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Articles the Global Optima HIV Allocative Efficiency Model 17TLHIV0277 THELANCETHIV-D-17-00277 0094 S2352-3018(18)30024-9 Articles Embargo: March 9, 2018—23:30 (GMT) JG Doctopic: Primary Research This version saved: 17:34, 07-Mar-18 The global Optima HIV allocative efficiency model: targeting resources in efforts to end AIDS Sherrie L Kelly, Rowan Martin-Hughes, Robyn M Stuart, Xiao F Yap, David J Kedziora, Kelsey L Grantham, S Azfar Hussain, Iyanoosh Reporter, Andrew J Shattock, Laura Grobicki, Hassan Haghparast-Bidgoli, Jolene Skordis-Worrall, Zofia Baranczuk, Olivia Keiser, Janne Estill, Janka Petravic, Richard T Gray, Clemens J Benedikt, Nicole Fraser, Marelize Gorgens, David Wilson, Cliff C Kerr, David P Wilson Summary Background To move towards ending AIDS by 2030, HIV resources should be allocated cost-effectively. We used the Lancet HIV 2018 Optima HIV model to estimate how global HIV resources could be retargeted for greatest epidemiological effect and Published Online how many additional new infections could be averted by 2030. March 9, 2018 http://dx.doi.org/10.1016/ S2352-3018(18)30024-9 Methods We collated standard data used in country modelling exercises (including demographic, epidemiological, See Online/Comment behavioural, programmatic, and expenditure data from Jan 1, 2000, to Dec 31, 2015) for 44 countries, capturing 80% http://dx.doi.org/10.1016/ of people living with HIV worldwide. These data were used to parameterise separate subnational and national models S2352-3018(18)30041-9 within the Optima HIV framework. To estimate optimal resource allocation at subnational, national, regional, and Burnet Institute, Melbourne, global levels, we used an adaptive stochastic descent optimisation algorithm in combination with the epidemic VIC, Australia (S L Kelly MSc, models and cost functions for each programme in each country. Optimal allocation analyses were done with R Martin-Hughes PhD, R M Stuart PhD, X F Yap MSc, international HIV funds remaining the same to each country and by redistributing these funds between countries. D J Kedziora PhD, S A Hussain MSc, I Reporter MSc, Findings Without additional funding, if countries were to optimally allocate their HIV resources from 2016 to 2030, J Petravic PhD, C C Kerr PhD, we estimate that an additional 7·4 million (uncertainty range 3·9 million−14·0 million) new infections could be Prof D P Wilson PhD); Monash University, Melbourne, VIC, averted, representing a 26% (uncertainty range 13−50%) incidence reduction. Redistribution of international funds Australia (S L Kelly, D J Kedziora, between countries could avert a further 1·9 million infections, a 33% (uncertainty range 20−58%) incidence reduction K L Grantham MAppStat, overall. To reduce HIV incidence by 90% relative to 2010, we estimate that more than a three-fold increase of current J Petravic, Prof D P Wilson); annual funds will be necessary until 2030. The most common priorities for optimal resource reallocation are to scale Department of Mathematical Sciences, University of up treatment and prevention programmes targeting key populations at greatest risk in each setting. Prioritisation of Copenhagen, Copenhagen, other HIV programmes depends on the epidemiology and cost-effectiveness of service delivery in each setting as well Denmark (R M Stuart); as resource availability. The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia (A J Shattock PhD, R T Gray PhD); Interpretation Further reductions in global HIV incidence are possible through improved targeting of international Institute for Global Health, and national HIV resources. University College London, London, UK (L Grobicki MSc, Funding World Bank and Australian NHMRC. H Haghparast-Bidgoli PhD, J Skordis-Worrall PhD); Institute of Global Health, University of Introduction allocated across a mix of interventions in the right Geneva, Geneva, Switzerland The global community is committed to reducing new combination to yield the greatest health outcomes. The (Z Baranczuk PhD, HIV infections by 90% from 2010 levels by 2030 to end objective of this modelling study is to estimate how Prof O Keiser PhD, J Estill PhD); Institute of Social and 1,2 the AIDS epidemic as a public health threat. To help to minimise the number of HIV infections by 2030 Preventive Medicine, reach this goal, UNAIDS has set ambitious diagnosis, by targeting global resources to the most cost-effective University of Bern, Bern, treatment, and viral suppression targets supplemented combination of interventions and locations worldwide. Switzerland (Z Baranczuk, with high coverage of prevention as a roadmap to International funding organisations, including The Prof O Keiser, J Estill); Institute of Mathematics, University of achieving this goal. However, because international Global Fund to Fight AIDS, Tuberculosis and Malaria, Zurich, Zurich, Switzerland funding decreased by 7% in 2016,3 national governments now require applicants to provide evidence that their (Z Baranczuk); Institute of are being urged to mobilise new domestic HIV resources proposed budget will be invested cost-effectively. Many Mathematical Statistics and 7 Actuarial Science, University of to cover the billions of dollars in additional funds countries have used HIV modelling tools such as Goals, Bern, Bern, Switzerland 4 8 9 anticipated to be needed to achieve these targets. the AIDS Epidemic Model, and Optima HIV to assist in (J Estill); World Bank Group, As part of their Investment Framework for the Global developing their investment strategy. Since 2011, more Washington, DC, USA HIV Response,5 UNAIDS directs national governments than 40 national governments have requested Optima (C J Benedikt PhD, N Fraser PhD, 10,11 M Gorgens MPH, D Wilson PhD); to invest strategically in HIV programmes. Siapka and HIV modelling analysis support, led by the World and School of Physics, 6 colleagues did a systematic review of cost-effectiveness Bank, UN agencies, or the US Centers for Disease University of Sydney, Sydney, of the six most essential HIV programmes included in Control and Prevention, to improve the allocative NSW, Australia (C C Kerr) this framework and showed that further evidence was efficiency of their HIV responses. This study incorporates Correspondence to: needed to better understand how to best achieve expansions of previously generated Optima HIV country Sherrie L Kelly, Infectious Disease efficiency gains in HIV programmes. One type of gain models as well as the generation of new subnational and Modelling, Burnet Institute, Melbourne, VIC 3004, Australia is known as allocative efficiency, whereby funding is national models (55 Optima HIV models in total) to [email protected] www.thelancet.com/hiv Published online March 9, 2018 http://dx.doi.org/10.1016/S2352-3018(18)30024-9 1 Articles Research in context Evidence before this study subnational, national, or regional level. Our study is unique in We searched PubMed from Jan 1, 2000, to July 31, 2017, without that it is the first global HIV allocative efficiency analysis. We language restrictions and using the terms “HIV” AND estimated that reductions in new infections of approximately (“efficiency” OR “optim*” OR “allocation”) AND (“resources” OR 30% could be achieved from reallocating funds to the most “fund*”) AND “model*”. Findings from several studies have cost-effective mix of HIV programmes, confirming findings shown that there are common principles for determining the from a previous study for sub-Saharan Africa. We showed that optimal allocation of HIV resources at the national similar gains are possible in regions in all parts of the world in (eg, Kenya, USA) and regional levels (eg, sub-Saharan Africa). both generalised and concentrated epidemic settings using Targeting resources to more cost-effective programme different mixes of programme prioritisation. We also showed combinations and to geographical hotspots (eg, Kenya) can lead that redistributing international funds between countries could to reductions in new HIV infections by up to about 30%. Goals lead to additional gains. International funds were mainly and the AIDS Epidemic Model are two other well known HIV shifted towards countries in sub-Saharan Africa, as previously resource allocation models that have been extensively used in recommended. By 2030, if allocations are optimised at the partnership with countries to guide strategic planning. The Goals subnational and national level and international funds model has also been applied to estimate programme coverage reallocated between countries, an absolute reduction in requirements and resource needs for achieving global HIV incidence of more than 30% is possible. Additionally, if global targets. However, neither model was specifically designed to HIV funding is either increased or, as forecasted, continues to identify optimum HIV resource allocations. Remme and decrease, we have identified funding priorities for HIV colleagues have shown that for countries in sub-Saharan Africa, investment. Our modelling results also confirm that reaching although additional domestic funds have yet to be leveraged, the global HIV incidence target by 2030 is possible but that international funds will still be needed to meet global AIDS goals. substantially more resources are needed (to a total of about According to Stover and colleagues, to reach global HIV targets, $40 billion each year until 2030). the 2016 annual HIV budget of US$19·1 billion for low-income Implications of all the available evidence and middle-income countries will need to be increased to Findings from modelling studies can be useful
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