1. 1 Book launch, Delhi 13 Aug 04 Integrating HIV prevention and antiretroviral therapy in India: Costs and Consequences of Policy Options

2. 2 Report team: Mead Over, Peter Heywood, Sudhakar Kurapati (World Bank) Julian Gold, Indrani Gupta, Abhaya Indrayan, Subhash Hira, Elliot Marseille, Nico Nagelkerke, and Arni S.R. Srinivasa Rao (Consultants)

3. 3 Objectives of the study Review the effects and consequences of ART Use a quantitative model to predict the course of the epidemic Use same model to determine the costs and consequences of –Maintaining current policies –Alternative government policies for ART

4. 4 Indian context for ART policy

5. 5 HIV Prevalence 1998 TN

6. 6 Indian context for ART policy HIV/AIDS in context of overall disease burden –in 1998: 2% of all deaths, 6% of inf. deaths –in 2033: 17% of all deaths, 40% of inf. Deaths Number of ART users in 2002 –>500,000 AIDS cases –370,000 urban –90,000 on treatment –12,000 on ART – mostly unstructured

7. 7 Analysis of ART policy options Definition of policy options Health impacts of options Cost impact of options Sensitivity of results to risk behavior Cost-effectiveness

8. 8 Definition of policy options Adhere: Support to help patients adhere –I.e. IEC, training, lab strengthening, subsidies for patient monitoring in both private & public sectors MTCT+: Structured ART for identified HIV+ mothers and their partners BPL: Structured ART for people below the poverty line TMART: Transmission-minimizing ART

9. 9 Structured treatment Standardized training of physician to a mandated level of competence in ART management; Prescription of a standard triple-drug regimen as recommended by the national guidelines; Access to support from a multi-disciplinary team including a counselor and a nutritionist; Access to a quality laboratory for immunological testing; Regular monitoring of the patient s treatment status (clinical and lab-based). Counseling to prevent transmission

10. 10 ART can affect HIV prevention

11. 11 Suggestive evidence of disinhibition in Kenya

12. 12 Transmission minimizing structure Structured ART treatment –maximize adherence –minimize infectivity –slow the development of resistant strains Incentives –for ART physicians to assist prevention efforts of government and non-government prevention programs –for state and local policy makers to expand and maximize the effectiveness of prevention programs Monitoring and evaluation –of adherence & spread of resistant strains –of prevention programs

13. 13 The model Modified previous epidemiological model Estimate costs and consequences over 35 year period Epidemiological and biological parameters related to transmission, disease progression, path from infection to death

14. 14 The model assumes In 1998 15% adult males clients of sex workers –Each client 50 sexual contacts per year 1.1% of women are sex workers –675 commercial transactions per sex worker per year Condoms used in half these transactions

15. 15 Health impacts of options Impact of ART on the path of the epidemic Impact of ART on the burden of the epidemic

16. 16 Impact of ART on the path of the epidemic: Number of new HIV infections

17. 17 Benefits of three ART policies No change in risk behavior -1.9% -0.4% 0.6% 5.7% 1.6% 1.1% 1.8% 1.5% 11.6% 7.6% 13.8% 12.4% -4.0% -2.0% 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0% Total HIV averted Discounted HIV averted Life years saved Discounted LYs saved Alternative measures of impact (Discount rate: 10%) Percent change relative to baseline Adhere MTCT+ BPL Health benefits of three ART policies No change in risk behavior

18. 18 Lessons from impact models All three ART policies save life years, but only MTCT+ & BPL would also avert HIV infections BPL has much greater health benefits than Adhere or MTCT+. Discount rate does not effect policy rankings Adhere policy produces effects more quickly than other policies

19. 19 Cost impact of options Assumptions used Total and incremental government cost of ART policies Components of government cost of ART policies Lessons from the cost model

20. 20 Assumptions used for costing Assume constant unit costs of testing separate from treatment Testing and monitoring: $100/patient/yr Cost of ART per year: $500 in both public and private sectors Government subsidizes 100% of ART cost in public sector, but only testing and monitoring in private

21. 21 Total and incremental government cost of Art policies (in 2002 dollars using discount rate of 10 percent)

22. 22 Lessons from cost model The policy options will cost between $1.7 billion and $7 billion in present value terms –Equivalent annual expense: $177 to $744 million per year for 31 years Compare these amounts to current expenditures –about US$1,200 million/year: central health & social welfare expenditures –about US$300 million/year: central health expenditures Least expensive option is 59% of health budget Most expensive outcome is 62% of health & social welfare budget combined

23. 23 Sensitivity of results to risk behavior Alternative levels of condom use on high risk sexual contacts –40%, 50%, 70%, 90% Sensitivity of the annual number of new HIV infections to these levels

24. 24 Sensitivity of the annual number of new HIV infections to condom use on high-risk contacts

25. 25 The net effect of BPL policy would then be negative on life-years saved... -18.1 25.2 -40 -20 0 20 40 60 80 100 120 140 40% condom 50% condom Assumed impact of BPL ART on condom use Millions of discounted life-years saved relative to the baseline

26. 26 Suppose that ART availability could be used to encourage prevention efforts …

27. 27 Thailand succeeded in increasing condom use to even higher levels a decade ago... 0 20% 40% 60% 80% 100% 1988198919901991199219931994 Condom use among sex workers Condom use

28. 28 Within India, Tamil Nadu has shown that condom use can attain high levels

29. 29 But average state performance is well below 75% Percent condom use in commercial sex transactions as reported by both FSWs & clients

30. 30 If condom use can be increased as a result of BPL policy, its benefits would be greater

31. 31 If condom use can be increased as a result of BPL policy, its cost would be much less

32. 32 Cost-effectiveness of ART Defined as years of life saved per dollar of government expenditure Compare to cost of saving life years –From HIV prevention programs –From other health programs Then suppose that ART could be an instrument to achieve good prevention

33. 33 Cost-effectiveness of alternative ART scenarios Note: Costs and effects are discounted at 10% $146 $199 $280 $0 $50 $100 $150 $200 $250 $300 AdhereMTCT+BPL Alternative ART polcies US$ per life year saved

34. 34 Cost-effectiveness of alternative ART scenarios Note: Costs and effects are discounted at 10%

35. 35 Lessons from C/E Model Assuming ART has no effect on prevention, the Adhere policy is most cost-effective At $146 per life year saved, Adhere is still very expensive compared to other options for saving life years If ART causes disinhibition the losses from new infections will outweigh the gains from treatment TMART is potentially extremely cost-effective only if the incentives can be made to work

36. 36 Transmission minimizing structure Structured ART treatment –maximize adherence –minimize infectivity –slow the development of resistant strains Incentives –for ART physicians to assist prevention efforts of government and non-government prevention programs –for state and local policy makers to expand and maximize the effectiveness of prevention programs Monitoring and evaluation –of adherence & spread of resistant strains –of prevention programs

37. 37 Performance-based fiscal mechanisms need: Clear policy framework Mechanisms for independent evaluation of proposals Effective project implementation capacity Agreements on performance-based mechanism Independent evaluation of performance Governments willing to make disbursements conditional on performance Capacity building