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Contribution of Economics to Operational Research for Evaluation of
Scaling Up Access to HIV Care & Treatment in Developing
Countries
Presentation by Pr Jean-Paul MoattiANRS-ETAPSUD Programme, University of the
Mediterranean WHO, Geneva, June 30, 2003
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Defining Operational Research
Learning lessons from what we’re doing while we’re doing it; finding out what works, what doesn’t, and what can be improved.
Contribution of economics to address questions relating to scaling up ART programmes:- How to maximise efficiency in access to care programs including ART in limited-resource settings ?- How to promote equity in access to ART ?- How to maximise the impact on the epidemic ?- How to assess the global impacts of these programs on public health, economic, social and human development ?
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More costly, less effective
Dominated strategy
Reject
Less costly, more effective
Domining strategy
Adoption
Costs (+)
Health benefit
Cost-effectiveness comparison of a new strategy Cost-effectiveness comparison of a new strategy versus current standardversus current standard
Less costly, less effective
More costly, more effective
Acceptability of health losses for reducing costs ?
Willingness to pay for additional benefit ?
(+)(-)
(-)
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Marginal cost per lifeyear
ARV
Population
Population
Others
ARVsV
SV
Hyp : ARVs always dominated Plausible hyp : ARV costeffectiveness ratios intersect those of
alternative strategies
Cost-effectiveness of ARV therapies versusCost-effectiveness of ARV therapies versus
Alternative strategies for HIV/AIDS careAlternative strategies for HIV/AIDS care
Others
Marginal cost per lifeyear
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Cost-effectiveness Criterion in rich countries
• Marginal cost per lifeyear gained
< 2 x GDP/cap => accepted
> 6 x GDP/tête => rejected
• Marginal health care cost per lifeyear gained of HAART vs Non HAART =
14,000US$ MC 26,000US$
OCDE countries GDP/cap = 28,000 US$
• HAART cost-saving when indirect costs are included
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Why not a similar criterion in developing countries ?
• => MTCT prevention, cotrimoxazole and tuberculosis prophyaxis = cost-effective
• => ARV treatment in well defined groups ?
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Contribution of Economics (1)
Cost-effectiveness research to optimize therapeutic strategies in limited-resource settings:
- Criteria for rational decision to initiate treatment.
- Optimal 1st, 2nd (and 3rd) line treatment for adult
patients.
- Optimal regimens for specific indications, e.g.,
opportunistic infections, tuberculosis, pregnancy,
children.
- Optimizing the use of generic drugs.
- Assessment of tolerance, adherence, and acceptability
of treatment.
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Contribution of Economics (2)
Cost-effectiveness research to optimize means of initiating and monitoring therapy in limited-resource settings:
- Feasibility of low-cost methods of enumerating CD4 cells, measuring plasma viral load, and assessment of their large-scale use.
- Optimal frequency of biological monitoring.- Feasibility and role of clinical scales for monitoring. - How to simplify monitoring protocols without jeopardizing
safety and tolerance.
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Contribution of Economics (3)
Cost-effectiveness research to to determine best practices in healthcare delivery of ART:
Impact of treatment guidelines and of standardizing first-line treatment
Econometric analysis to evaluate differential efficiency of public policies between countries and between centers.
Impact of different financial schemes for funding ARV costs and of different delivery systems
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Contribution of Economics (4)
Management research for improving the logistics of ARV-delivery programs:
- Capacity of existing medical operations at national,
regional, and district levels.
- Needed changes in organization and regulation of healthcare delivery systems.
- Trade-off in choice of adding specialized structures for the delivery of HIV care vs. integrating into general healthcare.
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Impact on HIV-infected population and general population
Economic and sociobehavioral research to assess the impact of expanding access to HIV treatment at the population level:
- Impact on life expectancy, quality of life, psychological and socioeconomic status of ARV-treated patients.- Best ways to address equity issues relating to access to care. - Impact on HIV-related risky behaviors and on prevention in HIV-infected and general population.- Impact on social perception of HIV/AIDS, stigma and discrimination.
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Microeconomic and macroeconomic, impact on development.
- Microeconomic impact on households, families, local/
regional food production, and productivity of various
economic sectors.
- Improvement of macroeconomic models to take into
account the impact on human capital.
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Minimum requirements for economic research in ARVT data base
- Longitudinal data or repeated cross-sectional in ”homogeneous” populations
- Data about health care resource use in standardised physical units
- Access to biological and clinical outcomes
- Minimum data about socio-economic characteristics of ARV-treated patients (level of education, size of household, areea of residence)
- Questionnaires in sub-samples (risk behaviours, adherence, indirect costs)
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Major difficulties for economic research in ARVT data base
- Data about the ”general” HIV-infected population in order to compare ARV-treated to non-ARV treated ?
- Data collection not only in health care centers but at the household level ?
- Treatment of selection bias and uncertainty on parameter estimates used in C/E or econometric models?
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Research priorities in next 12 months
Cost-effectiveness studies of ARV treatment in resource-limited settings using real data.
Assessment of logistics and management problems to scaling up access to ART at regional and district levels.
Evaluation of socio-economic, educational and informational characteristics of HIV+ patients benefiting from ART.