The financial implications of the 2010 WHO recommendations for ART in resource-limited settings

Lori Bollinger, John Stover and Carlos Avila

Vienna International AIDS Conference21 July 2010

Background New antiretroviral therapy (ART)

guidelines published in July 2010 Developed during 2009 through a

consultative process led by World Health Organization

Part of process was to evaluate financial implications of proposed guidelines

Model developed to perform this evaluation Switching eligibility criterion to CD4<350 Switching ARV regimen (away from d4T)

Methodology Model tracks the HIV+ population by CD4

count Results for impact on number needing ART are

presented separately Increases ART need by about 50%

Two ARV regimen scenarios presented here “Fast” phase-out of d4T: 24% of total by 2012 “Slow” phase-out of d4T: 38% of total by 2012

Costs include: ARV costs per patient per year Laboratory costs (US$180/pppy) Service delivery costs Outreach and testing costs

ARV costs (US$)

Regimen Low Income Countries Middle Income Countries d4T+3TC+NVP $89 $88 AZT+3TC+NVP $149 $226 AZT+EFV+3TC $220 $281 TDF+3TC+EFV $210 $268 TDF+FTC+EFV $255 $325 TDF+FTC+NVP $190 $243 TDF+3TC+LPV/r $590 $1070 AZT+3TC+LPV/r $585 $1150

Service delivery costs combine median number of IPD/OPV with WHO-CHOICE country-specific cost per visit

Regional Service Delivery Costs for ART patients

Annual cost of Inpatient Days (ART patient)

Annual cost of Outpatient visits (ART patient)

Total annual service delivery cost (ART patient)

Sub-Saharan Africa $18.43 $53.62 $72.05 East Asia $36.48 $64.36 $100.84 Oceania $56.33 $77.62 $133.94 South and South-East Asia $29.20 $64.77 $93.98 Eastern Europe and Central Asia

$52.07 $71.82 $123.89

Western and Central Europe $106.23 $239.38 $345.61 North Africa and Middle East

$63.44 $73.68 $137.12

Caribbean $58.92 $70.52 $129.45 Latin America $59.34 $72.91 $132.25

Outreach and testing costs Patients with symptoms of HIV (none) STI patients (none) TB patients (none) Pregnant women (none – assumed in PMTCT

costs) Other health system contacts (US$16) Sex workers (US$1 – HIV test cost only) MSM (US$1 – HIV test cost only) Injecting drug users (US$1 – HIV test cost only) VCT (US$16) General population (US$23)

Scenarios for results (again)

Switch eligibility criteria to CD4<350 Overall ART need increases by about 50%

Two scenarios: Fast phase-out of d4T – 24% of total by 2012 Slow phase-out of d4T – 38% of total by 2012

Reach 80% coverage of those needing ART by 2015

Results: Total resources required for ART (2009 US$)

Results: Breakdown of cumulative resources required 2010-2015

Results: Cost-effectiveness implications

Summary and Conclusions Increasing the eligibility criterion and

phasing out d4T results in annual ART costs ranging between US$3.5 billion in 2010 and US$9.5 billion by 2015

Once criterion changes, costs are split in thirds: 1/3 to ARVs, 1/3 to labs and 1/3 split evenly between service delivery and testing

Testing costs are significantly lower before change Cost per person year on ART is US$800,

while the cost per death averted is about US$10,000

Implementing a faster phase-out of d4T does not have a large impact on overall costs

The financial implications of the 2010 WHO recommendations for ART in resource-limited settings

Lori Bollinger, John Stover and Carlos Avila

Vienna International AIDS Conference21 July 2010