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No. 14, 6 th Avenue, Belleville St Michael Barbados Tel (246) 429 6859Fax (246) 435-0569

email:Training@aidincorporated.orgwww.aidincorporated.org

Associates forAssociates forInternational DevelopmentInternational Development

Social and Economic costs of HIV and AIDS

Current issues

Costs, cost-effectiveness & Sustainability

Sarah Ann Adomakoh

Low prevalence estimates indicate, 2 new cases every 3 days, but estimates are as high as 1 new HIV case every 30 hours

� Human suffering

�Morbidity

�Social functioning

�Participation- reduced output

�Reduced Quality of life

� Loss of human capital

�Increased and unexpected mortality in productive age-group

�Reduced Transmission of abilities to next generation

� Child rearing

1980s to 2000Impact of AIDS - lost lives &

livelihoods

HIV/AIDS

Illness or Death

Supply of labour Savings/capital

Prevention & Treatment

Public/Private Expenditure

Actual health expenditure

Socialcapital

GDP

Required health expenditure

HIV/AIDS & the Economic System

Economic impact on affected households

� Before HAART, out of pocket household expenditure due to treatment of HIV/AIDS is an average of 28-62% of annual household income for various subgroups, ranging from 24% for those covered by social welfare and 76% for those not covered

� Post HAART - In 2004 the range narrowed: 10% to 35%

� Survey Data demonstrated following reasons; � Household income did not rise (no return to work) and expenditure fell

due to free access

� Household income fell further and expenditure fell due to lack of funds and unmet needs

70

75

2005-2010

AJ9

Slide 6

AJ9 SarahYou just need to make passing reference to this slide and point to the exact location on the graph where you are making the comparisonAlies Jordan; 14/10/2005

Microeconomic and macroeconomic, impact on development.

- Microeconomic impact on households, families, local/

regional food production, and productivity of various

economic sectors.

- Macroeconomic models to take into

account the impact on human capital.

A new Era

The Cost of Sustaining lives through Treatment

Those who don’t know are almost 2 thirds of those with HIV!!!

Reduction in deaths by 42% and maintaining this trend- overall apprx. 73% reduction in deaths between 2001 and 2004

Sexual practices, mixing

Transmission probabilities -effectiveness of viral suppression

Access to treatment & VCT

Prevention efforts

Reported cases - PLWHA

Impact issues on Universal access to ARV Treatment, care,support

- Are we maximising efficiency in the delivery of our programs?

� Maximising outcomes?� cost savings , benefits and cost effectiveness

� Minimizing costs? � What is an adequate drug pricing strategy for Barbados � Service scope?� The right balance: Integratign within exisiting services and prevention programmes� Shared care between private and public settings� Effective and Community care approaches � Shared staff within institutions

- Balance of Coverage - Are we promoting equity in access to ART ? � Enabling environment – promote more trust , respect, less stigma, discrimination, rejection � Equity of access for higher SES: reverse sitiation most developing contries � Making patients pay can reduce effectivenss of outcomes � Equity of access for kep populations - effect of Stigma discrimination in households and

health care settings

� Can we sustain a positive impact of ARVs on the epidemic at minimised cost to minimise negative impacts ?• Sustainability plans:

� health financing and investments

� What are the other global impacts of the universal program ( accoridng to current and planned configurations) on public health, economic, social and human development ?

Incremental costs analysis

Pre HAART Programme

HAART Programme Difference

Inpatient costs $1,367,964 $810,045 ($557,919)HAART $631,134 $707,596 $76,462 OI drugs $100,209 $156,220 $56,011 Outpatient visit cost $94,533 $418,480 $323,947 Outpatient diagnostics $35,966.35 $258,200 $222,233.65

Net Incremental cost $120,735 net cost per patient $385.73 net cost per patient per month

$32.14

($600,734)

($556,461)

($1464)($122)

Increasing cost of HAART

Ladymead Reference Unit

ARV Total Qty Un Price BBD Total Exp. BBD

Epivir® (lamivudine) 3TC 800 $43.07 $34,456Combivir® (zidovudine/lamivudine) AZT/3TC 2,292 $137.62 $315,425

Retrovir® (zidovudine) AZT 75 $101.56 $7,617Sustiva TM (efavirenz/stocrin) 2,487 $179.90 $447,411Videx® (didanosine) 100 mg 540 $34.40 $18,576

Viramune® (nevirapine) 342 $82.57 $28,239Viracept® (nelfinavir mesylate) 190 $607.82 $115,486Zerit® (staduvine) d4T 30 mg 272 $64.54 $17,555Zerit® (staduvine) d4T 40 mg 888 $86.01 $76,377Videx® (didanosine) 25 mg 16 $29.94 $479Crixivan® (indinavir sulfate) 378 $209.18 $79,070Ziagen TM (abacavir sulfate) 340 $272.94 $92,800

Kaletra TM (lopinavir/ritonavir) 574 $981.20 $563,209Total 9,194 $1,796,699

2004

No. of clients followed up and on HAART at the LRU

0

200

400

600

800

1000

1200

2003 2004 2005 2006

Year

No.

No. of clientsfollowed up

No. of clients onHAART

Outcomes: Key Findings

� Overall reduction in deaths of clinic registered patients by approximately 56%

� Median CD4 rise of over 100cells/mm3 observed in AIDS patients

� 85% of patients achieving greater than 95% adherence (LB41)

� Baseline total cost of inpatient care for HIV patients is $1,367,964 compared with the inpatient cost post HAART of $810,045 (02/3) $457,391 (03/4); $465,052 (04/5)

� Therefore, cost of inpatient care reduced by 40.8% in first year and 66% between 2001 and 2004.

� Rise in patients attending clinic from apprx. 380 to 744 between 2003 to 2004

� Overall reduction in AIDS related events observed in clinic attendees

� Rise in outpatient visits by 128%

� Reduction in death rate 18 months by 42%

� Apprx. Incremental cost effe9ctiveness ratio: $2171 per death averted (life year saved in 2002) increased to $13,173 per death averted between 2002 and 2004.

Sustainability- Clinical effectiveness is not enough!!

Direct BenefitsPotential reductions in hospitalization costsPrevention - Potential reductions in new infections due to lower viral loads

� Indirect Benefits� Increased Quality of Life?� Increased productivity of the labour force� Increased stability and longevity of families- child rearing , impact on next

generation – sustainable development

� Returns on investment � Increased economic and social Productivity and increased saving� Shared costs � Increase client base to wider population beyond borders for cost recovery

� Reduce impact to other sectors � Save money

HRQoLHRQoL Short Form 29Short Form 29--itemitem--Barbados (SF29Barbados (SF29--Bds.) Bds.) Measures Physical and Mental Components of Measures Physical and Mental Components of

Health Health

Issues of Concern to Employersin the ARV Treatment Era

� Stigma: Life years lost due to mental health impact of non-disclosure of employees

� Over 30% of employed PLWHA leave workforce long before health effects take hold. Average up to 2 years before AIDS onset

� 13% left as result of enacted stigma or overt discrimination

� Almost 20% would not disclose, manifested social cost in terms of reduced mental health and quality of life

� Economic: mental health problems � reduced quality and output

� Employer denial of threat of HIV � self stigma enforces failure to act

� Refusal to face the cost of mitigation - what will it cost?

� Insurance firms may feel no impact due to failure to claim through company health plans (delayed effect of stigma)

� Households spendings and savings decline instead

� Impact of delayed stigma in higher SES on sectors and economy islethal and profound

Employee level impact- what lies beneath?

� Due to all forms of stigma and discrimination…..

� Partial or complete withdrawal from social and economically productive life

� ……mental health impact is observed

� …….Poor Quality of Life

� Leading to � Pressure on existing workers

� reduced output,

� days lost from work due to self stigma.

� Low self esteem, vitality and poor mental health as a result of non disclosure and inability opt openly seek effective counseling support

�Will reduce levels and quality of output

Staff won’t die, but……………

Strategies for Reducing the Burden on Employers

� Diminish the size of the burden.

�Invest in HIV prevention interventions.

�Invest in HIV/AIDS care and treatment interventions.

�Invest in replenishment of human capital (training).

Only sure cost-effective response

CE depends on cost of treatment, survival rate, level of employee, etc

Mitigation strategy to provide staff back up - need s close assessment off at risk workers to be CE• Shift the burden onto others

The Greatest Threat -Stigma & Discrimination

Source: S Adomakoh PhD Thesis

The case of William, age 35

� What do you do to relieve your depression?

“When I get depressed I take a long walk from the hostel to Browns Beach and walk on the beach instead”

� Instead of what?“Instead of the alternative (laughs and throws head back)”

� Which is what?

“I would get a gun and put it to my head”“……….But I am trying to stay alive to see my 13 year boy graduate

– he is much cleverer than I was and has a future………”

� William was also abusing substances to self treat his depression. This ranged from Marijuana, to crack to pethadine. He was also on HAART.

� William died 2 weeks later.

Increased Cost-effectiveness optimize therapeutic strategies depends on :

� Optimal pricing of � brand name drugs (non-generics)� Use of generic drugs.

� Increased tolerance, adherence, and acceptability of treatment (increased life years saved)

• 85% of patients achieving greater than 95% adherence

� Enabling environment � Policies regarding health fencing, equity of access issues

� Increased numbers of asymptomatic HIV and HIV negative patients attracted to the new programme through � a strengthened voluntary counseling and testing

(VCT/prevention) service� Contact tracing� Improved referral networks

� Support to PLWHA - Responsive welfare policies and progammes

Enabling Environment & Access to Effective Prevention,ARV, Care

Policy directivesStigma reduction

STI service useVCT increasetargeted progs.

Enabling Environment

Trust

Prevention

Treatment & Care

Health

WellBeing

Increased demand by key pop’ns & others

Increased servicesprovision

Support

Sustained improved outcomes

ARV coverage ARV Monitoring Support intensityCommunity support

Support intensity may reduce over time

Sustained improved Productivity Welfare programmes

to improve QoL

Improved equity of access to ARVs