Karin Stenberg Health Economist World Health Organization Ludovic Queuille Avenir Health Rachel Sanders Panamerican Health Organization Marcus Cadet Ministry of Public Health and Population,Haiti Claire Lebrun Specialist in health and gender equality COPRIN CChC Benefit-Cost Analysis Costs and benefits of interventions to reduce the transmission and disease burden of HIV / AIDs in Haiti Haïti Priorise Karin Stenberg Health Economist World Health Organization Ludovic Queuille Avenir Health, Washington DC, USA; Rachel Sanders Panamerican Health Organization, Port-au-Prince, Haiti Marcus Cadet Ministry of Public Health and Population,Haiti Working paper as of April 20, 2017. © 2017 Copenhagen Consensus Center [email protected] www.copenhagenconsensus.com This work has been produced as a part of the Haiti Priorise project. This project is undertaken with the financial support of the Government of Canada. 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Examples of components can include, but are not limited to, tables, figures, or images. Academic Abstract Haiti is the poorest country in the American region and has one of the highest rates of HIV/AIDS infection in the region (1.35% prevalence). HIV/AIDS was the top cause of death by rate in 2005, but in the ten years following was overtaken by ischemic heart disease and cerebrovascular disease, and is now the third most common cause of death. However it remains the top cause of premature death, and the top cause of death and disability combined (IHME, 2016). Over the past decade, efforts to curb the epidemic have resulted in significant advancements. The rate of new HIV infections fell by 54% and more than half of Haitians living with HIV are accessing antiretroviral therapy (REF). However, the sustainability of these investments can be called into question as total expenditure on HIV/AIDS services is almost exclusively funded from external sources and the total amount spent exceeds the national health budget. This analysis estimates costs and benefits of expanding coverage of HIV/AIDS interventions in Haiti. We present research conducted as part of the Haiti Priorise project, under the leadership of the Copenhagen Consensus Center. The main driver of the HIV/AIDS epidemic is unsafe sex (IHME 2016). Interventions are required to reduce risky behaviours. We therefore consider a key set of highly effective preventive interventions, including those that target the overall population (mass media campaigns; provision of condoms), as well as specific outreach to vulnerable groups with high HIV prevalence (female sex workers, and men who have sex with men). We also consider male circumcision as a preventive intervention. Furthermore, our analysis considers expanding treatment as care, specifically through the expansion of HIV testing and treatment as per the current global policy of treatment as prevention. We estimate costs and health impact of hypothetical scenarios where coverage would be increased from current levels to reach 80% or 95% in 2018 and with such coverage maintained until 2036. The projected health outcomes are then translated into economic benefits and compared against the projected costs, in order to derive cost benefit ratios. Our estimates indicate that packages of preventive interventions would avert around 200 deaths during the period of 2018-2036 (an average of 20 per year), whereas scaling up treatment to 80% or 95% would avert around 20,000 and 35,000 deaths respectively during the same time period, compared with a current- coverage scenario. In terms of averting new HIV infections, a comprehensive preventive package would ii avert over 3000 new infections, whereas Treatment as prevention would avert roughly twice as much (over 6000 new infections). The effect of incubation on HIV, and the time to death without treatment (which can be 8-11 years), is resulting in relatively low numbers of deaths averted for the preventive interventions during the time period in question. We project Healthy Life Years (HLYs) gained in the scale-up scenarios. Again, the effect is more pronounced for Care and Treatment. Within the modelled scale-up, the provision of ART slows the rate at which the CD4 count is reduced, and results in significant gains in Healthy Life Years (HLYs) for the infected population. Each HLY is valued at 3 times GDP per capita. The projected average additional cost per year 2018-2036 is in the range of US$1 to 3 per capita, both for preventive interventions and for testing and treatment. Given that additional costs are similar but projected impact is so much higher for the treatment interventions over the next 19 years, the calculated benefit- cost ratios (BCRs) are much higher for test and treatment than for the preventive package. BCRs are estimated at around 0.02 or less for the preventive interventions, whereas treatment as prevention (TasP) is estimated to have a BCR of around 3.1 (5% discount rate; benefits valued at 3 x GDP per capita). All interventions will have a longer term effect beyond 2036 which, when taken into account, may result in higher BCRs. iii Policy Abstract Overview Haiti is the poorest country in the American region and has one of the highest rates of HIV/AIDS infection in the region (1.35% prevalence). HIV/AIDS was the top cause of death by rate in 2005, but in the ten years following was overtaken by ischemic heart disease and cerebrovascular disease, and is now the third most common cause of death. However it remains the top cause of premature death, and the top cause of death and disability combined (IHME 2016). Over the past decade, efforts to curb the epidemic have resulted in significant advancements. The rate of new HIV infections fell by 54% and more than half of Haitians living with HIV are accessing antiretroviral therapy. However, the sustainability of these investments can be called into question as total expenditure on HIV/AIDS services is almost exclusively funded from external sources and the amount spent exceeds the national health budget. Rationale for Intervention The main driver of the HIV/AIDS epidemic is unsafe sex (IHME 2016). Interventions are required to reduce risky behaviours. Our analysis considers two areas of interventions: Expanding HIV prevention: effective interventions include those that target the entire population such as mass media campaigns and provision of condoms; as well as specific outreach to vulnerable groups: female sex workers (FSW), and men who have sex with men (MSM). We also consider male circumcision as a preventive intervention. Expanding HIV testing and treatment: the analysis for treatment interventions considers the current global policy which is treatment as prevention, or TasP (no CD4 criterion for ART eligibility). These interventions have demonstrated effectiveness and are part of global recommendations by UNAIDS and the World Health Organization. They are also part of the Haiti national AIDS strategy. We estimate costs and health impact of hypothetical scenarios where coverage would be increased from current levels (in 2017) to reach 80% or 95% in 2018 and be maintained at such levels until 2036. Our analysis adopts the provider perspective, meaning that we only estimate and report the direct costs associated with health service programme delivery from the point of view of the health provider (budget implications). iv Implementation models follow current guidelines and practice with respect to where services are provided (outpatient care, a mix of public and private sector providers). We have not modelled financing mechanisms such as user fees given our point of view that out of pocket payments should be limited particularly for those struck with a chronic disease such as HIV/AIDS. Projected health outcomes include deaths averted, new infections averted, and healthy life years gained in the scale-up scenarios compared with a current-coverage scenario. Within our model, the provision of ART slows the rate at which the CD4 count is reduced, and results in significant gains in healthy life years (HLYs) for the infected population. Each HLY is valued at 3 times GDP per capita. Our estimates indicate that packages of preventive interventions would avert around 200 deaths during the entire period of 2018-2036 (19 years), whereas scaling up treatment with antiretroviral treatment (ART) to 80% or 95% would avert around 20,000 and 35,000 deaths during the same time period. The effect of incubation on HIV, and the time to death without treatment, (which can be 8-11 years), is resulting in relatively low numbers of deaths averted for the preventive interventions. ART on the other hand is effective in reducing transmission (preventing new infections) as well as increasing the longevity as well as quality of life of those infected with HIV, which results in high numbers of deaths averted and HLYs for testing and treatment. The projected average additional cost per year 2018-2036 is in the range of US$1 to 3 per capita, both for preventive interventions and for the testing and treatment. Given that additional costs are similar but projected impact is so much higher for the treatment interventions in the next 18 years, the calculated benefit-cost ratios (BCRs) are much higher for the treatment interventions.