why high-quality population size estimates of key populations are important

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WHY HIGH-QUALITY POPULATION SIZEESTIMATES OF KEY POPULATIONS AREIMPORTANT

David WilsonHNP - GP World Bank

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‘We Have Run Out Of Money; Now We Have to Think’

W.S. Churchill

Joint Program Competencies as Pillars of Strategic Planning

• Multisectoral approach

• NSP3G guidance• Allocative efficiency

studies

• Service delivery solutions

• Program efficiency • Impact evaluation

• Multisectoral approach

• Evidence for strategic planning

• Epidemic appraisal

• Fiscal space analysis• Sustainable financing

research• Investment cases

Sustain Understand

DesignDeliver

What Does Success Look Like?India Joint Program Example

Understandthe epidemic

Design:Implementation

efficiency Deliver:Effectiveness

Sustain:Sustainability

Understand:Allocative Efficiency

70% of transmission sex work in 4 states

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UNDERSTAND

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Prevalence of Injecting Drug Use

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Prevalence of HIV among PWID

What we knowInaction is costly, and not the equivalent of nothing happening; It is hard to reverse epidemic once established

Whereas harm reduction is - Effective - in terms of HIV cases averted - Cost-effective - in terms of healthy years

gained and costs - Social benefits exceed treatment costs- And benefits the whole population

What is the global coverage of harm reduction services?

Source: Authors’ literature review and estimates, using Mathers et al. 2010

Few PWID access all three priority interventions

Female PWID far lower access than males

An estimated 10% access NSP

About 14% of HIV+ PWID

access ART

An estimated 8% access OST

How much is spent on harm reduction?

Sources: Stimson et al 2010 (three cents report), UNAIDS 2009; UNAIDS Progress report 2012; Global State of Harm Reduction, 2012; Bridge et al 2012

Estimated $160 million in LMIC in 2007 (3 cents per PWID per day): 90% from international donors

Global Fund largest HR funder (estimated $430 million 2002-2009) > 50% to Eastern Europe and Central Asia

How much is needed to scale up priority harm reduction interventions?

NSP coverage

(%)

Needles / PWID /year

OST uptake

(%)

ART uptake of HIV+ PWID

(%)Current estimated level 10 22 8 14Scenarios: Mid target 20 100 20 25 High target 60 200 40 75

Very preliminary resource estimates based on regional estimates of current NSP /OST /ART coverage, population sizes and unit costs

Mid and high target scenarios costed

Summary: Estimated annual cost of scale-up of NSP, OST and ART for PWIDs

Mid target20% NSP coverage20% OST coverage25% ART coverage

High target60% NSP coverage40% OST coverage75% ART coverage

South, East & South East Asia 527M 1,49B

Latin America & Caribbean 625M 1,47B

Middle East & North Africa 26M 55M

W- Europe, N- America & Australasia 17M 1,19B

Eastern Europe & Central Asia 1.04B 2,51B

Sub-Saharan Africa 414M 901M

Total per year 2,65B 7,62B

1: Mathers et al, Lancet (2010) 2: Scale-up calculations by UNSW

Annual scale-up costs by region and intervention

Costs dominated by Eastern Europe and Central Asia

E-Europe & C-Asia 38%

SSA16% S, E & SE

Asia20%

LA & Caribbean

24%

W-Europe, N-America & Australasia

1%M-East & N-

Africa1%

1: Mathers et al, Lancet (2010) 2: Scale-up calculations by UNSW

Cost-effectiveness and relative return on investment ranges by region

() number of studies in literature

Western Europe, North America & Australasia

CE1:ROI2:

$402-$34,278 (9)$1.1-$5.5 (3)

Sub-Saharan Africa

Eastern Europe & Central Asia

The Middle East & North Africa South, East & South East Asia

Latin America & The Caribbean

CE1:ROI2:

$97-$564 (3)$1.4 (1)

CE1: $1,456-$2,952 (1) CE1:ROI2:

$71-$2,800 (7)$1.2-$8.0 (4)

1: Cost per HIV infection averted 2: Total future return per $1 invested (3% discount rate)

Harm Reduction Data Challenges

• Limited population size estimates• Inconsistent service quality data• Surveys miss hidden populations• ATS increasingly used and injected but

missed in surveys• Significant but undocumented scale-down of

services

Sources: UNGASS country progress reports 2012; Mathers et al., 2010; Global State of Harm Reduction, 2012

Why we need reliable estimates of the size of populations at high risk

Policy- Advocacy- Response planning and resource allocation- Estimates number of infected with HIV and

projections of the burden diseaseProgramming- Intervention planning- Measurement of coverage- M & E interventions

Adjust for SW mobility with mathematical model to reduce double-counting of SW frequenting multiple spots

Regression modelling to generate province-wide SW population size estimates from the towns mapped, with lower and upper bounds and

Define Population Size and Program TargetsPopulation Size Estimation with Modeling to Improve Estimates

Know Your Epidemic: Epidemic, Response and Policy Syntheses