CHAI slide warehouse

1. CHAI slide warehouse Multi-Country Analysis of the Cost Implications of HIV Treatment Scale-Up Clinton Health Access Initiative and the Harvard School of Public Health in Collaboration with Ministries of Health of Swaziland, Malawi, Zambia and Rwanda International AIDS Society July 2014 This work has been funded by aid from the UK Government. The views expressed do not necessarily reflect the UK Government’s official policies.

2. Governments need evidence on costs to inform decisions on ART eligibility and scale-up Objective • Estimate the cost and HRH implications of reaching “universal access” (95% coverage) by 2020 under the 2010 and 2013 Guidelines in • Swaziland, Rwanda, Malawi and Zambia. Methodology • Epidemiology: The Bärnighausen, Bloom and Humair model (BBH), an analytically derived HIV “combination intervention” model.2 • Costs: 2010/11 MATCH study and 2012 study in Swaziland updated to reflect recent pricing and costs; Non-treatment costs from local sources and global literature.1 • Human Resources : CHAI’s demand-based workload model. • Scenario Analysis: Decision making tool used by government representatives to examine the impact of different policy options against available financial and human resources. 1-CDC and the Government of the Kingdom of Swaziland, unpublished; 2-Bärnighausen, T., D. E. Bloom and S. Humair (2012). "Economics of antiretroviral treatment vs. circumcision for HIV prevention." Proceedings of the National Academy of Sciences 109(52): 21271-21276

3. The cost of scale-up depends on the number and distribution of patients, as well as expected changes with ART scale-up • Total costs vary based on: • Patient mix • Patient numbers • Distribution of ART patients • Distribution of patients across pre-ART, ART and palliative care • Costs per patient per year by patient type • Commodity mix • Service delivery 1-CDC and the Government of the Kingdom of Swaziland, unpublished; 2-Bärnighausen, T., D. E. Bloom and S. Humair (2012). "Economics of antiretroviral treatment vs. circumcision for HIV prevention." Proceedings of the National Academy of Sciences 109(52): 21271-21276

4. There are more patients, but also a greater proportion with high CD4 count, under the 2013 Guidelines Example of Malawi: ART Patient Mix in 2014 vs. ART Patient Mix in 2020 ~ Current Coverage ~ 95% Coverage 2014 2020 4

5. Adding pre-ART and palliative care reduces the difference in patient numbers between policy options Example of Malawi: Patient Mix in 2014 vs. Patient Mix in 2020 ~ Current ART coverage ~ 50% pre-ART coverage ~ 95% ART Coverage ~ 50% pre-ART coverage 2014 2020 In 2020, there are 17-36% more ART patients and 7-12% more total patients under the 2013 Guidelines scenarios across Malawi, Rwanda, Zambia, Swaziland. *UA=Universal access; Pre-ART and palliative care=50% coverage 5

6. The cost of scale-up depends on the number and distribution of patients, as well as expected changes with ART scale-up • Total costs vary based on: • Patient mix • Patient numbers • Distribution of ART patients • Distribution of patients across pre-ART, ART and palliative care • Costs per patient per year by patient type • Commodity mix • Service delivery 1-CDC and the Government of the Kingdom of Swaziland, unpublished; 2-Bärnighausen, T., D. E. Bloom and S. Humair (2012). "Economics of antiretroviral treatment vs. circumcision for HIV prevention." Proceedings of the National Academy of Sciences 109(52): 21271-21276

7. Costing began with the results of previous facility-based studies Multi-Country Analysis of Treatment Costs for HIV/AIDS (MATCH) Study 2010/2011 Cost per ART Patient-Year by Country, USD Legend Max 3rd Q Median 1st Q Min Avg $682 $278 $232 $186 $136 South Africa * Malawi Ethiopia Rwanda Zambia *RSA cost include updated ARV prices, which were renegotiated by the RSA government in early 2010 and are 53% lower than those observed during the costing period; Avg=Average; Min=Minimum; Max=Maximum

8. In estimating total costs we reflect recent prices and expected differences between patient types • Commodity costs adjusted to reflect expected prices and mix • Service delivery costs adjusted to reflect differences by patient type: • Where patients seek care? • With which cadre? • How often? • For how long? Less intensive 790,000 patients at an average of $248/pppy 620,000 patients at an average of $270/pppy Given changes in patient mix, in 2020, the average cost PPPY under the 2013 Guidelines is 5-10% less across Malawi, Rwanda, Swaziland, Zambia. *CHW=Community Health Worker; Est=Established 8

9. Our methodology is as robust as current evidence allows, but contains important limitations Key Limitations • Treatment and care, testing, condoms and VMMC are included. The following are excluded: • Other HIV-related and prevention interventions (e.g., BCC, OVC); • Program management costs; and • Systems costs (e.g., expansion of supply chain and lab systems) • Costs and implications of scale-up are not well understood, but funding • must be available for these programs. • The implications of scale-up on costs require further refinement to account for economies of scale and decentralization

10. Universal access under the 2013 Guidelines costs 10-20% more than that under the 2010 Guidelines Universal Access in 2020 +17% +19% Note: Testing strategy mix varied across policy options; Resources are projected from national resource mapping exercises in 2012-2013 with the exception of Zambia where publicly available data was used.

11. At universal access, costed programs account for < 60% of projected available resources Universal Access in 2020 Projected resources Note: Testing strategy mix varied across policy options; Resources are projected from national resource mapping exercises in 2012-2013 with the exception of Zambia where publicly available data was used.

12. In Malawi, universal access may not be affordable - There is an urgent need for additional funding Universal Access to Treatment in 2020 25% • Malawi is one of the poorest countries in the world with little ability to contribute additional funding towards HIV. • Universal access under the 2013 Guidelines would account for almost half of the current health budget. 1- Malawi NHA 2011/2012; 2-National Resource Mapping, 2013; 3-World Dev.Indicators, 2012

13. Scale-up will be challenging in the face of operational constraints, such as existing HRH shortages Example of Swaziland: HRH Required to Meet Demand in 2020 Swaziland currently has half of the required HRH in 2020. *Optimal Staffing Levels For HIV Required to Meet 2010 WHO Guidelines in 2020

14. However, incremental impact of the 2013 Guidelines on HRH for treatment and care is negligible Swaziland: Facility-Level HRH Required for HIV Treatment and Care (Without Testing) Patients (Thous) Health Workers (FTE) • This is due to epidemiological changes and lower intensity of care for asymptomatic patients • Similar change in health workers required was seen in Zambia (-0.2%) and Malawi (-0.7%) • Finding, testing and linking patients is not included and will require significant staff time depending on the strategy

15. Conclusion: Debate should shift from whether to scale-up ART to how to do so efficiently Affordability: In Swaziland, Rwanda and Zambia, the cost of scale-up is manageable within the existing funding envelope, if programs run efficiently. Malawi will face significant financial constraints without aid. Feasibility: Countries will need to continue to address their existing sector-wide HRH shortages. However, the incremental HRH under more aggressive scenarios at universal access is less than expected. Key Considerations: • Excluded costs such as BCC and OVC and program management are important, but additional evidence is needed on cost and impact. • Upfront investment may be required (e.g., reaching hard-to-reach populations, building up systems and covering remote areas) and operational challenges vary by country. • HRH requirements will depend on the strategies used to find, test and link patients. Key Takeaways

16. Contributing Authors Harvard School of Public Health T. Bärnighausen D. Bloom S. Humair Clinton Health Access Initiative K. Callahan S. Diamond D. Gwinnell P. Haimbe R. Hurley C. Lejeune M. Lippitt C. McKay C. Middlecote S. Phanitsiri A. Sabino A. Shields E. Tagar F. Walsh Ministry of Health Zambia A. Mwango Ministry of Health Rwanda S. Nsanzimana Ministry of Health Swaziland V. Okello S. Zwane Ministry of Health Malawi A. Jahn

18. Innovative service delivery can mitigate costs in the short and long-term Innovative service delivery can reduce the costs of scale-up in the short-term… • In Malawi Multi-month scripts (MMS) and task shifting have reduced personnel costs by ~30%. • Home visits for complex patients would only slightly increase costs (~ 5%) and could improve retention • Additional evidence is needed on the effects of these models on retention. Task shifting, MMS …and in the long-term by improving patient retention. Costs of Achieving UA* by 2020 vs. Retention • Across 4 countries, a 5% increase in retention results in the following by 2020: • 4-6% Reduction in new infections • 4-6% Reduction in AIDS-related deaths • Up to 4% reduction in treatment/testing costs • Note: UA is defined as 95% coverage by 2020