Characterizing the South Africa ART Market Heather Awsumb, K. Little, P. Aylward and N. Hasen 9th IAS Conference on HIV Science (IAS 2017) 26 July 2017

Conflict of Interest No conflicts of interest to declare. 2.1 1.5 1.4

Background

There is little known about the role of HIV treatment service delivery in the private sector Source: Prevention Gap Report, 2016, UNAIDS

Why South Africa? Data Notes: All data from aidsinfo.unaids.org

South Africa spends the most on HIV, the majority of it from domestic/public sources Data Notes: All data reported for 2015 at aidsinfo.unaids.org

Key Questions Has the rapid increase in public sector treatment access reduced demand for treatment in the private sector? Is there any evidence that patients with treatment failure are turning to the private sector?

Methods

Data Sources & Definitions Global Price Reporting Mechanism (GPRM) – exported January 2017 IMS Health sales data for South Africa from June 2011 to May 2016 Complete data sets for calendar years 2012 - 2015 First line (1L) regimen = Efavirenz or Nevirapine & paediatric LPV/r Second line (2L) regimen = Atazanavir or Lopinavir/Ritonavir (all other doses)

Methods Only comparable units in GPRM and IMS Health datasets were total volume of units procured. Calculated “patient years of treatment” (PYT) by dividing the number of units procured by the number of units needed to treat a patient for 1 year. 𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑢𝑛𝑖𝑡𝑠 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑢𝑛𝑖𝑡𝑠 𝑝𝑒𝑟 𝑃𝑌𝑇 =𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑃𝑌𝑇 Analyzed data using Pivot Tables in Excel

Results

Private sector procurement would be enough for the 14th largest treatment program in the world and the 10th largest in Africa Data Notes: Data reported for 2015 at aidsinfo.unaids.org

The number of PYTs for 1L ARVs peaked in 2014 in the private sector

Rapid growth in total public sector PYTs for 1L regimens did not appear to significantly displace 1L PYTs in the private sector

TDF/FTC/EFV had the highest PYTs for 1L ARVs in the public and private sector Other for Private Sector included: LPV/r 80/20mg, LPV/r 100/25mg, EFV 200 mg, AZT/3TC/NVP 300/150/200, NVP 50mg/5ml, EFV 50mg, AZT/3TC/EFV 300/150/600mg Other for Public Sector included: LPV/r 80/20mg, EFV 50mg, NVP 10mg/ml

PYTs for 2L treatment in the private sector increased by 15% overall between 2012-2015

Growth in total public sector PYTs for 2L regimens also did not appear to significantly displace 2L PYTs in the private sector

Conclusions

Limitations The GPRM and IMS Health data may not be completely analogous. A patient year of treatment (PYT) is not the same thing as a person receiving treatment. Some private sector providers may be providing treatment using public sector procurement and/or financing.

Results Total procurement in the South African private sector is significant when looked at on a global scale. Evidence indicates that patients continue to rely on the private sector for 1L and 2L treatment even as they become increasingly available in the public sector. It appears that, on the whole, the private sector is in line with the South Africa treatment guidelines. Data suggests that there is almost no paediatric treatment in the private sector.

Opportunities There may be opportunities to leverage domestic funding through the private sector as donor and domestic public sector budgets and facilities reach capacity. Conduct landscaping of cost to patients in both the private and public sector.