Smart Investments: Making the Most of Every Dollar Invested (February 2011)

Experience in the field has taught us how to use every dollar invested in battling HIV/AIDS more effectively and efficiently. This means we are getting a bigger bang for the buck – every dollar is going a little further allowing us to do more to combat HIV/AIDS, and address issues across the global health spectrum.

APHIA: Kenya: Programming Efficiencies Lead to Improved Health Outcomes

In Kenya, linking HIV/AIDS to maternal and child health, TB, malaria and family planning funding under single, unified awards meant U.S. dollars paid for only one project director; for one administrative office and motor pool; and for one integrated technical assistance visit to sites that the U.S. supports. With no additional increase in family planning funding, geographic coverage of reproductive health services went from two to all eight provinces, couple-years of protection using a modern family planning method increased exponentially, and HIV/AIDS programs were enriched because they began to focus on the "whole patient" in the context of his or her family situation.

Similarly, the GHAIN program in Nigeria found that when linking HIV/AIDS to family planning, attendance at family planning clinics increased from 68% to 87% and referrals also increased. These models of integrated programming are being now being replicated in other areas.

Saving Money and Lives Through Generic Drugs

One of the biggest hurdles to rapid treatment scale-up was the high price of antiretroviral drugs (ARVs), generally available only as brand drugs for use in the U.S. and other high-income countries. To support the increased availability of safe, effective, low-cost, and generic antiretroviral drugs, the U.S. Food and Drug Administration reviews drugs for safety and approves them for purchase under PEPFAR. This process has led to 114 antiretroviral drugs approved for use in PEPFAR programs. By 2008, generics accounted for almost 90% of the 22 million ARV packs purchased, increasing from 14.8% in 2005, and resulting in an estimated cumulative savings of $323 million. PEPFAR is continuing to work to increase the procurement of generics to increase savings.

PEPFAR has also used its buying power to negotiate volume-based pricing for ARVs. In 2009, PEPFAR purchased 50% of ARVs through pooled procurement via the Supply Change Management System (SCMS), a consortium of organizations developed and supported by PEPFAR.

Going from Air Freight to Water and Land Delivery Systems Saves Money and Achieves Timely Delivery of Medicine

PEPFAR, working with SCMS, has become more efficient in shipping needed medicines in a timely fashion by using water and land delivery systems instead of air freight, reducing costs by as much as 90%. In May 2009, for example, SCMS shipped by road more than $95,000 of ARVs to Tanzania from PEPFAR’s regional distribution center in Kenya. The cost for road freight was $9,560 versus $26,679 for air freight, a savings of 64 percent. Similarly, as the political situation stabilized in Zimbabwe, the PEPFAR program, which supports 40,000 people on treatment, switched from air freight to road shipments of ARVs from SCMS’s regional distribution center in South Africa. This change saved approximately 60 percent in shipping costs, and initial savings were used to purchase HIV test kits to make up for the shortage in the national testing program.

In 2009, PEPFAR through SCMS, saved over $3.2 million by using sea freight for appropriate ARV shipments. Sea freight charges for products PEPFAR moved were $520,000, while moving the same volume by air would have cost an estimated $3.8 million.

Additionally, in 2009, SCMS saved $557,000 by use of road freight. Road freight charges for the product PEPFAR moved was $395,000, to move the same volume by air would have cost an estimated $953,000.

Medical Male Circumcision

Medical male circumcision (MC) is an ideal HIV prevention investment for countries and donors as it is a time limited intervention. The majority of the expenditure required to saturate a country with high levels of adult male circumcision takes place in the first 1-3 years, depending on the speed of the program, and expenditures drop precipitously following this initial investment to support neonatal and adolescent boys. Scaling up of MC to reach 80% of adult and newborn males in 14 African countries by 2015:

  • Could prevent more than 4 million adult HIV infections over 15 years (2009 – 2025)
  • Could result in cost savings of $20.2 billion between 2009 – 2025 with an overall investment of approximately $4 billion

Example: Cost Savings by Preventing HIV Infections

In Swaziland, the Government of the Kingdom of Swaziland has embraced male circumcision as an HIV prevention strategy. Swaziland’s male circumcision Accelerated Saturation Initiative is an unprecedented effort to roll out medical male circumcision for HIV prevention to achieve rapid coverage at a national level. The goal of this initiative is to slow the spread of HIV in one of the world’s most heavily impacted nations. The initiative will provide voluntary male circumcision to between 125,000-175,000 Swazi males 15-49 years of age in a 12- month period. Mathematical modeling studies suggest that circumcising 80% of 15-49 year old HIV-negative males within one year may:

  • Prevent 88,000 new adult HIV infections through 2025
  • Reduce annual HIV incidence by approximately 75% by 2025
  • Prevent one new HIV infection for every 3-4 male circumcisions performed

The financial savings in HIV care and treatment costs to the Swazi government of preventing 88,000 new HIV infections is approximately $650 million in HIV care and treatment costs; given that the U.S. financial support of Accelerated Saturation Initiative will cost a fraction of the total projected saving, this initiative represents a manifold return on investment. Through PEPFAR, the U.S. is supporting the Government of Swaziland’s leadership in rolling out this innovative initiative implementing a highly-effective HIV prevention intervention.

Prevention of Mother- to- Child Transmission

Prevention of mother- to-child transmission (PMTCT) is one of the most cost-effective interventions for HIV, largely because it is extremely effective. For example, by focusing on PMTCT, the nation of Botswana has had extraordinary success, reducing the likelihood of infant infection to levels similar to those found in the U.S. Keeping mothers alive by identifying HIV infection also helps avert infections in children and has improved under five years-of-age mortality rates. Starting mothers on cotrimoxazole in all HIV-exposed babies at six weeks has reduced a leading cause of newborn deaths in the first eight months of HIV infection. Not only does PMTCT save lives, it links babies and children to care for immunizations.

In addition, PMTCT programs work to ensure that each mother receives access to antiretroviral treatment when needed. This restores her health and prevents orphaning of her children, which in turn allows nations to avoid the heavy costs associated with caring for orphans.

Accordingly, PEPFAR’s Five-Year Strategy set goals to reach 80% of pregnant women with HIV counseling and testing, and to provide ARV prophylaxis or treatment, as appropriate, to 85% of pregnant HIV-infected women in PEPFAR countries.

  • In early 2010, PEPFAR solicited “PMTCT Acceleration Plans” from 6 countries – Zambia, South Africa, Nigeria, Mozambique, Malawi and Tanzania – with high rates and burden of maternal-to-child transmission of HIV. After two months of extensive vetting and technical assistance, an additional $100 million in FY2010 PEPFAR funding – above the more than $956 million being spent on PMTCT from fiscal years 2004 to 2009 – was allocated to fund plans targeting scale-up bottlenecks.
  • PEPFAR is also working closely with the Global Fund as it leads a reprogramming effort among 20 countries in an effort to stimulate further investment in PMTCT scale-up.

PEPFAR also recognizes the many ways in which PMTCT serves to bridge the gap between HIV and maternal and child health and other general health services, such as child immunizations. As part of the GHI, PEPFAR is collaborating with other US programs on strategies for the integration of services for mothers and children and their wider families, building on PEPFAR and other foundations.

Improving Technology

Point-of-care lab simplifications have introduced better technologies that reduce the costs of lab monitoring and make technology more portable at the point of care, reducing the need for overhead infrastructures and transport.

Investing in Early Infant Diagnosis of HIV Infection Means Earlier Treatment and More Lives Saved

Testing infants for HIV infection was a technological challenge, but a critically important challenge to overcome to save lives. To address the challenge, PEPFAR began promoting the use of dried blood spot samples on special paper for infant DNA PCR testing. This method has two main advantages over the traditional needle and tube system: blood can be taken from the infant using a lancet, by pricking the heel, toe, or finger, which is much easier than finding a tiny vein with a needle. Second, dried blood spots on paper are very stable, and can be stored (even without refrigeration) for weeks and remain stable.

PEPFAR funded a CDC project in Botswana to introduce dried blood spot DNA PCR testing into an existing PMTCT program. Prior to this, infant HIV testing existed only for the few patients able to afford private care or receiving HIV treatment in large clinics in cities. Francistown, Botswana’s second largest city, was the site of the pilot project. Midwives, nurses, and doctors from 12 clinics and 1 large hospital were trained to collect blood from infants using dried blood spot samples, and laboratory staff in the capital city of Gaborone were hired and trained to do dried blood spot DNA PCR testing. During the first 6 months, most of the babies with HIV-positive mothers in the town were tested, and important lessons about exactly how to collect the blood from infants efficiently were learned. Data were collected about each mother and infant and sent to the lab along with each blood sample. The program has now gone country-wide, allowing many infants to receive HIV treatment early, before they become ill. Health workers and the community now have much greater awareness of the benefits of taking medications to prevent mother-to-child transmission, since the vast majority of infants born to mothers who receive prenatal care and PMTCT services are not HIV-positive.

More countries have started using dried blood spot DNA PCR testing every year, and PEPFAR now supports laboratories and training programs for health workers in more than 23 countries worldwide. CDC has created a set of manuals and videos for programs managers, health workers, and laboratory staff that streamline the process of starting new programs. CDC laboratory and program staff travel extensively to support new programs and help improve maturing ones, and PEPFAR dollars have helped thousands of infants be tested for HIV at an early age using a state-of-the art technique previously unavailable in resource-limited settings.

Increasing Partner Country Ownership

The Partnership Framework between Nigeria and the United States provides a five-year joint strategic plan for cooperation between the Government of Nigeria, the U.S. Government, and other stakeholders to support Nigeria’s HIV/AIDS program. Under the agreement, the Government of Nigeria is responsible for leading the national HIV/AIDS response, including leading planning, oversight, management, and implementation. U.S. contributions are focused on supporting the Government of Nigeria’s efforts to provide universal access to HIV prevention, treatment and care services. By having clearly defined roles and responsibilities for the two parties, the Partnership Framework enables the Government of Nigeria to identify the met and unmet needs in their national HIV/AIDS strategy, and coordinate with other donors to meet the unmet needs. The Partnership Framework also reinforces the Government of Nigeria’s responsibility for investing in its people. Under the agreement, the Government of Nigeria has committed to increase their financing of the national HIV/AIDS response from 7% in 2008 to 50% of the cost of universal access by 2015.

Blood Safety

One of the key prevention areas in which PEPFAR has played a significant role is blood safety. PEPFAR works with Ministries of Health to develop and strengthen national blood transfusion services (NBTS), especially in countries with a high burden of HIV. Since 2004, PEPFAR has provided ongoing financial and technical assistance support to more than 14 countries with NBTS programs, with the goal of ensuring an adequate supply of safe blood through screening for transfusion-transmissible infections, such as HIV, syphilis, Hepatitis B, and Hepatitis C. In 13 of these countries, the NBTS reported a decrease in the percentage of collected blood units reactive for HIV between 2003 and 2009-- for example, in Botswana the percentage from 7.5% in 2003 to 2.1% in 2007. In Zambia, PEPFAR has supported the shift from a fragmented hospital-based system to a regionalized system under the control of the country’s NBTS. Zambia has also eliminated risky family replacement donations, where family members donate blood to each other without testing or other safety measures. The program has increased the number of voluntary non-compensated donations, which are at less risk for HIV reactivity, from 40,600 in 2003 to 104,000 in 2009. These achievements were made by building sustainable capacity within the health system, which will continue to benefit the health of Zambians long into the future.

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