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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 SocietyJuly 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.

Governments need evidence on costs to inform decisions on ART eligibility and scale-up

2

• 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1-CDC and the Government of the Kingdom of Swaziland, unpublished; 2-Bärnighausen, T., D. E. Bloom and S. Humair (2012).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

Objective

Methodology

• 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.

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

There are more patients, but also a greater proportion with high CD4 count, under the 2013 Guidelines

44

Example of Malawi: ART Patient Mix in 2014 vs. ART Patient Mix in 2020

2010 Guidelines

2013 Guidelines

Column2 2010 Guidelines.

2013 Guidelines.

0

200000

400000

600000

800000

1000000

1200000

New Adults - <350

Est Adults - <350

New Adults - >350

Est Adults - >350

Pediatric

PMTCT

Patie

nts (

Thou

s)

2014 2020

~ Current Coverage ~ 95% Coverage

Adding pre-ART and palliative care reduces the difference in patient numbers between policy options

55

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.

Example of Malawi: Patient Mix in 2014 vs. Patient Mix in 2020

2010 Guidelines

2013 Guidelines

Column2 2010 Guidelines.

2013 Guidelines.

0

200000

400000

600000

800000

1000000

1200000

Palliative CarePre-ARTNew Adults - <350Est Adults - <350New Adults - >350Est Adults - >350PediatricPMTCT

Patie

nts (

Thou

s)

2014 2020

*UA=Universal access; Pre-ART and palliative care=50% coverage

~ Current ART coverage~ 50% pre-ART coverage

~ 95% ART Coverage~ 50% pre-ART coverage

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

Multi-Country Analysis of Treatment Costs for HIV/AIDS (MATCH) Study 2010/2011Cost per ART Patient-Year by Country, USD

Costing began with the results of previous facility-based studies

5

Malawi Ethiopia Rwanda Zambia RSA $-

$100

$200

$300

$400

$500

$600

$700

$800

$900 Max

Min

Median1st Q

3rd Q

Avg

Legend

*

*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

$136$186

$232 $278

$682

Malawi Ethiopia Rwanda Zambia South Africa

New Adults -

>350

Est Adults -

>350

New Adults -

<350

Est Adults -

<350

PMTCT Pediatric Patients

$-

$150

$300

$450

Illustrative Cost PPPY

ARV Lab Personnel Other Costs

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?

In estimating total costs we reflect recent prices and expected differences between patient types

88

*CHW=Community Health Worker; Est=Established

Given changes in patient mix, in 2020, the average cost PPPY under the 2013 Guidelines is 5-10% less across Malawi, Rwanda, Swaziland, Zambia.

Less intensive

Our methodology is as robust as current evidence allows, but contains important limitations

9

• 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

Key Limitations

$-

$10,000,000

$20,000,000

$30,000,000

$40,000,000

$50,000,000

$60,000,000 Swaziland

+9%

$0

$20,000,000

$40,000,000

$60,000,000

$80,000,000

$100,000,000

Rwanda

Universal access under the 2013 Guidelines costs 10-20% more than that under the 2010 Guidelines

10

Universal Access in 2020

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.

+17%+19%

2010 Guidelines

2013 Guidelines (F

...$0

$100,000,000

$200,000,000

$300,000,000

$400,000,000 Zambia

ART PMTCT Pediatric Pre-ART Palliative Care Tests Condoms MC

$-

$20,000,000

$40,000,000

$60,000,000

$80,000,000

$100,000,000

$120,000,000 Swaziland

$0

$40,000,000

$80,000,000

$120,000,000

$160,000,000

Rwanda

At universal access, costed programs account for < 60% of projected available resources

11

Universal Access in 2020

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.

Projected resources

2010 Guidelines

2013 Guidelines (F

ull)$0

$100,000,000

$200,000,000

$300,000,000

$400,000,000

$500,000,000

$600,000,000

$700,000,000

Zambia

ART PMTCT Pediatric Pre-ART Palliative Care TestsCondoms MC Projected Resources

In Malawi, universal access may not be affordable - There is an urgent need for additional funding

12

• 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.

Resource Envelope

Gov Health Expenditure/ Total Gov Expenditure1 6.7%

Health Expenditure as % of GDP3 9.2%

Total Health Expenditure (% External) 2

$642 M (81%)

Total HIV expenditure (% External) 2

$215 M (99%)

1- Malawi NHA 2011/2012; 2-National Resource Mapping, 2013; 3-World Dev.Indicators, 2012

Universal Access to Treatment in 2020

2010 Guidelines 2013 Guidelines (Full) $-

$50,000,000

$100,000,000

$150,000,000

$200,000,000

$250,000,000

$300,000,000 Malawi Con-

doms

MC

Tests

Pal-liative Care

Pre-ART

Pe-di-atric PMTCT

ART

Pro-jected Re-sources

25%

Scale-up will be challenging in the face of operational constraints, such as existing HRH shortages

13

Example of Swaziland: HRH Required to Meet Demand in 2020

*Optimal Staffing Levels For HIV Required to Meet 2010 WHO Guidelines in 2020

Total Health Sector Staffing (HIV & Non-HIV Services)

2010 WHO Guidelines 2013 WHO Guidelines0

1,000

2,000

3,000

4,000

1,713

HIV Optimal Clinical Staff (Medical, Nursing, Laboratory, & Pharmacy)HIV Optimal Community Support Staff, Adherence Support Staff, & Data ClerksTotal Health Sector (Current Staff as of December 2013)Gap Between Current and Optimal Staffing Levels*

FTE

Optimal Staffing Requirements for HIV Services Only

*Optimal Staffing Levels For HIV Re-quired to Meet 2010 WHO Guidelines in 2020

Total: 3,544*

Total: 754 Total: 745

Swaziland currently has half of the required HRH in 2020.

0

40,000

80,000

120,000

160,000

200,000

New Adult, CD4 < 350 New Adult, CD4 > 350 Est Adult, CD4 < 350 Est Adult, CD4 > 350 PMTCT PatientsPediatric & Infant HIV Patients Pre-ART Patients

145,835156,654

+ 7.4% Pa-tients

0

200

400

600

800 754 745

- 1.2% Health Workers Required

• 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

However, incremental impact of the 2013 Guidelines on HRH for treatment and care is negligible

14

Swaziland: Facility-Level HRH Required for HIV Treatment and Care (Without Testing)

Patie

nts (

Thou

s)

Heal

th W

orke

rs

(FTE

)

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.

Conclusion: Debate should shift from whether to scale-up ART to how to do so efficiently

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Key Takeaways

Contributing Authors

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Harvard School of Public HealthT. BärnighausenD. BloomS. HumairClinton Health Access InitiativeK. CallahanS. DiamondD. GwinnellP. HaimbeR. HurleyC. LejeuneM. LippittC. McKayC. MiddlecoteS. PhanitsiriA. SabinoA. ShieldsE. TagarF. Walsh

Ministry of Health ZambiaA. Mwango

Ministry of Health RwandaS. Nsanzimana

Ministry of Health SwazilandV. OkelloS. Zwane

Ministry of Health MalawiA. Jahn

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Before Intervention Optimized $-

$100

$200

$300 Malawi Cost PPPY

ARVs Labs Personnel Other Costs

Innovative service delivery can mitigate costs in the short and long-term

18

• 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

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

Innovative service delivery can reduce the costs of scale-up in the short-term…

…and in the long-term by improving patient retention.

Note: UA is defined as 95% coverage by 2020

0% 3% 5% 8% 10%0%

2%

4%

Malawi Rwanda Zambia Swaziland% Increase in Retention

% S

avin

gs

Costs of Achieving UA* by 2020 vs. Retention

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