what are we learning about treatment benefits?
DESCRIPTION
What are we learning about treatment benefits?. Damien de Walque Development Research Group Mead Over Center for Global Development The World Bank November 30, 2006. Unmet need. 70% of the total unmet need. 5. Receiving ARV therapy. (Number of people in millions). 4. 3. 2. 1. - PowerPoint PPT PresentationTRANSCRIPT
What are we learning about What are we learning about treatment benefits?treatment benefits?
Damien de WalqueDamien de Walque
Development Research Group Development Research Group
Mead OverMead Over
Center for Global DevelopmentCenter for Global Development
The World BankThe World Bank
November 30, 2006November 30, 2006
ARV Therapy: global need, June ARV Therapy: global need, June 20062006
1
5
4
Sub-Saharan Africa
Latin America and the Caribbean
East, South and South-East Asia
Europe and Central Asia
North Africa andthe Middle East
3
2
(Nu
mber
of
people
in
mill
ions)
Unmet need
Receiving ARV therapy
70% of the total unmet need70% of the total unmet need
Source: Kevin de Cock’s Presentation in Toronto, Aug., 2006
OverviewOverview
Treatment benefits and the TAP Treatment benefits and the TAP Learning AgendaLearning Agenda
Determinants of treatment success Determinants of treatment success in Burkina Fasoin Burkina Faso
Health & non health benefits of Health & non health benefits of treatment in Kenyatreatment in Kenya
Long term benefit: Long term benefit: an “AIDS Transition”an “AIDS Transition”
Impact evaluations of programs Impact evaluations of programs delivering antiretroviral therapies to delivering antiretroviral therapies to
HIV/AIDS patientsHIV/AIDS patients In: Burkina Faso, Ghana and Mozambique In: Burkina Faso, Ghana and Mozambique (TAP “learning agenda”)(TAP “learning agenda”) But also in Rwanda, Kenya, South Africa But also in Rwanda, Kenya, South Africa
and Indiaand India Team: Damien de Walque, Varun Gauri, Team: Damien de Walque, Varun Gauri,
Harounan Kazianga & Mead OverHarounan Kazianga & Mead Over In collaboration with Africa Region (Act In collaboration with Africa Region (Act
Africa and MAP/TAP TTLs), Global AIDS Africa and MAP/TAP TTLs), Global AIDS Unit, HDVP and also with WHO and UNECAUnit, HDVP and also with WHO and UNECA
Question I: Measuring the impact of Question I: Measuring the impact of treatment on the welfare of patients treatment on the welfare of patients
and family membersand family members
Lives saved and health outcomesLives saved and health outcomes Labor supply of patient and Labor supply of patient and
family membersfamily members Schooling of childrenSchooling of children Other welfare indicatorsOther welfare indicators
Question II: Possible effects of ART on Question II: Possible effects of ART on HIV transmission and preventionHIV transmission and prevention
Direction of effect
Beneficial(Slow transmission)
Adverse(Speed transmission)
Type of effect
Biological
Reduce infectiousness Select for resistance.
Longer duration of infectivity
Behavioral
Encourage prevention,especially testing
Off-setting behavior,“disinhibition”
Other questions Other questions (more on the supply- facility side)(more on the supply- facility side)
3) Determinants of adherence to 3) Determinants of adherence to treatmenttreatment
4) 4) How to avoid the development and How to avoid the development and spread of resistance?spread of resistance?
5) 5) How are ART beneficiaries identified? How are ART beneficiaries identified? How to encourage timely uptake?How to encourage timely uptake?
6) How to assure the quality of HIV/AIDS service delivery?
7) How to encourage capacity building to 7) How to encourage capacity building to reinforce the sustainability of ART reinforce the sustainability of ART delivery?delivery?
Data collection (Longitudinally)Data collection (Longitudinally)
Biomedical follow-upBiomedical follow-up Health facility and association Health facility and association
surveys surveys Household surveys (HIV patients and Household surveys (HIV patients and
general population)general population) Surveys of employers and employees Surveys of employers and employees
(Ghana)(Ghana)
DeterminantsPatient
and ProviderBehavior
OutcomesImpact on
the entire country
Framework for Learning agenda
Treatment Outcome, Resistance
Development
Socio-Economic benefits
for households
Prevention
PatientAdherence Information
socio-economicvariables
Community variables
Stigmatization
Training
Selection / Recruiting
Impact On health systemQuality of
service deliveryEquipment
Staffing and Incentives
Associations
EmployersSocio-
Economic benefits for firms
What can we learn about the What can we learn about the quality of service delivery?quality of service delivery?
Examples from a survey of facilities Examples from a survey of facilities delivering ARVs in Burkina Faso.delivering ARVs in Burkina Faso.
Work in collaboration with Dr. Laetitia Work in collaboration with Dr. Laetitia NIKIEMA of the IRSS in Ouagadougou.NIKIEMA of the IRSS in Ouagadougou.
Very preliminary analysis (first batch of Very preliminary analysis (first batch of data)data)
Household data currently being collected Household data currently being collected by ISSPby ISSP
In Burkina Faso, 4 different types In Burkina Faso, 4 different types of facilities are delivering ARVsof facilities are delivering ARVs
Distribution des patients par sexe et type de formation (n=277)
0
50
100
150
200
Male
Female
Total
Satisfaction levels vary by gender Satisfaction levels vary by gender and by type of facility and by type of facility
0.1
.2.3
.4.5
Pro
po
rtio
n tré
s s
atisfa
it
Gouvernementale Confessionelle Associative
Male Female Male Female Male Female
Satisfaction géneralee par sexe et type de formation sanitairee
Expenses per visit Expenses per visit excluding transportationexcluding transportation
05
,000
10,0
00
15,0
00
Mo
nta
nt to
tal ajo
urd
hui sa
ns tra
nsp
ort
Gouvernementale Confessionelle Privée Associative
Male Female Male Female Male Female Male Female
par sexe et type de formationDistribution des dépenses pour soins sans transport
Transportation costs do matterTransportation costs do matter
Transportation cost and out-of-pocket expenses by reason of visit
0
500
1000
1500
2000
2500
Other adult care (non ARV) Adherence support Regular ARV follow-upReason for visit
CF
A F
ran
cs (
500 C
FA
= 1
$)
Transportation cost Other out-of-pocket expenses
Next stepsNext steps Study impacts on adherence and Study impacts on adherence and
treatment outcomes of:treatment outcomes of:• Impact of out-of-pocket expenses and Impact of out-of-pocket expenses and
transportation costs (w. household data)transportation costs (w. household data)• Type of facility and service qualityType of facility and service quality• Other variables …Other variables …
Similar work in Ghana, Mozambique, Similar work in Ghana, Mozambique, Rwanda, South Africa and KenyaRwanda, South Africa and Kenya
What is the benefit of ART? What is the benefit of ART? Example in Kenya. Example in Kenya.
From Goldstein, From Goldstein, Graff Zivin and Thirumurthy Graff Zivin and Thirumurthy 2005.2005.
- Life saved, quality of life. Fewer Life saved, quality of life. Fewer orphans.orphans.
- In addition: labor force participation, In addition: labor force participation, children going back to school, less children going back to school, less child laborchild labor
CD4 Counts CD4 Counts before and after treatmentbefore and after treatment
50
10
01
50
20
02
50
30
0M
ed
ian
CD
4 c
ou
nt
-40 -30 -20 -10 0 10 20 30 40 50 60 70 80 90Weeks Before/After ARV Initiation
Source: Goldstein, Graff Zivin and Thirumurthy 2005
Body Mass Index Body Mass Index before and after treatmentbefore and after treatment
19
20
21
22
Me
dia
n B
MI
-40 -30 -20 -10 0 10 20 30 40 50 60 70 80 90Weeks Before/After ARV Initiation
Source: Goldstein, Graff Zivin and Thirumurthy 2005
Labor force participation Labor force participation before and after treatmentbefore and after treatment
.6.7
.8.9
Fra
ction p
art
icip
ating in labor
forc
e
-8 0 8 16 24 32 40 48 56Weeks on ARVs
Source: Goldstein, Graff Zivin and Thirumurthy 2005
What are the consequences of What are the consequences of anti-retroviral treatmentanti-retroviral treatment
individual benefits and costsindividual benefits and costs benefits and costs at the household benefits and costs at the household
and extended family leveland extended family level
Also look at the impact of treatment on Also look at the impact of treatment on the dynamics of the epidemicthe dynamics of the epidemic
( spillovers: social benefit and cost)( spillovers: social benefit and cost)
The Demographic TransitionThe Demographic Transition
Rate per 1000 people
Time
Birth Rate
Death Rate
Population Explosion
Rate of growth of the population
““Hypothetical AIDS Transition”Hypothetical AIDS Transition”
Rate per 1000 people
Time
New infections
AIDS Deaths
“Explosion of ART patients”
Rate of growth of people living with HIV/AIDS
Source: Over (2004)
AIDS transition in the United States, AIDS transition in the United States, 1985-20031985-2003
AIDS Cases
Deaths
1987 1989 1991 1993 1995 1997 1999 2001Years
0
10
20
30
40
50
60
70
80
90
1985
(AID
S c
ase
s and d
eath
s in
thousa
nds) Persons living with AIDS
20030
50
100
150
200
250
300
350
400
450
(Pers
on
s liv
ing w
ith A
IDS
in
th
ou
sands)
How to maximize benefits and How to maximize benefits and minimize adverse effects?minimize adverse effects?
Need to learn as we scale-up ART Need to learn as we scale-up ART (example TAP learning agenda)(example TAP learning agenda)
Measure:Measure:
- private benefits and costs- private benefits and costs
- biological effects, including - biological effects, including resistance. Role of quality of service resistance. Role of quality of service provision and adherence.provision and adherence.
-- behavioral effectsbehavioral effects
Treatment in the long run?Treatment in the long run?
The greater the success of The greater the success of treatment, the more patients treatment, the more patients
Second line therapy is much more Second line therapy is much more expensive. expensive.
Adherence crucial: role of health Adherence crucial: role of health infrastructure and staffinfrastructure and staff
Prevention, prevention, prevention!Prevention, prevention, prevention!
Findings from India & ThailandFindings from India & Thailand
India ThailandIndia Thailand
But suppose ART availability But suppose ART availability causes complacency ...causes complacency ...
Source: Condom use among prostitutes in Nairobi from Jha et al, 2002
“Kemron” and “Pearl Omega” were the brand names for false “cures” for AIDS
that were announced in
the Nairobi press.
Is this a “disinhibition”
effect?
Impact of risk behavior on the Impact of risk behavior on the number of new HIV infections in Indianumber of new HIV infections in India
0
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
7,000,000
8,000,000
1995 2000 2005 2010 2015 2020 2025 2030 2035
Year
Nu
mb
er
of
HIV
in
fecti
on
s p
er
ye
ar
40% condom 50% condom 70% condom 90% condom
Source: Over et al, 2004
Potential impact of
“disinhibition”
Provision of ART in Thailand: Provision of ART in Thailand: current statuscurrent status
In 2004:In 2004: Persons with AIDS Persons with AIDS
61,394 61,394
New HIV infections New HIV infections 19,50019,500
New AIDS cases New AIDS cases 49,50049,500
Persons on ART Persons on ART 50,986 (as of 50,986 (as of
January 2005)January 2005)
People living with AIDS and Public ART Provision in Thailand
61,394
2,0958,341
64,832 62,87168,677
50,000
16,630
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
2000 2002 2003 2004 projected
PLWA Public ART
Thailand – Enormous current benefits Thailand – Enormous current benefits of prior prevention effortsof prior prevention efforts
0
2
4
6
8
10
1985
1990
1995
2000
2005
2010C
urr
ent
HIV
Infe
ctio
ns
in m
illio
ns
Baseline No Intervention
Red line represents what might have been if behaviors had not changed
Infectionsprevented
Under National AIDS Program Under National AIDS Program deaths are postponeddeaths are postponed
Annual Death
0
10,000
20,000
30,000
40,000
50,000
60,000
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
20
16
20
17
20
18
20
19
20
20
20
21
20
22
20
23
20
24
20
25
YearsScenario A NAPHA_1only NAPHA_1+2line
National AIDS Program will National AIDS Program will increase the prevalence of HIVincrease the prevalence of HIV
Current HIV Cases
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
20
16
20
17
20
18
20
19
20
20
20
21
20
22
20
23
20
24
20
25
YearsScenario A NAPHA_1only NAPHA_1+2line
Cost of treatment with 2Cost of treatment with 2ndnd line reaches line reaches a ceiling at US$500 million per yeara ceiling at US$500 million per year
Cost of ART (in million)
$0
$100
$200
$300
$400
$500
$600
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
20
16
20
17
20
18
20
19
20
20
20
21
20
22
20
23
20
24
20
25
YearsScenario A NAPHA_1only NAPHA_1+2line
After 2010, most costs After 2010, most costs are for second-line therapyare for second-line therapy
Total Cost of Public ART (NAPHA)
$0
$50
$100
$150
$200
$250
$300
$350
$400
$450
$500
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
20
16
20
17
20
18
20
19
20
20
20
21
20
22
20
23
20
24
20
25
Millions
Cost of Public ART_1 line_asy Cost of Public ART_1 line_sym
Cost of Public ART_2 line_asy Cost of Public ART_2 line_sym
Comparing the flows Comparing the flows of costs and benefits: of costs and benefits:
11stst & 2 & 2ndnd Lines Lines
ART Cost (net) and Benefit (LYS) in Scenario D1- Compared to Scenario A -
0
50,000
100,000
150,000
200,000
250,000
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
20
16
20
17
20
18
20
19
20
20
20
21
20
22
20
23
20
24
20
25
LYS
0
100
200
300
400
500
600
in million
LYS
Net Cost of ART
Total cost of NAPHA:
$5.68 billion
Total benefits of NAPHA:
2.64 mn. LYS
Cost-effectiveness of ART Cost-effectiveness of ART with 1with 1stst & 2 & 2ndnd line line
•$5.6 bn / 2.6 mn LYS = $2,144/LYS
NPV of Cost per LYS by Scenario- discounted at 3% -
$735
$2,144
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
NAPHA_1onlyNAPHA_1only NAPHA_1+2line
Treatment AND PreventionTreatment AND Prevention
Organize ART so that Organize ART so that prevention is reinforcedprevention is reinforced
Focus prevention efforts so Focus prevention efforts so that ART is sustainablethat ART is sustainable
Ingredients of a successfulIngredients of a successfulAIDS TransitionAIDS Transition
A “Learning Agenda” will help A “Learning Agenda” will help accomplish the AIDS transitionaccomplish the AIDS transition
Understand the health & non health Understand the health & non health benefits of treatment in each countrybenefits of treatment in each country
Understand all the determinants of Understand all the determinants of treatment success in each countrytreatment success in each country
Financing problem: Lower costs, Financing problem: Lower costs, increase effectiveness or increase increase effectiveness or increase funding? funding?
Prevention, prevention, preventionPrevention, prevention, prevention