Transcript Drivers and Determinants of Healthcare Systems

Department of Health, Behavior & Society
David Holtgrave, PhD, Professor & Chair
© 2005, Johns Hopkins University. All rights reserved.
NHAS Goals for Reducing HIV
Incidence
NHAS Goals for Improving
Treatment Access
NHAS Goals for Reducing
Health Disparities
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
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
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
CDC’s Total HIV Prevention Budget
(Actual and Inflation-Adjusted)
$900,000,000.00
$800,000,000.00
$700,000,000.00
Dollars
$600,000,000.00
$500,000,000.00
Actual Budget
$400,000,000.00
Inflation Adjusted
$300,000,000.00
$200,000,000.00
$100,000,000.00
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$-
Inflation-adjusted budget down 17.9% since FY02; buying power now approximates FY91
CDC UPDATE OF “GARDNER CASCADE”
Source: CDC MMWR Early Release Volume 60, November 29, 2011
ADAP Waiting Lists are the Tip of the
Iceberg
http://coastal.er.usgs.gov/ocean-acidification/arcticcruise2011/journal/index.php/2011/08/20/icebergs/
10
Housing Opportunities for People With
AIDS (HOPWA) Funding
Fiscal Year
Funding 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
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 costeffectiveness?
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).
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
S694YMC
69.4%
yes
Minimal coverage
S694YFSC
69.4%
yes
Fully scaled-up coverage
S694NMC
69.4%
no
Minimal coverage
S694NFSC
69.4%
no
Fully scaled-up coverage
S807YMC
80.7%
yes
Minimal coverage
S807YFSC
80.7%
yes
Fully scaled-up coverage
S807NMC
80.7%
no
Minimal coverage
S807NFSC
80.7%
no
Fully 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).
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).
Input parameter values: HIV transmission
rates
Scenario name
Transmission
rate, unaware
(TRU)
Transmission rate,
aware, baseline through
2013 (TR2013)
Transmission rate,
aware, 2014
(TR2014)
Transmission rate,
aware, 2015 to 2020
(TR2015)
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).
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).
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).
Incidence and transmission rate by scenario
Transmission
rate / 2010
transmission
rate (2015)
Transmission
rate / 2010
transmission
rate (2020)
Scenario
Incidence /
2010 incidence
(2015)
Incidence /
2010 incidence
(2020)
S694YMC
.789
.837
.713
.713
S694YFSC
.597
.610
.543
.543
S694NMC
1.006
1.110
.898
.898
S694NFSC
.835
.892
.750
.750
S807YMC
.710
.742
.643
.643
S807YFSC
.536
.542
.489
.489
S807NMC
.936
1.019
.837
.837
S807NFSC
.781
.826
.702
.702
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).
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).
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).
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).
Costs by scenario through 2015
Cumulative gross
Cost of fully
policy cost 2015
scaled-up risk
reduction for PLWH (discounted at 3%)
Scenario
name
Cost of
additional
diagnoses*
Cost of additional
housing
Cost of care and
treatment**
S694YMC
$1,476,681,741
$363,859,450
$14,770,581,633
N/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
$13,398,713,227
N/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
$14,770,581,633
N/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
$13,398,713,227
N/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).
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).
Incremental cost-effectiveness ratios
comparing combinations of scenarios of
HIV program expansion, as of Year 2020*
Scenario Comparison
S694YMC
vs.
S694NMC
S694YFSC
vs.
S694NFSC
S694YFSC
vs.
S694YMC
S694NFSC
vs.
S694NMC
S807YMC
vs.
S807NMC
S807YFSC
vs.
S807NFSC
S807YFSC
vs.
S807YMC
S807NFSC
vs.
S807NMC
S694YFSC
vs.
S694NMC
S807YFSC
vs.
S807NMC
Additional discounted gross
program costs per additional
discounted HIV infection averted
$101,759
$96,667
$27,961
$29,467
$98,198
$94,285
$33,222
$34,611
$69,025
$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).
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).
“COMBINATION PREVENTION”
HAS SADLY BECOME
“SUBSTITUTION PREVENTION”
WHEN WE NEED
“SYNERGISTIC PREVENTION”
TO URGENTLY IMPACT INCIDENCE
26
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 Load
Essentially no transmission
Essentially no transmission
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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
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
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
As President Obama said on
July 13, 2010….
“The question is not whether we
know what to do, but whether we
will do it.”