TUESDAY PLENARYTUESDAY PLENARY

Implementing The Implementing The Strategy: Where Do We Strategy: Where Do We

Go From HereGo From Here

Gay Men’s Chorus Gay Men’s Chorus of Washington DCof Washington DC

Thank you GMCW!Thank you GMCW!

Janet ClevelandJanet ClevelandDeputy Director for HIV Deputy Director for HIV

Prevetion Programs, Prevetion Programs, CDCCDC

Patricia NallsPatricia NallsFounder and Founder and

Executive Director of Executive Director of The Women’s CollectiveThe Women’s Collective

Calvin GeraldCalvin GeraldDC HIV Prevention DC HIV Prevention

Community Planning Community Planning Group MemberGroup Member

Dr. Ronald ValdiserriDr. Ronald Valdiserri Deputy Assistant Deputy Assistant

Secretary for Health, Secretary for Health, Infectious Diseases, U.S. Infectious Diseases, U.S.

Department of Human and Department of Human and Health ServicesHealth Services

Dr. David HoltgraveDr. David HoltgraveProfessor and Chair, Professor and Chair,

John Hopkins Bloomberg John Hopkins Bloomberg School of Public HealthSchool of Public Health

© 2005, Johns Hopkins University. All rights reserved.

Department of Health, Behavior & Society

David Holtgrave, PhD, Professor & Chair

How far we have come since the first Community Planning National Meeting

Community Planning National “Bootcamp”

(17 years ago)

Overview of Presentation

– What are the goals set in the recently released National HIV/AIDS Strategy? [a very brief recap]

– What are the epidemiologic implications of those goals?

– What are the economic costs and benefits of achieving these goals?

• What are the costs of NOT achieving these goals?

NHAS Goals for Reducing HIV Incidence

Relative Risk Calculations for National HIV/AIDS Strategy

Estimated Prevalence of Undiagnosed HIV Infection, US, 2006Campsmith, Rhodes, Hall, CROI, 2009;

Campsmith, Rhodes, Hall, Green, JAIDS, 2010

NHAS Goals for Improving Treatment Access

NHAS Goals for Reducing Health Disparities

What are the epidemiologic and economic consequences of the NHAS and how can we estimate them?

Refining Transmission Rates by Knowledge of Serostatus1-5

• Now assuming HIV prevalence of 1,106,400 and 79% awareness of HIV seropositivity per recent HIV prevalence MMWR…

• Overall transmission rate

– 5.0

• Unaware of HIV seropositivity

– Transmission rate estimated at 11.4

• Aware of HIV seropositivity

– Transmission rate estimated at 3.31. Holtgrave et al. Int J STD AIDS. 2004;15(12):789-92.2. Marks et al. AIDS. 2006;20(10):1447-50. 3. Holtgrave, Pinkerton. JAIDS. 2007;44(3):360-363.4. Hall et al. JAIDS. 2010;55(2):271-276.5. Holtgrave. Int J Clin Pract. 2010;64(6):678-681.

HIV infections averted and medical costs prevented, 1991-2006, US

(Farnham, Holtgrave, Sansom, Hall JAIDS 2010;54:565-567)

HIV Incidence and CDC HIV Prevention Budget (Adjusted for Inflation), United States, 1977-2006

0

50000000

100000000

150000000

200000000

250000000

300000000

350000000

400000000

450000000

500000000

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

Year

Infl

atio

n-A

dju

sted

Bu

dg

et (

1983

Do

llars

)

-

20,000

40,000

60,000

80,000

100,000

120,000

140,000

CDC HIV Prev. Budget (Real Dollars) CDC Incidence Estimate

Based on: Holtgrave, Kates Am J Prev Med 2007

Projected HIV Incidence(Hall, Green, Wolitski, Holtgrave, et al., JAIDS 2010)

Projected HIV Prevalence (Hall, Green, Wolitski, Holtgrave, et al., JAIDS 2010)

Quote: CDC website factsheet based on

Hall, Green, Wolitski, Holtgrave, et al., JAIDS 2010

Expanding HIV prevention in 5 years: The study found that intensifying national HIV prevention efforts over a five-year timeframe and maintaining them for the subsequent five years could reduce annual HIV incidence by 46 percent (from 55,400 to 30,200 new infections) — saving as many as an additional 306,000 people from becoming infected over the next 10 years — compared to maintaining current prevention efforts. HIV prevalence in this scenario would increase by only 13 percent (from 1.107 million to 1.247 million people living with HIV) — the smallest increase of any scenario included in the analysis. This rapid scale up would also save 25 times the amount that would need to be invested: expanding HIV prevention in five years would require an additional investment of $4.5 billion over 10 years, and would save up to $104 billion in avoided lifetime medical costs.

Additional Quote: CDC website factsheet based on

Hall, Green, Wolitski, Holtgrave, et al., JAIDS 2010

Expanding HIV prevention in 10 years: The study shows that expanding HIV prevention over a 10-year timeframe could reduce national HIV incidence by 40 percent (from 55,400 to 33,300 new infections) — preventing as many as an additional 215,000 new infections. In this scenario, HIV prevalence would increase by 20 percent (from 1.107 million to 1.329 million people living with HIV) — lower than any of the “base-case scenarios.” This expansion of HIV prevention would require an additional investment of $10.1 billion over 10 years, and would save as much as $66 billion in averted lifetime medical costs.

* It is assumed that all administrative and supporting program activities (such as necessary surveillance efforts) are also included in each year but are not separately listed.Note: Additional investment divided by additional infections averted (across all years) is appox. $26,900 indicating cost-savings when compared to HIV medical care costs.

Cost, Inputs, and Expected Consequences of Large Scale-Up of HIV Prevention Interventions, United States (Holtgrave Testimony at Congressional Hearing, 2008)

Year CDC Budget Major New Program Elements*

Expected Awareness

Level of HIV Seropositivity

Expected HIV Transmission

Rate

Expected HIV Incidence (Infections Averted)

0 Current Level Review of Current Resources;

Strategic Planning

75%

Current

4.98

Current

55,400

Current

1 $1.637B Public Information & Anti-Stigma Campaign;

Massive, Targeted Counseling & Testing

Effort

90% 3.57 40,600

(14,800 infections averted)

2 $1.239B Substantial, Targeted Counseling & Testing Effort; Prevention for

PLWH At Risk of Transmission; Prevention for Additional 5 Million

At-Risk HIV Seronegative Persons

90% 3.03 34,500

(20,900 infections averted)

3 $1.210B As in Year 2 90% 2.58 29,700

(25,700 infections averted)

4 $1.192B As in Year 2 90% 2.32 27,000

(28,400 infections averted)

* Reference: Lasry, A. et al. “A Model for Allocating HIV Prevention Resources in the United States” National HIV Prevention Conference, Aug 2009

CDC National Resource Allocation Model Results

* Reference: Lasry, A. et al. “A Model for Allocating HIV Prevention Resources in the United States” National HIV Prevention Conference, Aug 2009

CDC National Resource Allocation Model Results

CDC Prevention Research Synthesis Project

• Compendium of Effective Interventions– http://www.cdc.gov/hiv/

topics/research/prs/index.htm

• Tiers of Evidence

– Best evidence

– Promising evidence

• Meta-analyses

• Diffusing Effective Behavioral Interventions, and beyond

“With governments at all levels doing their parts, a committed private sector, and leadership from people living with HIV and affected communities, the United States can dramatically reduce HIV transmission and better support people living with HIV and their families.” (p.33, NHAS Implementation Plan)

Key implications of NHAS(from Holtgrave, JAIDS 2010)

• Can incidence be lowered by 25% by 2015?

– Yes if all other NHAS goals are met, and number of unprotected serostatus discordant partnerships is reduced 10% from already low levels

Key implications of NHAS (continued)(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 incidence without NHAS roughly 74,000 and with NHAS roughly 47,200

– 2015 prevalence without NHAS roughly 1.481M and with NHAS roughly 1.407M

• Appox. 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

– Appox. $2.1B for prevention

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

– Remainder for care and treatment (appox. $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

• Savings from prevention efforts can offset care expansion

Some may say, “but there will be no new money” and “we can’t reallocate across and within

agencies”

• Then– More HIV infection

– HIV prevalence growing even faster

– Treatment costs will rise in entitlement programs …OR…people living with HIV will go without treatment

– NHAS goals will not be achieved

• We must start with NHAS goals and work backwards, not start with status quo and work forward

CDC HIV Prevention Budget:Actual and Inflation Adjusted, by Fiscal Year*

Inflation Adjusted Budget dropped by 23.7% from FY02 to FY10.FY10 Inflation Adjusted Budget similar to 1993 budget in purchasing power.

* FY10 assumes $40M in DASH funding no longer considered in HIV budget.

Kaiser Family Foundation, HIV/AIDS Policy Fact Sheet, Feb 2010

President Barack Obama, July 13, 2010

“The question is not whether we know what to do, but whether we will do it.”

Baby’s got a lot of tears enough to cry a thousand yearsEnough to cry a thousand seas, enough to break a boy like meI want to stand and deliver and be the one that makes it better.-- Amy Ray, 2008, “Stand and Deliver”

Thank you for your individual and collective leadership, passion, perseverance, and devotion to addressing HIV/AIDS in your

neighborhood, state, and the nation

Safe and Warm Safe and Warm Travels Home!Travels Home!