Funding Universal Access through a “Global Health Charge”
on alcohol and tobacco: feasibility in the 20 countries with
the largest HIV epidemics
Dr Andrew Hill, Pharmacology and Therapeutics, Liverpool University, UK
Dr Will Sawyer, MetaVirology Ltd, London, UK
World AIDS Conference, Washington, USA, July 2012 [Abstract MOAE0306]
Thanks to:
Joep Lange
University of Amsterdam
Elly Katabira
International AIDS Society, Kampala
Ceppy Merry
Infectious Diseases Institute, Kampala
Praphan Phanuphak Thai Red Cross AIDS Society, Bangkok
Marco Vittoria
World Health Organization, Geneva
Dave Ripin
Clinton Foundation
Andrew Levin
Clinton Foundation
Chris Duncombe
Bill and Melinda Gates Foundation
Ben Plumley
Pangaea AIDS Foundation
Nathan Ford
Medecins Sans Frontieres, Geneva
The HIV epidemic in 2011: 34.2 million infected
2.5 million
new infections
per year
8 million
treated
19 million:
will need
ARVs in
future
In future, 19 million
more people will need
treatment
7 million need
treatment, but
have no
access
1.7 million
deaths
per year
Source: UNAIDS 2012: “Together we will end AIDS”
$7 billion per year shortfall in funding
for Universal Access
1. International funding for HIV: $8.6 billion in 2011
2. Funding from low / middle-income countries: $8.2 billion in 2011
3. Additional funding required: $7 billion per year
Source: UNAIDS 2012: “Together we will End AIDS”
Global Financial Crisis
How can we afford to treat 15-30
million people with HIV in the future?
Alcohol, tobacco, HIV/AIDS, malaria
and TB as causes of death worldwide
Annual deaths in 2010, worldwide:
Alcohol abuse: 2.5 million
Tobacco: 6 million (->8 million)
could be prevented by cutting
consumption
HIV/AIDS: 1.8 million
TB: 1.1 million
Malaria: 0.7-1.1 million
could be prevented by better
treatment and care
Alcohol and tobacco are under-taxed in low and middle income countries;
consumption is growing. Increasing tax on alcohol and tobacco is known
to improve public health.
UNAIDS Epidemiology Reports 2011, WHO smoking and alcohol
statistics, UN population reports
Taxes on tobacco and alcohol are low
in many African countries
World Health Organization standard: taxes should be at least 70% of the
retail price of a packet of cigarettes1
High income countries: 38/48 (79%) have a
tax rate of at least 50%
Low-income countries: 11/36 (31%) have a
tax rate of at least 50%
Packet of 20 cigarettes in UK and Kenya:
in UK = $11
Excise Tax + VAT = $9
80%
in Kenya2 = $1
Excise Tax + VAT = $0.47
47%
Ref 1: WHO report on global tobacco epidemic 2011
Ref 2: http://allafrica.com/stories/201106130136.html
Global Health Charge
Middle and low income countries introduce a small extra
“Global Health Charge”
on alcohol and tobacco:
1 US cent per 10mL
unit of unit of alcohol
10 US cents
per packet of
20 cigarettes
Global Health Charge – how would it
work?
Global Health Charge is collected by National Governments, from
the main alcohol and tobacco suppliers, when supplies are sent
out from their breweries and factories.
This money is collected and spent only at the National level,
to fund access to HIV, TB and malaria treatment and care.
Money can be used in partnership with Global Fund, PEPFAR and
NGOs to jointly fund treatment access programmes.
Global Health Charge:
calculations by country
Take the 20 countries with the largest HIV epidemics
Annual alcohol and tobacco consumption: commercial (recorded) supplies
Adult population size
Number of patients who need antiretroviral treatment by country?
Cost of Universal Access calculated assuming 2011 costs of treatment,
medical care and diagnostics ($861 per patient/year of treatment).
In each country, could the “Global Health Charge” fund Universal Access,
and what money could be left over to pay for TB, Malaria and other health
priorities?
UNAIDS Epidemiology Reports 2011, WHO smoking and alcohol
statistics, UN population reports
Global Health Charge:
calculations by country
Costs per person-year on antiretroviral treatment: $861
Antiretroviral treatment: $416 (73% 1st line, 20% 2nd line, 7% 3rd line)
Including importation and transport / storage.
Diagnostics: $145 (2 x HIV RNA, 2 x CD4, 5% with genotype)
Medical care: $300
UNAIDS Epidemiology Reports 2011, WHO smoking and alcohol
statistics, UN population reports
Results – example of Kenya
Adult population size / HIV:
26 million adults
1.5 to 1.6 million people HIV+,
430,000 people already on ARVs (2010 data)
Alcohol consumption per person-year: 1.6 litres recorded, 2.5 unrecorded
Tobacco consumption per person-year: 8.4 packs of 20 cigarettes
Annual revenue from Global Health Charge (1c / 10c): $63 million
Number of people needing antiretrovirals (2010): 277,000
Cost of Universal Access (100%): $239 million ($861 per patient)
Number of people who could be treated from GHC (1c / 10c): 73,000
Global Health Charge of 5c / unit alcohol and 25c / packet of cigarettes in
Kenya would fund 100% Universal Access ($260 million / year revenue)
10 countries could afford 100% Universal Access
to ARVs with “Global Health Charge”
Annual charges and funds available in ten countries (1c / 10c rate):
___________________________________________________________________________________
Country
Patients needing
ARV access
Global health
charges: value
ARV access
TB/malaria
extra costs*
funds
1c / 10c charge
___________________________________________________________________________________
Nigeria
1,040,000
$ 1120 m
$ 896 m
$ 223 m
Uganda
281,000
$ 259 m
$ 243 m
$
16 m
Botswana
35,000
$ 10 m
$ 8m
$
2m
Thailand
113,000
$ 446 m
$ 97 m
$ 348 m
Vietnam
47,000
$ 81 m
$ 40 m
$
41 m
India
825,000
$ 887 m
$ 710 m
$ 177 m
Brazil
89,000
$ 1170 m
$ 76 m
$ 1,094 m
Russia
250,000
$ 2165 m
$ 216 m
$ 1,949 m
Ukraine
147,000
$ 634 m
$ 126 m
$ 507 m
China
184,000
$11,002 m
$ 158 m
$10,844 m
___________________________________________________________________________________
Total: All 3,011,000 eligible patients put on ARV treatment (total cost: $2.57 billion/year)
Substantial additional funding available for HIV prevention, TB, Malaria, other diseases
___________________________________________________________________________________
*assumes $861/year cost for treatment and care, per person-year
References: UNAIDS Epidemiology Reports 2011, WHO smoking and
alcohol statistics, UN population reports
10 countries could help to pay for Universal
Access with “Global Health Charge”
Annual charges and funds available in ten countries (1c alcohol / 10c tobacco rate):
___________________________________________________________________________________
Country
Patients needing
ARV access
Global health
Extra patients
Tax for
charges: value
on ARV’s
100% UA
1c / 10c charge
1c / 10c charge
___________________________________________________________________________________
Cameroun
140,000
$ 74 m
86,000
2c / 10c
Cote d’Ivoire
125,000
$ 79 m
91,000
2c / 10c
DR Congo
256,000
$ 121 m
140,000
2c / 10c
Tanzania
351,000
$ 154 m
179,000
2c / 15c
South Africa
1,110,000
$ 323 m
375,000
3c / 25c
Kenya
277,000
$ 63 m
73,000
5c / 20c
Zambia
136,000
$ 24 m
28,000
5c / 25c
Zimbabwe
234,000
$ 39 m
45,000
5c / 25c
Mozambique
331,000
$ 41 m
48,000
10c / 30c
Malawi
189,000
$ 14 m
16,000
14c / 50c
___________________________________________________________________________________
Total: 1.08/3.1million (35%) eligible patients put on ARV treatment (total cost: $931 million/year)
___________________________________________________________________________________
*assumes $861/year cost for treatment and care, per person-year
References: UNAIDS Epidemiology Reports 2011, WHO smoking and
alcohol statistics, UN population reports
Limitations of the analysis
1. Calculations are based on average $861 cost per person-year for
antiretroviral treatment, diagnostics and care.
Analyses could be re-run with lower costs.
2. Antiretroviral drugs need to be accessible at minimum prices
(CHAI/MSF)
3. Analyses based on 2010 estimates of HIV prevalence – updating needed
4. Could increased taxation of alcohol and tobacco lead to cross-border
smuggling and/or increased use of non-commercial supplies?
5. Enforcement of taxation is required, including small-scale suppliers and
brewers.
6. Other “sin taxes” could be planned, to cover other public health
priorities – e.g. vaccination, cardiovascular disease.
Conclusions
A “Global Health Charge” of US 1c per 10mL unit of alcohol and US 10c
per packet of 20 cigarettes, collected and spent at the National level,
could fund 100%
Universal access to ARV treatment in 10 of the 20 countries with the
largest HIV epidemics (3 million additional people on ARV treatment).
In these countries, substantial additional funds would be available to
treat malaria, TB and other health priorities.
In the other 10 countries, 1.1 million people could be put on ARV
treatment with a 1c / 10c Global Health Charge. Higher charges could
allow 100% Universal Access in these countries (e.g. 5c / 20c in Kenya).
Increased taxation could lower consumption of alcohol and tobacco,
with associated public health benefits