Transcript Slide 1

The prevention benefits of
expanded AIDS treatment:
how large, how affordable?
The new era in HIV/AIDS treatment and
prevention: science, implementation and
finance
Wilton Park Meeting
Geneva, Switzerland
27 – 28 June 2012
Robert Hecht, Managing Director
Main Messages
1. The population-level prevention effects of expanded treatment are not
fully understood – but modeling suggests that these could be significant.
2. In a high prevalence setting like South Africa, treatment efforts to date
-- as imperfect as they have been – appear to have reduced new
infections by 15-30% over the past six years.
3. Broadening treatment will lower new infections further – the South
African government’s current expanded effort and a Universal Test and
Treat program could cut infections by an additional 26% over a decade.
4. Rapidly expanded treatment in South Africa will double ART costs over
the next five years. This is large but affordable. The cost of universal
test and treat would more severely strain the country’s fiscal capacity.
5. Coupling expanded ART with other proven prevention interventions
could achieve additional reductions in new infections.
Treatment as prevention in a
high prevalence setting
Estimated impact of AIDS treatment on incidence, South Africa 2006-11
Source: Eaton et al., 2012
What would be the impact of expanded
treatment in the coming years?
We modeled three scenarios for South Africa:
 Current Practice (CP): individuals access ART after symptoms
show, CD4 < 350 cells/mm from 2011, 15% drop out in first
year
 Expanded Effort (EE): individuals tested every two years; ART
initiated @ CD4 ~ 350; effective linkage to care, 4% drop-out
rate
 Universal Test and Treat (UTT): 90% receive an AIDS test every
year, initiation immediately after testing positive, 2% drop-out
rate
The number of ART patients would grow
significantly under EE and UTT
4,500,000
Annual number of ART patients
4,000,000
3,500,000
NSP
3,000,000
2,500,000
CP
2,000,000
EE
1,500,000
UTT
1,000,000
500,000
0
2010
2015
2020
2025
Year
2030
2035
2040
Annual infections would also fall substantially
600,000
500,000
New infections
400,000
300,000
200,000
100,000
0
2010
2015
2020
2025
2030
2035
Year
No ART
CP
EE
UTT
2040
How much would it cost?
Cost of annual treatment scale up 2-3X in first five years
Cost over 10 years
(USD billion)
R30,000
R25,000
$ 30.5
ZAR millions
R20,000
CP
R15,000
EE
$ 19.3
UTT
R10,000
$ 13.7
R5,000
R0
2010
2015
2020
2025
Year
2030
2035
2040
How affordable would rapid ART scale-up be?
2011 status quo:
 ART = ZAR 7.8 billion (US$ 0.93 billion)
 63% of total national AIDS spending
 8% of government health budget
2015 projected costs for each scenario, South Africa
CP
EE
UTT
Cost of ART (ZAR billion)
(US$ billion)
R 11.3
R 16
R 26.1
(US$ 1.35)
(US$ 1.92)
(US$ 3.13)
Share of estimated AIDS spending
38%
54%
88%
Share of estimated health budget
7%
10%
17%
Expanded treatment plus other prevention could further lower new infections
– KZN province
Intervention
Baseline (‘status quo’)
ART at CD4 200
cells/µl
ART at CD4 350
cells/µl
Early ART
Male circumcision
Long-acting PrEP (TMC
287 + DPV ring)
Assumption
Impact
ART is introduced in 2004 and subsequently scaled-up such that when CD4 drops below 200 cells/µl, 33% initiate ART
and when CD4 drops below 100 cells/µl, 37% initiate ART. A dropout rate of 7 per 100 PY is assumed.
From 2013 onwards, 75% of individuals with CD4 ≤200 cells/µl receive ART. A dropout rate of 7 per 100 PY is assumed.
18.5%
From 2014 onwards, 35% of individuals with CD4 ≤350 cells/µl receive ART. A dropout rate of 7 per 100 PY is assumed.
32.1%
From 2015 onwards, 25% of newly infected individuals are initiated on ART on average nine months following the end of
acute infection. A dropout rate of 7 per 100 PY is assumed.
Scaled-up from 2016. 50% of uncircumcised males are circumcised over a 5 year period, such that the proportion of men
circumcised increases from 27% in 2016 to 65% in 2021.
Scaled-up from 2017. 30% of men and women (15-54 years) receive PrEP. PrEP is scaled-up over 5 years (from 2017 to
2021) after which time coverage is maintained. PrEP efficacy of 70% and adherence of 100% are assumed.
42.1%
55.1%
68.7%
Issues for discussion
 What are the likely prevention gains from implementing
current ART guidelines in high prevalence settings?
 What are the financial implications in these extreme settings,
especially for governments in middle income countries (e.g.,
South Africa), for donors in low income countries (e.g.,
Mozambique)?
 How should national leaders regard the benefits, costs, and
feasibility of a more aggressive UTT approach, logistically and
financially?
 How far could a combination of scaled up ART and other costeffective prevention services go in blunting the epidemic in
Southern Africa?