treatment and care needs for hiv in india

* Corresponding author, Email: [email protected], [email protected]

Resource Needs for HIV in India

*Subhra Dattaa and Sulabha Parsuramanb

a Independent Consultant b Retired Professor, International Institute for Population Sciences, Mumbai, India

Abstract

Resource burden to provide necessary care, treatment, support and prevention for HIV is huge on scarce government resources. The current study tries to quantify the resource burden for HIV in India during 2009-2015. The premise being, even after revision of the estimate of PLHA from 5.2 million to 2.5 million in 2006, India still has the third largest share of PLHA in the world. We have used UNAIDS methodology to calculate PLHA, new infection, treatment needs, etc. by Spectrum and Workbook assuming three alternative scenarios which are derived based on treatment and care needs. Components of resource needs that have been considered in this study include prevention among high risk groups, service delivery and health care. The data sources include UNAIDS, Census of India, SRS, NFHS and BSS. Under the three scenarios, PLHA is projected to vary from 2.29-2.73 million in 2015 with an uncertainty bound of 2.24-2.95 million. The number of adults in need of first line ART will range from 0.6 to 1.1 million in 2015. Total resource needs for HIV is projected to be 28 percent of the health budget of Government of India in 2015.

Key words: Adult ART; second line ART; resource need; PMTCT; HIV/AIDS

Introduction

Ever since the reporting of the first case of acquired immunodeficiency syndrome (AIDS) in

1981, one of the greatest challenges faced by the mankind is the pandemic of AIDS. Since the

beginning of the epidemic, almost 60 million people have been infected with human

immunodeficiency virus (HIV) and 25 million people have died of HIV related causes (UNAIDS

and WHO, 2009). According to the United Nations Development Programme (UNDP), HIV has

inflicted the “single greatest reversal in human development” in modern history (UNDP, 2005).

In Asia, HIV causes a greater loss of productivity than any other disease, and is likely to push an

additional six million households into poverty by 2015 unless national responses are strengthened

(Commission on AIDS in Asia, 2008).

India accounts for roughly half of Asia’s HIV prevalence. Even after revising the estimate of

PLHA from 5.2 million to 2.5 million after the nationwide NFHS-3 (2005-06), which tested over

1,02,000 blood specimens from adult men and women, India has the third largest HIV population

(UNAIDS, 2007). Over the years, researchers have voiced their concern about the HIV epidemic

in India and its impact on individuals, families and society as a whole (Kanjilal, 1995; Basu,

Gupta & Krishna, 1997; Anand, Pandav & Nath, 1999; Gupta, Roy &. Trivedi, 2004; Mahal &

Rao, 2005; Pradhan, Sundar & Singh, 2006; Das, Mukhopadhyay & Ray, 2007; Haacker, 2009).

Because of low level of HIV prevalence in India and since the epidemic is concentrated in nature,

most of the macroeconomic impact is found to be insignificant. It has been argued that the impact

of the epidemic so far has not been serious enough to make any significant dent in the socio-

economic and demographic scenario of the country. On the other hand, at the micro level, a few

studies have shown a noticeable drop in household income, an increase in debt and mortgaging,

the continued presence of older household members in the labour market, effects on the form and

patterns of employment of care givers and significant hardship especially in treatment seeking

(Singh, Verma & Prasad, 2003; Pradhan, Sundar & Singh, 2006).

In India, households contribute a significant portion (71 percent) of total health expenditure for

availing health care services. Of the total health expenditure in 2004-05, the share of private

sector is 78.05 percent, public sector and the external flows contributed 19.67 and 2.28 percent

respectively (Ministry of Health and Family Welfare [MoHFW], 2009). Thus, in India, health

expenditure is mostly out of pocket household expenditure unlike most of the western countries

where majority of the health expenditures is usually borne by the public sector or the insurance

agencies. Since in India, public health services and insurance agencies play relatively a minor

role, the high costs of ART may expose households to the risk of poverty while the inability to

afford ART could spell disaster on the society. Also, in light of the small role of private insurance

and the costs of treatment, especially regarding a transition to second line treatment, ART may

not be affordable for a large number of households. Over (2009a) shows that for a four-person

household in India, the costs of first-line ART would push a household at the 40th percentile of

the income distribution down to the poverty line, that is, to a level of consumption at par with the

20th percentile of the income distribution.

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In 2004, the Government of India (GoI) has decided to provide free ART to those who need it

and had a target of providing free ART to 3,00,000 PLHA by 2011. Over (2009b) estimates that

public financing of AIDS treatment might avert poverty for about three percent of the Indian

population. The author in another paper argues that due to higher adherence quality of the

treatment by public health services, it is expected to crowd out lower-quality private AIDS

treatment, thereby preventing some negative spillovers of poor-quality treatment (Over, 2009a).

Observably the decision of the GoI for free ART is going to either increase the health budget or

else the necessary resources for HIV-related treatment cost will come from the share of other

diseases.

Though HIV prevalence in India is about 0.3 percent, it is a substantial number and the burden to

provide necessary care, treatment, support and prevention is huge on scarce government

resources. Currently the ongoing National AIDS Control Program – III (NACP-III), 2007-2012,

has a target of reversing the trend of the epidemic in the country by 2011. India’s success in

tackling the future spread of HIV depends on successful mobilization of resources that are needed

to meet the HIV related expenditure. The total outlay for NACP-III (2007-2012) is approximately

US$2574 million which includes support from the World Bank, Department for International

Development (DFID), UK and pooled funds from GoI, Global Fund against AIDS, TB and

Malaria (GFATM), and contributions from bilateral agencies and private initiatives such the Bill

and Melinda Gates Foundation. About 25 percent of this allocation is from direct budgetary

sources, 35 percent from external sources through the budget, and 30 percent extra-budgetary.

The outlay has a funding gap of 10 percent for which resource mobilization efforts are underway

(UNGASS, 2010). Since the direct contribution of GoI in NACP-III budget is about 25 percent,

India will struggle to fight HIV, if external funding dries up. Thus, India needs to find a way to

meet the expenditures associated with HIV in lieu of no external assistance. In this paper, we

have tried to predict the future course of HIV along with different treatment needs like adult and

child ART, prevention need for Mother to Child Transmission (MTCT) and children needing

cotrimoxazole.

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Rationale for the study

There are very few exhaustive studies in India that depict the burden on the health sector due to

the decision of the GoI to provide free ART to those who need it. Gupta et al., (2009) taking

different unit cost of providing ART, showed that by 2011, India will need Rupees (`) 6017 to `

9264 million to provide free ART to about 0.15 million patients. In the year 2007, this was about

1.5 percent of the total health and family welfare budget. Though the actual number of patients

on ART (0.48 million by end of January 2012) in the country has more than tripled than what the

above study projected to be, the research is one of the very few that throw light on the cost

associated with the free ART program of the GoI. Another study by Over (2009a), found that the

costs of treatment could rise to US$1.8 billion by 2020, corresponding to 1.2 percent of total

health expenditures. In light of the small share of public health expenditures in total health

spending, the costs of a comprehensive scaling up would correspond to a much higher share

(seven percent) of public health expenditures. The number of patients receiving second line

therapy was projected to rise to 0.5 million by 2020, accounting for 20 percent of people

receiving ART. However, reflecting higher prices, second line therapy would account for over

one-half (55 percent) of the total costs by the year 2020.

Both the above mentioned studies focus on the costs associated with providing free ART.

However, both did not include other components of treatment and care considered in this study

like PMTCT, STI management, OIs and palliative care costs. There would be further escalation

of the health budget if one includes costs of all these components. Even the projected patients on

ART were not linked with the number of people in need of ART. Also, the ART needs are

different than the time when the above mentioned studies were conducted. Due to the dynamic

nature of HIV infection, it is imperative to look after the different aspects of treatment and care

needs related to HIV in order to reverse the course of the pandemic. A comprehensive study

addressing the resource needs of treatment and care for HIV will not only serve to understand the

phenomenon better, it will also help to take initiatives to mobilize the required fund from

different donor agencies.

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Objectives

In this paper, we have tried to estimate the resource needs to provide treatment and care for

HIV/AIDS during the period 2012-2015, assuming three alternative scenarios which are derived

based on treatment and care needs for HIV/AIDS. The specific objectives are:

1. To project the magnitude of HIV/AIDS during 2012 to 2015.

2. To project the resource needs for treatment and care for HIV/AIDS from 2012 to 2015.

Methodology

We have used the UNAIDS methodology to estimate HIV till 2015 assuming three alternative

scenarios along with other suitable assumptions. The projected HIV population forms the base for

estimating the resource burden for treatment and care.

Estimation of HIV

For HIV estimation, we have used NACO and UNAIDS estimates of HIV prevalence (15-49

years) for India and fed the prevalence estimates in UNAIDS Workbook1 to generate an epidemic

curve from 1985-2006 by fitting a double logistic regression. The parameters were then used to

project the HIV prevalence for the period 1985-2015 (Figure 1). The projected HIV prevalence

was fed into Spectrum2 along with other demographic parameters and epidemiological

assumptions (Table 1) to calculate people living with HIV, new infection, treatment needs etc. in

three different scenarios (Table 2). People living with HIV were also projected assuming ‘No

Treatment’ scenario to see the impact of care and treatment. Uncertainty analyses around the 1 The UNAIDS Workbook was developed to estimate and build future scenarios of HIV prevalence in countries with low-level and concentrated epidemics. It consists of a series of Excel spreadsheets composed of point prevalence worksheets and epidemic curve worksheets. It can be used to generate an epidemic curve for HIV and estimates of adult prevalence. 2 Spectrum is a suite of policy models (DemProj, FamPlan, AIM, RAPID, Ben-Cost, NewGen, PMTCT, ProTrain, and SupplyPlan). We have used the demographic projection (DemProj) and the AIDS Impact Model (AIM) for HIV estimation. The DemProj have been used to project the population for India by age and sex, based on assumptions about fertility, mortality, and migration. AIM was used to project the consequences of the HIV/AIDS epidemic, including the number of people living with HIV/AIDS, new infections, AIDS deaths by age and sex, number of adults and children in need of antiretroviral (ARV) treatment and prevention need for MTCT.

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Figure 1: Adult HIV prevalence for India by UNAIDS Workbook, 1985-2015

Year 1985 1988 1991 1994 1997 2000 2003 2006 2009 2012 2015HIV Prevalence - Workbook 0.00% 0.00% 0.03% 0.15% 0.42% 0.52% 0.44% 0.36% 0.32% 0.31% 0.30%

different parameters were done using Spectrum. This involved generating up to 1000 logistic

curve fits. The uncertainty analysis is processed using these curves combined with distributions

around key assumptions in Spectrum.

Resource needs estimation for treatment and care

Resource Needs for HIV/AIDS are primarily for prevention and intervention, care and treatment

and mitigation. As mentioned earlier, we have only considered the care and treatment component

for the present study. Resource needs for the specific components that have been considered in

this study are: STI management, Opportunistic Infections (OIs), palliative drugs, PMTCT, access

to Post Exposure Prophylaxis (PEP), ART for adults, and ART for children. For resource needs

calculation, the basic step is to first estimate the number of people receiving each service. This is

done by multiplying the number of people needing the service by the coverage rate (the percent

of those needing the service that actually receive it). The resources needed are estimated by

multiplying the number of people getting the service by the unit cost of providing the service.

Since PMTCT requires a different methodology, it has been discussed separately.

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Table 1: Input parameters in Spectrum along with source of information

Parameters Source of information Demographic Data Base year (1985) population by age and sex

Our estimate using spectrum

Life expectancy by sex SRS and Registrar General of India (RGI) estimates (RGI, 2006) Total Fertility Rate (TFR) SRS and RGI estimates (RGI, 2006) Migration Was not considered Sex ratio at birth Till 2000, UNAIDS estimates.; 2001 onwards RGI 2006 Model Life Table Coale-Demeny West ASFR UN Asia model Epidemiological assumptions

HIV age distribution NFHS 3 (best possible source for HIV age distribution, year wise age distribution for HIV affected people are not available)

Infant feeding pattern NFHS 1, 2 and 3 (Breast feeding pattern till 1992-93 from NFHS-1, for 1998-99 and 2005-06, NFHS-2 and 3 data are used respectively. For intermediate years, interpolated figures are used)

Abortion data NFHS 1, 2 and 3 (Estimated from NFHS 1, 2 and 3; last five years preceding survey and only the last birth is considered)

TB Incidence and prevalence Spectrum default (No India specific other reliable prevalence data available)

Program data Till 2008, NACO/UNAIDS(UNAIDS, 2008b), after that three different scenarios assumed

Percent married among High Risk Groups (HRGs)

BSS (2006) [NACO, 2006]

Table 2: Three different scenarios assumed for projection of resource needs for treatment

and care

Adult ART Children needing

cotrimoxazole

Child ART PMTCT

Scenario 1 Level of ongoing NACP III scale up till 2015

Target 50% of all needs by the year 2015

100% on ART who needs it

100% coverage who needs it

Scenario 2 Target 75% on ART by the year 2015 among those who needs it




Scenario 3 Target 100% on ART by the year 2015 among those who needs it




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Estimating resource need for PMTCT

It is assumed that only those women who receive some antenatal care (ANC) can be reached

through PMTCT intervention. This is combined with data obtained from Spectrum projection

(total population and crude birth rate) to calculate pregnant women receiving antenatal care.

NFHS-3 (2005-06) reports that there are 77.7 percent women with some ANC. Institutional

delivery was reported to be 26 percent in NFHS-1, 34 percent in NFHS-2 and 41 percent in

NFHS-3 [International Institute for Population Sciences (IIPS) and Macro International, 2007;

2000; 1995]. Assuming the rate of improvement from NFHS-2 to NFHS-3 to be linear,

institutional delivery is projected to be about 55 percent by 2015.

We need to know three coverage indicators for estimating resource needs for PMTCT.

1. Percent of pregnant women attending ANC tested for HIV. This indicator combines the

availability of PMTCT at antenatal clinics and the percent of women who accept the test if

the service is available.

2. Percent of HIV positive pregnant women treated with ART. This is the percent of women who

are tested and found to be HIV-positive who receive treatment to prevent mother to child

transmission.

3. Percent of HIV positive women who receive infant formula to avoid transmission through

breastfeeding.

The calculations are as follows: Number of women attending ANC services (t) = Population (t) / 1000 * crude birth rate (t) *

percent of women who had some ANC / 100 Number of women receiving counselling and testing (t) = Number of women attending ANC

services (t) * % of pregnant women attending ANC tested for HIV / 100 Number of HIV+ women receiving ART prophylaxis (t) = Number of women receiving

counselling and testing (t) * HIV prevalence among pregnant women (t) /100 * % HIV positive women treated with ART/100

Number of HIV+ women receiving formula (t) = Number of women receiving counseling and

testing (t) * HIV prevalence among pregnant women (t) /100 * % HIV positive women receiving formula/100

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Resources required (t) = Number of women receiving counselling and testing (t) * cost per

women receiving counselling and testing + number of HIV+ women receiving ART prophylaxis

(t) * cost per women testing HIV+ and receiving ART + number of HIV+ women receiving

formula (t) * cost per woman of six months of formula

Results

Projected HIV/AIDS situation in India

Table 3-6 illustrates the need for adult ART, child ART, mothers needing PMTCT and children

needing cotrimoxazole in case if ‘No treatment’ is available for HIV for the projection period

2009-2015. Spectrum gives a low and high estimates of the parameters based on the confidence

intervals of the curves. On average, adult ART need will be about half a million during 2009-

2015 under ‘No Treatment’ scenario (Table 3). The need for child ART would be in the region of

fifty thousands (Table 4) whereas the need for PMTCT and children needing cotrimoxazole will

be around thirty thousand and 100 thousand respectively (Table 5 and Table 6). In case of

Scenario 1, for adult ART, we assumed that currently ongoing scale-up will continue till 2015.

Thus the input values in Spectrum was not in terms of percentage coverage but predicted values

obtained by fitting a simple linear trend line on the adult ART coverage till 2008. Table 7 gives

the values of program data that are used for predicting HIV in different assumed scenarios, which

is the numerical representation of Table 2.

Table 3: Total adult (15+) ART need assuming ‘No Treatment’ scenario

2009 2010 2011 2012 2013 2014 2015Total 573,801 565,156 551,198 535,296 519,703 505,780 494,221Low estimate 517,175 509,085 495,069 475,628 457,750 441,867 429,392High estimate 637,209 620,744 607,802 593,671 581,802 571,862 565,129

Table 4: Children needing ART assuming ‘No Treatment’ scenario


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Table 5: PMTCT need assuming ‘No Treatment’ scenario


Table 6: Children needing cotrimoxazole assuming ‘No Treatment’ scenario

2009 2010 2011 2012 2013 2014 2015Total 111,755 106,476 101,820 97,126 92,259 88,337 84,613Male 58,609 55,853 53,428 50,984 48,451 46,414 44,480Female 53,146 50,623 48,392 46,142 43,808 41,923 40,133

Table 7: Data used for HIV projection under three different scenarios

Scenario 1 2009 2010 2011 2012 2013 2014 2015

Adults on ART 225,268 266,385 307,502 348,619 389,736 430,853 471,970Children on cotrimoxazole 8,219 16,628 23,951 30,655 36,443 42,029 46,828Children on ART 35,731 48,715 53,136 55,242 55,204 53,949 51,986On MTCT 33,873 31,152 29,436 27,878 26,681 26,203 25,771

Scenario 2 Adults on ART 178,086 221,718 272,905 333,526 403,822 486,280 582,324Children on cotrimoxazole 12,387 24,895 35,974 46,123 55,049 63,696 71,544Children on ART 35,731 48,732 53,180 55,329 55,353 54,192 52,362On MTCT 33,872 31,164 29,492 28,023 26,985 26,763 26,687

Scenario 3 Adults on ART 198,133 265,907 347,983 448,750 571,407 721,453 903,083Children on cotrimoxazole 16,550 33,287 48,189 61,736 74,211 86,829 99,060Children on ART 35,730 48,749 53,229 55,440 55,566 54,574 53,002On MTCT 33,854 31,178 29,623 28,351 27,682 28,060 28,805

Under the assumed scenarios, adult (15-49 years) HIV prevalence rate is projected to vary from

0.30 to 0.38 percent in 2015 in the three different scenarios (Table 8). The corresponding number

of people living with HIV is projected to vary from 2.29 to 2.73 million in 2015 with an

uncertainty bound of 2.25-2.95 million (Table 9). As mentioned before, the assumed coverage

rate for program parameters for scenario 2 is higher than scenario 1 and for scenario 3 it is higher

than scenario 2. Since more people will be surviving because of increase in access to treatment

and care, the estimated HIV prevalence is projected to be the highest in case of scenario 3

compared to the other two scenarios. In case of scenario 2, the overall estimated HIV population

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Table 8: Estimated HIV prevalence (15-49 years) rate for India by Spectrum and Workbook, 2002-2015

Spectrum No Treatment Scenario 1 Scenario 2 Scenario 3

Year Work- book

Point Estimate

Low estimate

High estimate

Point Estimate

Low estimate

High estimate

Point Estimate

Low estimate

High estimate

Point Estimate

Low estimate

High estimate

2002 0.47 0.47 0.46 0.49 0.47 0.46 0.49 0.47 0.46 0.49 0.47 0.46 0.49 2003 0.44 0.44 0.43 0.46 0.44 0.43 0.46 0.44 0.43 0.46 0.44 0.43 0.46 2004 0.41 0.41 0.41 0.43 0.41 0.41 0.43 0.41 0.41 0.43 0.41 0.41 0.43 2005 0.38 0.38 0.38 0.40 0.38 0.38 0.40 0.38 0.38 0.40 0.38 0.38 0.40 2006 0.36 0.36 0.36 0.38 0.36 0.36 0.38 0.36 0.36 0.38 0.36 0.36 0.38 2007 0.35 0.35 0.35 0.36 0.35 0.35 0.36 0.35 0.35 0.36 0.35 0.35 0.36 2008 0.33 0.33 0.33 0.35 0.33 0.33 0.35 0.33 0.33 0.35 0.33 0.33 0.35 2009 0.32 0.32 0.32 0.34 0.32 0.32 0.35 0.32 0.32 0.35 0.32 0.32 0.35 2010 0.32 0.32 0.32 0.34 0.32 0.32 0.34 0.32 0.32 0.34 0.32 0.32 0.35 2011 0.31 0.31 0.31 0.33 0.31 0.31 0.34 0.31 0.31 0.34 0.32 0.31 0.35 2012 0.31 0.31 0.31 0.32 0.31 0.30 0.34 0.31 0.30 0.34 0.32 0.31 0.35 2013 0.30 0.30 0.30 0.32 0.31 0.30 0.34 0.31 0.30 0.34 0.33 0.31 0.36 2014 0.30 0.30 0.30 0.32 0.31 0.30 0.34 0.32 0.30 0.35 0.34 0.32 0.37 2015 0.30 0.30 0.30 0.31 0.31 0.30 0.34 0.32 0.31 0.36 0.35 0.33 0.38

Table 9: Estimated HIV population of India (in million), 2002-2015

No Treatment Scenario 1 Scenario 2 Scenario 3 Year Point

Estimate Low

estimate High

estimate Point

Estimate Low

estimateHigh

estimate Point

Estimate Low

estimateHigh

estimate Point

Estimate Low

estimateHigh

estimate 2002 2.75 2.70 2.88 2.75 2.70 2.88 2.75 2.70 2.88 2.75 2.70 2.88 2003 2.65 2.60 2.76 2.65 2.60 2.76 2.65 2.60 2.76 2.65 2.60 2.76 2004 2.55 2.50 2.66 2.55 2.50 2.66 2.55 2.50 2.66 2.55 2.50 2.66 2005 2.46 2.41 2.56 2.46 2.41 2.56 2.46 2.41 2.56 2.46 2.41 2.56 2006 2.39 2.34 2.47 2.39 2.34 2.47 2.39 2.34 2.47 2.39 2.34 2.47 2007 2.33 2.28 2.42 2.33 2.28 2.42 2.33 2.28 2.42 2.33 2.28 2.42 2008 2.29 2.24 2.37 2.29 2.24 2.37 2.29 2.24 2.37 2.29 2.24 2.37 2009 2.26 2.20 2.38 2.26 2.20 2.40 2.26 2.20 2.39 2.26 2.20 2.39 2010 2.24 2.19 2.36 2.25 2.19 2.40 2.25 2.20 2.41 2.26 2.20 2.42 2011 2.23 2.18 2.35 2.25 2.19 2.43 2.26 2.20 2.44 2.28 2.20 2.47 2012 2.23 2.18 2.35 2.26 2.19 2.47 2.28 2.20 2.49 2.33 2.23 2.55 2013 2.24 2.19 2.36 2.29 2.21 2.51 2.33 2.23 2.55 2.42 2.30 2.63 2014 2.26 2.22 2.38 2.34 2.24 2.57 2.40 2.29 2.64 2.55 2.41 2.77 2015 2.29 2.25 2.41 2.39 2.28 2.62 2.50 2.37 2.73 2.73 2.55 2.95

will increase from 2.29 million [2.24 – 2.37 million] in 2008 to 2.50 million [2.37-2.73 million]

in 2015 whereas, in case of scenario 3, predicted HIV population will reach 2.73 million [2.55-

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2.95 million]. As the assumed coverage of treatment and care is the highest in Scenario 3,

expectedly AIDS deaths are estimated to be the least in case of Scenario 3. In fact 35 percent of

AIDS deaths may be averted during 2009-2015 compared to ‘No Treatment’ scenario, if India

can scale up the treatment and care program as assumed in Scenario 3 (Table 10).

Table 10: Cumulative AIDS deaths (in million), India, 2006-2015

Year No Treatment Scenario 1 Scenario 2 Scenario 3 2006 1.61 1.61 1.61 1.61 2007 1.81 1.81 1.81 1.81 2008 2.00 2.00 2.00 2.00 2009 2.21 2.19 2.19 2.18 2010 2.41 2.36 2.36 2.35 2011 2.62 2.53 2.52 2.50 2012 2.82 2.69 2.68 2.64 2013 3.02 2.85 2.82 2.76 2014 3.22 3.00 2.96 2.87 2015 3.41 3.15 3.08 2.96

Projected need for treatment and care

Table 11 provides the rationale for arriving at the targets for different components of treatment

and care considered in this study. As mentioned earlier, Adult ART, MTCT, Children needing

cotrimoxazole and child ART are assumed to have different coverage in the three different

assumed scenarios (Table 12).

Projected cost of treatment and care for HIV/AIDS

As mentioned earlier, we just need to know the unit cost of coverage of a particular service and

along with that the number of people who are getting the service, in order to estimate the resource

needs for that particular component. Arriving at the unit cost of each of the services is a tedious

process and requires special expertise as the unit cost of service delivery is derived from multiple

sources. Hence it was decided, that we will use NACP III estimate of unit cost for different

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Table 11: Premise for arriving at the targets of different components of treatment and care

Components Target by 2015 Rationale Source of data

STD treatment 33.7 Mn Adult population in India is projected to be 674 million in 2015. 5 % of adults in India suffer from STD symptoms and 2% of those needs laboratory services. NACP-III will cover 50% under the program and remaining 50% with public-private partnership. We also assumed that 100% of those suffering from STD will be addressed by 2015

Spectrum prediction

Opportunistic Infections (OIs)

Scenario 1 0.30 Mn

Scenario 2 0.32 Mn

Scenario 3 0.35 Mn

10% of PLHA are immuno-compromised and prone to have opportunistic infections. Four OI episodes per year reported (Tambaram). ART is likely to reduce OI incidence by 60%. 80% of the AIDS cases are assumed to be identified

Spectrum prediction

PPTCT counselling coverage

13.1 Mn 80% of institutional deliveries by 2015

Prediction by Spectrum and NFHS- 3

MTCT Provision Scenario 1 100% coverage who needs it for each of the projection

year Spectrum prediction

Scenario 2 100% coverage who needs it for each of the projection year

Spectrum prediction

Scenario 3 100% coverage who needs it for each of the projection year

Spectrum prediction

Number of CHC, districts and tertiary hospitals having access to PEP

3000

All public sector units. It is assumed to remain same as that of NACP-III target by 2011 for the projection period

NACP-III

Adult ART Scenario 1 0.47 Mn Level of ongoing NACP-III scale up till 2015 Spectrum prediction

Scenario 2 0.58 Mn Target 75% on ART by the year 2015 among those who need it

Spectrum prediction

Scenario 3 0.90 Mn Target 100% on ART by the year 2015 among those who need it

Spectrum prediction

Child ART Scenario 1 100% on ART who needs it Spectrum prediction Scenario 2 100% on ART who needs it Spectrum prediction Scenario 3 100% on ART who needs it Spectrum prediction

Palliative drugs

The number of adults and children newly needing care minus those who start receiving ART plus those dying in the current year

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Table 12: Assumed targets for the projection period of different components of treatment and care

Components 2012 2013 2014 2015 Target

2015 (Mn) Number of adults with STD symptoms covered

32,390,470 32,847,733 33,289,573 33,731,052 33.73

OI infections Scenario1 289,714 293,480 298,892 306,146 0.30 Scenario2 292,061 298,234 307,356 319,925 0.32 Scenario3 298,310 309,631 326,267 349,055 0.35

Palliative drugs Scenario1 298,265 290,711 284,428 280,138 0.28 Scenario2 270,870 249,310 225,949 202,667 0.20 Scenario3 213,227 174,943 132,146 87,572 0.09

Number of women covered through PPTCT counselling

8,758,440 10,112,666 11,569,367 13,135,374 13.14

MTCT Coverage target Scenario1 27,878 26,681 26,203 25,771 0.25 Scenario2 28,023 26,985 26,763 26,687 0.27 Scenario3 28,351 27,682 28,060 28,805 0.29

Number of public hospitals having access to PEP

3000 3000 3000 3000

Adult ART (First Line) Scenario1 348,619 389,736 430,853 471,970 0.47 Scenario2 333,526 403,822 486,280 582,324 0.58 Scenario3 448,750 571,407 721,453 903,083 0.90

Child ART Scenario1 55,242 55,204 53,949 51,986 0.05 Scenario2 55,329 55,353 54,192 52,362 0.05 Scenario3 55,440 55,566 54,574 53,002 0.05

components for this exercise. Table 13 summarizes the total cost for the different components of

treatment and care for HIV/AIDS.

STI Management

The size estimation of the requirement of STI treatment needs depends on the prevalence of STI

and the number of adult population in each of the projection year. The target for STD treatment is

set at 33.7 million. The basis for arriving at the target is that in India adult population is projected

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to be 674 million in 2015. Five percent of adults in India suffer from STD symptoms and two

percent of those needs laboratory services. NACP III will cover 50 percent under the program

and the remaining 50 percent with public-private partnership. We also assumed that 100 percent

of those suffering from STD will be addressed by 2015. The unit cost (`15) of addressing one

STD case is taken from NACP III program document and the total cost of meeting the STD

treatment target is `1984 million for the projection period.

Opportunistic Infections

The target for treatment for OIs in 2015 varies from 0.30 million in Scenario-1 to 0.35 million in

Scenario-3. The logic of arriving at the target is: Ten percent of PLHA are immuno-compromised

and prone to have OIs. Four OI episodes per year are reported for HIV infected people

(Tambaram hospital, NACP III). ART is likely to reduce the OI incidence by 60 percent. Eighty

percent of the AIDS cases are assumed to get identified. Hence for 2.5 million HIV cases, OIs

will be (2.5*0.1*4*0.4*0.8). The average unit cost of treating one OI is taken as Rs. 836 in

NACP III. The total cost of meeting the target for OIs will vary from `993 million in Scenario 1

to `1073 million in Scenario 3 for the period 2012-2015.

Prevention of mother to child transmission (PMTCT)

We have assumed that 80 percent of the institutional delivery will be covered for PPTCT

intervention by 2015. The target was kept same as that of NACP-III for the period 2009-2011 and

was then scaled up for the remaining years.

Costing assumption for PMTCT

In NACP-III, it has been decided that all the ICTC centers will have PMTCT facility and hence

cost for no new PMTCT centre is required as the costing is incorporated in the ICTC centers. We

have assumed that the salary and construction allocation for the existing exclusive 502 PMTCT

centers will remain same for the projection period. As the case with any resource crunch set up,

we have assumed that only single dose nevirapine will be given to mother-baby pair. Assumed

15

costs for test are: 100% cases @ `13 per case, 10% cases @ `40 per case and 0.36% (HIV

prevalence) case at `100 per case. Costing of drugs for pregnant mothers are assumed as:

nevirapine tablets @ `10 per case, nevirapine syrup @ `95 per case (NACP-III, 2006). For

predicting financial requirement, we have kept the salary and construction cost fixed for the

projection period as is the case with current NACP-III budget. The cost does not vary much in the

three different scenarios as the number of HIV positive pregnant women remains more or less

same in the three scenarios. India will require an estimated `1491 million to address assumed

target of PMTCT.

Palliative Drugs

Palliative care refers to care that addresses pain and discomfort associated with HIV. The

population potentially in need of palliative care is the number of adults and children newly

needing care minus those who start receiving ART plus those dying in the current year. The costs

of caring for children are expressed as a ratio of the adult costs. The default value is 100 percent.

The calculations are as follows:

Population in need of palliative caret = (Adults newly needing caret + Children newly needing

care * Ratio of child care costs to adult care costs) * (1 - % on ART) + Patients dyingt

Population receiving palliative caret = Population in need of palliative caret * coveraget

Resources neededt = Population receiving palliative caret * unit cost

Table 12 gives the required data obtained from Spectrum for estimation of annual palliative care

need. Unit cost of providing palliative care per person per year is taken as `44 (NACP-III).

Resource needs for palliative care will be the least in case of Scenario 3 because of higher

number of assumed people on ART. Total estimated cost for palliative drugs will vary from `50

million in case of Scenario 1 to `27 million in Scenario 3 (Table 13).

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Table 13: Resource needs for different treatment and care components (` in Million)

Components 2012 2013 2014 2015 Total STI Management 485.9 492.7 499.3 506.0 1,984

OIs

Scenario 1 242.2 245.3 249.9 255.9 993 Scenario 2 244.1 249.3 256.9 267.4 1,018 Scenario 3 249.4 258.8 272.7 291.8 1,073

Palliative drugs Scenario 1 13.0 12.7 12.4 12.2 50 Scenario 2 11.8 10.9 9.8 8.8 41 Scenario 3 9.3 7.6 5.8 3.8 27

PMTCT Testing 152.0 175.6 200.8 228.0 756 Salary and construction work 180.7 180.7 180.7 180.7 723 Mother baby pair treatment drugs Scenario 1 3.1 2.9 2.8 2.8 12 Scenario 2 3.1 2.9 2.8 2.8 12 Scenario 3 3.1 3.0 2.9 2.9 12 Total PMTCT 342.0 365.1 390.0 417.2 1,514

Number of CHC, districts and tertiary hospitals having access to PEP 103.1 103.1 103.1 103.1 412

Adult ART (First Line) Scenario 1 ART Drugs 2,789.0 3,117.9 3,446.8 3,775.8 13,130 CD4 tests 348.6 389.7 430.9 472.0 1,641 Viral load test 871.5 974.3 1,077.1 1,179.9 4,103 Fixed cost 343.8 343.8 343.8 343.8 1,375 Total – scenario 1 4,352.9 4,825.7 5,298.6 5,771.5 20,249 Scenario 2 ART Drugs 2,668.2 3,230.6 3,890.2 4,658.6 14,448 CD4 tests 333.5 403.8 486.3 582.3 1,806 Viral load test 833.8 1,009.6 1,215.7 1,455.8 4,515 Fixed cost 343.8 343.8 343.8 343.8 1,375 Total – scenario 2 4,179.3 4,987.8 5,936.0 7,040.5 22,144 Scenario 3 ART Drugs 3,590.0 4,571.3 5,771.6 7,224.7 21,158 CD4 tests 448.8 571.4 721.5 903.1 2,645 Viral load test 1,121.9 1,428.5 1,803.6 2,257.7 6,612 Fixed cost 343.8 343.8 343.8 343.8 1,375 Total – scenario 3 5,504.5 6,915.0 8,640.5 10,729.3 31,789

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Child ART Scenario 1 Cost of Personnel 6.0 6.0 6.0 6.0 24 DNA PCR Testing 9.0 9.0 9.0 9.0 36 Paediatric ART drug cost 497.2 496.8 485.5 467.9 1,947 Subtotal 512.2 511.8 500.5 482.9 2,007 Scenario 2 Cost of Personnel 6.0 6.0 6.0 6.0 24 DNA PCR Testing 9.0 9.0 9.0 9.0 36 Paediatric ART drug cost 498.0 498.2 487.7 471.3 1,955 Subtotal 513.0 513.2 502.7 486.3 2,015 Scenario 3 Cost of Personnel 6.0 6.0 6.0 6.0 24 DNA PCR Testing 9.0 9.0 9.0 9.0 36 Paediatric ART drug cost 499.0 500.1 491.2 477.0 1,967 Subtotal 514.0 515.1 506.2 492.0 2,027

Post Exposure Prophylexis (PEP)

Post exposure prophylaxis (PEP) refers to anti-retroviral treatment provided, usually for one

month, to a person who may have been newly exposed to HIV. This is typically provided for

health care personnel who may have come in contact with infected blood through a needle stick

or other accident and for rape victims. The estimate of need is based on the estimated number of

PEP kits per million population. The budget allocation for PEP by NACP is not directly based on

the number of population but the allocation is made for each of the Primary Health

Centre/Community Health Centre (PHC/CHC). We have also assumed the same level of

provision as that of NACP-III i.e. 3000 PHC/CHC by 2015 (Table 12) and the estimated unit cost

for a particular PHC/CHC is also kept same at `34362 (NACP-III, 2006). The total cost for PEP

for the projection period is estimated to be `412 million (Table 13).

Adult ART

In treatment and care services, providing ART to adults constitutes the major cost. The need for

adult ART is obtained from Spectrum under three different scenarios. Target coverage of adult

ART by 2015 under the three different scenarios are given in Table 12. The assumed target for

18

adult ART in the three scenarios is assumed to be such that, the annual scale-up will address

about 0.47 million, 0.58 million and 0.90 million adults respectively who need ART in 2015. We

have assumed that the existing set up in case of NACP-III phase is sufficient to provide the

service. The unit costs for providing treatment to adult ART are:

· ART drugs @ `8000 per patient per annum.

· CD4 tests @ `1000 per patient per annum.

· Viral load test @ `2500 per patient per annum.

The total resources required (Table 13) for providing scaled up adult ART will vary from `20249

million in case of Scenario 1 to `31789 million in case of Scenario 3 whereas annual resource

required for adult ART in case of Scenario 3 will increase from estimated `5505 million in 2012

to `10729 million in 2015.

Child ART

Like adult ART, the need for child ART is also obtained from Spectrum. We have assumed that

all the children who need ART will be covered in the projection period. Our actual assumed

coverage is based on the point estimate of child ART need (Table 12). The need for child ART

will be around 55000 in the projection period. We have assumed that the cost of personnel and

DNA PCR testing cost will remain the same as that of NACP-III budget. Paediatric ART drug

cost is taken as `9000 per patient per annum. The total cost of providing child ART will be

around `2027 million in case of assumed Scenario 3 (Table 13).

Estimation of resource needs for second line ART in India

We have estimated the need for second line therapy by Spectrum and the resource burden is

calculated based on unit cost of `35000 per patient per year (UNGASS, 2010). Again we have

assumed that coverage of the second line therapy will be such that the number of people on

second line ART will be 50, 75 and 100 percent respectively by 2015 among those who need it in

the three scenarios.

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Survival probability assumed in Spectrum is different among adults and children availing ART.

Among adults, proportion surviving in the first year on ART is 0.86 and for subsequent years it is

0.90. For children under one year age the annual survival probability is 0.80 whereas for children

one year and older, survival probability for the first year on ART is 0.90 and for subsequent years

it is 0.95. Survival on ART increases as the starting level of CD4 levels increase. The pattern

suggests that, if data are available on the proportion starting ART with CD4 counts under 50,

then first year survival can be estimated as:

First year survival on ART = % starting under 50 x 0.16 + (1- % starting under 50) x 0.06 + 0.08

Currently, little information is available on the survival rates on second line ART. Spectrum uses

0.90 as annual survival on second line therapy, the same as first line. The first year survival is

worse than subsequent year survival because many patients start very late, at CD4 counts well

below 200. The median CD4 count in African cohorts reporting data is 87-125 (Egger, 2007). As

national programs improve treatment coverage, the median CD4 count at treatment initiation will

rise. At 100 percent coverage, the median CD4 count would be above 200 and survival should be

equal to the rate for subsequent years.

Table 14: Second line ART need and assumed coverage, 2009-2015

Need of second line ART 2012 2013 2014 2015 Scenario 1 78,927 105,384 133,183 162,154 Scenario 2 81,846 112,247 146,438 184,842 Scenario 3 94,998 135,313 182,910 238,973 Assumed coverage of second line ART

Scenario 1 28.6% 35.7% 42.9% 50.0% Scenario 2 42.9% 53.6% 64.3% 75.0% Scenario 3 57.1% 71.4% 85.7% 100.0% Assumed on second line ART Scenario 1 22,551 37,637 57,078 81,077 Scenario 2 35,077 60,132 94,139 138,632 Scenario 3 54,285 96,652 156,780 238,973

Table 14 gives the projected number of people in need of second line ART and the assumed

annual coverage rate. By 2015, about 0.24 million people will need second line ART in case of

20

Scenario 3. This number is obviously higher than the other two scenarios as the number of people

on ART is assumed to be higher in case of Scenario 3 and hence the failure rate is also higher in

Scenario 3. Thus, Scenario 3 will have a higher number of second line ART patients. Resource

need for second line ART is estimated to increase from `1900 million in 2012 to `8364 million

in 2015 in case of Scenario 3, if India is to provide second line ART to all those who need it by

2015 (Table 15). Our estimate of second line ART resource needs is significantly lower than

some of the other available estimates (World Bank, 2004; Over 2009a). This is mainly because of

the reason that the cost of second line ART treatment in our study (`35000 per annum) is

significantly lower compared to what is considered in other studies [for instance Over (2009a)

considered US$ 227 for second line ART in their study]. Thus the dynamics associated with the

cost of ART drugs is of utmost importance while projecting resource needs for treatment as the

reduction in drugs cost will significantly reduce the resource requirement. Also, in the present

study, the need estimate for second line ART is based on more recent data and thus the resource

requirement estimates are expected to be more accurate.

Table 15: Financial requirement for providing second line ART, 2009-2015

Year 2012 2013 2014 2015 Total

Scenario 1 789.3 1317.3 1997.7 2837.7 7524.7

Scenario 2 1227.7 2104.6 3294.9 4852.1 12363.7

Scenario 3 1900.0 3382.8 5487.3 8364.1 20422.5

Summarizing all costs

India will require a whopping `34129 million to `57937 million in the different scenarios

assumed to meet the resource needs for HIV during the projection period 2012-2015 (Table 16).

Estimated annual resource needs will vary from `6834 million in 2012 to `10381 million in 2015

in case of Scenario 1 while the cost would jump to `20902 million by 2015 in case of Scenario 3

which assumes higher ART and other treatment coverage. The health and family welfare budget

for 2012-13 is `344880 million. Our estimates of cost of the treatment and care program for 2012

come to about `9102 million in case of Scenario 3, which is around three percent of the total

21

health and family welfare budget. If we assume that the GDP of India will grow at seven percent

and the share of health and family welfare budget will remain same in 2015 as that of the year

2012-2013, then the share of HIV treatment to health and family welfare budget is expected to

increase significantly (seven percent) by 2015 if India is to provide ART to all eligible people

who need it including second line ART. The share of second line therapy is projected to be about

43 percent of all ART cost by 2015. The total resource required for treatment of HIV in the year

2015 is projected to be `20902 million, which is more than the entire NACP-III budget for care,

support and treatment.

Table 16: Financial requirement for treatment and care (` in million), 20012-2015

Scenarios 2012 2013 2014 2015 Total Scenario 1 6,834 7,868 9,046 10,381 34,129 Scenario 2 7,101 8,821 10,987 13,676 40,584 Scenario 3 9,102 12,034 15,899 20,902 57,937

Discussion and conclusion

The present study gives a fair idea of the HIV/AIDS situation that might prevail in India in the

next few years. Projection of treatment and care cost for different components related to HIV

gives us some sense about the resources that is required to be mobilized to meet the need. As

expectedly, scaling up of adult ART to a desired level will cost the exchequer a significant

amount of HIV budget. For the record, NACP-III has a budget of `115,850 million and scaling

up of adult ART to an extent such that by 2015 if everyone receives first line ART, who needs it,

will cost around `31789 million, which is about 27 percent of the current NACP-III budget. The

cost does not include meeting the need for second line ART which NACP have already started

providing, though in a miniscule scale. If the costs of second line ART are included, the total cost

of providing ART will increase further due to the higher cost of medicines for second line ART.

Also, looking at the historical trend of decline in prices of ART drugs, it is well understood that

in all probability the price of the drugs might come down in future, a factor which is not explored

here. Apart from these factors, we have not explored the possible impact on the HIV population

22

in case of an operational HIV vaccine, which is said to be in an advanced stage. We have also not

explored the impact of male circumcision on HIV which in all probability is not a feasible option

in the Indian context. All the results are shown without using any discount factors.

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