how universal will universal access be in europe by 2010? eddy beck evaluation department unaids,...

How ‘Universal’ will Universal Access be in Europe by 2010?

Eddy Beck

Evaluation Department

UNAIDS, Geneva 8-6-2007

The introduction of combination antiretroviral therapy has had a profound

impact on mortality and morbidity patterns of people living with HIV…..

…and scaling up services, which countries are involved with as part of the

Universal Access process. This was agreed at the High Level Meeting in New York in June 2006 and is described in the

2006 Political Declaration on HIV/AIDS

• Scaling up of HIV prevention, treatment, care and support services;• Country driven process, in which countries set own ‘ambitious’ but ‘realistic’ targets• To make this happen needs to be ‘country owned’ process involving all stakeholders, especially people living with HIV and other members of civil society

Universal Access, 2006 Political Declaration on HIV/AIDS

Build on the momentum of scaling up treatment and care programs, including

Universal Access, 2006 Political Declaration on HIV/AIDS

Introduction of combination antiretroviral therapy has reduced

the mortality and morbidity of people living with HIV…..

but the irony is, that the momentum generated by scaling up treatment and

care programs, has also highlighted the need for improved prevention

services…………….

*Per 100,000 US Population;

MMWR. 2005;54(46):1188.

HIV and AIDS diagnoses and deaths, UK

Numbers will rise, for recent years, as further reports are received.

Clinician reports of new HIV/AIDS diagnosis

HIV diagnoses by exposure category, UK

Numbers will rise, for recent years, as further reports are received.

Clinician reports of new HIV/AIDS diagnosis

Review of Newly Diagnosed People with HIV, UK 2000-2004

• 15,523 newly diagnosed heterosexuals • 74% Black Africans, 11% White & 4% black Caribbeans• 42% diagnosed late: 43% of Black Africans, 36% of

Whites and Black Caribbeans.• Most Black Africans infected in Africa• 20% of Black Africans infected in the UK diagnosed

late, compared with 44% of those infected in Africa.

Chadborn et al, AIDS 2006,20: 2371-9

Global number of people newly infected with HIV and AIDS

deaths 2001-2006

This bar indicates the range around the estimate.

2002 2003 2004 2005 2006

Year

2001

Mill

ion

s

0

1

2

3

4

7

6

5Number of new HIV infections and number of people who died of AIDS

Number of new HIV infections

Number of people who died of AIDS

This bar indicates the range around the estimate.

This bar indicates the range around the estimate.

2002 2003 2004 2005 2006

Year

2001

Mill

ion

s

0

1

2

3

4

7

6

5

0

1

2

3

4

7

6

5Number of new HIV infections and number of people who died of AIDS

Number of new HIV infections

Number of people who died of AIDS

Economics of providing health services

• Cost of providing services

• Cost-effectiveness of interventions, programs or services

Cost of providing health services

• “What does it cost to run an HIV service?”;• “Is the service affordable?” • “Are additional resources required to provide

services in a particular manner?” • “What is the gap between the cost of services

and the financial resources spent on services?

Cost-effectiveness of interventions, programs or

services

• “what does it cost to achieve a certain outcome or impact?”;

• “does a new intervention add value?”

Cost-effectiveness of HAART?

• Canada

• South Africa

• UK

Cost-effectiveness of HAARTin Canada

NON-AIDS Group

0.6

0.7

0.8

0.9

1

0 100 200 300 400 500 600 700 800 900 1000

1100

1200

1300

1400

1500

1600

1700

Time since entry into cohort (days)

Pro

port

ion

rem

aini

ng in

CD

C s

tage

A&

B

1991-1995 1997-2001

Adjusted for gender, age, sexual orientation and IDU use, baseline CD4 count and ARV treatment

Clinical Progression for non-AIDS Patients in Quebec, Canada

1991 – 1995 vs 1997-2001

Clinical Progression for AIDS patients in Quebec, Canada

1991 – 1995 vs 1997 - 2001

AIDS Group

0.4

0.5

0.6

0.7

0.8

0.9

1

0 100 200 300 400 500 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800

Time since entry into cohort (days)

1991-1995 1997-2001

Adjusted for gender, age, sexual orientation and IDU use, baseline CD4 count and ARV treatment

Incremental cost per life-year-gained by

stage of HIV infection

• US $14,587 for non-AIDS patients

• US $12,813 for AIDS patients

Beck EJ, Mandalia S, Gaudreault M, et al The Cost-effectiveness of

HAART, Canada 1991-2001. AIDS, 2004; 18: 2411-9.

Cost-effectiveness of HAARTin South Africa

Clinical Progression for non-

AIDS patients, 1995 - 2000

0 1 0 0 2 0 0 3 0 0 4 0 0 5 0 0 6 0 0 7 0 0 8 0 0 9 0 0 1 0 0 0 1 1 0 0 1 2 0 0 1 3 0 0 1 4 0 0

Da ys

0 .0

0 .1

0 .2

0 .3

0 .4

0 .5

0 .6

0 .7

0 .8

0 .9

1 .0

Pro

po

rtion

rem

ain

ing

in W

HO

No

n-A

IDS

sta

ge

?

0 1 0 0 2 0 0 3 0 0 4 0 0 5 0 0 6 0 0 7 0 0 8 0 0 9 0 0 1 0 0 0 1 1 0 0 1 2 0 0 1 3 0 0 1 4 0 0

T i m e

0 .0

0 .1

0 .2

0 .3

0 .4

0 .5

0 .6

0 .7

0 .8

0 .9

1 .0

Pro

po

rtion

rem

ain

ing

in W

HO

No

n-A

IDS

sta

ge

P<0.0001

Badri M, Maartens G, Mandalia S, et al. Cost-effectiveness of Highly Active Antiretroviral Therapy in South Africa. Plos Medicine January 2006; 3: e4

Clinical Progression for AIDS patients, 1995 - 2000

0 1 0 0 2 0 0 3 0 0 4 0 0 5 0 0 6 0 0 7 0 0 8 0 0 9 0 0 1 0 0 0 1 1 0 0 1 2 0 0 1 3 0 0 1 4 0 0

Da ys

0 .0

0 .1

0 .2

0 .3

0 .4

0 .5

0 .6

0 .7

0 .8

0 .9

1 .0

Pro

po

rtion

rem

ain

ing

in W

HO

AID

S s

tag

e

P<0.0001

Badri M, Maartens G, Mandalia S, et al. Cost-effectiveness of Highly Active Antiretroviral Therapy in South Africa. Plos Medicine January 2006; 3: e4

Cost-effectiveness of HAART in non-AIDS and AIDS patients, Cape Town 1995 - 2000

Cost savingat annual HAARTCost of

US$730 orUS$ 181

US$2506 LYGat annual cost

HAARTof US$730

andUS$ 327 LYG

at US$181 per annum

Non-AIDS AIDS

Cost-effectiveness of different HAART regimens in the UK

Time to treatment failure for people on different first-line

HAART regimens

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 200 400 600 800 1000 1200 1400 1600 1800 2000 2200

Duration since starting 1st line HAART

Pro

po

rtio

n w

ho

se t

reat

men

t re

mai

n s

ucc

essf

ul

wit

h t

hei

r fi

rst

lin

e H

AA

RT

Other combinations

2NRTI+NNRTI

2NRTI+PI

2NRTI+2PI (unboosted)

2NRTI+2PI (boosted)

2439 (1189 to 3689)

4832 (2332 to 7332)

1571 (738 to 2405)

2378 (1128 to 3628)

1631 (798 to 2464)

The cost-effectiveness per life year gained (LYG) for first line

HAART

2NRTIs+NNRTI versus 2NRTIs+ PI

boosted

US$19,577 per LYG

2NRTIs+NNRTI versus 2NRTIs + PI

US$19,659 per LYG

2NRTIs+NNRTI versus 2NRTIs+ 2PI

US$ 8,571 per LYG

Conclusions

• HAART enables people living with HIV to remain socially and economically active

• HAART a cost-effective intervention in a number of high- and middle-income countries, despite differences in health care systems

• Evidence that viral load levels reflect levels of infectivity, so HAART reduces the infectivity of individuals living with HIV

Rationale for treating People living with HIV with HAART

• Human Rights Argument – the Joint UNAIDS Program is based on the premise that access to services and treatment is a basic human right

• Public Health Argument: treating people with HAART, reduces their infectivity and exposes them to prevention services for themselves and people within their social environment

Requirements

• For optimal treatment people living with HIV need to be followed up regularly and attend for follow up

• Drug combinations will eventually fail: if not under regular supervision may fail earlier, develop resistance etc.

• This provides opportunities to regularly reinforce prevention messages and practices

Realities in many countries

• However, ‘irregular’ migrants may be less likely to regularly attend health services, in fear of coming into contact with government officials, with potential consequences including deportation

• Even ‘regular’ migrants, especially those who belong to ethnic minorities, often access services late and services may be of lesser quality than those used by non-migrants

Realities in many countries

• Most vulnerable populations - women, youth, prisoners etc. – and

• most at risk populations – MSMs, IDUs, sex workers etc –

may be socially marginalized, be migrants themselves or members of ethnic minorities, all resulting in reduced access to appropriate services

For Universal Access to become a reality, even in Europe………

…. all these populations need to be reached and constructively engaged...

Thank you!