Projected Population and HIV/AIDS Update 18 May 2011 National Health Insurance Policy Brief 18

South African Population Source: IMSA NHI Policy Brief 18: Projected Population and HIV/AIDS Update ASSA2008 is projecting a larger and growing population compared to the earlier ASSA2003. The projections used by the NDoH for planning are now lower than ASSA2008.

Provincial Population Estimates 2010 Source: IMSA NHI Policy Brief 18: Projected Population and HIV/AIDS Update A caution that different population projections have very different projections at provincial level. Of greatest interest is ASSA2008 compared to the NDoH/HISP projection which is based on StatsSA mid- year population 2009.

Age Profiles ASSA2008 and NDoH/HISP Source: IMSA NHI Policy Brief 18: Projected Population and HIV/AIDS Update At national level ASSA2008 shows more women aged 35 to 55 than the NDoH/HISP projection. The shapes for the Gauteng population have substantial differences.

ASSA2008 Projection Calibrated using data for deaths up to 2008, recent antenatal surveys and household surveys. Revised assumptions about mortality rates in untreated HIV-infected individuals: higher survival rates in African adults than previously. Reduction in estimated AIDS mortality largely due to the rapid expansion of the South African antiretroviral treatment programme. Substantial increases in condom use over the last decade. Separate ART roll-out rates for men, women and children. Allows for separate HIV survival for adult males and adult females: Weibull distribution has longer mean survival time but with greater variance. Survival of untreated children is assumed to be longer, especially for children infected at or before birth. Model now allows for the survival of some infected children to adulthood.”

Improvement in Survival Time Source: IMSA NHI Policy Brief 18: Projected Population and HIV/AIDS Update There has been a major change in the modeling of paediatric survival times. The ASSA2008 model now allows for survival of infected children into adulthood.

Impact on Price pbpm of Healthcare using ASSA2008 The price of healthcare in 2010 is very slightly lower for all benefit packages using ASSA2008 rather than ASSA2003. However with the population living longer, the age profile is older and the price pbpm in 2025 goes up by between 1.2 and 1.4% compared to the earlier projection. Source: IMSA NHI Policy Brief 18: Projected Population and HIV/AIDS Update

Impact on Total Cost of Healthcare using ASSA2008 The total cost of healthcare in 2010 is higher for all benefit packages using ASSA2008. With the larger population projected in 2025, the total cost goes up by 9.9% to 10.0% compared to the earlier projection. Note that these effects do not yet take into account the impact of the greater numbers who are HIV+ or on ARVs. Source: IMSA NHI Policy Brief 18: Projected Population and HIV/AIDS Update

ASSA2003 and ASSA2008 Source: IMSA NHI Policy Brief 18: Projected Population and HIV/AIDS Update ASSA2008 projects a very much larger ARV programme. As a result, people live longer and hence the total living with AIDS increases substantially.

Caution For the next few slides, two versions are given: the ASSA2003 version and the ASSA2008 version. The ASSA2003 graphs are supplied only to facilitate comparisons to previous work. It is advisable for all modelling and projection work to use the ASSA2008 version. Source: IMSA NHI Policy Brief 18: Projected Population and HIV/AIDS Update

Staging of HIV Infection In the absence of ART, adults are assumed to progress through four stages of disease before dying from AIDS (as defined in WHO Clinical Staging System). Two further stages are modeled: people receiving antiretroviral treatment and those who have discontinued treatment. Source: IMSA NHI Policy Brief 4: HIV and Future NHI ASSA2003

Staging of HIV Infection Source: IMSA NHI Policy Brief 18: Projected Population and HIV/AIDS Update In the absence of ART, adults are assumed to progress through four stages of disease before dying from AIDS (as defined in WHO Clinical Staging System). Two further stages are modeled: people receiving antiretroviral treatment and those who have discontinued treatment. The size and shape of the ARV group has changed significantly.

Waves of the Epidemic Cumulative AIDS deaths are estimated to have exceeded 1 million by 2004 and expected to exceed the total number of people living with HIV by 2017, some 6 million people. The period 1994 to 2003 saw an increase in total HIV infections from an estimated 533,000 to 4,742,000 people. Source: IMSA NHI Policy Brief 4: HIV and Future NHI ASSA2003

Waves of the Epidemic Source: IMSA NHI Policy Brief 18: Projected Population and HIV/AIDS Update AIDS deaths begin to decline from 2007 due to the ARV programme. Cumulative AIDS deaths and the number of AIDS orphans are therefore much lower than previously estimated. The number of HIV+ people continues to increase due to the greater numbers surviving on treatment.

HIV Prevalence Rates to 2025 A significant feature of the epidemic in South Africa has been the very different levels of infection by province. Overall prevalence levels out when new infections are balanced with deaths. KZN has the highest prevalence and Western Cape the lowest. Source: IMSA NHI Policy Brief 4: HIV and Future NHI ASSA2003

Provincial Impact of Age and Gender Differences This excludes the different effect of HIV/AIDS in each of the provinces. Source: IMSA NHI Policy Brief 18: Projected Population and HIV/AIDS Update

HIV Prevalence Rates to 2025 Source: IMSA NHI Policy Brief 18: Projected Population and HIV/AIDS Update A significant feature of the epidemic in South Africa has been the very different levels of infection by province. KZN continues to have the highest prevalence and Western Cape the lowest. Abrupt changes in prevalence are due to boundary shifts in some provinces.

Provincial Age Profiles 2010 Source: IMSA NHI Policy Brief 18: Projected Population and HIV/AIDS Update Substantial differences in age and gender profile between provinces which affects price or capitated amount needed for healthcare. Western Cape and Gauteng continue to have more working-age adults; provinces with fewer economic opportunities have many more children.

Recommendations It is strongly recommended that any costings of healthcare for a future National Health System (NHS) or National Health Insurance (NHI) be updated to include the revised population projections from the ASSA2008 model. Where possible, researchers should include the NDoH/HISP projections as well in order to be able to illustrate differences between ASSA2008 and the projections in use by Government departments. Source: IMSA NHI Policy Brief 18: Projected Population and HIV/AIDS Update

Innovative Medicines South Africa (IMSA) is a pharmaceutical industry association promoting the value of medicine innovation in healthcare. IMSA and its member companies are working towards the development of a National Health Insurance system with universal coverage and sustainable access to innovative research-based healthcare. Contact details: Val Beaumont (Executive Director) Tel: Fax: Innovative Medicines SA (IMSA) Cell: PO Box 2008, Houghton, South Africa

Material produced for IMSA by Heather McLeod