Long-term Projections of the Cost of

Treatment Under Various Scenarios –

Opportunities for Efficiency and Effectiveness?

Arin Dutta, Cathy Barker, and Ashley

Kallarakal

July 19/20, 2014

DRAFT : DO NOT CITE

1. Projecting and costing global HIV treatment Number on treatment

a) Current vs. WHO 2013 need for ARVsb) Scale-up of programmatic coveragec) Migration to 2nd line treatment

Cost of HIV treatment Funding gap analysis for HIV treatment

2. Emerging Themes: E2 in HIV Treatment

3. HPP E2 analyses Insights from Kenya, Tanzania, and Mozambique

Outline

UNAIDS 2014 “Ambitious Treatment Targets: Writing the final chapter of the AIDS epidemic”

Critical intervention in the response: preventing premature mortality and new infections

HIV treatment requires more resources than any other single area of the HIV and AIDS response UNAIDS : 39% of all resources for HIV

Exciting time in the discussion on ART: 90-90-90 call from UNAIDS: 90% diagnosed, 90% on ART; 90%

virally suppressed by 2020

Why focus on HIV Treatment?

93 countries included in the analysis, based on criteria: More than 1,000 PLHIV in country Eligible for Global Fund funding for HIV in 2014

Countries grouped into the following 6 regions: Africa: West and Central (AWC) - 22 Africa: East and Southern (AES) - 20 Latin America and the Caribbean (LAC) - 14 Middle East and North Africa (MENA) - 9 Eastern Europe and Central Asia (EECA) - 12 Asia and the Pacific (AP) - 16

Country Inclusion Criteria

Projecting Global HIV Treatment Needs

* Depending on current country guidelines as preset in Spectrum. # HIV & TB co-infected with CD4 above 350 (or 500) are a very small proportion; not included in this round of analysis.

Used AIM in Spectrum to estimate projected numbers of adult and pediatric patients that are eligible for ART from 2014-2020 in each of the 93 countries.

Spectrum AIM was used individually for each country

Two eligibility scenarios: Current eligibility#:

Adult: CD4<350 or 250* and Option B+ (all HIV+ PW) Children: CD4<350 for ages 5-14; CD4<750 for ages 24-59 mo.; all

under 24 mo. (irrespective of CD4)

WHO 2013 eligibility#: Adult: CD4<500 and Option B+ (all HIV+ PW) Children: CD4<500 for ages 5-14; all under 5 (irrespective of CD4)

a) ART Need: Methods

Global Need for ART: Adults

Curr

ent

WH

O 2

013

Curr

ent

WH

O 2

013

Curr

ent

WH

O 2

013

Curr

ent

WH

O 2

013

Curr

ent

WH

O 2

013

Curr

ent

WH

O 2

013

Curr

ent

WH

O 2

013

Curr

ent

WH

O 2

013

2013 2014 2015 2016 2017 2018 2019 2020

0

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

MENAEECALACAPAWCAES

Source: Dutta, Barker, Kallarakal (forthcoming, 2014)

Global Need for ART: Pediatric

Curr

ent

WH

O 2

013

Curr

ent

WH

O 2

013

Curr

ent

WH

O 2

013

Curr

ent

WH

O 2

013

Curr

ent

WH

O 2

013

Curr

ent

WH

O 2

013

Curr

ent

WH

O 2

013

Curr

ent

WH

O 2

013

2013 2014 2015 2016 2017 2018 2019 2020

0.0

500,000.0

1,000,000.0

1,500,000.0

2,000,000.0

2,500,000.0

MENA

EECA

LAC

AP

AWC

AES

Source: Dutta, Barker, Kallarakal (forthcoming, 2014)

* Sources: WHO/PAHO 2013 (“ART in Spotlight: LAC”); WHO et al. TUA Progress Report 2013, etc.

Coverage: Number on ART on Dec. 31st / Need for ART, Dec. 31st

Step 1: Established 2013 baseline coverage % for adults and children in each of 93 countries, looking at: Number on ART from 2013 UNGASS country reports; national reports

& documents*, or value in Spectrum (in this order)

Divided this by current need for ART on Dec. 31st in the country

Step 2: Set possible scale-up paths for countries from this base: 9.17 million on ART in 2012, a 19.8% increase on 2011* Two scale-up scenarios:

Slow scale-up: 20% annual increase in coverage % e.g., country’s coverage in 2014: 40%; coverage in 2015: 48%

Fast scale-up: 30% annual increase in coverage %

b) ART Coverage: Methods

Region

AES AP AWC EECA LAC MENA

0

10

20

30

40

50

60

70

80

90

100

110

Adult Coverage % 2013

India

Zimbabwe

Malawi

Republic of Moldova

Trinidad and TobagoPapau New Guinea

South Sudan

Sierra Leone

South Africa

Bangladesh

Guatemala

Nicaragua

Azerbaijan

UzbekistanPhilippines

Indonesia

Bahamas

Suriname

Comoros

JamaicaSri Lanka

Armenia

Pakistan

Uganda

Bulgaria

Ukraine

Guinea

Gabon

Nigeria

Algeria

Congo

Bhutan

Sudan

Nepal

China

Russia

Cuba

Belize

RegionAES

AP

AWC

EECA

LAC

MENA

Source: Dutta, Barker, Kallarakal (forthcoming, 2014)

2013 ART Coverage %: AdultBubble size shows Current ART Need in 2013

Region

AES AP AWC EECA LAC MENA

0

10

20

30

40

50

60

70

80

90

100

110

Pediatric Coverage % 2013

Republic of Moldova

Trinidad and Tobago

Dominican Republic

Mozambique

Cambodia

Azerbaijan

Uzbekistan

Kyrgyzstan

Myanmar

Indonesia

Barbados

Bahamas

Suriname

Comoros

Jamaica

Vietnam

Namibia

Armenia

Thailand

Georgia

Pakistan

Guyana

Senegal

Bulgaria

Somalia

Djibouti

Ukraine

Angola

Gabon

Nigeria

Algeria

Tunisia

Bolivia

Serbia

Nepal

Belize

Iran

RegionAES

AP

AWC

EECA

LAC

MENA

2013 ART Coverage %: PediatricBubble size shows Current ART Need in 2013

Source: Dutta, Barker, Kallarakal (forthcoming, 2014)

Step 1: Established 2013 split of patients on 1st vs. 2nd line ART, adults and children separately (if poss.) By country: UNGASS 2013 country reports, national data, global/regional

reports. WHO regional average used for missing

Step 2: Define region-specific annual migration rate ranges: % of 1st line moving to 2nd line, per year A region has countries classified into “high / med. / low.” This range

differs by region. Overall range across regions: 0.5% to 3% p.a. Country designated within region based on resistance*, LTFU, etc.

Step 3: Migration scenarios by country over 2014-2020: Base migration: As set above: assumes historical rates continue; increased

detection with VL cancelled by lower proximal factors for failure

Higher migration: Migration increases from base: Increased patient load stresses systems; higher detection with VL, etc. – greater switching E.g.: Country with low migration moves to medium; medium moves to high

c) 1st & 2nd line ART: methods

* Stanford Drug Resistance Database

ScenarioID Scenario Definition

C20ScaleBM1 Number of patients on 1st line ART regiment based on: current ART guidelines; Scale up of ART coverage by 20%, current migration scheme to 2nd line treatment

C30ScaleBM1 Number of patients on 1st line ART regiment based on: current ART guidelines; Scale up of ART coverage by 30%, current migration scheme to 2nd line treatment

C20ScaleHM1 Number of patients on 1st line ART regiment based on: current ART guidelines; Scale up of ART coverage by 20%,higher migration scheme to 2nd line treatment

C30ScaleHM1 Number of patients on 1st line ART regiment based on: current ART guidelines; Scale up of ART coverage by 30%, higher migration scheme to 2nd line treatment

WHO20ScaleBM1 Number of patients on 1st line ART regiment based on: WHO2013 ART guidelines; Scale up of ART coverage by 20%, current migration scheme to 2nd line treatment

WHO30ScaleBM1 Number of patients on 1st line ART regiment based on: WHO 20103 ART guidelines; Scale up of ART coverage by 30%, current migration scheme to 2nd line treatment

WHO20ScaleHM1 Number of patients on 1st line ART regiment based on: WHO 2013 ART guidelines; Scale up of ART coverage by 20%,higher migration scheme to 2nd line treatment

WHO30ScaleHM1 Number of patients on 1st line ART regiment based on: WHO 2013 ART guidelines; Scale up of ART coverage by 30%, higher migration scheme to 2nd line treatment

Median_1st_line Median of all 1st line scenario totals

C20ScaleBM2 Number of patients on 2nd line ART regiment based on: current ART guidelines; Scale up of ART coverage by 20%, current migration scheme to 2nd line treatment

C30ScaleBM2 Number of patients on 2nd line ART regiment based on: current ART guidelines; Scale up of ART coverage by 20%, current migration scheme to 2nd line treatment

C20ScaleHM2 Number of patients on 2nd line ART regiment based on: current ART guidelines; Scale up of ART coverage by 20%, high migration scheme to 2nd line treatment

C30ScaleHM2 Number of patients on 2nd line ART regiment based on: current ART guidelines; Scale up of ART coverage by 20%, high migration scheme to 2nd line treatment

WHO20ScaleBM2 Number of patients on 2nd line ART regiment based on: WHO2013 ART guidelines; Scale up of ART coverage by 20%, current migration scheme to 2nd line treatment

WHO30ScaleBM2 Number of patients on 2nd line ART regiment based on: WHO2013 ART guidelines; Scale up of ART coverage by 20%, current migration scheme to 2nd line treatment

WHO20ScaleHM2 Number of patients on 2nd line ART regiment based on: WHO2013 ART guidelines; Scale up of ART coverage by 20%, high migration scheme to 2nd line treatment

WHO30ScaleHM2 Number of patients on 2nd line ART regiment based on: WHO2013 ART guidelines; Scale up of ART coverage by 20%, high migration scheme to 2nd line treatment

Median_2st_line Median of all 2nd line scenario totals

Projected number of Adults on 2nd Line ART

2013 2014 2015 2016 2017 2018 2019 20200.0

500000.0

1000000.0

1500000.0

2000000.0

2500000.0

3000000.0

3500000.0

4000000.0

4500000.0

457,047.4642,294.2

919,457.4

1,260,764.3

1,641,620.1

2,042,485.4

2,456,902.0

2,879,091.6

Low

Median

Nu

mb

er

on

2n

d l

ine

AR

T (

in m

il-

lio

ns)

High: 3.9 million

Low: 2.2 million

Source: Dutta, Barker, Kallarakal (forthcoming, 2014)

Range based on 8 scenarios

Projected number of Children on 2nd Line ART

2013 2014 2015 2016 2017 2018 2019 20200

50000

100000

150000

200000

250000

300000

3699450028

68838

90533

114107

138915

164771

190756

Low

Median

Nu

mb

er

on

2n

d l

ine

AR

T (

in

tho

usa

nd

s)

High: 262 thousand

Low: 143 thousand

Source: Dutta, Barker, Kallarakal (forthcoming, 2014)

Range based on 8 scenarios

Projected numbers on ART: AdultBased on increasing coverage from current base

1 2 3 4 5 6 7 80

5000000

10000000

15000000

20000000

25000000

30000000

35000000

9,925,326.8

15,112,199.0

18,555,365.5

21,022,442.922,587,137.1

23,819,593.324,726,574.125,423,234.3

LowMedian

Nu

mb

er

on

AR

T (

in m

illion

s)

High: 29.2 million

Low: 22.1 million

Source: Dutta, Barker, Kallarakal (forthcoming, 2014)

Range based on 16 scenarios

2013 2014 2015 2016 2017 2018 2019 20200.0

500000.0

1000000.0

1500000.0

2000000.0

2500000.0

688,535.2

981,124.41,137,154.4

1,283,419.01,395,892.5

1,466,296.11,524,701.81,578,248.5

Low+'Projecte...

Nu

mb

er

on

AR

T (

in m

illion

s) High: 2 million

Low: 1.3 million

Source: Dutta, Barker, Kallarakal (forthcoming, 2014)

Range based on 16 scenarios

Projected numbers on ART: Ped.Based on increasing coverage from current base

Cost of HIV Treatment

Used regional average patient-year costs by income category for WHO-preferred regimens

Annual drug costs from WHO Global Price Reporting Mechanism database; as regional averages by income level Most prices are from 2013 (transactions before 2011 excluded) Assumed regimen prices stable from 2014 to 2020, in 2013 $ Substituted global averages, matching income level, for any missing

region/income level and regimen data

Regimen splits and per year costs reviewed against country-specific costing studies from HPP (2014) and CHAI (2012)

Costing Methods: Annual ARVs

Adult 1st line Adult 2nd line Pediatric 1st line Pediatric 2nd line

TDF + 3TC + EFV ZDV+3TC+LPV/r ABC+3TC + LPV/r ZDV + 3TC + EFV

ZDV+3TC+NVP TDF+FTC+LPV/r ZDV + 3TC + LPV/r ABC + 3TC + EFV

ZDV+3TC+EFV ABC + 3TC + EFV ZDV + 3TC + LPV/r

ZDV+3TC+EFV ABC + 3TC +LPV/r

Lab costs: 3 scenarios x 3 income levels Compiled estimates of country-specific unit costs* per test into

averages by low, low-middle and middle income level groups Three cost scenarios per income level: via # tests and unit cost:

Facility-level costs** Average % of direct commodity costs (ARV and lab) that is spent on

personnel and overhead (building utilities and contracted services) Percentages differ by income level group

Assumed stable percentage of costs from 2014-2020

Costing Methods: Lab and Facility-Level Costs

Scenario → High cost Medium cost Low cost

CD4 1 x yr., avg. unit cost 2 x yr., avg. unit cost 2 x yr., lowest unit cost

Viral loadRoutine, avg. unit cost

Targeted (5%), avg. unit cost

Targeted (5%), lowest unit cost

Hematology and clinical chemistry

2 x yr., avg. unit cost 2 x yr., avg. unit cost 2 x yr., lowest unit cost

Sources: * HPP 2014, CHAI 2013, MSF 2013; many others; Sources: ** Gallaraga et. al 2011, PEPFAR 2013, many others

Highest cost scenario Highest numbers on treatment

WHO 2013 eligibility, 30% annual scale-up rate in coverage, highest 2nd line migration scenario

Highest unit cost for lab

Medium cost scenario Median numbers on treatment Medium unit cost for lab

Lowest cost scenario Lowest numbers on treatment

Current eligibility, 20% annual scale-up rate in coverage, current 2nd line migration scenario

Lowest unit cost for lab

Total costs: Three Scenarios

Total Annual ART Costs (93 countries):ARVs, lab, personnel, and facility-level costs

High: $8.5 billion

Low: $5.5 billion

2014 2015 2016 2017 2018 2019 2020 $-

$1,000,000,000

$2,000,000,000

$3,000,000,000

$4,000,000,000

$5,000,000,000

$6,000,000,000

$7,000,000,000

$8,000,000,000

$9,000,000,000

$3,570,249,329.9

$4,414,585,484.4

$5,082,594,228.7

$5,570,658,266.3

$5,990,159,946.9

$6,350,963,799.0

$6,671,889,458.9

Low

Medium cost scenario

Tota

l co

st o

f H

IV t

rea

tme

nt

(in

US

D

bil

lio

ns)

All costs in 2013 US$. Source: Dutta, Barker, Kallarakal (forthcoming, 2014)

Disaggregating total costs of ART for 93 countries: Medium Scenario

2014 2015 2016 2017 2018 2019 2020 $-

$1,000,000,000

$2,000,000,000

$3,000,000,000

$4,000,000,000

$5,000,000,000

$6,000,000,000

$7,000,000,000

$8,000,000,000

OverheadPersonnelLabPediatric ART 2nd LinePediatric ART 1st LineAdult ART 2nd LineAdult ART 1st Line

All costs in 2013 US$. Source: Dutta, Barker, Kallarakal (forthcoming, 2014)

Proportion of Total Costs 2014-2020: Medium Scenario

Adult ART63%

Pediatric ART 5%

Lab10%

Personnel16%

Overhead6%

Source: Dutta, Barker, Kallarakal (forthcoming, 2014)

Sources: PEPFAR 2013 COPs (sum of budget codes HBHC, HKID, HLAB, HTXD, HTXS, HVTB, PDCS, PDTX only); GFATM 2014 disbursement report (July 2014 update)

Annual level of GFATM funding for HIV Based on late 2013 and 2014 funding disbursements for all open

HIV grants, excluding civil society organization PRs Global total: $558.7 million/year

Annual level of PEPFAR funding for ART 2013 funding commitments for treatment and care for 31 countries Total: $1.95 billion/year

3 funding gap scenarios: Largest gap: Highest cost scenario, current GFATM funding stays

constant, subtracted 30% from PEPFAR funding (overhead) Medium gap: Median cost scenario, current PEPFAR and GFATM

funding, constant over time Smallest gap: Lowest cost scenario, current PEPFAR and

GFATM funding, constant over time

Funding gap analysis: Methods

Annual funding gap across 93 countries (prior to domestic contribution)Includes ARV, lab, personnel and overhead costs

High: $6.6 billion

Low: $2.9 billion

All values in 2013 US$. Source: Dutta, Barker, Kallarakal (forthcoming, 2014)

2014 2015 2016 2017 2018 2019 2020 $-

$1,000,000,000

$2,000,000,000

$3,000,000,000

$4,000,000,000

$5,000,000,000

$6,000,000,000

$7,000,000,000

$1,063,710,332.0

$1,908,046,486.4

$2,576,055,230.7

$3,064,119,268.4

$3,483,620,948.9

$3,844,424,801.0

$4,165,350,460.9

Low

Medium cost scenario

Year

Fu

nd

ing

gap

(in

US

D b

illion

s)

High: $4.8 billion

Low: $1.7 billion

All values in 2013 US$. Source: Dutta, Barker, Kallarakal (forthcoming, 2014)

2014 2015 2016 2017 2018 2019 2020

$(1,000,000,000)

$-

$1,000,000,000

$2,000,000,000

$3,000,000,000

$4,000,000,000

$5,000,000,000

$6,000,000,000

$299,223,378.1

$957,912,073.7

$1,478,589,896.5

$1,860,219,171.0

$2,186,818,254.2

$2,465,423,197.9

$2,711,635,521.3

Low

Medium cost scenario

Year

Fu

nd

ing

gap

(in

US

D b

illion

s)

Annual funding gap across 93 countries (prior to domestic contribution)Includes ARV and lab costs only

Emerging Themes: E2 in HIV Treatment

Need to increase cost-efficiency: Continue to reduce ARV prices and wider use of low-cost WHO-

recommended regimens Example: A 5% reduction in ARV prices could save as much as $1.5

billion from 2014-2020

Reduce facility-level costs Example: Reducing proportion of direct costs spent on personnel and

overhead by 5% would save as much as $485 million from 2014-2020

Reduce lab costs Example: Reducing unit costs of all lab tests to the lowest current price

would save as much as $2.5 billion from 2014-2020

Need to increase effectiveness: How to increase coverage by 20-30% per year on existing base? Better use of viral load testing to detect and switch on failure Prevent large rise in future 2nd line treatment need

Key Findings

Potential E2 Gains across ART cascade

Interventions that reduce ART costs Interventions that promote sustained viral suppression up to 90%

Decentralize, but maintain viable facility-level patient loads

Treatment simplification: new methods to deliver ARVs with lower pill burden; long-term dosing

Task shifting: reduce per-patient personnel costs

Better patient monitoring whether via virological or immunological testing

Further expansion of FDC formulationsCommunity-based models of patient monitoring and adherence support

Consolidation of lower cost platforms for viral load testing, even at POC; reduction of reagent costs

Treat comorbidities, including malnutrition, to keep patient healthy and in care

Critical short-term investments (e.g., new VL equipment) may lead to long-term efficiency and effectiveness gains

Interventions that help increase coverage up to 90% or more Reduce cross-cutting delivery challenges

Eliminate losses across ART cascade (75% lost from test to treat? Mugglin et al. 2012)

Treatment site positioning and strengthening; timing; family-based approaches, structural/social enablers.

Assessment of needs Serodiscordant couples (also recommended) not included

Coverage projections Not able to use UNAIDS/WHO 2014 Country Progress Reports, data not

released

Costs of ART missing Costs of OI treatment (non-TB), psychosocial support, nutrition, where

these are available Above-facility level costs (programmatic support, training)

Gap analysis issues Overestimation of both GFATM and PEPFAR funds - values are not

specific to cost categories included. Data not available

Limitations of analysis

HPP Studies on E2

Lessons Learned from KenyaEfficient interventions Effective interventions

HIV testing; MoH switched testing algorithm to yield highest cost savings while maintaining accuracy

Option B+; averts more infant and adult infections than Option B, but at a significant additional cost

HCW training; harmonized in-service training curriculum with long-term mentoring is cost-efficient

Harm reduction services for key populations; combination package (NSP, MAT, HCT, and ART for PWID) is cost-effective (ICER of $1,600)

Screening blood supply for transfusions; cost-benefit ratio of 3 for additional costs to screen all blood vs. averted TTI treatment costs

Oral PrEP for sex workers; cost-effectiveness ratio in Kenya is $25 per HIV infection averted; costs could decrease through task shifting

New ART guidelines; adopting WHO 2013 guidelines would result in a significant reductions in new HIV infections and premature deaths

Workplace interventions; mainstream HIV response, promote prevention programs, fight stigma and discrimination

Lessons Learned from Mozambique Need to increase allocative efficiency:

Target geographic regions and population groups contributing the most to HIV incidence

Need to scale-up biomedical and behavior change interventions to achieve greatest health impact Revised HIV acceleration plan could avert 113,927 new infections

and 145,668 AIDS-related deaths Need both types of interventions to reach goal of halving HIV

incidence by 2017

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Thank You!

The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. The project’s HIV activities are supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). It is implemented by Futures Group, in collaboration with Plan International USA, Futures Institute, Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA).