From Revolution to Reality: How Will New Science Impact the U.S. National HIV/AIDS Strategy?

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From Revolution to Reality: How Will New Science Impact the U.S.

National HIV/AIDS Strategy?

Sunday, July 22, 2012 - IAC

Costs, Consequences and Feasibility of Achieving the NHAS Goals

David Holtgrave, PhD, Professor & ChairJohn Hopkins Bloomberg School of Public Health

Department of Health, Behavior & Society

Vision for the National HIV/AIDS Strategy“The United States will become a place where new HIV infections are rare and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity or socio-economic circumstance, will have unfettered access to high quality, life extending care, free from stigma and discrimination”

Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the NHAS – 2012 analysis• Is it still epidemiologically feasible to attain the incidence

and transmission rate reduction goals of the U.S. National HIV/AIDS Strategy (NHAS) by 2015?

• If so, what costs will be incurred in necessary program expansion, and will the investment be cost-effective?

• Would substantial expansion of prevention services for persons living with HIV (PLWH) augment the other strategies emphasized in the NHAS in terms of effectiveness and cost-effectiveness?

From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (in press).

This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

Definition of scenarios for HIV service implementation strategies

Scenario name*

Assumed percentage of clients in care achieving suppressed viral load, Year

2015 and beyondMeet NHAS diagnosis goal of 90% by 2015?

Level of coverage of risk behavior change services for PLWH

S694YMC 69.4% yes Minimal coverage

S694YFSC 69.4% yes Fully scaled-up coverage

S694NMC 69.4% no Minimal coverage

S694NFSC 69.4% no Fully scaled-up coverage

S807YMC 80.7% yes Minimal coverage

S807YFSC 80.7% yes Fully scaled-up coverage

S807NMC 80.7% no Minimal coverage

S807NFSC 80.7% no Fully scaled-up coverage

* All scenarios assume 85% care coverage by 2015 (with half-step toward achievement in 2014); up from baseline of 53.4% care coverage

From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (in press).

This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

Cost parameters (2011 dollars), costs saved per infection averted (2011 dollars), QALYs saved per infection averted

Cost per new diagnosis $10,085 Cost of prevention services for newly diagnosed PLWH $680

Cost of partner services  $1,046 Total cost for new diagnosis $11,810 Annual care costs (includes $680 in prev. services) $28,382

Annual housing costs $12,039 Medical care costs saved in lifetime (public sector) $291,565

QALYs saved per transmission averted 5.33

From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (in press).

This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

Input parameter values: HIV transmission rates

Scenario name

Transmission rate, unaware

(TRU)

Transmission rate, aware, baseline through

2013 (TR2013)

Transmission rate, aware, 2014

(TR2014)

Transmission rate, aware, 2015 to 2020

(TR2015)

S694YMC .1020 .0276 .0251 .0219

S694YFSC .1020 .0276 .0251 .0138

S694NMC .1020 .0276 .0251 .0219

S694NFSC .1020 .0276 .0251 .0138

S807YMC .1020 .0276 .0251 .0186

S807YFSC .1020 .0276 .0251 .0113

S807NMC .1020 .0276 .0251 .0186

S807NFSC .1020 .0276 .0251 .0113

From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (in press).

This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

Outcome measures for evaluating eight scenarios vs. flat transmission rate comparator

• Annual incidence• Overall annual transmission rate• Incidence / 2010 incidence• Transmission rate / 2010 transmission rate• Cumulative infections averted• Cumulative QALYs saved• Cumulative gross policy cost• Gross savings of downstream costs• Ratio of savings to costs• Net cost per QALY saved

From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (in press).

This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

Summary results comparing HIV service implementation scenarios one at a time to a flat transmission rate comparison condition• The incidence reduction and transmission rate reduction NHAS goals are met in three of the

eight scenarios (S694YFSC, S807YMC, and S807YFSC).

• The incidence reduction and transmission rate reduction NHAS goals are narrowly missed in two other scenarios (S694YMC and S807NFSC).

• The best cost-utility ratios are obtained when both diagnostic efforts and prevention services for PLWH are scaled up.

• The least effective scenario is to meet the care goal of the NHAS but fail to achieve the awareness of seropositivity goal or fully scale up risk reduction services for PLWH.

• Care expansion alone averts the least number of infections, and the resultant cost-utility ratio is over the often-used $100,000 cost-effectiveness standard.

• Inclusion of enough expansion of testing services to achieve the seropositivity awareness goal, inclusion of fully scaled-up risk-reduction interventions for PLWH, or both all serve to substantially improve performance on the outcome measures and to move the results into a range easily considered cost-effective.

From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (in press).

This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

Incidence and transmission rate by scenario

Scenario

Incidence / 2010 incidence (2015)

Incidence / 2010 incidence (2020)

Transmission rate / 2010 transmission rate (2015)

Transmission rate / 2010 transmission rate (2020)

S694YMC .789 .837 .713 .713

S694YFSC .597 .610 .543 .543

S694NMC 1.006 1.110 .898 .898

S694NFSC .835 .892 .750 .750

S807YMC .710 .742 .643 .643

S807YFSC .536 .542 .489 .489

S807NMC .936 1.019 .837 .837

S807NFSC .781 .826 .702 .702From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (in press).

This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

Costs by scenario through 2015

Scenario name

Cost of additional

diagnoses*

Cost of additional housing

Cost of care and treatment**

Cost of fully scaled-up risk reduction for

PLWH

Cumulative gross policy

cost 2015(discounted at

3%)S694YMC $1,476,681,741 $363,859,450 $14,770,581,633 N/A $16,611,122,824S694YFSC $1,476,681,741 $363,859,450 $14,770,581,633 $449,989,958 $17,061,112,782S694NMC N/A $363,859,450 $13,398,713,227 N/A $13,762,572,676 S694NFSC N/A $363,859,450 $13,398,713,227 $401,015,141 $14,163,587,817S807YMC $1,476,681,741 $363,859,450 $14,770,581,633 N/A $16,611,122,824

S807YFSC $1,476,681,741 $363,859,450 $14,770,581,633 $449,989,958 $17,061,112,782

S807NMC N/A $363,859,450 $13,398,713,227 N/A $13,762,572,676 S807NFSC N/A $363,859,450 $13,398,713,227 $401,015,141 $14,163,587,817

* Newly diagnosed PLWH also receive risk reduction services (included as approx. $85m in this cost total)

** PLWH receiving care under newly expanded services also receive risk reduction services (included as approx. $354m in “Y” scenarios, and approx. $321m in “N” scenarios)

From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (in press).

This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

Cost per QALY saved by scenario(one scenario at a time; relative to status quo)

Scenario nameNet cost per QALY saved 2015

(discounted at 3%)Net cost per QALY saved 2020

(discounted at 3%)S694YMC $67,896 $50,742

S694YFSC $39,540 $20,088

S694NMC $182,036 $162,043

S694NFSC $89,230 $59,745

S807YMC $53,081 $33,884

S807YFSC $32,670 $13,344

S807NMC $129,702 $100,399

S807NFSC $72,877 $44,465

From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (in press).

This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

Comparison of incidence across all scenarios of HIV program expansion, and including flat transmission rate comparator condition

From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (in press).

This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

Comparison of prevalence across all scenarios of HIV program expansion, and including flat transmission rate comparator condition

From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (in press).

This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

Comparison of transmission rate across all scenarios of HIV program expansion, and including flat transmission rate comparator condition

From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (in press).

This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

Incremental cost-effectiveness ratios comparing combinations of scenarios of HIV program expansion, as of Year 2020*

Scenario Comparison

Additional discounted gross program costs per additional

discounted HIV infection avertedS694YMC

vs.S694NMC

$101,759

S694YFSCvs.

S694NFSC$96,667

S694YFSCvs.

S694YMC$27,961

S694NFSCvs.

S694NMC$29,467

S807YMCvs.

S807NMC$98,198

S807YFSCvs.

S807NFSC$94,285

S807YFSCvs.

S807YMC$33,222

S807NFSCvs.

S807NMC$34,611

S694YFSCvs.

S694NMC$69,025

S807YFSCvs.

S807NMC$71,590

*entries lower than $291,565 indicate public sector costs savings

From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (in press).

This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

National HIV/AIDS Strategy

• Simply waiting for expansion of care services in 2014 and 2015 will not be enough to reach incidence and transmission rate reduction NHAS goals

• Investment in diagnostic services and prevention services for PLWH (in addition to care and housing services) enables us to reach those goals

• But very substantial progress toward investing in these services must be made in FY13

• Otherwise, the window on achieving the NHAS goals will be closed

We Must Avoid…

…But Time Has Almost Run Out

From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (in press).

This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

As President Obama said on July 13, 2010…. “The question is not whether we know what to do, but whether we will do it.”

This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

“COMBINATION PREVENTION” HAS SADLY BECOME

“SUBSTITUTION PREVENTION” WHEN WE NEED

“SYNERGISTIC PREVENTION”TO URGENTLY IMPACT INCIDENCE

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This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

HIV is transmitted during an act of unprotected risk behavior in a serostatus discordant partnership with virus present

In a serostatus discordant partnership…..

Unprotected transmission relevant risk behavior present

No unprotected transmission relevant risk behavior

Unsuppressed Viral Load Concentration of transmission Essentially no transmission

Suppressed Viral Load Essentially no transmission Essentially no transmission

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This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

Key US populations defined by HIV serostatus and relevance of various treatment-related prevention approaches

From: Holtgrave DR, Maulsby C, Wehrmeyer L, Hall HI. Behavioral Factors in Assessing Impact of HIV Treatment as Prevention. AIDS Behav. 2012 Apr 11. [Epub ahead of print].

This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

Number of forward HIV transmissions from subgroups of persons living with HIV, and potential points of prevention intervention

This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content. From: Holtgrave DR, Maulsby C, Wehrmeyer L, Hall HI. Behavioral Factors in Assessing Impact of HIV Treatment as Prevention. AIDS Behav. 2012 Apr 11. [Epub ahead of print].

Key services needs of the three subpopulations of persons living with HIV

This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content. From: Holtgrave DR, Maulsby C, Wehrmeyer L, Hall HI. Behavioral Factors in Assessing Impact of HIV Treatment as Prevention. AIDS Behav. 2012 Apr 11. [Epub ahead of print].