Articles tagged as "Financing"

The conundrum of future funding for HIV – who pays and how?

Long-term financing needs for HIV control in sub-Saharan Africa in 2015-2050: a modelling study. 

Atun R, Chang AY, Ogbuoji O, Silva S, Resch S, Hontelez J, Barnighausen T. BMJ Open. 2016 Mar 6;6(3):e009656. doi: 10.1136/bmjopen-2015-009656.

Objectives: To estimate the present value of current and future funding needed for HIV treatment and prevention in 9 sub-Saharan African (SSA) countries that account for 70% of HIV burden in Africa under different scenarios of intervention scale-up. To analyse the gaps between current expenditures and funding obligation, and discuss the policy implications of future financing needs.

Design: We used the Goals module from Spectrum, and applied the most up-to-date cost and coverage data to provide a range of estimates for future financing obligations. The four different scale-up scenarios vary by treatment initiation threshold and service coverage level. We compared the model projections to current domestic and international financial sources available in selected SSA countries.

Results: In the 9 SSA countries, the estimated resources required for HIV prevention and treatment in 2015-2050 range from US$98 billion to maintain current coverage levels for treatment and prevention with eligibility for treatment initiation at CD4 count of <500/mm3 to US$261 billion if treatment were to be extended to all HIV-positive individuals and prevention scaled up. With the addition of new funding obligations for HIV–which arise implicitly through commitment to achieve higher than current treatment coverage levels–overall financial obligations (sum of debt levels and the present value of the stock of future HIV funding obligations) would rise substantially.

Conclusions: Investing upfront in scale-up of HIV services to achieve high coverage levels will reduce HIV incidence, prevention and future treatment expenditures by realising long-term preventive effects of ART to reduce HIV transmission. Future obligations are too substantial for most SSA countries to be met from domestic sources alone. New sources of funding, in addition to domestic sources, include innovative financing. Debt sustainability for sustained HIV response is an urgent imperative for affected countries and donors

Abstract  Full-text [free] access 

Editor’s notes: The authors of this interesting paper use the most up-to-date cost and coverage data to provide a range of estimates for future treatment financing obligations. Epidemiological parameters are included to fit the Goals model and key prevention services such as ‘prevention of mother-to-child HIV transmission’ and ‘voluntary medical male circumcision’ are also included.

Financing needs for the nine countries are estimated by varying treatment initiation threshold (everyone initiated on treatment versus initiation at CD4 of <500cells/mm3) and/or coverage level for prevention and treatment (‘current’ levels and a ‘scale up’ scenario). The authors also attempt to assess both the ethics and the cost of different approaches.

For all scenarios, there is a steady decline in proportion of treatment costs and an increase in the proportion of prevention costs. This apparent contradiction is largely because there will be fewer individuals on treatment over time but prevention costs rise because they are mostly invested in non-infected populations, which increases with population growth.

In the nine countries, estimated resources required for HIV prevention and treatment from 2015-2050 will be large. This is increased further when human resources and supplies increase at the rate of GDP per capita.

However, there is undoubtedly an ethical responsibility to not only continue financing people receiving ART, but, that the responsibility extends to people in equal need who are not on treatment. The ethics is underpinned by the evidence. This illustrates how ‘front-loading’ investments in HIV scale-up now to ensure high levels of coverage, will significantly reduce future HIV incidence and prevalence. 

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Determinants of HIV prevention costs at scale in India

What determines HIV prevention costs at scale? Evidence from the Avahan programme in India.

Lépine A, Chandrashekar S, Shetty G, Vickerman P, Bradley J, Alary M, Moses S, Group CI, Vassall A. Health Econ. 2016 Feb;25 Suppl 1:67-82. doi: 10.1002/hec.3296. Epub 2016 Jan 14.

Expanding essential health services through non-government organisations (NGOs) is a central strategy for achieving universal health coverage in many low-income and middle-income countries. Human immunodeficiency virus (HIV) prevention services for key populations are commonly delivered through NGOs and have been demonstrated to be cost-effective and of substantial global public health importance. However, funding for HIV prevention remains scarce, and there are growing calls internationally to improve the efficiency of HIV prevention programmes as a key strategy to reach global HIV targets. To date, there is limited evidence on the determinants of costs of HIV prevention delivered through NGOs; and thus, policymakers have little guidance in how best to design programmes that are both effective and efficient. We collected economic costs from the Indian Avahan initiative, the largest HIV prevention project conducted globally, during the first 4 years of its implementation. We use a fixed-effect panel estimator and a random-intercept model to investigate the determinants of average cost. We find that programme design choices such as NGO scale, the extent of community involvement, the way in which support is offered to NGOs and how clinical services are organised substantially impact average cost in a grant-based payment setting.

Abstract  Full-text [free] access

Editor’s notes: This paper was published in the journal Health Economics, as part of a supplement on methods for economic evaluation in low-income and middle-income countries. The supplement eloquently summarizes the current state of the art for economic evaluation in these countries, providing a good background for readers who are less familiar with this field.  It also reflects challenges for the design, conduct, and use of economic evaluations in these settings and highlights some of the methodological innovations arising out of these challenges. 

This contribution reflects the importance of using cost functions when conducting economic evaluations of programmes that need to be scaled up. The authors present average costs for 138 non-governmental organisations providing HIV prevention services to key populations across four years in India, as part of the Avahan project. They find that scale is an important determinant of cost, with average costs falling as scale increases. They also find that community mobilization activities can reduce costs, potentially by encouraging uptake of other services.  Further, the way in which NGOs are supported can impact on costs. 

This article presents an important methodological step towards informing better decision-making and programme design. Understanding of cost drivers can also facilitate programme monitoring and resource allocation. This is one of the first studies fully powered to analyse the determinants of costs for NGO-delivered HIV prevention services.  The authors use a wealth of cost data which are not often available to researchers working in lower and middle income countries. As noted in the foreword for this supplement, further analysis of cost functions will be essential to inform future global and national-level decision-making in these countries. This will require investment in additional large-scale cost studies globally to generate data for this type of analysis.

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Would an HIV vaccine be cost-effective? Possibly…

Exploring the potential health impact and cost-effectiveness of AIDS vaccine within a comprehensive HIV/AIDS response in low- and middle-income countries.

Harmon TM, Fisher KA, McGlynn MG, Stover J, Warren MJ, Teng Y, Naveke A. PLoS One. 2016 Jan 5;11(1):e0146387. doi: 10.1371/journal.pone.0146387. eCollection 2016.

Background: The Investment Framework Enhanced (IFE) proposed in 2013 by the Joint United Nations Programme on HIV/AIDS (UNAIDS) explored how maximizing existing interventions and adding emerging prevention options, including a vaccine, could further reduce new HIV infections and AIDS-related deaths in low- and middle-income countries (LMICs). This article describes additional modeling which looks more closely at the potential health impact and cost-effectiveness of AIDS vaccination in LMICs as part of UNAIDS IFE.

Methods: An epidemiological model was used to explore the potential impact of AIDS vaccination in LMICs in combination with other interventions through 2070. Assumptions were based on perspectives from research, vaccination and public health experts, as well as observations from other HIV/AIDS interventions and vaccination programs. Sensitivity analyses varied vaccine efficacy, duration of protection, coverage, and cost.

Results: If UNAIDS IFE goals were fully achieved, new annual HIV infections in LMICs would decline from 2.0 million in 2014 to 550 000 in 2070. A 70% efficacious vaccine introduced in 2027 with three doses, strong uptake and five years of protection would reduce annual new infections by 44% over the first decade, by 65% the first 25 years and by 78% to 122 000 in 2070. Vaccine impact would be much greater if the assumptions in UNAIDS IFE were not fully achieved. An AIDS vaccine would be cost-effective within a wide range of scenarios.

Interpretation: Even a modestly effective vaccine could contribute strongly to a sustainable response to HIV/AIDS and be cost-effective, even with optimistic assumptions about other interventions. Higher efficacy would provide even greater impact and cost-effectiveness, and would support broader access. Vaccine efficacy and cost per regimen are critical in achieving cost-effectiveness, with cost per regimen being particularly critical in low-income countries and at lower efficacy levels.

Abstract  Full-text [free] access

Editor’s notes: Developing a vaccine against HIV has been an enormous scientific challenge. However, an effective vaccine could revolutionise the field of HIV prevention. A late-stage clinical trial is set to start at the end of 2016 and there are currently more than 30 early-stage clinical studies to evaluate vaccine candidates. This paper has modelled the potential health impacts and cost-effectiveness of an HIV vaccine. They used primary assumptions from the Investment Framework Enhanced from UNAIDS, which models the impact of different prevention programmes in 24 countries accounting for some 85% of new HIV infections. They also carried out sensitivity analyses on vaccine efficacy, duration of protection, coverage and cost.

The authors found that a 70% efficacious vaccine introduced in 2027 with three doses, strong uptake would reduce annual new infections by 78% by 2070. The vaccine would be cost-effective under several scenarios explored. At a cost of $5 per dose, the vaccine would be cost-effective under all vaccine effectiveness scenarios (30%-90%).  At 70% effectiveness, the vaccine would also be cost-effectives in a range of costs per dose ($5-$20).

This study is valuable in that it presents the scenarios in which the introduction of a vaccine against HIV could potentially be cost-effective; it gives an idea of feasibility under certain conditions. However (and the authors acknowledge this) the model is based on assumptions for which there is scant evidence. So far clinical trials have only achieved a vaccine that is 30% effective so 70% effectiveness is still a pipe dream. Secondly, given the enormous amount of resources that may yet need to be invested to develop a vaccine, the cost per vaccine may be much higher than estimated here (even higher than the ‘very high price’ scenario). In addition, the cost of targeting the vaccine to most at risk populations is not discussed; this could also raise the cost per dose considerably.  A probabilistic sensitivity analysis as well as further threshold analysis in this area would be valuable exercises to follow up the findings in this paper. 

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