IAS 2016 – Durban, South Africa Answering the financial question with country programs: what is the cost and impact of adopting the 2015 WHO pediatric HIV treatment guidelines? Aude Wilhelm, Carolyn Amole, Caroline Middlecote, Joseph Harwell, Elizabeth McCarthy IAS 2016 – Durban, South Africa (abstract # THPDE0203)

Costing Model comparing in-country Treatment Costs to implement Treat All in WHO 2016 vs 2013 Guidelines Background/Current Context Background: Excel-based model was first created in 2010 during rollout of 2010 WHO Guidelines and used to assist countries in making policy decisions on which parts of the WHO Guidelines they wanted to adopt for revisions to their National Treatment Guidelines. The model was revised for 2013 guideline decisions and continually updated to stay abreast of the latest pediatric ART recommendations. Current Context: With WHO’s 2016 Consolidated Guidelines now aligning with UNAIDS ambitious 90-90-90 HIV elimination strategy, further revisions to the model featuring a treat-all strategy were made in Q4 2015. Several countries with varied treatment landscapes (Cambodia, Uganda, Nigeria, Zambia) have used this model to update their treatment guidance accordingly, with other countries currently in the pipeline to do a costing. Nigeria Uganda Zambia Cambodia

Costing Model Outputs inform countries on both costs and additional HR needed to treat increased patient loads Methods/Scenario Analysis Scenarios to inform 2015 guideline considerations feature: Test and treat Scale-up VL monitoring / Reduce CD4 monitoring Move to newer, new optimal ARVs (ex. heat-stable LPV/r oral pellets) Baseline model assumptions of HIV landscape for hypothetical country: 68,000 patients on ART in Q4 2015 and WHO 2013 guideline adoption Emphasize that the changes are in defining the scenarios

Results highlight affordability of moving to treat all for pediatric HIV patients Model Outputs/Results Result 1 : Optimizing drug selection for new ART initiates with adoption of heat-stable LPV/r oral pellets only added an annual $4M to the total 5-year cost (2016-2020). In our hypothetical country, new pediatric treatment guidance added a relatively small amount in relation to the overall budget (between $14M - $33M over 5 years) compared to the 2013 WHO guidelines. Result 2 : Despite doubling those enrolled on ART, we did not find a significant increase in health worker requirements. This is due to the already large burden on health care workers of testing and providing care to those not yet initiated on ART, even before treat all. Mention verbally: -there is a small increases in cost associated with pediatric care are really insignificant relative to the overall HIV budget for a country -storage and administration challenges with cold chain LPV/r oral syrup is what led to IATT feature of LPV/r oral pellets – with a key driver of product adoption being several countries’ measures of poorer pediatric patient outcomes using LPV/r syrup. Added comments from Elizabeth: -result 1: cost increase to include LPV/r oral pellets is not a huge increase -result 2:I would explain the rationale behind the low increase in HRH rather than throw the 44 number out there. People will just wonder why so I’d suggest explaining it and avoiding a number that really is just a hypothetical anyway. 44 additional from 240 makes 18% increase Note: Implementation of Treat All should be gradual to avoid overwhelming heath systems and highlight the need for more aggressive case finding strategies in countries

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