Estimated Impact of HIV Prevention Budget Cuts for Selected Jurisdictions in California

Feng Lin, PhD; Arielle Lasry, PhD; Annette Ladan, MS; Stephanie Sansom, PhD

National HIV Prevention Conference August 14-17, 2011

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention

Objective
Develop a tool that state and local health departments can use to measure the impact of HIV prevention budget cuts on their jurisdictions

To examine the effect of budget cuts on people living with or at risk for HIV To estimate the impact of the budget cuts on HIV incidence To compare different budget allocation scenarios

Budget and Program Data

Data on selected jurisdictions were provided by the California State Office of AIDS
Included jurisdictions that did not receive direct funds from CDC Excluded Los Angeles and San Francisco

Type of data
Federal and state HIV prevention budgets administered by the Office of AIDS Number of local agencies that received HIV prevention funds Number of clients served
Number of positives who received test results Number of unique clients of health education and risk reduction (HERR) services

HIV Prevention Budget Allocated by Prevention Activities

Pre-cut scenario 21%

70%

* LA and SF excluded

Testing and Partner Services

* LA and SF excluded

Health Education and Risk Reduction (HERR)

* LA and SF excluded

Summary of Prevention Services

Pre-cut &: FY0506-FY0708 Total prevention budget Funded local health jurisdictions Funded prevention agencies $21,849,923 59 143 # $4,024,634 83,799 813 FY0910 $5,860,723 15 36 $3,160,148 52,590 465 Reduction (%) $15,989,200 (73) 44 (75) 107 (75) $864,486 (21) 31,209 (37) 348 (43)

Testing and partner services

Budget Number of tests performed Number of positives notified of test result

Health education and risk reduction (HERR)

Budget Number of unique clients Number of unique positive clients Number of unique negative clients $17,825,289 11,784 2,884 8,900 $2,700,575 3,386 1,100 2,286 $15,124,714 (85) 8,398 (71) 1,784 (62) 6,614 (74)

* LA and SF excluded & We took the average values from FY0506 to FY0708 for the pre-cut scenario. # Number of funded local prevention agencies was not available in FY0506 and FY0607.

Methods
Estimate the number of new infections associated with the budget cuts
Prevention service reduction Number of clients served (pre-cut scenario) Number of clients served (FY0910) Estimate HIV transmission: Bernoulli process model
Testing and partner services Health education and risk reduction (HERR)

Compare different budget allocation scenarios

Summary of Inputs to Bernoulli Model

Parameter Per-act transmission probability Vaginal receptive Vaginal insertive Anal receptive Anal insertive Condom effectiveness Annual nb. of sex acts all partners Annual nb. of sexual partners HET IDU MSM ART effectiveness (reduction in infectivity) Proportion new diagnosis among positives who received test results 1.1 (1-20) Long et al. Ann Intern Med 2010; 153(12):
778-89 3 (1-20) Metsch et al. NHPC2007 3.5 (1-20) NHBS

Value (Range)

Source

0.08% (0.060.11%) Boily et al. Lancet Infect Dis 2009; 9(2): 1180.04% (0.010.14%)
29.

1.40% (0.22.5%) Baggaley et al. Int J Epidemiol 2010; 39(4): 0.70% (0-1.3%)
1048-63.

90% (8595%) Pinkerton et al. Soc Sci Med 1997; 44(9):

1303-12 85 (26-365) Long et al. Ann Intern Med 2010; 153(12): 778-89

90% (80-99%) Attia et al. AIDS 2009; 23:1397-1404. (Bunnell

et al. Del Romero et al. Donnell et al.)

60% (40-80%) Hanna et al. JAIDS 2009; 51(5): p. 609-14.

ETI data

Summary of Inputs to Bernoulli Model (cont)

Parameter
HIV prevalence in California HET IDU MSM Proportion of protected sex acts Undiagnosed positives & those at risk Positive aware w/o particip ating in HERR Reduction in UAV for positive aware people Effect size of HERR for positives 1.0%(0.751.25%) CDC 2001 5.9%(410.2%) Friedman et al. J Urban Health 2005;
82(3): 434-45 19.1%(12.825.35%) Xia et al. JAIDS 2006; 41(2): 238-45

Value (Range)

Source

50% (0-100%) Gary Marks 75% (50-100%) Gary Marks 53% (45-60%) Marks et al. JAIDS 2005; 39(4): 446-53. 18% (0-40%) Options/Opciones Project,WiLLOW,
Healthy Living Project, Healthy Relationships, CLEAR

Effect size of HERR for negatives Proportion linked to care Proportion of positive aware in care who achieve viral load suppression

8% (0-20%) INSIGHT,Focus on the Future, Sister to

Sister

69% (66-71%) Marks et al. AIDS 2010; 24(17): 2665-78. 54.5% (40-70%) Marks et al. AIDS 2006; 20: 1447-50.

Estimates of Budget Cut Impact

Testing and partner services Budget cut ($) Estimated number of new infections associated with budget cuts HET IDU MSM Total Expected life-time HIV treatment cost generated Number of new infections per one million dollars cut 1.4 0.3 24.9 26.6 $ 9,760,335 1.9 0.3 37.2 39.4 $ 14,476,414 3.3 0.6 62.1 66.0 $ 24,236,749 $ 864,486 Health education and risk reduction (HERR) $15,124,714 Total

$15,989,200

30.75

1.92

4.13

* LA and SF excluded

Compare Budget Allocation Scenarios

Hypothetical pre-cut allocation scenario Total prevention budget Testing and partner services Health education and risk reduction (HERR) Number of local health jurisdictions funded Number of positives notified of test result Number of unique HERR clients Number of unique positive HERR clients Number of unique negative HERR clients Estimated number of infections associated with cuts Testing and partner services HERR for positive HERR for negative Expected life-time treatment cost generated
* LA and SF excluded

Actual allocation in FY0910 $5,860,723 (100%) $3,160,148 (54%) $2,700,575 (46%) 15 465 3,386 1,100 2,286 66.0 26.6 29.0 10.4 $ 24,236,749

$5,860,723 (100%) $1,079,512 (18%) $4,781,211 (82%) 59 159 5,995 1,467 4,527 88.4 58.9 22.2 7.2 $ 32,439,520

Limitations
We did not include Los Angeles and San Francisco because data for the two jurisdictions were incomplete. Only the first generation of transmissions were captured in the impact estimates. We assumed the reductions in prevention services were the same proportionately across risk groups. Data inputs for Bernoulli model had varying degrees of uncertainty. These were covered in sensitivity analyses.

Conclusions
Over $15 million was cut from HIV prevention in FY0910
Testing: we estimated 31,209 fewer tests were performed, 384 fewer positives were notified of their infection Health education and risk reduction (HERR): 1,784 fewer positive clients and 6,614 fewer negative clients were served

Impact of budget cuts in FY0910

Estimated 66 new infections were associated with the cuts in one year The first year new infections were expected to generate $24 million in HIV life-time treatment cost

Budget allocation in FY0910 appeared to partially reduce the impact of budget cuts
Allocate larger proportion of budget to testing Fewer new infections would occur

* LA and SF excluded

Acknowledgements
Richard Wolitski, Choi Wan, Jeffrey Brock, Robert Swayzer, Dale Stratford, Dwight Dunbar; Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention Michelle Roland, Susan Sabatier, Karen Mark, Kevin Sitter, David Webb, Christine Nelson, Karen Doran, Charlene Anderson, Brian Lew, Phillip Morris, Matt Facer, Amy Kile-Puente, Mark Damesyn, Schenelle Flores; Office of AIDS, California Department of Public Health

Questions?

For more information please contact: Feng Lin (Flin@cdc.gov) Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: http://www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention