ACHAP Economic and Social Impact Assessment

ACHAP Support Methods Epidemiological Impact Economic Impact Outline

PPP; Govt of Botswana, Bill & Melinda Gates Foundation and Merck/The Merck Company Foundation. – Country priorities; NSF for HIV/AIDS informed strategic direction – Mutual partnership: Govt strategy & policy guidance, in kind contribution – ACHAP financial, technical, human resources, infrastructure, and logistical support ACHAP Support

Phase I ( ) and Phase II (2010 to 2014) Two Pronged – National level – Districts level In most cases ACHAP operated from GOB infrastructures ACHAP Directly implemented ACHAP Staff seconded to GOB Collaborated with other partners Impact of ACHAP supported Programmes cannot be solely attributed to ACHAP ACHAP Support

After 13 years, ACHAP stands as a successful venture into the realm of PPP for public health interventions More than $128 million in financial disbursement Merck ARV’s donation valued at around $168 million O VERALL I NVESTMENT

ACHAP’s support helped Botswana reduce spread and impact of HIV and TB. ART program had an immediate impact on – reducing HIV-related mortality – Averted new HIV infections. – Reducing TB morbidity and Mortality – Contributed to a marked decline in the number of TB cases SMC program has averted – HIV infections – Future infections – Future HIV deaths H YPOTHESIS

GOALS Model of Spectrum used for ART and SMC – Model has been set up for Botswana using all available data sources on Botswana For TB analysis, used TB modelling program, TIME. – TIME is “TB Impact Model and Estimates” – Implemented on Spectrum modeling software. – Designed to inform national strategic TB program planning – Models TB interventions epidemiological impact and costs. – Model was developed and maintained by the Tuberculosis Modelling and Analysis Consortium (TB-MAC) and Futures Institute. M ETHODS

No Masa/SMC Support SMC Support Only Masa Program Only Both Masa/SMC Support S CENARIOS

R ESULTS OF ART AND MC A NALYSIS

Number of HIV new infections by year and scenario

By 2014, SMC program averted an estimated 7,470 infections ( Note ACHAP Directly Contribute 75% of all SMC’s ) – Equivalence of one(1) infection averted for every 11 circumcisions performed. About 42,000 infections averted by 2030 – One(1) infection averted for every 2 male circumcisions performed. – Infections averted will also lead to future deaths averted New HIV Infections Averted by SMC

ART program has had an even larger impact on new infections averted ART Cumulatively averted 110,000 new infections during the period – This is equivalent to 13 person-years of ART per infection averted. Combined ART/SMC new infections averted with ACHAP support is 114,000 new infections from 2001 to New HIV Infections Averted by ART

Number of HIV-related deaths by year and ACHAP Support

ART program averted an estimated 165,000 deaths from 2001 to 2014 or 48%. This is equivalent to one (1) death averted for 9 persons put on treatment. The ratio was as low as 5 earlier in the epidemic when most people starting ART had low CD4 counts. Note, deaths averted can occur later, so it is also useful to examine the number of life years gained; or measure additional person-years of life attributed to the intervention. – Over 949,000 life-years during the period were saved. – This is equivalent to 1.2 person-years of ART per life year gained. D EATHS A VERTED

TB Mortality by HIV Status

Cumulative TB mortality was reduced by 17% during In 2014 number of TB related deaths reduced by roughly half of deaths in the “no support” scenario. Note, nearly all of the deaths and cases of active disease averted by the national TB program were among HIV+ individuals. Comparison of TB scenarios with and without the scale up of ART and MC

New TB cases per year was reduced by roughly 50% in TB Incidence by HIV Status

Ideally a comprehensive analysis of ACHAP’s support would determine the economic benefits associated with all the funds spent. However, it would be problematic to link the resources used to specific outputs. For this reason, the economic impact analysis focused only on SMC and ART. S OCIO - ECONOMIC I MPACT

Benefits are 30 times greater than the overall costs. – Assessed costs that would be needed in order to treat an infected person (discounted cost of lifetime treatment) Estimated at $7,400 – For estimated infections averted $351.5 million future costs was saved. – Compared to $11.6 million as cost of 101,680 SMC’s. This would be even more favourable if one were to include other benefits of preventing each HIV infection (e.g., lost future earnings, loss of value to the household, etc.),. S AFE M ALE C IRCUMCISION ECONOMIC I MPACT

Average per SMC Cost by year Per SMC Cost reduced by over 2/3

Benefits exceed costs 5 fold – By averting infections, ART also averts future ART costs. – ART saved $814 million by averting 110,000 infections Assuming discounted cost of lifetime treatment of $7,400. Drug donation program costed $168.4 million. The $168.4 million drug donation exclude other costs Conversely, benefits of treatment cannot be defined solely by infections averted, since treatment also provides other benefits (reduced morbidity and mortality, increased productivity, etc.). ART E CONOMIC B ENEFITS

ART and SMC Combined saved $843.6 million by averting 114,000 infections. ART and SMC cost was $180 million. Cost ratio of $4.7/$1.0 cost. Still if other benefits are considered, benefit may be significantly higher. ART AND SMC C OMBINED E CONOMIC B ENEFITS

ACHAP creation was a timely and right move for Botswana’s national response to HIV/AIDS ACHAP has been a catalyst hence drawing development partners to assist expand and intensify initiatives. Without ACHAP, Botswana would have not easily attained the success it has enjoyed in HIV/AIDS fight. ACHAP became instrumental in ensuring that catastrophic impact of the epidemic on the economy and social fabric of Botswana, that was thought to be imminent at the turn of the century, has been largely mitigated. ACHAP served as a prime example of difficulties and successes of joint partnership between government and private companies. ACHAP achieved high level of integration across government, NGOs, CBOs, and the community. Conclusions

Acknowledgements – Futures Institute for this analysis