IMPACT AND COST OF HIV/AIDS PREVENTION AND TREATMENT IN KWAZULU-NATAL, SOUTH AFRICA

Transcription

1 IMPACT AND COST OF HIV/AIDS PREVENTION AND TREATMENT IN KWAZULU-NATAL, SOUTH AFRICA AUGUST 2013 This publication was produced for review by the U.S. Agency for International Development (USAID). It was prepared by Katharine Kripke (Futures Institute), Thami Mayise (KZN DoH), Eurica Palmer and Steven Forsythe(Futures Institute), Silindile Shezi and Teresa Guthrie (CEGAA), and Nthabiseng Khoza (NDoH).

2 Suggested citation: Kripke K, Mayise T, Palmer E, Forsythe S, Shezi S, Guthrie T, Khoza N Impact and Cost of HIV/AIDS Prevention and Treatment in Kwazulu-Natal, South Africa Washington, DC: Futures Group, Health Policy Initiative, Costing Task Order. The USAID Health Policy Initiative, Costing Task Order, is funded by the U.S. Agency for International Development under Contract No. GPO-I , beginning July 1, The Costing Task Order is implemented by Futures Group, in collaboration with Futures Institute and the Centre for Development and Population Activities (CEDPA), now part of Plan International USA.

3 IMPACT AND COST OF HIV/AIDS PREVENTION AND TREATMENT IN KWAZULU-NATAL, SOUTH AFRICA AUGUST 2013 The views expressed in this publication do not necessarily reflect the views of the U.S. Agency for International Development or the U.S. Government. i

4 TABLE OF CONTENTS Acknowledgements... iii Abbreviations... iv Executive summary... v Methodology... v Results... v Limitations... vi Recommendations... vi Introduction... 1 The Goals pilot study... 1 Goals Model and Methodology... 2 Cost-effectiveness analyses... 3 Data Collection Process... 3 Scenarios... 5 Results... 6 Conclusion and Recommendations Main findings Procedural recommendations Capacity building Study limitations Conclusion Appendix 1: Baseline Coverage Calculations Appendix 2: Unit Costs Appendix 3: Epidemiological and Behavioral Inputs Appendix 4: Scenario Coverage Levels References ii

5 ACKNOWLEDGEMENTS The authors of this report would like to acknowledge contributions of the following individuals: Dr. Thobile Mbengashe and Nthabiseng Khoza, of the South Africa National Department of Health, KwaZulu-Natal Provincial HIV Programme Managers, CEGAA, Human Sciences Research Council, the National Costing Task Team, and John Kuehnle of USAID-South Africa for their co-operation, collaboration, and facilitation on this project. iii

6 ACRONYMS AND ABBREVIATIONS AIDS acquired immune-deficiency syndrome ART antiretroviral therapy ARV antiretroviral ASSA Actuarial Society of South Africa CEGAA Centre for Economic Governance and AIDS in Africa DALY disability-adjusted life year DHIS District Health Information System DHS Demographic and Health Survey HE²RO Health Economics and Epidemiology Research Office HIV human immune-deficiency virus HPI Health Policy Initiative HSRC Human Sciences Research Council ICER incremental cost-effectiveness ratio IDU injecting drug user KZN Kwa-Zulu Natal MSM men who have sex with men MTEF Medium Term Expenditure Framework NACM National AIDS Costing Model NHBCS South African National HIV Prevalence, HIV Incidence, Behaviour and Communication Survey NDoH South African National Department of Health NSP South Africa National Strategic Plan on HIV, STIs and TB OI opportunistic infection PrEP pre-exposure prophylaxis PSP Multi-Sectoral Provincial Strategic Plan for HIV and AIDS, STI and TB STI sexually transmitted infection TB tuberculosis TO6 Task Order 6, the USAID Health Policy Initiative Costing Task Order USAID U.S. Agency for International Development VMMC voluntary medical male circumcision iv

7 EXECUTIVE SUMMARY HIV/AIDS program managers strive to utilize limited resources to maximize the number of people that are reached with prevention, care, and treatment services. It remains a challenge to establish how much of an impact programs will make on HIV incidence and prevalence. It can also be challenging to project costs for services that will be delivered in future years. However, these projections are essential aspects of effective program planning. The USAID Health Policy Initiative Costing Task Order conducted an analysis to link program implementation to impact and cost at a provincial level in KwaZulu-Natal (KZN), South Africa. The Goals model was employed to conduct the analysis. Goals is a module within the Spectrum suite of health policy modeling tools, i which projects the effects of prevention and treatment programs on HIV prevalence, incidence, and mortality. Methodology The KZN-specific demographic, epidemiological, behavioral, population, program coverage, and unit cost information required to populate the model was collected between September 2012 and February 2013, with assistance from the KZN provincial HIV/AIDS managers, the Human Sciences Research Council (HSRC), the South Africa National Costing Task Team, the Health Economics and Epidemiology Research Office (HE²RO), the Centre for Economic Governance and AIDS in Africa (CEGAA), and other stakeholders. The analyses were conducted in March and early April 2013 and presented to provincial and national stakeholders in a series of meetings in late April Results 1. When implementing the Provincial Strategic Plan for HIV and AIDS, STI and TB (PSP) targets or maintaining 2011 levels of program coverage, the funding required will rise over time as increasing numbers of people require antiretroviral therapy (ART). Three quarters of the cost of implementing the PSP will go towards providing ART. 2. Comparing the PSP costing with the Goals projection, the Goals projection and PSP costing are comparable. However, both are about twice the amount in the 2012 KZN Department of Health (DoH) conditional grant budget request. The majority of the discrepancy lies in the estimate of costs for ART. 3. Over the period , implementing the PSP targets is projected to avert over 600,000 new infections compared with maintaining coverage at 2011 levels. 4. The full implementation of the PSP would be highly cost-effective by international standards, costing R2337 (USD $230) ii per disability adjusted life-year saved compared with the impact and cost of maintaining 2011 coverage levels. 5. The most cost-effective intervention among all those examined was condom promotion and distribution. Scaling up male circumcision was second only to scaling up treatment in terms of total infections averted, and it was also one of the most cost-effective interventions. Scaling up treatment had the largest impact on new infections but was also the most expensive in terms of cost per infection averted. 6. It was not possible to reallocate resources within the PSP to achieve greater impact at the same or lower cost. However, the authors noted that the targets established in the PSP are ambitious, and the cost of implementing the targets articulated in the PSP far exceeds the funds available to the province. i The Spectrum modeling suite is available for downloading at ii As of 20 August, 2013, $1 US Dollar (USD) = R10.14 South African Rand () v

8 7. In a constrained scenario in which more moderate targets and rate of scale-up were considered compared with the PSP, there were fewer HIV infections averted. However, the constrained scenario still resulted in a total of 460,000 infections averted between 2011 and 2025, compared with 608,000 for the PSP scenario. Accordingly, the total costs for the constrained scenario were R109 billion over the period, compared with R116 billion for the PSP scenario. 8. If new resources became available (above and beyond those required for the PSP), the South African National Department of Health (NDoH) and program managers in KZN might consider implementing one of the new biomedical prevention approaches, such as pre-exposure prophylaxis (PrEP, providing antiretroviral therapy to uninfected at-risk people to protect them from infection), prevention of mother-to-child transmission Option B+ (putting all HIV+ pregnant women on ART for life), or treatment as prevention (expanding treatment eligibility for the sake of reducing transmission). Among the scenarios incorporating the new biomedical approaches, the best combination of impact and cost per infection averted was treatment as prevention, closely followed by Option B+. The Option B+ and treatment as prevention scenarios each averted more than 100,000 additional infections compared with the PSP scenario over the projection. PrEP and the combination of PrEP with Option B+ led to much higher cost per infection averted, while only averting 66,000 and 149,000 infections, respectively, compared with the PSP scenario. Limitations 1. Issues with data quality likely affected the accuracy of the projections. 2. Lack of information about program implementation by non-government actors makes it difficult to understand the extent of funding gaps. Recommendations iii 1. Strive to implement the targets set out within the PSP as much as possible, especially medical male circumcision and ART. 2. Address the projected shortfall in ART funds by delineating how much of this is being covered by other donors or within the private sector, by identifying opportunities for cost saving within the program, and by raising additional funds if necessary. 3. If additional resources become available, consider providing ART to all HIV-infected pregnant women or all adults with CD4 counts below Continue to improve the data collected for program management, particularly program coverage, unit costs, and STI prevalence to facilitate data-driven program management. The USAID Health Policy Initiative Costing Task Order provided technical assistance to the Government of South Africa, resulting in this report, entitled Impact and Cost of HIV/AIDS Prevention and Treatment in KwaZulu-Natal, South Africa. We have confidence that this pilot Goals analysis at the provincial level in South Africa will be incorporated into strategic planning processes in the future. iii Some of the trends identified in this analysis, such as the relative cost-effectiveness of scaling up different interventions, are likely to be applicable to other regions or countries with similar epidemics and behavior patterns to those found in KwaZulu- Natal. vi

9 INTRODUCTION According to the UNAIDS World AIDS Day Report 2012 (UNAIDS, 2012), South Africa, with 5.1 million people living with HIV, is the country with the largest HIV-infected population. The South African Government has demonstrated unprecedented commitment among low- and middle-income countries in contributing resources to the epidemic response. The South African Government is committed to scaling up and maintaining quality, evidence-based HIV treatment, prevention, and care. The National Strategic Plan for HIV, STIs and TB (South Africa National AIDS Council, 2011) aims to halve the number of new HIV infections, ensure that at least 80 percent of people who are eligible for treatment for HIV are receiving it, halve the number of new TB infections and deaths from TB, ensure that the rights of people living with HIV are protected, and halve the stigma related to HIV and TB. It seeks to accomplish these goals by: (1) addressing social and structural factors that drive these epidemics, influence their impact, and affect the way we care for affected people; (2) preventing new HIV, STI and TB infections through a combination of interventions; (3) sustaining health and wellness, primarily by reducing deaths and disability from HIV, AIDS and TB; and (4) protecting the human rights of people living with HIV and improving their access to justice. The Goals pilot study The South African National Department of Health (NDoH) requested technical assistance from the USAID-funded Health Policy Initiative Costing Task Order team to improve the strategic planning, budgeting, monitoring, and evaluation cycle of their HIV/AIDS programs, applying a Goals analysis at the provincial level. Management of HIV/AIDS programs and resources is largely decentralized to the provincial level in South Africa. Goals analysis projects prevention and treatment program impacts on HIV incidence, prevalence, and mortality based on program coverage, population sizes, and behavioral data. It can also link coverage to cost over time as the sizes of the populations in need change with program implementation. KwaZulu-Natal (KZN) was chosen since this is the province with the highest HIV prevalence and has rich data available for analysis. The NDoH hopes to build the capacity to conduct Goals analyses in all the provinces to assist NDoH HIV/AIDS resource allocation among the provinces based on a more detailed estimate of need. Goals is a module within the Spectrum suite of health policy modeling tools. iv The Goals model has been used in numerous national and global strategic planning and costing applications to project the impact and cost of different HIV/AIDS resource allocation strategies. It was used by UNAIDS in developing its Investment Framework and in South Africa for the AIDS 2031 analyses. (For more information on the Goals model and its use, see Stover et al., 2006; Bollinger et al., 2004; and Bollinger, For more information on Spectrum, see Stover et al., 2008; Stover et al., 2006; Stover, 2004; and Forsythe et al., 2009.) iv The Spectrum modeling suite is available for downloading at 1

10 The research questions addressed through this study were as follows: 1. How do to the cost and impact of implementing the targets set within the KZN Provincial Strategic Plan (PSP) compare with the cost and impact of maintaining current levels of program coverage? 2. What are the more and less cost-effective elements of the PSP in KZN? Can resources be reallocated to decrease costs without significantly decreasing impact? 3. What are the implications for cost and impact if a more moderate scale-up is conducted compared with the ambitious PSP targets? 4. What might KZN do to maximize impact if more resources were available? The information required to populate the model was collected between September 2012 and February 2013, with assistance from the KZN provincial HIV/AIDS managers, the Human Sciences Research Council (HSRC), the South Africa National Costing Task Team, the Health Economics and Epidemiology Research Office (HE²RO), the Centre for Economic Governance and AIDS in Africa (CEGAA), and other stakeholders. The analyses were conducted in March and early April 2013 and presented to provincial and national stakeholders in a series of meetings in late April. A capacity building component was included, in which a small group of provincial HIV/AIDS managers walked through the relevant modules within Spectrum to further inform program and budget planning processes. GOALS MODEL AND METHODOLOGY Goals is a resource allocation tool that has been used to answer the following types of questions: What resources are required to expand coverage of prevention, care, treatment and mitigation services to all who need them? What goals can be achieved with the available resources? How can resources be allocated most efficiently to provide the greatest benefit? What is the gap between resources required and those available? What will be the impact of cuts in current levels of funding? The Goals model examines four major components of a program: 1. Behavior change includes interventions intended to promote safer behaviors among the general population, such as community mobilization, mass media, VCT, and social marketing. 2. Vulnerable populations include prevention activities targeted towards specific populations at risk including sex workers, injecting drug users (IDUs), men who have sex with men (MSM), and youth in and out of school. 3. Service delivery includes services provided by the health or employment sector including blood safety, condom promotion and distribution, STI treatment, workplace prevention programs and prevention of mother-to-child transmission (PMTCT) of HIV. 4. Care and treatment refers to services for those living with HIV/AIDS and includes opportunistic infection (OI) treatment, OI prophylaxis, ART and TB treatment. A full description of the methods used in the Goals model is provided in the Goals manual (Futures Institute, 2011). 2

11 To conduct a Goals analysis, it is necessary to collect information about the demographics, epidemiology, behavior, population sizes, program coverage, and unit costs of the specific population to be analyzed. In this case, it was necessary to collect this data specifically for KZN. Goals calculates program cost by multiplying the size of the target population (e.g., sex workers, pregnant women, etc.) by the current and projected coverage of the program by the unit cost of the program. Impact is calculated based on a combination of coverage, behavior, and information collated from the scientific literature about the effectiveness of different prevention interventions with different populations. It is possible to estimate resource needs for interventions such as palliative care, orphan care, and tuberculosis using Goals and associated Spectrum modules. Since many of these costs were already determined as a part of the PSP costing exercise, in this analysis we did not include these costs, and instead focused on HIV prevention and treatment interventions that would impact HIV incidence, prevalence, and mortality. Cost-effectiveness Analyses For each implementation scenario, total annual new infections (both adult and child) and total annual program cost were calculated in Spectrum. Both costs and infections were discounted by 3 percent per year. Cost per infection averted was calculated as follows: (cumulative cost scenario 1 minus cumulative cost scenario 2) (cumulative infections scenario 1 minus cumulative infections scenario 2) Incremental cost-effectiveness ratios were calculated by dividing the cost per infection averted by 20 to produce the cost per disability-adjusted life year (DALY) saved (Bollinger, 2012). DATA COLLECTION PROCESS A data collection form was prepared, listing and defining all the inputs that would be needed to perform the Goals analysis. These data included baseline and historical program coverage, unit costs, and epidemiological, demographic, and behavioral data. Detailed descriptions of the data collected and all sources are provided in Appendices 1-3. A summary of the data types and principal data sources is depicted in Table 1. Most of the data from the District Health Information System (DHIS) was provided by the Data Management and GIS Services Unit and validated by provincial program managers. Interviews with the program mangers provided context about the indicators, data definitions, and issues that would affect interpretation, to assist with translating the indicators into the categories required by the Spectrum modules. Many of the baseline coverage levels were collected from published surveys: to accurately reflect the effect of programs on HIV incidence, it is necessary to look at total program coverage, not limiting coverage to government-sponsored programs. 3

12 Table 1: Data types and sources for KZN Goals analysis Data Examples Principal sources Demographics population distribution fertility life expectancy migration ASSA 2008 provincial output (ASSA, 2008) Epidemiology Behavioral Program Implementation HIV prevalence STI prevalence risk groups condom use marriage sexual behavior drug injection behavior coverage policies (e.g., PMTCT regimen, eligibility for ART) ASSA 2008 provincial output (ASSA, 2008) DHS, 2003 (NDoH, 2007) NHBCS, 2002 (Shisana et al., 2011), 2005 (Shisana et al., 2012), 2008 (Shisana et al., 2009) Antenatal Surveillance (various) (NDoH, 2011) NHBCS, 2005 (Shisana et al., 2012) PSP, 2012 (Office of the Premier, 2012) DHIS (various) Various surveys Program Costs unit costs PSP, 2012 (Office of the Premier, 2012) KZN Dept. of Basic Education (Mchunu, 2012) NSP Costing, 2012 NACM, 2012 Costing for Global Fund application, 2013 ASSA, Actuarial Society of South Africa; DHS, Demographic and Health Survey; NHBCS, National HIV Prevalence, HIV Incidence, Behaviour and Communication Survey; PSP, KZN Provincial Strategic Plan; DHIS, District Health Information System; NSP, South Africa National Strategic Plan on HIV, STIs and TB ; NACM, National AIDS Costing Model. Much of the behavioral data were extracted from the South African National HIV Prevalence, HIV Incidence, Behavior and Communication Survey (NHBCS) 2005 (Shisana et al., 2012). The curated dataset and associated documents were provided upon request by the Human Sciences Research Council (HSRC). Definitions of the different behavioral risk groups were established in relation to the survey questions, and queries were developed to extract the necessary data on the risk groups and their behavior, as described in Appendix 3. Where possible, unit costs were derived from the KZN PSP costing exercise that was conducted in In some cases, revised unit costs were subsequently available from other costing exercises. In other cases, the PSP costing did not include unit costs for interventions utilized in the Goals analysis, and other data sources needed to be found. When no other unit cost information was available, Spectrum defaults for South Africa were used. 4

13 SCENARIOS The analyses in this Goals exercise were based on four basic scenarios, summarized in Table 2. Details of each scenario are available in Appendix 4: Scenario coverage levels. Table 2: Scenarios used in Goals analyses Scenario Description Baseline Coverage stays the same as 2011 levels PSP Coverage based on targets established in the PSP Ideal Scenario Constrained Scenario PSP Coverage revised upwards: 100% HIV counseling and testing 100% sex worker interventions 100% condom promotion/distribution 100% workplace programs 100% out-of-school youth Treatment for CD4<500 Slower scale-up than in PSP HCT Condom promotion/distribution Primary and secondary school Male circumcision Adult ART Reduced targets and slower scale-up Community mobilization Mass media The baseline scenario extended estimated 2011 coverage levels through the end of the projection in The PSP scenario was based on coverage levels outlined in the PSP and then extended at 2016 levels through In the ideal scenario, targets were increased to 100 percent for HIV counseling and testing, female sex worker interventions, and condom promotion and distribution. The PSP scenario did not include any increase for workplace programs or programs for out-of-school youth, so the ideal scenario introduced those two interventions for scale-up. Finally, criteria for ART were changed such that all adults with CD4 counts below 500 were eligible for treatment. We also introduced a scenario with more moderate targets and pace of scale-up compared with the PSP, which we call the constrained scenario. Targets and pace were determined by the best judgment of the Task Order team based on historical patterns of implementation in KZN, knowledge of program implementation, and international targets. KZN program managers may wish to create their own scenario reflecting a realistic pace and level of scale-up based on their intimate knowledge of program implementation in KZN. 5

14 Billions RESULTS How much funding is required to reach the targets of the PSP, and what will be the impact? Goals projected the funding that would be needed under both the baseline scenario (maintaining 2011 levels of program coverage), and the PSP scenario, between 2011 and 2025 (Figure 1). In both scenarios the funding required rose over time as increasing numbers of people would require ART. Comparing the PSP costing and the KZN DoH conditional grant budget request as of 10 April 2013 with the Goals projection, the Goals projection and PSP costing are comparable, and both are about twice the amount requested in the conditional grant budget request. The majority of the discrepancy lies in the estimate of costs for ART (Table 3). Figure 1: Annual costs of baseline and PSP scenarios PSP scenario baseline scenario PSP costing 2 - DoH CG budget request CG, conditional grant. Note that categories of expenses included in the Goals estimate, PSP costing, and DoH conditional grant request are not the same; they are only included here for reference. The Goals projection, the PSP costing, and the conditional grant budget request contain non-overlapping categories of expenses. In order to drill down in the comparison of these different budget estimates, the categories were aligned in these different costing exercises (Table 3). In comparing only categories that each estimate has in common, the Goals projection was R4.4 billion compared with R1.9 billion among comparable categories in the conditional grant budget request. The Goals projection was R4.5 billion compared with R4.0 billion among comparable categories in the PSP costing. 6

15 The discrepancies among cost categories are worth investigating further. As mentioned in the methodology section, Goals calculates costs by multiplying a unit cost by the percent coverage of the population by the size of the target population for that intervention. The PSP costing was conducted using a mix of coverage-based and activity-based methodologies. The conditional grant budget request compiled projected personnel, activity, and supply costs from the districts and facilities within the province. Table 3: Comparison of projected budgets by budget category Category Antiretroviral Therapy (ART) Home-based Care (HBC) High Transmission Area Interventions (HTA) Post-Exposure Prophylaxis Sexual Assault (NOPEP) Prevention of Mother-to- Child Transmission (PMTCT) Program Management Strengthening (PM) Step Down Care (SDC) HIV and AIDS Counseling and Testing (HCT) Regional Training Center (RTC) Sexually Transmitted Infections (STI) & Barrier Methods Tuberculosis (TB) (including TB/HIV Coordination) Male Medical Circumcision (MMC) Community Mobilization KZN DoH CG budget KZN PSP costing Goals estimates (PSP scenario) 1,427,603,000 3,403,354,629 3,396,197,138 N/A 155,550, ,236,775 16,397,000 17,722,948 6,435,135 3,975,000 4,468,467 6,075,518 79,311,000 75,350, ,437,878 58,300,000 11,336, ,166,000 29,553,000 72,154,000 79,280,000 66,494,158 10,032, ,953,943 N/A 41,461, ,741,170 N/A N/A 299,349,473 N/A 34,228, ,596, ,298, ,713,183 27,548, ,159,418 Mass Media 17,028, ,686,225 Condoms 82,125,484 37,168,208 Youth 41,534,241 97,993,148 Workplace Programs - N/A Peer Education 350,873,055 Total 2,269,221,000 5,162,350,457 4,869,316,605 N/A 7

16 Particularly concerning is the discrepancy in projected costs for ART between the conditional grant request and both the PSP costing and the Goals projection, as this may prevent the province from reaching its ART coverage targets. The higher projected cost for PMTCT in the Goals exercise is due to the fact that antiretroviral (ARV) drug and laboratory costs for PMTCT are included in the Goals projection but not in the conditional grant budget, which only lists personnel costs. It is unclear where the laboratory and drug costs for PMTCT are reflected in the budget. The discrepancy in cost for medical male circumcision is largely due to an upwards revision in the unit cost for male circumcision between the time when the PSP costing was conducted (unit cost R572) and the time when the Goals projection was finalized (unit cost R882). For community mobilization, the Goals projection was based on stated coverage targets listed in the PSP (49.5% of the total population in ), which are considerably higher than current implementation levels (1.1% of the population in ). It is therefore unlikely that the province will actually achieve these targets. The cost for mass media is largely borne at the national level, since an estimated 81 percent of people reported exposure to one of the national awareness campaigns (Johnson et al., 2010). Therefore the discrepancy in this cost should not be of concern. Likewise the coverage of workplace programs is largely borne by the private sector, so the government is not responsible for this cost. It should be noted that unit costs for blood safety, safe medical injection, and universal precautions were set to zero, even though coverage of these programs was set to 100 percent for all scenarios. These activities are not part of the provincial HIV/AIDS budget specifically but are incorporated into the general costs of operating the health system. Figure 2 shows the relative distribution of costs in the PSP scenario by intervention from the Goals projection across the entire period. The costs for ART, including both first- and second-line drugs and service delivery, comprise 76 percent of the total HIV prevention and treatment costs. These costs are highly sensitive to the costs of ARV drugs and the proportion of the population on second-line drugs. As described in Appendix 1: Baseline coverage calculations, the Spectrum model was calibrated such that the proportions of the population on second-line drugs matched the prediction of the National AIDS Costing Model (NACM) for KZN; however, the NACM researchers felt that these percentages may represent an underestimate of the actual proportion on second-line drugs. The cost projections can be improved with better data on the proportion of the population migrating to second-line drugs per year. As the province moves towards less expensive ARV regimens and more efficient service delivery models, the costs for ART may be partially mitigated. In the long term only, stemming the tide of new infections will bring down treatment costs. 8

17 Millions Figure 2: Distribution of projected costs from the Goals model by intervention for the period ,600 Second line service delivery costs 1,400 1,200 1, First line service delivery costs Second line ARV First line ARV PMTCT Male circumcision PEP STI management Female sex workers Workplace programs - peer education AIDS education - secondary students AIDS education - primary students Condoms HCT Mass media Community mobilization The impact of the implementation of the full PSP targets on new HIV infections was projected, shown in Figure 3. Over the period , the PSP scenario is projected to avert over 600,000 new infections compared with the baseline scenario. The prevention effects are due to both the reduction in infectiousness among people on ART and to the impact of the combination of prevention interventions to be scaled up according to the PSP (data not shown). The KZN HAST team requested an ideal scenario in which all interventions were scaled up to 100 percent and ART eligibility was extended to all adults with CD4 counts below 500 (rather than the current criteria of CD4 below 350). While some of the PSP targets were already set to 100 percent, the ideal scenario did include some additional prevention implementation as well as the increase in ART eligibility. These are outlined in Table 2 and described in detail in Appendix 4: Scenario coverage levels Briefly, in the ideal scenario, targets were increased for HIV counseling and testing, sex worker interventions, and condom promotion and distribution. In addition, the scale-up of workplace programs and prevention among out-of-school youth was introduced. The ideal scenario resulted in nearly 800,000 infections averted between 2011 and 2025 compared with the baseline scenario (150,000 infections averted compared with the PSP scenario). These additional infections averted, as with the PSP scenario, were due to a combination of the prevention benefits of treatment as well as the additional prevention intervention implementation (data not shown). 9

18 Thousands Figure 3: Projected new HIV infections in the baseline and PSP scenarios baseline scenario PSP scenario Figure 4 shows the relationship between cost-effectiveness and impact of the PSP and ideal scenarios. Compared to the baseline scenario, the PSP is very cost-effective and will have a significant impact on South Africa s epidemic between 2011 and Moving from the PSP scenario to the ideal scenario will produce an even greater impact, but at a significantly higher cost per infection averted. The incremental cost-effectiveness ratio (ICER) of the PSP scenario compared to baseline is R2,337; the ICER of the ideal scenario compared to the PSP scenario is R11,836. WHO considers interventions to be very cost-effective if the ICER is less than the country s GDP per capita; as of 24 May 2013, the World Bank indicators (World Bank, 2013) list the GDP per capita of South Africa in 2011 (the last year for which data are available) as $8,070, or R77,135. Therefore the PSP scenario is more cost-effective than the ideal scenario, but both would be considered highly cost-effective according to international standards. It remains uncertain, however, if either the ambitious targets in the PSP, or the even more ambitious targets in the ideal scenario, are feasible. 10

19 cost per infection averted Thousands Figure 4: Cost-effectiveness and impact of the PSP and ideal scenarios compared to baseline scenario, projected PSP scenario ideal scenario Thousands infections averted Which interventions are most cost-effective and impactful? We examined the incremental cost-effectiveness of scaling up each of the prevention interventions to the level of coverage in the PSP scenario while keeping all other interventions at baseline levels. The discounted cost per infection averted and total infections averted of scaling up each intervention compared to the baseline scenario between 2011 and 2025 are depicted in Figure 5. The most cost-effective intervention among all those examined was condom promotion and distribution. The impact was not as high as some of the other interventions because coverage of condoms was already fairly high at baseline (66%), so there was not as much room for scale-up. Scaling up male circumcision was second only to scaling up ART in terms of total infections averted, and it was also one of the most cost-effective interventions. Scaling up ART had the largest impact on new infections but was also the most expensive in terms of cost per infection averted. The impact of the interventions with female sex workers was small, because the magnitude of projected scale-up was small, not because the interventions were ineffective. It is important to remember that Figure 5 is only describing effectiveness in terms of prevention (infections averted); interventions also have varying impacts on averting morbidity and mortality, and reducing the impact of HIV/AIDS on orphans. Also, cost-effectiveness is not the only criterion for implementing an intervention. For example, it may be important to consider equity in reaching different populations. In the case of HIV counseling and testing, this intervention functions not only as a prevention intervention but also as a gateway to providing treatment and care to those who are infected. 11

20 cost per infection averted Thousands Figure 5: Cost-effectiveness and impact of scaling up individual interventions community mobilization only mass media only 40 HCT only condoms only 2ndary school only out of school only 10 FSW only - (10) infections averted Thousands IDU only MC only treatment only HCT, HIV counseling and testing. FSW, female sex worker interventions. IDU, injecting drug user interventions. MC, medical male circumcision. What would happen if the targets in the PSP were not achieved? Some of the targets articulated in the PSP may not be achievable because of implementation constraints, or may take longer to achieve than initially projected. We asked how the impact and cost would be affected in the case of a more moderate set of targets than those described in the PSP. To do this we created what we are calling a constrained scenario, to indicate what cost or implementation considerations may prevent some of the targets in the PSP from being reached. The specifics of this scenario are outlined in Appendix 4: Scenario coverage levels. In the constrained scenario, some interventions had slower scale-up (HCT, condom promotion/distribution, primary and secondary school interventions, medical male circumcision, adult ART), some had both reduced targets and slower scale-up (community mobilization, mass media), and some had the same coverage as indicated in the PSP (workforce programs, sex worker interventions, STI treatment, blood safety, PEP, safe medical injections, universal precautions, pediatric ART, pediatric cotrimoxazole, PMTCT). The constrained scenario had somewhat more new HIV infections than the PSP scenario (Figure 6) but still resulted in a total of 460,000 infections averted between 2011 and 2025, compared with 608,000 for the PSP scenario. Accordingly, the total costs for the constrained scenario were R109 billion over the period, compared with R116 billion for the PSP scenario. By 2025, the annual costs of the PSP and constrained scenarios were almost equal (Figure 7). This is because the PSP scenario results in fewer new infections than the constrained scenario, and therefore requires fewer resources for ART in the later years of the projection. 12

21 Thousands Figure 6: Projected new infections in the baseline, PSP, and constrained scenarios baseline scenario constrained PSP scenario Considerations for KZN if more resources were available In order to accelerate ending the HIV epidemic, it would be necessary to incorporate additional prevention interventions. We experimented with scaling up programs for out-of-school youth and IDUs. These interventions each had a small additional impact on new infections (data not shown). The impact and cost-effectiveness of some of the new biomedical prevention approaches were also considered, namely pre-exposure prophylaxis (PrEP), PMTCT Option B+, and treatment as prevention. PrEP refers to providing antiretroviral drugs to uninfected at-risk people to protect them from acquiring HIV. It has been demonstrated to be effective among MSM and discordant heterosexual couples (Grant et al., 2010; Baeten et al., 2012; Thigpen et al., 2011). Treatment as prevention refers to the finding that HIV-infected people whose virus is completely suppressed by successful ART are 96 percent less likely to transmit HIV to an uninfected partner (Cohen et al., 2011). PMTCT Option B+ refers to a strategy for prevention of mother-to-child transmission in which as soon as an HIV-infected pregnant woman is identified as HIV positive, she is initiated on ART for life, rather than being referred for ARV prophylaxis if her CD4 counts are above 350 (Shouten et al., 2011; Thyssen et al., 2013). It can be conceptualized as a treatment as prevention intervention targeting pregnant women, although it does have small additional benefits for prevention of mother-to-child transmission as well. 13

22 Billions Figure 7: Annual costs of baseline, PSP, and constrained scenarios PSP scenario 6 constrained 4 2 baseline scenario - Several scenarios were examined in which these new biomedical prevention approaches were scaled up on top of the PSP targets. PrEP was targeted to adults with multiple partners ( medium risk adults in the Goals modeling exercise) for the PrEP scenario. For the treatment as prevention strategy, we targeted adults with CD4 counts below 500, as this was the population targeted in the HPTN 052 study, which demonstrated health benefits for those receiving treatment in addition to the reduction in HIV transmission to partners. (The health effects of treating adults with CD4 counts above 500 is currently unknown and is being tested in the START trial.) (Babiker et al., 2013). The Option B+ scenario transitioned from the current PMTCT regimen to Option B+ by We also looked at a scenario combining both PrEP for medium risk adults and Option B+. The impacts of the various scenarios on new infections are depicted in Figure 8, with the impacts of the baseline, PSP, and ideal scenarios included for comparison. All of the biomedical approaches resulted in additional infections averted, with the most infections averted from the combination of Option B+ and PrEP targeted to medium risk adults, followed by treatment as prevention, Option B+, and PrEP, in that order. 14

23 Thousands Figure 8: Projected new infections in the scenarios adding new biomedical prevention approaches to the PSP scenario baseline scenario PSP scenario PSP PrEP med risk PSP Opt B+ PSP Opt B+ PrEP med risk ideal scenario PSP treatment as prevention Figure 9 depicts the total cost of the various scenarios over the period The highest cost was the scenario combining both Option B+ and PrEP, followed by PrEP, Option B+, and treatment as prevention, in that order. Figure 9: Total cost of scenarios adding new biomedical prevention approaches to the PSP scenario, baseline scenario PSP scenario PSP treatment as prevention PSP Opt B+ PSP PrEP med risk ideal scenario PSP Opt B+ PrEP med risk Total cost Billions 15

24 discounted cost per infection averted Thousands Among the scenarios incorporating the new biomedical approaches, the most cost-effective was treatment as prevention, closely followed by Option B+ (Figure 10). The Option B+ and treatment as prevention scenarios each averted more than 100,000 additional infections compared with the PSP scenario over the period. PrEP and the combination of PrEP with Option B+ led to much higher cost per infection averted while only averting 66,000 and 149,000 infections, respectively, compared with the PSP scenario. Thus, PrEP targeted toward medium risk adults is the least cost-effective of the three strategies, whereas expanding ART eligibility either to all pregnant women (Option B+) or to all adults with CD4 counts below 500 (referred to here as treatment as prevention ) are only marginally less cost-effective than the PSP scenario but could have a fairly significant impact. Figure 10: Cost-effectiveness and impact of various scenarios PSP scenario PSP PrEP med risk PSP CD4 500 PSP Opt B+ PSP Opt B+ PrEP med risk Thousands discounted infections averted ideal scenario 16

25 CONCLUSION AND RECOMMENDATIONS Main Findings The study sets out to examine the costs and impact of KwaZulu-Natal s Provincial Strategic Plan for HIV, STIs and Tuberculosis, and to examine variations on the plan that might lead to more effective resource allocation. Since an estimated 76 percent of the HIV/AIDS prevention and treatment resources are committed towards scaling up ART, there is little room for reallocating the remaining funds among the different prevention program areas. There are minimal opportunities for cost savings within the prevention portfolio because the province is already committed to scaling up most HIV prevention interventions to 80 percent or more. Importantly, the various prevention approaches all contribute incrementally to the overall prevention impact. Moreover, sacrificing prevention activities now results in a larger treatment mortgage in the future, so continuing and scaling up the effective prevention activities is essential for long-term management of the epidemic and long-term cost savings. Another important point to note is that treatment scale-up as projected in the PSP, while expensive, will have a large impact on averting new infections. Therefore sacrificing treatment scale-up today, in addition to leading to greater mortality, would also result in more new HIV infections over time, further increasing the need for treatment in the future. Resources will need to be raised for the province to reach its targets, particularly its treatment targets. Both the Goals analysis and the PSP costing exercise predict significant shortfalls in ART funds in the current KZN DoH conditional grant budget. It will be important for the province to assess the landscape of sources of funds for ART to ensure continuity in coverage as the need continues to rise. The overall cost of ART is particularly sensitive to the percentage of the population on second-line ARVs. It will be important to gather these data and determine the actual proportion of patients on secondline drugs to accurately forecast the budget. At the same time the provincial ART managers will need to ensure that patients are not transitioning to second-line drugs unnecessarily due to poor clinical management or poor adherence. Because of the large proportion of the budget taken up by ART, the main opportunities for cost savings lie with decreasing the cost of both first- and second-line ARV drugs, and increasing the efficiency of service delivery for ART. After ART the most expensive program is HIV counseling and testing, so looking for opportunities to improve efficiencies within the HIV counseling and testing program will be another area to explore for cost savings. If the province is successful in reaching the targets articulated in the PSP, or even making progress in increasing coverage over a longer time horizon, the scale-up will result in significant infections averted. If additional resources become available, they could be allocated towards expanding ART eligibility, either to adults with CD4 counts below 500, or to all HIV-infected pregnant women. Either of these strategies would further accelerate the end of the epidemic. 17

26 Procedural Recommendations A few procedural recommendations arose in the course of this analysis. The data intensive nature of the Goals analysis highlighted some weaknesses in the system for gathering data for decision-making. The most challenging data to collect were the baseline coverage numbers. The DHIS generally collects information about the numbers of people served, but translating these numbers into coverage can be challenging for a number of reasons, such as: Service delivery reports often include double-counting. For example, the number of HIV tests performed is not the same as the number of people tested in a given year, since some people get tested multiple times. Some services are also provided by non-governmental implementers, such as PEPFAR and private medical providers. In many instances, the size of the target population (denominator) is unknown. Examples include STI treatment services and programs targeting sex workers. In some instances, such as mass media and community mobilization, the number of people reached by the various outreach activities is unknown. It can be difficult to define what constitutes coverage, since the quality of programs varies. This is true for behavior change programs such as sex worker outreach, community mobilization, and condom promotion/distribution. Monitoring the coverage of programs is essential to evaluating the success of implementation and the impact of programs. These data can be difficult to gather, but efforts towards improving the understanding of program coverage will be critical. Improving data collection and use so that the coverage of programs can be monitored is a key recommendation coming from this exercise. Unit costs were also challenging and will need to be revised as better quality data become available. In many cases, the unit costs provided were several years old. In the case of condom promotion and distribution, some stakeholders had observed that the unit cost was too low, but better data were not available at the time of finalizing this report. For those unit costs that were derived from the PSP costing, it is possible that some of the activity costs were left out of the PSP costing database, so the unit costs may represent an underestimation. Overall STI prevalence in the population and among the different risk groups was difficult to determine because with the exception of syphilis testing in antenatal clinics, STI prevalence was determined by selfreport rather than based on biologic testing. Therefore it is difficult to estimate the overall need for STI treatment in the population and the role of STIs on enhancing HIV transmission within the different risk groups. Capacity Building As for building the capacity within the government to conduct the exercise, much more work will be needed. The data collection and modeling process is time-consuming and requires advanced data analysis skills. Staff within the government, with the requisite quantitative training and ability, will need ongoing support, as well as adequate available time to conduct the analyses and to maintain, or adjust, the model with updated data. At the same time, data systems will need to continue to be improved in order to streamline the data collection process if this type of analysis is to be expanded and integrated into HIV planning and budgeting processes. 18

27 Study Limitations This study has several limitations. Some of the issues with data quality are mentioned above. These likely affect the accuracy of the projections, particularly those with respect to cost. That said, as long as the actual unit costs do not vary much in relation to one another, the overall trends observed are probably accurate. It is not possible to estimate the exact impact of the data quality issues on the outcomes, since there are so many inputs to the model and the uncertainty of each input is unknown. Another issue has to do with the available behavioral data. The process of fitting the model to the historical trends in the epidemic revealed that the 2005 NHBCS greatly underestimated the proportion of the population with multiple partners (medium risk adults in the model) and the proportion of the population that includes sex workers and their clients (high risk adults in the model). This is predictable from the fact that the NHBCS is a household survey conducted by interview, so therefore subject not only to misreporting of behaviors but also likely to under-represent members of transient populations such as sex workers, truck drivers, and migrant laborers. Special types of surveillance need to be conducted to quantify population sizes and risk behaviors of vulnerable groups such as sex workers, MSM, and IDUs, in order to better model the contribution of these groups to continuing HIV transmission within the population. Further, improvements in methodology of the household surveys may result in eliciting more accurate responses about sexual behavior from the general population. Improvements in behavioral data would translate into more accurate targeting of HIV programs to key populations driving the epidemic, and to better estimates of program coverage. Another key limitation is the lack of information about program implementation by non-government actors. In order to conduct a gap analysis and measure progress towards the targets articulated in the PSP, it will be necessary to quantify the coverage of all the key HIV prevention and treatment programs in KZN. Conclusion In conclusion, it will take continuing investment, commitment, and determination to meet the targets set out in the PSP. The South African Government is committed to scaling up prevention, treatment and care services and is improving its capacity to effectively manage the programs. The most exciting finding from this study is that KwaZulu-Natal has ambitious targets which, if achieved, will have a significant impact on the epidemic in the province. 19