1. Dr Chewe Luo MMed (Paed); MTrop Paed; PhD Patricia Doughty (MPH) On behalf of the costing study team ICASA, Addis Ababa, December 5th, 2011 Estimating the cost of PMTCT of HIV: A multi-country appraisal

2. The PMTCT costing study team Central team: Martine Audibert, François Dabis, Patricia Doughty, Ragini Dutt, Chewe Luo, Hapsatou Touré. Countries: – China: Sufong Guo, Etienne Poirot, Yuning Yang, Ailing Wang, Linhong Wang. – Côte d’Ivoire: Makan Coulibaly, Virginie Ettiègne-Traoré, Kapet Kouadio, Valérie Lago-Kouraï, Thomas Munyuzangabo, Moïse Tuho. – Namibia: Cedric Limbo, Agostino Munyiri, Steve Okokwu, James Sankwasa. – Rwanda: David Kamugundu, Jules Mugabo, Placidie Mugwaneza, Elevanie Munyana, Grace Muriisa, Nadine Shema, Landry Tsague. – Ukraine: Yukie Mokuo, Anastasiya Nitsoy, Oksana Solatenkova, Tetyana Tarasova. Advisory Committee : Carlos Avilla-Figueroa, Omotolu Bayo, John Blandford, Halima Dao, Elliot Marseille, Christian Pitter.

3. There are 2 presentations related to this work Full cost data for Rwanda and Cote d’Ivoire will be presented by Francois Dabis on Wednesday 7/12/11 at 2.00pm Session room A5 Omo

4. Background Countries are rapidly scaling up PMTCT services There is need to analyse unit costs to establish costs needed Findings will assist in costing national plans to eliminate new paediatric infections

5. Objectives Estimate (median, range) unit costs associated with PMTCT service provision in 5 countries with different epidemic typologies Calculate national cost projections under three scenarios of scaling-up: –I: Status-quo –II: Towards universal access -- 80% coverage –III: Virtual elimination (+2010 WHO recommendations)

6. Timelines for first phase of field work 6 Oct 2009 Rwanda Nov 2009 Namibia Feb 2010 Ukraine Mar April 2010 China April 2010 Côte d'Ivoire

7. Methodology Selection of countries and sites: – Countries with different characteristics chosen – A convenient sample of up 10 facilities selected for direct observations Definition of PMTCT package: – Select specific PMTCT interventions to be measured and define items in a standardized manner Data collection: mostly from the field Analysis: – Unit costs/National costs/Projections 7

8. Selection (1): Geographic location 8 Côte d’Ivoire China Ukraine Rwanda Namibia Map Source : UNICEF, 2009

9. Selection (2): Resources available (in $ Purchasing Power Parity PPP) 9 Data Source : WHO, World Health Statistics, 2010

10. Selection (3): Health expenses as a share of GDP 10 Data Source : WHO, World Health Statistics, 2010

11. Selection (4): MNCH system coverage 11 Data Source : WHO, World Health Statistics, 2010

12. Selection (5): HIV prevalence and PMTCT coverage (2009) 12 Data source : UNICEF, 4th Stocktaking Report, 2009

13. Average hourly gain, 2009$

14. Data sources Bottom-up approach: – Health Facility level: Team of Data Collectors – National and District level data: National Consultant – Evidence from existing literature: Costing Team 14

15. Ingredient based costing method Point of view: – Provider perspective Horizon: – 2 years postpartum Integration: ANC additional resources – Capital costs not included – Resources to make the program work disaggregated in three components: Human resources (salaries, time spent on PMTCT) Antiretroviral drugs (cost and quantities) Commodities (cost and quantities) 15

16. Unit costs 16 1. Counseling and testing [C&T] 1.1. Provider-initiated HIV testing (PITC) and counseling for pregnant women 1.2. HIV testing and counseling of couples/male partners of pregnant women 1.3. Community based activities and outreach programs 2. ARVs for HIV-infected pregnant women during pregnancy [Prophylaxis] 2.1. Single Dose Nevirapine (sd-NVP) prophylaxis 2.2. Prophylactic regimens using a combination of two ARVs 2.3. Prophylactic regimens using a combination of three ARVs 2.4. ART for pregnant women eligible for treatment 3. Labor & Delivery and immediate Postpartum [L&D] 3.1. ARVs to HIV-pregnant women during L&D 3.2. Cotrimoxazole (CTX) to new mothers 3.3. Counseling on early initiation of exclusive breastfeeding 5. Provision of family planning services to HIV-infected mothers [FP]

17. National estimation, 2009$M 5.20 3.14 5.42 5.06

18. 18 MOTHER Cost ($M) # PW HIV+ # PW HIV+ receiving ARVs (%) Rwanda 5.2010 042 7 197(72) Côte d’Ivoire 3.1422 454 9 296(41) Namibia 5.428 222 7 474(91) INFANT Natural MTCT With national PMTCTcoverage (2009) MTCT Cases averted #% Rwanda 3 335 1 848 1 48745 Côte d’Ivoire 7 457 5 610 1 84725 Namibia 2 730 1 4761 25446 3 African countries (2009)

19. 19 MOTHER Cost ($M) # PW HIV+ # PW HIV+ receiving ARVs (%) Rwanda 5.2010 042 7 197(72) Côte d’Ivoire 3.1422 454 9 296(41) Namibia 5.428 222 7 474(91) INFANT Natural MTCT With national PMTCTcoverage (2009) MTCT$/case averted$/capita Rwanda 3 335 1 848 3 4970.53 Côte d’Ivoire 7 457 5 610 1 7030.15 Namibia 2 730 1 4764 3232.55 3 African countries (2009)

20. Scaling up projections (Rwandan case)

21. Scaling-up scenarios * DenominationDescription Scenario 1Status-quo 2009 national coverage levels maintained Scenario 2Universal access Linear increase in PMTCT service coverage Scenario 3 Virtual elimination 2010 WHO guidelines + 90% service coverage 21 * Period : 2010 -2015

22. Key considerations 22 Natural growth – 3% Unit costs discounted over years – 3% (0%-5%)

23. Status-quo (Cumulative $million by 2015) 23

24. Scenario 1: Status-quo 24 Actualisation 0%Actualisation 3%Actualisation 5% MinMaxMinMaxMinMax 20092.75.152.75.152.75.15 20102.765.262.845.422.905.52 20112.815.392.975.723.105.94 20122.875.523.146.033.326.39 20132.935.663.296.373.566.88 20142.995.803.466.723.817.40 20153.055.943.647.104.087.97 (2010-2015)$17.4$33.6$19.4$37.3$20.8$40.1

25. Scenario 2: Towards UA 25 Natural population growth – 3% Unit costs discounted over years – 3% (0%-5%) The relative weight of the ARV regimens is kept constant Linear coverage trend +++

26. Scaling-up scenarios: Cummulative costs by 2015 26

27. Conclusions Resources needed to scale up PMTCT vary from country to country based on programme inputs and standard costs – salary structure, male engagement in Rwanda, Ceasarean section in Ukraine Use national coverage data and not performance of the sites selected could bias the findings More studies are needed to evaluate PMTCT expenditures for more efficient planning