Methods for Estimating Global Resource Needs for HIV/AIDS John Stover, Lori Bollinger International AIDS Economic Network Meeting, Washington, DC February 22, 2008

Purpose Estimate the global resource needs from all sources to implement a comprehensive program of HIV prevention, care, treatment and mitigation in low- and middle-income countries through 2015

Goals and Scenarios Universal access by 2010 Universal access to prevention, care and mitigation in all countries by 2010 Phased Scale Up to Universal Access UA by 2010 for MARP and all services in hyper-endemic countries, by 2015 in generalized epidemics, current scale up elsewhere Current Scale Up Continue current rates of scale up to 2015 UNAIDS, Financial Resources Required to Achieve Universal Access to HIV Prevention, Treatment, Care and Support, September 2007.

Components of a Comprehensive Program Prevention Care and treatment Support for orphans and vulnerable children National program costs International support costs

Prevention Programs Vulnerable populations Sex workers MSM IDU Prisoners Other special populations Youth (in/out of school) Formal sector employees Behavior change Community mobilization Mass media Social marketing VCT Condoms Violence against women Medical services Blood safety STI treatment PMTCT Post-exposure prophylaxis Safe medical injection Universal precautions New technologies Male circumcision HSV-2 suppressive therapy Pre-exposure prophylaxis Microbicides Vaccines

Prevention of Violence Against Women Workplace Community mobilization Education and sensitivity training for adolescents Enabling environment (special populations) Gender perspective in health services Mass media Post-rape services NGO strengthening

Approach Resources required = population in need x coverage x unit cost

Key Questions About Unit Costs What are the sources of information? Do unit costs remain constant? What has been costed?

Source of Information on Unit Costs 1. Published studies 2. RNM and Goals applications 3. National plans 4. Unit cost surveys 1. UNFPA Young People 2. UNAIDS/UNICEF OVC 5. RNM regional workshops 6. Regional averages

Validation Top 15 validation workshop in Geneva Latin America validation workshop in Mexico

Economies of Scale? Not much information on economies of scale as programs expand We assumed unit costs decline by 30% with each doubling of scale for most prevention interventions Marseille E, et al. HIV prevention costs and program scale: data from the PANCEA project in five low and middle- income countries BMC Health Services Research 2007, 7:108.

What has been costed? “Resources needs” implies high quality programs Difficult to tell what unit costs include Key area for future work

Care and Treatment ART Drug costs FL, SL, Pediatric, HIV- TB Laboratory costs Nutrition supplements Service delivery Non-ART Palliative care OI treatment Cotrimoxazole OI prophylaxis PITC STI screening Counseling

Spectrum: AIDS Impact Module (AIM) New HIV Infection Need for Treatment First Line ART AIDS Death Second Line ART Normal M 7.5yrs/F 8.5yrs, fast 6.1/6.9 3 years 15%/5% 15% FY / 5% SY Prevalence trends

Adult Male Progression without Treatment

Adult Male Progression with Treatment

Estimates of ARV Prices for First Line Regimens (US$) Brazil Ukraine Botswana Peru, Mexico Honduras, SA Tanzania

Estimates of ARV Prices for First Line Regimens (US$) By 2015 typical first line becomes EFV+TDF+3TC

Estimates of ARV Prices for Second Line Regimens (US$) Botswana, SA, Mexico, Tanzania Honduras Brazil Ukraine El Salvador

Estimates of ARV Prices for Second Line Regimens (US$) Middle-income Low-income

Orphans and Vulnerable Children Who is vulnerable? How are services delivered? What should be included in AIDS resource needs? Stover J et al. Resource needs to support orphans and vulnerable children in sub-Saharan Africa Health Policy and Planning 2007;22:21-27.

National Program Costs Health facilities Program management IEC & advocacy M&E including OR Training Logistics and supply Lab upgrading Supervision and patient tracking Drug resistance surveillance Human resources

International Support Costs Civil society strengthening Technical assistance Global advocacy and coordination Policy, human rights, stigma

Major Challenges Aligning unit costs with ‘best practices’ Matching resource needs with estimated expenditures GRNE = national strategic plan budgets Who should pay? UNAIDS, Financial Resources Required to Achieve Universal Access to HIV Prevention, Treatment, Care and Support, September 2007.