Where are we on ART Scale-up: Updates from a PEPFAR Conference
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Reducing HIV/AIDS related morbidity and mortality is a major health system issue in high prevalence countries. In this context, where are PEPFAR countries today on achieving their coverage targets for ART? Given the current economic crisis in developing country finances and the uncertainty in foreign donor commitments, what is the likelihood of further scale-up? An update from recent data presented at a PEPFAR ART Costing Conference in February 2009
Recently, I attended a conference in Johannesburg (over February 3-4, 2009) on the issue of "Understanding the costs of scale-up in PEPFAR treatment programs". Besides staff from CDC, OGAC, and USAID based in the respective headquarters, US Government teams from 12 PEPFAR focus countries were invited to present the status of ARV treatment programs in their country. The agenda for the conference also included the discussion of some modeling frameworks and tools which could be used by PEPFAR countries to understand the future costs of HIV treatment. One of the tools discussed at length was the HealthSystem 20/20 'HAPSAT' methodology.
Achieving success in scaling up HIV treatment is one of the most important goals for the health system in high HIV prevalence countries. Since the conference yielded much up-to-date information on the likelihood that scale-up targets could be met, it seems important for the HealthSystems 20/20 blog to report on it. A separate blog entry can focus on the costing tools that were discussed, which may also be of interest to our community.
Where are we now on ARV treatment?
The PEPFAR-I goal of treating at least 2 million with ARVs in the 15 focal countries over 2004-2008 was achieved before schedule in September 2008 (see figure below). Keeping this caseload alive on treatment is a huge challenge, to which we must add the challenge of increasing coverage to reach all those HIV+ individuals who are eligible for ARV treatment.
Source: Conference materials. Do not cite or copy.
While governments have their own national targets, PEPFAR established certain targets for ART coverage as well. On these, achievement differs across countries exceeding the targets (better progress towards universal coverage) to those underperforming that value. The table below cites figures by country for the last comparable date.
Source: Conference materials. Do not cite or copy.
As a percentage of the total eligible population in need for ART, the achievements vary even more. The following table shows the best available estimates of coverage for the countries that were represented at the Johnannesburg conference. No claim is made for the validity of the following numbers, since the estimation of 'ART eligible population' at a point of time is a sensitive issue, and there may well be some under- or over-counting of the current service load.
| Country | Percentage of ART need served in 2008 |
| Zambia | 76% |
| Botswana | 78% (across public & private) |
| South Africa | 32% |
| Cote d'Ivoire | 28% |
| Ethiopia | 43% |
| Kenya | 52% |
| Mozambique | 28% adults |
| Namibia | 70-75%* |
| Nigeria | 25-49%** |
| Tanzania | 32% |
| Uganda | 52% |
** based on higher or lower projections of ART eligible in UNAIDS 2008
Source: Conference materials. Do not cite or copy
Most countries will face an uphill climb in reaching their own national goals of universal ART coverage (i.e., reaching 100% of the eligible population). Some countries such as Zambia and Botswana may look well-placed to get close to universal coverage given the numbers above. Others not as well-placed are still confident of making large gains by end-2009, such as Ethiopia (projected coverage = 77% by 2009, 86% by 2010).
What is the likelihood of further scale-up?
In a very basic characterization, the achievement of ART coverage in any country is dependent on bringing together funding sources, local capacity (organizational and human resources), the identification of those requiring treatment, and the timely availability of drugs and equipment. Therefore, it is only a partial answer to the 'likelihood' question, forced by limitations of space, to focus on two of those factors: funding and drugs. The constraints of local human resources and organizational capacity will continue to require attention, and they are not to be considered diminished by the lack of discussion in this blog post (they are in case related to the funding question). It is only that certain elements of the current worldwide 'crisis' have affected the sustainability of ART scale-up; while other trends in choice of drugs in regimens have their implications as well.
These are the major factors that influence the ability to achieve higher ART coverage, according to the teams from the 12 countries reporting:
- External funding: Most countries expect that the external sources for funding are flat-lined (or declining) for 2009. If the USG allocation for HIV/AIDS in the short-term does grow marginally as expected (given that foreign aid assistance in Budget 2010 is 10% higher than FY 2009), then at least the flat-line expectation is met. However, since there are no exact numbers yet for the annual commitment going forward via PEPFAR-2, this is still speculative, as are any discussions of change in priorities as signalled in some quarters. Similarly, there is little information yet to understand what the impact of the 'IHP Compact' will be in the countries affected (e.g. Ethiopia). The Global Fund will continue to exercise 'efficiency cuts' it instituted in late 2008, which does not bode well for increased funding via the Round 9 channel. You can read an advocacy group's summary of the Global Fund's 'funding gap' here (while the summary of Global Fund funding decisions is factual, we do not vouch for the other information). In addition, some donors such as the Clinton Foundation and UNITAID are reducing their commitments in the ART field. Most other bilateral donors do not participate in ART funding, and the contribution towards ART of multilaterals such as the World Bank (via the MAP) is a much smaller proportion of the total.
- Domestic funding: Governments have in the past matched external financing in some countries (e.g. Botswana), or promised to provide an increasingly significant share as external funds 'phase out' (e.g., in Zambia the government would have taken on a commitment equivalent to 80% of the external funds by 2011 for ART). However, the current decline in natural resource prices has dealt a major shock to governments, who are as a result struggling to maintain even their existing commitment to the ART funding pie. This is certainly the case in countries such as South Africa, Botswana, and Zambia. In addition, other commitments, such as general development, other health and education needs, as well as debt servicing will consume some of the government budget. The recent World Bank estimation puts a figure on the overall shortfall in developing country finances as between $270 to $700 billion.
- Regimen change and drug prices: Movement on drug prices has been generally positive - many new generic formulations for fixed-dose combinations are available or in the process of seeking FDA approval, and those offered by original innovators are also declining in price. This matches the general decline in the prices of bulk chemicals required for the manufacture of the drugs. However, many governments have instituted a move to switch regimens based on their understanding of issues of toxicity in the previously preferred regimens (i.e., from fixed-dose combinations with d4T or stavudine to those with higher-priced tenofivir or TDF). These changes, if they become more common, would affect the ability to scale-up in the current budgetary environment. A study estimated that the TDF price would have to fall by 64% to be cost-neutral to the South African government, when compared to d4T (Rosen et al., JAIDS 2008). Increasing coverage of those requiring second-line treatment (more expensive regimens) will be another factor in reducing the funds available for scale-up of first-line ART.
The picture on the likelihood of scale-up succeeding given the funding and ARV prices situation is therefore mixed. The decline in drug feedstock pricing and rise in generics availability (including pipeline generics for TDF formulations) bode well, but the flipside of the decline in commodity pricing is a declining government ability to meet its ART funding commitments. There is much national treatment programs can do to achieve cost-effectiveness without sacrificing program quality. Some of these are already in discussion and can be controversial (such as central lab testing, pooled procurements, partner rationalization, etc.). These will have to be taken up in a future blog posting. Please do motivate me to write such a posting by commenting below!
