Contribution of Economics to Operational Research for Evaluation of Scaling Up Access to HIV Care & Treatment in Developing Countries Presentation by Pr Jean-Paul Moatti ANRS-ETAPSUD Programme, University of the Mediterranean WHO, Geneva, June 30, 2003

Defining Operational Research Learning lessons from what were doing while were doing it; finding out what works, what doesnt, and what can be improved. Contribution of economics to address questions relating to scaling up ART programmes: - How to maximise efficiency in access to care programs including ART in limited-resource settings ? - How to promote equity in access to ART ? - How to maximise the impact on the epidemic ? - How to assess the global impacts of these programs on public health, economic, social and human development ?

More costly, less effective Dominated strategy Reject Less costly, more effective Domining strategy Adoption Costs (+) Health benefit Cost-effectiveness comparison of a new strategy versus current standard Less costly, less effective More costly, more effective Acceptability of health losses for reducing costs ? Willingness to pay for additional benefit ? (+)(-)

Marginal cost per lifeyear ARV Population Oth ers AR Vs V SV Hyp : ARVs always dominated Plausible hyp : ARV cost effectiveness ratios intersect those of alternative strategies Cost-effectiveness of ARV therapies versus Alternative strategies for HIV/AIDS care Othe rs Marginal cost per lifeyear

Cost-effectiveness Criterion in rich countries Marginal cost per lifeyear gained accepted > 6 x GDP/tête => rejected Marginal health care cost per lifeyear gained of HAART vs Non HAART = 14,000US$ MC 26,000US$ OCDE countries GDP/cap = 28,000 US$ HAART cost-saving when indirect costs are included

Why not a similar criterion in developing countries ? => MTCT prevention, cotrimoxazole and tuberculosis prophyaxis = cost- effective => ARV treatment in well defined groups ?

Contribution of Economics (1) Cost-effectiveness research to optimize therapeutic strategies in limited-resource settings: - Criteria for rational decision to initiate treatment. - Optimal 1st, 2nd (and 3rd) line treatment for adult patients. - Optimal regimens for specific indications, e.g., opportunistic infections, tuberculosis, pregnancy, children. - Optimizing the use of generic drugs. - Assessment of tolerance, adherence, and acceptability of treatment.

Contribution of Economics (2) Cost-effectiveness research to optimize means of initiating and monitoring therapy in limited- resource settings: -Feasibility of low-cost methods of enumerating CD4 cells, measuring plasma viral load, and assessment of their large-scale use. -Optimal frequency of biological monitoring. -Feasibility and role of clinical scales for monitoring. -How to simplify monitoring protocols without jeopardizing safety and tolerance.

Contribution of Economics (3) Cost-effectiveness research to to determine best practices in healthcare delivery of ART : Impact of treatment guidelines and of standardizing first- line treatment Econometric analysis to evaluate differential efficiency of public policies between countries and between centers. Impact of different financial schemes for funding ARV costs and of different delivery systems

Contribution of Economics (4) Management research for improving the logistics of ARV-delivery programs : - Capacity of existing medical operations at national, regional, and district levels. - Needed changes in organization and regulation of healthcare delivery systems. - Trade-off in choice of adding specialized structures for the delivery of HIV care vs. integrating into general healthcare.

Impact on HIV-infected population and general population Economic and sociobehavioral research to assess the impact of expanding access to HIV treatment at the population level: - Impact on life expectancy, quality of life, psychological and socioeconomic status of ARV-treated patients. - Best ways to address equity issues relating to access to care. - Impact on HIV-related risky behaviors and on prevention in HIV-infected and general population. - Impact on social perception of HIV/AIDS, stigma and discrimination.

Microeconomic and macroeconomic, impact on development. - Microeconomic impact on households, families, local/ regional food production, and productivity of various economic sectors. - Improvement of macroeconomic models to take into account the impact on human capital.

Minimum requirements for economic research in ARVT data base - Longitudinal data or repeated cross-sectional in homogeneous populations - Data about health care resource use in standardised physical units - Access to biological and clinical outcomes - Minimum data about socio-economic characteristics of ARV-treated patients (level of education, size of household, areea of residence) - Questionnaires in sub-samples (risk behaviours, adherence, indirect costs)

Major difficulties for economic research in ARVT data base - Data about the general HIV-infected population in order to compare ARV-treated to non-ARV treated ? - Data collection not only in health care centers but at the household level ? - Treatment of selection bias and uncertainty on parameter estimates used in C/E or econometric models?

Research priorities in next 12 months Cost-effectiveness studies of ARV treatment in resource-limited settings using real data. Assessment of logistics and management problems to scaling up access to ART at regional and district levels. Evaluation of socio-economic, educational and informational characteristics of HIV+ patients benefiting from ART.