Background
The
World Health Organization (WHO) released revised guidelines in 2015
recommending that all people living with HIV, regardless of CD4 count, initiate
antiretroviral therapy (ART) upon diagnosis. However, few studies have
projected the global resources needed for rapid scale-up of ART. Under the
Health Policy Project, we conducted modeling analyses for 97 countries to
estimate eligibility for and numbers on ART from 2015 to 2020, along with the
facility-level financial resources required. We compared the estimated
financial requirements to estimated funding available.
Methods and Findings
Current
coverage levels and future need for treatment were based on country-specific
epidemiological and demographic data. Simulated annual numbers of individuals
on treatment were derived from three scenarios: (1) continuation of countries’
current policies of eligibility for ART, (2) universal adoption of aspects of
the WHO 2013 eligibility guidelines, and (3) expanded eligibility as per the
WHO 2015 guidelines and meeting the Joint United Nations Programme on HIV/AIDS
“90-90-90” ART targets. We modeled uncertainty in the annual resource
requirements for antiretroviral drugs, laboratory tests, and facility-level
personnel and overhead.
We
estimate that 25.7 million adults and 1.57 million children could receive ART by 2020 if countries maintain current
eligibility plans and increase coverage based on historical rates, which may be
ambitious. If countries uniformly adopt aspects of the WHO 2013 guidelines,
26.5 million adults and 1.53 million
children could be on ART by 2020. Under the 90-90-90 scenario, 30.4 million adults and 1.68 million children could
receive treatment by 2020. The facility-level financial resources needed for
scaling up ART in these countries from 2015 to 2020 are estimated to be US$45.8 billion under the current scenario, US$48.7billion under the WHO 2013 scenario, and US$52.5 billion under the 90-90-90 scenario. After projecting recent external and
domestic funding trends, the estimated 6-y financing gap ranges from US$19.8
billion to US$25.0 billion, depending on the costing scenario and the U.S.
President’s Emergency Plan for AIDS Relief contribution level, with the gap for
ART commodities alone ranging from US$14.0 to US$16.8 billion.
The
study is limited by excluding above-facility and other costs essential to ART
service delivery and by the availability and quality of country- and
region-specific data.
Conclusions
The projected number of people receiving ART across three
scenarios suggests that countries are unlikely to meet the 90-90-90 treatment
target (81% of people living with HIV on ART by 2020) unless they adopt a
test-and-offer approach and increase ART coverage. Our results suggest that
future resource needs for ART scale-up are smaller than stated elsewhere but
still significantly threaten the sustainability of the global HIV response
without additional resource mobilization from domestic or innovative financing
sources or efficiency gains. As the world moves towards adopting the WHO 2015
guidelines, advances in technology, including the introduction of lower-cost, highly
effective antiretroviral regimens, whose value are assessed here, may prove to
be “game changers” that allow more people to be on ART with the resources
available.
Below: Baseline adult coverage by country under current eligibility
scenario.
Bubble size represents the number of adults in need of ART
in 2013, according to current country eligibility guidelines. The vertical axis
shows the percentage of adults eligible for ART who received ART in 2013, which
is the baseline coverage rate. The horizontal axis sorts the countries into six
regions: Eastern and Southern Africa (AES), Asia and the Pacific (AP), Western
and Central Africa (AWC), Eastern Europe and Central Asia (EECA), Latin America
and the Caribbean (LAC), and the Middle East and North Africa (MENA). Not all
countries included in the analysis are labeled in the figure.
Below: Baseline pediatric coverage by country under current
eligibility scenario.
Bubble size represents the number of children in need of ART
in 2013, according to current country eligibility guidelines. The vertical axis
shows the percentage of children eligible for ART who received ART in 2013,
which is the baseline coverage rate. The horizontal axis sorts the countries
into six regions: Eastern and Southern Africa (AES), Asia and the Pacific (AP),
Western and Central Africa (AWC), Eastern Europe and Central Asia (EECA), Latin
America and the Caribbean (LAC), and the Middle East and North Africa (MENA).
Not all countries included in the analysis are labeled in the figure.
Below: Antiretroviral regimens used in cost calculations.
This figure shows the regimens used to calculate the average
cost of treatment in each country, along with the percentage of patients on
each regimen in 2015 and 2020 among adult and pediatric patients on first- and
second-line ART. Regimen distributions for 2016 to 2019 were estimated but are
omitted from this figure. Please note: fixed-dose regimens are in square
brackets. 3TC, lamivudine; ABC, abacavir; d4T, stavudine; EFV, efavirenz; FTC,
emtricitabine; LPV/r, lopinavir/ritonavir; NVP, nevirapine; TDF, tenofovir;
ZDV, zidovudine.
Below: Estimating the funding gap.
We separately calculated the funding gap for ARVs and
laboratory commodities versus that for facility-level overhead and personnel.
For each country, we considered Global Fund contributions to commodity
procurement, as well as PEPFAR and DCs to commodity procurement and overhead
and personnel, as applicable. DCs were estimated using Global Fund CFTs in
eligible countries or country-reported proportional contributions to the HIV
response.
Below: Estimated range of adults living with HIV on ART.
The vertical axis shows the number of adults, in millions,
who are estimated to be on ART each year, while the horizontal axis shows
years. Each color represents a different scenario, and the whiskers on each bar
represent the lower and upper bound of the 95% confidence interval.
Below: Estimated range of children living with HIV on ART.
The vertical axis shows the number of children, in
thousands, who are estimated to be on ART each year, while the horizontal axis
shows years. Each color represents a different scenario, and the whiskers on
each bar represent the lower and upper bound of the 95% confidence interval.
Below: Total pediatric resource needs for HIV treatment by
scenario.
The vertical axis shows the cost of HIV treatment in
millions of US dollars, and the horizontal axis shows the three scenarios. The
whiskers show the upper and lower bounds of the 95% confidence interval.
Below: Total adult ART resource requirements by region.
The graph shows percent of total adult ART resource
requirements by region based on the current eligibility scenario. The vertical
axis shows the cost of HIV treatment in billions of US dollars, and the
horizontal axis shows the years of analysis. Labeled values do not equal 100%
as only selected percentages are shown. AES, Eastern and Southern Africa; AP,
Asia and the Pacific; AWC, Western and Central Africa; EECA, Eastern Europe and
Central Asia; LAC, Latin America and the Caribbean; MENA, Middle East and North
Africa.
Below: Total pediatric ART resource requirements by region.
The graph shows percent of total pediatric ART resource
requirements by region based on the current eligibility scenario. The vertical
axis shows the cost of HIV treatment in billions of US dollars, and the
horizontal axis shows the years of analysis. Labeled values do not equal 100%
as only selected percentages are shown. AES, Eastern and Southern Africa; AP,
Asia and the Pacific; AWC, Western and Central Africa; EECA, Eastern Europe and
Central Asia; LAC, Latin America and the Caribbean; MENA, Middle East and North
Africa.
Below: Funding gap for HIV treatment.
This map shows the percentage of total costs under the
current eligibility scenario—assuming conservative PEPFAR contributions—that
remains unfunded after incorporating Global Fund, PEPFAR, and domestic
contributions to ART. Countries' funding gaps are larger under the WHO 2013 and
90-90-90 scenarios.
By: Arin Dutta, Catherine Barker, Ashley Kallarakal
Palladium, Washington, District
of Columbia, United States of America
