The economics, financing and implementation of HIV treatment as prevention: What will it take to get there?

Abstract

The 2013 Lancet Commission Report, Global Health 2035, rightly pointed out that we are at a unique place in history where a "grand convergence" of health initiatives to reduce both infectious diseases, and child and maternal mortality--diseases that still plague low income countries--would yield good returns in terms of development and health outcomes. This would also be a good economic investment. Such investments would support achieving health goals of reducing under-five (U5) mortality to 16 per 1000 live births, reducing deaths due to HIV/AIDS to 8 per 100,000 population, and reducing annual TB deaths to 4 per 100,000 population. Treatment as prevention (TasP) holds enormous potential in reducing HIV transmission, and morbidity and mortality associated with HIV/AIDS--and therefore contributing to Global Health 2035 goals. However, TasP requires large financial investments and poses significant implementation challenges. In this review, we discuss the potential effectiveness, financing and implementation of TasP. Overall, we conclude that TasP shows great promise as a cost-effective intervention to address the dual aims of reducing new HIV infections and reducing the global burden of HIV-related disease. Successful implementation will be no easy feat, though. The dramatic increases in the numbers of persons who need antiretroviral therapy (ART) under a TasP approach will pose enormous challenges at all stages of the HIV treatment cascade: HIV diagnosis, antiretroviral (ARV) initiation, ARV adherence and retention, and increased drug resistance with long-term enrolment on ART. Overcoming these implementation challenges will require targeted implementation, not focusing exclusively on TasP, most-at-risk population (MARP)-friendly services for key populations, integrating services, task shifting, more efficient programme management, balancing supply and demand, integration into universal health coverage efforts, demand creation, improved ART retention and adherence strategies, the use of incentives to improve HIV treatment outcomes and reduce unit costs, continued operational research and tapping into technological innovations.

Estimation of the HIV Incidence and of the Number of People Living With HIV/AIDS in Brazil, 2012

“…Although the increasing coverage of HIV testing in Brazil gives some indication that people are generally open to routine HIV screening, as HIV testing in antenatal care for pregnant women, known benefits of early treatment are outweighed by a perceived burden related to stigma and fear of being positive [52][53][54]. The Brazilian Behavioral Surveillance Survey, 2012 found that more than 60% of those with self-evaluation of high HIV infection risk had never tested for HIV.…”

The cost-effectiveness of harm reduction

“…Many studies have shown that ART is cost-effective not only for the purpose of keeping people alive but also because of its prevention benefits (Kahn et al, 2011;Loubiere et al, 2010;Wilson et al, 2014). Considering the prevention and treatment benefits, ART is a highly favourable intervention.…”

Injection Drug Use Among West Virginia Medicaid Beneficiaries: An Analysis of Health Outcomes, Service Utilization, and Cost

“…(D. P. Wilson et al, 2015) According to one estimate, implementing and maintaining a SEP costs approximately $23-$71 per person accessing services per year. (D. Wilson et al, 2014) Further, one study found that in addition to significantly reducing HIV incidence, a SEP reported an approximate $5 saved as a result of infection aversion for every $1 invested in providing services. (Kwon et al, 2009) Moreover, considering the cost of treating new cases of HIV (~$136 million per year) and HCV (~$176 million per year) just among PWID, the economic benefits of having optimal coverage of SEP could be profound.…”

“…(Van Handel et al, 2016) Highly effective and cost containing public health interventions to counter IDU associated events have been identified in both rural and urban areas of the world, including syringe and injection equipment exchange programs (SEP). (Kwon, Iversen, Maher, Law, & Wilson, 2009;D. Wilson, Taaffe, Fraser-Hurt, & Gorgens, 2014;D.…”

“…(Mackesy-Amiti et al, 2013)Compared to other prevention strategies, SEPs are relatively inexpensive to implement and sustain, with an estimated cost ranging between $23-$71 (US) per person, per visit depending on location and services offered with the return on investment of approximately $5 saved to every $1 spent. (Kwon et al, 2009;D. Wilson et al, 2014;D.…”