1. Financial Implications of HIV/AIDS in South Africa – the role of the Business Sector Findings from aids2031 costing & the efforts of the National AIDS Spending Assessment 7 Apr Teresa Guthrie, CEGAA
Teresa Guthrie, Robert Hecht, Yogan Pillay , Mark Blecher, Kelsey Case

2. Overview of the Cost Estimates
The aids2031 South African costing project was carried out during , sponsored and guided by a national Steering Committee composed of senior South Africa officials and other leading national figures. It was part of a larger international project led by R4D which included the estimation of global costs. It aimed to estimate the long-term costs of various response scenarios till 2031.

3. Methodology
Developed epi baseline & 3 scenarios to 2031 – SPECTRUM parameterised to ASSA outputs to 2016
Collected, reviewed and verified existing costing studies (unit costs) – limited from private sector
Obtained current coverage rates for every intervention
Received input from the project Steering Committee on current coverage and target rates
Agreed on program scale up scenarios with Steering Committee

4. Methodology (continued)
Cost and Epi Projections – for each scenario
Epidemiological impact assessed (incidence, mortality, need for treatment, numbers on ART) using Spectrum with Goals
Costs estimated using Resource Needs Model (Futures)
Resource requirements by program area and intervention
For ART & PMTCT incorporated BU-HERO estimates (Meyer Rath, 09) – note that the ART costs have been further adjusted based on the new Tender prices, which will reduce the cost estimates presented here.

5. The South African Scenarios
Narrow NSP by 2011
Expanded NSP by 2021
Hard Choices by 2015
Baseline (maintaining current coverage as comparator)

6. Scenario 1 – Narrow NSP
Political will to achieve universal access is strong
Rapid scaling-up of prevention & treatment
Achieving key NSP targets by 2011
ART – old WHO regime and 200 CD4 criteria
PMTCT single dose till 2009, replaced by dual therapy
Early paediatric ART from 2009
No male circumcision

7. Scenario 2 – Expanded NSP
Achievement of all NSP & extra targets by 2021
ART – new regime & CD4 350 eligibility from 2010, 90% reached by 2015/6
MC introduced 2010, reaching 90% by 2021
Expanded workplace programmes, education and behaviour change
Mobilization and higher coverage for CSW & MSM
Expanded efforts for youth-out-of-school
Programs to reduce violence against women
Expanded mitigation interventions

8. Scenario 3 – Hard Choices
Resources are limited, focus on scaling up to high levels the most effective prevention interventions; some other prevention and social programs reduced; targets achieved by 2015:
same ART effort as under Narrow NSP
Increased coverage for Youth in school, condoms, male circumcision, SW & MSMs, STI treatment
Maintaining current coverage for VCT & FCG
Reduction below NSP targets for: mass media, youth- out of-school, workplace, HBC, palliative care, food parcels, uniforms
Mitigation efforts significantly reduced

9. Estimated Epidemiological Impact

10. Only the expanded NSP will halve the new infections, as per the NSP goal, but only by 2020 – long road ahead!

11. Adult (15+yrs) HIV Prevalence (2000–2031)
With increasing treatment coverage, HIV prevalence is unlikely to reduce below 10%.

12. Adult is 15+ years old. Numbers on treatment will continue to grow, upto 3million by 2018, but thereafter will start to decrease with the expanded NSP & the expanded prevention efforts.

13. Infant HIV-related Deaths (1993 –2031)

14. Key points from the Epi-projections
Only the expanded NSP will halve the new infections, as per the NSP goal, but only by 2020.
Compared to Baseline, the expanded NSP will avert nearly 6,000 infections in total by 2031, where as continuing with the current NSP will only avert 3,000 – half!
With increasing treatment coverage, HIV prevalence is unlikely to reduce below 10%, best case scenario.
Numbers on treatment will continue to grow, up to 3million by 2018, but thereafter will start to decrease with the expanded NSP & the expanded prevention efforts.
PMTCT will significantly reduce infant mortality, in all scenarios since same coverage.

15. Estimated Resource Requirements

16. Total HIV/AIDS Costs by Scenario (2009-2031, ZAR Billions)
With Expanded NSP costs will double from 2010 to But thereafter they start to decrease signficantly.
NB. These estimations include all sectors and all sources of funding
DRAFT-do not copy or disseminate

17. Expanded NSP – Total Resources Required and their Distribution (ZAR billions)
Treatment taking 60% by 2020, but thereafter reducing.

18. Expanded NSP – Programme Disaggregation (ZAR billions)
Orphan care includes the FCG (55% of current coverage for HIV-related). This will decrease with treatment reducing mortality.
DRAFT-do not copy or disseminate

19. Expanded NSP delivery
Largest proportion will be DOH responsibility for the delivery of public ART – therefore important to increase the role of businesses and external aid for ART. The role of Ngos could be expanded.

20. Cost Implications
With Expanded NSP costs will double from 2010 to 2021 (but will be significantly reduced with new tender prices, should allow for all on at 350CD4 – greater prevention effects)
But thereafter they start to decrease significantly. Treatment taking 60% by 2020, but thereafter reducing.
Largest proportion will be DOH responsibility for the delivery of public ART – therefore important to increase the role of businesses in provision of ART and PMTCT.
Workplace programmes are important for other prevention interventions & Private sector important.
The role of NGOs could be expanded.

22. Sustainable Funding Sources?

23. Sources of Financing for HIV/AIDS in SA
No SA NASA yet to ascertain current spending trends of all sectors (public, external & private).
No comprehensive database of external sources (some from Burlington (2009).
No database of business sector CSI activities (some from Trilogue)
Budgetary allocations show national spending, conditional grants to provinces & some provincial voted allocations – limited disaggregation.
OOPE – unknown.
Development partners appear uneasy to share their longer-term commitments to HIV/AIDS in SA?
DPs also struggle to provide year-specific expenditures by province.
Business sector is not willing to share their expenditure for the NASA process.
Therefore impossible to measure the projected financing gap.

24. SA Public HIV/AIDS Budget Allocations (2006/07-2012/13)
Note that this only shows those specific HIV-labelled budgets. It excluded what DOH spending on OI and hospitalisation (about R5bill pa).
Mark Blecher feels this slide underestimates govt spending and therefore should be exluded.

25. Rough Questimate of Total Resource Gap (for all actors, not only public)
NB> Using Expanded NSP costs, and underestimated donor contributions due to lack of data.
Mark Blecher felt this exaggerated the funding gap

26. SA DOH Budget Allocations for HIV/AIDS (ZAR millions)

27. Rough Guestimate of public ART shortfall, assuming 90% coverage by 2015
NB> Using Expanded NSP costs, and underestimated donor contributions due to lack of data.
Mark Blecher felt this exaggerated the funding gap

28. Importance of the National AIDS Spending Assessment (NASA)

29. Objectives of NASA in South Africa
For the years 2007/08, 2008/09 & 2009/10, to identify in each province: All the sources (public, external and private) of financing for HIV/AIDS and TB The providers of the HIV/AIDS and TB services The activities services delivered – and their alignment with the PSP priorities The beneficiaries of the services In order to make recommendations for the improved targeting of funds and efficiency of spending, according to the provincial priorities.
NB. TB spending was limited to the integrated TB management through DOH.
DRAFT - DO NOT DISSEMINATE.

30. Methodology
Aimed to include data from all sources, from all agents and from sampled service providers.
All DOE, DSD, DOH expenditure by activity and service provider – from BAS records.
Wellness programme spending – included all departments but challenge of coding of HIV-related in BAS records.
All NGOs receiving DOH/ DSD/ EU/ PEPFAR grants – sampled others (but nothing received).
Districts & Municipalities – most included
Donors – Most - EU, GF, UN agencies (NB PEPFAR limitations excl) – pending other donors
Private - Businesses - limited response. Medical aid estimates incld.
Limited research activities
90% public, 80% external, 80% NGOs & almost no business
Note medical aids did not break down by province – not even numbers of patients. Therefore proportional breakdown based on percentage share of public sector ARV patients.

31. Business sector HIV activities in SA
MISSING……. ??

32. Estimating & Securing Resource Requirements
Using estimates of the future costs of an expanded NSP
Comparing current spending per intervention
More detailed and accurate financing gaps can be calculated
Sustainable resources mobilised
This requires all partners to:
participate more actively in the achievement of the Expanded NSP
be transparent about their current and future funding activities
What are the HIV services currently being provided / funded by business?
How could these be expanded?
What does government need to do to encourage business sector involvement?

33. Acknowledgements
WEBSITE: SANAC, PACs, HASTs, etc UNAIDS Mark Blecher, National Treasury Drs Pillay & Mbengashe (NDOH) aids2031 Steering Committee Gesine Meyer-Rath & Lawrence Long, BU/HERO Kelsey Case, Imperial College London John, Lori & Steve, Futures Institute Leigh Johnson, UCT Susan Cleary, UCT Steve Cohen, SDC All the DoH departments that provided data The teams at CEGAA and Results for Development Institute