using modelling to inform our diagnostics strategy

Using modeling to inform our diagnostics strategy

July 18, 2011

Christine Rousseau, Ph. D.

© 2011 Bill & Melinda Gates Foundation |

Our Areas of Focus

2

25%United States Program

50%Global Health Program

25%Global Development Program

April 13, 2023


3

Our Approach to Giving

STEP ONE: Develop Strategy

STEP TWO: Make Grants

STEP THREE: Measure Progress

STEP FOUR: Adjust Strategy

1DevelopStrategy

2MakeGrants

3MeasureProgress

4AdjustStrategy

April 13, 2023


The Importance of Advocacy

4

President’s Emergency Plan for AIDS Relief Commitment in 2008: $6 billion

Foundation HIV/AIDS grant total in 2008:$343 million

$6B <6%of President’s Emergency Plan for AIDS Relief commitment

Our money alone can’t fix these problems. Consider:

April 13, 2023


GoalOutcome

Improved coverage

Reduced exposure

Reduced transmission

(given exposure)

Reduced disease burden (given

infection)

5

HIV Theory of ChangeActivities

Plan Execute

Political will

Social & structural conditions

Synthesize knowledge

Research delivery

(efficiency & effectiveness)

Pro

gre

ss

ive

ly a

nd

su

sta

ina

bly

red

uc

e th

e in

cid

en

ce

of

HIV

an

d in

cre

as

e life

ex

pe

cta

nc

y fo

r tho

se

livin

g w

ith H

IV

Funding and financing

mechanisms

Optimize resource allocation

among interventions

Optimize targeting

Generate tools & knowledge

Impact

R&D and health

infrastructure

Generate demand

Deliver services

• population• providers

Changed behavior

Input costs

Discover, develop, refine

tools

Enabling Environment


GoalOutcome

Improved coverage

Reduced exposure


(given exposure)


infection)

6

What happens as a result of our (collective) action

Activities

Plan Execute

Political will



Research delivery


Pro

gre

ss

ive

ly a

nd

su

sta

ina

bly

red

uc

e th

e in

cid

en

ce

of

HIV

an

d in

cre

as

e life

ex

pe

cta

nc

y fo

r tho

se

livin

g w

ith H

IV


mechanisms


among interventions

Optimize targeting


Impact

R&D and health

infrastructure

Generate demand

Deliver services


Changed behavior

Input costs


tools


Where most national & international actors focusExogenous?Where the foundation can act


Investment Principles

Take risks and fill gaps where others won’t play

Maximize leverage

Maximize flexibility

Exploit comparative advantage

7


GoalOutcome

Improved coverage

Reduced exposure


(given exposure)


infection)

8

Activities

Plan Execute

Political will



Research delivery


Pro

gre

ss

ive

ly a

nd

su

sta

ina

bly

red

uc

e th

e in

cid

en

ce

of

HIV

an

d in

cre

as

e life

ex

pe

cta

nc

y fo

r tho

se

livin

g w

ith H

IV


mechanisms


among interventions

Optimize targeting


Impact

R&D and health

infrastructure

Generate demand

Deliver services


Changed behavior

Input costs


tools


$$$$$$$$$$

© 2011 Bill & Melinda Gates Foundation | 9


GoalOutcome

Improved coverage

Reduced exposure


(given exposure)


infection)

2

HIV Theory of ActionActivities

Plan Execute

Political will



Research delivery


Pro

gre

ss

ive

ly a

nd

su

sta

ina

bly

red

uc

e th

e in

cid

en

ce

of

HIV

an

d in

cre

ase

life e

xp

ec

tan

cy fo

r tho

se

livin

g w

ith H

IV


mechanisms


among interventions

Optimize targeting


Impact

R&D and health

infrastructure

Generatedemand

Deliver services

•population•providers

Changed behavior

Input costs


tools


Focus of BMGF investments (historical)

Focus of BMGF investments (future)

1 2 4

3

3

3

3 6

5 7

Vaccines

ARV-based Prevention

Efficiency & Effectiveness (E2)

Diagnostics

Male Circumcision

TB/HIV

Prevention implementation

Our Theory of Action identified 7 strategic initiatives

1234

567


Number of people (all age groups) receiving and needing antiretroviral therapy, and percentage coverage in low- and middle-income countries by region, 2008 to 2009

Source: Towards universal access; Progress report 2010; UNAIDS, WHO


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The cost of providing HIV treatment in PEPFAR-supported programs

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Menzies et al AIDS 2011


12April 13, 2023

Diagnostics for HIV

Treatment 2nd line

HIV rapid tests Haematology Biochemistry Opportunistic infections (TB, crypto, etc) STDs Other infections (sepsis, leish, schisto) CD4 Viral load Drug resistance Adherence monitoring

Detection of infection

Which tests?When to use?Impact on individual?Impact on epidemic?

HIV Synthesis transmission model

Andrew Phillips1, Valentina Cambiano1, Alec Miners2, Diane Bennett1, Deenan Pillay1, Geoff Garnett3, Marco

Vitoria1, Tim Hallett3, and Jens Lundgren4

1UCL, London, UK, 2LSHTM, London, UK, 3Imperial College, London, UK and 4Universitty of Copenhagen,

Denmark


Additional variables updated over time

Years from 1985

1985 1985.25 1985.5 1985.75 1986.00 1986.25

e.g.Calendar dateInfection with HIVSexual risk behaviour:- Long term partnership status- Number of new partners

HIV transmission synthesis model: Heterosexual epidemic in southern Africa

Creates a ‘dataset’ of the lifetime experiences of ~50,000 people in apopulation, aged over 15.


Number of new partners

Gender

Risk of HIV infection in uninfected subject

Probability ofHIV infection

Long term partner HIV+

Number of newpartners who are

HIV+

Number of new partnerships formed

by HIV+ people Current viralload of infectedpartner

Subject

ConcurrentHIV+ population

Incidence and prevalenceof HIV in people with

long term partnerships

Longterm partnership

status

Age

Risk of infection also depends on current STI


No CD4 Central CD4 POC CD40

2000

4000

6000Life-years saved


5

10x 10

5 Cost ($)


140

160

180Cost per life-year saved

-$25 per life-year

+65% per life-year cf no CD4

+11% per life-year cf central CD4

Hallett et al (personal comm.)


17April 13, 2023

Prediction of the Impact of Potentially Newly Available Diagnostic and Monitoring Tools


Assumption of % of people with CD4 count access

central lab device- device-freedependent

No change 40% 0% 0%

Device-dependent only 40% 30% 0%scenario

With device-free 40% 30% 20%scenario*

* Thus, we assume availability of a device-free test would result in 20% more people having CD4 available by 2018, because it can be used in more remote areas. - All measures assumed to be equally accurate


Incremental cost effectiveness ratio (ICER)(quality adjusted and with discounting)of device-free test introduction, according to share of CD4 counts done by a device-free test by 2018

20% (as in main results shown) $ 551

66% $ 301

If device-free coverage expands beyond 20% and takes some of Centralized lab or device-based test share of then introduction becomes more cost-effective since it has a lower unit cost.

If we assume that the CD4 count at initiation of ART remains at 200 throughout (rather than increasing to 350): cost per qaly = $338


AIM: To significantly improve scientific support for decision making by co-coordinating a wide range of research activities in mathematical modelling the HIV epidemic.

HIV Modelling Consortium

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>> Identify questions that demand mathematical modelling input and identify new modeling results

that may require further validation;

>> Facilitate sharing of information, modelling techniques, data and expertise between research

groups.

>> Provide a forum for rigorous review of new mathematical modelling research.

>> Provide funding through sub-contracts to commission research to address those needs;


TheModelling

Consortium

Rapid funding for modelling research prompted by new

developments

Co-ordinate Independent Research for

Efficiency and Cross-validation Work

Accelerate Adoption of

New Technology

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Main Themes


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Questions to address

Which model to select?

Impact on total cost of treatment weighed against impact on the epidemic

How to define scenario?

How to define costs? Take into account implementation costs, volume discounts, transportation costs, etc.

Combination of tests based on decision points

Platform technologies that can apply to multiple tests

April 13, 2023


EVERY PERSON DESERVES THE CHANCE TO LIVE A HEALTHY, PRODUCTIVE LIFE.

23April 13, 2023

using modelling to inform our diagnostics strategy

Health & Medicine

global development program25

global health programaugust

united states program50

aids relief commitment

presidents emergency

areas of focus225

measure progressstep

adjuststrategyour approach