1

Sustainable Financing Sustainable Financing HIV/AIDS and ART Program HIV/AIDS and ART Program

Viroj Tangcharoensathien MD. Ph.D. International Health Policy Program-

Thailand www.ihpp.thaigov.net

The 10th National AIDS Conference 15 July 2005

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Acknowledgements National Partners

Chureerat Bovornpatanawong, the leading ART clinician Patients, hospital staffs and Provincial Health Offices of

Udonthani, Chonburi, Nakornsrithammarat and Lampang Department of Disease control, Ministry of Public Health National Economic and Social Development Board

Funding agencies Thailand Research Fund for Senior Research Scholar Program

grant (1998-2005) Health Systems Research Institute for institutional grants of

iHPP-Thailand

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Objectives 1. Background 2. Financing HIV/AIDS program 2000-20033. ART and financing ART in 2004-20204. Cost effectiveness analysis and financial

forecast ART program, 2004-20205. Summary

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Enormous current benefits of prior Enormous current benefits of prior prevention effortsprevention efforts

0.7

7.1

0

2

4

6

8

10

1985 1990 1995 2000 2005 2010

Cur

rent

HIV

Infe

ctio

ns in

mill

ions

Baseline No Intervention

Red line represents what might have been if behaviors had not changed

Infectionsprevented

7

907

680

277

292174 136

461

803915

1208

10611145

1250

0

200

400

600

800

1000

1200

1400

1984-1990

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Outcome of PMTCT 2000Outcome of PMTCT 2000Infection rate 6-8% if AZP+NVP infection rate would be 2%Infection rate 6-8% if AZP+NVP infection rate would be 2%

Paediatric AIDS cases 1984 – 2003Paediatric AIDS cases 1984 – 2003

MOPH Thailand, Epidemiology Division, May 2003

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2. Financing HIV/AIDS program 2000-03

SourceTeokul et al 2004 National AIDS Account 2000-2003

9

Selected indicators, NAA, Thailand 2000-2003

Source: Teokul et al 2004

Selected indicators 2000 2001 2002 2003Population (1,000) 61,87

962,30

963,14

263,65

6No. of PHA (1,000) 695 665 635 604Current Health Expenditure USD per capita 63.3 58.4 69.3 75.5Expenditure on HIV/AIDS USD per capita 1.3 1.2 1.4 1.7Expenditure on HIV/AIDS USD per PHA 113 117 138 179HIV/AIDS expense as % HE 2.0% 2.1% 2.0% 2.2%

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National AIDS expenditure profile, 2000-2003

Source: adjusted from Teokul et al 2004, Prevention (STI, PMTCT, VCT, Blood safety, condom, surveillance); Rehabilitation (IDU detoxification & rehabilitation, mitigating impact)

  2000 2001 2002 2003Total current expenditure on HIV/AIDS, million USD, nominal term 78.2 77.5 87.9 107.9% distributionprevention 20.4 19.7 20.7 11.6curative

OIART

67.948.619.3

68.245.123.1

70.637.832.8

78.432.845.6

Rehabilitation 5.9 3.6 3.8 3.4R&D 4.3 6.1 3.3 6.6Program administration 1.4 2.2 1.2 0

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Financing sources for HIV/AIDS, Thailand 2000-2003

Source: adjusted from Teokul et al 2004

58

13

7

46

20

12

58

14 16

65

2320

0

10

20

30

40

50

60

70m

illio

ns U

SD

2000 2001 2002 2003

Year

public

household

ROW

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Summary NAA 2000-2003 HIV/AIDS expenditure increased significantly, 38% in nominal

term in 2000-2003 Expense per PHA was high compared to other developing

countries, Foresee increasing trend of expenditure per PHA due to

mature ART program and OI cost saving does not keep pace to offset ART expenditures

ART and OI treatment took the lion share, 78% in 2003 need to revisit program effectiveness

Public is the major source, increasing role of GF in 2003 observed, attention on financial sustainability

In the ART era, decreasing trend of spending on prevention observed, in term of percentage of Total Expenditure on HIV/AIDS

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3. ART program and financing ART in 2004-2020

Source • Tantivess and Tangcharoensathien 2004 • Teokul et al 2004 National AIDS Account 2000-03

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Financing sources of ART program Largest source: National Access to ARV for PHA (NAPHA, MOPH

Budget + GF) – main features Program start up–training of cadres of HCW Central purchasing ARV (mostly generic ARV), lab reagent, flow cytometer.

Allocation of non-labour operating to MOPH healthcare systems. Other sources

Civil Servant Medical Benefit Scheme Social Health Insurance OOP by households

NAPHA Provides non-labour operating, labour operating expenditure was mostly

cross-subsidized by UC budget and other sources of revenue ART integrated with existing healthcare systems (mostly public rural

district hospitals with referral for laboratory monitoring to Provincial hosp) First line drug regimens for NAPHA, with limited 2nd line for ATC

participants GPO Vir FDC (D4 T3+ TC + Nevirapine): 1 , 200 Baht or 30 USD/month D4 T, 3TC, Efavirenz: 3 , 000 Baht or 75USD/month) D4 T, 3TC, Boosted PI (Indinavir +Ritonavir): 4 , 500 Bah or 113USD/month

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Financing sources of ART, Thailand 2000-2003

Source: Teokul et al 2004

12

21

8

10

0.5

16

12

1

21 21

7

-

5

10

15

20

25

mill

ions

USD

2000 2001 2002 2003

Year

public

household

ROW

17

Generic ARV–main driver: Generic ARV–main driver: GPO products GPO products 1995-20041995-2004

1. AZT capsule 100, 300 mg, syrup May 1995 2. Didanosine (ddI) powder 115, 170, 230, 280 mg May 2000 3. Stavudine (d4T) capsule 15, 20, 30, 40 mg, syrup June 2000 4. Lamivudine (3TC) tablet 150 mg, syrup July 2001 5. AZT 300mg + 3TC 150 mg tablet November 2001 6. Nevirapine tablet 200 mg , syrup April 2002 7. GPO-VIR S30, S40 (d4T+3TC+NVP) April 2002 8. Nelfinavir tablet 250 mg November 2003 9. ddI tablet 125, 200 mg October 2004 10. GPO-VIR Z 250 October 2004 o Lamivudine tab. (300 mg) o Indinavir cap. (200, 400 mg) o Saquinavir tab (200, 400, 500 mg) o Ritonavir oral solution o GPO-Vir S7 (chewable tablet) (NVP 50 mg + 3TC 30 mg + d4T 7 mg) o ddI 25 mg (chewable tablet)

2005 pipe-line products

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Summary financing ART

NAPHA implemented in 2002, when some 10,000 PHA were on triple drugs (ATC, CSMBS, SHI and OOP) for several years and mostly required 2nd line drugs.

But NAPHA offers only first line drugs in 2002 One 2nd line can purchase 7-10 1st line – affordability

problem Initially, NAPHA offers to most PHA who did not access

ART (naïve cases)– equity considerations for those who were already on ART for some years (and required 2nd line regimen)

This results in high OOP in ART program

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4. Cost effectiveness analysis, financial forecast ART program, 2004-2020

Source• Lertiendumrong et al 2004 Cost and consequence of ART policy in Thailand: Economic evaluation of Anti-retroviral policy• MOPH-WB joint study 2004 Expanding Access to ART in Thailand

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Outcome of NAPHA--deaths are postponedSource Over et al 2005

Annual Death

0

10,000

20,000

30,000

40,000

50,000

60,000

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

2021

2022

2023

2024

2025

Years

Scenario A Scenario D1

Scenario A: Baseline Scenario D1: NAPHA Policy

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And more life years saved

Source: Lertiendumrong et al 2004

Life year with and without ART for 2004-2020 cohorts

24,466

7,884

70,311

85,897

92,270

86,442

78,658

70,050

61,417

53,268

45,891

39,377

33,713

28,83824,674

21,130

9,201

10,75312,58114,72117,212

20,08623,349

26,93730,698

34,35737,468

39,578

35,189

40,39539,399

42,735

94,917

93,223

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022

year

life

year

no ARTwith ART

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And orphan years averted

Source: Lertiendumrong et al 2004

Years with parents w ith and w ithout ART for 2004-2020 cohorts

71,075

86,042

90,521

84,364

76,432

67,802

59,245

51,241

44,047

37,732

32,267

27,58123,588

20,195

25,067

37,29034,096

30,39026,609

23,02319,776

16,92814,467

12,35810,5597,740

43,784

93,65092,664

9,034

39,51040,488

39,677

35,667

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022

year

life

year

no ART

with ART

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And cost savings from OI treatment averted

Source: Lertiendumrong et al 2004

39

344

61

728498114

132151

172192223 210

227221201

163

105

111129

151177

207

242283

329379

432483

527557

568554

495

-

100

200

300

400

500

600

year

mill

ion

Baht

with ARTno ART

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ART program cost and cost savings from OI

Source: Lertiendumrong et al 2004

908

305

1,387

1,606

1,682 1,6711,597

1,321

1,472

1,163

1,010

870746

638545

466398

341

390 391 367

336

300

261222

187157

131

110

93

7967 58 49

-

200

400

600

800

1,000

1,200

1,400

1,600

1,800

year

mill

ion

Baht

sum costOI saving

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Cost effectiveness analysis, ART programCohort analysis, 2004-2020, Adherence 0.8, not allow for 2nd line ARV

USD Total ART program cost (million) 455 Total potential OI saving (million) 87 Cost per life year saved 592 Cost per year of orphan-hood prevented 614 Total life years saved (year) 620,486 Year of orphan avoided (year) 598,757

Source: Lertiendumrong et al 2004Source: Lertiendumrong et al 2004

Cost per life year saved is 0.3 of GNI per capita Cost per life year saved is 0.3 of GNI per capita

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After 2010, most costs are 2nd line drugs

Total Cost of Public ART (NAPHA)

$0$50

$100$150$200$250$300$350$400$450$500

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

2021

2022

2023

2024

2025

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

Source: MOPH WB joint study 2004

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5. Summary

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Lessons learned Context

ART introduced in a mature comprehensive HIV program Major determinants of adoption of universal access to ART

Government affordability due to low cost generic ARV Health systems readiness and capacity to scale up rapidly, now

more than 80% coverage of eligible PHA, to date >70,000 on ART in >600 sites of District and provincial hospitals, and other centres

District and provincial hospitals are major hubs of ART delivery Key program configurations

After ART enrolment, free at point of service, prior recruit --expenses on CD4 shouldered by PHA

NAPHA provide first line drugs for most PHA not access, and limited second line for ATC participants

Result in significant role of OOP in ART ART (not allow 2nd line drugs) is cost effective

If judged from 1 GNI per capita for one life year gain

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Current and future challenges Demand side

Ensure early recruit for better outcome Ensure adherence and prevent dis-inhibition behaviour Minimize stigma, provide job opportunities and economic productivity

among ART enrolees Supply side

Economic growth, internal brain drain from public to private, fortunately international brain drain is not a serious problem!!

Universal Coverage increased significant workload and tension, burn-out

HCW home visit for lose to follow up ART enrolees ARV paediatric formulation—pipe line production by GPO Strengthening IT and MIS, survival probability and forecast prevalence

of PHA enrolee financial project, MTEF and resource mobilization Financing

Ensure longest durability of 1st line regimens, honey-moon period should be >5 years

Future decisions on public funded second line regimens and salvage treatment?

Maintain high level of prevention spending in ART era

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Sex behaviourSex behaviour: impact of ART : impact of ART programprogram

Asymp. Sympt. <6m ART Avg. monthly sex acts 6.4 3.8 3.4 spouse 52% 79% 86% Boyfriend/girlfriend 12% 10% 6% Friend 6% 2% 3% Direct sex worker 15% 4% 4% Indirect sex worker 7% 2% 0% Casual sex 7% 3% 1% Percent use condom every sex act

spouse 9% 56% 78% Boyfriend/girlfriend 10% 54% 93% Friend 14% 50% 83% Direct sex worker 27% 64% 100% Indirect sex worker 18% na 100% Casual sex 26% 25% 50% N 562 in N 562 in 4 PH 13 DH in 4 PH 13 DH in 4 provinces, 2004 Source: Lertiendumrong et al 20044 provinces, 2004 Source: Lertiendumrong et al 2004

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More evidences needed in future

2nd line drugs Cost, toxicity and outcome (CEA, ICER of adding 2nd to the 1st line

regimens) Budget impact analysis and role of co-pay and equity implications Ethical dimension Health systems capacity to handle 2nd line drugs including lab

capacity Associated cost of lab monitoring (VL not CD4) for failure of

treatment in order to early switch to 2nd line Multi-site vigilance of resistance

In order to stimulate demand and early enrolment Demand for VCT among general population and high risk group Demand for ART among asymptomatic HIV Supply side assessment of VCT – major entry point for effective

ART program Negative externality of ART

Sex behaviour surveillance among ART enrolees

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Thank you for your attention