World AIDS Day 2016: Economic evaluation for HIV in South Africa

Using Economic Evaluation to Strengthen South Africa’s National HIV Program:

Boston University’s ExperienceSydney Rosen

Department of Global HealthBoston University School of Public Health

Health Economics and Epidemiology Research Office, University of the Witwatersrand

December 1, 2016

What To Expect Today• Ten minutes about economic evaluation• The setting: a safari to South Africa• How much does it cost?• Is it cost-effective?• What are the benefits?• Can we afford to do what we want?• Final thoughts (if any are left)

With thanks to all the colleagues whose work I’ve borrowed…

Ten Minutes About Economic Evaluation

Economics is about the allocation of scarce resources to meet competing ends• What resources do we have?

• What are our goals (ends)?

• Who decides?

• Who wins?

• Who loses?

• Economics is about value (and values), not money. Money is merely a unit of measurement.

Economic evaluation is about how to allocate resources under constraint• Allocating resources: Deploying our constrained resources to

achieve our goals over space and time

• Minimizing costs: Choosing strategies to spend the least we can to generate the outcomes or impacts we want

• Maximizing benefits: Getting the most health and other desirable outcomes from the resources we have

• Various other things that we won’t talk about today

Within the world of evaluation…

Can it work? (Efficacy)

Does it work? (Effectiveness)

Is it feasible to implement in the setting we care

about? (Feasibility)

How much does it cost, and can we

afford it?Is it cost-effective? Do the benefits

exceed the costs?

Source: Drummond et al, Methods for the Economic Evaluation of Health Care Programmes, 2005

Some types of economic evaluation• Value of changes in resources used• Can be incremental or total costCost

• Cost per successful health outcome achieved• Outcomes are natural (meaningful) units of healthCost/outcome

• Difference in cost per successful outcome achieved • Comparison between options with same outcomeCost/effectiveness

• Cost per unit of utility gained or disutility avoided• DALYs or QALYs can combine multiple or disparate outcomesCost/utility

• Ratio of value of total costs to value of total benefits• Costs and benefits are valued in monetary units and presented as

net benefits (= benefits-costs) Cost/benefit

More about types of evaluationApproach Question Definition and uses

Incremental cost

How much more does it cost than what I’m already spending?

Additional cost of adding an additional service, per patient served; budgeting to scale up additional service

Total cost How much should I budget? Total cost per patient to achieve the outcomes being evaluated; budgeting to provide service to a specified number of patients

Cost/outcome How much does it cost to get the outcomes I want?

Average cost per successful or unsuccessful outcome achieved; monitoring changes and identifying opportunities for better resource allocation

Cost-effectiveness

How does my intervention compare to standard care or other interventions with the same outcome?

Difference in costs divided by difference in specific health outcomes; comparing different service delivery strategies for achieving a single outcome

Cost-utility How does my intervention compare to other health interventions with different or multiple outcomes?

Difference in costs divided by difference in utility outcomes (QALYs, DALYs); determining whether an intervention is a “good buy” compared to dissimilar interventions or a threshold

Cost-benefit Do the benefits of my intervention exceed the costs?

Ratio of costs to benefits, in monetary terms; deciding whether the service should be provided at all

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Cost-effectiveness is not all it’s cracked up to be

Cost-effectiveness analysis is a comparison between options

• A new intervention compared to standard of care• One intervention compared to another intervention

Each intervention has a cost, expressed in monetary terms

Each intervention has an effect, expressed in health or utility terms

• For example, proportion of patients achieving viral suppression, or disability adjusted life years (DALYs)

Cost-effectiveness does not tell us if something is “worth it”. Let’s see what it does tell us.

When is cost-effectiveness analysis useful?

Effectiveness

Cos

t

Cost of status quoE

ffect

iven

ess

of s

tatu

s qu

oHigher or equal cost, lower effectiveness—almost never do it

Lower cost, lower effectiveness—only do it to reduce budget

Higher cost, higher effectiveness—do it if it’s affordable and cost-effective compared to alternatives

Lower cost, higher or equal effectiveness—almost always do it

✔

?

?

• Minimize cost to achieve a predetermined target—for example, 90-90-90• Maximize benefits for a predetermined cost—for example, a national budget• Compare two approaches to achieving the same health outcomes—for

example, a new drug or device compared to an existing one--BUSPH Professor Bruce Larson

Last and least: What exactly is an ICER?

An ICER is an Incremental Cost Effectiveness Ratio

ICER =Difference in costs

Difference in effects

Standard careCost = $8,000Effects = 10 units of health

New interventionCost = $12,000Effects = 14 units of health

Difference in costs = $4000Difference in effects = 4 unitsICER = $1000

Is an ICER of $1000 worth it? It depends on two main things:

What is the value of a unit of health?What is the alternative use of the resources?

Upshot: Context matters. Whether something is cost-effective or not depends on the comparison in question and can vary widely (if not wildly) by place, time, and situation. A thing cannot be “cost-effective” in the abstract.

The Setting: South Africa

HIV prevalence 2014

The problemSub-Saharan Africa has the most severe HIV/AIDS epidemic in the world and southern Africa the most severe in Africa.

HIV prevalence adults 15-49 in 2013 (UNAIDS)

In South Africa:• Adult HIV prevalence is estimated at 19%:

- 7 million HIV-positive people- 19% of global burden (0.7% of global

population)- Nearly 300,000 new infections/year

• HIV and tuberculosis are the two leading causes of adult deaths; 70% of TB patients have HIV co-infection

• Life expectancy at birth fell from 62 in 1995 to 52 in 2010

Sources: Stats SA, National Department of Health, UN Population Division

The solution

• An estimated 3.4 million patients are on ART (just under half the HIV-positive population)

• Among those on ART, 78% are virally suppressed

• Mortality has declined and life expectancy is rising

• Adult incidence is declining and vertical transmission is < 2%

• Large-scale, public sector provision of ART began in 2004

The need for efficient resource allocation• In September 2016, South Africa adopted “treat all” guidelines; all HIV-positive

individuals are eligible for ART

• For the country to reach its first two “90-90-90” targets (90% diagnosed, 90% on treatment), > 2.4 million more people must be placed on ART

• The estimated additional cost of this is about $1 billion/year, or about a 60% increase over current expenditure on HIV (SA funds 85% of its own HIV program; poorer countries fund very little)

• The South African economy is weak, with low growth and unemployment at 36%, and donor funding is unlikely to increase

• Economic evaluation (combined with some clever modeling) is helping South Africa decide how to allocate its constrained resources as efficiently as possible to maximize health benefits

Source: Stats SA; personal communication, Gesine Meyer-Rath

• The Department of Global Health at BUSPH began collaborating with the University of the Witwatersrand (Wits University) in Johannesburg in 2004.

• We helped to found HE2RO, the Health Economics and Epidemiology Research Office, in partnership with Wits.

• In collaboration with HE2RO, we’ve been conducting applied research on the economics and epidemiology of the HIV epidemic for > 10 years.

• We work closely with the South African Government, particularly the National Department of Health, to inform its policies.

• HE2RO now has ≈ 60 investigators and staff and dozens of studies.

• Funders include USAID, the NIH, the Gates Foundation, the CDC, the World Bank, and others.

BUSPH’s partnership in South Africa

How Much Does It Cost?

• Cost and price are not the same: I produce something at its cost; I sell it at its price

• Costs are independent of source of funding• We typically discount and inflate future costs

(and benefits)

Cost = monetary value of resources utilized to provide a service or achieve an outcome

• NO: “HIV treatment costs $10,000.”• YES: “In 2016, first-line HIV treatment per

patient per 12-month period in the United States, delivered on an outpatient basis and including medications, laboratory tests, clinic visits, patient management, and overhead for these services cost, Medicaid average of $10,000 (USD 2016).”

Cost to whom, when, for what, for how long?

How much does it cost is a loaded question

How much does HIV treatment cost in South Africa?

All outcomes In care and responding

In care but not responding

No longer in care

$-

$200

$400

$600

$800

$1,000

$1,200

$1,400

Site 1 (hospital based HIV clinic) Site 2 (NGO clinic)

Site 3 (NGO clinic) Site 4 (private GPs)

Cos

t per

pat

ient

(200

6 U

SD

)

• Study conducted in 2005-2006

• Retrospective cohort with chart review and unit cost data collection

• Primary outcome = adult patient “in care and responding” 12 months after ART initiation

• Perspective = provider (Department of Health)

• Included all resources used to provide outpatient ART

• First empirical data on actual cost of providing ART in Africa Today, first-line ART in South Africa costs about

$200/patient/year. In the U.S. it is $10,000-$20,000.

Is It Cost-Effective?

Cost-effectiveness of task-shifting and decentralization

• Two strategies for maintaining stable patients on ART:- Centralized, full-service HIV

clinics- Primary health clinics

• Why use cost-effectiveness analysis?- Minimize cost to achieve a pre-

determined outcome (viral suppression) for maximum number of patients

• Evaluation of a pilot implementation project following an RCT- RCT controlled for everything- Pilot was somewhere between

RCT and routine care

Centralized PHC

Effects (% of cohort in care and responding at 12 months)

90% 96%

Costs (average cost/patient for 12 months)

$539 $486

Most improvements in health are not cost-saving. In general, we don’t get more for less. We get more for more, and less for less.

An example of getting more for more—the RapIT study• Randomized trial of same-day

ART initiation for adult patients- Used point-of-care tests and

accelerated procedures- Patients could be dispensed ARVs

on the day of their first clinic visit, compared to 4-6 visits required under standard care

- Outcomes = ART initiation < 90 days and viral suppression < 10 months

• Intervention was effective, increasing - ART initiation by 36% - Viral suppression by 26%

• Intervention cost more. Cost per patient achieving primary outcome=- $524 in rapid arm- $483 in standard arm

Is $780 (base case) or $220 (best case) per additional patient virally suppressed cost-effective? It depends on what other ways there are to achieve it…and on the value of the outcome.

A useful application of cost-effectiveness analysis: screening costs versus treatment savings

• South Africa endorsed two strategies for identifying cryptococcal meningitis in HIV patients- Reflexive CrAg screening for all

patients with CD4 < 100- Provider-initiated CrAg screening

based on clinician’s decision- Which is a better strategy?

• Cost-effectiveness model developed using programmatic data from pilot screening programs in South Africa- Reflexive strategy was more

effective (saved more lives) and- Costs for treatment were lower

under reflexive approach, but- Costs for screening were higher

under reflexive strategy

Per 100,000 CD4 counts Reflexive screening

Provider initiated

screening

Difference (reflexive - provider initiated)

Number screened 9,500 1,536 7,964

Cost of screening $47,044 $9,508 $37,536

Cost of treatment $209,399 $264,564 -$55,165

Total cost $256,443 $274,072 -$17,629

Number of additional surviving patients 148 118 30

Total years of life saved 3,189 2,542 647

Cost per life year saved $80 $108 -$27

Reflexive screening is clearly cost-effective compared to provider-initiated screening, because savings on treatment more than offset costs of screening. But Government has to pay for screening up front, in a lump sum; treatment costs are incurred less conspicuously.

Using cost-effectiveness analysis to inform policyIntervention ICER ($/Life-year saved)Condom availability Cost saving Male medical circumcision Cost saving ART at current guidelines (CD4 < 500) 106 PMTCT 138 Universal treatment (“treat all”) 243 Infant testing at 6 weeks 274 SBCC campaign (HCT, reduction in MSP) 761 SBCC campaign (condoms) 1,216General population HCT 1,233 SBCC campaign 3 (condoms, HCT, MMC) 1,819 HCT for sex workers 2,644 Infant testing at birth 2,937 PrEP for sex workers 9,894 HCT for adolescents 19,546 PrEP for young women 26,216 Early infant male circumcision 53,785,494

Source: Meyer-Rath et al, Optimising South Africa’s HIV response: Results of the HIV and TB Investment Case, CROI 2016

What Are the Benefits?

Benefits can be estimated, but it’s a lot of work

• Prospective, adult cohort followed for six years after ART initiation

• 879 patients interviewed at routine clinic visits (average 8 interviews per patient)

• Study focused on general wellness, activities, employment

• Probability of not being able to do normal activities in previous week fell from 47% before starting treatment to 5% at 5 years

• Employment increased from 32% to 44%

A major benefit: patients on ART can go back to work and contribute to the economy

Comparison of productivity between HIV-negative workers and HIV-positive workers on ART

We could estimate the overall benefits of ART using data like these…but we rarely do. The decision to provide ART to all was political, not economic.

Can We Afford To Do What We Want?

Cost-effectiveness doesn’t matter if you can’t afford it

Country GDP/capita Health expenditure/capita (USD 2014)

Estimated cost of ART/patient/year

South Africa $5,692 $570 $263 (2015)

Kenya $1,377 $78 $249 (2013)

Malawi $381 $29 $135 (2016)

India $1,582 $75 No data

China $7,925 $420 No data

U.S. $55,837 $9,403 >$10,000Sources: World Bank; unpublished reports

HIV treatment is extremely effective. Its cost has plummeted (except in the U.S.). But can we afford it?

The South African HIV Investment Case

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Total cost of HIV programme

Baseline Government targetsUnconstrained optimisation Constrained optimisationBudget Constraint Linear (Budget Constraint)90/90/90

US

D (b

illio

ns)

National Department of Health and South African National AIDS

Council

Final Thoughts

Why should we care about economics? “Cost is never the first, but almost always the second

consideration in rolling out an intervention. As such it stands between evidence and implementation.”

--BUSPH Assistant Professor Gesine Meyer-Rath Resources are always constrained. There are always

options. Economics helps us choose. Economics is about benefits, not just costs. It forces

us to confront our values. How much is a specific health benefit to someone (else) worth?

Economic evaluation can incorporate considerations of equity and fairness, but only if we are willing to make explicit the values or weights we place on these things.

Last and least: When to call an economist Wrong answer: After we’ve finished our randomized,

controlled clinical trial and suddenly realize that it would be nice to know if our intervention is cost-effective.

Right answer: At the start of our study, to design it in a way that will make the results generalizable and capture all the resources used.

Wrong answer: To prove that we can afford what we’ve already decided to do, regardless of our resources.

Right answer: To decide what we can afford to do, for whom, when, and how, given our resource constraints.

Acknowledgements• BUSPH South Africa team: Gesine Meyer-Rath, Matthew

Fox, Jacob Bor, Bruce Larson, Alana Brennan, and others• HE2RO: Lawrence Long, Mhairi Maskew, Ian Sanne, and

others• Funders: USAID, NIH, Gates Foundation, CDC, and others• Collaborators: South African National Department of Health,

Right to Care, City of Johannesburg, and others

World AIDS Day 2016: Economic evaluation for HIV in South Africa

Health & Medicine

Transcript of World AIDS Day 2016: Economic evaluation for HIV in South Africa