Contributions of declining mortality, overall and from HIV, TB and malaria, to reduced health inequality and inequity across countries.

The objective to reduce global health inequalities and inequities is integral to the global development agenda, from the Universal Declaration of Human Rights to the sustainable development goals and the ongoing response to coronavirus disease. Yet, summary measures of global health gains or of the cost-effectiveness of global health programmes barely capture how well they improve the lives of the most disadvantaged populations. This paper instead explores the distribution of global health gains across countries and the implications for health inequality and inequity (here referring to health disadvantages that reinforce economic disadvantage, and vice versa) across countries. Specifically, it studies the distribution of gains in life expectancy across countries (overall and owing to reduced mortality from HIV, TB and malaria), using the Gini index and a concentration index ranking countries by gross domestic product (GDP) per capita as indicators of health inequality and inequity. By these counts, global inequality in life expectancy across countries declined by one-third between 2002 and 2019. Reduced mortality from HIV, TB and malaria accounted for one-half of this decline. Fifteen countries in sub-Saharan Africa, containing 5% of the global population, accounted for 40% of the global decline in inequality, with nearly six-tenth of this contribution coming from HIV, TB and malaria. Inequity in life expectancy across countries declined by nearly 37%, with a contribution from HIV, TB and malaria of 39% of this gain. Our findings show how simple indicators on the distribution of health gains across countries usefully complement aggregate measures of global health gains and underscore their positive contribution to the global development agenda.

Economic implications of COVID-19 for the HIV epidemic and the response in Zimbabwe.

Understanding the economic implications of COVID-19 for the HIV epidemic and response is critical for designing policies and strategies to effectively sustain past gains and accelerate progress to end these colliding pandemics. While considerable cross-national empirical evidence exists at the global level, there is a paucity of such deep-dive evidence at national level. This article addresses this gap. While Zimbabwe experienced fewer COVID-19 cases and deaths than most countries, the pandemic has had profound economic effects, reducing gross domestic product by nearly 7% in 2020. This exacerbates the long-term economic crisis that began in 1998. This has left many households vulnerable to the economic fallout from COVID-19, with the number of the extreme poor having increased to 49% of the population in 2020 (up from 38% in 2019). The national HIV response, largely financed externally, has been one of the few bright spots. Overall, macro-economic and social conditions heavily affected the capacity of Zimbabwe to respond to COVID-19. Few options were available for borrowing the needed sums of money. National outlays for COVID-19 mitigation and vaccination amounted to 2% of GDP, with one-third funded by external donors. Service delivery innovations helped sustain access to HIV treatment during national lockdowns. As a result of reduced access to HIV testing, the number of people initiating HIV treatment declined. In the short term, there are likely to be few immediate health care consequences of the slowdown in treatment initiation due to the country's already high level of HIV treatment coverage. However, a longer-lasting slowdown could impede national progress towards ending HIV and AIDS. The findings suggest a need to finance the global commons, specifically recognising that investing in health care is investing in economic recovery.

On time horizons in health economic evaluations.

The issue of time horizons has received scant attention in discussions pertaining to health economic evaluations unlike discounting or translation of health outcomes into life-cycle measures (e.g. quality-adjusted life years or disability-adjusted life years). The available guidelines do not offer clear and consistent guidance for many problems addressed in health economic evaluations. In practice, variation of time horizons between studies for the same diseases is a matter of concern, as results on cost-effectiveness depend on the time horizon. Our paper contributes to establishing a consistent approach to setting time horizons across common types of health economic evaluations and mitigating potential bias where the choice of a time horizon may affect results of the evaluation. We find that available guidance is clear only for patient-focused interventions, but not in the presence of population-level effects owing to transmission of infections or other linkages. We distinguish between a policy period-over which an intervention is delivered or initiated-and an evaluation period over which the effects are measured. One important challenge in establishing a time horizon for evaluation is that, at least for infectious diseases, the state of the epidemic at the end of the policy period cannot be evaluated precisely and incorporated in the results of an economic evaluation. While longer policy periods partly mitigate this challenge, they are subject to greater uncertainty, and outcomes may not adequately reflect the cost-effectiveness of current policies because outcomes reflect an average over the policy period. Incremental analysis on interventions implemented in sub-periods of the policy period (especially at the beginning) potentially improves accuracy and helps to identify potential for improving cost-effectiveness by varying the path of implementation or the mix of interventions offered over time.

On discount rates for economic evaluations in global health.

Choices on discount rates have important implications for the outcomes of economic evaluations of health interventions and policies. In global health, such evaluations typically apply a discount rate of 3% for health outcomes and costs, mirroring guidance developed for high-income countries, notably the USA. The article investigates the suitability of these guidelines for global health [i.e. with a focus on low- and middle-income countries (LMICs)] and seeks to identify best practice. Our analysis builds on an overview of the academic literature on discounting in health evaluations, existing academic or government-related guidelines on discounting, a review on discount rates applied in economic evaluations in global health, and cross-country macroeconomic data. The social discount rate generally applied in global health of 3% annually is inconsistent with rates of economic growth experienced outside the most advanced economies. For low- and lower-middle-income countries, a discount rate of at least 5% is more appropriate, and one around 4% for upper-middle-income countries. Alternative approaches-e.g. motivated by the returns to alternative investments or by the cost of financing-could usefully be applied, dependent on policy context. The current practise could lead to systematic bias towards over-valuing the future costs and health benefits of interventions. For health economic evaluations in global health, guidelines on discounting need to be adapted to take account of the different economic contexts of LMICs.

HIV and the growing health burden from noncommunicable diseases in Botswana: modelling study.

BACKGROUND: The "greying of AIDS" - the aging of the population living with HIV who benefit from antiretroviral treatment (ART) and the emergence of age-related non-communicable diseases (NCDs) - has been well documented. The emerging health systems challenges - eg, the implications of HIV on the disease burden from NCDs on the population level, and the evolving role of HIV as a co-morbidity or co-existing disease of various NCDs - are less well understood. The paper elucidates these challenges by providing a quantitative analysis of HIV-NCD interactions for Botswana. METHODS: We projected the prevalence of HIV and of selected NCDs in Botswana using demographic and HIV-specific estimates building on data on the state and the dynamics of the HIV epidemic, using the Spectrum modelling software, and extrapolating on estimates of the prevalence of NCDs from the 2015 global burden of disease (GBD). RESULTS: HIV has slowed down overall population aging and thus has attenuated the growing burden of many NCDs so far, because cohorts reaching old age have been decimated by AIDS-related mortality in the 1990s and early 2000s. Aging and the rise in the prevalence of NCDs, however, will accelerate rapidly from about 2030 because of reduced attrition of cohorts living with HIV since the start of the ART scale-up in Botswana. While HIV prevalence will decline over time, the health needs of people living with HIV will become more complex. HIV prevalence among the growing populations affected by various important NCDs will not decline for decades, because of the aging of the population living with HIV and interactions between HIV, ART and NCDs. CONCLUSIONS: Even though HIV prevalence is projected to decline steeply to 2030 because of reduced HIV incidence, the prevalence of HIV among people affected by many of the most important NCDs will increase or barely change. While the health care needs of people living with HIV will increase and become more complex, HIV will also emerge as a key factor complicating the management of the growing burden of NCDs. Health systems will need to prepare for the challenge of large numbers of patients living with both HIV and NCDs.

Cost-effectiveness of scaling up of hepatitis C screening and treatment: a modelling study in South Korea.

BACKGROUND: The prices and the coverage of effective direct-acting antivirals (DAAs) to treat hepatitis C vary across countries. South Korea expanded DAAs coverage through national health insurance. This study aims to analyse the cost-effectiveness of scale-up of hepatitis C screening and treatment with DAAs in South Korea, a high-income country. METHODS: This study uses a compartmental age-sex structured model of progression of hepatitis C to analyse effects of different policy choices for the scale up of screening and treatment with DAAs on hepatitis C disease burden and costs from 2017 to 2050. Policy scenarios considered in our study are (1) no treatment, (2) status quo, (3) screening population aged over 60 years, (4) screening population over 40 years and (5) screening population aged over 20 years. RESULTS: The continuation of current policy with the expansion of DAAs coverage is estimated to reduce the prevalence of hepatitis C antibody from 0.6% in 2015 to 0.25% in 2050 of the adult population. Status quo policy, screening from age 60, screening from age 40 and screening from age 20 are cost-effective in terms of averted infection at estimated incremental cost-effective ratio of US$101 208, US$111 770, US$107 909 and US$229 604. CONCLUSIONS: The expansion of DAAs coverage by the national health insurance is highly effective in alleviating hepatitis C disease burden. The scale-up of screening and treatment with DAAs for targeted adult population with high prevalence of hepatitis C is cost-effective. This study provides a case for policy-makers to invest in rapid expansion of hepatitis C comprehensive screening and treatment with DAAs.

Poverty as a barrier to antiretroviral therapy access for people living with HIV/AIDS in Kenya.

Understanding barriers to access to essential health services is critical for devising effective strategies to improve access and align such strategies with national health and development policy objectives. However, while considerable empirical evidence exists on correlates of HIV prevalence and populations at risk of contracting HIV, there is very little such evidence on access to antiretroviral therapy. This paper addresses this gap through a cross-sectional analysis of coverage of antiretroviral therapy and its correlates across 47 counties in Kenya. It considers health-sector and social factors, and applying instrumental variables to address error-in-variables and reverse-causality issues regarding HIV prevalence. Poverty was the most robust and - statistically and substantially - significant determinant of treatment coverage. The gap in treatment coverage between the poorest and richest counties amounted to about 40 percentage points and has not narrowed between 2012 and 2015. Health sector capacities independently played a role and exacerbated the poverty gap. For Kenya, the results suggest that policies on expanding treatment access need to be differentiated across counties to greatest effect and to align the HIV/AIDS response with national health and social policy objectives. Regarding global HIV/AIDS policies, the findings suggest a need to recognise "people left behind" owing to socio-economic and specifically poverty-related barriers to access to services.

Effectiveness of and Financial Returns to Voluntary Medical Male Circumcision for HIV Prevention in South Africa: An Incremental Cost-Effectiveness Analysis.

BACKGROUND: Empirical studies and population-level policy simulations show the importance of voluntary medical male circumcision (VMMC) in generalized epidemics. This paper complements available scenario-based studies (projecting costs and outcomes over some policy period, typically spanning decades) by adopting an incremental approach-analyzing the expected consequences of circumcising one male individual with specific characteristics in a specific year. This approach yields more precise estimates of VMMC's cost-effectiveness and identifies the outcomes of current investments in VMMC (e.g., within a fiscal budget period) rather than of investments spread over the entire policy period. METHODS/FINDINGS: The model has three components. We adapted the ASSA2008 model, a demographic and epidemiological model of the HIV epidemic in South Africa, to analyze the impact of one VMMC on HIV incidence over time and across the population. A costing module tracked the costs of VMMC and the resulting financial savings owing to reduced HIV incidence over time. Then, we used several financial indicators to assess the cost-effectiveness of and financial return on investments in VMMC. One circumcision of a young man up to age 20 prevents on average over 0.2 HIV infections, but this effect declines steeply with age, e.g., to 0.08 by age 30. Net financial savings from one VMMC at age 20 are estimated at US$617 at a discount rate of 5% and are lower for circumcisions both at younger ages (because the savings occur later and are discounted more) and at older ages (because male circumcision becomes less effective). Investments in male circumcision carry a financial rate of return of up to 14.5% (for circumcisions at age 20). The cost of a male circumcision is refinanced fastest, after 13 y, for circumcisions at ages 20 to 25. Principal limitations of the analysis arise from the long time (decades) over which the effects of VMMC unfold-the results are therefore sensitive to the discount rate applied, and more generally to the future course of the epidemic and of HIV/AIDS-related policies pursued by the government. CONCLUSIONS: VMMC in South Africa is highly effective in reducing both HIV incidence and the financial costs of the HIV response. The return on investment is highest if males are circumcised between ages 20 and 25, but this return on investment declines steeply with age.

Optima: A Model for HIV Epidemic Analysis, Program Prioritization, and Resource Optimization.

Optima is a software package for modeling HIV epidemics and interventions that we developed to address practical policy and program problems encountered by funders, governments, health planners, and program implementers. Optima's key feature is its ability to perform resource optimization to meet strategic HIV objectives, including HIV-related financial commitment projections and health economic assessments. Specifically, Optima allows users to choose a set of objectives (such as minimizing new infections, minimizing HIV-related deaths, and/or minimizing long-term financial commitments) and then determine the optimal resource allocation (and thus program coverage levels) for meeting those objectives. These optimizations are based on the following: calibrations to epidemiological data; assumptions about the costs of program implementation and the corresponding coverage levels; and the effects of these programs on clinical, behavioral, and other epidemiological outcomes. Optima is flexible for which population groups (specified by behavioral, epidemiological, and/or geographical factors) and which HIV programs are modeled, the amount of input data used, and the types of outputs generated. Here, we introduce this model and compare it with existing HIV models that have been used previously to inform decisions about HIV program funding and coverage targets. Optima has already been used in more than 20 countries, and there is increasing demand from stakeholders to have a tool that can perform evidence-based HIV epidemic analyses, revise and prioritize national strategies based on available resources, set program coverage targets, amend subnational program implementation plans, and inform the investment strategies of governments and their funding partners.

Reorienting the HIV response in Niger toward sex work interventions: from better evidence to targeted and expanded practice.

BACKGROUND: Niger's low-burden, sex-work-driven HIV epidemic is situated in a context of high economic and demographic growth. Resource availability of HIV/AIDS has been decreasing recently. In 2007-2012, only 1% of HIV expenditure was for sex work interventions, but an estimated 37% of HIV incidence was directly linked to sex work in 2012. The Government of Niger requested assistance to determine an efficient allocation of its HIV resources and to strengthen HIV programming for sex workers. METHODS: Optima, an integrated epidemiologic and optimization tool, was applied using local HIV epidemic, demographic, programmatic, expenditure, and cost data. A mathematical optimization algorithm was used to determine the best resource allocation for minimizing HIV incidence and disability-adjusted life years (DALYs) over 10 years. RESULTS: Efficient allocation of the available HIV resources, to minimize incidence and DALYs, would increase expenditure for sex work interventions from 1% to 4%-5%, almost double expenditure for antiretroviral treatment and for the prevention of mother-to-child transmission, and reduce expenditure for HIV programs focusing on the general population. Such an investment could prevent an additional 12% of new infections despite a budget of less than half of the 2012 reference year. Most averted infections would arise from increased funding for sex work interventions. CONCLUSIONS: This allocative efficiency analysis makes the case for increased investment in sex work interventions to minimize future HIV incidence and DALYs. Optimal HIV resource allocation combined with improved program implementation could have even greater HIV impact. Technical assistance is being provided to make the money invested in sex work programs work better and help Niger to achieve a cost-effective and sustainable HIV response.

Macroeconomic impact of HIV: the need for better modelling.

PURPOSE OF REVIEW: To critically evaluate the recent literature on macroeconomic repercussions of the HIV pandemic and the response to it. The review focuses on the impacts of HIV through both its health consequences and its impact on the accumulation of human capital. RECENT FINDINGS: So far, most studies have found a moderate impact of the HIV epidemic on macroeconomic growth. However, recent studies tend to emphasize the fact that HIV undermines human capital and implies a long-term detriment for economic development. Availability of data from Demographic and Health Surveys offers opportunities for better understanding the relationship between the HIV epidemic and economic growth through pathways linking its microeconomic and macroeconomic impacts. SUMMARY: The macroeconomic impact of HIV observed so far appears moderate. Our analysis of recent literature, however, points out three important issues that may have been previously underestimated. First, the most important effects may occur in the longer run, through changes in the accumulation of human capital. Second, aggregate impact often masks an unequal impact among different economic groups. Third, the empirical evidence on which current macroeconomic models are based remains weak, in particular in the way it takes into account responses to HIV at the households' level. Microsimulation models and the recently increasing availability of robust datasets at households' level offer promising opportunities to address these issues.

Financing HIV/AIDS programs in sub-Saharan Africa.

This paper offers an analysis of the costs and the financing of HIV/AIDS programs for countries in sub-Saharan Africa. The rate of external financing varies with gross domestic product (GDP) per capita, but not much at all with HIV prevalence. In six of the thirty-four countries examined, the costs of HIV/AIDS programs will exceed 3 percent of GDP by 2015. Most of these are low-income countries. Considerable external support at current rates in these countries would help contain the fiscal costs to around 1 percent of GDP. But if that support dwindles, countries would have to borrow money or cut back on their own spending for HIV/AIDS.

Financing the response to AIDS: some fiscal and macroeconomic considerations.

This article examines the international response to AIDS from a fiscal perspective: first the financing of the international response to AIDS, especially the role of external financing, and second, a more comprehensive perspective on the costs of the national response to AIDS relevant for fiscal policy. The second half of the article focuses on the effectiveness of the response to AIDS. We find that there is little basis for concerns about macroeconomic constraints to scaling up, in light of the moderate scale of AIDS-related aid flows relative to overall aid. Regarding sectoral constraints, the picture is more differentiated. Many countries with high prevalence rates have also achieved high rates of access to treatment, but most of these are middle-income countries. Our econometric analysis credits external aid as a key factor that has enabled higher-prevalence countries to cope with the additional demands for health services. At the same time, gross domestic product per capita and health sector capacities are important determinants of access to treatment.