Transcript Defining the Operational Reseach Agenda for an International

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 we’re doing while we’re
doing it; finding out what works, what doesn’t, 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 ?
Cost-effectiveness comparison of a new strategy
versus current standard
Costs (+)
More costly, less effective

More costly, more effective
Dominated strategy
Willingness to pay for
additional benefit ?
 Reject
(-)
(+)
Health benefit
Less costly, less effective
Less costly, more effective

Acceptability of health losses for
reducing costs ?
Domining strategy
 Adoption
(-)
Cost-effectiveness of ARV therapies versus
Alternative strategies for HIV/AIDS care
Marginal cost
per lifeyear
Marginal
cost
per lifeyear
Oth
ers
ARV
Othe AR
rs
VsV
SV
Populati
on
Population
Hyp : ARVs always dominated
Plausible hyp
: ARV cost
effectiveness ratios intersect those of
alternative strategies
Cost-effectiveness Criterion in
rich countries
• Marginal cost per lifeyear gained
< 2 x GDP/cap => 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 = costeffective
• => 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 firstline 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.