Multi-Country Analysis of the Cost Implications of HIV Treatment
Scale-Up
Clinton Health Access Initiative and the Harvard School of Public Health in Collaboration with
Ministries of Health of Swaziland, Malawi, Zambia and Rwanda
CHAI slide warehouse
International AIDS Society
July 2014
This work has been funded by aid from the UK Government. The views
expressed do not necessarily reflect the UK Government’s official policies.
Governments need evidence on costs to inform decisions on ART
eligibility and scale-up
Objective
• Estimate the cost and HRH implications of reaching “universal access” (95% coverage)
by 2020 under the 2010 and 2013 Guidelines in
Swaziland, Rwanda, Malawi and Zambia.
Methodology
• Epidemiology: The Bärnighausen, Bloom and Humair model (BBH), an analytically
derived HIV “combination intervention” model.2
• Costs: 2010/11 MATCH study and 2012 study in Swaziland updated to reflect recent
pricing and costs; Non-treatment costs from local sources and global literature.1
• Human Resources : CHAI’s demand-based workload model.
• Scenario Analysis: Decision making tool used by government representatives to
examine the impact of different policy options against available financial and human
resources.
1-CDC and the Government of the Kingdom of Swaziland, unpublished; 2-Bärnighausen, T., D. E. Bloom and S. Humair (2012). "Economics of antiretroviral treatment vs.
circumcision for HIV prevention." Proceedings of the National Academy of Sciences 109(52): 21271-21276
2
The cost of scale-up depends on the number and distribution of
patients, as well as expected changes with ART scale-up
Total costs vary based on:
 Patient mix
• Patient numbers
• Distribution of ART patients
• Distribution of patients across pre-ART, ART and
palliative care
 Costs per patient per year by patient type
• Commodity mix
• Service delivery
1-CDC and the Government of the Kingdom of Swaziland, unpublished; 2-Bärnighausen, T., D. E. Bloom and S. Humair (2012). "Economics of antiretroviral treatment vs.
circumcision for HIV prevention." Proceedings of the National Academy of Sciences 109(52): 21271-21276
3
There are more patients, but also a greater proportion with high CD4
count, under the 2013 Guidelines
Example of Malawi:
ART Patient Mix in 2014 vs. ART Patient Mix in 2020
1200
Patients (Thous)
~ Current Coverage
~ 95% Coverage
1000
New Adults <350
Est Adults - <350
800
600
New Adults >350
Est Adults - >350
400
200
Pediatric
0
2010
2013
Guidelines Guidelines
2014
Column2
2010
2013
Guidelines. Guidelines.
2020
4
Adding pre-ART and palliative care reduces the difference in patient
numbers between policy options
Example of Malawi: Patient Mix in 2014 vs. Patient Mix in 2020
Patients (Thous)
1200
~ Current ART coverage
~ 50% pre-ART coverage
~ 95% ART Coverage
~ 50% pre-ART coverage
Palliative Care
1000
800
Pre-ART
600
New Adults <350
Est Adults <350
New Adults >350
400
200
0
2010
2013
Guidelines Guidelines
Column2
2014
2010
2013
Guidelines. Guidelines.
2020
In 2020, there are 17-36% more ART patients and 7-12% more total patients under
the 2013 Guidelines scenarios across Malawi, Rwanda, Zambia, Swaziland.
*UA=Universal access; Pre-ART and palliative care=50% coverage
5
The cost of scale-up depends on the number and distribution of
patients, as well as expected changes with ART scale-up
Total costs vary based on:
 Patient mix
• Patient numbers
• Distribution of ART patients
• Distribution of patients across pre-ART, ART and
palliative care
 Costs per patient per year by patient type
• Commodity mix
• Service delivery
1-CDC and the Government of the Kingdom of Swaziland, unpublished; 2-Bärnighausen, T., D. E. Bloom and S. Humair (2012). "Economics of antiretroviral treatment vs.
circumcision for HIV prevention." Proceedings of the National Academy of Sciences 109(52): 21271-21276
6
Costing began with the results of previous facility-based studies
Multi-Country Analysis of Treatment Costs for HIV/AIDS (MATCH) Study 2010/2011
Cost per ART Patient-Year by Country, USD
Legend
$1,200
Max
3rd Q
$1,000
Median
1st Q
Min
Avg
$800
$682
$600
$400
$200
$186
$136
$278
$232
$Malawi
Malawi
Ethiopia
Rwanda
Rwanda
Zambia
Zambia
South
RSA *
Africa
*RSA cost include updated ARV prices, which were renegotiated by the RSA government in early 2010 and are 53% lower than those
observed during the costing period; Avg=Average; Min=Minimum; Max=Maximum
5
In estimating total costs we reflect recent prices and expected
differences between patient types
Commodity costs adjusted to
reflect expected prices and mix
Service delivery costs adjusted to
reflect differences by patient
type:
- Where patients seek care?
- With which cadre?
- How often?
- For how long?
Illustrative Cost PPPY
$450
$300
Less
intensive
$150
$New
Est
New
Est
Adults - Adults - Adults - Adults >350
>350
<350
<350
ARV
Lab
Personnel
PMTCT Pediatric
Patients
Other Costs
Given changes in patient mix, in 2020, the average cost PPPY under the 2013
Guidelines is 5-10% less across Malawi, Rwanda, Swaziland, Zambia.
*CHW=Community Health Worker; Est=Established
8
Our methodology is as robust as current evidence allows, but
contains important limitations
Key Limitations
• Treatment and care, testing, condoms and VMMC are included. The
following are excluded:
- Other HIV-related and prevention interventions (e.g., BCC, OVC);
- Program management costs; and
- Systems costs (e.g., expansion of supply chain and lab systems)
Costs and implications of scale-up are not well understood, but funding
must be available for these programs.
• The implications of scale-up on costs require further refinement to
account for economies of scale and decentralization
9
Universal access under the 2013 Guidelines costs 10-20% more than
that under the 2010 Guidelines
Universal Access in 2020
Swaziland
$75
$400
$100
+17%
+19%
+9%
Millions (USD)
Zambia
Rwanda
$80
$300
$50
$60
$200
$40
$25
$100
$20
$0
$2010
Guidelines
ART
PMTCT
2013
Guidelines
(Full)
Pediatric
$0
2010
Guidelines
Pre-ART
2013
Guidelines
(Full)
Palliative Care
2010
Guidelines
Tests
2013
Guidelines
(Full)
Condoms
Note: Testing strategy mix varied across policy options; Resources are projected from national resource mapping exercises in 20122013 with the exception of Zambia where publicly available data was used.
MC
10
At universal access, costed programs account for < 60% of projected
available resources
Universal Access in 2020
Swaziland
$125
$700
$160
$600
$100
Millions (USD)
Zambia
Rwanda
$120
$500
Projected
resources
$75
$400
$80
$300
$50
$200
$40
$25
$100
$0
$0
$2010
Guidelines
2013
Guidelines
(Full)
2010
Guidelines
2010
Guidelines
2013
Guidelines
(Full)
ART
PMTCT
Pediatric
Pre-ART
Tests
Condoms
MC
Projected Resources
2013
Guidelines
(Full)
Palliative Care
Note: Testing strategy mix varied across policy options; Resources are projected from national resource mapping exercises in 20122013 with the exception of Zambia where publicly available data was used.
11
In Malawi, universal access may not be affordable There is an urgent need for additional funding
Universal Access to Treatment in 2020
Malawi
$300
25%
Condoms
MC
Resource Envelope
Tests
$200
Palliative
Care
Pre-ART
Health Expenditure as %
of GDP3
9.2%
Total Health Expenditure
(% External) 2
$642 M
(81%)
Total HIV expenditure
(% External) 2
$215 M
(99%)
Millions
$250
Gov Health Expenditure/
Total Gov Expenditure1
$150
6.7%
Pediatric
$100
PMTCT
$50
ART
$2010 Guidelines
•
•
2013 Guidelines (Full)
Projected
Resources
Malawi is one of the poorest countries in the world with little ability to contribute additional
funding towards HIV.
Universal access under the 2013 Guidelines would account for almost half of the current health
budget.
1- Malawi NHA 2011/2012; 2-National Resource Mapping, 2013; 3-World Dev.Indicators, 2012
12
Scale-up will be challenging in the face of operational constraints,
such as existing HRH shortages
Example of Swaziland: HRH Required to Meet Demand in 2020
4,000
Total: 3,544*
3,000
FTE
1,713
Optimal Staffing Requirements for HIV Services Only
2,000
1,000
Total: 754
Total: 745
0
Total Health Sector Staffing (HIV
& Non-HIV Services)
2010 WHO Guidelines
2013 WHO Guidelines
*Optimal Staffing Levels For HIV
Gap Between Current and Optimal Staffing Levels*
Required to Meet 2010 WHO
Total Health Sector (Current Staff as of December 2013)
Guidelines in 2020
HIV Optimal Community Support Staff, Adherence Support Staff, & Data Clerks
HIV Optimal Clinical Staff (Medical, Nursing, Laboratory, & Pharmacy)
Swaziland currently has half of the required HRH in 2020.
*Optimal Staffing Levels For HIV Required to Meet 2010 WHO Guidelines in 2020
13
However, incremental impact of the 2013 Guidelines on HRH for
treatment and care is negligible
Swaziland: Facility-Level HRH Required for HIV Treatment and Care (Without Testing)
+ 7.4%
Patients
145,835
800
754
745
156,654
Health Workers
(FTE)
Patients (Thous)
200
160
- 1.2% Health
Workers Required
120
80
40
600
400
200
0
0
2010 WHO
Guidelines
New Adult, CD4 < 350
Est Adult, CD4 > 350
Pre-ART Patients
2013 WHO
Guidelines
New Adult, CD4 > 350
PMTCT Patients
2010 WHO
Guidelines
2013 WHO
Guidelines
Est Adult, CD4 < 350
Pediatric & Infant HIV Patients
• This is due to epidemiological changes and lower intensity of care for asymptomatic patients
• Similar change in health workers required was seen in Zambia (-0.2%) and Malawi (-0.7%)
• Finding, testing and linking patients is not included and will require significant staff time
depending on the strategy
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Conclusion: Debate should shift from whether to scale-up ART to
how to do so efficiently
Key Takeaways
Affordability: In Swaziland, Rwanda and Zambia, the cost of scale-up is manageable
within the existing funding envelope, if programs run efficiently. Malawi will face
significant financial constraints without aid.
Feasibility: Countries will need to continue to address their existing sector-wide HRH
shortages. However, the incremental HRH under more aggressive scenarios at universal
access is less than expected.
Key Considerations:
- Excluded costs such as BCC and OVC and program management are important, but
additional evidence is needed on cost and impact.
- Upfront investment may be required (e.g., reaching hard-to-reach populations,
building up systems and covering remote areas) and operational challenges vary by
country.
- HRH requirements will depend on the strategies used to find, test and link patients.
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Contributing Authors
Harvard School of Public Health
T. Bärnighausen
D. Bloom
S. Humair
Clinton Health Access Initiative
K. Callahan
S. Diamond
D. Gwinnell
P. Haimbe
R. Hurley
C. Lejeune
M. Lippitt
C. McKay
C. Middlecote
S. Phanitsiri
A. Sabino
A. Shields
E. Tagar
F. Walsh
Ministry of Health Zambia
A. Mwango
Ministry of Health Rwanda
S. Nsanzimana
Ministry of Health Swaziland
V. Okello
S. Zwane
Ministry of Health Malawi
A. Jahn
16
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Innovative service delivery can mitigate costs in the short and longterm
Innovative service delivery can reduce the costs of scale-up in the short-term…
Malawi Cost PPPY
$300
Task shifting,
MMS
$200
•
•
$100
•
$Before Intervention
ARVs
Labs
Personnel
Optimized
Other Costs
In Malawi Multi-month scripts (MMS) and task
shifting have reduced personnel costs by ~30%.
Home visits for complex patients would only
slightly increase costs (~ 5%) and could
improve retention
Additional evidence is needed on the effects of
these models on retention.
…and in the long-term by improving patient retention.
Costs of Achieving UA* by 2020
vs. Retention
% Savings
4%
2%
0%
0%
Malawi
3%
Rwanda
5%
8%
10%
% Increase in Retention
Zambia
Swaziland
Across 4 countries, a 5% increase in retention
results in the following by 2020:
•
4-6% Reduction in new infections
•
4-6% Reduction in AIDS-related deaths
•
Up to 4% reduction in treatment/testing costs
Note: UA is defined as 95% coverage by 2020
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