European clinical experience with assisted reproductive technology in HIV-discordant couples
The economics of TasP · HIV-SD couples Pregnant women + TB/HIV HBV/HIV SD couples Pregnant...
Transcript of The economics of TasP · HIV-SD couples Pregnant women + TB/HIV HBV/HIV SD couples Pregnant...
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The economics of TasP
David Wilson and Nicole Fraser Global HIV/AIDS Program
The World Bank
23 September, 2013
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• Public goods
• Burden of AIDS
• Population level effectiveness and implementability of TasP
• Cost-effectiveness of TasP
• Current AIDS financing
• Required AIDS financing
• Smarter implementation
• Conclusion
The economics of TasP
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• Public goods non-excludable and non-rivalrous:
– individuals can’t be excluded from use
–use by any individual doesn’t reduce
availability to others
–Eg. clean air and street lighting
Public goods
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• TasP not a public good but ART has major positive
externalities
• Elimination of HIV a public good – non-excludable
and non-rivalrous
• Economic analysis of TasP must focus on feasibility,
affordability, probability and cost-effectiveness of
eliminating HIV
Public goods – TasP and HIV?
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From the positive externalities of TasP to the public good of AIDS elimination
• ART
• Benefits to non users, including reduced HIV transmission, health and social expenses, increased productivity, household income and parental participation
Public good
• AIDS elimination
• Benefits everyone, without excluding anyone
Positive externalities
Feasibility, affordability, probability and cost-effectiveness of eliminating HIV
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• Public goods
• Burden of AIDS
• Population level effectiveness and implementability of TasP
• Cost-effectiveness of TasP
• Current AIDS financing
• Required AIDS financing
• Smarter implementation
• Conclusion
The economics of TasP
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AIDS fastest growing cause of disease burden globally in last 20 years
IHME/World Bank, 2013
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AIDS and malaria greatest causes of disease burden in Sub-Saharan Africa
IHME/World Bank, 2013
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AIDS by far the largest cause of disease burden in Uganda
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• Public goods
• Burden of AIDS
• Population level effectiveness and implementability of TasP
• Cost-effectiveness of TasP
• Current AIDS financing
• Required AIDS financing
• Smarter implementation
• Conclusion
The economics of TasP
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Population level effectiveness of TasP
• TAsP clinical trial efficacy 96%+
• TAsP real world effectiveness lower?
– Infection 34% lower in area with 30%-40% ART coverage (the effect saturation point) than area with <10% coverage in KZN (Tanser et al, 2013)
– Infection 26% lower in discordant couples in China - for transfusion or sexually infected but not IDU infected indexes (Jia, 2012)
– No difference in discordant couples in Uganda (Birungi et al. 2013)
– HIV infections rising in highly treated MSM communities in developed countries (Wilson et al, 2012)
– Less effective in MSM epidemics? (Cohen 2013)
– With ~85% on ART at CD4<350, Swaziland has measured HIV incidence of 2.4% on top of 26% adult prevalence (SHIMS, 2013)
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Population level effectiveness of TasP
HPTN 071 (PopART)
TasP Botswana/ HSPH
SEARCH
Sites Lusaka, Cape Town South Africa Mochudi, Botsana Kenya, Uganda
Design Cluster RCT 24 @ 55,000 3 arm
Cluster RCT 34 @ 1,250 2 arm
Paired cluster RCT, 30 @ 5,000, 2 arm
Paired cluster RCT, 32 cl @ 10,000, 2 arm
Intervention Immediate ART if HIV+ HCT, VMMC, condom, risk reduction counselling
Immediate ART if HIV+ HCT home-based
ART for CD4<350, WHO I/II or VL>10,000 HCT, VMMC, PMTCT-B
Immediate ART if HIV+ Combination HIV prevention package
Outcome 2 year HIV incidence in cohort
2 year HIV incidence in cohort
Cumulative 2 year HIV incidence in cohort
Cumulative HIV incidence 3 + 5 years, cross-sectional
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CD4 ≤ 200
CD4 ≤ 350 +
TB/HIV HBV/HIV
CD4 ≤ 350 +
TB/HIV HBV/HIV
+
CD4 ≤ 500
“Test and treat”
All HIV+
1 2 3 4 5
ART regardless of
CD4 count for: HIV-SD couples
Pregnant women
+ TB/HIV HBV/HIV
SD couples Pregnant
Children < 5
Apollo et al, 2013
11 million 17 million 21 million 26 million 32 million
Recommended since 2010
Recommended until 2010
• 9.7 million on ART - 26 million eligible at CD4<500 and 32 million eligible for “test and treat”
Implementability of TasP: Numbers
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1. http://www.irinnews.org/report/98217/uganda-running-out-of-arvs-hiv-test-kits 2. http://www.irinnews.org/report/95904/africa-domestic-investment-in-hiv-up-but-uneven
3. http://www.trust.org/item/20130821105629-qn26o
Zambia, 21 Aug 2013 - The
Zambian government has
introduced a rationing
system for antiretroviral drugs
causing concern among
people living with HIV (3)
Implementability of TasP: Access and implicit rationing
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1,178,350
941,950
725,302
480,395 426,590
328,475
100% 79% 62% 41% 36% 28% 0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
HIV infected HIV diagnosed Linked to HIV care Retained in HIV care On ART Suppressed viral load (equal or less than 200
copies/mL)
CDC, 2012
US treatment cascade - 28% virally suppressed
100%
75% 70% 65% 60% 55% 40%
10%
0% 20% 40% 60% 80%
100% 120%
PLWHA Access to screening Actually do the test Fetch their results Are supported Benefit from ARV treatment
Remain on ARV (death, loss of sight)
Have access to a second line treatment
West Africa treatment cascade - 10% virally suppressed
U Montpellier, 2013
Implementability of TasP: Cascades
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Implementability of TasP: Retention
WHO/UNAIDS 2012
<60%
<50%
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Implementability of TasP: Viral load
Kranzer et al, 2013
74%
30%
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0
5
10
15
20
25
6-11 months 12--23 months 24-35 months >36 months
Acquired HIV drug resistance in low resource settings
Stadeli et al, 2013
Implementability of TasP: Resistance
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Implementability of TasP: Unknowns
• Feasibility and cost of identification, enrolment, retention and adherence of:
• Last 20-30%
• Most marginalized
• The healthy
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• Public goods
• Burden of AIDS
• Population level effectiveness and implementability of TasP
• Cost-effectiveness of TasP
• Current AIDS financing
• Required AIDS financing
• Smarter implementation
• Conclusion
The economics of TasP
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• After treatment:
• All adult mortality declined by 20% in Africa (Herbst et al, 2009)
• Population level life expectancy increased by 11 years in South Africa (Bor et al, 2013)
• Adult working hours increased, child labor declined and children’s nutrition and school attendance increased in Kenya (Goldstein et al, 2010)
• Absenteeism declined to pre-infection levels in Botswana Habyarimana J et al, 2007)
Positive externalities of treatment
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Cost-effectiveness of TasP: South Africa
• Barninghausen et al examined cost-effectiveness of ART, MC and TasP in South Africa from 2009-2020
• All cost-effective at WHO rule of 3x/per capita GDP
• Significant cost savings through optimal intervention mix without compromising prevention or mortality
• High ART+MC coverage similar HIV incidence reduction as TasP
• High ART+MC coverage $5 billion less expensive than TasP
• Increased MC ($1,100 per infection averted) outperforms ART ($6,800) and TasP ($8,400)
• Most cost-effective prevention and mortality scenario is MC first then ART - 50% ART and 60% MC coverage optimal
• MC more cost-effective than TasP because cost is one-ninth, accrued once versus lifetime
• As only half needing ART at CD4<350 receive it, increasing treatment in this group should precede treatment expansion to earlier disease stages
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Mysore Belgaum Bellary Guntur
Size of general population 480,000 460,000 490,000 620,000
Size of FSW population 2300 2000 4300 6400
% gen pop HIV positive 0.94% 0.63% 1.36% 1.9%
Cost of testing general population every 5 years
(US$)
960,000 920,000 980,000 1,240,000
Estimate of annual test-and-treat costs
4,600,000 3,200,000 6,300,000 10,600,000
Annual cost of core group intervention
470,000 400,000 570,000 1,200,000
Cost-effectiveness of TasP: India
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• Public goods
• Burden of AIDS
• Population level effectiveness and implementability of TasP
• Cost-effectiveness of TasP
• Current AIDS financing
• Required AIDS financing
• Smarter implementation
• Conclusion
The economics of TasP
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$16.8 billion AIDS financing in 2011
UNAIDS, 2012
25%
10%
9%
1% 1%
48%
6%
USA
Global Fund
Bilateral
Philantropic
Development banks/funds
Domestic public
Domestic private
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Trajectory and sources of AIDS financing
UNAIDS, 2012
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Allocation of AIDS financing, 2009-2011
Prevention
Management
OVCs
HR incentives Social protection Research
Antiretroviral drugs
OIs & palliative care
HBC
Laboratory monitoring
Psychological care
PICT
Nutritional support
53% for care and treatment
UNAIDS, 2012
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Treatment dominates HIV budgets in concentrated epidemics
Am
ico
et
al. 2
01
2
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Treatment increasingly dominates budgets in generalised epidemics
Am
ico
et
al. 2
01
2
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Treatment still reliant on international financing
• 43 LMIC finance over 75% of treatment costs from international sources
• Another 59 LMIC finance over half of treatment costs from international sources
• In Malawi, treatment costs externally financed and almost equal to total health budget
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LMIC domestic AIDS spending has grown, especially in UMC
UNAIDS, 2012
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The BRICS have stepped up
• Brazil and Russia now fund almost all their AIDS programs
• China will fund its entire AIDS program after GF resources end
• India funds 93% of its AIDS program
• South Africa’s AIDS budget grew 500% in a decade to $1.9 billion, the second largest globally
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Declining overall development assistance
OECD, 2013
OECD, 2013
2% decline in 2011
4% decline in 2012
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Wagstaff, 2013
Many competing priorities: Post-2015 MDG High Level Panel Report Word Cloud
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Africa’s rapid economic growth
since 2000
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• Public goods
• Burden of AIDS
• Population level effectiveness and implementability of TasP
• Cost-effectiveness of TasP
• Current AIDS financing
• Required AIDS financing
• Smarter implementation
• Conclusion
The economics of TasP
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Treatment expansion scenarios
Ap
ollo
et
al, 2
01
3
5.1
6.2
9.7
11
17
21
26
32
0 5 10 15 20 25 30 35
By 2010
By 2011
By 2012
<200 CD4
<350 CD4
<350 + selected pop's
<500 + selected pop's
All HIV+
Pra
ctic
e P
olic
y
Million people
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Required global financing
• In 2011, global AIDS care and treatment spending was $5 billion
• Treating all 26 million PLHIV at CD4<500 could cost $16 billion annually
• Treating all PLHIV could cost $20 billion annually
• Economies of maturity and scale offset by greater cost to reach and retain hard to reach and healthy
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Treatment at CD4<500 could equal South Africa’s entire health budget
27,557,018
35,490,000
43,680,000
-
5,000,000
10,000,000
15,000,000
20,000,000
25,000,000
30,000,000
35,000,000
40,000,000
45,000,000
50,000,000
Audited 08/09
Audited 09/10
Audited 10/11
Appropr. 11/12
MTEF 12/13
R '000
Nat. health budget
Nat. heath HIV budget
Spend HIV treatment (NASA)
Current ART guidelines
TasP CD4 <500
TasP for all
South Africa GARPR 2012, MoF 2013, Meyer-Rath PloS 2012 (average unit cost $800)
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Spend for ART in 2010 (est., NASA)
Cost - National guideline
Cost - WHO Guideline 2013
Cost of treating all HIV+ (T&T)
Total spend on HIV/AIDS 2010
(NASA)
NASA 2010, GARPR 2012, NACA fact sheet 2011 on ART, Aliyu HB et al JAIDS 2012, Health expenditure/ capita World Bank
TasP could equal 10% of Nigeria’s health budget
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• Public goods
• Burden of AIDS
• Population level effectiveness and implementability of TasP
• Cost-effectiveness of TasP
• Current AIDS financing
• Required AIDS financing
• Smarter implementation
• Conclusion
The economics of TasP
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Treatment expansion outpaced resource growth as efficiency increased
UNAIDS / WHO, 2012
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Major declines in drug costs, 2008-2011
UNAIDS/WHO 2012 Global price reporting mechanism
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Task shifting to reduce personnel costs in Kampala, Uganda
Babigumira et al. BMC Health Services Research 2009 9:192 doi:10.1186/1472-6963-9-192
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Reduce management costs to increase efficiency
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Site maturity and client volume major determinants of cost per patient
Menzies et al, 2012
-50% -50%
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Red dots represent lowest cost(most efficient) facilities
Blue dots show higher cost (less efficient) facilities
NACC/World Bank, 2012 Patients
C o S T ($)
Major variations in treatment costs in Kenya
Drive costs from inefficient blue to
efficient red spectrum
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Scientific innovation may further reduce costs
• Cheaper, better diagnostics?
• Longer acting ART?
• Lower dose ART?
• Treatment interruption with early initiation or new drugs?
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• Public goods
• Burden of AIDS
• Population level effectiveness and implementability of TasP
• Cost-effectiveness of TasP
• Current AIDS financing
• Required AIDS financing
• Smarter implementation
• Conclusion
The economics of TasP
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Conclusion
• TasP feasible in high income countries with limited epidemics and early treatment initiation
• In lower income countries with large epidemics, approach TasP with progressively earlier initiation of those with more advanced infection
CD4<200 CD4<350 CD$<500
• Redouble focus on male circumcision
• In high burden counties, TasP progress painstaking, incremental, patient-by-patient, building demand, sustaining quality – no short cuts