The Epidemiology of HIV and AIDS in the World

The worldwide epidemic of HIV continues to expand in many regions of the world, particularly in southern Africa, South and Southeast Asia, East Asia and Eastern Europe and Central Asia. Estimates are that at the end of 2005 there were 38.6 million persons living with HIV infection and that 4.1 million new infections and 2.8 million deaths from HIV occurred during the year. Regionally different patterns predominate from generalized heterosexual epidemics in sub-Saharan Africa and parts of the Caribbean to mixes of epidemics in which transmission among injection drug users, their sexual partners, commercial sex workers and their partners intersect. Multilateral and bilateral antiretroviral access campaigns, such as the World Health Organization’s 3 x 5 initiative, have resulted in broader access to live-saving therapy for infected persons in low- and middle-income countries, but several million infected people who are clinically eligible for antiretroviral therapy remain untreated. The public health challenge worldwide is to keep the uninfected and to treat and care for those who have already been infected

Kazakhstan can achieve ambitious HIV targets despite expected donor withdrawal by combining improved ART procurement mechanisms with allocative and implementation efficiencies

Background Despite a non-decreasing HIV epidemic, international donors are soon expected to withdraw funding from Kazakhstan. Here we analyze how allocative, implementation, and technical efficiencies could strengthen the national HIV response under assumptions of future budget levels. Methodology We used the Optima model to project future scenarios of the HIV epidemic in Kazakhstan that varied in future antiretroviral treatment unit costs and management expenditure-two areas identified for potential cost-reductions. We determined optimal allocations across HIV programs to satisfy either national targets or ambitious targets. For each scenario, we considered two cases of future HIV financing: the 2014 national budget maintained into the future and the 2014 budget without current international investment. Findings Kazakhstan can achieve its national HIV targets with the current budget by (1) optimally re-allocating resources across programs and (2) either securing a 35% [30%-39%] reduction in antiretroviral treatment drug costs or reducing management costs by 44% [36%-58%] of 2014 levels. Alternatively, a combination of antiretroviral treatment and management cost-reductions could be sufficient. Furthermore, Kazakhstan can achieve ambitious targets of halving new infections and AIDS-related deaths by 2020 compared to 2014 levels by attaining a 67% reduction in antiretroviral treatment costs, a 19% [14%-27%] reduction in management costs, and allocating resources optimally. Significance With Kazakhstan facing impending donor withdrawal, it is important for the HIV response to achieve more with available resources. This analysis can help to guide HIV response planners in directing available funding to achieve the greatest yield from investments. The key changes recommended were considered realistic by Kazakhstan country representatives.sch_iih12pub4673pub

Allocations to programs, associated coverages levels, and key epidemiological outcomes.

<p>This table summarizes the allocation to–and associated coverage of–each modeled program for the status-quo scenario and also the multi-efficiency scenario to achieve ambitious targets. This table also contains several key summary epidemiological outcomes from the modeled scenarios. We note here that whilst total 2015 spending is constrained by the relevant assumption of available budget, spending in consecutive years may vary slightly due to treatment liabilities, where treatment <i>coverage</i> is held constant rather than the <i>number of people</i> receiving treatment.</p

Gross domestic product per capita, ART unit costs, and key HIV/AIDS program spending data in selected EECA countries.

<p>This figure highlights key HIV-related spending data from selected countries in the Eastern Europe and Central Asia region. Only countries for which data were available are illustrated. The pie charts represent total HIV spending in 2014, and the bar graphs represent national gross domestic product (GDP) per capita and ART unit costs. The red text within the parentheses represents the proportion of the respective national budget consumed by management costs.</p

Contour plot of thresholds to achieve national and ambitious targets with varying levels of management cost reductions and treatment cost reductions.

<p>This figure illustrates the estimated reduction in management costs and treatment costs required to achieve i) national targets (light grey region), and ii) ambitious targets (dark grey region) should the annual budget be restricted to a) 2014 levels (Fig 2A), or b) 2014 levels without international donor funding (Fig 2B). The colored contours show the thresholds for percentage reductions in both newly acquired HIV infections and AIDS-related deaths by 2020 compared to 2014 levels. The ‘no increase’ contour is the threshold for satisfying the national targets (and is hence the border for the light grey region), whilst the ‘50% decrease’ contour satisfies the ambitious targets (and is hence the border for the dark grey region). In each simulation, the proportion of the budget dedicated to direct programs is optimally distributed across programs to minimize incidence, minimize deaths, and virtually eliminate MTCT.</p

Allocations to programs under the status-quo scenario and the realistic scenario to achieve ambitious targets.

<p>This figure illustrates the 2014 allocation to HIV programs in Kazakhstan, alongside the optimal distribution of funds under the realistic scenario to achieve ambitious targets. This bar illustrates the ‘best-fit’ result, whilst uncertainty bounds around the program allocations are presented in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0169530#pone.0169530.t001" target="_blank">Table 1</a> and <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0169530#pone.0169530.s004" target="_blank">S4 Fig</a>.</p