1. Evaluating the cost-effectiveness of the test and treat program in Zimbabwe

2. Background Population almost 16 million PLWHA 1.3 million
13.5% adult prevalence
on ART
# virally suppressed
HIV prevalence in key pops
Sex workers 57.1%
Prisoners (MSM) 28%

4. Source: National AIDS Council

6. Decline in MTCT rate Source: Big Win
In partnership with the Elizabeth Glaser Pediatric AIDS Foundation, Big Win Philanthropy previously supported this program which dramatically reduced Zimbabwe’s mother-to-child HIV transmission rates from 30% in 2010 to less than 7% in 2014, and an estimated 5% in 2015
Source: Big Win

7. Factors fueling the spread of HIV
High prevalence of STIs
Low levels of male circumcision
High rates of multiple concurrent sexual relationships
Incorrect or inconsistent condom use
Low socio-economic status of women
Distressed economic conditions ,population mobility and settlement patterns
Source: national AIDS Council

8. Factors which contributed to the decline
Implementation of the Zimbabwe National HIV/AIDS strategic plan which declared HIV a national emergency in 1999
Enactment of the National AIDS Council by an act of parliament
Introduction of 3% AIDS levy on all taxable income in all sectors.
A multi-sectoral approach
Gender sensitive approach

9. Ctd….. Meaningful involvement of PLWHA
Well packaged and targeted interventions for high risk groups
Robust BCC programme leading to a massive cultural shift in sexual behaviour
Rapid scaling up of PMTCT services

10. Methodology Goals model a dynamic compartmental model
Simulates transmission trends in adults aged in these risks categories
injecting drug users (IDU)
MSM
female sex workers and their clients
multiple partners
Couples
Study period:
3% discount rate

11. Sexual Mixing Males SW clients Males Non-regular partners Males PWID
Stable couple
Males
MSM
Females
Sex workers
Females
Non-regular partners
Females
PWID
Females
Stable couple
SPECTRUM

12. Determinants of risk of infection
Susceptible Partner
Infected Partner
HIV infection
Stage of infection
ART
Vaccination
Number of partners
Male circumcision
Oral PrEP
Topical PrEP
Vaccination
Number of acts per partner
STI prevalence
Heterosexual, MSM, IDU contact
Condom use
The factors that determine the risk of transmission can be categorized as characteristics of the infected partner, the susceptible partner and the partnership.
SPECTRUM

13. Probability of Sexual Transmission
{1 – [Ps’,g,t x (1 - rs x Rg,t x Sg,t x MCg,t x Cg,t x Prg,t x Ag,t x Vg,t)a + (1 – Ps’,g,t)]n }
Vaccine
ART
PrEP use
Condom use Acts/partner Partners/yr
Male circumcision
STI prevalence
Stage of infection
Probability of transmission per act by sex and type of sex
Prevalence in partner
Where: MC, C, Pr, A, V = 1 – effectiveness x coverage
Here is the full transmission equation. It expands on the one we saw earlier by adding the effect on the probability of transmission per act (r) of these other factors.
SPECTRUM

14. Data Sources Category of Data Source Population size
DemProj, UN Population Division
HIV program data (ART, PMTCT)
AIM
Epidemic dynamics (progression, mortality)
BY RISK GROUP
Surveys, population size studies (e.g., RDS)
Global reviews: Aceijas, Caceres, Carael, Dagenhardt, Van de Pitte
Condom use
DHS/AIS, Key population surveys (e.g., IBBS)
Number of partners
Key population surveys
Acts per partner
Key population surveys, global defaults
Percentage ‘married’
Surveys
Increased recruitment
Prevalence patterns
STI prevalence
Surveillance, studies
PWID: Proportion sharing needles
PWID surveys
Age at first sex
Demographic surveys
SPECTRUM

15. A few adjustments were done in condom use and acts per partner in order to fit the model

16. Scenario analysis
A comparison of CD4 <500 cells per µL(Constant Coverage) and universal test and treat (UTT) using the following metrics;
QALY
ICER
orphan years are averted per year
New HIV infections averted
AIDS related deaths prevented

17. Key findings

18. AIDS deaths averted

19. Key findings
the UTT program cost $11.2 billion and $13.2 billion with discount and without discount, respectively.
Under constant coverage the ART program cost $7.8 billion and $8.9 billion with discount and without discount, respectively.
Between 0.45 and 0.61 orphan years are averted per year that an adult survives
the cost of orphan care averted was $324 per every orphan year.
14.2 million life years saved
QALYs saved
(31%) new infections averted
39% AIDS death prevented
ICER of $ of UTT over constant coverage

20. ICER sensitive to ARV costs and incidence

21. Discussions points UTT has huge fiscal implications upon Zimbabwe
Possible challenges with defaulters and challenges with accessing second line of ART
Some similar studies have showed that ART scale up might not be as effective in the long term
UTT based its conclusions on RCT of which real life scenario might offer a different result
Need for right mix of prevention interventions
-PrEP cost effective for key population
Need to watch form unintended consensus for some interventions eg
sex workers reported circumcised men
increased STIs due to PrEP

22. Conclusion
UTT is a good investment opportunity for Zimbabwe as it shows big cost saving opportunity, prevention of new infections, increases in life span and quality of PLWHA.
Combined with right mix of prevention strategies, country specific test and treat programs might even be more effective