achap economic and social impact assessment. achap support methods epidemiological impact economic...

ACHAP Economic and Social Impact Assessment

• ACHAP Support

• Methods

• Epidemiological Impact

• Economic Impact

Outline

• PPP; Govt of Botswana, Bill & Melinda Gates Foundation and Merck/The Merck Company Foundation.– Country priorities; NSF for HIV/AIDS informed strategic direction – Mutual partnership: Govt strategy & policy guidance, in kind

contribution – ACHAP financial, technical, human resources, infrastructure, and

logistical support

ACHAP Support

• Phase I (2001-2009) and Phase II (2010 to 2014)• Two Pronged

– National level– Districts level

• In most cases ACHAP operated from GOB infrastructures

• ACHAP Directly implemented• ACHAP Staff seconded to GOB• Collaborated with other partnersImpact of ACHAP supported Programmes cannot be

solely attributed to ACHAP

ACHAP Support

After 13 years, ACHAP stands as a successful venture into the realm of PPP for public health interventions

• More than $128 million in financial disbursement

• Merck ARV’s donation valued at around $168 million

OVERALL INVESTMENT

• GOALS Model of Spectrum used for ART and SMC– Model has been set up for Botswana using all available data

sources on Botswana

• For TB analysis, used TB modelling program, TIME. – TIME is “TB Impact Model and Estimates”– Implemented on Spectrum modeling software. – Designed to inform national strategic TB program planning – Models TB interventions epidemiological impact and costs.– Model was developed and maintained by the Tuberculosis

Modelling and Analysis Consortium (TB-MAC) and Futures Institute.

METHODS

• No Masa/SMC Support

• SMC Support Only

• Masa Program Only

• Both Masa/SMC Support

SCENARIOS

RESULTS OF ART AND MC ANALYSIS

Number of HIV new infections by year and scenario

20002001

20022003

20042005

20062007

20082009

20102011

20122013

20140

5,000

10,000

15,000

20,000

25,000

30,000

35,000

SMC Only ART Only SMC/ART Support No ACHAP Support

Year

Infe

ction

s


20002001

20022003

20042005

20062007

20082009

20102011

20122013

20140

5,000

10,000

15,000

20,000

25,000

30,000

35,000

No ACHAP Support

Year

Infe

ction

s A

vert

ed


20002001

20022003

20042005

20062007

20082009

20102011

20122013

20140

5,000

10,000

15,000

20,000

25,000

30,000

35,000

SMC Only No ACHAP Support

Year

Infe

ction

s A

vert

ed


20002001

20022003

20042005

20062007

20082009

20102011

20122013

20140

5,000

10,000

15,000

20,000

25,000

30,000

35,000

SMC Only ART Only No ACHAP Support

Year

Infe

ction

s A

vert

ed


20002001

20022003

20042005

20062007

20082009

20102011

20122013

20140

5,000

10,000

15,000

20,000

25,000

30,000

35,000

SMC Only ART Only SMC/ART Support No ACHAP Support

Year

Infe

ction

s

• By 2014, SMC program averted an estimated 7,470 infections (Note ACHAP Directly Contribute 75% of all

SMC’s)– Equivalence of one(1) infection averted for every

11 circumcisions performed.• About 42,000 infections averted by 2030– One(1) infection averted for every 2 male

circumcisions performed. – Infections averted will also lead to future deaths

averted

New HIV Infections Averted by SMC

ART program has had an even larger impact on new infections averted

• ART Cumulatively averted 110,000 new infections during the period 2000-2014– This is equivalent to 13 person-years of ART per infection

averted.

• Combined ART/SMC new infections averted with ACHAP support is 114,000 new infections from 2001 to 2014.

New HIV Infections Averted by ART

Number of HIV-related deaths by year and ACHAP Support

20002001

20022003

20042005

20062007

20082009

20102011

20122013

20140

5,000

10,000

15,000

20,000

25,000

30,000

Number of HIV-related deaths by year and ACHAP Support

No ACHAP Support With ACHAP Supported Programmes

• ART program averted an estimated 165,000 deaths from 2001 to 2014 or 48% .

• This is equivalent to one (1) death averted for 9 persons put on treatment.

• The ratio was as low as 5 earlier in the epidemic when most people starting ART had low CD4 counts.

• Note, deaths averted can occur later, so it is also useful to examine the number of life years gained; or measure additional person-years of life attributed to the intervention. – Over 949,000 life-years during the period 2000-2014 were saved. – This is equivalent to 1.2 person-years of ART per life year gained.

DEATHS AVERTED

TB Mortality by HIV Status

19901992

19941996

19982000

20022004

20062008

20102012

20142016

20182020

0

1,000

2,000

3,000

4,000

5,000

6,000

No Program, Total With Program, TotalNo Program, HIV- With Program, HIV-No Program, HIV+ With Program, HIV+

Num

ber o

f Dea

ths

19901992

19941996

19982000

20022004

20062008

20102012

20142016

20182020

0

1,000

2,000

3,000

4,000

5,000

6,000


No Program, Total

Num

ber o

f Dea

ths

19901992

19941996

19982000

20022004

20062008

20102012

20142016

20182020

0

1,000

2,000

3,000

4,000

5,000

6,000


No Program, Total With Program, Total

Num

ber o

f Dea

ths

19901992

19941996

19982000

20022004

20062008

20102012

20142016

20182020

0

1,000

2,000

3,000

4,000

5,000

6,000


No Program, HIV+

Num

ber o

f Dea

ths

19901992

19941996

19982000

20022004

20062008

20102012

20142016

20182020

0

1,000

2,000

3,000

4,000

5,000

6,000


No Program, HIV+ With Program, HIV+

Num

ber o

f Dea

ths

19901992

19941996

19982000

20022004

20062008

20102012

20142016

20182020

0

1,000

2,000

3,000

4,000

5,000

6,000


No Program, HIV-

Num

ber o

f Dea

ths

19901992

19941996

19982000

20022004

20062008

20102012

20142016

20182020

0

1,000

2,000

3,000

4,000

5,000

6,000


No Program, HIV- With Program, HIV-

Num

ber o

f Dea

ths


19901992

19941996

19982000

20022004

20062008

20102012

20142016

20182020

0

1,000

2,000

3,000

4,000

5,000

6,000


Num

ber o

f Dea

ths

• Cumulative TB mortality was reduced by 17% during 2001-2014

• In 2014 number of TB related deaths reduced by roughly half of deaths in the “no support” scenario.

• Note, nearly all of the deaths and cases of active disease averted by the national TB program were among HIV+ individuals.

Comparison of TB scenarios with and without the scale up of ART and MC

• New TB cases per year was reduced by roughly 50% in 2014.

TB Incidence by HIV Status

19901992

19941996

19982000

20022004

20062008

20102012

20142016

20182020

02,0004,0006,0008,000

10,00012,00014,00016,00018,00020,000


Num

ber o

f New

Cas

es

• Ideally a comprehensive analysis of ACHAP’s support would determine the economic benefits associated with all the funds spent.

• However, it would be problematic to link the resources used to specific outputs.

• For this reason, the economic impact analysis focused only on SMC and ART.

SOCIO-ECONOMIC IMPACT

• Benefits are 30 times greater than the overall costs. – Assessed costs that would be needed in order to treat an

infected person (discounted cost of lifetime treatment)• Estimated at $7,400

– For estimated infections averted $351.5 million future costs was saved.

– Compared to $11.6 million as cost of 101,680 SMC’s.

• This would be even more favourable if one were to include other benefits of preventing each HIV infection (e.g., lost future earnings, loss of value to the household, etc.),.

SAFE MALE CIRCUMCISION ECONOMIC IMPACT

Average per SMC Cost by year

20102011

20122013

$-

$50

$100

$150

$200

$250

$300

$350

$400

$338

$291

$204

$112

Year

Per SMC Cost reduced by over 2/3

• Benefits exceed costs 5 fold– By averting infections, ART also averts future ART costs. – ART saved $814 million by averting 110,000 infections

• Assuming discounted cost of lifetime treatment of $7,400.

• Drug donation program costed $168.4 million.

• The $168.4 million drug donation exclude other costs• Conversely, benefits of treatment cannot be defined solely by

infections averted, since treatment also provides other benefits (reduced morbidity and mortality, increased productivity, etc.).

ART ECONOMIC BENEFITS

• ART and SMC Combined saved $843.6 million by averting 114,000 infections.

• ART and SMC cost was $180 million. • Cost ratio of $4.7/$1.0 cost. • Still if other benefits are considered, benefit may be

significantly higher.

ART AND SMC COMBINED ECONOMIC BENEFITS

• ACHAP creation was a timely and right move for Botswana’s national response to HIV/AIDS

• ACHAP has been a catalyst hence drawing development partners to assist expand and intensify initiatives.

• Without ACHAP, Botswana would have not easily attained the success it has enjoyed in HIV/AIDS fight.

• ACHAP became instrumental in ensuring that catastrophic impact of the epidemic on the economy and social fabric of Botswana, that was thought to be imminent at the turn of the century, has been largely mitigated.

• ACHAP served as a prime example of difficulties and successes of joint partnership between government and private companies.

• ACHAP achieved high level of integration across government, NGOs, CBOs, and the community.

Conclusions

• Acknowledgements– Futures Institute for this analysis

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