© 2005, Johns Hopkins University. All rights reserved. Department of Health, Behavior & Society...

© 2005, Johns Hopkins University. All rights reserved.

Department of Health, Behavior & Society

David Holtgrave, PhD, Professor & Chair

NHAS Goals for Reducing HIV Incidence

NHAS Goals for Improving Treatment Access

NHAS Goals for Reducing Health Disparities

Key implications of NHAS (from Holtgrave, JAIDS 2010)

• How will epidemic be changed if goals are met?– Prevent roughly 75,800 infections (2010-2015)– Prevent roughly 237,700 infections (2010-2020)– 2015 prevalence without NHAS roughly 1.481M and with

NHAS roughly 1.407M• Approx. 218,900 more people on care and treatment

Key Implications of NHAS -- continued(from Holtgrave, JAIDS 2010)

• Cost of NHAS in expanded funding (be it new, redirected, or new private sector)

– Total across years through 2015• Roughly $15.2B need to achieve NHAS

– Approx.. $2.1B for prevention

– Just under $1B for housing (to achieve NHAS goal)

– Remainder for care and treatment (approx. $12.2B)

» 43% is due to expanded awareness

» 57% due to expanded coverage

Key Implications of NHAS - continued(from Holtgrave, JAIDS 2010)

– However, investing in NHAS could save money– Medical costs offset by HIV infections averted through expanded

prevention efforts– Net present value of medical care costs saved due to prevention efforts: $17.981B

– Savings larger than investments needed (cost saving)

– Bend the cost curve by bending the incidence curve– Choosing to not expand prevention efforts is the MORE expensive

policy option

CDC’s Total HIV Prevention Budget (Actual and Inflation-Adjusted)

Inflation-adjusted budget down 17.9% since FY02; buying power now approximates FY91

CDC UPDATE OF “GARDNER CASCADE”

Source: CDC MMWR Early Release Volume 60, November 29, 2011

ADAP Waiting Lists are the Tip of the Iceberg

10

http://coastal.er.usgs.gov/ocean-acidification/arcticcruise2011/journal/index.php/2011/08/20/icebergs/

http://coastal.er.usgs.gov/ocean-acidification/arcticcruise2011/journal/wp-content/uploads/2011/08/Iceberg3.jpg

Housing Opportunities for People With AIDS (HOPWA) Funding

Fiscal Year Funding Amount

2010 $335.0 million

2011 $334.3 million

2012 $332.0 million

President’s Request 2013 $330.0 million

Community Request: $427 million.National AIDS Housing Coalition Estimate: 140,000 PLWH in U.S. in immediate need of housing assistance

Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the NHAS – 2012 analysis

• Is it still epidemiologically feasible to attain the incidence and transmission rate reduction goals of the U.S. National HIV/AIDS Strategy (NHAS) by 2015?

• If so, what costs will be incurred in necessary program expansion, and will the investment be cost-effective?

• Would substantial expansion of prevention services for persons living with HIV (PLWH) augment the other strategies emphasized in the NHAS in terms of effectiveness and cost-effectiveness?

From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (2012).

Definition of scenarios for HIV service implementation strategies

Scenario name*

Assumed percentage of clients in care achieving suppressed

viral load, Year 2015 and beyond

Meet NHAS diagnosis goal of

90% by 2015?

Level of coverage of risk behavior change services for

PLWH

S694YMC 69.4% yes Minimal coverage

S694YFSC 69.4% yes Fully scaled-up coverage

S694NMC 69.4% no Minimal coverage

S694NFSC 69.4% no Fully scaled-up coverage

S807YMC 80.7% yes Minimal coverage

S807YFSC 80.7% yes Fully scaled-up coverage

S807NMC 80.7% no Minimal coverage

S807NFSC 80.7% no Fully scaled-up coverage

* All scenarios assume 85% care coverage by 2015 (with half-step toward achievement in 2014); up from baseline of 53.4% care coverage


Cost parameters (2011 dollars), costs saved per infection averted (2011 dollars), QALYs saved per infection averted

Cost per new diagnosis $10,085

Cost of prevention services for newly diagnosed PLWH $680

Cost of partner services $1,046

Total cost for new diagnosis $11,810

Annual care costs (includes $680 in prev. services) $28,382

Annual housing costs $12,039

Medical care costs saved in lifetime (public sector) $291,565

QALYs saved per transmission averted 5.33


Input parameter values: HIV transmission rates

Scenario name

Transmission rate, unaware

(TRU)

Transmission rate, aware, baseline through

2013 (TR2013)

Transmission rate, aware, 2014

(TR2014)

Transmission rate, aware, 2015 to 2020

(TR2015)

S694YMC .1020 .0276 .0251 .0219

S694YFSC .1020 .0276 .0251 .0138

S694NMC .1020 .0276 .0251 .0219

S694NFSC .1020 .0276 .0251 .0138

S807YMC .1020 .0276 .0251 .0186

S807YFSC .1020 .0276 .0251 .0113

S807NMC .1020 .0276 .0251 .0186

S807NFSC .1020 .0276 .0251 .0113


Outcome measures for evaluating eight scenarios vs. flat transmission rate comparator

• Annual incidence• Overall annual transmission rate• Incidence / 2010 incidence• Transmission rate / 2010 transmission rate• Cumulative infections averted• Cumulative QALYs saved• Cumulative gross policy cost• Gross savings of downstream costs• Ratio of savings to costs• Net cost per QALY saved


Summary results comparing HIV service implementation scenarios one at a time to a flat transmission rate comparison condition

• The incidence reduction and transmission rate reduction NHAS goals are met in three of the eight scenarios (S694YFSC, S807YMC, and S807YFSC).

• The incidence reduction and transmission rate reduction NHAS goals are narrowly missed in two other scenarios (S694YMC and S807NFSC).

• The best cost-utility ratios are obtained when both diagnostic efforts and prevention services for PLWH are scaled up.

• The least effective scenario is to meet the care goal of the NHAS but fail to achieve the awareness of seropositivity goal or fully scale up risk reduction services for PLWH.

• Care expansion alone averts the least number of infections, and the resultant cost-utility ratio is over the often-used $100,000 cost-effectiveness standard.

• Inclusion of enough expansion of testing services to achieve the seropositivity awareness goal, inclusion of fully scaled-up risk-reduction interventions for PLWH, or both all serve to substantially improve performance on the outcome measures and to move the results into a range easily considered cost-effective.


Incidence and transmission rate by scenario


Scenario

Incidence / 2010 incidence (2015)

Incidence / 2010 incidence (2020)

Transmission rate / 2010 transmission rate (2015)

Transmission rate / 2010 transmission rate (2020)

S694YMC .789 .837 .713 .713

S694YFSC .597 .610 .543 .543

S694NMC 1.006 1.110 .898 .898

S694NFSC .835 .892 .750 .750

S807YMC .710 .742 .643 .643

S807YFSC .536 .542 .489 .489

S807NMC .936 1.019 .837 .837

S807NFSC .781 .826 .702 .702

Comparison of incidence across all scenarios of HIV program expansion, and including flat transmission rate comparator condition


Comparison of prevalence across all scenarios of HIV program expansion, and including flat transmission rate comparator condition


Comparison of transmission rate across all scenarios of HIV program expansion, and including flat transmission rate comparator condition


Costs by scenario through 2015

Scenario name

Cost of additional

diagnoses*Cost of additional

housingCost of care and

treatment**

Cost of fully scaled-up risk reduction for

PLWH

Cumulative gross policy cost 2015

(discounted at 3%)

S694YMC $1,476,681,741 $363,859,450 $14,770,581,633 N/A $16,611,122,824

S694YFSC $1,476,681,741 $363,859,450 $14,770,581,633 $449,989,958 $17,061,112,782

S694NMC N/A $363,859,450 $13,398,713,227 N/A $13,762,572,676

S694NFSC N/A $363,859,450 $13,398,713,227 $401,015,141 $14,163,587,817

S807YMC $1,476,681,741 $363,859,450 $14,770,581,633 N/A $16,611,122,824

S807YFSC $1,476,681,741 $363,859,450 $14,770,581,633 $449,989,958 $17,061,112,782

S807NMC N/A $363,859,450 $13,398,713,227 N/A $13,762,572,676

S807NFSC N/A $363,859,450 $13,398,713,227 $401,015,141 $14,163,587,817

* Newly diagnosed PLWH also receive risk reduction services (included as approx. $85m in this cost total)

** PLWH receiving care under newly expanded services also receive risk reduction services (included as approx. $354m in “Y” scenarios, and approx. $321m in “N” scenarios)


Cost per QALY saved by scenario(one scenario at a time; relative to status quo)

Scenario nameNet cost per QALY saved 2015

(discounted at 3%)Net cost per QALY saved 2020

(discounted at 3%)

S694YMC $67,896 $50,742

S694YFSC $39,540 $20,088

S694NMC $182,036 $162,043

S694NFSC $89,230 $59,745

S807YMC $53,081 $33,884

S807YFSC $32,670 $13,344

S807NMC $129,702 $100,399

S807NFSC $72,877 $44,465


Incremental cost-effectiveness ratios comparing combinations of scenarios of HIV program expansion, as of Year 2020*

Scenario Comparison

Additional discounted gross program costs per additional

discounted HIV infection avertedS694YMC

vs.S694NMC

$101,759S694YFSC

vs.S694NFSC

$96,667

S694YFSCvs.

S694YMC$27,961

S694NFSCvs.

S694NMC$29,467

S807YMCvs.

S807NMC$98,198

S807YFSCvs.

S807NFSC$94,285

S807YFSCvs.

S807YMC$33,222

S807NFSCvs.

S807NMC$34,611

S694YFSCvs.

S694NMC$69,025

S807YFSCvs.

S807NMC$71,590

*entries lower than $291,565 indicate public sector costs savings


National HIV/AIDS Strategy

• Simply waiting for expansion of care services in 2014 and 2015 will not be enough to reach incidence and transmission rate reduction NHAS goals

• Investment in diagnostic services and prevention services for PLWH (in addition to care and housing services) enables us to reach those goals

• But very substantial progress toward investing in these services must be made in FY13

• Otherwise, the window on achieving the NHAS goals will be closed

We Must Avoid…

…But Time Has Almost Run Out


“COMBINATION PREVENTION” HAS SADLY BECOME

“SUBSTITUTION PREVENTION” WHEN WE NEED

“SYNERGISTIC PREVENTION”TO URGENTLY IMPACT INCIDENCE

26

HIV is transmitted during an act of unprotected risk behavior in a serostatus discordant partnership with virus present

In a serostatus discordant partnership…..

Unprotected transmission relevant risk behavior present

No unprotected transmission relevant risk behavior

Unsuppressed Viral Load Concentration of transmission Essentially no transmission

Suppressed Viral Load Essentially no transmission Essentially no transmission

27

Key US populations defined by HIV serostatus and relevance of various treatment-related prevention approaches

From: Holtgrave DR, Maulsby C, Wehrmeyer L, Hall HI. Behavioral Factors in Assessing Impact of HIV Treatment as Prevention. AIDS Behav. 2012

Number of forward HIV transmissions from subgroups of persons living with HIV, and potential points of prevention intervention


Key services needs of three subpopulations of persons living with HIV


As President Obama said on July 13, 2010…. “The question is not whether we know what to do, but whether we will do it.”

© 2005, Johns Hopkins University. All rights reserved. Department of Health, Behavior & Society...

Documents

Transcript of © 2005, Johns Hopkins University. All rights reserved. Department of Health, Behavior & Society...