About the Author: Charles Holmes serves as the Chief Medical Officer at the Office of the U.S. Global AIDS Coordinator.
On February 10, U.S. President's Emergency Plan for AIDS Relief (PEPFAR) convened a forum on "PEPFAR's Smart Investments to Save More Lives: Efficiencies, Innovation, Impact" at the World Bank in Washington, DC. The meeting was part of an ongoing discussion with leaders in government, civil society, and business about how the global community can work together to become more efficient and achieve greater impact in the global fight against HIV/AIDS.
Ambassador Eric Goosby, the U.S. Global AIDS Coordinator, opened the meeting. In his remarks, Ambassador Goosby discussed how PEPFAR is systematically addressing efficiency and impact at all levels of the HIV response, from the site and intervention, to program level, to national and broader systems levels.
The opening panel looked at how PEPFAR's support of country ownership through Partnership Frameworks and other high-level coordination has helped us become more effective in saving lives. PEPFAR Partnership Frameworks provide a five-year joint strategic framework for cooperation between the U.S. Government, the partner government, and other partners to combat HIV/AIDS. The Frameworks place a particular focus on cooperation around service delivery, policy reform, and coordinated financial commitments. Joining us were government colleagues from Botswana and South Africa, who discussed how Partnership Frameworks and related strategic coordination have helped align country goals and PEPFAR goals, clarifying roles for each partner. This coordination has led to sustainable cost savings. Officials from the South African Department of Health and Ministry of Finance described how a one-time, additional $120 million PEPFAR investment in competitively priced antiretroviral drugs helped launch national drug procurement reforms that will save the South African Government over $600 million over the next two years. This was an example of how strategic U.S. investments are continuing to expand treatment access, while enabling partner governments to move farther down the road toward sustainability. In fact, the South African Government officials expressed confidence that they will be able to support their HIV program with purely domestic resources by the year 2016.
Three other key themes emerged from the conference: first, using data to drive efficiency; second, integrating services to drive improved programmatic success and impact; and third, harnessing new innovations and technologies to save more lives with less.
Under PEPFAR, we are accelerating the collection and use of cost and expenditure data. Building on five years of intensive costing studies on antiretroviral treatment, we are working to identify efficiencies in quality care and treatment service delivery models. Dr. Sydney Rosen of Boston University explained how PEPFAR programs are achieving cost savings by caring for stable patients at lower-level health facilities and through nurse-initiated HIV treatment in South Africa and Zambia. PEPFAR is also supporting efforts to use costing data in projection models that allow policymakers to weigh the implications of various policy choices. In 2009, a PEPFAR-funded model developed by Rosen's group and the South African Government projected that by lowering HIV drug costs and allowing nurses to initiate HIV treatment, South Africa could afford to move to new HIV treatment guidelines that would increase the numbers eligible for treatment. This rapidly led to a policy decision by the government to move to the new guidelines, and South Africa now treat pregnant women and those with TB earlier, saving more lives now while saving on costlier treatments later on. With PEPFAR support, the country now has over 1.3 million people in its treatment program -- by far the world's largest.
Presenters at the meeting described how PEPFAR has also recently pioneered efforts to analyze program spending at the country and partner level, comparing the amounts we spend with the output of each program, e.g., cost per person retained in care and on treatment at one year, in prevention, care, and treatment. We are moving quickly to make this a routine PEPFAR-wide activity and are working closely with Global Fund and multilateral colleagues to better understand how this can serve national programs. This work will put better financial information in the hands of PEPFAR and partner government program managers and decision-makers.
Programmatic innovations, such the strategic integration of TB and HIV services, are also amplifying the impact of PEPFAR's investments. TB is a leading cause of HIV deaths worldwide, and as we heard from colleagues working in Rwanda, PEPFAR, and the Government's work in that country has driven the integration of TB and HIV services. Nearly all of the district hospitals and a majority of health centers nationwide now offer both TB and HIV services, and a study of over three-quarters of HIV treatment clinics nationwide found that 90 percent of HIV-positive patients were screened for TB. This integration yields great clinical and efficiency benefits for individual patients suffering from both diseases, as well as efficiencies for the program as a whole. Further research is needed to better understand the cost implications of these programmatic efficiencies, and this will be a critical priority of our implementation science agenda.
PEPFAR is also making smart investments by increasing investments in new technologies and interventions. With an upfront investment of about $1 billion to rapidly scale up male circumcision, a highly effective HIV prevention intervention, to an 80 percent coverage level, we learned that we could prevent about 20 eprcent of new HIV infections in East and Southern Africa, and save an estimated $20 billion in long-term care and treatment costs.
Significant cost savings have also been seen in HIV treatment programs. A presentation by the Supply Chain Management System, an organization established by PEPFAR and managed by USAID, noted that antiretroviral drugs purchased through that mechanism for PEPFAR are now over 98 percent generic. This is an amazing achievement that has saved us over $380 million dollars in 2010 alone -- meaning we can provide treatment to more people and save more lives. This system has also saved millions of dollars by moving HIV drugs and other supplies by sea and overland routes rather than by air. These savings can be reinvested in programs and supplies, again saving more lives.
On Friday, PEPFAR and the guests shared these messages to the U.S. Congress, meeting with staff to discuss our efforts to ensure maximum impact and efficiency from each dollar the American people entrust to us.
PEPFAR is in the late stages of developing a comprehensive strategic plan to further accelerate these gains in efficiency and impact. Going forward, PEPFAR will continue to aggressively pursue the smart investments highlighted in these meetings -- and others -- with the goal of becoming more efficient and increasing our impact to save more lives.