Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized The rest of this page intentionally left blank. OPTIMIZING INVESTMENTS IN KAZAKHSTAN’S HIV RESPONSE Republican AIDSCenter author: B.S. Baiserkin UNAIDS Kazakhstan author: Aliya Bokazhanova World Bank authors: Clemens Benedikt, David Wilson, Emiko Masaki, Marelize Görgens and Michael Obst UNDP authors: Predrag Đurić, Christoph Hamelmann University of New South Wales authors: Andrew Shattock, Cliff C. Kerr, Robyn M. Stuart, and David P. Wilson Global Fund authors: Nicolas Farcy, David Kokiashvili Tatyana Vinichenko, and Shufang Zhang UNAIDS authors: Roman Hailevich, Manoela Manova, and Otilia Scutelniciuc © International Bank for Reconstruction and Development / The World Bank 1818 H Street NW, Washington DC 20433 Internet: www.worldbank.org; Telephone: 202 473 1000 This work is a product of the staff of The World Bank with external contributions. Note that The World Bank does not necessarily own each component of the content included in this work. The World Bank therefore does not warrant that the use of the content contained in the work will not infringe on the rights of third parties. The risk of claims resulting from such infringement rests solely with you. The contents of this report do not necessarily represent the views and positions of the World Bank, UNAIDS, UNDP, the Global Fund, participating government agencies or other partner institutions. In particular, the findings and modeling analyses presented in this report focus primarily on the cost considerations and epidemiological effects of HIV programs. Individual findings represented in tables or specific sections of this report should not be viewed or cited in isolation. They should be seen in the context of the overall recommendations of this report and other considerations such as equity in service access and health benefits beyond the HIV response. Nothing herein shall constitute or be considered to be a limitation upon or waiver of the privileges and immunities of The World Bank, all of which are specifically reserved. Rights and Permissions This work is available under the Creative Commons Attribution 3.0 Unported licence (CC BY 3.0) http://creativecommons.org/licences/by/3.0. Under the Creative Commons Attribution license, you are free to copy, distribute and adapt this work, including for commercial purposes, under the following conditions: Attribution – Please cite the work as follows: The World Bank. 2015. Optimizing Investments in Kazakhstan’s HIV Response Washington DC: World Bank. License: Creative Commons Attribution CC BY 3.0 Translations – If you create a translation of this work, please add the following disclaimer along with the attribution: This translation was not created by The World Bank and should not be considered an official World Bank translation. The World Bank shall not be liable for any content or error in its translation. All queries on rights and licenses should be addressed to the Office of the Publisher, The World Bank, 1818 H Street NW, Washington DC, 20433, USA; fax: 202-522-2625; email: [email protected]. CONTENTS Key Messages: ............................................................................................................................................. vii Executive Summary .................................................................................................................................... ix 1. Introduction ......................................................................................................................................... 1 1.1 Necessity for allocative efficiency ..................................................................................................... 1 1.2 Objectives of the analysis ...................................................................................................................... 2 2. Kazakhstan’s Health and HIV Financing Context ................................................................... 5 3. Methodology: How Will This Report Answer Key Questions? ............................................ 9 3.1 Optima Model ............................................................................................................................................. 9 3.2 Analytical framework ............................................................................................................................. 9 3.3 Limitations of analysis ........................................................................................................................ 11 4. Results and Their Interpretations ............................................................................................ 13 4.1 What is the status of the HIV epidemic in Kazakhstan? ........................................................ 13 4.2 What are the expected trends if current conditions are maintained? ............................ 13 4.3 Optimizing resources toward moderate targets and national strategy targets using current unit costs by 2020 ..................................................................................... 16 4.4 How much would it cost to achieve moderate and ambitious national targets with reduced ART cost? ...................................................................................................... 25 4.5 Impact of funding to opioid substitution therapy programs .............................................. 28 4.6 Efficiency gains from optimized allocations .............................................................................. 29 5. Conclusions and Recommendations ........................................................................................ 31 Appendixes A. Technical Summary of Optima ..................................................................................................................... 35 B. Calibration of the Model to Epidemic Data ............................................................................................. 40 C. Cost-Coverage-Outcome curves ................................................................................................................... 41 D. Other results ......................................................................................................................................................... 42 E. Glossary .................................................................................................................................................................. 45 F. References ............................................................................................................................................................. 47 Figures 1.1 Actual and optimized allocations in Kazakhstan’s HIV response with reduced unit cost of ART and reduced management costs, 2015–20............................................................ x 2.1 Kazakhstan: General Government Expenditure on Health (GGHE) as share of general government expenditure, 1995–2012 (%) ............................................................................................. 6 2.2 Kazakhstan: Health spending by source of financing, 1995–2012 (% GDP) ............................ 6 2.3 Kazakhstan: Aid disbursements, 2002–12 (US$ million) ................................................................. 7 2.4 Kazakhstan: HIV/AIDS spending by source of financing, 2012 (%) ............................................ 7 2.5 Kazakhstan: HIV/AIDS-related aid disbursements by donor, 2002–12 (US$ million) ........ 8 iii iv Contents 2.6 Levels of HIV disease burden compared to levels of HIV spending (%) .................................... 8 4.1 Kazakhstan: Model-predicted evolution of annual HIV incidence, 2000–20 ........................ 16 4.2 Kazakhstan: Optimizing spending toward national ambitious targets to reduce HIV incidence and AIDS-related deaths to 50 percent of their 2014 levels by 2020 .................. 16 4.3 Kazakhstan: Comparison of epidemic outcomes key to the national targets, 2014 ........... 18 4.4 Kazakhstan: Total number of new HIV infections over time, 2010–20 ................................... 19 4.5 Kazakhstan: Total number of AIDS-related deaths over time, 2010–20 ................................. 19 4.6 Kazakhstan: Total number of people living with HIV over time, 2010–20 ............................ 20 4.7 Kazakhstan: Total population prevalence over time, 2010–20 .................................................. 20 4.8 Kazakhstan: Number of new HIV infections by population, 2010–20 ..................................... 21 4.9 Kazakhstan: Number of people receiving treatment, 2010–20 .................................................. 21 4.10 Breakdown of “management and other costs,” 2013 (%) ............................................................. 24 4.11 Minimal spending to achieve national and ambitious targets with reduced ART cost ..... 26 4.12 Epidemic outcomes associated with allocations with reduced ART cost, 2014–20 ........... 26 4.13 Spending scenarios simulated to assess the impact of OST programs, 2015–30 ................ 28 4.14 Incidence among PWID and the number of PWID living with HIV in the 3 OST scenarios, 2010–30 ........................................................................................................................... 29 Tables 3.1 Modeling parameterization ........................................................................................................................ 10 3.2 Costs