Stenberg - HIV

1. Test and treat HIV/AIDS
(preliminary results)
Karin Stenberg, World Health Organization
Ludovic Queuille, Panamerican Health Organization, Port-au-Prince, Haiti
Rachel Sanders, Avenir Health, Washington DC, USA
Marcus Cadet, Ministry of Public Health and Population, Port-au-Prince, Haiti
Haiti Priorise conference, Port-au-Prince April 29-May 2, 2017

2. Outline
The challenge
Expand coverage of testing and treatment of HIV: Treatment as prevention
- Cost estimates
- Benefit estimates
- Cost Benefit Ratio
Discussion

3. The challenge
• Haiti has one of the highest rates of HIV/AIDS infection in the region
• 1.35% prevalence.
• A mix of a generalized epidemic and high risk groups (female sex workers, MSM)
• The main driver of the HIV/AIDS epidemic is unsafe sex (IHME 2016).
• 55% of Haitians living with HIV are accessing antiretroviral therapy (SI/PNLS/MSPP (2017)).
• What are the implications?
• Mortality and illness for infected persons
• HIV is the top cause of death and disability (IHME 2016)
• Lower productivity, reduced income
• Effects on family:
• orphans
• coping strategies within household (sale of assets, loans, borrowing and removing children from school are the major
coping strategies used by HIV-affected households)
• time spent by family members caring for AIDS infected family members.

4. 1st analyzed
solution
Expanding HIV testing and treatment
“Treatment as Prevention”
Photo: UN/Eskinder Debebe

5. Expanding HIV testing and treatment (“Treatment
as Prevention”)
• Providing ART early in the course of the disease:
• Improved health state of those infected
• Reduced transmission rates: fewer new HIV infections
• Voluntary Counselling and Testing (VCT)
• Adults first line ART
• Adults second line ART
• Pediatric ART for children
• Preventing mother to child transmission (PMTCT) of HIV
• Cotrimoxazole for children

6. Estimating costs
• Inputs-based costing, by year:
• Commodities: drugs, supplies, lab tests
• Supply chain costs and commodity waste
• Service delivery (inpatient & outpatient) operational costs
• Programme support
• UNAIDS Spectrum-tools/ UN-OneHealth Tool
• Projected HIV epidemic 2017-2036
• Country-tailored analysis: assumptions validated by Ministry
Annual commodity costs per patient
(USD) ART
Additional Lab costs
(CD4, viral load,
complete blood count)
ART (First-Line Treatment) for men 153.2 190
ART (First-Line Treatment) for women 153.2 190
ART (Second-Line Treatment) for adults 427.6 190
Cotrimoxazole for children 9.8
Pediatric ART 117.7
Source: WHO guidelines, UN price estimates

7. Average annual cost (additional, millions)
Coverage
target
Commodities Service Delivery Supply chain Programme costs Total
USD 2014
80% 5.4 0.6 0.9 0.5 7.4
95% 10.8 1.1 1.8 0.8 14.5
HTG 2014
80% 245.5 25.4 40.3 24.3 335.4
95% 490.0 49.8 80.3 37.6 657.7

8. Estimating benefits
• Deaths averted
• New infections averted
• DALYs gained from higher CD4
counts in infected population
(slower progression of AIDS)
2018-2036 (19 years)
Target
coverage
New
infections
AIDS
deaths
New
infections
averted
AIDS
deaths
averted
Baseline:
current
coverage
maintained
10,290 65,284
80% 5,766 45,667 4,524 19,617
95% 3,735 30,016 6,555 35,268

9. (preliminary) Benefit-Cost Ratios
Benefits are valued at 3x GDP
Strength of evidence is considered as Moderate/Uncertain
BCRs may be as high as 10
ART costs should be verified with local cost assumptions
3% 5% 12%
Coverage target of 80% 3.2 3.0 2.6
Coverage target of 95% 3.3 3.1 2.6

10. Discussion
Ensuring treatment and care:
• Challenges with ART retention
• Addressing stigma
• Integrating HIV services into general health services.
Ascertaining the Benefits
• Behaviour change -> individuals take more risks /reduce other prevention strategies
• Incorporating productivity gains (~ up to 5 days lost/month due to illness)
Financial Sustainability
• 98% of current measured HIV/AIDS spending is from external sources (REDES, 2014 et 2015)
• Reported HIV/AIDS spending was US$ 138 million in 2014 and US$ 128 million in 2015;
compared to US$ 110 million for the 2015/2016 government health budget (HTG 6,622 billion);
and = around 20% of health spending in 2012/2013 (REDES; CNS 2015)
• Financing Treatment as people live longer: financial sustainability of maintaining current ART
coverage vs. further expansion of programme