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© 2005, Johns Hopkins University. All rights reserved.

Department of Health, Behavior & Society

David Holtgrave, PhD, Professor & Chair

Source: Prejean et al. PLoS ONE 2011

Social Injustice Never Takes A Holiday

Presentation Headlines

– Prevention Works: Evidence of national level success– Prevention Pays Off: In lives, and in dollars– We Have Many Cost-Effective Prevention Tools From

Which to Choose For a Combination Prevention Package…

– …But How Can We Choose Among These Tools?– Current Resources Are Not Enough to Reach the Goals

of the National HIV/AIDS Strategy– As President Obama Said….It is not about whether we

know what to do, it is about whether we will do it

Prevention Works: Evidence of National

Level Success

Estimated Number of New HIV Infections, Extended Back-Calculation Model, 1977–2006

Source: CDC Website; Hall et al., JAMA 2008

HIV Transmission Rate =

(Incidence / Prevalence) * 100

(aka, “Incidence-Prevalence Ratio”)

HIV Transmission Rate, United States, 1977-2006

0.00

20.00

40.00

60.00

80.00

100.00

120.00

1977

1978

1979

1980

1981

1982

1983

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1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

Year

Source: Holtgrave et al. JAIDS 2009

U.S. HIV Transmission Rate One of Lowest in the World

Source: Holtgrave, Int J STD & AIDS 2009;20:876-878

Refining Transmission Rates by Knowledge of Serostatus1-4

• Assuming 2006 HIV incidence and prevalence estimates, and assuming 79% awareness of HIV seropositivity…

• Overall transmission rate for Year 2006– 5.0

• Unaware of HIV seropositivity– Transmission rate estimated at 11.4

• Aware of HIV seropositivity– Transmission rate estimated at 3.3

– Reflects behavioral changes and treatment effects1. Holtgrave DR et al. Int J STD AIDS. 2004;15(12):789-92.2. Marks G et al. AIDS. 2006;20(10):1447-50. 3. Holtgrave, Pinkerton. JAIDS. 2007.4. Hall et al. JAIDS. 2010

Updated Annual HIV Transmission Rates Per 100 PLWH, 2006-2008, United States

Scenario 2006 2007 2008

“Lower Bound” 4.01 4.49 3.70

Base Case 4.39 4.90 4.06

“Upper Bound” 4.73 5.28 4.38

Source: Holtgrave, Hall, Prejean. Under review.

A General Epidemiologic Fact

• If Incidence is flat, and• Prevalence is

increasing, then• The Transmission Rate

must be going down

This appears to be the situation for HIV in the U.S.; though the 2007 incidence estimates

add some complexity to the interpretation

Prevention Pays Off:

In Lives, and In Dollars

HIV Incidence and CDC HIV Prevention Budget (Adjusted for Inflation), United States, 1977-2006

0

50000000

100000000

150000000

200000000

250000000

300000000

350000000

400000000

450000000

500000000

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

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1989

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1991

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2005

2006

Year

Infla

tion-

Adj

uste

d B

udge

t (19

83 D

olla

rs)

-

20,000

40,000

60,000

80,000

100,000

120,000

140,000

CDC HIV Prev. Budget (Real Dollars) CDC Incidence Estimate

Based on: Holtgrave, Kates Am J Prev Med 2007

HIV infections averted and medical costs prevented, 1991-2006, US

(Farnham, Holtgrave, Sansom, Hall JAIDS 2010;54:565-567)

Projected HIV Incidence(Hall, Green, Wolitski, Holtgrave, et al., JAIDS 2010)

CDC Website Factsheet Excerpt based on

Hall, Green, Wolitski, Holtgrave, et al., JAIDS 2010

Expanding HIV prevention in 5 years: The study found that intensifying national HIV prevention efforts over a five-year timeframe and maintaining them for the subsequent five years could reduce annual HIV incidence by 46 percent… — saving as many as an additional 306,000 people from becoming infected over the next 10 years — compared to maintaining current prevention efforts. …This rapid scale up would also save 25 times the amount that would need to be invested: …(it) would require an additional investment of $4.5 billion over 10 years, and would save up to $104 billion in avoided lifetime medical costs.

Source: http://www.cdc.gov/hiv/resources/factsheets/PDF/us-epi-future-courses.pdf

Additional CDC Website Factsheet Excerptbased on

Hall, Green, Wolitski, Holtgrave, et al., JAIDS 2010

Expanding HIV prevention in 10 years: The study shows that expanding HIV prevention over a 10-year timeframe could reduce national HIV incidence by 40 percent… — preventing as many as an additional 215,000 new infections. …This expansion of HIV prevention would require an additional investment of $10.1 billion over 10 years, and would save as much as $66 billion in averted lifetime medical costs.

Source: http://www.cdc.gov/hiv/resources/factsheets/PDF/us-epi-future-courses.pdf

We Have Many Cost-Effective Prevention Tools From Which to

Choose For a Combination Prevention Package…

Core Domains of Combination Prevention Package by Client Populations

BEHAVIORAL BIOMEDICAL STRUCTURALHIV-, general population risk levelHIV-, most at risk persons / communitiesPersons living with HIV, unawarePerson living with HIV, aware, no risk behaviorPersons living with HIV, aware, risk behavior (very small minority of PLWH)

Cost-per-quality-adjusted-life-year-saved of a sample of Non-HIV Medical Interventions

Intervention Appox. Cost per QALY Saved

Year of Dollars Source (Reviews)

Kidney Dialysis $52,000 to $129,000

2000 Grosse, 2008

Mammography, 50-69 y.o.

$57,500 2001 Walensky, 2009

Type 2 diabetes screening >25 y.o.

$63,000 2001 Walensky, 2009

Note: “Cost-saving” would refer to ratios less than $0 per QALY saved; though there is no single cut-off, ratios less than $100,000 per QALY saved are generally considered “cost-effective”

Cost-per-quality-adjusted-life-year-saved of a sample of HIV Biomedical Interventions

Intervention Appox. Cost per QALY Saved

Year of Dollars Source

Targeted HIV testing Cost-saving NA Holtgrave, 2007

HIV screening every 5 years

$42,200 2001 Walensky, 2009 (review)

PrEP $298,000* 2006 Paltiel et al., 2009

Early vs deferred HAART

$15,159 to $36,301 2005 Hornberger et al., 2007 (review)

Deferred vs no HAART

$46,423 2005 Hornberger et al., 2007(review)

Expanded screening & treatment

$21,580 2009 Long et al., 2010

Newborn circumcision (US)

Cost-saving to $87,792

2007 Sansom et al., 2010

Vaginal microbicide Result depends on local HIV prevalence

NA Verguet et al., 2010

*result varies by assumptions of effectiveness and narrowness of targeting population to be served;also post-exposure prophylaxis has been estimated at $12,567 per QALY saved by Pinkerton et al., 2004

Cost-per-quality-adjusted-life-year-saved of a sample of HIV Behavioral and Structural

InterventionsIntervention Appox. Cost per

QALY SavedYear of Dollars Source

Housing as Prevention

$62,493 2005 Holtgrave et al., under review

Peer Opinion Leader & Group (MSM and Women)

Cost-saving NA Pinkerton et al.,2001 (review)

Behavioral (Youth Living with HIV)

Cost-saving NA Lee et al., 2005

Syringe Exchange Cost-saving NA Holtgrave et al., 1998

Condom Distribution

Cost-saving NA Bedimo et al., 2002

Clinical provider counseling (PLWH)

Cost-saving NA Marseille et al., 2011

…But How Can We Choose

Among These Tools?

Important Caveats About Cost-Effectiveness Analyses

• Sensitivity analyses are important to express uncertainty– here we’ve quickly summarized some cost-effectiveness analysis base case

results

• Always customize results to your local area – e.g., by HIV seroprevalence

• Many (but not all) of the cost-effectiveness studies compare an intervention to nothing (or the status quo)– Nearly always, something looks better than nothing

With So Many Good Alternatives to Select From, What Do I Choose?

• A comprehensive set of key policy/program questions need to be asked about interventions, including….– Is the intervention evidence-based?– Is it based on the real needs and life circumstances of my clients?– How much does it cost per client? (Can I afford it?)– What does it cost per new HIV diagnosis? Per HIV infection averted? Per life

year saved?– Is it cost-saving, or cost-effective….or neither?– Is it scalable, and can I afford to provide it to a large number of clients?– What is the best mix of interventions given the resources I have to work

with?– How much would it take to achieve the NHAS percentage goals in my

jurisdiction?– Are there policy barriers that prevent me from implementing the program?

Moving From Cost-effectiveness Toward Optimization Analyses

• Given that set of key policy/program questions….• Optimization modeling is increasingly important to compare multiple

programs/policies to identify the “best set” of options – Consideration must be given simultaneously to scale, resource

availability, overall population level impact, and unmet need– Example, ECHPP modeling to be discussed in next section of

presentation– Other examples include

• Walensky et al., 2010 estimates of impact of testing and treatment in Washington, DC

• Holtgrave, 2007 comparison of a variety of HIV testing policies for the U.S.

• Lasry et al., 2011 resource allocation model• Cohen & Farley, 2005 resource allocation model

ENHANCED COMPREHENSIVE HIV PREVENTION PLAN for the

BALTIMORE – TOWSON MSA, Maryland

Heather L. Hauck, DirectorInfectious Disease and Environmental Health Administration

Maryland Department of Health and Mental Hygiene

Infectious Disease & Environmental Health Administration February 2011

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ECHPP Objectives

Develop an enhanced plan that aligns the jurisdiction’s prevention activities with the National HIV/AIDS Strategy Using resources so that they have the biggest impact on HIV incidence Identifying and addressing gaps in scope and reach of prevention

activities among priority populations Enhancing coordination between prevention, care, and treatment

Identifying/implementing the optimal combination of prevention, care, and treatment activities to maximally reduce new infections Assuring that the most effective biomedical, behavioral and

community/structural interventions are prioritized Assuring that interventions are going to populations/communities in such

a way that the level of investment matches the level of risk


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Maryland ECHPP Process

Presentations/meetings with key stakeholders– Seven local heath departments and five HIV/AIDS community

planning bodies

Assessment of existing programming– Current level of implementation, including data on program funding,

activities, reach and outcomes

Mathematical modeling– Developed a resource optimization model to inform the allocation of

current resources and quantify additional resources needed to reach the prevention goals of the NHAS

Collaborative planning– Identification of priority areas to increase coordination and

integration across the prevention, care and treatment continuum


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Estimated HIV Transmission Rates for the Baltimore-Towson MSA

Type of Transmission RateTransmission Rate Per 100

PLWHOverall for the Baltimore-Towson MSA 4.4Persons Living with HIV and Unaware of Seropositivity 9.5Persons Living with HIV and Aware of Seropositivity 3.0Persons Living with HIV, Aware of Seropositivity, and NotEngaged in Any Risk Behavior (Vast Majority of PLWH)

0.0(by definition)

Persons Living with HIV, Aware of Seropositivity, and Engaged in Risk Behavior (Small Minority of PLWH)

18.7

Definition of Three Testing Approaches in the Baltimore-

Towson MSARoutine Testing in Emergency Department and Similar Settings

Targeted HIV Counseling and Testing – Target by Venue Type

Targeted HIV Counseling and Testing – Target Via Outreach

HIV Seropositivity Rate

0.8% 1.2% 4.0%

HIV New Diagnosis Rate

0.5% 1.0% 1.2%

Counseling and Cost Comments

Post-testcounseling for PLWH and 11.9% of HIV- persons

Post-testcounseling for all

Post-testcounseling for all; 10% of cost devoted to “targeting via outreach”


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Three Testing Approaches in Baltimore: Results of Modeling

Routine “ED” Target by Setting Target via Outreach

No. Tested 45,260 34,472 28,916 No. Undiagnosed HIV+ Persons Reached 226 345 347 No. High Risk HIV-Persons Reached 5,343 16,859 13,741 Total Testing Cost $ 1,130,000 $ 1,130,000 $ 1,130,000 Transmissions Averted 15 22 23Infections Averted 4 13 11 Transmissions + Infections Averted 19 36 34 Gross Cost Per Trans+Inf Averted $ 59,435 $ 31,507 $ 33,707 Public Support for Med Care Needed Year 1 $ 3,867,450 $ 5,891,225 $ 5,930,184

Issue of Category B language in CDC’s Health Dept. FOA PS12-1201

• We need local flexibility to do what is most cost-effective in Baltimore

• Flexibility in Category A doesn’t address Category B

• “At least 70% of Category B funding must be allocated to the delivery of services in healthcare settings. Up to 30% may be used to support targeted testing efforts in non-healthcare settings.”– quote from FOA p.30


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Interventions Included in the Baltimore-Towson MSA Modeling

HIV Counseling and Testing – hybrid reflective of Baltimore-Towson experiences and best practices in the

field (assuming rapid testing model; 1.5% seropositivity rate; and 0.9% new diagnosis rate);

– includes post-test counseling for at-risk HIV- persons

Prevention Services with Persons Living with HIV– intensive behavioral risk-reduction intervention services (and reinforcement

of linkage to other needed services)

Partner Services and Intensive Linkage to Care Prevention Services for HIV- Persons at High Risk of Infection

– intensive behavioral interventions above and beyond post-test counseling

Total Size of Funding Pool: $6 million


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Interventions Assumed to be Provided with Separate Funding by

DHMH

Syringe Exchange Services Public Information Campaigns Condom Distribution Structural Interventions (such as work on HIV-

related policies; and HIV-related housing which is supported via other funding streams)

Overall Program Management and Evaluation Provider Training and Capacity Building


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Modeled “Best Performance”: Costs by Category

Year 0 Year 1 Year 2 Year 3 Year 4 Total Y1-4Total Costs $6,002,859 $6,002,844 $5,724,757 $6,007,416 $6,276,419 $24,011,436

Counselingand Testing $3,260,500 $3,807,730 $2,293,361 $2,411,791 $2,521,157 $11,034,039 Prev. with PLWH and Engaged in Risk Behavior $290,663 $608,014 $2,475,500 $2,590,367 $2,704,418 $ 8,378,299

Prev. for HIV-Persons $1,162,653 $ - $ - $ - $ - $ -

PartnerServices $789,043 $1,587,100 $955,896 $1,005,259 $1,050,844 $4,599,098

ECHPP $ $500,000 $ - $ - $ - $ -


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Modeled “Best Performance”: Results

Year 0 Year 1 Year 2 Year 3 Year 4Incidence

1,201 1,103 995 967 936 Prevalence

27,550 28,194 28,722 29,213 29,667 TransmissionRate 4.3593 3.9108 3.4628 3.3086 3.1539Unawareness of Seropositivity 21.00% 17.69% 15.45% 13.22% 10.98%

Note: HIV incidence is reduced 22.09% (vs the 25% goal in the NHAS) and HIV transmission rate is reduced 27.65% (vs the 30% goal in the NHAS). Unawareness of seropositivity does not quite reach the NHAS goal of 10%.


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Unmet Needs Scenarios: Baltimore-Towson MSA

Year 1 to 4 Total Resources

Total IncidenceReduction

Total TransmissionRate Reduction

HIV SeropositivityAwarenessLevel

Better Use of Current Resources $24,011,436 22.09% 27.65% 89.02%

Meeting Awareness Goal $25,769,082 23.26% 28.69% 90.00%

Same as Above But Front Loaded

$25,984,400 24.04% 29.24% 90.00%

Meeting All Goals $32,281,882 24.94% 30.12% 90.00%

Same as Above But Front Loaded $32,538,589 25.73% 30.68% 90.00%

NHAS Target 25.00% 30.00% 90.00%


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Maryland ECHPP Activities

Significantly increase:– Routine HIV screening in clinical settings– Targeted HIV testing in non-clinical settings – Initial and ongoing HIV/STI partner services – Activities to support linkage to care, retention in care, and adherence to

antiretroviral treatment– Risk reduction interventions for PLWH

Decrease and redirect resources for:– Behavioral risk reduction interventions for HIV-negative persons

Across all programming:– Increase utilization of local HIV and STI surveillance data– Increase partnerships across funding sources & with private providers

What is “Optimal” for Baltimore May or May Not Be Optimal in Other Jurisdictions;

But Modeling Process Might Be Useful

…But Current Resources Are Not Enough to Reach the Goals of the National HIV/AIDS Strategy

Wasted Opportunities to Improve Health of Persons Living with HIV and Help Prevent HIV

Transmission

Source: Gardner et al. Clinical Infectious Diseases. 2011

Populations Sizes by HIV Serostatus and Behavioral Risk Level, 2008

General Population of U.S. (≈ 304.4 million)

HIV- at Possible Risk[in 13-64 year old, ≈ 25 million ]

HIV- at Highest Actual Risk

[Number in Unprotected Serostatus Discordant

Partnerships Wherein Viral Load is Not Suppressed]

Unaware

HIV+

Aware HIV+; No Risk Beh.

Aware HIV+; Risk Beh.

Updated from: Holtgrave, McGuire, Milan: AJPH, 2007; CDC MMWR June 3, 2011; Anderson et al. CDC, Advance Data from Vital and Health Stats, October 23, 2006

Care/Tx*

[≈236,400] [≈150,700]

[≈791,200]

*Fraction of 791,200 and 150,700 on treatment and achieving suppressed viral load is unclear; assume none of 236,400 are on treatment

Key implications of NHAS (from Holtgrave, JAIDS 2010)

• How will epidemic be changed if goals are met?– Prevent roughly 75,800 infections (2010-2015)– Prevent roughly 237,700 infections (2010-2020)– 2015 prevalence without NHAS roughly 1.481M and with

NHAS roughly 1.407M

• Appox. 218,900 more people on care and treatment

Key Implications of NHAS (continued)(from Holtgrave, JAIDS 2010)

• Cost of NHAS in expanded funding (be it new, redirected, or new private sector)– Total across years through 2015

• Roughly $15.2B need to achieve NHAS– Appox. $2.1B for prevention– Just under $1B for housing (to achieve NHAS goal)– Remainder for care and treatment (appox. $12.2B)

» 43% is due to expanded awareness » 57% due to expanded coverage

Key Implications of NHAS (continued)(from Holtgrave, JAIDS 2010)

– However, investing in NHAS could save money– Medical costs offset by HIV infections averted

through expanded prevention efforts– Net present value of medical care costs saved due to

prevention efforts: $17.981B– Savings larger than investments needed (cost saving)

– Bend the cost curve by bending the incidence curve– Choosing to not expand prevention efforts is the

MORE expensive policy option

As President Obama said on July 13, 2010…. “The question is not whether we know what to do, but whether we will do it.”

Issue of $20M from Category A in CDC’s Health Dept. FOA PS12-1201

• In times of great need, maximizing every dollar of core prevention service delivery is essential; $20 million should be restored immediately to Category A

• Source could be from an FY12 continuation of the FY11 $31 million increase in CDC base HIV prevention funding (or from another CDC or HHS resource pool)

• $284 million instead of previous $304 million in Category A– $20 million moved to

Category C for demonstration projects conducted by health departments

CDC’s Total HIV Prevention Budget (Actual and Inflation-Adjusted)

$-

$100,000,000.00

$200,000,000.00

$300,000,000.00

$400,000,000.00

$500,000,000.00

$600,000,000.00

$700,000,000.00

$800,000,000.00

$900,000,000.00 19

7819

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Dol

lars

Actual Budget

Inflation Adjusted

Inflation-adjusted budget down 17.9% since FY02; buying power now approx. FY91

Kaiser Family Foundation, HIV/AIDS Policy Fact Sheet, March 2011

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Someone Living With HIVDies Approximately Every….

Minutes in the United States

A death rate roughly 1.79 times that of the general population in the U.S.

Baby’s got a lot of tears enough to cry a thousand yearsEnough to cry a thousand seas, enough to break a boy like meI want to stand and deliver and be the one that makes it better.

-- Amy Ray, 2008, “Stand and Deliver”

Thank you for your individual and collective leadership, passion, perseverance, and devotion to addressing HIV/AIDS in your

neighborhood, state, and the nation

http://en.wikipedia.org/wiki/File:Tianasquare.jpg

Health & Medicine

1 mon 0841 mon holtgrave