1

Book launch, Delhi

13 Aug 04

Integrating HIV prevention and antiretroviral therapy in India: Costs and Consequences of Policy Options

2

Report team:

Mead Over, Peter Heywood, Sudhakar Kurapati

(World Bank)

Julian Gold, Indrani Gupta, Abhaya Indrayan, Subhash Hira, Elliot Marseille, Nico Nagelkerke, and

Arni S.R. Srinivasa Rao

(Consultants)

3

Objectives of the study

Review the effects and consequences of ART

Use a quantitative model to predict the course of the epidemic

Use same model to determine the costs and consequences of – Maintaining current policies– Alternative government policies for ART

4

Indian context for ART policy

5

HIV Prevalence 1998

Pondichery

Gujarat

KarnatakaGoa

Lakshwadeep

Dadra Nagar HaveliMaharashtra

Madhya Pradesh

Kerala

Tamil Nadu

Andhra Pradesh

Punjab

Rajasthan

Daman & Diu

Jammu & Kashmir

Haryana

Uttar Pradesh

Himachal Pradesh

Delhi

Chandigarh

Bihar

West Bengal

Orissa

Mizoram

Meghalaya

Assam

Sikkim

Manipur

Tripura

Arunachal Pradesh

Nagaland

Source: NACO, 1998

> 1% Antenatal Women

> 5% High Risk Group

< 5% High Risk Group

No Data

TN

6

Indian context for ART policy HIV/AIDS in context of overall disease

burden– in 1998: 2% of all deaths, 6% of inf. deaths– in 2033: 17% of all deaths, 40% of inf.

Deaths Number of ART users in 2002

– >500,000 AIDS cases– 370,000 urban– 90,000 on treatment– 12,000 on ART – mostly unstructured

7

Analysis of ART policy options

Definition of policy options Health impacts of options Cost impact of options Sensitivity of results to risk

behavior Cost-effectiveness

8

Definition of policy options Adhere: Support to help patients adhere

– I.e. IEC, training, lab strengthening, subsidies for patient monitoring in both private & public sectors

MTCT+: Structured ART for identified HIV+ mothers and their partners

BPL: Structured ART for people below the poverty line

TMART: Transmission-minimizing ART

9

Structured treatment Standardized training of physician to a mandated

level of competence in ART management; Prescription of a standard triple-drug regimen as

recommended by the national guidelines; Access to support from a multi-disciplinary team

including a counselor and a nutritionist; Access to a quality laboratory for immunological

testing; Regular monitoring of the patient’s treatment status

(clinical and lab-based). Counseling to prevent transmission

10

ART can affect HIV prevention

Effects whichmight slowTransmission

Effects which mightspeed Transmission

Biological Reduces viralload

Lengthens duration Selects for

resistance

Behavioral Motivates testing Promotes

solidarity

Reduces perceivedrisk of unsafebehavior

11

Suggestive evidence of disinhibition in Kenya

12

Transmission minimizing structure

Structured ART treatment– maximize adherence– minimize infectivity– slow the development of resistant strains

Incentives – for ART physicians to assist prevention efforts of

government and non-government prevention programs– for state and local policy makers to expand and maximize

the effectiveness of prevention programs Monitoring and evaluation

– of adherence & spread of resistant strains– of prevention programs

13

The modelModified previous epidemiological

modelEstimate costs and consequences

over 35 year periodEpidemiological and biological

parameters related to transmission, disease progression, path from infection to death

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The model assumes In 1998 15% adult males clients of sex workers

– Each client 50 sexual contacts per year

1.1% of women are sex workers

– 675 commercial transactions per sex worker per year

Condoms used in half these transactions

15

Health impacts of options

Impact of ART on the path of the epidemic

Impact of ART on the burden of the epidemic

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Impact of ART on the path of the epidemic: Number of new HIV infections

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

1995 2000 2005 2010 2015 2020 2025 2030 2035

Year

Nu

mb

er

of

HIV

infe

ctio

ns

pe

r ye

ar

ADHERE Policy No Govt Policy MTCT+ Policy BPL Policy

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Benefits of three ART policies

No change in risk behavior

-1.9%-0.4%

0.6%

5.7%

1.6% 1.1%1.8% 1.5%

11.6%

7.6%

13.8%12.4%

-4.0%

-2.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

Total HIV

averted

Discounted

HIV averted

Life years

saved

Discounted

LYs saved

Alternative measures of impact

(Discount rate: 10%)

Per

cen

t ch

ang

e re

lati

ve t

o b

asel

ine

Adhere

MTCT+

BPL

Health benefits of three ART policies No change in risk behavior

18

Lessons from impact models All three ART policies save life years, but only

MTCT+ & BPL would also avert HIV infections BPL has much greater health benefits than Adhere or

MTCT+. Discount rate does not effect policy rankings Adhere policy produces effects more quickly than

other policies

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Cost impact of options

Assumptions used Total and incremental government cost

of ART policies Components of government cost of ART

policies Lessons from the cost model

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Assumptions used for costing

Assume constant unit costs of testing separate from treatment

Testing and monitoring: $100/patient/yr Cost of ART per year: $500 in both

public and private sectors Government subsidizes 100% of ART

cost in public sector, but only testing and monitoring in private

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$575

$2,257

$1,173

$7,632

$1,682

$598

$7,057

0.0

1,000.0

2,000.0

3,000.0

4,000.0

5,000.0

6,000.0

7,000.0

8,000.0

9,000.0

Baseline Adhere MTCT+ BPL

Treatment option

Mill

ion

s o

f 20

02 U

S d

olla

rs

Total cost

Incremental cost

Total and incremental government cost of Art policies

(in 2002 dollars using discount rate of 10 percent)

22

Lessons from cost model The policy options will cost between $1.7 billion and

$7 billion in present value terms– Equivalent annual expense: $177 to $744 million per year for

31 years

Compare these amounts to current expenditures– about US$1,200 million/year: central health & social welfare

expenditures– about US$300 million/year: central health expenditures

Least expensive option is 59% of health budget Most expensive outcome is 62% of health & social

welfare budget combined

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Sensitivity of results to risk behavior Alternative levels of condom use on

high risk sexual contacts– 40%, 50%, 70%, 90%

Sensitivity of the annual number of new HIV infections to these levels

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Sensitivity of the annual number of new HIV infections to condom use on high-risk

contacts

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

8,000,000

1995 2000 2005 2010 2015 2020 2025 2030 2035

Year

Nu

mb

er

of

HIV

infe

ctio

ns

pe

r ye

ar

40% condom 50% condom 70% condom 90% condom

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The net effect of BPL policy would then be negative on life-years saved ...

-18.1

25.2

-40

-20

0

20

40

60

80

100

120

140

40%condom

50%condom

Assumed impact of BPL ART on condom use

Mil

lio

ns

of

dis

cou

nte

d l

ife-

yea

rs s

aved

re

lati

ve t

o t

he

bas

eli

ne

26

Suppose that ART availability could be used to encourage prevention efforts …

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Thailand succeeded in increasing condom use to even higher levels a decade ago...

0

20%

40%

60%

80%

100%

1988 1989 1990 1991 1992 1993 1994

Condom use among sex workers

Condom use

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Condom use in Tamil Nadu during last paid sex

56

7480

88

28

41

67 67

0

20

40

60

80

100

1996 1997 1998 2000

Year

Co

nd

om

use

(%

)

Sexworkers

Truckers& helpers

Malefactoryworkers

Within India, Tamil Nadu has shown that condom use can attain high levels

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But average state performance is well below 75%

clie

nts

with

FS

Ws

female sex workers20 40 50.4 60 75 80

20

40

57.560

7580

Andhra P

AssamBihar

Delhi

Goa

Gujarat

Haryana

Himachal

J and KKarnatak

Kerala

Madhya P

Maharash

Manipur

Orissa

Other NE

Punjab

Rajastha

Tamil Na Uttar P

W Bengal

Percent condom use in commercial sex transactionsas reported by both FSWs & clients

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If condom use can be increased as a result of BPL policy, its benefits would be greater

-18.1

25.2

79.2

120.1

-40

-20

0

20

40

60

80

100

120

140

40%condom

50%condom

70%condom

90%condom

Assumed impact of BPL ART on condom use

Mill

ion

s o

f d

isc

ou

nte

d li

fe-y

ea

rs s

av

ed

re

lati

ve

to

th

e b

as

elin

e

31

If condom use can be increased as a result of BPL policy, its cost would be much less

$421 $389 $338 $319

$9,200

$7,632

$5,281

$4,175

0.0

1,000.0

2,000.0

3,000.0

4,000.0

5,000.0

6,000.0

7,000.0

8,000.0

9,000.0

10,000.0

40%condom

Baseline 70%condom

90%condom

Pre

se

nt

va

lue

of

futu

re e

xp

en

dit

ure

s in

mill

ion

s o

f U

S$

s

Indirect: OI costs

Direct: Cost of govttesting

Direct: Cost of ART

Total govt cost

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Cost-effectiveness of ART

Defined as years of life saved per dollar of government expenditure

Compare to cost of saving life years– From HIV prevention programs– From other health programs

Then suppose that ART could be an instrument to achieve good prevention

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Cost-effectiveness of alternative ART scenarios

Note: Costs and effects are discounted at 10%

$146

$199

$280

$0

$50

$100

$150

$200

$250

$300

Adhere MTCT+ BPL

Alternative ART polcies

US

$ p

er

life

ye

ar

sav

ed

34

Cost-effectiveness of alternative ART scenarios

Note: Costs and effects are discounted at 10%

$146

$199

$280

$51

$30

$0

$50

$100

$150

$200

$250

$300

Adhere MTCT+ BPL BPL + 70%condoms

BPL + 90%condoms

Alternative ART polcies

US

$ p

er

life

ye

ar

sa

ved

35

Lessons from C/E Model

Assuming ART has no effect on prevention, the Adhere policy is most cost-effective

At $146 per life year saved, Adhere is still very expensive compared to other options for saving life years

If ART causes disinhibition the losses from new infections will outweigh the gains from treatment

TMART is potentially extremely cost-effectiveonly if the incentives can be made to work

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Transmission minimizing structure

Structured ART treatment– maximize adherence– minimize infectivity– slow the development of resistant strains

Incentives – for ART physicians to assist prevention efforts of

government and non-government prevention programs– for state and local policy makers to expand and maximize

the effectiveness of prevention programs Monitoring and evaluation

– of adherence & spread of resistant strains– of prevention programs

37

Performance-based fiscal mechanisms need:

Clear policy framework Mechanisms for independent evaluation of

proposals Effective project implementation capacity Agreements on performance-based

mechanism Independent evaluation of performance Governments willing to make disbursements

conditional on performance Capacity building