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2011 National HIV Prevention Conference-Plenaries-Monday

2011 National HIV Prevention Conference-Plenaries-Monday

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  • 1. Department of Health, Behavior & Society David Holtgrave, PhD, Professor & Chair© 2005, Johns Hopkins University. All rights reserved.
  • 2. Social Injustice Never Takes A Holiday Source: Prejean et al. PLoS ONE 2011
  • 3. Presentation Headlines– Prevention Works: Evidence of national level success– Prevention Pays Off: In lives, and in dollars– We Have Many Cost-Effective Prevention Tools From Which to Choose For a Combination Prevention Package…– …But How Can We Choose Among These Tools?– Current Resources Are Not Enough to Reach the Goals of the National HIV/AIDS Strategy– As President Obama Said….It is not about whether we know what to do, it is about whether we will do it
  • 4. Prevention Works:Evidence of National Level Success
  • 5. Estimated Number of New HIV Infections, Extended Back-Calculation Model, 1977–2006 Source: CDC Website; Hall et al., JAMA 2008
  • 6. HIV Transmission Rate = (Incidence / Prevalence) * 100(aka, “Incidence-Prevalence Ratio”)
  • 7. HIV Transmission Rate, United States, 1977-2006120.00100.00 80.00 60.00 40.00 20.00 0.00 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 20 Year Source: Holtgrave et al. JAIDS 2009
  • 8. U.S. HIV Transmission Rate One of Lowest in the World Source: Holtgrave, Int J STD & AIDS 2009;20:876-878
  • 9. Refining Transmission Rates by Knowledge of Serostatus1-4• Assuming 2006 HIV incidence and prevalence estimates, and assuming 79% awareness of HIV seropositivity…• Overall transmission rate for Year 2006 – 5.0• Unaware of HIV seropositivity – Transmission rate estimated at 11.4• Aware of HIV seropositivity – Transmission rate estimated at 3.3 – Reflects behavioral changes and treatment effects1. Holtgrave DR et al. Int J STD AIDS. 2004;15(12):789-92.2. Marks G et al. AIDS. 2006;20(10):1447-50.3. Holtgrave, Pinkerton. JAIDS. 2007.4. Hall et al. JAIDS. 2010
  • 10. Updated Annual HIV Transmission RatesPer 100 PLWH, 2006-2008, United StatesScenario 2006 2007 2008“Lower Bound” 4.01 4.49 3.70Base Case 4.39 4.90 4.06“Upper Bound” 4.73 5.28 4.38 Source: Holtgrave, Hall, Prejean. Under review.
  • 11. A General Epidemiologic Fact• If Incidence is flat, and• Prevalence is increasing, then• The Transmission Rate must be going down This appears to be the situation for HIV in the U.S.; though the 2007 incidence estimates add some complexity to the interpretation
  • 12. Prevention Pays Off:In Lives, and In Dollars
  • 13. HIV Incidence and CDC HIV Prevention Budget (Adjusted for Inflation), United States, 1977- 2006 500000000 140,000 450000000 120,000 400000000Inflation-Adjusted Budget (1983 Dollars) 350000000 100,000 300000000 80,000 250000000 60,000 200000000 150000000 40,000 100000000 20,000 50000000 0 - 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 20 Year CDC HIV Prev. Budget (Real Dollars) CDC Incidence Estimate Based on: Holtgrave, Kates Am J Prev Med 2007
  • 14. HIV infections averted and medical costs prevented, 1991-2006, US(Farnham, Holtgrave, Sansom, Hall JAIDS 2010;54:565-567)
  • 15. Projected HIV Incidence(Hall, Green, Wolitski, Holtgrave, et al., JAIDS 2010)
  • 16. CDC Website Factsheet Excerpt based on Hall, Green, Wolitski, Holtgrave, et al., JAIDS 2010 Expanding HIV prevention in 5 years: The study found that intensifying national HIV prevention efforts over a five-year timeframe and maintaining them for the subsequent five years could reduce annual HIV incidence by 46 percent… — saving as many as an additional 306,000 people from becoming infected over the next 10 years — compared to maintaining current prevention efforts. …This rapid scale up would also save 25 times the amount that would need to be invested: …(it) would require an additional investment of $4.5 billion over 10 years, and would save up to $104 billion in avoided lifetime medical costs.Source: http://www.cdc.gov/hiv/resources/factsheets/PDF/us-epi-future-courses.pdf
  • 17. Additional CDC Website Factsheet Excerpt based on Hall, Green, Wolitski, Holtgrave, et al., JAIDS 2010 Expanding HIV prevention in 10 years: The study shows that expanding HIV prevention over a 10-year timeframe could reduce national HIV incidence by 40 percent… — preventing as many as an additional 215,000 new infections. …This expansion of HIV prevention would require an additional investment of $10.1 billion over 10 years, and would save as much as $66 billion in averted lifetime medical costs.Source: http://www.cdc.gov/hiv/resources/factsheets/PDF/us-epi-future-courses.pdf
  • 18. We Have Many Cost-EffectivePrevention Tools From Which to Choose For a Combination Prevention Package…
  • 19. Core Domains of Combination Prevention Package by Client Populations BEHAVIORAL BIOMEDICAL STRUCTURALHIV-, generalpopulation risklevelHIV-, most at riskpersons /communitiesPersons living withHIV, unawarePerson living withHIV, aware, no riskbehaviorPersons living withHIV, aware, riskbehavior (verysmall minority ofPLWH)
  • 20. Cost-per-quality-adjusted-life-year-saved of a sample of Non-HIV Medical InterventionsIntervention Appox. Cost per Year of Dollars Source QALY Saved (Reviews)Kidney Dialysis $52,000 to 2000 Grosse, 2008 $129,000Mammography, $57,500 2001 Walensky, 200950-69 y.o.Type 2 diabetes $63,000 2001 Walensky, 2009screening >25 y.o.Note: “Cost-saving” would refer to ratios less than $0 per QALY saved; thoughthere is no single cut-off, ratios less than $100,000 per QALY saved aregenerally considered “cost-effective”
  • 21. Cost-per-quality-adjusted-life-year-saved of a sample of HIV Biomedical Interventions Intervention Appox. Cost per Year of Dollars Source QALY Saved Targeted HIV testing Cost-saving NA Holtgrave, 2007 HIV screening every $42,200 2001 Walensky, 2009 5 years (review) PrEP $298,000* 2006 Paltiel et al., 2009 Early vs deferred $15,159 to $36,301 2005 Hornberger et al., HAART 2007 (review) Deferred vs no $46,423 2005 Hornberger et al., HAART 2007 (review) Expanded screening $21,580 2009 Long et al., 2010 & treatment Newborn Cost-saving to 2007 Sansom et al., 2010 circumcision (US) $87,792 Vaginal microbicide Result depends on NA Verguet et al., 2010 local HIV prevalence*result varies by assumptions of effectiveness and narrowness of targeting population to be served; also post-exposure prophylaxis has been estimated at $12,567 per QALY saved by Pinkerton et al., 2004
  • 22. Cost-per-quality-adjusted-life-year-saved of a sample of HIV Behavioral and Structural InterventionsIntervention Appox. Cost per Year of Dollars Source QALY SavedHousing as $62,493 2005 Holtgrave et al.,Prevention under reviewPeer Opinion Cost-saving NA Pinkerton et al.,Leader & Group 2001 (review)(MSM andWomen)Behavioral (Youth Cost-saving NA Lee et al., 2005Living with HIV)Syringe Exchange Cost-saving NA Holtgrave et al., 1998Condom Cost-saving NA Bedimo et al.,Distribution 2002Clinical provider Cost-saving NA Marseille et al.,counseling 2011(PLWH)
  • 23. …But How Can We Choose Among These Tools?
  • 24. Important Caveats About Cost-Effectiveness Analyses• Sensitivity analyses are important to express uncertainty – here we’ve quickly summarized some cost-effectiveness analysis base case results• Always customize results to your local area – e.g., by HIV seroprevalence• Many (but not all) of the cost-effectiveness studies compare an intervention to nothing (or the status quo) – Nearly always, something looks better than nothing
  • 25. With So Many Good Alternatives to Select From, What Do I Choose?• A comprehensive set of key policy/program questions need to be asked about interventions, including…. – Is the intervention evidence-based? – Is it based on the real needs and life circumstances of my clients? – How much does it cost per client? (Can I afford it?) – What does it cost per new HIV diagnosis? Per HIV infection averted? Per life year saved? – Is it cost-saving, or cost-effective….or neither? – Is it scalable, and can I afford to provide it to a large number of clients? – What is the best mix of interventions given the resources I have to work with? – How much would it take to achieve the NHAS percentage goals in my jurisdiction? – Are there policy barriers that prevent me from implementing the program?
  • 26. Moving From Cost-effectiveness Toward Optimization Analyses• Given that set of key policy/program questions….• Optimization modeling is increasingly important to compare multiple programs/policies to identify the “best set” of options – Consideration must be given simultaneously to scale, resource availability, overall population level impact, and unmet need – Example, ECHPP modeling to be discussed in next section of presentation – Other examples include • Walensky et al., 2010 estimates of impact of testing and treatment in Washington, DC • Holtgrave, 2007 comparison of a variety of HIV testing policies for the U.S. • Lasry et al., 2011 resource allocation model • Cohen & Farley, 2005 resource allocation model
  • 27. ENHANCED COMPREHENSIVE HIV PREVENTION PLAN for the BALTIMORE – TOWSON MSA, Maryland Heather L. Hauck, DirectorInfectious Disease and Environmental Health Administration Maryland Department of Health and Mental Hygiene
  • 28. ECHPP Objectives Develop an enhanced plan that aligns the jurisdiction’s prevention activities with the National HIV/AIDS Strategy  Using resources so that they have the biggest impact on HIV incidence  Identifying and addressing gaps in scope and reach of prevention activities among priority populations  Enhancing coordination between prevention, care, and treatment Identifying/implementing the optimal combination of prevention, care, and treatment activities to maximally reduce new infections  Assuring that the most effective biomedical, behavioral and community/structural interventions are prioritized  Assuring that interventions are going to populations/communities in such a way that the level of investment matches the level of risk Infectious Disease & Environmental Health Administration February 2011 30
  • 29. Maryland ECHPP Process Presentations/meetings with key stakeholders – Seven local heath departments and five HIV/AIDS community planning bodies Assessment of existing programming – Current level of implementation, including data on program funding, activities, reach and outcomes Mathematical modeling – Developed a resource optimization model to inform the allocation of current resources and quantify additional resources needed to reach the prevention goals of the NHAS Collaborative planning – Identification of priority areas to increase coordination and integration across the prevention, care and treatment continuum Infectious Disease & Environmental Health Administration February 2011 31
  • 30. Estimated HIV Transmission Rates for the Baltimore-Towson MSA Transmission Type of Transmission Rate Rate Per 100 PLWHOverall for the Baltimore-Towson MSA 4.4Persons Living with HIV and Unaware of Seropositivity 9.5Persons Living with HIV and Aware of Seropositivity 3.0Persons Living with HIV, Aware of Seropositivity, and Not 0.0Engaged in Any Risk Behavior (Vast Majority of PLWH) (by definition)Persons Living with HIV, Aware of Seropositivity, and 18.7Engaged in Risk Behavior (Small Minority of PLWH) Infectious Disease & Environmental Health Administration February 2011 32
  • 31. Definition of Three Testing Approaches in the Baltimore- Towson MSA Routine Testing in Targeted HIV Targeted HIV Emergency Counseling and Counseling and Department and Testing – Target by Testing – Target Similar Settings Venue Type Via OutreachHIV Seropositivity 0.8% 1.2% 4.0%RateHIV New 0.5% 1.0% 1.2%Diagnosis RateCounseling and Post-test Post-test Post-testCost Comments counseling for counseling for all counseling for all; PLWH and 11.9% 10% of cost of HIV- persons devoted to “targeting via outreach” Infectious Disease & Environmental Health Administration February 2011 33
  • 32. Three Testing Approaches in Baltimore: Results of Modeling Routine “ED” Target by Setting Target via OutreachNo. Tested 45,260 34,472 28,916No. Undiagnosed HIV+Persons Reached 226 345 347No. High Risk HIV-Persons Reached 5,343 16,859 13,741Total Testing Cost $ 1,130,000 $ 1,130,000 $ 1,130,000Transmissions Averted 15 22 23Infections Averted 4 13 11Transmissions +Infections Averted 19 36 34Gross Cost PerTrans+Inf Averted $ 59,435 $ 31,507 $ 33,707Public Support for MedCare Needed Year 1 $ 3,867,450 $ 5,891,225 $ 5,930,184 Infectious Disease & Environmental Health Administration February 2011 34
  • 33. Issue of Category B language in CDC’s Health Dept. FOA PS12-1201• “At least 70% of • We need local flexibility Category B funding to do what is most cost- must be allocated to effective in Baltimore the delivery of services • Flexibility in Category A in healthcare settings. doesn’t address Up to 30% may be Category B used to support targeted testing efforts in non-healthcare settings.” – quote from FOA p.30
  • 34. Interventions Included in the Baltimore-Towson MSA Modeling HIV Counseling and Testing – hybrid reflective of Baltimore-Towson experiences and best practices in the field (assuming rapid testing model; 1.5% seropositivity rate; and 0.9% new diagnosis rate); – includes post-test counseling for at-risk HIV- persons Prevention Services with Persons Living with HIV – intensive behavioral risk-reduction intervention services (and reinforcement of linkage to other needed services) Partner Services and Intensive Linkage to Care Prevention Services for HIV- Persons at High Risk of Infection – intensive behavioral interventions above and beyond post-test counseling Total Size of Funding Pool: $6 million Infectious Disease & Environmental Health Administration February 2011 36
  • 35. Interventions Assumed to be Provided with Separate Funding by DHMH Syringe Exchange Services Public Information Campaigns Condom Distribution Structural Interventions (such as work on HIV- related policies; and HIV-related housing which is supported via other funding streams) Overall Program Management and Evaluation Provider Training and Capacity Building Infectious Disease & Environmental Health Administration February 2011 37
  • 36. Modeled “Best Performance”: Costs by Category Year 0 Year 1 Year 2 Year 3 Year 4 Total Y1-4Total Costs $6,002,859 $6,002,844 $5,724,757 $6,007,416 $6,276,419 $24,011,436Counselingand Testing $3,260,500 $3,807,730 $2,293,361 $2,411,791 $2,521,157 $11,034,039Prev. withPLWH andEngaged inRiskBehavior $290,663 $608,014 $2,475,500 $2,590,367 $2,704,418 $ 8,378,299Prev. forHIV-Persons $1,162,653 $ - $ - $ - $ - $ -PartnerServices $789,043 $1,587,100 $955,896 $1,005,259 $1,050,844 $4,599,098ECHPP $ $500,000 $ - $ - $ - $ - Infectious Disease & Environmental Health Administration February 2011 38
  • 37. Modeled “Best Performance”: Results Year 0 Year 1 Year 2 Year 3 Year 4 Incidence 1,201 1,103 995 967 936 Prevalence 27,550 28,194 28,722 29,213 29,667 Transmission Rate 4.3593 3.9108 3.4628 3.3086 3.1539 Unawareness of Seropositivity 21.00% 17.69% 15.45% 13.22% 10.98%Note: HIV incidence is reduced 22.09% (vs the 25% goal in the NHAS) and HIVtransmission rate is reduced 27.65% (vs the 30% goal in the NHAS).Unawareness of seropositivity does not quite reach the NHAS goal of 10%. Infectious Disease & Environmental Health Administration February 2011 39
  • 38. Unmet Needs Scenarios: Baltimore-Towson MSA Year 1 to 4 Total Total HIV Total Incidence Transmission Seropositivity Resources Reduction Rate Reduction Awareness LevelBetter Use of CurrentResources $24,011,436 22.09% 27.65% 89.02%Meeting AwarenessGoal $25,769,082 23.26% 28.69% 90.00%Same as Above ButFront Loaded 90.00% $25,984,400 24.04% 29.24%Meeting All Goals $32,281,882 24.94% 30.12% 90.00%Same as Above ButFront Loaded $32,538,589 25.73% 30.68% 90.00%NHAS Target 25.00% 30.00% 90.00% Infectious Disease & Environmental Health Administration February 2011 40
  • 39. Maryland ECHPP Activities Significantly increase: – Routine HIV screening in clinical settings – Targeted HIV testing in non-clinical settings – Initial and ongoing HIV/STI partner services – Activities to support linkage to care, retention in care, and adherence to antiretroviral treatment – Risk reduction interventions for PLWH Decrease and redirect resources for: – Behavioral risk reduction interventions for HIV-negative persons Across all programming: – Increase utilization of local HIV and STI surveillance data – Increase partnerships across funding sources & with private providers Infectious Disease & Environmental Health Administration February 2011 41
  • 40. What is “Optimal” for Baltimore May orMay Not Be Optimal in Other Jurisdictions; But Modeling Process Might Be Useful
  • 41. …But Current ResourcesAre Not Enough to Reachthe Goals of the NationalHIV/AIDS Strategy
  • 42. Wasted Opportunities to Improve Health ofPersons Living with HIV and Help Prevent HIV Transmission Source: Gardner et al. Clinical Infectious Diseases. 2011
  • 43. Populations Sizes by HIV Serostatus and Behavioral Risk Level, 2008 General Population of U.S. (≈ 304.4 million) Unaware Aware HIV+; HIV- at Possible Risk No Risk Beh. HIV+ [in 13-64 year old, ≈ 25 million ] [≈791,200] Care/Tx* HIV- at Highest Actual Risk Aware HIV+; [Number in Unprotected Risk Beh. Serostatus Discordant [≈236,400] [≈150,700] Partnerships Wherein Viral Load is Not Suppressed] *Fraction of 791,200 and 150,700 on treatment and achieving suppressed viral load is unclear; assume none of 236,400 are on treatmentUpdated from: Holtgrave, McGuire, Milan: AJPH, 2007; CDC MMWR June 3, 2011;Anderson et al. CDC, Advance Data from Vital and Health Stats, October 23, 2006
  • 44. Key implications of NHAS (from Holtgrave, JAIDS 2010)• How will epidemic be changed if goals are met? – Prevent roughly 75,800 infections (2010-2015) – Prevent roughly 237,700 infections (2010-2020) – 2015 prevalence without NHAS roughly 1.481M and with NHAS roughly 1.407M• Appox. 218,900 more people on care and treatment
  • 45. Key Implications of NHAS (continued) (from Holtgrave, JAIDS 2010)• Cost of NHAS in expanded funding (be it new, redirected, or new private sector) – Total across years through 2015 • Roughly $15.2B need to achieve NHAS – Appox. $2.1B for prevention – Just under $1B for housing (to achieve NHAS goal) – Remainder for care and treatment (appox. $12.2B) » 43% is due to expanded awareness » 57% due to expanded coverage
  • 46. Key Implications of NHAS (continued) (from Holtgrave, JAIDS 2010)– However, investing in NHAS could save money– Medical costs offset by HIV infections averted through expanded prevention efforts – Net present value of medical care costs saved due to prevention efforts: $17.981B – Savings larger than investments needed (cost saving)– Bend the cost curve by bending the incidence curve– Choosing to not expand prevention efforts is the MORE expensive policy option
  • 47. As President Obama said on July13, 2010…. “The question is notwhether we know what to do, butwhether we will do it.”
  • 48. Issue of $20M from Category A in CDC’s Health Dept. FOA PS12-1201 • In times of great need,• $284 million instead of maximizing every dollar of previous $304 million in core prevention service Category A delivery is essential; $20 – $20 million moved to million should be restored Category C for immediately to Category A demonstration • Source could be from an projects conducted by FY12 continuation of the health departments FY11 $31 million increase in CDC base HIV prevention funding (or from another CDC or HHS resource pool)
  • 49. CDC’s Total HIV Prevention Budget (Actual and Inflation-Adjusted) $900,000,000.00 $800,000,000.00 $700,000,000.00 $600,000,000.00 $500,000,000.00Dollars Actual Budget $400,000,000.00 Inflation Adjusted $300,000,000.00 $200,000,000.00 $100,000,000.00 $- 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011Inflation-adjusted budget down 17.9% since FY02; buying power now approx. FY91
  • 50. Kaiser Family Foundation,HIV/AIDS Policy Fact Sheet, March 2011
  • 51. Someone LivingWith HIVDiesApproximately 33Every…. Minutes in the United States A death rate roughly 1.79 times that of the general population in the U.S.
  • 52. Thank you for your individual and collective leadership, passion, perseverance, and devotion to addressing HIV/AIDS in your neighborhood, state, and the nationBaby’s got a lot of tearsenough to cry a thousand yearsEnough to cry a thousand seas,enough to break a boy like meI want to stand and deliverand be the one that makes it better. -- Amy Ray, 2008, “Stand and Deliver”