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ACHAP Economic and Social Impact Assessment
• ACHAP Support
• Methods
• Epidemiological Impact
• Economic Impact
Outline
• PPP; Govt of Botswana, Bill & Melinda Gates Foundation and Merck/The Merck Company Foundation.– Country priorities; NSF for HIV/AIDS informed strategic direction – Mutual partnership: Govt strategy & policy guidance, in kind
contribution – ACHAP financial, technical, human resources, infrastructure, and
logistical support
ACHAP Support
• Phase I (2001-2009) and Phase II (2010 to 2014)• Two Pronged
– National level– Districts level
• In most cases ACHAP operated from GOB infrastructures
• ACHAP Directly implemented• ACHAP Staff seconded to GOB• Collaborated with other partnersImpact of ACHAP supported Programmes cannot be
solely attributed to ACHAP
ACHAP Support
After 13 years, ACHAP stands as a successful venture into the realm of PPP for public health interventions
• More than $128 million in financial disbursement
• Merck ARV’s donation valued at around $168 million
OVERALL INVESTMENT
• GOALS Model of Spectrum used for ART and SMC– Model has been set up for Botswana using all available data
sources on Botswana
• For TB analysis, used TB modelling program, TIME. – TIME is “TB Impact Model and Estimates”– Implemented on Spectrum modeling software. – Designed to inform national strategic TB program planning – Models TB interventions epidemiological impact and costs.– Model was developed and maintained by the Tuberculosis
Modelling and Analysis Consortium (TB-MAC) and Futures Institute.
METHODS
• No Masa/SMC Support
• SMC Support Only
• Masa Program Only
• Both Masa/SMC Support
SCENARIOS
RESULTS OF ART AND MC ANALYSIS
Number of HIV new infections by year and scenario
20002001
20022003
20042005
20062007
20082009
20102011
20122013
20140
5,000
10,000
15,000
20,000
25,000
30,000
35,000
SMC Only ART Only SMC/ART Support No ACHAP Support
Year
Infe
ction
s
Number of HIV new infections by year and scenario
20002001
20022003
20042005
20062007
20082009
20102011
20122013
20140
5,000
10,000
15,000
20,000
25,000
30,000
35,000
No ACHAP Support
Year
Infe
ction
s A
vert
ed
Number of HIV new infections by year and scenario
20002001
20022003
20042005
20062007
20082009
20102011
20122013
20140
5,000
10,000
15,000
20,000
25,000
30,000
35,000
SMC Only No ACHAP Support
Year
Infe
ction
s A
vert
ed
Number of HIV new infections by year and scenario
20002001
20022003
20042005
20062007
20082009
20102011
20122013
20140
5,000
10,000
15,000
20,000
25,000
30,000
35,000
SMC Only ART Only No ACHAP Support
Year
Infe
ction
s A
vert
ed
Number of HIV new infections by year and scenario
20002001
20022003
20042005
20062007
20082009
20102011
20122013
20140
5,000
10,000
15,000
20,000
25,000
30,000
35,000
SMC Only ART Only SMC/ART Support No ACHAP Support
Year
Infe
ction
s
• By 2014, SMC program averted an estimated 7,470 infections (Note ACHAP Directly Contribute 75% of all
SMC’s)– Equivalence of one(1) infection averted for every
11 circumcisions performed.• About 42,000 infections averted by 2030– One(1) infection averted for every 2 male
circumcisions performed. – Infections averted will also lead to future deaths
averted
New HIV Infections Averted by SMC
ART program has had an even larger impact on new infections averted
• ART Cumulatively averted 110,000 new infections during the period 2000-2014– This is equivalent to 13 person-years of ART per infection
averted.
• Combined ART/SMC new infections averted with ACHAP support is 114,000 new infections from 2001 to 2014.
New HIV Infections Averted by ART
Number of HIV-related deaths by year and ACHAP Support
20002001
20022003
20042005
20062007
20082009
20102011
20122013
20140
5,000
10,000
15,000
20,000
25,000
30,000
Number of HIV-related deaths by year and ACHAP Support
No ACHAP Support With ACHAP Supported Programmes
• ART program averted an estimated 165,000 deaths from 2001 to 2014 or 48% .
• This is equivalent to one (1) death averted for 9 persons put on treatment.
• The ratio was as low as 5 earlier in the epidemic when most people starting ART had low CD4 counts.
• Note, deaths averted can occur later, so it is also useful to examine the number of life years gained; or measure additional person-years of life attributed to the intervention. – Over 949,000 life-years during the period 2000-2014 were saved. – This is equivalent to 1.2 person-years of ART per life year gained.
DEATHS AVERTED
TB Mortality by HIV Status
19901992
19941996
19982000
20022004
20062008
20102012
20142016
20182020
0
1,000
2,000
3,000
4,000
5,000
6,000
No Program, Total With Program, TotalNo Program, HIV- With Program, HIV-No Program, HIV+ With Program, HIV+
Num
ber o
f Dea
ths
19901992
19941996
19982000
20022004
20062008
20102012
20142016
20182020
0
1,000
2,000
3,000
4,000
5,000
6,000
TB Mortality by HIV Status
No Program, Total
Num
ber o
f Dea
ths
19901992
19941996
19982000
20022004
20062008
20102012
20142016
20182020
0
1,000
2,000
3,000
4,000
5,000
6,000
TB Mortality by HIV Status
No Program, Total With Program, Total
Num
ber o
f Dea
ths
19901992
19941996
19982000
20022004
20062008
20102012
20142016
20182020
0
1,000
2,000
3,000
4,000
5,000
6,000
TB Mortality by HIV Status
No Program, HIV+
Num
ber o
f Dea
ths
19901992
19941996
19982000
20022004
20062008
20102012
20142016
20182020
0
1,000
2,000
3,000
4,000
5,000
6,000
TB Mortality by HIV Status
No Program, HIV+ With Program, HIV+
Num
ber o
f Dea
ths
19901992
19941996
19982000
20022004
20062008
20102012
20142016
20182020
0
1,000
2,000
3,000
4,000
5,000
6,000
TB Mortality by HIV Status
No Program, HIV-
Num
ber o
f Dea
ths
19901992
19941996
19982000
20022004
20062008
20102012
20142016
20182020
0
1,000
2,000
3,000
4,000
5,000
6,000
TB Mortality by HIV Status
No Program, HIV- With Program, HIV-
Num
ber o
f Dea
ths
TB Mortality by HIV Status
19901992
19941996
19982000
20022004
20062008
20102012
20142016
20182020
0
1,000
2,000
3,000
4,000
5,000
6,000
No Program, Total With Program, TotalNo Program, HIV- With Program, HIV-No Program, HIV+ With Program, HIV+
Num
ber o
f Dea
ths
• Cumulative TB mortality was reduced by 17% during 2001-2014
• In 2014 number of TB related deaths reduced by roughly half of deaths in the “no support” scenario.
• Note, nearly all of the deaths and cases of active disease averted by the national TB program were among HIV+ individuals.
Comparison of TB scenarios with and without the scale up of ART and MC
• New TB cases per year was reduced by roughly 50% in 2014.
TB Incidence by HIV Status
19901992
19941996
19982000
20022004
20062008
20102012
20142016
20182020
02,0004,0006,0008,000
10,00012,00014,00016,00018,00020,000
No Program, Total With Program, TotalNo Program, HIV- With Program, HIV-No Program, HIV+ With Program, HIV+
Num
ber o
f New
Cas
es
• Ideally a comprehensive analysis of ACHAP’s support would determine the economic benefits associated with all the funds spent.
• However, it would be problematic to link the resources used to specific outputs.
• For this reason, the economic impact analysis focused only on SMC and ART.
SOCIO-ECONOMIC IMPACT
• Benefits are 30 times greater than the overall costs. – Assessed costs that would be needed in order to treat an
infected person (discounted cost of lifetime treatment)• Estimated at $7,400
– For estimated infections averted $351.5 million future costs was saved.
– Compared to $11.6 million as cost of 101,680 SMC’s.
• This would be even more favourable if one were to include other benefits of preventing each HIV infection (e.g., lost future earnings, loss of value to the household, etc.),.
SAFE MALE CIRCUMCISION ECONOMIC IMPACT
Average per SMC Cost by year
20102011
20122013
$-
$50
$100
$150
$200
$250
$300
$350
$400
$338
$291
$204
$112
Year
Per SMC Cost reduced by over 2/3
• Benefits exceed costs 5 fold– By averting infections, ART also averts future ART costs. – ART saved $814 million by averting 110,000 infections
• Assuming discounted cost of lifetime treatment of $7,400.
• Drug donation program costed $168.4 million.
• The $168.4 million drug donation exclude other costs• Conversely, benefits of treatment cannot be defined solely by
infections averted, since treatment also provides other benefits (reduced morbidity and mortality, increased productivity, etc.).
ART ECONOMIC BENEFITS
• ART and SMC Combined saved $843.6 million by averting 114,000 infections.
• ART and SMC cost was $180 million. • Cost ratio of $4.7/$1.0 cost. • Still if other benefits are considered, benefit may be
significantly higher.
ART AND SMC COMBINED ECONOMIC BENEFITS
• ACHAP creation was a timely and right move for Botswana’s national response to HIV/AIDS
• ACHAP has been a catalyst hence drawing development partners to assist expand and intensify initiatives.
• Without ACHAP, Botswana would have not easily attained the success it has enjoyed in HIV/AIDS fight.
• ACHAP became instrumental in ensuring that catastrophic impact of the epidemic on the economy and social fabric of Botswana, that was thought to be imminent at the turn of the century, has been largely mitigated.
• ACHAP served as a prime example of difficulties and successes of joint partnership between government and private companies.
• ACHAP achieved high level of integration across government, NGOs, CBOs, and the community.
Conclusions
• Acknowledgements– Futures Institute for this analysis