1. © 2005, Johns Hopkins University. All rights reserved. Department of Health, Behavior & Society David Holtgrave, PhD, Professor & Chair

2. NHAS Goals for Reducing HIV Incidence

3. NHAS Goals for Improving Treatment Access

4. NHAS Goals for Reducing Health Disparities

5. Key implications of NHAS (from Holtgrave, JAIDS 2010) How will epidemic be changed if goals are met? –Prevent roughly 75,800 infections (2010-2015) –Prevent roughly 237,700 infections (2010-2020) –2015 prevalence without NHAS roughly 1.481M and with NHAS roughly 1.407M Approx. 218,900 more people on care and treatment

6. Key Implications of NHAS -- continued (from Holtgrave, JAIDS 2010) Cost of NHAS in expanded funding (be it new, redirected, or new private sector) –Total across years through 2015 Roughly $15.2B need to achieve NHAS –Approx.. $2.1B for prevention –Just under $1B for housing (to achieve NHAS goal) –Remainder for care and treatment (approx. $12.2B) »43% is due to expanded awareness »57% due to expanded coverage

7. Key Implications of NHAS - continued (from Holtgrave, JAIDS 2010) –However, investing in NHAS could save money –Medical costs offset by HIV infections averted through expanded prevention efforts –Net present value of medical care costs saved due to prevention efforts: $17.981B –Savings larger than investments needed (cost saving) –Bend the cost curve by bending the incidence curve –Choosing to not expand prevention efforts is the MORE expensive policy option

8. CDC’s Total HIV Prevention Budget (Actual and Inflation-Adjusted) Inflation-adjusted budget down 17.9% since FY02; buying power now approximates FY91

9. CDC UPDATE OF “GARDNER CASCADE” Source: CDC MMWR Early Release Volume 60, November 29, 2011

10. ADAP Waiting Lists are the Tip of the Iceberg 10 http://coastal.er.usgs.gov/ocean-acidification/arcticcruise2011/journal/index.php/2011/08/20/icebergs/

11. Housing Opportunities for People With AIDS (HOPWA) Funding Fiscal YearFunding Amount 2010$335.0 million 2011$334.3 million 2012$332.0 million President’s Request 2013$330.0 million Community Request: $427 million. National AIDS Housing Coalition Estimate: 140,000 PLWH in U.S. in immediate need of housing assistance

12. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the NHAS – 2012 analysis Is it still epidemiologically feasible to attain the incidence and transmission rate reduction goals of the U.S. National HIV/AIDS Strategy (NHAS) by 2015? If so, what costs will be incurred in necessary program expansion, and will the investment be cost-effective? Would substantial expansion of prevention services for persons living with HIV (PLWH) augment the other strategies emphasized in the NHAS in terms of effectiveness and cost- effectiveness? From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (2012).

13. Definition of scenarios for HIV service implementation strategies Scenario name* Assumed percentage of clients in care achieving suppressed viral load, Year 2015 and beyond Meet NHAS diagnosis goal of 90% by 2015? Level of coverage of risk behavior change services for PLWH S694YMC69.4%yesMinimal coverage S694YFSC69.4%yesFully scaled-up coverage S694NMC69.4%noMinimal coverage S694NFSC69.4%noFully scaled-up coverage S807YMC80.7%yesMinimal coverage S807YFSC80.7%yesFully scaled-up coverage S807NMC80.7%noMinimal coverage S807NFSC80.7%noFully scaled-up coverage * All scenarios assume 85% care coverage by 2015 (with half-step toward achievement in 2014); up from baseline of 53.4% care coverage From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (2012).

14. Cost parameters (2011 dollars), costs saved per infection averted (2011 dollars), QALYs saved per infection averted Cost per new diagnosis $10,085 Cost of prevention services for newly diagnosed PLWH $680 Cost of partner services $1,046 Total cost for new diagnosis $11,810 Annual care costs (includes $680 in prev. services) $28,382 Annual housing costs $12,039 Medical care costs saved in lifetime (public sector) $291,565 QALYs saved per transmission averted 5.33 From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (2012).

15. Input parameter values: HIV transmission rates Scenario name Transmission rate, unaware (TR U ) Transmission rate, aware, baseline through 2013 (TR 2013 ) Transmission rate, aware, 2014 (TR 2014 ) Transmission rate, aware, 2015 to 2020 (TR 2015 ) S694YMC.1020.0276.0251.0219 S694YFSC.1020.0276.0251.0138 S694NMC.1020.0276.0251.0219 S694NFSC.1020.0276.0251.0138 S807YMC.1020.0276.0251.0186 S807YFSC.1020.0276.0251.0113 S807NMC.1020.0276.0251.0186 S807NFSC.1020.0276.0251.0113 From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (2012).

16. Outcome measures for evaluating eight scenarios vs. flat transmission rate comparator Annual incidence Overall annual transmission rate Incidence / 2010 incidence Transmission rate / 2010 transmission rate Cumulative infections averted Cumulative QALYs saved Cumulative gross policy cost Gross savings of downstream costs Ratio of savings to costs Net cost per QALY saved From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (2012).

17. Summary results comparing HIV service implementation scenarios one at a time to a flat transmission rate comparison condition The incidence reduction and transmission rate reduction NHAS goals are met in three of the eight scenarios (S694YFSC, S807YMC, and S807YFSC). The incidence reduction and transmission rate reduction NHAS goals are narrowly missed in two other scenarios (S694YMC and S807NFSC). The best cost-utility ratios are obtained when both diagnostic efforts and prevention services for PLWH are scaled up. The least effective scenario is to meet the care goal of the NHAS but fail to achieve the awareness of seropositivity goal or fully scale up risk reduction services for PLWH. Care expansion alone averts the least number of infections, and the resultant cost-utility ratio is over the often-used $100,000 cost-effectiveness standard. Inclusion of enough expansion of testing services to achieve the seropositivity awareness goal, inclusion of fully scaled-up risk-reduction interventions for PLWH, or both all serve to substantially improve performance on the outcome measures and to move the results into a range easily considered cost-effective. From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (2012).

18. Incidence and transmission rate by scenario From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (2012). Scenario Incidence / 2010 incidence (2015) Incidence / 2010 incidence (2020) Transmission rate / 2010 transmission rate (2015) Transmission rate / 2010 transmission rate (2020) S694YMC.789.837.713 S694YFSC.597.610.543 S694NMC 1.006 1.110.898 S694NFSC.835.892.750 S807YMC.710.742.643 S807YFSC.536.542.489 S807NMC.936 1.019.837 S807NFSC.781.826.702

19. Comparison of incidence across all scenarios of HIV program expansion, and including flat transmission rate comparator condition From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (2012).

20. Comparison of prevalence across all scenarios of HIV program expansion, and including flat transmission rate comparator condition From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (2012).

21. Comparison of transmission rate across all scenarios of HIV program expansion, and including flat transmission rate comparator condition From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (2012).

22. Costs by scenario through 2015 Scenario name Cost of additional diagnoses* Cost of additional housing Cost of care and treatment** Cost of fully scaled-up risk reduction for PLWH Cumulative gross policy cost 2015 (discounted at 3%) S694YMC $1,476,681,741 $363,859,450 $14,770,581,633N/A $16,611,122,824 S694YFSC $1,476,681,741 $363,859,450 $14,770,581,633 $449,989,958 $17,061,112,782 S694NMC N/A $363,859,450 $13,398,713,227N/A $13,762,572,676 S694NFSC N/A $363,859,450 $13,398,713,227 $401,015,141 $14,163,587,817 S807YMC $1,476,681,741 $363,859,450 $14,770,581,633N/A $16,611,122,824 S807YFSC $1,476,681,741 $363,859,450 $14,770,581,633 $449,989,958 $17,061,112,782 S807NMC N/A $363,859,450 $13,398,713,227N/A $13,762,572,676 S807NFSC N/A $363,859,450 $13,398,713,227 $401,015,141 $14,163,587,817 * Newly diagnosed PLWH also receive risk reduction services (included as approx. $85m in this cost total) ** PLWH receiving care under newly expanded services also receive risk reduction services (included as approx. $354m in “Y” scenarios, and approx. $321m in “N” scenarios) From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (2012).

23. Cost per QALY saved by scenario (one scenario at a time; relative to status quo) Scenario name Net cost per QALY saved 2015 (discounted at 3%) Net cost per QALY saved 2020 (discounted at 3%) S694YMC$67,896$50,742 S694YFSC$39,540$20,088 S694NMC$182,036$162,043 S694NFSC$89,230$59,745 S807YMC$53,081$33,884 S807YFSC$32,670$13,344 S807NMC$129,702$100,399 S807NFSC$72,877$44,465 From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (2012).

24. Incremental cost-effectiveness ratios comparing combinations of scenarios of HIV program expansion, as of Year 2020* Scenario Comparison Additional discounted gross program costs per additional discounted HIV infection averted S694YMC vs. S694NMC $101,759 S694YFSC vs. S694NFSC $96,667 S694YFSC vs. S694YMC $27,961 S694NFSC vs. S694NMC $29,467 S807YMC vs. S807NMC $98,198 S807YFSC vs. S807NFSC $94,285 S807YFSC vs. S807YMC $33,222 S807NFSC vs. S807NMC $34,611 S694YFSC vs. S694NMC $69,025 S807YFSC vs. S807NMC $71,590 *entries lower than $291,565 indicate public sector costs savings From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (2012).

25. National HIV/AIDS Strategy Simply waiting for expansion of care services in 2014 and 2015 will not be enough to reach incidence and transmission rate reduction NHAS goals Investment in diagnostic services and prevention services for PLWH (in addition to care and housing services) enables us to reach those goals But very substantial progress toward investing in these services must be made in FY13 Otherwise, the window on achieving the NHAS goals will be closed We Must Avoid… …But Time Has Almost Run Out From Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, Consequences and Feasibility of Strategies for Achieving the Goals of the National HIV/AIDS Strategy in the United States: A Closing Window for Success? AIDS Behav. (2012).

26. “COMBINATION PREVENTION” HAS SADLY BECOME “SUBSTITUTION PREVENTION” WHEN WE NEED “SYNERGISTIC PREVENTION” TO URGENTLY IMPACT INCIDENCE 26

27. HIV is transmitted during an act of unprotected risk behavior in a serostatus discordant partnership with virus present In a serostatus discordant partnership….. Unprotected transmission relevant risk behavior present No unprotected transmission relevant risk behavior Unsuppressed Viral Load Concentration of transmission Essentially no transmission Suppressed Viral LoadEssentially no transmission 27

28. Key US populations defined by HIV serostatus and relevance of various treatment-related prevention approaches From: Holtgrave DR, Maulsby C, Wehrmeyer L, Hall HI. Behavioral Factors in Assessing Impact of HIV Treatment as Prevention. AIDS Behav. 2012

29. Number of forward HIV transmissions from subgroups of persons living with HIV, and potential points of prevention intervention From: Holtgrave DR, Maulsby C, Wehrmeyer L, Hall HI. Behavioral Factors in Assessing Impact of HIV Treatment as Prevention. AIDS Behav. 2012

30. Key services needs of three subpopulations of persons living with HIV From: Holtgrave DR, Maulsby C, Wehrmeyer L, Hall HI. Behavioral Factors in Assessing Impact of HIV Treatment as Prevention. AIDS Behav. 2012

31. As President Obama said on July 13, 2010…. “The question is not whether we know what to do, but whether we will do it.”