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Katherine Floyd, Lilani Kumaranayake, Haileyesus Getahun, Paul Nunn

Resources required for TB/HIV collaborative activities or What will it cost to implement TB/HIV collaborative activities?. Katherine Floyd, Lilani Kumaranayake, Haileyesus Getahun, Paul Nunn 4 th TB/HIV Working Group meeting Addis Ababa, Ethiopia September 20th 2004. Background.

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Katherine Floyd, Lilani Kumaranayake, Haileyesus Getahun, Paul Nunn

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  1. Resources required for TB/HIV collaborative activitiesorWhat will it cost to implement TB/HIV collaborative activities? Katherine Floyd, Lilani Kumaranayake, Haileyesus Getahun, Paul Nunn 4th TB/HIV Working Group meeting Addis Ababa, Ethiopia September 20th 2004

  2. Background • Cost estimates important for • advocacy and resource mobilization • to inform budgeting process • assessing affordability of activities proposed and extent to which new funding is needed • Cost estimates made for HIV/AIDS and TB control published in high profile journals • HIV/AIDS – prevention and care (Science 2001) • DOTS expansion to reach global control targets (Science 2002) • "3 by 5" initiative (Lancet 2004)

  3. Background • Existing estimates for TB/HIV are out-of-date • from 2001 • predate interim policy on TB/HIV collaborative activities 4. Now that policy document exists, frequently asked question is: What will these activities cost?

  4. Objective To estimate the financial resources required for TB/HIV collaborative activities

  5. Methods - general • Defined the TB/HIV collaborative activities to be costed as the 12 activities recommended in WHO's interim policy document

  6. Methods - general • Which countries? 34 countries prioritized in "3 by 5" • Focus on health system (provider) costs • Focus on total annual costs; because detailed implementation plans not yet available for most countries, present 2 scenarios • First year of implementation, with ART limited to 10% HIV+ TB patients • Maximum levels of implementation, ART provided to all HIV+ TB patients ( ~350,000 people) • Estimate total annual costs by combining data on unit costs for each activity with estimates of annual numbers of people to whom activity relates. • Various estimates produced: present upper estimates

  7. Sources Unit cost data TB/HIV pilot projects in Malawi, Zambia, South Africa Cost analysis for "3 by 5" Numbers of people to whom activity relates TB notification data WHO estimates of number of HIV+ TB patients HIV prevalence data UN population estimates Futures group data on T+C Most important assumption ART costs only consider ART costs during period during which individual has TB and assume this is 6 months activity 12 defined as "ART for TB patients" Otherwise, cumulative cost effect large as costs will increase year on year Methods – sources and assumptions

  8. ART regimens • Standard first-line regimen : d4T/3TC/NVP, fixed-dose combination • US$140 low-income countries, US$304 elsewhere • TB patients: d4T/3TC/EFZ for 6 months • adds US$201 to fixed-dose first-line regimen • Female TB patients who are pregnant or at risk of pregnancy: ZDV/3TC/ABC for 6 months • adds US$527 to fixed-dose first-line regimen

  9. Annual costs by activity, US$ millions Scenario 1: Year 1, all start-up costs but limited ART Scenario 2: Full implementation, ART for all HIV+ TB patients Total = US$149 million ~ 35,000 HIV+ TB patients (10% total) enrolled on ART "3 by 5"assumed ~150,000 in 2004 Total = US$ 240 million ~ 350,000 TB patients enrolled on ART

  10. Annual costs by country (Scenario 2) South Africa (~ 2/3 is ART) Zimbabwe India Kenya Ethiopia Zambia 6 countries account for ~ 60% total costs ART unit costs used for S. Africa v. similar to national estimates (~ US$1200 p.a.)

  11. Key points to highlight 1. Limited data from which to produce estimates, especially • India and China • ART costs apart from the drugs themselves • Scaled up (vs. small scale) costs • Numbers that will access interventions in practice Important to collect more data as implementation proceeds 2. ART dominates costs, so is key cost to "get right" • Costs could be higher if Zambia consensus approach not followed • Costs to patients not included but may be important for health system to cover 3. Analysis of available funding and funding gaps is needed – e.g. through review of GFATM and PEPFAR proposals

  12. Conclusions 1. About US$250 million per year is needed for implementation of TB/HIV collaborative activities in the 34 countries that account for 90% of the global burden of HIV, and the biggest cost is ART 2. Figures are provisional but can be used for advocacy purposes 3. Estimates should be refined through: • Review of existing and future country plans and budgets for TB/HIV collaborative activities • Review of available funding • More analysis of both costs and numbers accessing interventions as activities are scaled up

  13. Acknowledgements Taghreed Adam Benjamin Johns John Stover Catherine Watt THD team

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