Evaluating the cost-effectiveness of the test and treat program in Zimbabwe 2016-2026

Background Population almost 16 million PLWHA 1.3 million 13.5% adult prevalence 980 000 on ART # virally suppressed 790 000 HIV prevalence in key pops Sex workers 57.1% Prisoners (MSM) 28%

Source: National AIDS Council

Decline in MTCT rate Source: Big Win In partnership with the Elizabeth Glaser Pediatric AIDS Foundation, Big Win Philanthropy previously supported this program which dramatically reduced Zimbabwe’s mother-to-child HIV transmission rates from 30% in 2010 to less than 7% in 2014, and an estimated 5% in 2015 Source: Big Win

Factors fueling the spread of HIV High prevalence of STIs Low levels of male circumcision High rates of multiple concurrent sexual relationships Incorrect or inconsistent condom use Low socio-economic status of women Distressed economic conditions ,population mobility and settlement patterns Source: national AIDS Council

Factors which contributed to the decline Implementation of the Zimbabwe National HIV/AIDS strategic plan which declared HIV a national emergency in 1999 Enactment of the National AIDS Council by an act of parliament Introduction of 3% AIDS levy on all taxable income in all sectors. A multi-sectoral approach Gender sensitive approach

Ctd….. Meaningful involvement of PLWHA Well packaged and targeted interventions for high risk groups Robust BCC programme leading to a massive cultural shift in sexual behaviour Rapid scaling up of PMTCT services

Methodology Goals model a dynamic compartmental model Simulates transmission trends in adults aged 15-49 in these risks categories injecting drug users (IDU) MSM female sex workers and their clients multiple partners Couples Study period: 2016-2026 3% discount rate

Sexual Mixing Males SW clients Males Non-regular partners Males PWID Stable couple Males MSM Females Sex workers Females Non-regular partners Females PWID Females Stable couple SPECTRUM

Determinants of risk of infection Susceptible Partner Infected Partner HIV infection Stage of infection ART Vaccination Number of partners Male circumcision Oral PrEP Topical PrEP Vaccination Number of acts per partner STI prevalence Heterosexual, MSM, IDU contact Condom use The factors that determine the risk of transmission can be categorized as characteristics of the infected partner, the susceptible partner and the partnership. SPECTRUM

Probability of Sexual Transmission {1 – [Ps’,g,t x (1 - rs x Rg,t x Sg,t x MCg,t x Cg,t x Prg,t x Ag,t x Vg,t)a + (1 – Ps’,g,t)]n } Vaccine ART PrEP use Condom use Acts/partner Partners/yr Male circumcision STI prevalence Stage of infection Probability of transmission per act by sex and type of sex Prevalence in partner Where: MC, C, Pr, A, V = 1 – effectiveness x coverage Here is the full transmission equation. It expands on the one we saw earlier by adding the effect on the probability of transmission per act (r) of these other factors. SPECTRUM

Data Sources Category of Data Source Population size DemProj, UN Population Division HIV program data (ART, PMTCT) AIM Epidemic dynamics (progression, mortality) BY RISK GROUP Surveys, population size studies (e.g., RDS) Global reviews: Aceijas, Caceres, Carael, Dagenhardt, Van de Pitte Condom use DHS/AIS, Key population surveys (e.g., IBBS) Number of partners Key population surveys Acts per partner Key population surveys, global defaults Percentage ‘married’ Surveys Increased recruitment Prevalence patterns STI prevalence Surveillance, studies PWID: Proportion sharing needles PWID surveys Age at first sex Demographic surveys SPECTRUM

A few adjustments were done in condom use and acts per partner in order to fit the model

Scenario analysis A comparison of CD4 <500 cells per µL(Constant Coverage) and universal test and treat (UTT) using the following metrics; QALY ICER orphan years are averted per year New HIV infections averted AIDS related deaths prevented

Key findings

AIDS deaths averted

Key findings the UTT program cost $11.2 billion and $13.2 billion with discount and without discount, respectively. Under constant coverage the ART program cost $7.8 billion and $8.9 billion with discount and without discount, respectively. Between 0.45 and 0.61 orphan years are averted per year that an adult survives the cost of orphan care averted was $324 per every orphan year. 14.2 million life years saved 13852.8 QALYs saved 432 125(31%) new infections averted 39% AIDS death prevented ICER of $3 871.91 of UTT over constant coverage

ICER sensitive to ARV costs and incidence

Discussions points UTT has huge fiscal implications upon Zimbabwe Possible challenges with defaulters and challenges with accessing second line of ART Some similar studies have showed that ART scale up might not be as effective in the long term UTT based its conclusions on RCT of which real life scenario might offer a different result Need for right mix of prevention interventions -PrEP cost effective for key population Need to watch form unintended consensus for some interventions eg sex workers reported circumcised men increased STIs due to PrEP

Conclusion UTT is a good investment opportunity for Zimbabwe as it shows big cost saving opportunity, prevention of new infections, increases in life span and quality of PLWHA. Combined with right mix of prevention strategies, country specific test and treat programs might even be more effective