26 July 2017 Catherine Barker, Arin Dutta, Kate Klein Can differentiated care models solve the crisis in HIV treatment financing? Analysis of prospects for 38 countries in sub-Saharan Africa 26 July 2017 Catherine Barker, Arin Dutta, Kate Klein

Facility-level ART funding gap1 Countries face financial and health system constraints to meeting 90-90-90 Facility-level ART funding gap1 WHO projects a net shortage of 15 million health workers by 20302 Sources: Dutta A, Barker C, Kallarakal A (2015) The HIV Treatment Gap: Estimates of the Financial Resources Needed versus Available for Scale-Up of Antiretroviral Therapy in 97 Countries from 2015 to 2020. PLOS Medicine 12(11): e1001907. https://doi.org/10.1371/journal.pmed.1001907 Liu JX, Goryakin Y, Maeda A, Bruckner T, Scheffler R. Global health workforce labor market projections for 2030. Human resources for health. 2017 Feb 3;15(1):11. Palladium Corporate Presentation

Are differentiated care models (DCMs) a potential solution? “Differentiated care is a client-centered approach that simplifies and adapts HIV services across the cascade to reflect the preferences and expectations of various groups of people living with HIV (PLHIV) while reducing unnecessary burdens on the health system.” -International AIDS Society Beatrice Tierney Health Clinic in Bupoto, Uganda Jhpiego. Community workers in Mozambique Facility-level ART management Community-level ART management Evidence from: South Africa Zimbabwe Uganda Swaziland Zambia Frequency of visits and lab monitoring depend on patient characteristics and behavior, including response to treatment Palladium Corporate Presentation

Laboratory monitoring Frontline health workers Our analysis: Estimating facility-level cost and health-worker savings from DCMs Research question: What are the potential health system efficiency gains in terms of reduced facility-level costs and number of health workers needed for ART from implementing DCMs in 38 countries from 2016 to 2020? Stylized DCMs: Two criteria: Age and stability Four criteria: Age, stability, key vs. general population, rural vs. urban population Costs included: Countries included: ARVs Laboratory monitoring Frontline health workers Facility overhead Community ART support (DCMs only) Palladium Corporate Presentation

Our analysis: Stylized DCM scenarios Frequency per year or percentage receiving community-based support Model 1: Undiffer-entiated care Model 3: Four-criteria DCM (differentiation by age, stability, key population, and urban/rural) Model 2: Two-criteria - Age and stability DCM Key popu-lations^ Urban# Rural# Children 0-9 Adolescents 10-19 Adults 20+ New Stable~ Unstable Clinical visits 6 4 5 3 2 4 to 6 2 to 6 Refill visits 3 to 7 1 to 5 Diagnostic management* Viral load 1 1 to 2 CD4 Clinical chemistry 1* Hematology 1** Coverage of community-based ART support or home visits 0% 100% Lower cost Higher cost ~Stable patients are those receiving ART for at least one year with no adverse drug reactions, no current opportunistic infections or pregnancy, a good understanding of lifelong adherence, and evidence of treatment success. We assumed all patients who are on treatment for at least one year and virally suppressed are stable. Country- or regional-specific data on viral suppression came from peer-reviewed literature. *Clinical chemistry tests are for those on TDF-containing regimens. **Hematology tests are for those on AZT-containing regimens. ^Key populations for this analysis are defined as men who have sex with men, sex workers, and people who inject drugs. For our analysis, key populations are a subset of the adult population only. New and stable key populations have 4 visits per year, unstable key populations have 6. #The entire population can be segmented in urban vs. rural. Due to closer proximity to facilities in urban areas, the model assumes additional refill visits and fewer community ART support meetings for those residing in urban areas compared with rural areas. Palladium Corporate Presentation

Full-time equivalent (FTE) health workers Methods: Estimating numbers on treatment, unit costs, and health workers needed Numbers on treatment Description of methods Estimated number of people living with HIV by age group (accounting for uncertainty) Assumed linear scale-up in coverage to 81% by 2020 or 2025, depending on baseline levels Further segmented numbers on ART by stability, key vs. general population, and urban vs. rural population Data sources Official country AIM files (2016) AIDSinfo PEPFAR COPs Peer-reviewed literature Unit costs Estimated baseline facility and community level ART costs Assumed declines in costs for ARVs and lab commodities over time Accounted for uncertainty in unit costs Global Price Reporting Mechanism (GPRM) database Peer-reviewed literature Full-time equivalent (FTE) health workers Estimated the number of FTEs based on the number of patient visits per year and the amount of time health workers spend per visit Peer-reviewed literature Palladium Corporate Presentation

Results: Number of people on ART Numbers on treatment in 2020 19.0 17.5 16.1 14.7 13.5 Note: Whiskers denote 95% confidence interval. Note: Key vs. general population segmentation for adults only. Palladium Corporate Presentation

Results: ART costs across all 38 countries Total: $23.3 billion Key takeaways: 17.5% (US$4.1 billion) and 16.8% (US$3.9 billion) could be saved from 2016 to 2020 from implementing the two- criteria DCM and four- criteria DCM, respectively. Community health costs would need to average US$125 per person to eliminate any cost savings from DCMs. Total: $19.2 billion Total: $19.4 billion Palladium Corporate Presentation

Results: FTE health workers required by scenario Key takeaways: DCM scenarios require fewer health worker FTEs for ART, meaning health workers may be able to see additional patients or perform other tasks. In 2020, about 46% fewer FTE health workers are needed under the DCM scenarios compared with the undifferentiated care scenario. Palladium Corporate Presentation

Estimated cost savings from implementing DCMs from 2016 to 2020. DCMs may allow more people on treatment with the same resource envelope Limitations: Lack of data on community-level ART support costs. Exclusion of above- site costs, including start-up costs for implementing DCMs. Examined cost savings only from the health system funders’ perspective. US$3.9 to US$4.1 billion Estimated cost savings from implementing DCMs from 2016 to 2020. Reduction in the financing gap for facility-based ART services under DCMs, even after accounting for additional community-level ART support costs. 32% to 36% 46% Savings in health worker time in 2020 from implementing DCMs. Palladium Corporate Presentation

Realizing efficiency gains will depend on how countries implement DCMs After DCM, can health workers be managed such that any freed-up time is fully utilizable? Multi-month scripting reduces patient refill visits. DCM may also reduce clinical visits  This frees up facility-based staff time  If staff are assigned only to ART site/CCT then they cannot be easily shifted to other needs X  Facility owners (government, NGOs) may need to make a decision Option: manage more ART patients at same site to use freed capacity?  But what if decentralizing ART? Will there be policies and plans in place to guide roll-out of DCMs, including re-training of health workers? What will this cost? What if some patients do not want to visit the clinic less often or be managed at the community level? Patients Will health information systems be responsive to DCMs? Health workers Even if efficiency gains from DCMs cannot be fully realized, DCMs may be worthwhile due to reduced cost and effort for most patients, and pilot programs showing DCMs may improve ART outcomes Palladium Corporate Presentation