HIV resource needs case studies:
Belarus and Armenia
Cliff C. Kerr, David P. Wilson,
Anna Yakusik, Carlos Avila
Background
o Belarus and Armenia have been heavily reliant on international aid
to fund HIV/AIDS responses
o ~50% of funding is from international sources, predominantly the
Global Fund in 2011
o These sources are withdrawing
o GFATM resources will not be available beyond 2015
o There is need to establish transitional funding mechanisms
o Leadership over national response
o Including innovative financing systems
o Sustainable financing
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
Objectives
o UNAIDS “Getting to zero”:
How can we best strive to achieve the
“getting to zero” goal without many of
the current sources of funding?
o Calculate the costs of HIV prevention and treatment interventions
and activities
o Assess modes of transmission and project future epidemic
trajectories for the period 2015-2020 and beyond
o Identify specific strategies that are likely to have greatest potential
for achieving the “getting to zero” goal
o Calculate the resources required to implement these strategies
o Including optimization of allocations so that resources are not
wasted
o Develop recommendations and a framework for resource
mobilization
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
Calculating HIV/AIDS spending
o NASAs 2007-2011
o
Belarus:
Domestic funds
International funds
o
Armenia:
Spending (US$ mil.)
6
5
4
3
2
1
0
2007
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2008
2009
Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
2010
2011
HIV spending in Belarus
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
HIV spending in Armenia
HIV prevention allocation
2007-2011: US$8,711,591
Total HIV investment
2007-2011: US$17,615,592
Direct and nontargeted costs for
prevention
25.99%
49.45%
MSM
8.88%
9.96%
24.56%
4.41%
12.13%
11.12%
10.11%
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FSW and clients
24.74%
HIV care and treatment
costs
Indirect costs and
critical enablers
Low-risk population
18.64%
Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
PWID
PMTCT
HCT
Blood saftey
Indirect or unknown
Key assumption: relationship between
change in behavior and spending
Example: Syringe sharing rate among IDUs in Belarus
Risk over time
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Risk vs. investment
Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
Other relationships for Belarus
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
Relationships for Armenia
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
Formalized and calculations conducted
with epidemiological mathematical model
• Optima: The HIV Optimization and Analysis Toolbox
• Best-practice HIV epidemic modeling
• Realistic biological transmission processes, infection
progression, sexual mixing patterns and drug injection
behaviors
• Simultaneously calibrated to reflect available HIV
surveillance data across 7 population groups
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
Formalized and calculations conducted
with epidemiological mathematical model
• Population groups
• Male and female injecting drug users (IDU)
• Direct and indirect female sex workers (FSWs)
• Clients of FSWs
• Men who have sex with men (MSM)
• Low-risk males and females in the general population
• Flexible to Belarus-specific characteristics and data
• Full health economic analyses
• Uncertainty bounds
• Resource optimization
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
Calibration to HIV prevalence (Belarus)
Male IDU
FSW
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Female IDU
Clients of FSW
MSM
Low-risk female
Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
Low-risk male
Model also calibrated to diagnosis and
treatment
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
Calibration (Armenia)
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
Inferred new HIV infections from 2000 to
2020 in Belarus by population group
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
Inferred new HIV infections from 2000 to
2020 in Armenia by population group
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
What have investments in Belarus bought?
o HIV investment, 2008-2012,
o Averted 3 800 new HIV infections and averted 1 860 deaths
o But incidence is not declining
o Late diagnosis means late initiation of ART
o Poorer clinical outcomes
o Greater potential to transmit to others
o Treatment has trebled
o 1200 on ART in 2008, 3 500 in 2012
o But treatment coverage can/should be increased
o 60-70% of diagnosed treatment eligible are treated
o 1 in 3 are being treated (including undiagnosed who would
be eligible)
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
What is the future of the Belarus epidemic?
Is it concentrated?
Male IDU
FSW
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Female IDU
Clients of FSW
MSM
Low-risk female
Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
Low-risk male
Even without MARPs, prevalence will
continue to increase: generalized epidemic?
Males
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Females
Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
Belarus: projections of current conditions
HIV prevalence is expected to
increase by 50% in the general
population
HIV has stabilized to high levels
(15%) among IDUs
7500 people are expected to be
on ART by 2020 with current
treatment uptake rates
A further 5800 people will be
ready for treatment by 2020
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
What needs to be improved in Belarus?
o Current resources are not allocated towards greatest
disease burden and potential for impact
o Currently, greatest funding is towards low-risk
populations
Not enough money is targeted to
MARP programs with proven
effectiveness
o A formal mathematical optimization procedure was
combined with the epidemiological transmission model to
find the allocation that minimized new infections
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
Illustration of methodology
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
Belarus: current vs. optimal allocations
Programs targeting MARPs are much more
effective & cost-effective than general
population programs
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
Armenia: current vs. optimal allocations
With limited
funds, PMTCT is
more costeffective than
untargeted ART
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
What needs to be improved?
o In both Belarus and Armenia, shift funds away from the general
population and towards programs targeted to the MARPs
o Facility-based funding model may require additional resources for MARPs
o Increase spending on needle-syringe programs
o OST programs are not cost-effective for HIV alone, but are when all health
implications are considered
o Increase spending on MSM programs
o Double spending on FSW programs.
o Increase total spending on ART + PMTCT, prioritizing latter if not at
saturation
Spending the same amount of money smarter can
reduce the number of new infections by 15-30%
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
Prioritization of scale-up (Belarus)
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
Defunding investment (Belarus)
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
Increasing investment (Armenia)
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
Economic rationale not to delay smart
decisions (Belarus, 2015-2020)
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
How much money is needed for the
future?
o Depends on what one wants to achieve
o Fill in the gap from international aid withdrawals
o Maintain status quo
o Getting to zero
o Actually zero
o WHO definition (<1 per 1000 per year)
o UN political declaration (50% reduction)
o Reverse increasing trend to attain stabilization
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
How much money is needed for the
future?
o Depends on what one wants to achieve
o Fill in the gap from international aid withdrawals
o Maintain status quo
o Getting to zero
o Actually zero
o WHO definition (<1 per 1000 per year)
o UN political declaration (50% reduction)
o Reverse increasing trend to attain stabilization
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
How much money is needed for the
future?
o Among MARPs
o Possible with increased investment
o Almost there with reallocation of resources
o 50% increase overall will accomplish this
o Transition from international to domestic program of MARP
interventions
o Among the general population
o Only target after MARP programs at saturation
o Not foreseeable with realistic assumptions according to current
environments and infrastructure.
o Large socio-cultural shifts (e.g. large increases to consistent
condom use among heterosexual regular sexual partners) is
unrealistic
o Increased testing and early treatment most viable
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
Required cascade for 50% reduction
in incidence in Belarus
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
How much money is needed for the future
for Belarus?
o US$20 million will be needed per year, allocated optimally among
MARPs, and at least an additional $10.8 million for the general
population
= $30.8 million per year to achieve 50% reduction in overall
incidence
o Recommended
o Maintain current programs
o Expand MARP interventions
o Ensure universal ART coverage (80%) for those diagnosed and
in need
= $25.9 million per year
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
What is the funding gap in Belarus?
o The Belarusian central government is committed to take over 100%
funding of ART by the end of 2015.
o In 2013, it is funding 40% of ART costs.
o The government is committed to take over funding of current
prevention programs through revenue of local governments (i.e.
regional/municipal budgets) in collaboration with local NGOs.
o If current investment in prevention and treatment is covered and any
further treatment burdens that arise, the funding gap would then be
an extra $3.2 million per year, along with optimal allocation of all
resources
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
What is the funding gap in Armenia?
14000
o Current HIV spending
is ~US$5 million per
year
12000
10000
Spending (US$ '000s)
o Universal coverage
can be achieved with
total spending of
US$23 million per year
(incl. overhead costs)
8000
6000
4000
2000
o Funding gap is US$18
million per year
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0
Current
Optimal
Universal coverage
PMTCT
571
1037
1500
ART
296
0
6100
HTC
353
324
1300
PWID
399
493
900
MSM
181
224
400
FSW
388
593
700
LRP
483
0
2400
Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan
Conclusions
• HIV epidemics are getting worse in both
Belarus and Armenia
• By spending the same money smarter, 15-30%
of infections can be averted
• But this is not enough to halt the epidemics:
more money is needed
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Cliff Kerr | Case studies: Belarus and Armenia | May 28, 2014, Almaty, Kazakhstan