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Supplementary webappendix
This webappendix formed part of the original submission and has been peer reviewed.
We post it as supplied by the authors.
Supplement to: Schwartländer B, Stover J, Hallett T, et al, on behalf of the Investment
Framework Study Group. Towards an improved investment approach for an effective
response to HIV/AIDS. Lancet 2011; published online June 3. DOI:10.1016/S0140-
6736(11)60702-2.
SUPPLEMENTAL MATERIAL
    Towards an improved investment approach for an effective
       response to AIDS; Schwartländer et al. May 2011


Table of Content
APPENDIX I
SUMMARY........................................................................................................................ 3
BACKGROUND INFORMATION ................................................................................... 3
METHODS FOR ESTIMATING THE COST AND IMPACT OF THE PROPOSED
INVESTMENT FRAMEWORK ........................................................................................ 4
  Impact and effectiveness of interventions....................................................................... 5
  Coverage targets.............................................................................................................. 6
  Projections of the number of HIV infected people in need and receiving ART............. 8
  Estimated cost of programme activities........................................................................ 11
    Assumptions about the cost of HIV interventions .................................................... 11
    Estimated cost of counseling and testing (C&T) ...................................................... 12
    Estimated cost of treatment, care and support .......................................................... 13
       Assumptions about the cost and changes in cost of ART..................................... 13
    Estimated costs for IDU interventions...................................................................... 15
       OST: Coverage targets lower and middle income countries ................................ 16
       Unit cost of OST ................................................................................................... 17
       NSP: coverage targets lower and middle income countries.................................. 18
    Estimated cost of PMTCT ........................................................................................ 19
       Screening............................................................................................................... 19
       Family Planning .................................................................................................... 19
       CD4 Testing .......................................................................................................... 20
       Prophylaxis for HIV infected pregnant women .................................................... 20
       ART for mothers who need it for their own health............................................... 21
       Early infant diagnosis ........................................................................................... 22
       Cotrimoxazole Prophylaxis................................................................................... 22
    Estimated cost of Behavior Change programmes..................................................... 22
  Estimated cost of community mobilization .................................................................. 23
  Estimated cost of programme support functions .......................................................... 24
  Estimated cost for synergies with development sectors ............................................... 24
  Costing Spreadsheets .................................................................................................... 26
APPENDIX II: THE SYNERGISTIC IMPACT OF CRITICAL ENABLERS.............. 28
APPENDIX III: ESTIMATED CONTRIBUTION OF TREATMENT TO REDUCING
TRANSMISSION ............................................................................................................. 30
APPENDIX IV: INFORMATION ON NEW PREVENTION TECHNOLOGIES ......... 32
APPENDIX V: RELEVANT TERMS AND DEFINITIONS......................................... 34
  Basic Programme Activities ......................................................................................... 34
    Treatment care and support for PLWH (including facility-based testing) ............... 34
    Prevention of mother-to-child transmission (PMTCT)............................................. 34


                                                                1                                                26/05/2011
Male circumcision..................................................................................................... 34
    Condom promotion and distribution......................................................................... 35
    Behaviour Change Programmes ............................................................................... 35
    Component elements of social and behavioural change communication programmes
    ................................................................................................................................... 36
    Key populations ........................................................................................................ 37
        Sex work interventions ......................................................................................... 37
        MSM programmes ................................................................................................ 37
        IDU programmes .................................................................................................. 38
  Critical enablers ............................................................................................................ 38
    Social Enablers.......................................................................................................... 38
        Political commitment and advocacy ..................................................................... 38
        Laws, legal policies and practices......................................................................... 39
        Community Mobilization...................................................................................... 39
        Stigma reduction ................................................................................................... 40
        Gender based violence .......................................................................................... 41
        Local responses to change the risk environment .................................................. 42
    Programme Enablers................................................................................................. 43
        Community centered design and delivery............................................................. 43
        Programme communication .................................................................................. 44
        Management and incentives.................................................................................. 44
        Procurement and distribution................................................................................ 44
        Research and innovation ....................................................................................... 45
REFERENCES ................................................................................................................. 46




                                                                    2                                                   26/05/2011
SUMMARY
A new investment approach is proposed for the response to HIV. It is simpler and more
strategic than current approaches and is intended to support better management of the
HIV response, both at national and international levels. The framework proposes three
categories of investment: a small number of basic programme activities scaled up to
reach the relevant populations; a set of critical interventions that create an enabling
environment for achieving maximum impact; and support for programmatic efforts set in
wider health and development sectors related to AIDS. In this document we describe in
greater detail the methods used for estimating the annual cost of implementing these
programmes to achieve universal access to HIV treatment, care and support by 2015, as
well as estimating the potential future impact of the new investment strategy.


BACKGROUND INFORMATION
Estimating the level of investments required for AIDS is being aligned with the timeline
and methods to cost other health-related Millennium Development Goals (MDGs) for a
comprehensive response to the epidemic. UNAIDS has conducted several exercises to
estimate the resource requirements from all sources, including domestic and international,
to respond to the HIV epidemic. The first estimates were prepared for the United Nations
General Assembly Special Session on HIV/AIDS (UNGASS) in 20011 and it was
inspired by the Secretary General’s call in Abuja for US$ 7-10 billion to fight AIDS,
tuberculosis and malaria. It involved estimating the cost of HIV prevention and AIDS
care needs in 135 low- and middle- income countries.2

The second exercise was conducted for the UNAIDS Programme Coordinating Board in
November 2002.3 Recognising that the global response was less than required to meet
the UNGASS goals in many countries by 2005, the achievement of programming levels
for a comprehensive response was projected up to 2007. In view of plans for treatment
scale-up, two programmes important to health worker retention and morale, namely
universal precautions and occupational post-exposure prophylaxis, were added. The
medical injection safety4 which had not been specifically included as a prevention
measure in the 2001 work was also added.

The third set of estimates, published in the 2004 UNAIDS Report on the Global AIDS
Epidemic, benefited from an extensive consultation through 9 regional/sub-regional
workshops with over 155 experts drawn from 78 affected countries. It took into account
the reduction in treatment costs and the streamlined public health model of service
delivery for antiretroviral drugs.5




                                            3                                 26/05/2011
In 2005, estimates initiated by a working group of the UNAIDS Reference Group on
Economics (URGE), were refined for the High-Level Meeting on “The Global Response
to AIDS: Making the Money Work – The Three Ones in Action”.6 These estimates
showed global resource requirements of US$ 15 billion in 2006, US$ 18 billion in 2007
and US$ 22 billion in 2008 for prevention, treatment and care, support for orphans and
vulnerable children (OVC), as well as programme and human resource costs. Estimates
were also reported in 2009 in the UNAIDS publication “What Countries Need:
investments needed for 2010 targets in low- and middle-income countries”.7

Estimating resources needed for AIDS represents an ongoing activity aimed to improve
the methods and figures by incorporating the most recent data with each cycle in the
estimation process. A set of standard definitions, methods and tools has been developed
as a common reference for the working groups. The resource needs estimation process is
aimed at ensuring the delivery of useful products, and involves coordination,
consultation, standardization and estimation.

The current investment framework benefits from the experience of the aids2031
international consortium. The aids2031 project modelled long-term funding needs for
HIV/AIDS in developing countries with a range of scenarios and substantial variation in
costs: ranging from US$397 to $722 billion globally between 2009 and 2031, depending
on policy choices adopted by governments and donors.8 The results suggested that
countries will move in increasingly divergent directions over the next 20 years; middle-
income countries with a low burden of HIV/AIDS will gradually be able to take on the
modest costs of their HIV/AIDS response, whereas low-income countries with a high
burden of disease will remain reliant upon external support for their rapidly expanding
costs.


METHODS FOR ESTIMATING THE COST AND IMPACT OF THE
PROPOSED INVESTMENT FRAMEWORK
The resource needs and returns on investment of the proposed investment framework
were estimated for 139 low- and middle-income countries and summed to a global total.
The resource needs estimate is the cost of increasing from current levels of coverage in
2011 to achieve universal access target coverage levels by 2015 and maintain them
thereafter. For the baseline scenario we assumed constant coverage at about present
funding levels (estimated from analysis of spending data from national and international
sources9) except for the reduction in ART drug costs which we assume would decline
over time at the same rate as in the investment framework scenario.




                                           4                                26/05/2011
The basic programme activities provided directly to populations in need (such as
treatment, male circumcision, or PMTCT) were costed by multiplying the number of
people in need of the service by the coverage (to determine the number of people
receiving the service) and multiplying the result by the unit cost of providing the service
to one individual. The costs of support programs that do not provide a service directly to
individuals (such as advocacy, policy reform, stigma reduction, and management and
administration) were estimated as a proportion of the total direct costs.

Estimates of the number of people in need of services were based on demographic data
from the United Nations Population Division10 for services reaching the general
population (e.g., PMTCT for pregnant women, male circumcision for men 15-49, testing
and counseling for adult males and females). Estimates of the sizes of key populations,
including sex workers, men who have sex with men (MSM) and injecting drug users
(IDU) were based on national estimates provided to UNAIDS and published reviews of
studies of size estimates.11-15

Information on unit costs of providing services were based on published literature and
advice from experts from 58 countries participating in four regional workshops on
resource needs in 2009.16 Regional or sub-regional averages for coverage levels and unit
costs were used for countries where there were no specific data. Coverage was scaled up
from current levels to target levels by 2015 with targets for basic programme activities set
as maximum plausible coverage level according to size of the relevant population. More
information on coverage levels and unit cost is provided elsewhere in the document.

Estimates of the annual number of people in need of treatment were based on an
epidemic projection model17 that reproduces at a global level the country-specific
estimates of need for treatment, given the assumptions on coverage scale-up reported by
national programs.18

The estimated cost for the critical social and programme enablers as well as the synergies
with development sectors are described below.



Impact and effectiveness of interventions
The Goals model, developed by the Futures Institute,16,19 was used to assess the impact of
the selected programme activities on the epidemic. The model considers male and
females aged 15-49 years divided into six groups: not sexually active, low risk
heterosexual (one partner), medium risk heterosexual (more than 1 partner in the last
year), high risk heterosexual (female sex workers and male clients), MSM and IDU. The



                                             5                                  26/05/2011
probability of acquiring a new HIV infection is determined by characteristics of the index
person (number of partners), the partner (HIV status, stage of infection, ART use) and the
partnership (sex acts per partner, condom use, STI prevalence, heterosexual or MSM
contact, male circumcision status). Infected persons progress through a primary stage of
infection with high infectivity, an asymptomatic stage with low infectivity, and a
symptomatic stage with high infectivity, to AIDS death. Infectivity is reduced by ART
use. The model includes a component to estimate the effects of prevention interventions
on key behaviours based on a summary of the impact literature, described below.

The model simulates the effect of biomedical interventions, such as male circumcision
and PMTCT, using trial data on effectiveness and simulates the effects of behaviour
change interventions using data showing the effect of exposure to these interventions on
key behaviour such as condom use, number of partners and age at first sex.

Goals models had been prepared for 23 high burden countries, which together account for
77% of the total HIV burden. The models for all these countries were updated with the
latest coverage information from the national 2010 UNGASS reports and with unit costs
from the latest round of country estimates from the UNAIDS regional Resource Needs
workshops and from the AIDS2031 activities.20 Estimates of new HIV infections and
AIDS deaths were extracted for the 23 countries and scaled up to obtain global estimates,
matching the 2009 UNAIDS estimates.18

An extensive literature review had been conducted to determine the impact of prevention
interventions in developing countries. An impact matrix was developed to classify
effectiveness results into those prevention intervention categories that UNAIDS use to
estimate resource needs,21 with the purpose to harmonize efforts among the various
elements of national strategic planning processes. This impact matrix, described in detail
by Bollinger in 2008,21 provides the basis for the Goals model. In addition, it is assumed
that the probability per act of female to male transmission is reduced by 60% among
those men who are circumcised,22-24 and that ART reduces transmission per sexual act by
92% for those on ART.25


Coverage targets
Information on current levels of coverage was obtained from country UNGASS reports in
2010 including data from published surveys (such as DHS) and information provided by
national programmes. This data can be accessed using AIDSinfo, a data visualization and
dissemination tool used by UNAIDS to facilitate the use of AIDS-related data by country
and globally (available at:


                                            6                                 26/05/2011
http://www.unaids.org/en/dataanalysis/tools/aidsinfo/). Regional averages were used for
countries where there were no specific data. Coverage was scaled up from current levels
to target levels by 2015, as shown in Table 1. Targets for basic programme activities
were set as maximum plausible coverage level according to the size of the relevant
population, in many cases resulting in 80% coverage of the relevant activity. Coverage of
ART is discussed in detail in the section below.

In countries with well established opioid substitution therapy (OST) for injecting drug
users (IDU), coverage of about 20-40% can be achieved, and this target is included in
internationally endorsed target setting guidance, based on the levels of coverage which
have been achieved in countries with established OST programmes.26-29 In countries (e.g.
Western Europe and Australia) where these levels of coverage were reached HIV
epidemics among IDU’s have stabilized or reversed,30 and a coverage target of 40% of
opioid injectors on OST by 2015 would be desirable. Based on historic evidence and
country consultation and estimation we assume that we can determine two levels of OST
coverage: it is anticipated that countries that have already introduced OST, such as India
and China, could arrive at a coverage level of 40% by 2015. However, countries that have
not yet introduced (or registered) OST, such as the Russian Federation, may implement
OST after 2011 (assuming a coverage of 0% until 2011) and will reach a lower coverage
of around 20% by 2015. More information on OST coverage and denominator
populations is provided elsewhere in this document.

Table 1. Coverage targets for 2015 by epidemic type (*)
                           Hyper-Endemic,       Generalized, Concentrated Low level
                           Low Circumcision     Mixed        epidemics    epidemics
Basic Programs
 PMTCT                                    90%           90%          90%          90%
 Condoms (discordant                      60%           60%          60%          60%
couples)
Condoms (medium risk                      60%           60%          20%          20%
populations)
 Condoms (high risk                       50%           50%          50%          50%
populations
 Sex work                                 60%           60%          60%          60%
 MSM                                      60%           60%          60%          60%
 IDU outreach                             60%           60%          60%          60%
 IDU needle and syringe                   60%           60%          60%          60%
exchange
 IDU drug substitution                     0%            0%          40%          40%
* More detailed description of treatment coverage is provided below




                                               7                              26/05/2011
Projections of the number of HIV infected people in need and
receiving ART
Estimates of ART eligibility are based on the 2010 WHO guidelines,31 using evidence
that starting ART earlier (CD4≤350 cells/μL) is cost effective, improves health outcomes,
and reduces HIV and tuberculosis transmission.

The estimates of the number of people in need of treatment for the investment framework
were based on an epidemic projection model that reproduces at a global level the country
specific estimates of need for treatment reported by national programs. The model is
described elsewhere by Stover et al.17 and estimates are consistent with those produced
by UNAIDS using the model developed by the UNAIDS Reference Group on Estimates,
Models and Projections.18 The model was used to estimate the number of people needing
treatment each year given assumptions about the scale up of coverage.

The model tracks the HIV population by CD4 counts, assuming that all newly infected
people start with CD4 counts above 500, and that their CD4 cell counts decline over time.
People progress from CD4 category to the next, while assumptions are made about the
transition probabilities and probability of death from HIV-related or non-HIV related
causes. The number starting ART each year is determined by the assumed coverage and
the number of people eligible for treatment.

The total number of PLHIV eligible for treatment according to the latest WHO guidelines
is estimated to be about 18.3 million in 2015. In no society, and for no disease, are 100
percent of those who might benefit from treatment actually treated as some of those
eligible remain outside the health system (whether by choice or due to imperfect system
coverage), refuse to take treatments, or cannot take treatments due to other conditions. In
this light, universal access for ART is described herein as coverage levels of about 80%.
If universal access targets are to be treated as serious programme goals and not merely
aspirational, modeling and cost assumptions need to better address programme realities.
The models used in this analysis assume that 80% will be reached with a very rapid
treatment uptake once CD4 cell counts drop to 350, reaching the assumed maximum
coverage levels before CD4 counts drop to levels of 200 and below (Figure 1). The total
number of people estimated to be on treatment by 2015 will be 13 million. With better
treatment models available and a shift to community and primary care delivery over the
coming decade, we assume that coverage will be further increased reaching levels of 90
percent and more for those with severe symptoms of HIV disease (Figure 2). By 2020, a
total of 18.7 million (86%) of the 22 million eligible under the current guidelines are
assumed to be on treatment (Figure 3).



                                            8                                  26/05/2011
100%

             90%

             80%

             70%

             60%
  Coverage




             50%

             40%

             30%

             20%

             10%

              0%
                    >500   350‐499         250‐349          200‐249   100‐199      50‐99     <50
                                     350             CD4 Count (cells/ml)


                                          CD4                     CD4              CD4         CD4
                                       350-500                 250-350          200-250        <200
  Treatment coverage                       5%                     45%              70%         80%

Figure 1. ART coverage in 2015 by CD4 count, as assumed in the Investment Framework




                                                        9                                  26/05/2011
100%

    90%

    80%

    70%

    60%                                                                                   >500

                                                                                          350‐499
    50%
                                                                                          250‐349
    40%
                                                                                          200‐249
    30%                                                                                   <200

    20%

    10%

        0%
               1995       2000       2005       2010       2015          2020   2025


Figure 2. Assumed coverage of ART by CD4 category



             20
  Millions




             18

             16

             14

             12

             10

              8

              6

              4

              2

              0
                  2005                  2010                      2015                 2020


             Figure 3. Projected number of adults receiving ART over time


                                                 10                              26/05/2011
Estimated cost of programme activities
Assumptions about the cost of HIV interventions
We assumed that unit costs for some services would decline as programmes expand, due
to economies of scale and changes to more efficient service provision modalities in
particular through community approaches. Although there is limited information on
changes in unit costs over time, recent work indicates that substantial economies of scale
are likely to exist.32 Unit costs of providing population-based services were provided by
experts from 58 countries participating in four regional workshops on resources needs in
2009.16

Tables 2 provides estimates of the unit costs of key interventions by region in 200916
while assumptions about the ART costs over time are described below. In addition, unit
costs for interventions by country are provided in the Excel Spreadsheet (UnitCosts.xlsx)
available on-line.




 Table 2. Median unit costs (US$) of key interventions by region, 2009
                                                                    Condom
                                                                   Promotion        Outreach      Outreach
                               PMTCT              PMTCT                and           for sex        for
                              Screening**      Prophylaxis***      Distribution     workers*       MSM*
                                                                                     Per Sex
                              Per Woman         Per Woman          Per Condom        Worker       Per MSM
                               Screened        Receving ARVs       Distributed      Reached       Reached
 Sub-Sahara Africa               4.48              607                    0.18           20.24       25.97
 East Asia and the
 Pacific                            3.93               1564                 0.09            49.38     62.24
 South and South-east
 Asia                               3.92                848                 0.08            33.38     41.87
 Eastern Europe                     3.92               2204                 0.23            60.02     69.32
 North Africa and Near
 East                               3.90               2265                 0.25            71.92     76.17
 Latin America and the
 Caribbean                          3.97               1721                 0.27            55.26     65.78
 * Interventions marked with * have declining unit costs with increasing scale.
 **Assumes $3.90 per woman screened and found to be HIV-negative and $13 per woman screened and found
    to be HIV-positive
 ***Assumes costs in 22 focus countries in sub-Saharan Africa of $237 for Option A, $705 for Option B, $20
    for CD4 counts, $3 for community mobilization, $33 for early infant diagnosis, $5 for Cotrimoxazole. For
    all other countries costs are adjusted for purchasing power. More information is provided below.




                                                  11                                       26/05/2011
Outreach and                Opiod                                  Social and
                        needle/syringe           substitution                               behavior             Counseling
                         exchange for              therapy                Male               change                 and       Community
                             IDU                   (2011*)            circumcision       communications           testing*    mobilization
                            Per IDU                   Per IDU           Per Person         Per National                        Per Person
                            Reached                   Reached          Circumcised          Campaign             Per Client     Reached
Sub-Sahara Africa                 23.43               1,008.00          59.10               809,775               14.87           3.38
East Asia and the
Pacific                                64.77          1,008.00                                 195,007            26.00           2.27
South and South-
east Asia                              24.49          1,008.00                             3,475,231              14.66           1.31
Eastern Europe                         36.37          1,008.00                               262,515              15.58           2.62
North Africa and
Near East                              44.35          1,008.00                                 479,354            20.15           2.62
Latin America and
the Caribbean                          71.36          1,008.00                                 467,342            14.53           3.16
* unit costs for OST ae assumed to decrease by 20 percent by 2015 and 50% by 2020


Estimated cost of counseling and testing (C&T)
The average unit cost of counseling and testing per region is provided in Table 3. These
estimates are associated with coverage of C&T and costs generally decline with
increasing coverage, as shown in Figure 4.32

                                        Cost per client counselled and tested
   $90

   $80

   $70

   $60

   $50

   $40

   $30

   $20

   $10

    $0
     0%




                                                        5%
            %


                   %


                            %


                                  %


                                          %


                                                 %




                                                                %


                                                                        %


                                                                               %


                                                                                     %


                                                                                           %


                                                                                                 %


                                                                                                        %


                                                                                                             %


                                                                                                                     %
            01


                   03


                          05


                                  20


                                          40


                                                 75




                                                             15


                                                                      25


                                                                            35


                                                                                   45


                                                                                         55


                                                                                                65


                                                                                                     75


                                                                                                            85


                                                                                                                  95
          0.


                 0.


                        0.


                                0.


                                        0.


                                               0.




                                                                 Coverage


 Figure 4. Declining cost per client with increasing coverage of counseling and testing



                                                                 12                                              26/05/2011
The following approach is assumed in the investment framework to determine the amount
of testing undertaken within the health sector:
    1. Provider initiated counseling and testing (PICT): we assume that for each person
         starting treatment at least three would be tested for differential diagnosis. This
         approach would most likely identify the patients coming to the clinics with
         advanced stages of HIV disease (CD4 cell counts below 200/ μL).
    2. Pregnant women: It is assumed that all pregnant women in sub-Saharan Africa
         will be tested for HIV, except those already known to be HIV positive. We
         assume that 60% of HIV positive women will have CD4 cell counts above
         350/μL.
    3. STI patients: It is assumed that all people diagnosed with an STI will be tested for
         HIV. Testing among symptomatic STI patients is assumed to find HIV+ cases at a
         rate 3 times higher than the HIV prevalence rate.

   In addition to the testing in health care settings, there is wider population testing.
   This can happen as part of VCT or community mobilization, as described elsewhere
   in the document. With our assumption of gradually moving from VCT modalities to
   community testing approaches we assume that the number tested through VCT will
   drop from 230M in 2010 to 60M in 2015. The number tested through community
   mobilization will increase from 46M in 2010 to 109M in 2015. It is assumed that the
   overall detection rate of PLWH will increase through more focused testing
   approaches. Globally, an assumed 316 million people will receive an HIV test in
   2015 either in health settings, VCT clinics or community settings, broken down as
   follows: VCT 60 million, community mobilization 109 million, sex workers 6
   million, IDU 7 million, MSM 18.5 million, people with HIV related symptoms 2.5
   million, PMTCT 111 million, STI 1.6 million. 


Estimated cost of treatment, care and support
The Investment Framework methodology to estimate resources required for treatment,
care and support has been revised to be consistent with the Treatment 2.0 initiative.33 We
assume that people who start ART early do not require the treatment and prophylaxis for
opportunistic infections (OI) that would be required otherwise. Other OI costs are
included in the estimated “end-of-life” costs of $228 per patient. These are estimated at
the time of death but reflect both pre-ART and pre-death treatment costs.




                                            13                                 26/05/2011
Assumptions about the cost and changes in cost of ART
Based on past trends in ARV prices and the possibilities of new, less expensive drug
combinations in the future, we assumed that the average cost per patient on first line ART
would decline by about 65% by 2020. We assume that less expensive diagnostic tests that
can be used at point-of-care and task shifting of treatment would lead to average
reductions of 60% and 40%, respectively, in laboratory and service delivery costs
(weighted across low income, lower middle income and upper middle income countries)
by 2020. Substantial savings are expected from a reduction in the frequency of visits to
facility-based services with the use of more potent, less toxic and resilient antiretroviral
schemes. We assumed a reduction in the number of outpatient visits, from published
averages to four check-ups per year, most of them based on community support activities.
It is also assumed that the service delivery costs in lower-middle and upper middle
income countries do not decline at the same rate as these countries are unlikely to switch
to a community-based model. The costs in low-income countries decline to $17 per
patient per year (assuming reduction from 12 visits per year to 4 plus some migration to
task shifting approaches reducing average salary costs by half. The result is that the
weighted average service delivery costs decline from $176 in 2010 to $125 by 2020.

We also considered changes in the costs of testing programs as a result of shifting from
fixed facilities to community-based approaches. Given recent available data from
developing countries these reductions seem plausible. Per-person ART costs in large
scale PEPFAR programmes have fallen as implementation experience has grown. In
South Africa and Zambia costs fell by half or more over time, and quality was not
impaired when services shifted to lower level delivery sites34 and in five other countries
(Botswana, Ethiopia, Nigeria, Uganda and Vietnam) median per-patient costs 24-29
months after programme initiation were 37% of their levels in the first 5 months.35
Similarly, large scale ART programmes implemented by Médecins Sans Frontières in
Malawi have been delivered at $237 per patient/year, with ARV medicines representing
two-thirds of the total cost: a level far below countries with smaller numbers of people
receiving ARVs and lower than costs in Malawi when the numbers of persons receiving
ARVs was lower.36 The significant majority of the cost savings will occur after 2015 with
an increasing shift to primary care and community based approaches and cheaper point of
care diagnostics. Average costs and assumed changes over time are provided in Table 3.

Drugs: A weighted average of drug costs for four different first-line regimens and two
different second-line regimens is used, weighted by the proportion of patients on each
regimen.37,38 Separate prices are available for low-income and middle-income countries.
The cost of both 1st and 2nd line drugs for middle-income countries is assumed to
increase/decrease at the same rate as the cost for low-income countries.



                                            14                                  26/05/2011
Laboratory costs have been calculated as the annual median cost for laboratory tests
  across countries as obtained from recent literature, including studies from Cote d’Ivoire,
  Ethiopia, Mexico, Nigeria, Rwanda, South Africa, Thailand, Zambia.39-48 The median
  cost in 2010 is estimated at $180 (USD) per patient, decreasing to less than $80 by 2020 .
  Service delivery costs: Studies of service delivery costs conducted by PEPFAR found a
  range from $79 per patient per year to $345. We used an average cost (weighted across
  low income, lower middle, and upper middle income countries) of about $180 per patient
  per year in 2010, declining to $112 by 2020.

Table 3. Average cost of ART (US$) and estimated changes over time  

       Cost per Patient Per Year                                              2010      2015   2020
  Labs: new patients                                                           180       129     79
  Labs: continuing patients                                                    180       128     76
  Service delivery: weighted average                                           176       144    112
    Low income countries                                                       103        60     17
    Lower middle income countries                                              181       136     91
    Upper middle income countries                                              332       332    332
  Procurement                                                                 20%       13%      5%
  End of life care                                                             228       228    228


   ARV Prices                                                                2009      2015    2020
First Line ARVs
  Low income countries                                                        137       130      50
  Lower middle income countries                                               141       134      51
  Upper middle Income countries                                               202       192      74
   Weighted average                                                           155       147     57 
Second Line ARVs
  Low income countries                                                        853       500     150
  Lower middle income countries                                              1378       808     242
  Upper middle Income countries                                              3638      2,132    640
  Weighted average                                                           1678       984     295



  Estimated costs for IDU interventions
  In addition to responses which apply to other populations (such as HIV testing and
  counseling and ART) the main interventions for the prevention, treatment and care of
  HIV/AIDS among injecting drug users (IDUs) are needle and syringe programmes
  (NSP), and drug dependence treatment including opioid substitution therapy (OST). NSP
  is a well-established intervention which has been extensively studied and found to reduce
  HIV incidence and self-reported risk behaviours. Similarly OST is a critical component


                                             15                                 26/05/2011
of IDU programmes and has been proven to reduce risk behaviours, stabilize drug users’
lives with consequent improvement in access and adherence to HIV/AIDS treatment and
care and to reduce the incidence of HIV.49

The assumed denominator populations used in our estimations are 13.5 million opiate
users in low and middle income countries and 10.3 million injecting drug users (all
substances) in low and middle income countries. These estimates are based on the
UNODC World Drug Reports50 and estimates prepared under the auspices of the UN
reference group on HIV and injecting drug use.13

It is assumed that the size of the denominator populations will remain stable at current
levels by the year 2015, while coverage levels will be increasing.


OST: Coverage targets lower and middle income countries
Using information from countries with well established OST programmes, approximately
40% of opioid dependent persons can be covered in treatment programmes.26,27 In
countries where these levels of coverage have been reached, HIV epidemics among IDUs
have generally stabilized.51 We have therefore assumed the desirable target of opioid
injectors on OST by 2015 to be 40%, consistent with the WHO/UNODC/UNAIDS target
setting guide for injecting drug users.

When using a denominator population of 8.1 million opioid injectors in our calculations
of coverage and cost estimates for OST, it is assumed that priority is given to scaling up
OST to opioid injectors. However, consideration needs to be given to the fact that
dependent opioid users who do not inject also benefit from OST and providing OST to
them could prevent the transition to starting to inject opioids. Hence 8.1 million is a
conservative estimate.

Based on historic evidence and (limited) country consultation and estimation we further
assume that we can determine two levels of coverage: it is anticipated that countries that
have already introduced OST, such as India and China, will arrive at a coverage level of
40% by 2015. However, countries that have not yet introduced (or registered) OST, such
as the Russian Federation, may implement OST after 2011 (assuming a coverage of 0%
until 2011) and will reach a lower coverage of around 20% by 2015. Countries that have
implemented OST with methadone and or buprenorphine and that can be expected to
achieve (or have already achieved) 40% coverage by 2015 are shown below in Table 4.




                                           16                                 26/05/2011
Based on the above coverage targets for OST in low- and middle-income countries we
assume that approximately 2.7 million injectors will be on OST by 2015, a considerable
scale up from the approximately 300,000 on OST in 2009.28



Table 4. List of countries that have implemented OST by 2010
Countries in which Methadone maintenance Countries in which Buprenorpine
treatment is available                   maintenance treatment and/or detoxification
                                         is available (including pilot programmes)
Albania, Andorra, Australia, Austria, Azerbaijan,   Australia, Austria, Belgium, Bulgaria, China
Belgium, Bosnia and Herzegovina, Bulgaria,          (Hong Kong), Czech Republic, Denmark,
Canada, China, Croatia, Czech Republic,             Estonia, Finland, France, Germany, Greece,
Denmark, Estonia, Finland, France, Georgia,         Iceland, India, Indonesia, Iran, Israel, Italy,
Germany, Greece, Hungary, Indonesia, Iran,          Latvia, Lebanon, Lithuania, Luxembourg,
Ireland, Israel, Italy, Kyrgyzstan, Latvia,         Malaysia, Netherlands, Norway, Portugal,
Liechtenstein,      Lithuania,      Luxembourg,     Singapore, Slovak Republic, Slovenia, South
Macedonia, Malaysia, Malta, Mexico, Moldova,        Africa, Sweden, Switzerland, Ukraine,
Myanmar, the Netherlands, New Zealand,              United Kingdom, United States of America.
Norway, Poland, Portugal, Romania, San Marino,
Serbia, Slovak Republic, Slovenia, Spain,
Sweden, Switzerland, Thailand, United Kingdom
(plus overseas territories/dependencies), United
States of America, Ukraine (about to start)


Based on current levels of utilization and assumption that the relatively less expensive
methadone will be used in preference to buprenorphine it is assumed that of those
receiving OST in low- and middle-income countries, 80% will be on methadone and 20%
on buprenorphine.


Unit cost of OST
Unit costs include programme costs directly related to delivery of methadone or
buprenorphine and medication costs and not the costs covered elsewhere, such as HIV
testing and counselling.
Cost of Methadone: USD 1.00 – 2.90 per patient per day (medication costs 33c for 80mg
in Iran to $2.06 for 80mg in Indonesia). Range: USD 363.65 – 1,057 per patient per year.
Cost of Buprenorphine (only low dose estimates available 4-10mg per day, as compared
to recommended doses of 12-24mg) USD 3.39 – 8.68 per patient per day (medication




                                              17                                      26/05/2011
costs $2.72 for 10mg in Iran to $7.84 for 8mg in Indonesia). Range: USD 1,236 –
3,166.70 per patient per year.
The non medication costs include salaries and to a lesser extent pathology tests (mainly
urine drug screens). These estimates do not include the costs of building clinics or
training staff. The estimates are based on ongoing maintenance treatment, and do not
include the additional costs involved with commencement of treatment and therapeutic
withdrawal from treatment.

Based on the above, an average current cost of $1,008 per IDU reached per year was
assumed in the Investment Framework models. It was further assumed that the costs of
OST will be reduced by 20% by 2015 and by 50% by 2020.  


NSP: coverage targets lower and middle income countries
Based on a retrospective analysis of the coverage required to reverse the HIV/AIDS
epidemic among IDUs in New York52 and coverage rates typically reached in those
European countries that averted or reversed epidemics, coverage of 60% or more of IDUs
regularly reached (more than once a month) is considered very good.28 In Odessa in the
Ukraine, where prevalence among IDUs had already reach very high levels by 2000,
60% NSP coverage showed a reduction in HIV prevalence by 4% over a 5 year period.42
The projected coverage target for all IDUs in regular reach of NSP in the Investment
Framework models have therefore been set at 60% by 2015.

A denominator population of 10.3 million IDUs in low and middle income countries (as
described above) was used in our calculation of coverage and cost estimation for NSPs.
Regular reach is defined as an IDU being in contact with an NSP more than once a
month. Our estimated coverage target for IDUs in NSP programmes is therefore
estimated at about 6 million by 2015. The unit costs for NSP, which is assumed to decline
with increasing coverage levels (see Figure 5), was assumed to be between 7-10 USD per
person per year.




                                           18                                26/05/2011
$50.00

               $45.00

               $40.00

               $35.00

               $30.00
   Unit cost




               $25.00

               $20.00

               $15.00

               $10.00

                $5.00

                 $-
                        0%   10%   20%   30%   40%   50%    60%   70%    80%     90%    100%

                                                 NSP coverage


Figure 5. Unit cost of NSP by level of coverage




Estimated cost of PMTCT
Screening
The estimation assumes that 90% of pregnant women will be provided with at least one
HIV screening test to ascertain her HIV status. However, women who test positive will
also be provided with counseling services to help them decide on future courses of action
for the benefits of themselves and their unborn children. With PEPFAR estimates of the
cost of VCT services in low-income settings ranging between US$3.90 and US$20 per
person, we used a weighted average cost of US$ 3.90 for the cost of HIV serological tests
per woman for all HIV negative women. For HIV positive women in the population we
assumed the cost of testing and counseling to be US$ 13 per woman. An additional 10%
was included to take account of other programmatic costs related to the services.


Family Planning
For family planning costing, we used standard published methods. To avoid double
counting family planning is included as part of the health systems component in the
mayor synergies. However, it is also an important cost item of PMTCT services and a
clear distinction is made whenever necessary. Prevention of unintended pregnancies


                                               19                              26/05/2011
among HIV infected women of reproductive age were calculated by multiplying the
population of women with unmet need for family planning (15-49 years) by the number
of HIV pregnant women in each country. This number is then multiplied by the annual
average cost of providing family planning per woman. Family planning was estimated to
cost US$ 20 per woman per year.53


CD4 Testing
In line with the 2010 WHO guidelines on PMTCT,54 all women who test positive for HIV
should ideally undergo CD4 cell count screening in order to identify those women who
require lifelong antiretroviral treatment. The new WHO guidelines stipulate that women
whose CD4 counts are below 350cells/μL are to commence lifelong antiretroviral
therapy. To ensure that all women who require ART for their own health are identified
and treated, it is recommended that CD4 testing should be included in the essential
package of care for HIV-infected pregnant women. We assumed that 90% of HIV
positive women in the population will have access to CD4 testing at an average cost of
US$ 20. This is an average across the high-burden countries and does not include start-up
costs, laboratory upgrades or the cost of additional machines. For the purpose of this
analysis, we only used the cost of the laboratory tests.



Prophylaxis for HIV infected pregnant women
In the 2010 WHO guidelines on antiretroviral treatment for pregnant women and
preventing HIV infection in infants,54 there are two recommended treatment options for
women not eligible for ART i.e. women with CD4 counts > 350cells/μL; Option A and
Option B.

WHO Option A
The mother is given ante-partum AZT twice per day starting from as early as 14 weeks of
gestation and continued during pregnancy. At the onset of labour, she may be given sd-
NVP and initiation of twice daily AZT + 3TC for 7 days postpartum. If maternal AZT
was provided for more than 4 weeks antenatally, omission of the sd-NVP and AZT +
3TC tail can be considered; in this case, continue maternal AZT during labour and stop at
delivery. For breastfeeding infants, administration of daily NVP from birth for a
minimum of 4 to 6 weeks, and until 1 week after all exposure to breast milk has ended.
For infants receiving replacement feeding only, administration of daily NVP or sd-NVP +
twice-daily AZT from birth until 4 to 6 weeks of age.




                                           20                                26/05/2011
WHO Option B
The mother is given triple ARV prophylaxis starting from as early as 14 weeks of
gestation and continued until delivery, or, if breastfeeding continued until 1 week after all
infant exposure to breast milk has ended. Recommended regimens include:
                AZT + 3TC + LPV/r or
                AZT + 3TC + ABC or
                AZT + 3TC + EFV or
                TDF + 3TC (or FTC) + EFV
Irrespective of the mode of feeding for the infant, the infant is administered daily NVP or
twice daily AZT from birth until 4 to 6 weeks of age.

Costing of Options A and B
In line with WHO guidelines,54 we estimated costs assuming a breastfeeding duration of
12 months. Therefore, if women started receiving antiretroviral prophylaxis at 14 weeks
gestational age, it means they will receive the drugs for a period of 18 months in total.
We further assumed that on the average, at least 40% of HIV positive women will be
eligible for ART for their own health.55 Therefore, 60% of infected women will require
antiretroviral prophylaxis using option A or B. As most countries still use a combination
of single and dual drug regimens, the 60% of HIV positive women not eligible for ART
was split into 36% receiving Option A (dual prophylaxis) and 24% receiving Option B
(triple prophylaxis). The total cost for women using Option A used is US$ 237 and
consists of $30 for AZT+3TC, $63 for NVP, $54 for laboratory tests and $90 for service
delivery. The total cost per women using Option B used is $ 470 which consists of $149
for ARVs, $180 for laboratory tests and $141 for service delivery. When this is
multiplied for an 18 month period, we get a total cost of $705 per women.17,56


ART for mothers who need it for their own health
Treatment for mothers is a comprehensive package that includes antiretroviral therapy,
laboratory monitoring and delivery cost in health facilities at a cost of US$ 600 per
mother per year. We assumed that 40% of the women would have CD4<350 cells//μL
and are therefore eligible for full antiretroviral therapy. Women who require ART for
their own health are assumed to receive triple therapy according to the WHO Guidelines.
The unit costs made for mothers who need treatment for their own health are consistent
with the assumptions made for all adults receiving ART as described above. Following
12 months of breastfeeding, it is assumed that HIV-infected women (post-natal) who
require ART for their own health are transferred to ART centres for the continuation of
treatment. This assumption is to avoid double counting in relation to other estimates for
adults receiving ART.



                                             21                                  26/05/2011
Early infant diagnosis
All children born to HIV-infected mothers have maternal HIV antibodies which may be
detectable in the first six months of life. Therefore, immunological assays performed
early in infants may only detect HIV exposure in infants. HIV infection in infants is
diagnosed by detecting the presence of viral nucleic acid (viral RNA or viral DNA) or
other viral products such as p24 Ag. Polymerase chain reaction (PCR) – based HIV DNA
has become the most widely used assays in resource-limited settings for both diagnostic
and monitoring purposes. For the purpose of this costing analysis, 90% of all infants
exposed to HIV through their mothers are assumed to have access to early infant
diagnosis and the cost of PCR-DNA test per infant was assumed to be US$ 32.50.


Cotrimoxazole Prophylaxis
Cotrimoxazole prophylaxis is considered part of an additional package of care for HIV
positive women and essential for the postpartum treatment of infected infants.
Cotrimoxazole prophylaxis is used to reduce the incidence of opportunistic infections
particularly in women with low CD4 counts and to prevent the development of
opportunistic infections in infants and it is a proven cost-effective measure for
improvement of the quality of life of persons living with HIV/AIDS. Therefore, all the
women eligible for treatment for their own health, as well as all infants, are assumed to
be given cotrimoxazole prophylaxis for a period of 6-12 months. The cost of
cotrimoxazole was assumed to be US$5 per person per year.


Estimated cost of Behavior Change programmes
Behaviour change in generalized epidemics, such as delaying the initiation of sex or
partner reduction, affects the likelihood of exposure and it is axiomatic that reducing
these behaviours reduces the likelihood of transmission. Furthermore, the importance of
behaviour change has been confirmed as a plausible explanation for changes in incidence
derived from ecological studies that explain past successes in HIV prevention.57-61 For
this reason, behaviour change appears as a discrete basic programme activity –
notwithstanding the challenge of amassing consistent, direct and generalizable evidence
on the impact of different elements of behaviour change programmes.62,63,64 The most
efficacious interventions to accomplish such changes are less well established, but
include programs of interpersonal and group communication delivered through the
mobilization of civil society, faith based organizations and in the work place.




                                           22                                26/05/2011
Limited information is available on costing of such programmes. For the purpose of this
exercise, the cost of workplace programmes have been used as a proxy to arrive at a
plausible overall estimate of resource needs for Behavior Change programmes included
in Basic Programme Activities of the investment framework. Work place programs
typically include services such as the provision of condoms, counseling and testing and
STI treatment services either provided on site or through a near by health clinic, as well
as health education provided through peer educators. To arrive at an overall estimate of
resource needs, we assumed the proxy of workplace programs in 2015 to be scaled up to
50% coverage of the 148 million employees in the formal sector in countries with
generalized epidemics, with an average unit cost of US$ 9 per employee per year.



Estimated cost of community mobilization
Community mobilization, which underlies many of the critical enablers, has objectives
essential to an effective AIDS response. These objectives include: community outreach
and engagement, support, advocacy and transparency; community-driven approaches in
outreach and engagement activities that successfully connect people facing similar issues
and engage them in a broad spectrum of HIV-related interventions thus leading to
improved uptake and use of many of the basic programme activities (e.g. HIV-specific
education, behavioural change, access to condoms and clean syringes, ART); support
activities that target people already engaged in care and enhance quality, adherence and
impact in a range of settings such as people who are on treatment, engaged in harm
reduction or drug treatment services, or who are already using sexual and reproductive
health services; advocacy, transparency and accountability efforts, such as local-level
advocacy to ensure that high-quality health services are available and accessible to
vulnerable populations.

 The cost of community mobilization, as one of the critical enablers, was estimated in two
ways. First, in generalized epidemics, it was estimated from the number of people in
need, coverage levels, and unit costs based on data on community health worker
programmes. In the case of concentrated epidemics, the costs of community mobilization
were subsumed into the costs of outreach for key populations and thus included under
basic activities for these populations.

Recent unit cost data, supplied in 2009 by 59 countries in workshops sponsored by
UNAIDS, suggest a unit cost for community mobilization in HIV ranging between less
than US$ 1 and US$ 14.65 A comprehensive literature search for community-based
distribution of various services and commodities, including community-based care, child



                                           23                                 26/05/2011
health interventions, and safe water systems, found that the median unit cost, excluding
commodities, in 2009 US dollars was US$ 0.88 (mean: US$ 2.06).66-73 This unit cost is
consistent with the range described above for community mobilization efforts in HIV.

We applied the unit cost for community mobilization as provided by the country experts
and applied regionally where no data were available. The country-specific unit costs can
be found in the attached models. These unit costs were applied to the total adult
population to arrive at an overall cost for community mobilization. The model also
assumes that all people reached by community workers receive an HIV test every two
years for an additional cost of US$ 1 per test. The framework assumes that major
efficiency gains are possible through shifting service provision modalities to place greater
emphasis on community mobilization




Estimated cost of programme support functions
Assessments of total HIV expenditures and expenditures for program support functions18
indicate that expenditures for program support range from under 10% to over 60% with
an average of 12.6%. For this analysis we assume ongoing improvements in efficiency
and use 10% of direct expenditure on basic programme activities as the total average for
all programme support functions. This includes programs for political commitment and
advocacy, legal reform, human rights, stigma reduction, management, research and
innovation, monitoring and evaluation, communications, procurement and logistics.



Estimated cost for synergies with development sectors
The cost for major synergies is the least specific of the estimates included. For the
investment framework we assessed existing expenditure data on systems strengthening
activities and made a cost estimate for specific interventions such as blood safety, STI
treatment, school based education, support to the most vulnerable populations including
orphans, and gender programmes. Unit costs were based on estimates from country
reports from the regional UNAIDS Resource Needs workshops, as shown below in Table
5. Total costs for programs to combat gender-based violence and to support AIDS
orphans were adopted from previous resource needs estimates.

The financing needed to achieve better synergies with development sectors, particularly
in gender, health, education and social protection sectors, is estimated at US$ 3.59 billion
in 2011, increasing to about US$ 5.43 billion investment by 2020. The estimates
comprise gender based violence programmes (increasing from US48.5 million in 2011 to


                                            24                                  26/05/2011
nearly US$1 billion in 2020), a number of health sector elements including family
planning, STI management, blood safety, post-exposure prophylaxis, safe injections and
universal precautions (increasing from a total of US$1.3 billion in 2011 to US$2.7 billion
in 2020), youth in schools programmes (US$64 million in 2011 to US$118 million in
2020), and support for children orphaned by AIDS (declining from US$2.1 billion in
2011 to US$1.5 billion in2020).

While this framework does not intend to be prescriptive about spending to support
sectoral synergies, this estimate is consistent with current funding approaches to systems
strengthening, for example by the Global Fund.


Table 5. Median unit costs (US$) of programs classified as Major Synergies, 2009

                                                                                   North        Latin
                                           East Asia     South and               Africa and    America
                             Sub-Saharan    and the      South-East   Eastern     Middle         and
                                Africa      Pacific         Asia      Europe        East      Caribbean
School-based AIDS
education (per student)            15.98       27.44          11.33      15.30        18.76          14.53
Family planning (per FP
user)                                 20            20          20         20            20               20
Prevention in prisons (per
prisoner)                          29.28       35.00          65.39      22.13        27.65          15.83
STI management* (per
case treated)                      25.69      101.72          66.53     160.26       811.66          68.22
Blood safety (per unit of
blood transfused)                   8.54        6.32           4.19      13.73        17.41          17.32
Post-exposure prophylaxis
(per case)                         34.01       94.60          97.48      95.56       125.00         124.69
Safe medical injections
(per injection)                     0.22        0.16           0.15       0.22         0.03           0.07
Universal precautions (per
hospital bed)                     303.18      336.86         180.19      66.97        58.98         154.12




                                               25                                    26/05/2011
Costing Spreadsheets

Excel spreadsheets that were used for the Investment Framework calculations are
available from the authors on request. The approach was based on the assumptions that
the number reached is estimated by the population times coverage, while resource needs
is estimated by the number reached times the unit costs.

The spreadsheets include:

      PopData.xls : This spreadsheet contains population data. Different worksheets
       show the different target populations.
      Behavior.xls: This spreadsheet includes additional information for calculations
       including ANC coverage, units of blood needed per 1000 population, % casual
       sex, coital frequency, injections per person, proportion married.
      Coverage.xls : The spreadsheet includes coverage targets and different worksheets
       are used for the different interventions. The coverage targets for different
       scenarios are specified in the Goals worksheet.
      NumberReached.xls : This spreadsheet provides the numbers reached by each
       intervention. Different worksheets are used for different interventions. Most of the
       worksheets simply show the result of population x coverage. The number of
       people on ART (Figure 3) is drawn from the Goals model applications.
      UnitCosts.xls : Different worksheets are used with the unit costs specified for
       different interventions. Most are constant over time while a few are assumed to
       change with scale. ART is shown by country type (low / middle income) rather
       than by individual country.
      ResourceNeeds.xlsm : This spreadsheet shows the estimated resources that are
       required for the investment framework, by intervention. Different worksheets
       show country estimates for the different interventions. Charts and summary tables
       are also shown.

To use the spreadsheets, all five spreadsheets should be opened in Excel in order
(PopData, Coverage, NumberReached, UnitCosts, ResourceNeeds). The first time this is
done the spreadsheets may need to be re-linked if the links are not automatically updated.

Warnings
   The analysis is intended to provide estimates of resource needs at the global level.
     Results for individual countries will require further work and confirmation.


Results
Results are shown in the spreadsheet “ResourceNeeds.xlsm”. The following worksheets
include results:


                                           26                                  26/05/2011
   Results table. Results for all countries are summed together by intervention.
       Summary by County. The results by country for all interventions are shown for
       the 22 countries for which we did Goals applications.
      Country by Intervention. The name of a single country can be entered in the
       yellow cell, B1, to see the resource needs for that country. If it is not one of the 23
       Goals countries then resource needs for ART will not be shown.
      Summary by Scenario. This worksheet shows the total resources needed for all
       countries by major component (prevention, treatment, mitigation, support,
       structural interventions) and by scenario.

Scenarios. The coverage scenarios can be changes in the Coverage spreadsheet, in the
Goals worksheet in cell B2. This will change the coverage to the specified scenario,
according to the table in the Coverage.xls spreadsheet, Goals worksheet. The region or
country can also be changed in the yellow cell B3, but if a country is chosen that is not
one of the 23 Goals countries ART costs will not be available.




                                             27                                  26/05/2011
APPENDIX II: THE SYNERGISTIC IMPACT OF CRITICAL
ENABLERS

Critical enabling factors can have a substantial impact on HIV incidence for a low cost if
they help change, for the better, the proximate determinants of HIV transmission.
Quantifying the link between such enabling activities, implemented at a community level,
and individual changes in risk behaviour is difficult, but recent studies provide examples
that can be examined in mathematical model projections. Community mobilisation, along
with mobile voluntary HIV counselling and testing and post-test support services,
increased HIV testing rates four-fold in Tanzania, Zimbabwe, South Africa and
Thailand.74 Therefore, increased testing could potentially reduce HIV incidence if more
of those who are infected know their status and increased condom use or initiate
treatment (on time for clinical need). Furthermore, in Kenya, a four-fold greater odds of
reporting consistent condom use over the previous 12 months was associated with living
in areas with good engagement of community-based organizations.75 These factors were
included in a model representing the population of KwaZulu-Natal to explore how the
impact of a hypothetical ‘core’ circumcision intervention might be enhanced by enabling
interventions that result in greater HIV testing and condom use (Figure 6). In the model
scenario, the core intervention averted 240,000 infections over ten years but key enabling
interventions could, for modest marginal increase in costs, avert an additional 180,000
infections.




                                           28                                 26/05/2011
Core + Enablers
Interventions




                          Core




                                  0        100          200       300      400      500
                                      Number of infections averted, 2012-2022 (1000s)

       Figure 6: A model of the HIV epidemic in Kwazulu-Natal, South Africa, was used to
       calculate the number of new HIV infections that would be averted by a “Core”
       intervention (70% of the uncircumcised men are circumcised over a 5 year period) and the
       same core intervention in tandem with some key enabling intervention – “Core+Enablers”
       – (including community mobilization, post-test support) that had the net effect of
       increasing testing rates (by four-fold) and increasing the odds of condom use across the
       community by 1.5-fold. Model description can be found (Alsallaq et al, Forthcoming).




                                                                29                        26/05/2011
APPENDIX III: ESTIMATED CONTRIBUTION OF TREATMENT
TO REDUCING TRANSMISSION

The infectiousness of HIV is correlated with the levels of virus in the infected individual,
which means that infectiousness increases as disease progresses and viral replication is
less constrained. Further, the reductions in viral load associated with ART have been
shown to reduce infectiousness in observational studies.25,76 Promptly initiated treatment
for clinical need should therefore lead to reductions in transmission. Several
mathematical modelling exercises have estimated the proportion of onward transmission
that, in the absence of treatment, would come after the point when ART should normally
be initiated (Figure 7). These suggest that once an HIV epidemic has matured to near
endemic levels approximately 30% of infections are generated by those with CD4 cell
counts < 200 cells/µL and approximately 50% of infections are generated by those with
CD4 cell counts < 350 cells/µL. During the early stages of an epidemic more infections
are recent and therefore contribute a greater proportion of new infections. These
estimates provide an upper-limit for the extent to which treatment could reduce infections
because, in reality, (i) ART does not perfectly reduce infectiousness, and (ii) individuals
for whom ART is failing might become more infectious. New models, accounting for
these factors, have estimated that, with 80% able to initiate treatment promptly when they
require it, the rate of new infections could be reduced by approximately 20% with
treatment starting at CD4<200/μL and 30% with treatment starting at CD4<350 /μL
(Eaton et al., personal communication).




                                            30                                  26/05/2011
100%

  Cumulative transmission
                                                                                Hollingsworth et al. (serial partnerships)

                                                                                Hollingsworth et al. (random mixing)
                            80%
                                                                                Eaton et al. (substantial  concurrrency)

                            60%                                                 Eaton et al. (minimal  concurrrency)

                                                                                Abu‐Raddad & Longini (Kisumu)
                            40%                                                 Abu‐Raddad & Longini (Yaoundé)

                                                                                Goodreau et al.
                            20%
                                                  CD4<350        CD4<200
                             0%
                                   0   2     4       6       8        10   12
                                           Years since infection

Figure 7: The number of new infections generated by each HIV-infected individual accumulates over time
since infection in published model estimates.77-80 The approximate partition of time spent with CD4 cell
counts > 350 cells/µL (pale green), CD4 cell count between 200 and 350 cells/µL (light green) and < 200
cells/µL (dark green) are based on estimate of disease progression in observational cohorts.81,82




                                                            31                                    26/05/2011
APPENDIX IV: INFORMATION ON NEW PREVENTION
TECHNOLOGIES
Although considerable progress has yet to be made by expanding the coverage of existing
interventions, there will still be a need for new prevention options once existing programs
reach maximum scale. Incidence rates have shown to level off even in countries with
very high coverage of prevention and treatment programmes at levels of one third to a
quarter of peak incidence.83-85 Promising new technologies could contribute to future
prevention efforts; including vaginal microbicides, HIV vaccines, and pre-exposure
prophylaxis (PrEP) delivered through oral pills.

Increased and more efficient research and development spending are needed to speed up
the development of HIV vaccines, microbicides, and other new prevention technologies
and deliver them to populations most in need.86 Although funding from public and
philanthropic agencies for these efforts have more than doubled in recent years,
significant resource gaps still remain. Financial resources needed for new technologies
are large but the enormous potential benefits of successful products would make these
investments worthwhile.

Expanding efficacy trial capacity for new HIV vaccine and microbicide candidates will
require additional investments between now and 2015. The recent CAPRISA 004 trial
conducted in South Africa showed that tenofovir used as a microbicide gel could be
effective and safe.87 Tenofovir gel reduced HIV acquisition by an estimated 39% overall,
and by 54% in women with high gel adherence, and could potentially fill an important
HIV prevention gap. Modelling the potential impact of tenofovir as a microbicide gel
showed that up to 2 million new infections and 1 million AIDS deaths could be averted
over the next 20 years in South Africa if good adherence is achieved. This new female
controlled prevention method could have a significant impact on the HIV epidemic but
will depend on the levels of adherence.88 Several other microbicide candidates are
currently being tested in clinical trials.89,90

While an effective AIDS vaccine does not currently exist, the results of the ALVAC RV-
144 Thai prime-boost vaccine trial91 showed for the first time that it is possible for a
vaccine to offer protection against HIV in humans, but more research is needed to
understand the immune responses. Several HIV vaccine candidates currently in Phase II
trials could move to Phase III efficacy testing over the next decade.90

Recent research into the use of pre-exposure prophylaxis (PrEP) to prevent HIV showed
promising results.92 The iPrEx study showed that in gay men, transgender women and


                                            32                                 26/05/2011
other men who have sex with men, daily TDF/FTC (tenofovir disoproxyl fumarate plus
emtricitabine also known as Truvada) reduced the risk of HIV by 44%. Additional studies
are ongoing in other populations. A modelling exercise predicted that the cost-
effectiveness of PrEP relative to ART will decrease rapidly as ART coverage increases
beyond three times its coverage in 2010, after which the ART program would provide
coverage to more than 65% of HIV+ individuals. To have a high relative cost-effective
impact on reducing infections in generalized epidemics, PrEP must utilize a window of
opportunity until ART has been scaled up beyond this level.93 Although it is unlikely to
confer sufficient benefits to justify current TDF/FTC costs, price reductions and/or
increases in efficacy could make PrEP a cost-effective option in younger or higher-risk
populations94 and further research of using PrEP-based HIV prevention is warranted.

Without new innovations, the decrease in the number of new infections is likely to stall,
as shown in Figure 8, but potential new technologies developed and implemented at scale
over the next decade could enable the downward trajectory of new infections to be
continued. As such programmes do not exist to date, costs for possible scale up of new
innovations have not been included in our analysis, nevertheless it is useful to bear in
mind that innovation is likely and should be anticipated.


                        3,000,000

                        2,500,000
   New HIV infections




                        2,000,000


                        1,500,000

                        1,000,000

                         500,000

                               0
                               2011   2013       2015     2017      2019       2021      2023      2025

                                      Baseline          Investment Framework          New technologies



   Figure 8. New HIV infections in low and middle-income countries expected under
   the baseline scenario (assuming constant coverage at around present funding rates
   and approaches), new investment framework approach, and with the potential effect
   of new technologies (Microbicides, PrEP and Vaccines) introduced starting in 2015.



                                                         33                                  26/05/2011
APPENDIX V: RELEVANT TERMS AND DEFINITIONS



Basic Programme Activities
Treatment care and support for PLWH (including facility-based
testing)
This includes the provision of clinic-based, home-based or community-based services
and commodities for the treatment and care of HIV-positive adults and children.
Treatment care and support includes several categories: antiretroviral therapy provided to
infected adults and children in need of treatment; routine counselling and testing;
treatment and care of opportunistic infections; essential illness prevention interventions
for PLHIV; nutrition supplements for those on ART; treatment for tuberculosis; and
palliative care. This category also includes provider initiated counselling and testing in
facilities and utilizing health services. ART significantly reduces viral load and restores
immune function, thereby raising the possibility of using ART not only to increase the
survival time and quality of life of people infected with HIV, but also to reduce HIV
transmission.

Prevention of mother-to-child transmission (PMTCT)
Comprehensive PMTCT programs for pregnant women include pre-test counselling, HIV
testing, post-test counselling, drug prophylaxis, initiation of antiretroviral therapy,
counselling on infant feeding options and post partum monitoring and interventions for
mother and child. Drug prophylaxis may be a single drug regimen (single dose
Nevirapine [sd-NVP] or AZT), a combination prophylactic regimen (AZT+sd-NVP with
or without 7-day postpartum, AZT+3TC), or a highly active triple drug regimen (AZT +
3TC + NRTI/NNRTI or PI). WHO currently recommends provision of ARVs to all HIV-
infected mothers, starting in the second trimester of pregnancy and throughout the
breastfeeding period to prevent vertical transmission.54 National authorities should decide
on the best infant feeding option (breast feeding with ARV interventions or to avoid all
breastfeeding) that will most likely give infants the greatest chance of HIV-free survival.
Where breastfeeding is judged the best option, complementary feeding (infant formula)
may be introduced at 6 months and continue breastfeeding for at least 12 months.

Male circumcision
Refers to the removal of the prepuce or foreskin covering the tip of the penis for the
purpose of reducing the risk of HIV infection. The program includes the operation itself,


                                            34                                 26/05/2011
as well as related activities such as counselling, post-operative support, promotion of
male circumcision, programme communication, strengthening of necessary medical
infrastructure and training. Male circumcision (MC) has been demonstrated to reduce the
risk of female-to-male sexual transmission by 60%.22-24 WHO and UNAIDS recommends
that male circumcision should now be recognized as an efficacious intervention for HIV
prevention. However, MC provides only partial protection against the risk of HIV sexual
transmission from women to men and it should therefore always be considered as part of
a comprehensive HIV prevention package.

Condom promotion and distribution
Includes programmes to increase the correct and consistent use of male and female
condoms by making them more accessible and acceptable. This can involve activities to
increase condom availability (such as procurement and distribution) and generate demand
(such as social marketing, awareness raising and communication programmes). Evidence
from research among heterosexual couples in which one partner is infected with HIV
shows that correct and consistent condom use – male and female – significantly reduces
the risk of HIV transmission from men to women, from women to men and also from
men to men.95 Condoms are an integral and essential part of comprehensive HIV
prevention and care programmes, and the promotion thereof must be accelerated. Male
and female condom provision, including lubricants, covers mainly the supply side of
condom programming including selecting products that appeal to clients, forecasting
condom needs, procuring sufficient quantities of high-quality male and female condoms,
managing inventories, and distributing condoms.

Behaviour Change Programmes
Behaviour change has had a major impact on the trajectory of concentrated and low level
epidemics. In generalized epidemics, behaviour change such as delaying the initiation of
sex, increasing condom use or reducing the number of sex partners, affects the likelihood
of exposure and reduces the likelihood of HIV transmission.

Behavioural change programmes for AIDS includes the strategic use of an integrated
programme of advocacy, communication and social mobilization to systematically
facilitate and accelerate behaviour change and social change to the underlying drivers of
HIV risk, vulnerability and impact. It enables communities and national AIDS
programmes to support behaviour change and to tackle underlying structural barriers to
effective AIDS responses including inequality and social exclusion. Successful
programmes have the capacity to blend participatory methods of community dialogue and
empowerment with mass media approaches and other forms of informational and




                                           35                                26/05/2011
motivational communication and advocacy. The goal of such programmes is to act as a
catalyst for action at the individual, community and policy levels.


Social and behavioural change communication methods support development of locally
owned and implemented solutions that can be measured and tracked over time.
Monitoring and evaluation of social and behavioural change communication fosters both
local engagement and quality improvement of change activities. They also foster the
ability to share results horizontally (i.e. across similar programmes or communities) and
vertically (from community to national levels) for learning and accountability.

Social and behavioural change communication programmes have been shown to work,
although careful evaluation has been the exception rather than the rule in implementing
these programmes. Where rigorous evaluation has been conducted these programmes
have been shown to make significant and durable change in deeply rooted harmful
practices; from domestic violence to police complicity in violence against men who have
sex with men; from denial of HIV in rural communities to fear of using condoms in stable
couples. Social and behaviour change communication activities should include rigorous
impact evaluation to make sure that they are reaching audiences effectively.

Key objectives for social and behavioural change communication programmes need to
include changing sexual behaviour at both the societal and individual level (including
reduction of number of sexual partners, age of sexual onset. Communication for social
and behaviour change involves targeting the general population or specific groups
through mass media and outreach activities.

Component elements of social and behavioural change
communication programmes
       Interpersonal communication: face-to-face communication either through a
       one-on-one exchange or discussions in a small group with a trained facilitator.
       Several critical components to interpersonal communication could include having
       a facilitator who is from the same ethnic, cultural and/or linguistic background;
       having participatory and non-judgmental interactions; ensuring that information
       shared is factual and based on evidence; and ensuring that exchanges go beyond
       raising awareness and knowledge building. Interpersonal communication can be
       delivered through various personal interactions such as individual outreach, small
       discussion groups, counselling, and client-provider dialogue. The key objectives
       of interpersonal communication is to address barriers to adopting healthier
       behaviours, focus on increasing risk perception, increasing use of available
       services, and improve skills and self-efficacy to enable individuals to be


                                           36                                26/05/2011
responsible for and protect their own health by making healthier behavioural
       choices.
       Media communication utilizes one or more channels to transmit the same
       message to a large audience. Examples include brochures, billboards, posters,
       newspaper or magazine articles, comic books, television, radio, music videos,
       Internet, cell phones, songs, dramas, traditional and folk media, and interactive
       theatre. Media communication includes development of communication messages
       and materials and their transmission. Media communication seeks to promote
       positive changes in cognitive and behavioural outcomes such as increasing
       knowledge of modes of HIV transmission, increasing perceived risk of
       contracting HIV, reducing high-risk sexual behaviours such as having multiple
       partners, increasing positive protective behaviours such as condom use, and
       increasing the utilization of health care services. Media communication can also
       be utilized to create a supportive environment and often targets social, cultural
       and gender norms that may hinder behaviour change.


Key populations
Assessing the needs of different population groups and identification and removal of
barriers to access services is relevant to planning a programmatic effective response.
Community mobilization is often geared towards those who are marginalized from
community processes, including young people, women, minorities, sex workers, people
who inject drugs (IDU) and men who have sex with men (MSM). A wide range of
priority populations have utilized community mobilization in the prevention and
mitigation of HIV. Outreach programmes usually include peer education on HIV
transmission and risk reduction strategies and HIV testing. Interventions for female and
male sex workers and MSM are based on a peer outreach model. These interventions
combine one-on-one or small group awareness, group education and access to
commodities and services.

       Sex work interventions: Programmes to promote risk-reduction measures among
       commercial sex workers and their clients. Includes STI treatment, peer outreach
       and counselling, condom promotion, removing stigma and discrimination,
       elimination of gender-based violence, programmes addressing clients, HIV testing
       and treatment.

       MSM programmes: Activities that address men who regularly or occasionally
       have sex with other men. This includes risk-reduction activities, outreach
       (including by peers), prevention of sexual transmission of HIV (including condom


                                          37                                26/05/2011
use, prevention and treatment of STIs), voluntary and confidential HIV
       counselling and testing, and initiatives to ensure that these groups are able to
       access these services.

       IDU programmes: Initiatives directed at injecting drug users to reduce the risk of
       spreading HIV and to mitigate other harmful effects of drug use. This can involve
       harm reduction programmes, such as sterile needle and syringe programmes, as
       well as opioid substitution and peer outreach.

       Needle and syringe programmes aim at reducing the risk of blood borne infection
       of HIV (and others such as viral hepatitis) transmission associated with using
       contaminated drug injecting equipment among people who inject drugs.
       Pogrammes consists of ensuring easy, consistent and safe access to sterile needles
       and syringes to people who inject drugs. Modalities for needle and syringe
       programmes include provision of needles and syringes free or for cost; one-for-
       one exchange, intended to remove used injection equipment from circulation;
       secondary distribution, where people who inject drugs collect a relatively large
       number of clean syringes and needles and distribute them to other people who
       inject drugs with whom they are in contact, aiming to reach users who may not be
       in touch with services; and provision of other paraphernalia such as alcohol
       swaps, citric acid, spoons and condoms.


Critical enablers

Social Enablers

Political commitment and advocacy
Political commitment enables AIDS responses at all levels, including through resource
allocation, creation of enabling environments where community mobilization and social
and behavioural communication can take place, and supporting the realization of rights.
Political commitment may be generated through advocacy. Advocacy is the combined
effort of a group of individuals or organizations to persuade influential individuals,
groups and/or organizations to adopt an effective approach to AIDS as quickly as
possible. Advocacy efforts have diverse targets of change: policies, laws, regulations,
guidelines, additional funding, and/or programmatic or institutional change. Advocates
use a wide variety of organizational techniques and communication channels to bring
about political change, including letters, meetings, social networking and internet
campaigning, face-to-face interactions, media campaigns, forums and newspaper articles.



                                           38                                26/05/2011
While it is possible to identify advocacy techniques which are applicable across a wide
range of settings, the impact of political commitment and advocacy on improving the
AIDS response depends greatly on specific context where it takes place. External actors
can be enormously influential over political and advocacy outcomes, but can also fail to
have any real or lasting impact if they run counter to local needs and understanding of the
roots of problem to be addressed.


Laws, legal policies and practices
A supportive legal environment entails having laws in place that protect people living
with HIV and key populations from discrimination and having policies that facilitate all
populations having access to the HIV programmes and services they require. It also
involves removing punitive laws, regulations and policies that block effective HIV
responses. These may include: criminalization of same sex sexual activity; laws or police
practices which punish possession of condoms or drug paraphernalia and undermine
harm reduction measures; inappropriate criminal penalties applied in the context of sex
work or to HIV transmission and exposure; laws that preclude importation of generic
medicines; policies that impede distribution of sexual health education and information;
restrictions on the distribution of condoms, e.g. in prisons; regulations which prevent
non-citizens from accessing ART; and the lack of a legal framework for non-
governmental organizations to operate effectively.

HIV-related legal services include legal information and referral, legal advice, and legal
representation. Test cases or ‘strategic litigation’ may also establish a new legal rule,
clarify the application of the law or address discriminatory policy or practice. Legal
services can also include informal or traditional legal systems (e.g. village courts). HIV-
related legal services help improve access to HIV prevention, treatment, care and support
services by people living with HIV or other key populations; increase the demand for
justice; empower affected populations to advocate for their rights; and provide redress for
discrimination.


Community Mobilization
A community becomes mobilized when a particular group of people becomes aware of a
shared concern or common need, and together decides to take action in order to create
shared benefits. This action may be helped by the participation of an external
facilitator—either a person or organization. However, momentum for continued
mobilization must come from within the concerned group or it will not be sustained over
time. Community mobilization can be conducted through various activities such as group


                                            39                                 26/05/2011
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2 supplementary-webappendix-if-lancet-paper

  • 1. Supplementary webappendix This webappendix formed part of the original submission and has been peer reviewed. We post it as supplied by the authors. Supplement to: Schwartländer B, Stover J, Hallett T, et al, on behalf of the Investment Framework Study Group. Towards an improved investment approach for an effective response to HIV/AIDS. Lancet 2011; published online June 3. DOI:10.1016/S0140- 6736(11)60702-2.
  • 2. SUPPLEMENTAL MATERIAL Towards an improved investment approach for an effective response to AIDS; Schwartländer et al. May 2011 Table of Content APPENDIX I SUMMARY........................................................................................................................ 3 BACKGROUND INFORMATION ................................................................................... 3 METHODS FOR ESTIMATING THE COST AND IMPACT OF THE PROPOSED INVESTMENT FRAMEWORK ........................................................................................ 4 Impact and effectiveness of interventions....................................................................... 5 Coverage targets.............................................................................................................. 6 Projections of the number of HIV infected people in need and receiving ART............. 8 Estimated cost of programme activities........................................................................ 11 Assumptions about the cost of HIV interventions .................................................... 11 Estimated cost of counseling and testing (C&T) ...................................................... 12 Estimated cost of treatment, care and support .......................................................... 13 Assumptions about the cost and changes in cost of ART..................................... 13 Estimated costs for IDU interventions...................................................................... 15 OST: Coverage targets lower and middle income countries ................................ 16 Unit cost of OST ................................................................................................... 17 NSP: coverage targets lower and middle income countries.................................. 18 Estimated cost of PMTCT ........................................................................................ 19 Screening............................................................................................................... 19 Family Planning .................................................................................................... 19 CD4 Testing .......................................................................................................... 20 Prophylaxis for HIV infected pregnant women .................................................... 20 ART for mothers who need it for their own health............................................... 21 Early infant diagnosis ........................................................................................... 22 Cotrimoxazole Prophylaxis................................................................................... 22 Estimated cost of Behavior Change programmes..................................................... 22 Estimated cost of community mobilization .................................................................. 23 Estimated cost of programme support functions .......................................................... 24 Estimated cost for synergies with development sectors ............................................... 24 Costing Spreadsheets .................................................................................................... 26 APPENDIX II: THE SYNERGISTIC IMPACT OF CRITICAL ENABLERS.............. 28 APPENDIX III: ESTIMATED CONTRIBUTION OF TREATMENT TO REDUCING TRANSMISSION ............................................................................................................. 30 APPENDIX IV: INFORMATION ON NEW PREVENTION TECHNOLOGIES ......... 32 APPENDIX V: RELEVANT TERMS AND DEFINITIONS......................................... 34 Basic Programme Activities ......................................................................................... 34 Treatment care and support for PLWH (including facility-based testing) ............... 34 Prevention of mother-to-child transmission (PMTCT)............................................. 34 1 26/05/2011
  • 3. Male circumcision..................................................................................................... 34 Condom promotion and distribution......................................................................... 35 Behaviour Change Programmes ............................................................................... 35 Component elements of social and behavioural change communication programmes ................................................................................................................................... 36 Key populations ........................................................................................................ 37 Sex work interventions ......................................................................................... 37 MSM programmes ................................................................................................ 37 IDU programmes .................................................................................................. 38 Critical enablers ............................................................................................................ 38 Social Enablers.......................................................................................................... 38 Political commitment and advocacy ..................................................................... 38 Laws, legal policies and practices......................................................................... 39 Community Mobilization...................................................................................... 39 Stigma reduction ................................................................................................... 40 Gender based violence .......................................................................................... 41 Local responses to change the risk environment .................................................. 42 Programme Enablers................................................................................................. 43 Community centered design and delivery............................................................. 43 Programme communication .................................................................................. 44 Management and incentives.................................................................................. 44 Procurement and distribution................................................................................ 44 Research and innovation ....................................................................................... 45 REFERENCES ................................................................................................................. 46 2 26/05/2011
  • 4. SUMMARY A new investment approach is proposed for the response to HIV. It is simpler and more strategic than current approaches and is intended to support better management of the HIV response, both at national and international levels. The framework proposes three categories of investment: a small number of basic programme activities scaled up to reach the relevant populations; a set of critical interventions that create an enabling environment for achieving maximum impact; and support for programmatic efforts set in wider health and development sectors related to AIDS. In this document we describe in greater detail the methods used for estimating the annual cost of implementing these programmes to achieve universal access to HIV treatment, care and support by 2015, as well as estimating the potential future impact of the new investment strategy. BACKGROUND INFORMATION Estimating the level of investments required for AIDS is being aligned with the timeline and methods to cost other health-related Millennium Development Goals (MDGs) for a comprehensive response to the epidemic. UNAIDS has conducted several exercises to estimate the resource requirements from all sources, including domestic and international, to respond to the HIV epidemic. The first estimates were prepared for the United Nations General Assembly Special Session on HIV/AIDS (UNGASS) in 20011 and it was inspired by the Secretary General’s call in Abuja for US$ 7-10 billion to fight AIDS, tuberculosis and malaria. It involved estimating the cost of HIV prevention and AIDS care needs in 135 low- and middle- income countries.2 The second exercise was conducted for the UNAIDS Programme Coordinating Board in November 2002.3 Recognising that the global response was less than required to meet the UNGASS goals in many countries by 2005, the achievement of programming levels for a comprehensive response was projected up to 2007. In view of plans for treatment scale-up, two programmes important to health worker retention and morale, namely universal precautions and occupational post-exposure prophylaxis, were added. The medical injection safety4 which had not been specifically included as a prevention measure in the 2001 work was also added. The third set of estimates, published in the 2004 UNAIDS Report on the Global AIDS Epidemic, benefited from an extensive consultation through 9 regional/sub-regional workshops with over 155 experts drawn from 78 affected countries. It took into account the reduction in treatment costs and the streamlined public health model of service delivery for antiretroviral drugs.5 3 26/05/2011
  • 5. In 2005, estimates initiated by a working group of the UNAIDS Reference Group on Economics (URGE), were refined for the High-Level Meeting on “The Global Response to AIDS: Making the Money Work – The Three Ones in Action”.6 These estimates showed global resource requirements of US$ 15 billion in 2006, US$ 18 billion in 2007 and US$ 22 billion in 2008 for prevention, treatment and care, support for orphans and vulnerable children (OVC), as well as programme and human resource costs. Estimates were also reported in 2009 in the UNAIDS publication “What Countries Need: investments needed for 2010 targets in low- and middle-income countries”.7 Estimating resources needed for AIDS represents an ongoing activity aimed to improve the methods and figures by incorporating the most recent data with each cycle in the estimation process. A set of standard definitions, methods and tools has been developed as a common reference for the working groups. The resource needs estimation process is aimed at ensuring the delivery of useful products, and involves coordination, consultation, standardization and estimation. The current investment framework benefits from the experience of the aids2031 international consortium. The aids2031 project modelled long-term funding needs for HIV/AIDS in developing countries with a range of scenarios and substantial variation in costs: ranging from US$397 to $722 billion globally between 2009 and 2031, depending on policy choices adopted by governments and donors.8 The results suggested that countries will move in increasingly divergent directions over the next 20 years; middle- income countries with a low burden of HIV/AIDS will gradually be able to take on the modest costs of their HIV/AIDS response, whereas low-income countries with a high burden of disease will remain reliant upon external support for their rapidly expanding costs. METHODS FOR ESTIMATING THE COST AND IMPACT OF THE PROPOSED INVESTMENT FRAMEWORK The resource needs and returns on investment of the proposed investment framework were estimated for 139 low- and middle-income countries and summed to a global total. The resource needs estimate is the cost of increasing from current levels of coverage in 2011 to achieve universal access target coverage levels by 2015 and maintain them thereafter. For the baseline scenario we assumed constant coverage at about present funding levels (estimated from analysis of spending data from national and international sources9) except for the reduction in ART drug costs which we assume would decline over time at the same rate as in the investment framework scenario. 4 26/05/2011
  • 6. The basic programme activities provided directly to populations in need (such as treatment, male circumcision, or PMTCT) were costed by multiplying the number of people in need of the service by the coverage (to determine the number of people receiving the service) and multiplying the result by the unit cost of providing the service to one individual. The costs of support programs that do not provide a service directly to individuals (such as advocacy, policy reform, stigma reduction, and management and administration) were estimated as a proportion of the total direct costs. Estimates of the number of people in need of services were based on demographic data from the United Nations Population Division10 for services reaching the general population (e.g., PMTCT for pregnant women, male circumcision for men 15-49, testing and counseling for adult males and females). Estimates of the sizes of key populations, including sex workers, men who have sex with men (MSM) and injecting drug users (IDU) were based on national estimates provided to UNAIDS and published reviews of studies of size estimates.11-15 Information on unit costs of providing services were based on published literature and advice from experts from 58 countries participating in four regional workshops on resource needs in 2009.16 Regional or sub-regional averages for coverage levels and unit costs were used for countries where there were no specific data. Coverage was scaled up from current levels to target levels by 2015 with targets for basic programme activities set as maximum plausible coverage level according to size of the relevant population. More information on coverage levels and unit cost is provided elsewhere in the document. Estimates of the annual number of people in need of treatment were based on an epidemic projection model17 that reproduces at a global level the country-specific estimates of need for treatment, given the assumptions on coverage scale-up reported by national programs.18 The estimated cost for the critical social and programme enablers as well as the synergies with development sectors are described below. Impact and effectiveness of interventions The Goals model, developed by the Futures Institute,16,19 was used to assess the impact of the selected programme activities on the epidemic. The model considers male and females aged 15-49 years divided into six groups: not sexually active, low risk heterosexual (one partner), medium risk heterosexual (more than 1 partner in the last year), high risk heterosexual (female sex workers and male clients), MSM and IDU. The 5 26/05/2011
  • 7. probability of acquiring a new HIV infection is determined by characteristics of the index person (number of partners), the partner (HIV status, stage of infection, ART use) and the partnership (sex acts per partner, condom use, STI prevalence, heterosexual or MSM contact, male circumcision status). Infected persons progress through a primary stage of infection with high infectivity, an asymptomatic stage with low infectivity, and a symptomatic stage with high infectivity, to AIDS death. Infectivity is reduced by ART use. The model includes a component to estimate the effects of prevention interventions on key behaviours based on a summary of the impact literature, described below. The model simulates the effect of biomedical interventions, such as male circumcision and PMTCT, using trial data on effectiveness and simulates the effects of behaviour change interventions using data showing the effect of exposure to these interventions on key behaviour such as condom use, number of partners and age at first sex. Goals models had been prepared for 23 high burden countries, which together account for 77% of the total HIV burden. The models for all these countries were updated with the latest coverage information from the national 2010 UNGASS reports and with unit costs from the latest round of country estimates from the UNAIDS regional Resource Needs workshops and from the AIDS2031 activities.20 Estimates of new HIV infections and AIDS deaths were extracted for the 23 countries and scaled up to obtain global estimates, matching the 2009 UNAIDS estimates.18 An extensive literature review had been conducted to determine the impact of prevention interventions in developing countries. An impact matrix was developed to classify effectiveness results into those prevention intervention categories that UNAIDS use to estimate resource needs,21 with the purpose to harmonize efforts among the various elements of national strategic planning processes. This impact matrix, described in detail by Bollinger in 2008,21 provides the basis for the Goals model. In addition, it is assumed that the probability per act of female to male transmission is reduced by 60% among those men who are circumcised,22-24 and that ART reduces transmission per sexual act by 92% for those on ART.25 Coverage targets Information on current levels of coverage was obtained from country UNGASS reports in 2010 including data from published surveys (such as DHS) and information provided by national programmes. This data can be accessed using AIDSinfo, a data visualization and dissemination tool used by UNAIDS to facilitate the use of AIDS-related data by country and globally (available at: 6 26/05/2011
  • 8. http://www.unaids.org/en/dataanalysis/tools/aidsinfo/). Regional averages were used for countries where there were no specific data. Coverage was scaled up from current levels to target levels by 2015, as shown in Table 1. Targets for basic programme activities were set as maximum plausible coverage level according to the size of the relevant population, in many cases resulting in 80% coverage of the relevant activity. Coverage of ART is discussed in detail in the section below. In countries with well established opioid substitution therapy (OST) for injecting drug users (IDU), coverage of about 20-40% can be achieved, and this target is included in internationally endorsed target setting guidance, based on the levels of coverage which have been achieved in countries with established OST programmes.26-29 In countries (e.g. Western Europe and Australia) where these levels of coverage were reached HIV epidemics among IDU’s have stabilized or reversed,30 and a coverage target of 40% of opioid injectors on OST by 2015 would be desirable. Based on historic evidence and country consultation and estimation we assume that we can determine two levels of OST coverage: it is anticipated that countries that have already introduced OST, such as India and China, could arrive at a coverage level of 40% by 2015. However, countries that have not yet introduced (or registered) OST, such as the Russian Federation, may implement OST after 2011 (assuming a coverage of 0% until 2011) and will reach a lower coverage of around 20% by 2015. More information on OST coverage and denominator populations is provided elsewhere in this document. Table 1. Coverage targets for 2015 by epidemic type (*) Hyper-Endemic, Generalized, Concentrated Low level Low Circumcision Mixed epidemics epidemics Basic Programs PMTCT 90% 90% 90% 90% Condoms (discordant 60% 60% 60% 60% couples) Condoms (medium risk 60% 60% 20% 20% populations) Condoms (high risk 50% 50% 50% 50% populations Sex work 60% 60% 60% 60% MSM 60% 60% 60% 60% IDU outreach 60% 60% 60% 60% IDU needle and syringe 60% 60% 60% 60% exchange IDU drug substitution 0% 0% 40% 40% * More detailed description of treatment coverage is provided below 7 26/05/2011
  • 9. Projections of the number of HIV infected people in need and receiving ART Estimates of ART eligibility are based on the 2010 WHO guidelines,31 using evidence that starting ART earlier (CD4≤350 cells/μL) is cost effective, improves health outcomes, and reduces HIV and tuberculosis transmission. The estimates of the number of people in need of treatment for the investment framework were based on an epidemic projection model that reproduces at a global level the country specific estimates of need for treatment reported by national programs. The model is described elsewhere by Stover et al.17 and estimates are consistent with those produced by UNAIDS using the model developed by the UNAIDS Reference Group on Estimates, Models and Projections.18 The model was used to estimate the number of people needing treatment each year given assumptions about the scale up of coverage. The model tracks the HIV population by CD4 counts, assuming that all newly infected people start with CD4 counts above 500, and that their CD4 cell counts decline over time. People progress from CD4 category to the next, while assumptions are made about the transition probabilities and probability of death from HIV-related or non-HIV related causes. The number starting ART each year is determined by the assumed coverage and the number of people eligible for treatment. The total number of PLHIV eligible for treatment according to the latest WHO guidelines is estimated to be about 18.3 million in 2015. In no society, and for no disease, are 100 percent of those who might benefit from treatment actually treated as some of those eligible remain outside the health system (whether by choice or due to imperfect system coverage), refuse to take treatments, or cannot take treatments due to other conditions. In this light, universal access for ART is described herein as coverage levels of about 80%. If universal access targets are to be treated as serious programme goals and not merely aspirational, modeling and cost assumptions need to better address programme realities. The models used in this analysis assume that 80% will be reached with a very rapid treatment uptake once CD4 cell counts drop to 350, reaching the assumed maximum coverage levels before CD4 counts drop to levels of 200 and below (Figure 1). The total number of people estimated to be on treatment by 2015 will be 13 million. With better treatment models available and a shift to community and primary care delivery over the coming decade, we assume that coverage will be further increased reaching levels of 90 percent and more for those with severe symptoms of HIV disease (Figure 2). By 2020, a total of 18.7 million (86%) of the 22 million eligible under the current guidelines are assumed to be on treatment (Figure 3). 8 26/05/2011
  • 10. 100% 90% 80% 70% 60% Coverage 50% 40% 30% 20% 10% 0% >500 350‐499 250‐349 200‐249 100‐199 50‐99 <50 350 CD4 Count (cells/ml) CD4 CD4 CD4 CD4 350-500 250-350 200-250 <200 Treatment coverage 5% 45% 70% 80% Figure 1. ART coverage in 2015 by CD4 count, as assumed in the Investment Framework 9 26/05/2011
  • 11. 100% 90% 80% 70% 60% >500 350‐499 50% 250‐349 40% 200‐249 30% <200 20% 10% 0% 1995 2000 2005 2010 2015 2020 2025 Figure 2. Assumed coverage of ART by CD4 category 20 Millions 18 16 14 12 10 8 6 4 2 0 2005 2010 2015 2020 Figure 3. Projected number of adults receiving ART over time 10 26/05/2011
  • 12. Estimated cost of programme activities Assumptions about the cost of HIV interventions We assumed that unit costs for some services would decline as programmes expand, due to economies of scale and changes to more efficient service provision modalities in particular through community approaches. Although there is limited information on changes in unit costs over time, recent work indicates that substantial economies of scale are likely to exist.32 Unit costs of providing population-based services were provided by experts from 58 countries participating in four regional workshops on resources needs in 2009.16 Tables 2 provides estimates of the unit costs of key interventions by region in 200916 while assumptions about the ART costs over time are described below. In addition, unit costs for interventions by country are provided in the Excel Spreadsheet (UnitCosts.xlsx) available on-line. Table 2. Median unit costs (US$) of key interventions by region, 2009 Condom Promotion Outreach Outreach PMTCT PMTCT and for sex for Screening** Prophylaxis*** Distribution workers* MSM* Per Sex Per Woman Per Woman Per Condom Worker Per MSM Screened Receving ARVs Distributed Reached Reached Sub-Sahara Africa 4.48 607 0.18 20.24 25.97 East Asia and the Pacific 3.93 1564 0.09 49.38 62.24 South and South-east Asia 3.92 848 0.08 33.38 41.87 Eastern Europe 3.92 2204 0.23 60.02 69.32 North Africa and Near East 3.90 2265 0.25 71.92 76.17 Latin America and the Caribbean 3.97 1721 0.27 55.26 65.78 * Interventions marked with * have declining unit costs with increasing scale. **Assumes $3.90 per woman screened and found to be HIV-negative and $13 per woman screened and found to be HIV-positive ***Assumes costs in 22 focus countries in sub-Saharan Africa of $237 for Option A, $705 for Option B, $20 for CD4 counts, $3 for community mobilization, $33 for early infant diagnosis, $5 for Cotrimoxazole. For all other countries costs are adjusted for purchasing power. More information is provided below. 11 26/05/2011
  • 13. Outreach and Opiod Social and needle/syringe substitution behavior Counseling exchange for therapy Male change and Community IDU (2011*) circumcision communications testing* mobilization Per IDU Per IDU Per Person Per National Per Person Reached Reached Circumcised Campaign Per Client Reached Sub-Sahara Africa 23.43 1,008.00 59.10 809,775 14.87 3.38 East Asia and the Pacific 64.77 1,008.00 195,007 26.00 2.27 South and South- east Asia 24.49 1,008.00 3,475,231 14.66 1.31 Eastern Europe 36.37 1,008.00 262,515 15.58 2.62 North Africa and Near East 44.35 1,008.00 479,354 20.15 2.62 Latin America and the Caribbean 71.36 1,008.00 467,342 14.53 3.16 * unit costs for OST ae assumed to decrease by 20 percent by 2015 and 50% by 2020 Estimated cost of counseling and testing (C&T) The average unit cost of counseling and testing per region is provided in Table 3. These estimates are associated with coverage of C&T and costs generally decline with increasing coverage, as shown in Figure 4.32 Cost per client counselled and tested $90 $80 $70 $60 $50 $40 $30 $20 $10 $0 0% 5% % % % % % % % % % % % % % % % 01 03 05 20 40 75 15 25 35 45 55 65 75 85 95 0. 0. 0. 0. 0. 0. Coverage Figure 4. Declining cost per client with increasing coverage of counseling and testing 12 26/05/2011
  • 14. The following approach is assumed in the investment framework to determine the amount of testing undertaken within the health sector: 1. Provider initiated counseling and testing (PICT): we assume that for each person starting treatment at least three would be tested for differential diagnosis. This approach would most likely identify the patients coming to the clinics with advanced stages of HIV disease (CD4 cell counts below 200/ μL). 2. Pregnant women: It is assumed that all pregnant women in sub-Saharan Africa will be tested for HIV, except those already known to be HIV positive. We assume that 60% of HIV positive women will have CD4 cell counts above 350/μL. 3. STI patients: It is assumed that all people diagnosed with an STI will be tested for HIV. Testing among symptomatic STI patients is assumed to find HIV+ cases at a rate 3 times higher than the HIV prevalence rate. In addition to the testing in health care settings, there is wider population testing. This can happen as part of VCT or community mobilization, as described elsewhere in the document. With our assumption of gradually moving from VCT modalities to community testing approaches we assume that the number tested through VCT will drop from 230M in 2010 to 60M in 2015. The number tested through community mobilization will increase from 46M in 2010 to 109M in 2015. It is assumed that the overall detection rate of PLWH will increase through more focused testing approaches. Globally, an assumed 316 million people will receive an HIV test in 2015 either in health settings, VCT clinics or community settings, broken down as follows: VCT 60 million, community mobilization 109 million, sex workers 6 million, IDU 7 million, MSM 18.5 million, people with HIV related symptoms 2.5 million, PMTCT 111 million, STI 1.6 million.  Estimated cost of treatment, care and support The Investment Framework methodology to estimate resources required for treatment, care and support has been revised to be consistent with the Treatment 2.0 initiative.33 We assume that people who start ART early do not require the treatment and prophylaxis for opportunistic infections (OI) that would be required otherwise. Other OI costs are included in the estimated “end-of-life” costs of $228 per patient. These are estimated at the time of death but reflect both pre-ART and pre-death treatment costs. 13 26/05/2011
  • 15. Assumptions about the cost and changes in cost of ART Based on past trends in ARV prices and the possibilities of new, less expensive drug combinations in the future, we assumed that the average cost per patient on first line ART would decline by about 65% by 2020. We assume that less expensive diagnostic tests that can be used at point-of-care and task shifting of treatment would lead to average reductions of 60% and 40%, respectively, in laboratory and service delivery costs (weighted across low income, lower middle income and upper middle income countries) by 2020. Substantial savings are expected from a reduction in the frequency of visits to facility-based services with the use of more potent, less toxic and resilient antiretroviral schemes. We assumed a reduction in the number of outpatient visits, from published averages to four check-ups per year, most of them based on community support activities. It is also assumed that the service delivery costs in lower-middle and upper middle income countries do not decline at the same rate as these countries are unlikely to switch to a community-based model. The costs in low-income countries decline to $17 per patient per year (assuming reduction from 12 visits per year to 4 plus some migration to task shifting approaches reducing average salary costs by half. The result is that the weighted average service delivery costs decline from $176 in 2010 to $125 by 2020. We also considered changes in the costs of testing programs as a result of shifting from fixed facilities to community-based approaches. Given recent available data from developing countries these reductions seem plausible. Per-person ART costs in large scale PEPFAR programmes have fallen as implementation experience has grown. In South Africa and Zambia costs fell by half or more over time, and quality was not impaired when services shifted to lower level delivery sites34 and in five other countries (Botswana, Ethiopia, Nigeria, Uganda and Vietnam) median per-patient costs 24-29 months after programme initiation were 37% of their levels in the first 5 months.35 Similarly, large scale ART programmes implemented by Médecins Sans Frontières in Malawi have been delivered at $237 per patient/year, with ARV medicines representing two-thirds of the total cost: a level far below countries with smaller numbers of people receiving ARVs and lower than costs in Malawi when the numbers of persons receiving ARVs was lower.36 The significant majority of the cost savings will occur after 2015 with an increasing shift to primary care and community based approaches and cheaper point of care diagnostics. Average costs and assumed changes over time are provided in Table 3. Drugs: A weighted average of drug costs for four different first-line regimens and two different second-line regimens is used, weighted by the proportion of patients on each regimen.37,38 Separate prices are available for low-income and middle-income countries. The cost of both 1st and 2nd line drugs for middle-income countries is assumed to increase/decrease at the same rate as the cost for low-income countries. 14 26/05/2011
  • 16. Laboratory costs have been calculated as the annual median cost for laboratory tests across countries as obtained from recent literature, including studies from Cote d’Ivoire, Ethiopia, Mexico, Nigeria, Rwanda, South Africa, Thailand, Zambia.39-48 The median cost in 2010 is estimated at $180 (USD) per patient, decreasing to less than $80 by 2020 . Service delivery costs: Studies of service delivery costs conducted by PEPFAR found a range from $79 per patient per year to $345. We used an average cost (weighted across low income, lower middle, and upper middle income countries) of about $180 per patient per year in 2010, declining to $112 by 2020. Table 3. Average cost of ART (US$) and estimated changes over time   Cost per Patient Per Year 2010 2015 2020 Labs: new patients 180 129 79 Labs: continuing patients 180 128 76 Service delivery: weighted average 176 144 112 Low income countries 103 60 17 Lower middle income countries 181 136 91 Upper middle income countries 332 332 332 Procurement 20% 13% 5% End of life care 228 228 228 ARV Prices 2009 2015 2020 First Line ARVs Low income countries 137 130 50 Lower middle income countries 141 134 51 Upper middle Income countries 202 192 74 Weighted average 155  147  57  Second Line ARVs Low income countries 853 500 150 Lower middle income countries 1378 808 242 Upper middle Income countries 3638 2,132 640 Weighted average 1678 984 295 Estimated costs for IDU interventions In addition to responses which apply to other populations (such as HIV testing and counseling and ART) the main interventions for the prevention, treatment and care of HIV/AIDS among injecting drug users (IDUs) are needle and syringe programmes (NSP), and drug dependence treatment including opioid substitution therapy (OST). NSP is a well-established intervention which has been extensively studied and found to reduce HIV incidence and self-reported risk behaviours. Similarly OST is a critical component 15 26/05/2011
  • 17. of IDU programmes and has been proven to reduce risk behaviours, stabilize drug users’ lives with consequent improvement in access and adherence to HIV/AIDS treatment and care and to reduce the incidence of HIV.49 The assumed denominator populations used in our estimations are 13.5 million opiate users in low and middle income countries and 10.3 million injecting drug users (all substances) in low and middle income countries. These estimates are based on the UNODC World Drug Reports50 and estimates prepared under the auspices of the UN reference group on HIV and injecting drug use.13 It is assumed that the size of the denominator populations will remain stable at current levels by the year 2015, while coverage levels will be increasing. OST: Coverage targets lower and middle income countries Using information from countries with well established OST programmes, approximately 40% of opioid dependent persons can be covered in treatment programmes.26,27 In countries where these levels of coverage have been reached, HIV epidemics among IDUs have generally stabilized.51 We have therefore assumed the desirable target of opioid injectors on OST by 2015 to be 40%, consistent with the WHO/UNODC/UNAIDS target setting guide for injecting drug users. When using a denominator population of 8.1 million opioid injectors in our calculations of coverage and cost estimates for OST, it is assumed that priority is given to scaling up OST to opioid injectors. However, consideration needs to be given to the fact that dependent opioid users who do not inject also benefit from OST and providing OST to them could prevent the transition to starting to inject opioids. Hence 8.1 million is a conservative estimate. Based on historic evidence and (limited) country consultation and estimation we further assume that we can determine two levels of coverage: it is anticipated that countries that have already introduced OST, such as India and China, will arrive at a coverage level of 40% by 2015. However, countries that have not yet introduced (or registered) OST, such as the Russian Federation, may implement OST after 2011 (assuming a coverage of 0% until 2011) and will reach a lower coverage of around 20% by 2015. Countries that have implemented OST with methadone and or buprenorphine and that can be expected to achieve (or have already achieved) 40% coverage by 2015 are shown below in Table 4. 16 26/05/2011
  • 18. Based on the above coverage targets for OST in low- and middle-income countries we assume that approximately 2.7 million injectors will be on OST by 2015, a considerable scale up from the approximately 300,000 on OST in 2009.28 Table 4. List of countries that have implemented OST by 2010 Countries in which Methadone maintenance Countries in which Buprenorpine treatment is available maintenance treatment and/or detoxification is available (including pilot programmes) Albania, Andorra, Australia, Austria, Azerbaijan, Australia, Austria, Belgium, Bulgaria, China Belgium, Bosnia and Herzegovina, Bulgaria, (Hong Kong), Czech Republic, Denmark, Canada, China, Croatia, Czech Republic, Estonia, Finland, France, Germany, Greece, Denmark, Estonia, Finland, France, Georgia, Iceland, India, Indonesia, Iran, Israel, Italy, Germany, Greece, Hungary, Indonesia, Iran, Latvia, Lebanon, Lithuania, Luxembourg, Ireland, Israel, Italy, Kyrgyzstan, Latvia, Malaysia, Netherlands, Norway, Portugal, Liechtenstein, Lithuania, Luxembourg, Singapore, Slovak Republic, Slovenia, South Macedonia, Malaysia, Malta, Mexico, Moldova, Africa, Sweden, Switzerland, Ukraine, Myanmar, the Netherlands, New Zealand, United Kingdom, United States of America. Norway, Poland, Portugal, Romania, San Marino, Serbia, Slovak Republic, Slovenia, Spain, Sweden, Switzerland, Thailand, United Kingdom (plus overseas territories/dependencies), United States of America, Ukraine (about to start) Based on current levels of utilization and assumption that the relatively less expensive methadone will be used in preference to buprenorphine it is assumed that of those receiving OST in low- and middle-income countries, 80% will be on methadone and 20% on buprenorphine. Unit cost of OST Unit costs include programme costs directly related to delivery of methadone or buprenorphine and medication costs and not the costs covered elsewhere, such as HIV testing and counselling. Cost of Methadone: USD 1.00 – 2.90 per patient per day (medication costs 33c for 80mg in Iran to $2.06 for 80mg in Indonesia). Range: USD 363.65 – 1,057 per patient per year. Cost of Buprenorphine (only low dose estimates available 4-10mg per day, as compared to recommended doses of 12-24mg) USD 3.39 – 8.68 per patient per day (medication 17 26/05/2011
  • 19. costs $2.72 for 10mg in Iran to $7.84 for 8mg in Indonesia). Range: USD 1,236 – 3,166.70 per patient per year. The non medication costs include salaries and to a lesser extent pathology tests (mainly urine drug screens). These estimates do not include the costs of building clinics or training staff. The estimates are based on ongoing maintenance treatment, and do not include the additional costs involved with commencement of treatment and therapeutic withdrawal from treatment. Based on the above, an average current cost of $1,008 per IDU reached per year was assumed in the Investment Framework models. It was further assumed that the costs of OST will be reduced by 20% by 2015 and by 50% by 2020.   NSP: coverage targets lower and middle income countries Based on a retrospective analysis of the coverage required to reverse the HIV/AIDS epidemic among IDUs in New York52 and coverage rates typically reached in those European countries that averted or reversed epidemics, coverage of 60% or more of IDUs regularly reached (more than once a month) is considered very good.28 In Odessa in the Ukraine, where prevalence among IDUs had already reach very high levels by 2000, 60% NSP coverage showed a reduction in HIV prevalence by 4% over a 5 year period.42 The projected coverage target for all IDUs in regular reach of NSP in the Investment Framework models have therefore been set at 60% by 2015. A denominator population of 10.3 million IDUs in low and middle income countries (as described above) was used in our calculation of coverage and cost estimation for NSPs. Regular reach is defined as an IDU being in contact with an NSP more than once a month. Our estimated coverage target for IDUs in NSP programmes is therefore estimated at about 6 million by 2015. The unit costs for NSP, which is assumed to decline with increasing coverage levels (see Figure 5), was assumed to be between 7-10 USD per person per year. 18 26/05/2011
  • 20. $50.00 $45.00 $40.00 $35.00 $30.00 Unit cost $25.00 $20.00 $15.00 $10.00 $5.00 $- 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% NSP coverage Figure 5. Unit cost of NSP by level of coverage Estimated cost of PMTCT Screening The estimation assumes that 90% of pregnant women will be provided with at least one HIV screening test to ascertain her HIV status. However, women who test positive will also be provided with counseling services to help them decide on future courses of action for the benefits of themselves and their unborn children. With PEPFAR estimates of the cost of VCT services in low-income settings ranging between US$3.90 and US$20 per person, we used a weighted average cost of US$ 3.90 for the cost of HIV serological tests per woman for all HIV negative women. For HIV positive women in the population we assumed the cost of testing and counseling to be US$ 13 per woman. An additional 10% was included to take account of other programmatic costs related to the services. Family Planning For family planning costing, we used standard published methods. To avoid double counting family planning is included as part of the health systems component in the mayor synergies. However, it is also an important cost item of PMTCT services and a clear distinction is made whenever necessary. Prevention of unintended pregnancies 19 26/05/2011
  • 21. among HIV infected women of reproductive age were calculated by multiplying the population of women with unmet need for family planning (15-49 years) by the number of HIV pregnant women in each country. This number is then multiplied by the annual average cost of providing family planning per woman. Family planning was estimated to cost US$ 20 per woman per year.53 CD4 Testing In line with the 2010 WHO guidelines on PMTCT,54 all women who test positive for HIV should ideally undergo CD4 cell count screening in order to identify those women who require lifelong antiretroviral treatment. The new WHO guidelines stipulate that women whose CD4 counts are below 350cells/μL are to commence lifelong antiretroviral therapy. To ensure that all women who require ART for their own health are identified and treated, it is recommended that CD4 testing should be included in the essential package of care for HIV-infected pregnant women. We assumed that 90% of HIV positive women in the population will have access to CD4 testing at an average cost of US$ 20. This is an average across the high-burden countries and does not include start-up costs, laboratory upgrades or the cost of additional machines. For the purpose of this analysis, we only used the cost of the laboratory tests. Prophylaxis for HIV infected pregnant women In the 2010 WHO guidelines on antiretroviral treatment for pregnant women and preventing HIV infection in infants,54 there are two recommended treatment options for women not eligible for ART i.e. women with CD4 counts > 350cells/μL; Option A and Option B. WHO Option A The mother is given ante-partum AZT twice per day starting from as early as 14 weeks of gestation and continued during pregnancy. At the onset of labour, she may be given sd- NVP and initiation of twice daily AZT + 3TC for 7 days postpartum. If maternal AZT was provided for more than 4 weeks antenatally, omission of the sd-NVP and AZT + 3TC tail can be considered; in this case, continue maternal AZT during labour and stop at delivery. For breastfeeding infants, administration of daily NVP from birth for a minimum of 4 to 6 weeks, and until 1 week after all exposure to breast milk has ended. For infants receiving replacement feeding only, administration of daily NVP or sd-NVP + twice-daily AZT from birth until 4 to 6 weeks of age. 20 26/05/2011
  • 22. WHO Option B The mother is given triple ARV prophylaxis starting from as early as 14 weeks of gestation and continued until delivery, or, if breastfeeding continued until 1 week after all infant exposure to breast milk has ended. Recommended regimens include: AZT + 3TC + LPV/r or AZT + 3TC + ABC or AZT + 3TC + EFV or TDF + 3TC (or FTC) + EFV Irrespective of the mode of feeding for the infant, the infant is administered daily NVP or twice daily AZT from birth until 4 to 6 weeks of age. Costing of Options A and B In line with WHO guidelines,54 we estimated costs assuming a breastfeeding duration of 12 months. Therefore, if women started receiving antiretroviral prophylaxis at 14 weeks gestational age, it means they will receive the drugs for a period of 18 months in total. We further assumed that on the average, at least 40% of HIV positive women will be eligible for ART for their own health.55 Therefore, 60% of infected women will require antiretroviral prophylaxis using option A or B. As most countries still use a combination of single and dual drug regimens, the 60% of HIV positive women not eligible for ART was split into 36% receiving Option A (dual prophylaxis) and 24% receiving Option B (triple prophylaxis). The total cost for women using Option A used is US$ 237 and consists of $30 for AZT+3TC, $63 for NVP, $54 for laboratory tests and $90 for service delivery. The total cost per women using Option B used is $ 470 which consists of $149 for ARVs, $180 for laboratory tests and $141 for service delivery. When this is multiplied for an 18 month period, we get a total cost of $705 per women.17,56 ART for mothers who need it for their own health Treatment for mothers is a comprehensive package that includes antiretroviral therapy, laboratory monitoring and delivery cost in health facilities at a cost of US$ 600 per mother per year. We assumed that 40% of the women would have CD4<350 cells//μL and are therefore eligible for full antiretroviral therapy. Women who require ART for their own health are assumed to receive triple therapy according to the WHO Guidelines. The unit costs made for mothers who need treatment for their own health are consistent with the assumptions made for all adults receiving ART as described above. Following 12 months of breastfeeding, it is assumed that HIV-infected women (post-natal) who require ART for their own health are transferred to ART centres for the continuation of treatment. This assumption is to avoid double counting in relation to other estimates for adults receiving ART. 21 26/05/2011
  • 23. Early infant diagnosis All children born to HIV-infected mothers have maternal HIV antibodies which may be detectable in the first six months of life. Therefore, immunological assays performed early in infants may only detect HIV exposure in infants. HIV infection in infants is diagnosed by detecting the presence of viral nucleic acid (viral RNA or viral DNA) or other viral products such as p24 Ag. Polymerase chain reaction (PCR) – based HIV DNA has become the most widely used assays in resource-limited settings for both diagnostic and monitoring purposes. For the purpose of this costing analysis, 90% of all infants exposed to HIV through their mothers are assumed to have access to early infant diagnosis and the cost of PCR-DNA test per infant was assumed to be US$ 32.50. Cotrimoxazole Prophylaxis Cotrimoxazole prophylaxis is considered part of an additional package of care for HIV positive women and essential for the postpartum treatment of infected infants. Cotrimoxazole prophylaxis is used to reduce the incidence of opportunistic infections particularly in women with low CD4 counts and to prevent the development of opportunistic infections in infants and it is a proven cost-effective measure for improvement of the quality of life of persons living with HIV/AIDS. Therefore, all the women eligible for treatment for their own health, as well as all infants, are assumed to be given cotrimoxazole prophylaxis for a period of 6-12 months. The cost of cotrimoxazole was assumed to be US$5 per person per year. Estimated cost of Behavior Change programmes Behaviour change in generalized epidemics, such as delaying the initiation of sex or partner reduction, affects the likelihood of exposure and it is axiomatic that reducing these behaviours reduces the likelihood of transmission. Furthermore, the importance of behaviour change has been confirmed as a plausible explanation for changes in incidence derived from ecological studies that explain past successes in HIV prevention.57-61 For this reason, behaviour change appears as a discrete basic programme activity – notwithstanding the challenge of amassing consistent, direct and generalizable evidence on the impact of different elements of behaviour change programmes.62,63,64 The most efficacious interventions to accomplish such changes are less well established, but include programs of interpersonal and group communication delivered through the mobilization of civil society, faith based organizations and in the work place. 22 26/05/2011
  • 24. Limited information is available on costing of such programmes. For the purpose of this exercise, the cost of workplace programmes have been used as a proxy to arrive at a plausible overall estimate of resource needs for Behavior Change programmes included in Basic Programme Activities of the investment framework. Work place programs typically include services such as the provision of condoms, counseling and testing and STI treatment services either provided on site or through a near by health clinic, as well as health education provided through peer educators. To arrive at an overall estimate of resource needs, we assumed the proxy of workplace programs in 2015 to be scaled up to 50% coverage of the 148 million employees in the formal sector in countries with generalized epidemics, with an average unit cost of US$ 9 per employee per year. Estimated cost of community mobilization Community mobilization, which underlies many of the critical enablers, has objectives essential to an effective AIDS response. These objectives include: community outreach and engagement, support, advocacy and transparency; community-driven approaches in outreach and engagement activities that successfully connect people facing similar issues and engage them in a broad spectrum of HIV-related interventions thus leading to improved uptake and use of many of the basic programme activities (e.g. HIV-specific education, behavioural change, access to condoms and clean syringes, ART); support activities that target people already engaged in care and enhance quality, adherence and impact in a range of settings such as people who are on treatment, engaged in harm reduction or drug treatment services, or who are already using sexual and reproductive health services; advocacy, transparency and accountability efforts, such as local-level advocacy to ensure that high-quality health services are available and accessible to vulnerable populations. The cost of community mobilization, as one of the critical enablers, was estimated in two ways. First, in generalized epidemics, it was estimated from the number of people in need, coverage levels, and unit costs based on data on community health worker programmes. In the case of concentrated epidemics, the costs of community mobilization were subsumed into the costs of outreach for key populations and thus included under basic activities for these populations. Recent unit cost data, supplied in 2009 by 59 countries in workshops sponsored by UNAIDS, suggest a unit cost for community mobilization in HIV ranging between less than US$ 1 and US$ 14.65 A comprehensive literature search for community-based distribution of various services and commodities, including community-based care, child 23 26/05/2011
  • 25. health interventions, and safe water systems, found that the median unit cost, excluding commodities, in 2009 US dollars was US$ 0.88 (mean: US$ 2.06).66-73 This unit cost is consistent with the range described above for community mobilization efforts in HIV. We applied the unit cost for community mobilization as provided by the country experts and applied regionally where no data were available. The country-specific unit costs can be found in the attached models. These unit costs were applied to the total adult population to arrive at an overall cost for community mobilization. The model also assumes that all people reached by community workers receive an HIV test every two years for an additional cost of US$ 1 per test. The framework assumes that major efficiency gains are possible through shifting service provision modalities to place greater emphasis on community mobilization Estimated cost of programme support functions Assessments of total HIV expenditures and expenditures for program support functions18 indicate that expenditures for program support range from under 10% to over 60% with an average of 12.6%. For this analysis we assume ongoing improvements in efficiency and use 10% of direct expenditure on basic programme activities as the total average for all programme support functions. This includes programs for political commitment and advocacy, legal reform, human rights, stigma reduction, management, research and innovation, monitoring and evaluation, communications, procurement and logistics. Estimated cost for synergies with development sectors The cost for major synergies is the least specific of the estimates included. For the investment framework we assessed existing expenditure data on systems strengthening activities and made a cost estimate for specific interventions such as blood safety, STI treatment, school based education, support to the most vulnerable populations including orphans, and gender programmes. Unit costs were based on estimates from country reports from the regional UNAIDS Resource Needs workshops, as shown below in Table 5. Total costs for programs to combat gender-based violence and to support AIDS orphans were adopted from previous resource needs estimates. The financing needed to achieve better synergies with development sectors, particularly in gender, health, education and social protection sectors, is estimated at US$ 3.59 billion in 2011, increasing to about US$ 5.43 billion investment by 2020. The estimates comprise gender based violence programmes (increasing from US48.5 million in 2011 to 24 26/05/2011
  • 26. nearly US$1 billion in 2020), a number of health sector elements including family planning, STI management, blood safety, post-exposure prophylaxis, safe injections and universal precautions (increasing from a total of US$1.3 billion in 2011 to US$2.7 billion in 2020), youth in schools programmes (US$64 million in 2011 to US$118 million in 2020), and support for children orphaned by AIDS (declining from US$2.1 billion in 2011 to US$1.5 billion in2020). While this framework does not intend to be prescriptive about spending to support sectoral synergies, this estimate is consistent with current funding approaches to systems strengthening, for example by the Global Fund. Table 5. Median unit costs (US$) of programs classified as Major Synergies, 2009 North Latin East Asia South and Africa and America Sub-Saharan and the South-East Eastern Middle and Africa Pacific Asia Europe East Caribbean School-based AIDS education (per student) 15.98 27.44 11.33 15.30 18.76 14.53 Family planning (per FP user) 20 20 20 20 20 20 Prevention in prisons (per prisoner) 29.28 35.00 65.39 22.13 27.65 15.83 STI management* (per case treated) 25.69 101.72 66.53 160.26 811.66 68.22 Blood safety (per unit of blood transfused) 8.54 6.32 4.19 13.73 17.41 17.32 Post-exposure prophylaxis (per case) 34.01 94.60 97.48 95.56 125.00 124.69 Safe medical injections (per injection) 0.22 0.16 0.15 0.22 0.03 0.07 Universal precautions (per hospital bed) 303.18 336.86 180.19 66.97 58.98 154.12 25 26/05/2011
  • 27. Costing Spreadsheets Excel spreadsheets that were used for the Investment Framework calculations are available from the authors on request. The approach was based on the assumptions that the number reached is estimated by the population times coverage, while resource needs is estimated by the number reached times the unit costs. The spreadsheets include:  PopData.xls : This spreadsheet contains population data. Different worksheets show the different target populations.  Behavior.xls: This spreadsheet includes additional information for calculations including ANC coverage, units of blood needed per 1000 population, % casual sex, coital frequency, injections per person, proportion married.  Coverage.xls : The spreadsheet includes coverage targets and different worksheets are used for the different interventions. The coverage targets for different scenarios are specified in the Goals worksheet.  NumberReached.xls : This spreadsheet provides the numbers reached by each intervention. Different worksheets are used for different interventions. Most of the worksheets simply show the result of population x coverage. The number of people on ART (Figure 3) is drawn from the Goals model applications.  UnitCosts.xls : Different worksheets are used with the unit costs specified for different interventions. Most are constant over time while a few are assumed to change with scale. ART is shown by country type (low / middle income) rather than by individual country.  ResourceNeeds.xlsm : This spreadsheet shows the estimated resources that are required for the investment framework, by intervention. Different worksheets show country estimates for the different interventions. Charts and summary tables are also shown. To use the spreadsheets, all five spreadsheets should be opened in Excel in order (PopData, Coverage, NumberReached, UnitCosts, ResourceNeeds). The first time this is done the spreadsheets may need to be re-linked if the links are not automatically updated. Warnings  The analysis is intended to provide estimates of resource needs at the global level. Results for individual countries will require further work and confirmation. Results Results are shown in the spreadsheet “ResourceNeeds.xlsm”. The following worksheets include results: 26 26/05/2011
  • 28. Results table. Results for all countries are summed together by intervention. Summary by County. The results by country for all interventions are shown for the 22 countries for which we did Goals applications.  Country by Intervention. The name of a single country can be entered in the yellow cell, B1, to see the resource needs for that country. If it is not one of the 23 Goals countries then resource needs for ART will not be shown.  Summary by Scenario. This worksheet shows the total resources needed for all countries by major component (prevention, treatment, mitigation, support, structural interventions) and by scenario. Scenarios. The coverage scenarios can be changes in the Coverage spreadsheet, in the Goals worksheet in cell B2. This will change the coverage to the specified scenario, according to the table in the Coverage.xls spreadsheet, Goals worksheet. The region or country can also be changed in the yellow cell B3, but if a country is chosen that is not one of the 23 Goals countries ART costs will not be available. 27 26/05/2011
  • 29. APPENDIX II: THE SYNERGISTIC IMPACT OF CRITICAL ENABLERS Critical enabling factors can have a substantial impact on HIV incidence for a low cost if they help change, for the better, the proximate determinants of HIV transmission. Quantifying the link between such enabling activities, implemented at a community level, and individual changes in risk behaviour is difficult, but recent studies provide examples that can be examined in mathematical model projections. Community mobilisation, along with mobile voluntary HIV counselling and testing and post-test support services, increased HIV testing rates four-fold in Tanzania, Zimbabwe, South Africa and Thailand.74 Therefore, increased testing could potentially reduce HIV incidence if more of those who are infected know their status and increased condom use or initiate treatment (on time for clinical need). Furthermore, in Kenya, a four-fold greater odds of reporting consistent condom use over the previous 12 months was associated with living in areas with good engagement of community-based organizations.75 These factors were included in a model representing the population of KwaZulu-Natal to explore how the impact of a hypothetical ‘core’ circumcision intervention might be enhanced by enabling interventions that result in greater HIV testing and condom use (Figure 6). In the model scenario, the core intervention averted 240,000 infections over ten years but key enabling interventions could, for modest marginal increase in costs, avert an additional 180,000 infections. 28 26/05/2011
  • 30. Core + Enablers Interventions Core 0 100 200 300 400 500 Number of infections averted, 2012-2022 (1000s) Figure 6: A model of the HIV epidemic in Kwazulu-Natal, South Africa, was used to calculate the number of new HIV infections that would be averted by a “Core” intervention (70% of the uncircumcised men are circumcised over a 5 year period) and the same core intervention in tandem with some key enabling intervention – “Core+Enablers” – (including community mobilization, post-test support) that had the net effect of increasing testing rates (by four-fold) and increasing the odds of condom use across the community by 1.5-fold. Model description can be found (Alsallaq et al, Forthcoming). 29 26/05/2011
  • 31. APPENDIX III: ESTIMATED CONTRIBUTION OF TREATMENT TO REDUCING TRANSMISSION The infectiousness of HIV is correlated with the levels of virus in the infected individual, which means that infectiousness increases as disease progresses and viral replication is less constrained. Further, the reductions in viral load associated with ART have been shown to reduce infectiousness in observational studies.25,76 Promptly initiated treatment for clinical need should therefore lead to reductions in transmission. Several mathematical modelling exercises have estimated the proportion of onward transmission that, in the absence of treatment, would come after the point when ART should normally be initiated (Figure 7). These suggest that once an HIV epidemic has matured to near endemic levels approximately 30% of infections are generated by those with CD4 cell counts < 200 cells/µL and approximately 50% of infections are generated by those with CD4 cell counts < 350 cells/µL. During the early stages of an epidemic more infections are recent and therefore contribute a greater proportion of new infections. These estimates provide an upper-limit for the extent to which treatment could reduce infections because, in reality, (i) ART does not perfectly reduce infectiousness, and (ii) individuals for whom ART is failing might become more infectious. New models, accounting for these factors, have estimated that, with 80% able to initiate treatment promptly when they require it, the rate of new infections could be reduced by approximately 20% with treatment starting at CD4<200/μL and 30% with treatment starting at CD4<350 /μL (Eaton et al., personal communication). 30 26/05/2011
  • 32. 100% Cumulative transmission Hollingsworth et al. (serial partnerships) Hollingsworth et al. (random mixing) 80% Eaton et al. (substantial  concurrrency) 60% Eaton et al. (minimal  concurrrency) Abu‐Raddad & Longini (Kisumu) 40% Abu‐Raddad & Longini (Yaoundé) Goodreau et al. 20% CD4<350 CD4<200 0% 0 2 4 6 8 10 12 Years since infection Figure 7: The number of new infections generated by each HIV-infected individual accumulates over time since infection in published model estimates.77-80 The approximate partition of time spent with CD4 cell counts > 350 cells/µL (pale green), CD4 cell count between 200 and 350 cells/µL (light green) and < 200 cells/µL (dark green) are based on estimate of disease progression in observational cohorts.81,82 31 26/05/2011
  • 33. APPENDIX IV: INFORMATION ON NEW PREVENTION TECHNOLOGIES Although considerable progress has yet to be made by expanding the coverage of existing interventions, there will still be a need for new prevention options once existing programs reach maximum scale. Incidence rates have shown to level off even in countries with very high coverage of prevention and treatment programmes at levels of one third to a quarter of peak incidence.83-85 Promising new technologies could contribute to future prevention efforts; including vaginal microbicides, HIV vaccines, and pre-exposure prophylaxis (PrEP) delivered through oral pills. Increased and more efficient research and development spending are needed to speed up the development of HIV vaccines, microbicides, and other new prevention technologies and deliver them to populations most in need.86 Although funding from public and philanthropic agencies for these efforts have more than doubled in recent years, significant resource gaps still remain. Financial resources needed for new technologies are large but the enormous potential benefits of successful products would make these investments worthwhile. Expanding efficacy trial capacity for new HIV vaccine and microbicide candidates will require additional investments between now and 2015. The recent CAPRISA 004 trial conducted in South Africa showed that tenofovir used as a microbicide gel could be effective and safe.87 Tenofovir gel reduced HIV acquisition by an estimated 39% overall, and by 54% in women with high gel adherence, and could potentially fill an important HIV prevention gap. Modelling the potential impact of tenofovir as a microbicide gel showed that up to 2 million new infections and 1 million AIDS deaths could be averted over the next 20 years in South Africa if good adherence is achieved. This new female controlled prevention method could have a significant impact on the HIV epidemic but will depend on the levels of adherence.88 Several other microbicide candidates are currently being tested in clinical trials.89,90 While an effective AIDS vaccine does not currently exist, the results of the ALVAC RV- 144 Thai prime-boost vaccine trial91 showed for the first time that it is possible for a vaccine to offer protection against HIV in humans, but more research is needed to understand the immune responses. Several HIV vaccine candidates currently in Phase II trials could move to Phase III efficacy testing over the next decade.90 Recent research into the use of pre-exposure prophylaxis (PrEP) to prevent HIV showed promising results.92 The iPrEx study showed that in gay men, transgender women and 32 26/05/2011
  • 34. other men who have sex with men, daily TDF/FTC (tenofovir disoproxyl fumarate plus emtricitabine also known as Truvada) reduced the risk of HIV by 44%. Additional studies are ongoing in other populations. A modelling exercise predicted that the cost- effectiveness of PrEP relative to ART will decrease rapidly as ART coverage increases beyond three times its coverage in 2010, after which the ART program would provide coverage to more than 65% of HIV+ individuals. To have a high relative cost-effective impact on reducing infections in generalized epidemics, PrEP must utilize a window of opportunity until ART has been scaled up beyond this level.93 Although it is unlikely to confer sufficient benefits to justify current TDF/FTC costs, price reductions and/or increases in efficacy could make PrEP a cost-effective option in younger or higher-risk populations94 and further research of using PrEP-based HIV prevention is warranted. Without new innovations, the decrease in the number of new infections is likely to stall, as shown in Figure 8, but potential new technologies developed and implemented at scale over the next decade could enable the downward trajectory of new infections to be continued. As such programmes do not exist to date, costs for possible scale up of new innovations have not been included in our analysis, nevertheless it is useful to bear in mind that innovation is likely and should be anticipated. 3,000,000 2,500,000 New HIV infections 2,000,000 1,500,000 1,000,000 500,000 0 2011 2013 2015 2017 2019 2021 2023 2025 Baseline Investment Framework New technologies Figure 8. New HIV infections in low and middle-income countries expected under the baseline scenario (assuming constant coverage at around present funding rates and approaches), new investment framework approach, and with the potential effect of new technologies (Microbicides, PrEP and Vaccines) introduced starting in 2015. 33 26/05/2011
  • 35. APPENDIX V: RELEVANT TERMS AND DEFINITIONS Basic Programme Activities Treatment care and support for PLWH (including facility-based testing) This includes the provision of clinic-based, home-based or community-based services and commodities for the treatment and care of HIV-positive adults and children. Treatment care and support includes several categories: antiretroviral therapy provided to infected adults and children in need of treatment; routine counselling and testing; treatment and care of opportunistic infections; essential illness prevention interventions for PLHIV; nutrition supplements for those on ART; treatment for tuberculosis; and palliative care. This category also includes provider initiated counselling and testing in facilities and utilizing health services. ART significantly reduces viral load and restores immune function, thereby raising the possibility of using ART not only to increase the survival time and quality of life of people infected with HIV, but also to reduce HIV transmission. Prevention of mother-to-child transmission (PMTCT) Comprehensive PMTCT programs for pregnant women include pre-test counselling, HIV testing, post-test counselling, drug prophylaxis, initiation of antiretroviral therapy, counselling on infant feeding options and post partum monitoring and interventions for mother and child. Drug prophylaxis may be a single drug regimen (single dose Nevirapine [sd-NVP] or AZT), a combination prophylactic regimen (AZT+sd-NVP with or without 7-day postpartum, AZT+3TC), or a highly active triple drug regimen (AZT + 3TC + NRTI/NNRTI or PI). WHO currently recommends provision of ARVs to all HIV- infected mothers, starting in the second trimester of pregnancy and throughout the breastfeeding period to prevent vertical transmission.54 National authorities should decide on the best infant feeding option (breast feeding with ARV interventions or to avoid all breastfeeding) that will most likely give infants the greatest chance of HIV-free survival. Where breastfeeding is judged the best option, complementary feeding (infant formula) may be introduced at 6 months and continue breastfeeding for at least 12 months. Male circumcision Refers to the removal of the prepuce or foreskin covering the tip of the penis for the purpose of reducing the risk of HIV infection. The program includes the operation itself, 34 26/05/2011
  • 36. as well as related activities such as counselling, post-operative support, promotion of male circumcision, programme communication, strengthening of necessary medical infrastructure and training. Male circumcision (MC) has been demonstrated to reduce the risk of female-to-male sexual transmission by 60%.22-24 WHO and UNAIDS recommends that male circumcision should now be recognized as an efficacious intervention for HIV prevention. However, MC provides only partial protection against the risk of HIV sexual transmission from women to men and it should therefore always be considered as part of a comprehensive HIV prevention package. Condom promotion and distribution Includes programmes to increase the correct and consistent use of male and female condoms by making them more accessible and acceptable. This can involve activities to increase condom availability (such as procurement and distribution) and generate demand (such as social marketing, awareness raising and communication programmes). Evidence from research among heterosexual couples in which one partner is infected with HIV shows that correct and consistent condom use – male and female – significantly reduces the risk of HIV transmission from men to women, from women to men and also from men to men.95 Condoms are an integral and essential part of comprehensive HIV prevention and care programmes, and the promotion thereof must be accelerated. Male and female condom provision, including lubricants, covers mainly the supply side of condom programming including selecting products that appeal to clients, forecasting condom needs, procuring sufficient quantities of high-quality male and female condoms, managing inventories, and distributing condoms. Behaviour Change Programmes Behaviour change has had a major impact on the trajectory of concentrated and low level epidemics. In generalized epidemics, behaviour change such as delaying the initiation of sex, increasing condom use or reducing the number of sex partners, affects the likelihood of exposure and reduces the likelihood of HIV transmission. Behavioural change programmes for AIDS includes the strategic use of an integrated programme of advocacy, communication and social mobilization to systematically facilitate and accelerate behaviour change and social change to the underlying drivers of HIV risk, vulnerability and impact. It enables communities and national AIDS programmes to support behaviour change and to tackle underlying structural barriers to effective AIDS responses including inequality and social exclusion. Successful programmes have the capacity to blend participatory methods of community dialogue and empowerment with mass media approaches and other forms of informational and 35 26/05/2011
  • 37. motivational communication and advocacy. The goal of such programmes is to act as a catalyst for action at the individual, community and policy levels. Social and behavioural change communication methods support development of locally owned and implemented solutions that can be measured and tracked over time. Monitoring and evaluation of social and behavioural change communication fosters both local engagement and quality improvement of change activities. They also foster the ability to share results horizontally (i.e. across similar programmes or communities) and vertically (from community to national levels) for learning and accountability. Social and behavioural change communication programmes have been shown to work, although careful evaluation has been the exception rather than the rule in implementing these programmes. Where rigorous evaluation has been conducted these programmes have been shown to make significant and durable change in deeply rooted harmful practices; from domestic violence to police complicity in violence against men who have sex with men; from denial of HIV in rural communities to fear of using condoms in stable couples. Social and behaviour change communication activities should include rigorous impact evaluation to make sure that they are reaching audiences effectively. Key objectives for social and behavioural change communication programmes need to include changing sexual behaviour at both the societal and individual level (including reduction of number of sexual partners, age of sexual onset. Communication for social and behaviour change involves targeting the general population or specific groups through mass media and outreach activities. Component elements of social and behavioural change communication programmes Interpersonal communication: face-to-face communication either through a one-on-one exchange or discussions in a small group with a trained facilitator. Several critical components to interpersonal communication could include having a facilitator who is from the same ethnic, cultural and/or linguistic background; having participatory and non-judgmental interactions; ensuring that information shared is factual and based on evidence; and ensuring that exchanges go beyond raising awareness and knowledge building. Interpersonal communication can be delivered through various personal interactions such as individual outreach, small discussion groups, counselling, and client-provider dialogue. The key objectives of interpersonal communication is to address barriers to adopting healthier behaviours, focus on increasing risk perception, increasing use of available services, and improve skills and self-efficacy to enable individuals to be 36 26/05/2011
  • 38. responsible for and protect their own health by making healthier behavioural choices. Media communication utilizes one or more channels to transmit the same message to a large audience. Examples include brochures, billboards, posters, newspaper or magazine articles, comic books, television, radio, music videos, Internet, cell phones, songs, dramas, traditional and folk media, and interactive theatre. Media communication includes development of communication messages and materials and their transmission. Media communication seeks to promote positive changes in cognitive and behavioural outcomes such as increasing knowledge of modes of HIV transmission, increasing perceived risk of contracting HIV, reducing high-risk sexual behaviours such as having multiple partners, increasing positive protective behaviours such as condom use, and increasing the utilization of health care services. Media communication can also be utilized to create a supportive environment and often targets social, cultural and gender norms that may hinder behaviour change. Key populations Assessing the needs of different population groups and identification and removal of barriers to access services is relevant to planning a programmatic effective response. Community mobilization is often geared towards those who are marginalized from community processes, including young people, women, minorities, sex workers, people who inject drugs (IDU) and men who have sex with men (MSM). A wide range of priority populations have utilized community mobilization in the prevention and mitigation of HIV. Outreach programmes usually include peer education on HIV transmission and risk reduction strategies and HIV testing. Interventions for female and male sex workers and MSM are based on a peer outreach model. These interventions combine one-on-one or small group awareness, group education and access to commodities and services. Sex work interventions: Programmes to promote risk-reduction measures among commercial sex workers and their clients. Includes STI treatment, peer outreach and counselling, condom promotion, removing stigma and discrimination, elimination of gender-based violence, programmes addressing clients, HIV testing and treatment. MSM programmes: Activities that address men who regularly or occasionally have sex with other men. This includes risk-reduction activities, outreach (including by peers), prevention of sexual transmission of HIV (including condom 37 26/05/2011
  • 39. use, prevention and treatment of STIs), voluntary and confidential HIV counselling and testing, and initiatives to ensure that these groups are able to access these services. IDU programmes: Initiatives directed at injecting drug users to reduce the risk of spreading HIV and to mitigate other harmful effects of drug use. This can involve harm reduction programmes, such as sterile needle and syringe programmes, as well as opioid substitution and peer outreach. Needle and syringe programmes aim at reducing the risk of blood borne infection of HIV (and others such as viral hepatitis) transmission associated with using contaminated drug injecting equipment among people who inject drugs. Pogrammes consists of ensuring easy, consistent and safe access to sterile needles and syringes to people who inject drugs. Modalities for needle and syringe programmes include provision of needles and syringes free or for cost; one-for- one exchange, intended to remove used injection equipment from circulation; secondary distribution, where people who inject drugs collect a relatively large number of clean syringes and needles and distribute them to other people who inject drugs with whom they are in contact, aiming to reach users who may not be in touch with services; and provision of other paraphernalia such as alcohol swaps, citric acid, spoons and condoms. Critical enablers Social Enablers Political commitment and advocacy Political commitment enables AIDS responses at all levels, including through resource allocation, creation of enabling environments where community mobilization and social and behavioural communication can take place, and supporting the realization of rights. Political commitment may be generated through advocacy. Advocacy is the combined effort of a group of individuals or organizations to persuade influential individuals, groups and/or organizations to adopt an effective approach to AIDS as quickly as possible. Advocacy efforts have diverse targets of change: policies, laws, regulations, guidelines, additional funding, and/or programmatic or institutional change. Advocates use a wide variety of organizational techniques and communication channels to bring about political change, including letters, meetings, social networking and internet campaigning, face-to-face interactions, media campaigns, forums and newspaper articles. 38 26/05/2011
  • 40. While it is possible to identify advocacy techniques which are applicable across a wide range of settings, the impact of political commitment and advocacy on improving the AIDS response depends greatly on specific context where it takes place. External actors can be enormously influential over political and advocacy outcomes, but can also fail to have any real or lasting impact if they run counter to local needs and understanding of the roots of problem to be addressed. Laws, legal policies and practices A supportive legal environment entails having laws in place that protect people living with HIV and key populations from discrimination and having policies that facilitate all populations having access to the HIV programmes and services they require. It also involves removing punitive laws, regulations and policies that block effective HIV responses. These may include: criminalization of same sex sexual activity; laws or police practices which punish possession of condoms or drug paraphernalia and undermine harm reduction measures; inappropriate criminal penalties applied in the context of sex work or to HIV transmission and exposure; laws that preclude importation of generic medicines; policies that impede distribution of sexual health education and information; restrictions on the distribution of condoms, e.g. in prisons; regulations which prevent non-citizens from accessing ART; and the lack of a legal framework for non- governmental organizations to operate effectively. HIV-related legal services include legal information and referral, legal advice, and legal representation. Test cases or ‘strategic litigation’ may also establish a new legal rule, clarify the application of the law or address discriminatory policy or practice. Legal services can also include informal or traditional legal systems (e.g. village courts). HIV- related legal services help improve access to HIV prevention, treatment, care and support services by people living with HIV or other key populations; increase the demand for justice; empower affected populations to advocate for their rights; and provide redress for discrimination. Community Mobilization A community becomes mobilized when a particular group of people becomes aware of a shared concern or common need, and together decides to take action in order to create shared benefits. This action may be helped by the participation of an external facilitator—either a person or organization. However, momentum for continued mobilization must come from within the concerned group or it will not be sustained over time. Community mobilization can be conducted through various activities such as group 39 26/05/2011