1. The Costs and Consequences of HIV/AIDS Interventions Damien de Walque Development Research Group (DECRG) The World Bank December 1 st, 2005

2. Cost-benefit analysis? Yes, but… Yes, but… What do we mean by costs? What do we mean by costs? What do we mean by benefits? What do we mean by benefits? The value added of merging biomedical and socio-economic data… The value added of merging biomedical and socio-economic data… Examples from HIV prevention and anti- retroviral treatment (ART) Examples from HIV prevention and anti- retroviral treatment (ART)

3. Prevention: Information campaigns

4. HIV prevalence is declining in Uganda Due to behavioral changes or mortality? Due to behavioral changes or mortality? Due to information campaigns? Due to information campaigns? Which segment of the population is driving it? Which segment of the population is driving it?

5. Looking at response by education Source: De Walque, 2004 Source: De Walque, 2004

6. What do we learn by looking at socio-economic variables? - behavioral changes - behavioral changes - education facilitates response to information - education facilitates response to information - need other approaches to target less educated group. - need other approaches to target less educated group.

7. Anti-retroviral treatment (ART) What is the benefit of ART? Example in Kenya. (from Goldstein, Graff Zivin and Thirumurthy 2005) What is the benefit of ART? Example in Kenya. (from Goldstein, Graff Zivin and Thirumurthy 2005) - Life saved, quality of life. Fewer orphans. - In addition: labor force participation, children going back to school, less child labor

8. CD4 Counts before and after treatment Source: Goldstein, Graff Zivin and Thirumurthy 2005

9. Body Mass Index before and after treatment Source: Goldstein, Graff Zivin and Thirumurthy 2005

10. Labor force participation before and after treatment Source: Goldstein, Graff Zivin and Thirumurthy 2005

11. What are the consequences of anti-retroviral treatment individual benefits and costs individual benefits and costs benefits and costs at the household and extended family level benefits and costs at the household and extended family level Also look at the impact of treatment on the dynamics of the epidemic ( spillovers: social benefit and cost)

12. Possible effects of ART on HIV transmission From: M. Over, et al. (2004) Direction of effect Beneficial (Slow transmission) Adverse (Speed transmission) Type of effect Biological Reduce infectiousnessSelect for resistance. Longer duration of infectivity Behavioral Encourage prevention, especially testing Off-setting behavior

13. “Hypothetical AIDS Transition” Rate per 1000 people Time New infections AIDS Deaths “Explosion of ART patients” Rate of growth of people living with HIV/AIDS Source: Over (2004)

14. Transition might fail either because treatment stops working … AIDS Deaths Rate of growth of people living with HIV/AIDS Rate per 1000 people Time New infections “Boom” of ART patients Source: Over (2004)

15. … or because the rate of new infections never declines. Rate of growth of people living with HIV/AIDS Rate per 1000 people Time New infections AIDS Deaths “Explosion of ART patients” Source: Over (2004)

16. If ART engenders complacency, the number of new infections might increase. “Explosion of ART patients” Rate of growth of people living with HIV/AIDS Rate per 1000 people Time New infections AIDS Deaths Source: Over (2004)

17. How to maximize benefits and minimize adverse effects? Need to learn as we scale-up ART (example TAP learning agenda) Need to learn as we scale-up ART (example TAP learning agenda)Measure: - private benefits and costs - biological effects, including resistance. Role of quality of service provision and adherence. -behavioral effects

18. How to sustain ART in the long run? Example: Thailand Source: Revenga et al, Forthcoming

19. Treatment in the long run? The greater the success of treatment, the more patients The greater the success of treatment, the more patients Second line therapy is much more expensive. Second line therapy is much more expensive. Adherence crucial: role of health infrastructure and staff Adherence crucial: role of health infrastructure and staff Still… Still… Prevention, prevention, prevention! Prevention, prevention, prevention!

20. Impact of condom use on the number of new HIV infections in India (Over et al. 2004)

21. Conclusions Socio-economic variables together with biomedical data Socio-economic variables together with biomedical data Treatment AND Prevention Treatment AND Prevention - Organize ART so that prevention is reinforced - Organize ART so that prevention is reinforced - Focus prevention efforts so that ART is sustainable - Focus prevention efforts so that ART is sustainable