How should HIV resources be allocated? Lessons learnt from applying Optima HIV in 23 countries

Abstract

IntroductionWith limited funds available, meeting global health targets requires countries to both mobilize and prioritize their health spending. Within this context, countries have recognized the importance of allocating funds for HIV as efficiently as possible to maximize impact. Over the past six years, the governments of 23 countries in Africa, Asia, Eastern Europe and Latin America have used the Optima HIV tool to estimate the optimal allocation of HIV resources.MethodsEach study commenced with a request by the national government for technical assistance in conducting an HIV allocative efficiency study using Optima HIV. Each study team validated the required data, calibrated the Optima HIV epidemic model to produce HIV epidemic projections, agreed on cost functions for interventions, and used the model to calculate the optimal allocation of available funds to best address national strategic plan targets. From a review and analysis of these 23 country studies, we extract common themes around the optimal allocation of HIV funding in different epidemiological contexts.Results and discussionThe optimal distribution of HIV resources depends on the amount of funding available and the characteristics of each country's epidemic, response and targets. Universally, the modelling results indicated that scaling up treatment coverage is an efficient use of resources. There is scope for efficiency gains by targeting the HIV response towards the populations and geographical regions where HIV incidence is highest. Across a range of countries, the model results indicate that a more efficient allocation of HIV resources could reduce cumulative new HIV infections by an average of 18% over the years to 2020 and 25% over the years to 2030, along with an approximately 25% reduction in deaths for both timelines. However, in most countries this would still not be sufficient to meet the targets of the national strategic plan, with modelling results indicating that budget increases of up to 185% would be required.ConclusionsGreater epidemiological impact would be possible through better targeting of existing resources, but additional resources would still be required to meet targets. Allocative efficiency models have proven valuable in improving the HIV planning and budgeting process.

The City of Johannesburg can end AIDS by 2030: modelling the impact of achieving the Fast‐Track targets and what it will take to get there

“…To understand what it will take for the City of Johannesburg to achieve the Fast-Track targets, we adapted the Optima HIV epidemic and resource allocation model in order to capture the key aspects of the HIV care and treatment cascade [18]. Although the Optima HIV model has been successfully applied in many countries to assess the impact and optimize the allocation of HIV programme spending [19], it has yet to be used for a detailed analysis of the care and treatment cascade, largely due to a lack of comprehensive data. For this analysis, we sought data from a number of sources, including clinic-level data, cohort studies, national reports, and a novel record-linkage analysis providing comprehensive viral load and CD4 data for Johannesburg.…”

Optima attempts to objectively and pragmatically assist countries meet their targets most efficiently and effectively

“…Importantly, this means that the analyses investigate questions considered important by country teams, including what it would take to achieve 90-90-90, and other questions of interest to them. In our paper, we summarized the results of 23 studies in which the central question of concern for countries was how to maximize the health outcomes of their HIV responses assuming that no additional funds are immediately available [3]. Focusing on improving programmatic efficiency in the present moment does not preclude focusing on longer-term targets in the future.…”

HIV, 95‐95‐95 and the allocative efficiency fallacy: why treating everyone makes sense from a humanitarian, clinical, economic and disease control perspective

“…This decline calls into question the mainstream modelling framing and assumptions around treatment as prevention for illness, death and transmission. The recent article on the Optima models from 23 countries is a case in point as the paper is flawed in both its framing and its parameterization of the HIV response [3].The Optima models [3] do not take into account the global 90-90-90 by 2020 or the 95-95-95 by 2030 target [4]. The 90-90-90 target includes 81% of people living with HIV on antiretroviral therapy (ART) or 73% on treatment and virally suppressed [4].…”

“…This decline calls into question the mainstream modelling framing and assumptions around treatment as prevention for illness, death and transmission. The recent article on the Optima models from 23 countries is a case in point as the paper is flawed in both its framing and its parameterization of the HIV response [3].…”

“…The Optima models [3] do not take into account the global 90-90-90 by 2020 or the 95-95-95 by 2030 target [4]. The 90-90-90 target includes 81% of people living with HIV on antiretroviral therapy (ART) or 73% on treatment and virally suppressed [4].…”