Without a serious change in approach AIDS will still be a major pandemic and funding required in resource-poor countries could reach an estimated $35 billion annually, three times the current level, by 2031 – the fiftieth year of the pandemic – according to modelling carried out for the AIDS 2031 project by Robert Hecht and colleagues and published in the November/December edition of Health Affairs.
Results from the Cost and Financing Working Group, AIDS 2031, headed by Robert Hecht were presented at a Health Affairs briefing on Capitol Hill ‘Meeting HIV/AIDS cost demands: is the global response working?’ in Washington, DC on November 10 2009. Others presenting at the briefing included: Anthony S. Fauci, Tom Walsh, Daniel Wikler, Alan E. Greenberg and Shannon L. Hader.
Results support policy choices focusing on investments in high-impact prevention for most-at-risk groups—sex workers, men who have sex with men, and injecting drug users—, efficient treatments, new prevention tools together with significant behaviour-change efforts. These could help cut costs by half as well as help control the pandemic.
Progress over the past twenty-five years has been made yet an estimated thirty-three million people are still living with HIV. There were 2.3 million new infections in 2007.
The AIDS 2031 project was set up to see how things might be done differently with the idea that by 2031 there would be few new infections, nearly all those needing treatment would get it and AIDS orphans would be helped to live normal lives. Working groups were formed to examine HIV/AIDS epidemiology, social drivers, leadership, science and technology, financing and sub-regional topics.
The AIDS 2031 Cost and Financing Working Group’s estimation of future AIDS costs followed the Joint United Nations Programme on HIV/AIDS (UNAIDS) Global Resource Needs Estimates with some changes. Estimates first done in 2001 evolved to include 48 interventions in prevention, care, treatment, mitigation, programme support and international support.
Estimates for 2031 used target population costs, unit costs and coverage through 2031 and took into consideration interventions such as pre-exposure prophylaxis, microbicides as well as vaccines.
The group calculated costs for low- and middle-income countries (the twenty countries with the most infections plus Mexico and Brazil for geographic representation) using a simple equation: population in need x coverage x unit cost = resources required.
The model has limitations, the authors note, including not taking account of possible synergies between variables. However, they argue, it is intuitive, easy to understand and use.
The authors developed four broad scenarios to look at the financial and epidemiological outcomes of widely varying policy choices and stress that “the four scenarios frame the possibilities and identify actions that could result in better control of the pandemic at lower cost” and include:
- Rapid scale up: Political will is strong, and resource availability continues to grow. It assumes all countries will achieve universal access to key prevention, care and treatment, and support services for vulnerable children by 2015 and continue at that level to 2031. How realistic this is within certain political and capacity contexts is questionable, but it does represent what the authors call a ‘what is possible’ scenario.
- Current trends: coverage of key interventions continues to grow at recent rates and coverage reaches about two-thirds of universal access targets by 2015 and stays at that level.
- Hard choices for prevention: Limited resources will mean that countries use most cost-effective approaches to achieve maximum impact. Focus is on most-at-risk populations including sex workers, men who have sex with men, and injecting drug users. Countries with low-level and concentrated epidemics will give less attention to general population interventions. Treatment would remain at “rapid scale-up”.
- Structural change: Focus is on looking at changes that would reduce vulnerability and help promote a sustained response and include: reducing violence against women, change employment practices that separate workers from their families, remove legal and stigma-related barriers and strengthen health systems. Such changes will bring better coverage for most-at-risk populations, improved effectiveness of prevention programmes but would take an additional ten years to put in place.
In all scenarios even in the best of circumstances and with the scaling-up of current interventions to the maximum, the authors conclude that new adult infections would only be cut by 48 percent and more than one million would still become infected in 2031.
The authors note that regardless of the “scale-up” strategy, adopted costs will increase rapidly over the next five to eight years and continue to rise over the following 15 years in low- and middle-income countries. All stakeholders, from government, foundations, nongovernmental organisations, households to companies will be under pressure to meet the costs.
Of the four scenarios “rapid scale-up” is the most expensive requiring $35 billion in 2031 with a cumulative cost of $722 billion over the next twenty-two years; “current trends” and “hard choices” will cost $24 billion and $19 billion in 2031 respectively, with cumulative costs of $490 billion and $397 billion.
The “hard choices” scenario is the most cost-effective, achieving almost the same number of infections averted with an incremental cost-effectiveness ratio of $1,429 for each HIV infection averted. “Rapid scale-up” averts the most infections but is the least cost-effective ($7,594). “Current trends” and “structural change” are in the middle with $6,225 and $6,803 respectively.
Choices made today by governments, international organisations, foundations and civil society groups, the authors argue, will affect how much there will be to spend for AIDS in the future.
They highlight some important policy considerations.
Putting “hard choices” into practice means investing in high-impact prevention efforts for most-at-risk populations—sex workers, men who have sex with men, and injecting drug users—and dealing with the barriers these groups face, such as stigma and discrimination as well as governments’ limited willingness to direct resources their way.
Implementation of this scenario also means looking at all drug-related costs including measures such as patent pooling and adopting low-cost, high-quality delivery approaches such as task-shifting.
While broader structural changes may increase costs in the short-term the long-term benefits may result in averting the largest numbers of new infections, in addition to improvements in women’s status and economic productivity.
The authors highlight the need for investments in new HIV prevention tools, such as AIDS vaccines and treatments, as well as significant behaviour-change strategies.
They conclude that mobilising the considerable sums required in resource-poor settings between now and 2031 will be difficult. The challenge is to sustain support from individual donors, foundations, and companies, notably from private sources, as well as appealing to new philanthropists emerging not only in Europe and North America but in China, India, Mexico and the Middle East.
Hecht R et al. Critical choices in financing the response to the global HIV/AIDS pandemic. Health Affairs 28 (6): 1591-1605, 2009.