00% 0 0 0 0.0 $0 $0 $0 Year 7 0.00% 0 0 0 0.0 $0 $0 $0 Year 8 0.00% 0 0 0 0.0 $0 $0 $0 Year 9 0.00% 0 0 0 0.0 $0 $0 $0 Year 10 0.00% 0 0 0 0.0 $0 $0 $0 10-year total 0 0 0 0.0 $0 $0 $0 See text summary of these results Previous screen See advanced options Return to start 43

Results: Estimated impact of change in STD prevention funding Based on published evidence of the impact of STD prevention programs and the cost of STDs, a budget increase of $0 will result in: In the first year alone, there will be an estimated decrease of 0 cases of syphilis (range: 0 to 0), 0 cases of gonorrhea (range: 0 to 0), 0 cases of chlamydia (range: 0 to 0), and 0.0 cases of STD-attributable HIV (range: 0.0 to 0.0). Over 10 years, there will be an estimated cumulative decrease of 0 cases of syphilis (range: 0 to 0), 0 cases of gonorrhea (range: 0 to 0), 0 cases of chlamydia (range: 0 to 0), and 0.0 cases of STD-attributable HIV (range: 0 to 0). Over 10 years, there will be an estimated cumulative decrease in direct medical costs of $0 (range: 0 to 0) due to decreases in STIs and STI-attributable HIV infections. With a budget increase of $0, positions for disease intervention specialists will be increased, resulting in: Additional DIS interviews or effective behavioral counseling for an estimated 0 patients with STDs. DIS are public health professionals who work to find people diagnosed with syphilis and other STDs. DIS work to find new cases of the disease and to prevent new ones from happening. In addition to STDs, DIS fight other disease outbreaks and epidemics, including Ebola, flu, anthrax, and SARS with additional DIS, we will be better prepared for emergencies. Since an estimated 1 in 4 DIS interviews identifies a new STD case, an estimated 0 people with syphilis, gonorrhea, or chlamydia will become aware that they are infected, will be more likely to be treated, and will be less likely to spread STDs in their communities. Previous screen 44

ADVANCED OPTIONS MENU Change the calculation method Change one or more of the background assumptions Get more information about SPACE MONKEY calculations See the complete lower bound and upper bound results Go back to results 45

SPACE MONKEY calculation methods Method 1: Historical formula approach Calculate change in budget, per capita Each 1 dollar change in budget per capita changes STD rates by 16% The new STD rate is calculated and phased in over 10 years Method 2: Disease Intervention Specialist (DIS) approach Calculate the change in the number of DIS Calculate the change in DIS activities due to the change in DIS Each 10% change in DIS activities changes STD rates by 2% The new STD rate is calculated and phased in over 10 years The historical formula is based on Chesson et al Eval Rev. 2005;29(1):3-23. The DIS approach is based on Du et al Sex Transm Dis. 2007;34(4):189-194. These methods are described in detail in Chesson, Ludovic, Berruti, and Gift (Sex Transm Dis, forthcoming)

Program management & evaluation tools 47

Summary Funding for STD prevention matters Analyses of historical, state-level data have demonstrated an association between prevention funding and subsequent STD rates STD prevention funding, gonorrhea case rates syphilis elimination funding, syphilis case rates Although the impact of budget changes are difficult to predict, published studies offer evidence-based estimates User-friendly Excel tools available to STD programs SPACE MONKEY allows programs to estimate the health and direct medical cost impact of budget changes STIC Figure allows programs to estimate the direct costs and productivity losses averted by their program activities 48

Thank you HChesson@cdc.gov For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: http://www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of STD Prevention

Per-capita funding model of syphilis prevention impact Bottom line: 10 cents per capita of syphilis elimination funding was associated with decreases of 23% in reported rates of early syphilis Chesson and Owusu-Edusei, Soc Sci Med 2008. Impact of funding shown in slide was adjusted to 2014 US dollars.. 50

Per-capita funding model of syphilis prevention impact Decreases of 23% in syphilis incidence rates for every $0.10 per capita of prevention funding Advantages Simple and evidence-based Can provide illustrations of the benefits of targeting resources Consistent with dynamic transmission models when assuming declining marginal effect of interventions Disadvantages Model based on ecological analysis Syphilis elimination effort mainly effective in reducing syphilis rates among heterosexuals Approach assumes same marginal impact on syphilis in MSM 51

Several published studies have provided evidence that the amount of resources allocated for the prevention of sexually transmitted diseases (STDs) does indeed have an effect on the incidence of STDs at the population level. 1-6 Chesson, Ludovic, Berruti, and Gift (Sex Transm Dis, forthcoming) 1. Chesson HW, Harrison P, Scotton CR, Varghese B. Does funding for HIV and sexually transmitted disease prevention matter? Evidence from panel data. Eval Rev 2005;29(1):3-23. 2. Chaulk CP, Zenilman J. Sexually transmitted disease control in the era of managed care: "magic bullet" or "shadow on the land"? J Public Health Manag Pract 1997;3(2):61-70. 3. Chesson H, Owusu-Edusei K, Jr. Examining the impact of federally-funded syphilis elimination activities in the USA. Soc Sci Med 2008;67(12):2059-2062. 4. Du P, Coles FB, Gerber T, McNutt LA. Effects of partner notification on reducing gonorrhea incidence rate. Sex Transm Dis 2007;34(4):189-194. 5. Brown ST, Wiesner PJ. Problems and approaches to the control and surveillance of sexually transmitted agents associated with pelvic inflammatory disease in the United States. Am J Obstet Gynecol 1980;138(7 Pt 2):1096-1100. 6. Gallet CA. The impact of public health spending on California STD rates. Int Adv Econ Res 2017;23(2):149-159. 52

Several published studies have provided evidence that the amount of resources allocated for the prevention of sexually transmitted diseases (STDs) does indeed have an effect on the incidence of STDs at the population level. 1-6 1. Chesson HW, Harrison P, Scotton CR, Varghese B. Does funding for HIV and sexually transmitted disease prevention matter? Evidence from panel data. Eval Rev 2005;29(1):3-23. 2. Chaulk CP, Zenilman J. Sexually transmitted disease control in the era of managed care: "magic bullet" or "shadow on the land"? J Public Health Manag Pract 1997;3(2):61-70. 3. Chesson H, Owusu-Edusei K, Jr. Examining the impact of federally-funded syphilis elimination activities in the USA. Soc Sci Med 2008;67(12):2059-2062. 4. Du P, Coles FB, Gerber T, McNutt LA. Effects of partner notification on reducing gonorrhea incidence rate. Sex Transm Dis 2007;34(4):189-194. 5. Brown ST, Wiesner PJ. Problems and approaches to the control and surveillance of sexually transmitted agents associated with pelvic inflammatory disease in the United States. Am J Obstet Gynecol 1980;138(7 Pt 2):1096-1100. 6. Gallet CA. The impact of public health spending on California STD rates. Int Adv Econ Res 2017;23(2):149-159. Chesson, Ludovic, Berruti, and Gift (Sex Transm Dis, forthcoming) 53