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How ‘Universal’ will Universal Access be in Europe by 2010?
Eddy Beck
Evaluation Department
UNAIDS, Geneva 8-6-2007
The introduction of combination antiretroviral therapy has had a profound
impact on mortality and morbidity patterns of people living with HIV…..
…and scaling up services, which countries are involved with as part of the
Universal Access process. This was agreed at the High Level Meeting in New York in June 2006 and is described in the
2006 Political Declaration on HIV/AIDS
• Scaling up of HIV prevention, treatment, care and support services;• Country driven process, in which countries set own ‘ambitious’ but ‘realistic’ targets• To make this happen needs to be ‘country owned’ process involving all stakeholders, especially people living with HIV and other members of civil society
Universal Access, 2006 Political Declaration on HIV/AIDS
Build on the momentum of scaling up treatment and care programs, including
Universal Access, 2006 Political Declaration on HIV/AIDS
Introduction of combination antiretroviral therapy has reduced
the mortality and morbidity of people living with HIV…..
but the irony is, that the momentum generated by scaling up treatment and
care programs, has also highlighted the need for improved prevention
services…………….
*Per 100,000 US Population;
MMWR. 2005;54(46):1188.
HIV and AIDS diagnoses and deaths, UK
Numbers will rise, for recent years, as further reports are received.
Clinician reports of new HIV/AIDS diagnosis
HIV diagnoses by exposure category, UK
Numbers will rise, for recent years, as further reports are received.
Clinician reports of new HIV/AIDS diagnosis
Review of Newly Diagnosed People with HIV, UK 2000-2004
• 15,523 newly diagnosed heterosexuals • 74% Black Africans, 11% White & 4% black Caribbeans• 42% diagnosed late: 43% of Black Africans, 36% of
Whites and Black Caribbeans.• Most Black Africans infected in Africa• 20% of Black Africans infected in the UK diagnosed
late, compared with 44% of those infected in Africa.
Chadborn et al, AIDS 2006,20: 2371-9
Global number of people newly infected with HIV and AIDS
deaths 2001-2006
This bar indicates the range around the estimate.
2002 2003 2004 2005 2006
Year
2001
Mill
ion
s
0
1
2
3
4
7
6
5Number of new HIV infections and number of people who died of AIDS
Number of new HIV infections
Number of people who died of AIDS
This bar indicates the range around the estimate.
This bar indicates the range around the estimate.
2002 2003 2004 2005 2006
Year
2001
Mill
ion
s
0
1
2
3
4
7
6
5
0
1
2
3
4
7
6
5Number of new HIV infections and number of people who died of AIDS
Number of new HIV infections
Number of people who died of AIDS
Economics of providing health services
• Cost of providing services
• Cost-effectiveness of interventions, programs or services
Cost of providing health services
• “What does it cost to run an HIV service?”;• “Is the service affordable?” • “Are additional resources required to provide
services in a particular manner?” • “What is the gap between the cost of services
and the financial resources spent on services?
Cost-effectiveness of interventions, programs or
services
• “what does it cost to achieve a certain outcome or impact?”;
• “does a new intervention add value?”
Cost-effectiveness of HAART?
• Canada
• South Africa
• UK
Cost-effectiveness of HAARTin Canada
NON-AIDS Group
0.6
0.7
0.8
0.9
1
0 100 200 300 400 500 600 700 800 900 1000
1100
1200
1300
1400
1500
1600
1700
Time since entry into cohort (days)
Pro
port
ion
rem
aini
ng in
CD
C s
tage
A&
B
1991-1995 1997-2001
Adjusted for gender, age, sexual orientation and IDU use, baseline CD4 count and ARV treatment
Clinical Progression for non-AIDS Patients in Quebec, Canada
1991 – 1995 vs 1997-2001
Clinical Progression for AIDS patients in Quebec, Canada
1991 – 1995 vs 1997 - 2001
AIDS Group
0.4
0.5
0.6
0.7
0.8
0.9
1
0 100 200 300 400 500 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800
Time since entry into cohort (days)
1991-1995 1997-2001
Adjusted for gender, age, sexual orientation and IDU use, baseline CD4 count and ARV treatment
Incremental cost per life-year-gained by
stage of HIV infection
• US $14,587 for non-AIDS patients
• US $12,813 for AIDS patients
Beck EJ, Mandalia S, Gaudreault M, et al The Cost-effectiveness of
HAART, Canada 1991-2001. AIDS, 2004; 18: 2411-9.
Cost-effectiveness of HAARTin South Africa
Clinical Progression for non-
AIDS patients, 1995 - 2000
0 1 0 0 2 0 0 3 0 0 4 0 0 5 0 0 6 0 0 7 0 0 8 0 0 9 0 0 1 0 0 0 1 1 0 0 1 2 0 0 1 3 0 0 1 4 0 0
Da ys
0 .0
0 .1
0 .2
0 .3
0 .4
0 .5
0 .6
0 .7
0 .8
0 .9
1 .0
Pro
po
rtion
rem
ain
ing
in W
HO
No
n-A
IDS
sta
ge
?
0 1 0 0 2 0 0 3 0 0 4 0 0 5 0 0 6 0 0 7 0 0 8 0 0 9 0 0 1 0 0 0 1 1 0 0 1 2 0 0 1 3 0 0 1 4 0 0
T i m e
0 .0
0 .1
0 .2
0 .3
0 .4
0 .5
0 .6
0 .7
0 .8
0 .9
1 .0
Pro
po
rtion
rem
ain
ing
in W
HO
No
n-A
IDS
sta
ge
P<0.0001
Badri M, Maartens G, Mandalia S, et al. Cost-effectiveness of Highly Active Antiretroviral Therapy in South Africa. Plos Medicine January 2006; 3: e4
Clinical Progression for AIDS patients, 1995 - 2000
0 1 0 0 2 0 0 3 0 0 4 0 0 5 0 0 6 0 0 7 0 0 8 0 0 9 0 0 1 0 0 0 1 1 0 0 1 2 0 0 1 3 0 0 1 4 0 0
Da ys
0 .0
0 .1
0 .2
0 .3
0 .4
0 .5
0 .6
0 .7
0 .8
0 .9
1 .0
Pro
po
rtion
rem
ain
ing
in W
HO
AID
S s
tag
e
P<0.0001
Badri M, Maartens G, Mandalia S, et al. Cost-effectiveness of Highly Active Antiretroviral Therapy in South Africa. Plos Medicine January 2006; 3: e4
Cost-effectiveness of HAART in non-AIDS and AIDS patients, Cape Town 1995 - 2000
Cost savingat annual HAARTCost of
US$730 orUS$ 181
US$2506 LYGat annual cost
HAARTof US$730
andUS$ 327 LYG
at US$181 per annum
Non-AIDS AIDS
Cost-effectiveness of different HAART regimens in the UK
Time to treatment failure for people on different first-line
HAART regimens
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0 200 400 600 800 1000 1200 1400 1600 1800 2000 2200
Duration since starting 1st line HAART
Pro
po
rtio
n w
ho
se t
reat
men
t re
mai
n s
ucc
essf
ul
wit
h t
hei
r fi
rst
lin
e H
AA
RT
Other combinations
2NRTI+NNRTI
2NRTI+PI
2NRTI+2PI (unboosted)
2NRTI+2PI (boosted)
2439 (1189 to 3689)
4832 (2332 to 7332)
1571 (738 to 2405)
2378 (1128 to 3628)
1631 (798 to 2464)
The cost-effectiveness per life year gained (LYG) for first line
HAART
2NRTIs+NNRTI versus 2NRTIs+ PI
boosted
US$19,577 per LYG
2NRTIs+NNRTI versus 2NRTIs + PI
US$19,659 per LYG
2NRTIs+NNRTI versus 2NRTIs+ 2PI
US$ 8,571 per LYG
Conclusions
• HAART enables people living with HIV to remain socially and economically active
• HAART a cost-effective intervention in a number of high- and middle-income countries, despite differences in health care systems
• Evidence that viral load levels reflect levels of infectivity, so HAART reduces the infectivity of individuals living with HIV
Rationale for treating People living with HIV with HAART
• Human Rights Argument – the Joint UNAIDS Program is based on the premise that access to services and treatment is a basic human right
• Public Health Argument: treating people with HAART, reduces their infectivity and exposes them to prevention services for themselves and people within their social environment
Requirements
• For optimal treatment people living with HIV need to be followed up regularly and attend for follow up
• Drug combinations will eventually fail: if not under regular supervision may fail earlier, develop resistance etc.
• This provides opportunities to regularly reinforce prevention messages and practices
Realities in many countries
• However, ‘irregular’ migrants may be less likely to regularly attend health services, in fear of coming into contact with government officials, with potential consequences including deportation
• Even ‘regular’ migrants, especially those who belong to ethnic minorities, often access services late and services may be of lesser quality than those used by non-migrants
Realities in many countries
• Most vulnerable populations - women, youth, prisoners etc. – and
• most at risk populations – MSMs, IDUs, sex workers etc –
may be socially marginalized, be migrants themselves or members of ethnic minorities, all resulting in reduced access to appropriate services
For Universal Access to become a reality, even in Europe………
…. all these populations need to be reached and constructively engaged...
Thank you!