using modelling to inform our diagnostics strategy
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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
© 2011 Bill & Melinda Gates Foundation |
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
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© 2011 Bill & Melinda Gates Foundation |
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:
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© 2011 Bill & Melinda Gates Foundation |
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
© 2011 Bill & Melinda Gates Foundation |
GoalOutcome
Improved coverage
Reduced exposure
Reduced transmission
(given exposure)
Reduced disease burden (given
infection)
6
What happens as a result of our (collective) action
Activities
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
Where most national & international actors focusExogenous?Where the foundation can act
© 2011 Bill & Melinda Gates Foundation |
Investment Principles
Take risks and fill gaps where others won’t play
Maximize leverage
Maximize flexibility
Exploit comparative advantage
7
© 2011 Bill & Melinda Gates Foundation |
GoalOutcome
Improved coverage
Reduced exposure
Reduced transmission
(given exposure)
Reduced disease burden (given
infection)
8
Activities
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
$$$$$$$$$$
© 2011 Bill & Melinda Gates Foundation | 9
© 2009 Bill & Melinda Gates Foundation |
GoalOutcome
Improved coverage
Reduced exposure
Reduced transmission
(given exposure)
Reduced disease burden (given
infection)
2
HIV Theory of ActionActivities
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
ase
life e
xp
ec
tan
cy 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
Generatedemand
Deliver services
•population•providers
Changed behavior
Input costs
Discover, develop, refine
tools
Enabling Environment
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
© 2011 Bill & Melinda Gates Foundation |
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
© 2011 Bill & Melinda Gates Foundation |
11
The cost of providing HIV treatment in PEPFAR-supported programs
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Menzies et al AIDS 2011
© 2011 Bill & Melinda Gates Foundation |
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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
© 2011 Bill & Melinda Gates Foundation |
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.
© 2011 Bill & Melinda Gates Foundation |
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
© 2011 Bill & Melinda Gates Foundation |
No CD4 Central CD4 POC CD40
2000
4000
6000Life-years saved
No CD4 Central CD4 POC CD40
5
10x 10
5 Cost ($)
No CD4 Central CD4 POC CD4120
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.)
© 2011 Bill & Melinda Gates Foundation |
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Prediction of the Impact of Potentially Newly Available Diagnostic and Monitoring Tools
© 2011 Bill & Melinda Gates Foundation |
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
© 2011 Bill & Melinda Gates Foundation |
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
© 2011 Bill & Melinda Gates Foundation |
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;
© 2011 Bill & Melinda Gates Foundation |
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
© 2011 Bill & Melinda Gates Foundation |
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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
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© 2011 Bill & Melinda Gates Foundation |
EVERY PERSON DESERVES THE CHANCE TO LIVE A HEALTHY, PRODUCTIVE LIFE.
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