Prioritizing Investment for HIV Response: Experiences
of improving allocative efficiency in HIV Programmes
Emiko Masaki1, Nicole Fraser-Hurt1, Clemens Benedikt1, Cliff Kerr2, Robyn Stuart2, Richard Gray2, Andrew Shattock2, Markus Haacker1, David Wilson1,
Marelize Gorgens1, David P. Wilson2
Bank, Washington DC, United States, 2Kirby Institute, University of New South Wales, Sydney, Australia
Lessons learned: In order to translate evidence and analysis into
policy decisions and, ultimately, improved HIV responses, Optima's
country studies offer useful lessons: (i) work closely with local
champion(s), (ii) conduct allocative efficiency study at the right
time by identifying an entry point for change (such as the budget
planning, mid-term review, strategy development); (iii) identify low
hanging fruits; (iv) make recommendations within the reality of
national and partner budgets; (v) recognize that change may be
incremental; and (vi) ensure accountability for change.
This analysis was supported by
The World Bank
Niger
Sudan
Zambia
% allocated to VMMC
n/a
n/a
Increase from 6% to 18%
% management and
enablers
22%
47%
41%
Other findings:
Halving HIV incidence Substantial potential
Reallocating 20% of
by 2025 is feasible, at for efficiency gains
management cost could
$7.4 m/y —115% of
in mgt. cost and
reduce 16% new
average acquired 2014–
costly program
infections
17
components
* PMTCT in Sudan would be cost-effective if unit cost per pregnant women living with HIV identified was reduced from 9,016
USD to 2,666 USD and total funding increased by 50 %. The practical recommendation arising out of this analysis was not to stop
PMTCT but to target it geographically to areas and populations with highest HIV prevalence and ensure technical efficiency.
Source: Populated Optima models for Niger, Sudan and Zambia
Figure I. ART, PMTCT and VMMC are the most important programs
for greater health impact: Results from Zambia Analysis**
500
Antiretroviral therapy
450
400
HIV counseling and testing
350
300
Prevention of mother
to child transmission
250
200
MSM condom programs
150
100
Medical male circumcision
50
Optimized-190%
Optimized-200%
Optimized-150%
Optimized-160%
Optimized-170%
Optimized-180%
Optimized-120%
Optimized-130%
Optimized-140%
Optimized-90%
Actual 2013 Spend
Optimized 2013 Spend
Optimized-110%
0
Optimized-60%
Optimized-70%
Optimized-80%
Results: Analyses carried out in all three countries established that
optimized allocation of resources would lead to reductions in new
HIV infections (by 12% in Niger, 37% in Sudan and 21% in Zambia).
The pathway to achieve these was a strong focus on a combination
of ART and high-impact HIV prevention programs. Table I illustrates
the required programmatic focus of prevention programs. In the
case of Niger and Sudan, programs for key populations require
strengthening, while in the case of Zambia voluntary medical male
circumcision (VMMC) and prevention of-mother-to child
transmission (PMTCT) require the bulk of HIV prevention funding.
Investment cascades were developed for all countries to explore
which combination of programs provide the highest impact if
available HIV funding is reduced or increased (Figure I). The study
conducted in Sudan was used by Government to inform a shift
towards prioritization of key populations and scale up of ART as
documented in the country’s national strategy 2015-17 and Global
Fund concept note for the same period. In Niger, the analysis made
the case for increased investment in sex work interventions to
minimize future HIV incidence and DALYs. The analysis in Zambia
indicated that ART and PMTCT remain critical, while VMMC should
be scaled up faster for greater health impact in Zambia’s HIV
response (Figure II).
Current vs. Optimal
Estimated effects of optimized resource allocation (with stable funding)
12% reduction in new
21% reduction of new
37 % reduction of
% new infections
infections (with the
infections and 14%
new infections with
averted and/or
2014-17 acquired $6.4
reduction in AIDS deaths
optimal allocation of
% of AIDS related
m/y compared to base
with optimal allocation of
US$ 6.4 million by
deaths averted
case of $16.3 m/y as
$ 291 million/year by
2020
spent 2012)
2030
Optimized resource allocations (in % of all HIV spending)
Increase from 26% to Increase from 12%
% allocated to ART
Sustain at 36%
48%
to 22%
Increase from 11% to Reduce from 7% to
% allocated PMTCT
Sustain at 5 %
20%
low levels*
% allocated FSW
Increase from <1% to Increase from 4 % to Increase from 0.1% to
programs
4%
15%
1.1%
Optimized-30%
Optimized-40%
Optimized-50%
Methods: The Optima model was developed to help HIV decisionmakers and planners determine optimal distribution of HIV
investments to best serve national needs and priorities. Optima is a
mathematical model of HIV transmission and disease progression,
which is integrated with an economic and financial analysis
framework and a formal mathematical optimization routine. The
optimization algorithm quantitatively determines best allocations
of HIV resources across numerous HIV prevention and treatment
programs using country HIV epidemic, program and cost
information as well as international evidence on intervention
effectiveness. Optima was applied in the three countries to answer
a range of standard and country-specific policy questions.
Table I. HIV allocative efficiency analysis in three countries: Key results
Optimized-10%
Optimized-20%
Background: In an era of increasingly competing demands for health
financing, the global focus on increased domestic financing of health
programmes and amidst calls for the rapid scale-up of prioritised HIV
programmes, improved efficiency of HIV resource allocation is
paramount. In search of efficiency and improved resource allocation,
countries are increasingly applying mathematical models and tools to
support their priority-setting and HIV investment decisions. Optima, a
mathematical model, was used to answer the key policy question on
how countries can prioritize HIV investment to attain maximum HIV
and health impact. Practical lessons and experiences of applying
Optima are presented to support in-country priority setting.
Millions
1World
FSW and client programs
Youth BCC and condom
programs
Adult BCC and condom
programs
** These are optimized allocations for minimizing HIV incidence and deaths between 2014 and 2044. It should be noted that this
chart only includes treatment and prevention programs and does not include social enablers, synergies and management costs.
Source: The World Bank (2014). Zambia’s HIV response: Prioritised and strategic allocation of HIV resources for impact and
sustainability: Findings from the HIV allocative efficiency study
Figure II. Outcomes with optimized spending, Zambia