Methods for Estimating Global Resource Needs for HIV/AIDS 2008-2015

1. Methods for Estimating Global Resource Needs for HIV/AIDS 2008-2015 John Stover, Lori Bollinger International AIDS Economic Network Meeting, Washington, DC February 22, 2008

2. Purpose • Estimate the global resource needs from all sources to implement a comprehensive program of HIV prevention, care, treatment and mitigation in low- and middle-income countries through 2015

3. Goals and Scenarios • Universal access by 2010 • Universal access to prevention, care and mitigation in all countries by 2010 • Phased Scale Up to Universal Access • UA by 2010 for MARP and all services in hyper-endemic countries, by 2015 in generalized epidemics, current scale up elsewhere • Current Scale Up • Continue current rates of scale up to 2015 UNAIDS, Financial Resources Required to Achieve Universal Access to HIV Prevention, Treatment, Care and Support, September 2007.

4. Components of a Comprehensive Program • Prevention • Care and treatment • Support for orphans and vulnerable children • National program costs • International support costs

5. Vulnerable populations Sex workers MSM IDU Prisoners Other special populations Youth (in/out of school) Formal sector employees Behavior change Community mobilization Mass media Social marketing VCT Condoms Violence against women Medical services Blood safety STI treatment PMTCT Post-exposure prophylaxis Safe medical injection Universal precautions New technologies Male circumcision HSV-2 suppressive therapy Pre-exposure prophylaxis Microbicides Vaccines Prevention Programs

6. Prevention of Violence Against Women • Workplace • Community mobilization • Education and sensitivity training for adolescents • Enabling environment (special populations) • Gender perspective in health services • Mass media • Post-rape services • NGO strengthening

7. Approach Resources required = population in need x coverage x unit cost

8. Key Questions About Unit Costs • What are the sources of information? • Do unit costs remain constant? • What has been costed?

9. Source of Information on Unit Costs • Published studies • RNM and Goals applications • National plans • Unit cost surveys • UNFPA Young People • UNAIDS/UNICEF OVC • RNM regional workshops • Regional averages

10. Validation • Top 15 validation workshop in Geneva • Latin America validation workshop in Mexico

11. Economies of Scale? • Not much information on economies of scale as programs expand • We assumed unit costs decline by 30% with each doubling of scale for most prevention interventions Marseille E, et al. HIV prevention costs and program scale: data from the PANCEA project in five low and middle-income countries BMC Health Services Research 2007, 7:108.

12. What has been costed? • “Resources needs” implies high quality programs • Difficult to tell what unit costs include • Key area for future work

13. ART Drug costs FL, SL, Pediatric, HIV-TB Laboratory costs Nutrition supplements Service delivery Non-ART Palliative care OI treatment Cotrimoxazole OI prophylaxis PITC STI screening Counseling Care and Treatment

14. Spectrum: AIDS Impact Module (AIM) Prevalence trends New HIV Infection NormalM 7.5yrs/F 8.5yrs, fast 6.1/6.9 Need for Treatment 3 years First Line ART AIDS Death 15% FY / 5% SY 15%/5% Second Line ART

15. Adult Male Progression without Treatment

16. Adult Male Progression with Treatment

17. Estimates of ARV Prices for First Line Regimens (US$) Brazil Ukraine Botswana Peru, Mexico Honduras, SA Tanzania

18. Estimates of ARV Prices for First Line Regimens (US$) By 2015 typical first line becomes EFV+TDF+3TC

19. Estimates of ARV Prices for Second Line Regimens (US$) El Salvador Ukraine Brazil Honduras Botswana, SA, Mexico, Tanzania

20. Estimates of ARV Prices for Second Line Regimens (US$) Middle-income Low-income

21. Orphans and Vulnerable Children • Who is vulnerable? • How are services delivered? • What should be included in AIDS resource needs? Stover J et al. Resource needs to support orphans and vulnerable children in sub-Saharan Africa Health Policy and Planning 2007;22:21-27.

22. Health facilities Program management IEC & advocacy M&E including OR Training Logistics and supply Lab upgrading Supervision and patient tracking Drug resistance surveillance Human resources National Program Costs

23. International Support Costs • Civil society strengthening • Technical assistance • Global advocacy and coordination • Policy, human rights, stigma

24. Major Challenges • Aligning unit costs with ‘best practices’ • Matching resource needs with estimated expenditures • GRNE = national strategic plan budgets • Who should pay? UNAIDS, Financial Resources Required to Achieve Universal Access to HIV Prevention, Treatment, Care and Support, September 2007.