From Revolution to Reality: How Will New Science Impact the U.S. National HIV/AIDS Strategy?

1. From Revolution to Reality: How Will New Science Impact the U.S. National HIV/AIDS Strategy? Costs, Consequences and Feasibility of Achieving the NHAS Goals David Holtgrave, PhD, Professor & Chair John Hopkins Bloomberg School of Public Health Department of Health, Behavior & Society Sunday, July 22, 2012 - IAC

2. Vision for the National HIV/AIDS Strategy “The United States will become a place where new HIV infections are rare and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity or socio-economic circumstance, will have unfettered access to high quality, life extending care, free from stigma and discrimination”

3. 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. (in press). This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

4. Definition of scenarios for HIV service implementation strategies * All scenarios assume 85% care coverage by 2015 (with half-step toward achievement in 2014); up from baseline of 53.4% care coverage 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. (in press). This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

5. Cost parameters (2011 dollars), costs saved per infection averted (2011 dollars), QALYs saved per infection averted 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. (in press). This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

6. Input parameter values: HIV transmission rates 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. (in press). This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

7. 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 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. (in press). This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

8. 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. 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. (in press). This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

9. Incidence and transmission rate by scenario 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. (in press). This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

10. Costs by scenario through 2015 * 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) 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. (in press). This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

11. Cost per QALY saved by scenario(one scenario at a time; relative to status quo) 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. (in press). This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

12. Comparison of incidence across all scenarios of HIV program expansion, and including flat transmission rate comparator condition 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. (in press). This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

13. Comparison of prevalence across all scenarios of HIV program expansion, and including flat transmission rate comparator condition 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. (in press). This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

14. Comparison of transmission rate across all scenarios of HIV program expansion, and including flat transmission rate comparator condition 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. (in press). This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

15. Incremental cost-effectiveness ratios comparing combinations of scenarios of HIV program expansion, as of Year 2020* *entries lower than $291,565 indicate public sector costs savings This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content. 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. (in press).

16. 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 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. (in press). This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

17. As President Obama said on July 13, 2010…. “The question is not whether we know what to do, but whether we will do it.” This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

18. “Combination Prevention” has sadly become “substitution prevention” when we need “synergistic prevention”to urgently impact incidence This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

19. HIV is transmitted during an act of unprotected risk behavior in a serostatus discordant partnership with virus present This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

20. Key US populations defined by HIV serostatus and relevance of various treatment-related prevention approaches This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content. From: Holtgrave DR, Maulsby C, Wehrmeyer L, Hall HI. Behavioral Factors in Assessing Impact of HIV Treatment as Prevention. AIDS Behav. 2012 Apr 11. [Epub ahead of print].

21. Number of forward HIV transmissions from subgroups of persons living with HIV, and potential points of prevention intervention This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content. From: Holtgrave DR, Maulsby C, Wehrmeyer L, Hall HI. Behavioral Factors in Assessing Impact of HIV Treatment as Prevention. AIDS Behav. 2012 Apr 11. [Epub ahead of print].

22. Key services needs of the three subpopulations of persons living with HIV This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content. From: Holtgrave DR, Maulsby C, Wehrmeyer L, Hall HI. Behavioral Factors in Assessing Impact of HIV Treatment as Prevention. AIDS Behav. 2012 Apr 11. [Epub ahead of print].