ELIZABETH MZIRAY Health, Nutrition and Population Department World Bank

Acknowledgements Lead Consultant and Author Dr. Markus Haacker Planning Institute of Jamaica Ms. Barbara Scott, Mr. Easton Williams, Mr. Walter James, and other PIOJ staff Ministry of Health Dr. Nicola Skyers and the NHP Development Partners PAHO, CHAI UNAIDS Dr. Ernest Massiah, Dr. Pierre Somse, Ms. Roxanne Morris

Outline 1 Context 2 Purpose of the Study 3 Approach and Methodology 4 Results of Analysis 5 Recommendations

Status of the Epidemic in Jamaica Prevalence rate: 1.1% – MSM (31.8%) – CSW (4.9%) – Crack cocaine users (4.5%) – Prisoners (3.35%)

Status of the Epidemic in Jamaica Main achievements: – Reduction in AIDS mortality – Reduction in MTCT – Improved prevention programs with increased focus on MARPs Challenges: – Current prevention efforts have failed to impact the epidemic among MSM – Only 50% of PLHIV know their status

Context - Jamaica Jamaica maintains a robust treatment program – More than 90% of ANC clients access VCT – Treatment coverage is 58%

Slowdown in donor financing globally Source: UNAIDS IHP+ Gates Foundation

Financing of the National HIV/AIDS Response Financing for the current national AIDS strategy ( ) includes: – $10mil from the World Bank – $45mil from the Global Fund – $10mil from the US Government Future donor financing is likely to decline substantially in the next 2 years – Challenge is how to sustain the national AIDS program, and finance the next NSP The availability of domestic resources is and will be very tight, and – Fiscal space constrained by high public debt (139% of GDP) Financing of the national response is under pressure both from the domestic fiscal adjustment and the shrinking external resources

Purpose of the Study 1.Review and assess the current spending for HIV/AIDS and the sources of financing (both domestic and external) 2.Assess the future availability of financing for HIV/AIDS and the anticipated fiscal burden of an efficient and effective response 3.Project the course of the epidemic and the costs associated with different policy scenarios 4.Provide recommendations to inform policy decisions on sustaining the national HIV response

Methodology – 3 Building Blocks Epidemiological Model Economic Framework Costing Framework

Current Spending and Sources of Financing

Projected Costs of National Response ( ) Scenario 1: Declining HIV incidence Scenario 2: Constant HIV incidence Scenario 3: Increasing HIV incidence Scenario 1: Declining HIV incidence Scenario 2: Constant HIV incidence Scenario 3: Increasing HIV incidence

Projected Costs of National Response ( ) Little variance in projected costs of the national response across the three scenarios Most significant cost of the national response is in treatment and care

Costs Incurred by new HIV infections Direct costs incurred by an HIV infection estimated at US$5,800 Analysis shows disproportionate role in the spread of HIV by some population groups (taking into account downstream infections) – MSM: Almost 10X the direct costs – FSW: More than 4X the direct costs Costs Incurred by HIV infections, by Population Group Direct Costs Incurred by HIV infection US$ 5,800 Additional Costs from Downstream Infections Low-risk individualUS$ 4,200 Female Sex WorkerUS$24,700 Men who have sex with menUS$56,400

Fiscal Evaluation of the Costs of the HIV Program Spending needs rise from : 0.14% of GDP (2010) to 0.2% of GDP (2030) Spending needs rise from : 0.14% of GDP (2010) to 0.2% of GDP (2030)

Implications of Reduced External Financing Decline in external financing will result in even steeper increase in domestic financing needs Declines from 67 to 45% will require a doubling of domestic financing by 2015, and more than triple by 2030 – Changes in financing needs across scenarios are subtle in the short run but more significant by 2030

Perspectives on Sustainability Analysis finds large differences in the cost caused by additional infections across population groups – Costs significantly higher for most at risk populations (MSM and Sex Workers) due to large share of current infections and disproportionate risk of onward infections HIV spending is projected to remain at about 2-3% of public health spending which is in line with the burden of disease Annual treatment costs (10-20% of GDP/capita) within range that could be reasonably supported through public health spending Commitments on provision of treatment cannot be rescinded

Perspectives on Sustainability Total projected costs for the national response will remain below 0.2% of GDP – HIV/AIDS does not pose immediate challenges to fiscal sustainability. But will need to compete for scarce fiscal resources The national response faces considerable financing challenges due to: – Rising costs of the program (mainly from the increasing need for treatment) – Uncertain outlook for the availability of financing with the end of the current sources of external financing

Key Messages A significant increase in domestic financing for HIV/AIDS is FISCALLY SUSTAINABLE The bulk of the projected costs for the national AIDS response represent TREATMENT costs (both first and second line treatment) For an efficient and effective national AIDS response there’s need to ACCELERATE PREVENTION EFFORTS particularly targeted prevention interventions for MARPs

Thank You!