Health and budget impact of combined HIV prevention. S. Vermeersch, hict L. Annemans, UGent

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1 Health and budget impact of combined HIV prevention S. Vermeersch, hict L. Annemans, UGent

2 Outline Context and objectives Modeling approach Model validation Results Conclusions Disclosures The study was performed independently by Sebastian Vermeersch and supervised by Lieven Annemans hict and Lieven Annemans received financial compensation to perform this study as part of a consultancy agreement with Gilead. 2

3 Luxembourg United Kingdom Malta Belgium San Marino Portugal Ireland Spain France Greece West Switzerland Italy Israel Norway Netherlands Denmark Germany Andorra Sweden Iceland Finland Austria Monaco New HIV diagnoses rates per population, by country, in 2014 (West European WHO region) 4th highest! European Centre for Disease Prevention and Control, WHO Regional Office for Europe. HIV/AIDS surveillance in Europe 2014.

4 Context & objectives Can we make a difference? Prevention!? Impact of prevention on Epidemiology Budget 4 4

5 Model scope & terminology Treatment cost only Outreach Treatment as Prevention (TasP) Prevention Pre-exposure prophylaxis (PreP) General prevention Not included 5

6 Modeling approach 6

7 Model mechanics Year # NET LOSS = # Patients in medical follow-up # New HIV diagnoses Entering follow-up # Death + # inflow (re-entering follow-up) - #outflow (lost to follow-up) Year+1? # Patients in medical follow-up

8 Model mechanics # NET LOSS = # Patients in medical follow-up # New HIV diagnoses Entering follow-up # Death + # inflow (re-entering follow-up) - #outflow (lost to follow-up)?

9 Model mechanics # NET LOSS = # Patients in medical follow-up # New HIV diagnoses Entering follow-up # Death + # inflow (re-entering follow-up) - #outflow (lost to follow-up) # unknown # Known, untreated # Treated, VL>200 copies/ml

10 Modeling prevention: Outreach & TasP # NET LOSS = # Patients in medical follow-up # New HIV diagnoses Entering follow-up # Death + # inflow (re-entering follow-up) - #outflow (lost to follow-up) # unknown # Known, untreated # Treated, VL>200 copies/ml Outreach TasP

11 Modeling prevention: PreP # NET LOSS = # Patients in medical follow-up # New HIV diagnoses Entering follow-up # Death + # inflow (re-entering follow-up) - #outflow (lost to follow-up) PreP risk # treated PreP # infections avoided

12 Costs included in the model HIV treatment: /year 1 PreP: 6 328/year (before 2017) 4 929/year (generics & cluster opening 2017) 2 596/year (post 2017) 1 Vandijck et al.,

13 Additional principles (Sub)population differences MSM, hetero, PWID Differing infectiousness Undiagnosed, diagnosed but untreated, treated and VL>=200 HIV infections in migrants occurring prior to migration Effect of aging HIV population 13

14 Model validation 14

15 Model validation - Actual vs estimated # patients in medical follow-up # new HIV diagnoses Adults in medical follow-up (Actual) New diagnoses (actual) Adults in medical follow-up (estimated) New diagnoses (estimated)

16 Results 16

17 Epidemiology 17

18 New HIV diagnoses in the absence of additional prevention effort 3% reduction in % undiagnosed (13% -> 10%) 3% increase in % patients on ART (89% -> 92%) +21%

19 New HIV diagnoses - TasP 3% reduction in % undiagnosed (13% -> 10%) 7% (+4%) increase in % patients on ART (89% -> 96%) Old world New world -12% +6%

20 New HIV diagnoses - Outreach % (+5%) reduction in % undiagnosed (13% -> 5%) 3% increase in % patients on ART (89% -> 92%) Old world New world -28% -41%

21 New HIV diagnoses - PreP 3% reduction in % undiagnosed (13% -> 10%) 3% increase in % patients on ART (89% -> 92%) patients treated with PreP (90% MSM) Old world New world -14% +5%

22 New HIV diagnoses Combined prevention % -60% Old world New world

23 Budget 23

24 MILIONS 260 Total budget in the absence of additional prevention %

25 MILLIONS 8 Budget impact - TasP 6 4 3,1 4,3 5,4 6,4 5,7 5,0 4,3 3,5 2,7 2 1,7 1,8 0,9 0-0, ,9-1,9-3,

26 MILLIONS Budget impact - Outreach 2,4 3,8 4,7 5,1 4,9 1,9 - -1,2-4,3-7,6-10,9-14,3-17,9-21,5-25,2-29,1-33,

27 MILLIONS 6 Budget impact - PreP ,6 2,5 3,4 4,1 4,6 3,4 2,2 1,0-0,3-2 -1, ,9-4,3-5,6-7,

28 MILLIONS Budget impact Combined prevention 11,5 12,8 14,3 11,1 4,1 6,9 7,6 2,4 - -2,9-8,3-13,8-19,4-25,2-31,0-37,0-43,

29 MILLIONS 260 Total budget Combined prevention % Old world New world

30 Conclusions 30

31 Conclusions Can we make a difference?? Impact of prevention on Epidemiology Budget 31 31

32 Conclusions Can we make a difference? Yes, we can! Not investing in prevention = not an option! new diagnoses total budget Added value of combined prevention: new diagnoses total budget 32 32

33 New HIV diagnoses and rates per population, by country, in 2014 (West European WHO region) Luxembourg United Kingdom Malta Belgium San Marino Portugal Ireland Spain France Greece West Switzerland Italy Israel Norway Netherlands Denmark Belgium (2) Germany Andorra Sweden Iceland Finland Austria Monaco

34 Acknowledgements Acknowledgements Prof.Dr. Goffard Prof.Dr. Laga Prof.Dr. De Wit Prof.Dr. Callens Dr. Van Beckhoven Contact Sebastian Vermeersch Lieven Annemans 34

35 Data sources Main data source: WIV-ISP. Epidemiologie van aids en hiv infectie in België. Toestand op 31 december Additional references: Smit et al. Future challenges for clinical care of an ageing population infected with HIV: a modelling study. Lancet Infect Dis 2015;15: Skarbinsky et al. Human immunodeficiency virus transmission at each stage of the care continuum in the United States. JAMA Intern Med 2015; 175(4): Zheng et al. HIV acquisition post-migration. Evidence from four European Countries. Poster at the 21st International AIDS Conference (AIDS 2016). Grant et al. Preexposure Chemoprophylaxis for HIV Prevention in Men Who Have Sex with Men. N Engl J Med 2010; 363: Thigpen et al. Antiretroviral Preexposure Prophylaxis for Heterosexual HIV Transmission in Botswana. N Engl J Med 2012; 367: Choopanya et al. Antiretroviral prophylaxis for HIV infection in injecting drug users in Bangkok, Thailand (the Bangkok Tenofovir Study): a randomised, double-blind, placebo-controlled phase 3 trial. The Lancet 2013; 381: