What can we learn from the impact of dramatically scaling-up

treatment on future costs and prevention efforts?

Viviane Dias Lima

British Columbia Centre for Excellence in HIV/AIDSvlima@cfenet.ubc.ca

British Columbia Centre for Excellence in HIV/AIDS

Rationale Evidence

HAART stops HIV replication

HIV levels fall to undetectable

in blood as well as in sexual

fluids

Sharp reduction in HIV

transmission

MTCT (De Cock 2000; Coovadia 2009)

PEP (Pinkerton 2004, Fisher 2006)

Discordant Couples (Quinn

2000; Castilla 2005; Wawer 2005;

Bechange 2008; Garnett 2008)

Population-based studies (Fang 2004; Lima 2007; Anema 2009)

Mathematical Models (Blower

2000; Law 2001; Abbas 2006; Montaner

2006; Lima 2007-2009; Granich 2009; De

Cock 2009)

Evidence from British Columbia

Lima V JID 2008

Increase HAART Coverage from 50% to 75%

250

300

350

400

450

500

1995 2005 2015 2025 2035

Year

Nu

mb

er o

f New

Infe

ctio

ns

No intervention Immediate uptake 3 years uptake 6 years uptake

`

Increase HAART Coverage from 50% to 75%

400

500

600

700

800

900

1000

1100

1200

2000 2010 2020 2030 2040

Year

Dri

rect

Dru

g C

ost

(CA

N$

per

100

,000

)

No intervention Immediate uptake 3 years uptake 6 years uptake

Lima VD, et al. Expanded access to highly active antiretroviral therapy: a potentially powerful strategy to curb the growth of the HIV epidemic. J Infect Dis 2008; 198:59-67

ex at the age of 20 years: 23.6 yearsDirect cost to treat each person with first-line therapy: $15,400 CAN

Lima VD, et al. Expanded access to highly active antiretroviral therapy: a potentially powerful strategy to curb the growth of the HIV epidemic. J Infect Dis 2008; 198:59-67

1 year 3 years 6 yearsAverted New infections (N) 3,202 3,169 2,695Total Cost Savings (CAN$) 49,310,494 48,801,574 41,506,163

Total Lifetime Cost Savings (CAN$) 1,163,727,652 1,151,717,136 979,545,445

Coverage: from 50% to 75%HAART uptake

1 year 3 years 6 yearsAverted New infections (N) 4,926 4,869 4,205Total Cost Savings (CAN$) 75,868,259 74,989,186 64,766,118

Total Lifetime Cost Savings (CAN$) 1,790,490,908 1,769,744,789 1,528,480,393

Coverage: from 50% to 90%HAART uptake

1 year 3 years 6 yearsAverted New infections (N) 5,885 5,851 5,472Total Cost Savings (CAN$) 90,636,910 90,108,679 84,266,694

Total Lifetime Cost Savings (CAN$) 2,139,031,087 2,126,564,814 1,988,693,986

Coverage: from 50% to 100%HAART uptake

Lima V JID 2008

$50

$150

$250

$350

$450

$550

$650

$750

$850

0 10 20 30 40year

mill

ions

$(c

umul

ativ

e)

Guidelines before the year 20082008 Guidelines & 50% Expansion Scenario2008 Guidelines & 75% Expansion Scenario

Return on increased investment resulting from status quo approach versus 50% and 75% expansion scenarios

Current global ARV need

Number of people receiving antiretroviral drugs in low- and middle-income countries (2002 - 2007)

UNAIDS & WHO 2008

Geographical Region

Antiretroviral Therapy Coverage(i.e. % of those who need therapy)

Percent ChangeDecember 2006

(range)December 2007

(range)

Sub-Saharan Africa 21% (18% - 23%) 30% (27% - 34%) + 43%

Latin America and the Caribbean

58% (47% - 68%) 62% (51% - 70%) + 7%

East, South and South-East Asia

18% (14% - 23%) 25% (20% - 32%) + 39%

Europe and Central Asia 13% (9% - 19%) 17% (12% - 22%) + 31%

North Africa and the Middle East

5% (4% - 8%) 7% (5% - 10%) + 40%

Total 22% (19% - 25%) 31% (27% - 34%) + 41%UNAIDS & WHO 2008

Funding gap between resource needs and resource availability (2005-2007)

Needs

Availability

UNAIDS & WHO 2008

Effect of PEPFAR on HIV Incidence

Lima 2009

Where do we go next?

…

Scaling-up ART: Needs & Constraints → Cost (direct & indirect)

→ Limited Resources - How to prioritize the available funds?

→ Treatment Guidelines - When to start?

- 1st & 2nd Line Therapy?

- Laboratory Monitoring

→ Treatment of Co-morbidities & other Health Issues

→ Long-term Sustainability: Health Systems & Funding

→ Other Concurrent Prevention Efforts

→ Social & Gender Inequalities

→ Cultural & Governmental Barriers

→ Human Rights Issues

Thanks!

Other slides

Effect of PEPFAR on HIV Incidence

Lima 2009

Current global ARV need

UNAIDS & WHO 2008