Although major progress has been made in recent years to tackle the scourge of HIV, major challenges still remain, not least in closing very large and persistent coverage gaps for life-saving antiretroviral therapy.
Our work in this area is particularly policy-orientated and seeks to identify how available resources for HIV can be better allocated so as to improve their impact on the prevention, treatment and mitigation of the disease.
CHE is a key partner providing economics input to the HIV Modelling Consortium. The Consortium, with a secretariat in the Department for Infectious Disease Epidemiology at Imperial College London, leads the engagement between infectious disease modellers and global HIV policy-makers.
In 2015, WHO updated their existing International Guidelines on how HIV treatment (in particular antiretroviral therapy – ART) is provided to the 35 million people living with HIV worldwide. Of particular concern is those living with the virus in low- and middle-income countries (LMICs), in particular in sub-Saharan Africa which bears the bulk of the burden and where 24.7 million people with HIV reside.
The Treatment Guidelines cover a range of policy questions (e.g. relating to testing/identification, choice of drugs, monitoring and switching of patients and other approaches to ensuring health improvement) and draws upon expertise covering a number of academic disciplines (e.g. clinical, modelling/economics, social science) and inputs from patients and providers.
As part of the Guideline development process, the HIV Modelling Consortium was asked by WHO to convene leading international experts in modelling and economic analysis on two major topics:
Researchers from CHE were engaged in both workstreams and co-led the second on monitoring and switching. These were major activities involving engagement with leading officials from: international organisations (WHO, UNAIDS, US Government (PEPFAR/CDC), Global Fund for AIDS, TB and Malaria), international NGOs (Clinton Health Access Foundation, Medicines Sans Frontiers), philanthropic organisations (Bill and Melinda Gates Foundation), high level officials from African Governments (in particular: Zimbabwe, Uganda, Malawi, Kenya, South Africa), and patient and provider representatives.
- Phillips A, et al, Revill P. (Working group on modelling of antiretroviral therapy monitoring strategies in sub-Saharan Africa). Sustainable HIV treatment in Africa through viral-load-informed differentiated care. Nature2015;528:7580:S68–S76. Download from nature
- Barnabus RV, Bendavid E, Bershteyn A, Boulle A, Eaton JW, Ford N, Hallett TB, Hontelez JAC, Klein DJ, Olney JJ, Phillips AN, Reniers G, Revill P, Slaymaker E, Zaba B, Priorities for HIV care in sub-Saharan Africa: a population perspective. HIV Modelling Consortium. Report for the World Health Organization HIV Treatment Guidelines Development Committee 2015. Download from HIV modelling
- Revill P, Hallett T, Phillips A. The costs and benefits of alternatives approaches to monitoring patients on antiretroviral therapy: modelling and economic analysis, HIV Modelling Consortium report for the World Health Organization HIV Treatment Guidelines Development Committee 2015. Download from HIV modelling
Resources for HIV treatment and prevention strategies should be allocated according to local epidemiological conditions (e.g. resources may be targeted at areas signalling an HIV transmission focal point). However, estimates of HIV prevalence and high-risk behaviour are not known with certainty, and so standard economic evaluation methods typically recommend that decision-makers work with expected costs and effects when deciding which programmes to implement.
Budgets are often allocated to specific diseases and/or localities, and decision-makers may sometimes be forced to cut planning programmes to avoid cost over-runs. As a result, expected costs and effects of the planned programmes are never realised.
Researchers from CHE are leading the development of research, in collaboration with researchers from the Department of Infectious Disease Epidemiology at Imperial College London, exploring how alternative budgetary policies perform under conditions of uncertainty:
This study will allow us to assess the opportunity cost of different policy choices and provide insight into the merit of alternative policies for HIV and other settings.
CHE collaborates with infectious disease modellers in the HIV Epidemiology and Biostatistics Group at University College London on a Bill and Melinda Gates Foundation (BMGF) funded project to investigate the economic benefit of potential new HIV testing and monitoring diagnostics.
The work is intended to guide investments in the product development pipeline and in the uptake of new diagnostic technologies.
We are also contributing to work for the World Health Organization (WHO) on public health responses to emergent HIV drug resistance.
- Cambiano V, Ford D, Mabugu T, Napierala Mavedzenge S, Miners A, Mugurungi O, Nakagawa F, Revill P, Phillips A. Assessment of the potential impact and cost-effectiveness of self-testing for HIV in low-income countries. The Journal of Infectious Diseases 2015;212(4):570-577. Download from Oxford journals
- Phillips A, Cambiano V, Nakagawa F, Magubu T, Miners A, Ford D, Pillay D, De Luca A, Lundgren J, Revill P. Cost-effectiveness of HIV drug resistance testing to inform switching to second line antiretroviral therapy in low income settings. PLoS ONE2014;9(10);e109148. Download from plosone