What are we learning about treatment benefits?

1. What are we learning about treatment benefits? Damien de Walque Development Research Group Mead Over Center for Global Development The World Bank November 30, 2006

2. Unmet need 70% of the total unmet need 5 Receiving ARV therapy (Number of people in millions) 4 3 2 1 Latin America and the Caribbean East, South and South-East Asia Europe and Central Asia North Africa and the Middle East Sub-Saharan Africa ARV Therapy: global need, June 2006 Source: Kevin de Cock’s Presentation in Toronto, Aug., 2006

3. Overview • Treatment benefits and the TAP Learning Agenda • Determinants of treatment success in Burkina Faso • Health & non health benefits of treatment in Kenya • Long term benefit: an “AIDS Transition”

4. Impact evaluations of programs delivering antiretroviral therapies to HIV/AIDS patients • In: Burkina Faso, Ghana and Mozambique (TAP “learning agenda”) • But also in Rwanda, Kenya, South Africa and India • Team: Damien de Walque, Varun Gauri, Harounan Kazianga & Mead Over • In collaboration with Africa Region (Act Africa and MAP/TAP TTLs), Global AIDS Unit, HDVP and also with WHO and UNECA

5. Question I: Measuring the impact of treatment on the welfare of patients and family members • Lives saved and health outcomes • Labor supply of patient and family members • Schooling of children • Other welfare indicators

6. Question II: Possible effects of ART on HIV transmission and prevention

7. Other questions (more on the supply- facility side) • 3) Determinants of adherence to treatment • 4) How to avoid the development and spread of resistance? • 5) How are ART beneficiaries identified? How to encourage timely uptake? • 6) How to assure the quality of HIV/AIDS service delivery? • 7) How to encourage capacity building to reinforce the sustainability of ART delivery?

8. Data collection (Longitudinally) • Biomedical follow-up • Health facility and association surveys • Household surveys (HIV patients and general population) • Surveys of employers and employees (Ghana)

9. Determinants Patient and Provider Behavior Outcomes Impact on the entire country Impact On health system Training Quality of service delivery Equipment Socio- Economic benefits for households Staffing and Incentives Associations Treatment Outcome, Resistance Development Selection / Recruiting Employers Socio- Economic benefits for firms Community variables Stigmatization Patient Adherence Information Prevention socio-economic variables Framework for Learning agenda

10. What can we learn about the quality of service delivery? • Examples from a survey of facilities delivering ARVs in Burkina Faso. • Work in collaboration with Dr. Laetitia NIKIEMA of the IRSS in Ouagadougou. • Very preliminary analysis (first batch of data) • Household data currently being collected by ISSP

11. In Burkina Faso, 4 different types of facilities are delivering ARVs

12. Satisfaction levels vary by gender and by type of facility

13. Expenses per visit excluding transportation

14. Transportation costs do matter

15. Next steps • Study impacts on adherence and treatment outcomes of: • Impact of out-of-pocket expenses and transportation costs (w. household data) • Type of facility and service quality • Other variables … • Similar work in Ghana, Mozambique, Rwanda, South Africa and Kenya

16. What is the benefit of ART? Example in Kenya. • From Goldstein, Graff Zivin and Thirumurthy 2005. • Life saved, quality of life. Fewer orphans. • In addition: labor force participation, children going back to school, less child labor

17. CD4 Counts before and after treatment Source: Goldstein, Graff Zivin and Thirumurthy 2005

18. Body Mass Index before and after treatment Source: Goldstein, Graff Zivin and Thirumurthy 2005

19. Labor force participation before and after treatment Source: Goldstein, Graff Zivin and Thirumurthy 2005

20. What are the consequences of anti-retroviral treatment • individual benefits and costs • benefits and costs at the household and extended family level Also look at the impact of treatment on the dynamics of the epidemic ( spillovers: social benefit and cost)

21. Rate of growth of the population Population Explosion The Demographic Transition Rate per 1000 people Birth Rate Death Rate Time

22. Rate per 1000 people Rate of growth of people living with HIV/AIDS New infections AIDS Deaths Time “Explosion of ART patients” “Hypothetical AIDS Transition” Source: Over (2004)

23. 90 450 Persons living with AIDS 80 400 AIDS Cases 70 350 60 300 50 250 (AIDS cases and deaths in thousands) (Persons living with AIDS in thousands) 40 200 Deaths 30 150 20 100 10 50 0 0 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 Years AIDS transition in the United States, 1985-2003

24. How to maximize benefits and minimize adverse effects? • Need to learn as we scale-up ART (example TAP learning agenda) Measure: - private benefits and costs - biological effects, including resistance. Role of quality of service provision and adherence. - behavioral effects

25. Treatment in the long run? • The greater the success of treatment, the more patients • Second line therapy is much more expensive. • Adherence crucial: role of health infrastructure and staff • Prevention, prevention, prevention!

26. India Thailand Findings from India & Thailand

27. But suppose ART availability causes complacency ... “Kemron” and “Pearl Omega” were the brand names for false “cures” for AIDS that were announced in the Nairobi press. Is this a “disinhibition” effect? Source: Condom use among prostitutes in Nairobi from Jha et al, 2002

28. Potential impact of “disinhibition” Impact of risk behavior on the number of new HIV infections in India Source: Over et al, 2004

29. Provision of ART in Thailand: current status In 2004:  Persons with AIDS 61,394  New HIV infections 19,500  New AIDS cases 49,500  Persons on ART 50,986 (as of January 2005) People living with AIDS and Public ART Provision in Thailand

30. Infections prevented Thailand – Enormous current benefits of prior prevention efforts 10 Red line represents what might have been if behaviors had not changed 8 6 Current HIV Infections in millions 4 2 0 1985 1990 1995 2000 2005 2010 Baseline No Intervention

31. Under National AIDS Program deaths are postponed

32. National AIDS Program will increase the prevalence of HIV

33. Cost of treatment with 2nd line reaches a ceiling at US$500 million per year

34. After 2010, most costs are for second-line therapy

35. Comparing the flows of costs and benefits: 1st & 2nd Lines Total cost of NAPHA: $5.68 billion Total benefits of NAPHA: 2.64 mn. LYS

36. Cost-effectiveness of ART with 1st & 2nd line • $5.6 bn / 2.6 mn LYS = $2,144/LYS

37. Treatment AND Prevention • Organize ART so that prevention is reinforced • Focus prevention efforts so that ART is sustainable

38. Ingredients of a successfulAIDS Transition • A “Learning Agenda” will help accomplish the AIDS transition • Understand the health & non health benefits of treatment in each country • Understand all the determinants of treatment success in each country • Financing problem: Lower costs, increase effectiveness or increase funding? • Prevention, prevention, prevention