HIV/AIDS Funding in Namibia in 2020: Epidemiological Models using Stata

I wrote this analysis for a course called Financing Aids to Zika in LMICs that I took as part of my Health and the Public Interest master’s program. For the assignment, I used AIDSCost with Stata statistical software to model AIDS/HIV spending scenarios for Namibia. NOTE: This paper was written before the COVID-19 pandemic and does not reflect shifting spending priorities.

Background and Burden of Disease

        Namibia is located in the southwestern part of Africa and ranks 35th of all countries in the world for landmass. The country’s 2.5 million citizens are unevenly settled throughout this large area, with roughly half clustered in rural areas in the northeast of the country and half living in urban areas (1). This low population density creates challenges for healthcare accessibility in rural areas and contributes to an uneven distribution of the disease burden. Additionally, rural-urban migration is substantial, and there are growing numbers of informal settlements around cities and towns. These settlements present new difficulties with maintaining hygiene and sanitation, and it is difficult to reach these populations with public health initiatives. Changing demographic patterns are impacting all aspects of healthcare access and remain a challenge for health outreach efforts.

Communicable, neonatal, and nutritional diseases make up the largest share of Namibia’s disease burden (2). These categories of diseases are slowly declining, and non-communicable disease (NCD) burdens are growing. However, HIV/AIDs, neonatal disorders, lower respiratory infections, and tuberculosis remain particular challenges for shifting the burden of disease. Namibia’s disease burden increasingly reflects the “double burden” of communicable and non-communicable disease seen in many middle-income African economies (3). This double burden is predicted to be a growing strain on the country’s health systems and health funding in the future (4).

HIV/AIDs is the largest contributor to Namibia’s disease burden and comprised 25.01% of total DALYs in 2017. The country has one of the highest HIV/AIDS prevalence rates in the world at 11.8% (5). The burden posed by HIV is easy to perceive in GDB Compare visualization (Fig. 1) due to the large area covered by the disease and the deep red color illustrating a positive rate of change in HIV disability-adjusted life years (DALYs).

Fig 1. The burden of Disease for Namibia

Namibia’s government has made great progress in slowing the progression of HIV/AIDS since implementing its National Strategic Framework on HIV in 2017 (6). The framework identified a combination of interventions targeting behavioral, biomedical and structural drivers of the epidemic. These interventions include a Fast-Track approach to identifying areas of high impact, index partner testing, community-based treatment models, and support for key populations. The Ministry of Health and Social Services (MHSS) also attributes progress in expanding treatment coverage to a strong partnership with PEPFAR and the Global Fund (7). These efforts resulted in a sharp increase in ART uptake rates (60% in 2018), and the country is close to reaching the UN 90-90-90 goals by 2020. These rapid improvements have generated much media attention and global commendation (8, 9). However, populations of young women 15-24 remain under-treated, and adherence has proven difficult among children and adult men. These barriers may slow progress towards the 90-90-90 targets (10). ART coverage by age and sex is lowest among males 20 to 34 years of age and females 15 to 24 years of age.

Progress Towards Universal Health Coverage

Universal Health Coverage (UHC) is defined by the World Health Organization (WHO) to be achieved when “…all people obtain the health services they need without suffering financial hardship when paying for them” (11). UHC also entails equity in access to health services and the quality of health services. Namibia faces challenges achieving UHC due to high-income inequality (Gini coefficient of 0.572), geographic barriers to access, and rapid urbanization (12). Over the past 30 years, Namibia has grappled with inequities in financial and political power left by a political history of apartheid rule. As a consequence of pre-independence colonial policies, a large portion of wealth and agricultural land ownership is concentrated among mostly white, German-speaking citizens, and foreign investors (13). These inequities also impact population distribution and consequently, healthcare access. The country faces stark inequalities between those citizens who have access to a highly modernized private health system (15-16 %), and those who rely on an overstretched public health system (84-85%) (14). Citizens in rural areas may have difficulties regularly reaching clinics and face shortages of qualified medical staff. Those in quickly-built urban settlements face persistent sanitation issues.

In spite of these challenges, household expenditures on health fall well below the level indicative of catastrophic health expenditures, indicating some success in the financial equity component of UHC (15). Health insurance schemes facilitate healthcare access for many Namibians, but there are inequalities in who receives coverage through these schemes. Total Health Expenditure (THE) is unevenly distributed, and 36% of THE  goes towards health insurance that covers less than one-fifth of the population (16). Recent analyses have found that women and the less wealthy are disproportionately uninsured (15). These inequities in health insurance coverage suggest that additional financial resources may be necessary to achieve UHC.

Namibia’s HIV/AIDS Fast-track success may provide some inspiration for measures that will move the country closer to UHC. To overcome challenges with reaching dispersed populations, health officials implemented a decentralized ART treatment model by investing in mobile clinics to reach patients in remote locations. Patients in rural areas were also given access to larger supplies of treatment to reduce the need for frequent appointments. Health care providers created community support groups that enabled experienced patients to assist new patients with learning appropriate treatment routines to improve compliance (17). The health system also invested in a nationwide electronic health record system to better gather treatment data. This data allows providers to spot compliance issues as soon as they occur (18). These innovations were driven by the HIV/AIDS epidemic, but they may improve access to additional forms of care for rural populations. HIV treatment strategies have spurred positive steps towards UHC.

Health Funding Structure

Healthcare in Namibia is funded through government funds, citizen out of pocket expenditures, and donor support. The most recent Health Accounts Report was published in FY 2014/2015 (16). Total health expenditure (THE) at that time was N$12,067,742,100 (US$1,329,046,487), 64% of which was provided by the Namibian Government. THE made up around 13% of government expenditure for the fiscal year. Donors represented 6% of financing in 2014/2015, as seen in Table 1. below.

Table 1. Key Health Accounts Findings

HIV Funding

The most recent government analyses of HIV/AIDS spending cover the financial years of  2015/16 and 2016/17 and draw on data from the Health Spending Accounts (19, 20). The data indicate that 64 percent of the HIV response was financed domestically in 2016/17, a 2% increase over 2015/16. HIV receives a greater share (13 percent) of national health spending than any other disease. The largest source of domestic financing for the epidemic over the two years was the Government of Namibia. As illustrated in Figure 2. below, domestic financing of the HIV/AIDS  response has increased over the past several years, as donor contributions have fallen from 54 percent in 2012/13 to 36 percent in 2016/17 (21).

Figure 2. Trends in sources of funding for HIV/AIDS expenditures, 2012/13 – 2016/2017

The MoHSS is especially committed to funding HIV commodities and medicines. In a 2018 media interview, former Minister of Health Dr. Bernard Haufiku claimed “we don’t get donor money to buy antiretroviral treatment, it comes from our budget”(7). Donor support (primarily from PEPFAR and the Global Fund) is used for health systems maintenance, staff training, public health outreach, and health facilities expansion. Training and funding of qualified health staff is a key funding sustainability issue identified by PEPFAR (20).

Namibia is currently in an economic recession, with overall GDP growth falling from 6 percent in 2015 to -0.1 percent in 2018. The recession has led to an overall decline in government spending, which has led to spending limits on hiring new personnel and new budget constraints on program operations for the MoHSS (20). Namibia’s classification as an upper-middle-income country has also led to declining donor support and fewer “soft loans” for developmental projects (22). Donors increasingly expect the government to take responsibility for larger portions of AIDS spending. These limitations are key challenges to consider when planning for sustained HIV progress in the face of reduced donor support. The remainder of this report will explore the cost-effectiveness of several HIV funding scenarios with the aim of identifying budget options that will best prepare MHSS to continue HIV/AIDS treatment progress in the face of declining donor support.

Economic Projections for HIV/AIDS Spending

Baseline Projections

The baseline projection (Fig. 3) replicates historical ART uptake rates as reported by UNAIDS Country Data for Namibia (23). As of 2018, ART coverage is estimated to be at 76% of the HIV-positive population, with a 60% uptake rate. Namibia’s ART coverage has progressed rapidly since implementing an HIV/AIDS acceleration plan in 2015 (10). Although the recent attainment of a 60% ART uptake rate is impressive, this level of uptake is unlikely to be sustainable at current funding levels. The baseline projection assumes a 20% uptake rate as a better estimation of historical uptake. 2018 UNAIDS data also estimates that 3.7% of patients are on second-line treatment. The second line treatment target in the baseline AIDScost projection was lowered from the default value to reflect a more realistic goal based on this rate. The transmission reduction variable (gp) is also lowered in the baseline projection to reflect treatment adherence challenges inherent in treating a geographically dispersed population (10). (See Table 2 for projection variable values).

 Namibia follows the WHO 2016 antiretroviral therapy guidelines, which state that ART should be initiated in all adults with severe or advanced HIV clinical disease or adults with CD4 count of ≤350 cells/mm3 (24). The baseline CD4 initiation threshold in AIDSCost reflects this “treat all” approach. Namibia’s ART coverage has progressed rapidly since implementing an HIV/AIDS acceleration plan in 2015 (25). The plan scaled up HIV testing and treatment efforts with much success;  however, prevention efforts through voluntary male circumcision and condom distribution programs are currently low. As of 2013, 25.5% of men aged 15-49 self-reported being circumcised (26). The circumcision and prevention target variables in the baseline projections reflect these low prevention rates.

        The baseline projection estimates that at historic uptake levels, Namibia will not achieve an HIV/AIDS epidemic control by 2050. New HIV infections, AIDS deaths, and expenditures are all expected to rise. Although the unmet need for ART remains low, focusing on ART coverage alone would not reduce the number of AIDS deaths and new HIV cases. Additional prevention efforts, such as voluntary male circumcision and condom distribution programs, are needed to reduce the incidence of new infections. Without reducing the incidence, the number of AIDS deaths doubles to over 10,000 by 2050, and the number of new infections increases fivefold.

Figure 3. Baseline Projections

High Treatment, No Prevention Projections (Hi-trt)

In spite of current challenges with treatment adherence, maintaining recent gains in ART uptake is possible if the government is willing to commit additional funds to treatment provision. The Ministry of Health currently funds 60% of Namibia’s ART spending, and the government has expressed commitment to maintaining these levels in light of acceleration plan achievements (10). In the high treatment projection (Fig. 4), the ART uptake rate, target second line coverage proportion, and ART initiation threshold are all increased to reflect this investment in treatment expansion. Additionally, the health system’s recently deployed integrated electronic pharmaceutical management system will improve ART adherence tracking among its dispersed  HIV populations (18). The transmission reduction variable is higher than the baseline in the high treatment projection to reflect this technological improvement. For budget planning purposes, it is useful to examine how AIDS spending would progress if funding resources were used exclusively to maintain high levels of treatment and ART uptake. To model this effect in the high treatment, zero prevention projections, all prevention variables are set to zero, with the exception of the target circumcision level. Target circumcision levels are left at baseline to reflect current circumcision rates.

The projection reveals that if the Ministry of Health neglects to invest in preventative services, a high uptake rate and improved treatment efficacy will not be sufficient to control the AIDS epidemic. By 2050, a high uptake rate increases expenditures to $330 million, a $77 million increase over the $253 million baseline 2050 projections. In 2050, high treatment results in 3500 fewer deaths than at baseline and 4,000 fewer new infections. In spite of high treatment coverage, new infections continue to outpace deaths. Investments in preventative care are necessary to maintain the momentum of the initial acceleration effort.

Figure 3. High treatment projections with no investments in prevention

Projections for Recommended Funding Model:

 Medium Treatment, High Prevention Scenario with Vaccination (Med_Trt_w_Prev_and_Vac)

The above models demonstrate that eradicating the AIDS epidemic is not feasible through treatment alone. However, investments in prevention can maintain current treatment levels and slow transmission of the disease. The medium treatment, high prevention projection (Fig. 3) reflects a recent acceleration in ART treatment by doubling the baseline rate of uptake. A rate of 40% uptake balances the achievements of the Fast Track initiative with the likelihood of declining donor support in future years. A 40% uptake rate would be more sustainable than 60% in the face of probably budget restrictions. The medium treatment scenario also reflects expanded investment in prevention programs. These prevention programs largely focus on voluntary adult male circumcision, condom distribution, PrEP for key populations, and health education efforts. These interventions are the most frequently recommended strategies for HIV prevention by global health regulatory agencies (27). The Cost-effectiveness of these interventions vary based on how appropriately they target at-risk populations, but this model optimistically assumes interactions are deployed effectively.

It is estimated that men in Sub-Saharan Africa use an average of 40 condoms per male per year (28). Condoms are estimated to cost US$ 0.26 per condom for condom distribution programs in Southern and Eastern Africa (29). In Namibia, there is considerable mistrust of the quality of free condoms distributed by health agencies(30). Based on these data, the projections assume a cost of condom distribution per person is US$ 11. This figure accounts for the average cost of condoms and is rounded up to reflect extra investments in education needed to counteract misinformation about free condom quality. Namibia also faces cultural barriers to circumcision in many regions (26). With high levels of investment in outreach and male medical staff to overcome these barriers, it is possible to double the voluntary circumcision rate cover to 50% of the adult male population in an optimistic scenario. The circumcision target variable in the medium treatment, high prevention scenario reflects these efforts.

In addition to reflecting significant investments in prevention efforts, the medium treatment, high prevention scenario incorporates the introduction of a vaccine in 2030. Several vaccination trials are currently underway, with results from HVTN 702 expected in 2021(31). Many experts are optimistic that an HIV vaccine will be developed as early as 2030 (32). Based on ongoing trials, the medium treatment, high prevention projection (Fig. 4) assumes the introduction of a vaccine that is 75% effective in 2030. Future vaccines are predicted to have an average cost of  US$ 77.50 per person (33). This figure is used as the vaccination cost variable in the projection. Namibia’s recent investments in decentralizing HIV treatment infrastructure to facilitate rural access will enable high population coverage once a vaccine is developed. The projection assumes this infrastructure will enable clinicians to vaccinate 90% of the population by 2035. With investments in prevention and the introduction of a vaccine, Namibia will achieve an AIDS transition, the point at which new infections are pushed below the number of annual deaths, in 2034 (34). The policy team recommends aligning funding with the high prevention, vaccination model to achieve this key transition metric.

Figure 4. High prevention, medium treatment, with vaccination scenario

The impact of introducing a vaccine is noticeable in the top right panel of Fig. 4. The number of new infections rapidly drops after the introduction of a vaccine. However, vaccination alone is not sufficient to sustain the transition. Sensitivity analyses show that although introducing a vaccine with baseline levels of uptake and prevention also leads to an AIDS transition, the number of new infections rises above deaths again by 2050. The transition enabled by the vaccine is only sustainable if the MHSS maintains treatment and prevention programs. With investments in prevention, moderate levels of treatment, and the introduction of a vaccine, Namibia can greatly reduce the number of AIDS deaths by 2050 and prevent HIV treatment costs from ballooning.

Table 2. AIDScost projection variables and data dictionary

Cost-Effectiveness of High Prevention, Medium Treatment Strategy

Global development experts advise that maintaining treatment and expanding prevention is the most cost-effective HIV/AIDS strategy (34). The high prevention, medium treatment, with vaccination scenario follows this recommendation and balances treatment and prevention costs better than the historical baseline and high treatment funding models. As seen in Fig. 5, prevention programs cost 41% less per life-year saved than high treatment models. This statistic is not surprising when one considers that treatment is not curative. Once a patient is initiated on treatment, maintaining treatment becomes a lifelong expense. However, given the recent advances in treatment delivery through the fast track initiative, it would not be ethical or politically advisable to reduce treatment expenditures to baseline levels. It is crucial to fund a moderate push in treatment uptake even though it is not the most cost-effective method of achieving an AIDS transition.

Economic benefits of ART

        Incorporating incentives for patients receiving treatment to participate in focus groups and patient education programs can partially mitigate the expense of ART programs (34) . Partnering experienced patients with new patients can improve compliance and outcomes, which improves the cost-effectiveness of treatment. Namibia is already experimenting with focus group programs and will be able to improve these programs based on initial results. There are also experimental drug pricing models for antiviral drugs being trialed in several countries. These experimental drug subscription models may improve the affordability of ART prices in the future (35, 36).

There are also some economic benefits to investing in ART programs that can mitigate the expense of treatment. HIV treatment provides an economic stimulus by creating new employment opportunities for health workers, health care administrators, and those working in hospital development and health infrastructure. Treatment programs can also lead to educational opportunities for health workers that are trained to work with new ART delivery methods and technologies. These investments have been found to produce economic returns (37). With Namibia in an economic recession, continued investment in treatment levels above the historical baseline may produce a helpful economic stimulus that partially mitigates the expense of these therapies. Additionally, these investments help the country to build healthcare capacities for other diseases and potential outbreaks. Namibia experiences a high influx of tourism and international trade every year. It has been vulnerable to pandemic outbreaks in the past. HIV monitoring facilities can also be utilized to monitor antimicrobial resistance and enable faster responses to pandemic outbreaks, chemical hazards, and other public health threats. Ultimately, investing in health infrastructure has spillover benefits for national security (38).

Figure 5: Cost-effectiveness of HIV funding strategies

Cost-effectiveness of prevention   

        Although Namibia’s recent success in improving ART uptake is impressive, the above projections have established that it is necessary to supplement these investments with prevention programs to make lasting progress in reducing AIDS deaths. Prevention measures are essential to achieving an AIDS transition, and in models for Namibia, they are more cost-effective than treatment in the long run. Voluntary male medical circumcision and oral PrEP are estimated to reduce HIV incidence by 50 percent. Using condoms and having fewer partners are predicted to have similar effectiveness, though effectiveness data for prevention programs are more difficult to collect than for treatment programs (27). Condom programs also have spillover benefits and prevent a number of other sexually transmitted infections. They have been shown to produce economic gains by reducing morbidities and unintended pregnancies (39).

Approaches to prevention programs vary, but there is a general consensus in the literature that appropriate targeting of the populations at risk is key to cost-effective prevention programs. The most appropriate intervention will vary with the targeted population. Simply providing communities with a product such as condoms or medications is not a sufficient public health intervention to create health behavior change. Instead, public health interventions should be tailored to local community needs. Education programs and incentives that promote behavior change should accompany product distribution. Namibia is already investing in these tailored programs through Project DREAMS. The program launched in the summer of 2019 and aims to provide community support to adolescent girls. Young women remain one of the populations most at risk for HIV/AIDS, and the program provides them with life coaches and support for academic advancement (40). Although it is too early to assess outcomes of Project DREAMS, the prevention initiative demonstrates that Namibia’s health partners are able to develop creative new approaches to improving prevention efforts. Learning from these experimental models will be key to improving the cost-effectiveness of future prevention programs.

Vaccines create cost savings

 Vaccines are the most cost-effective HIV prevention method in the above projections and the only strategy which is predicted to save money. The introduction of a hypothetical vaccine would facilitate cost savings by reducing the incidence of new infections. These savings can be used to subsidize funding for treatment and prevention efforts. Studies have shown that the cost-effectiveness of a future vaccine will largely depend on its efficacy (33). The above projections optimistically assume the availability of a 75% effective vaccine, but estimates of future efficacy vary widely (33). The MHSS will need to evaluate future efficacy carefully against vaccine price to determine more precise cost-effectiveness. The threshold for vaccine pricing will likely be based upon GDP per capita. GDP per capita measurements often result in skewed pricing for Namibia due to its relatively small population, so the MHSS will likely need to be prepared to advocate for reduced pricing when a vaccine is introduced.  

With these considerations in mind, vaccination will enable sustainable levels of HIV/AIDS expenditures for Namibia through 2050. The high prevention, medium treatment with vaccination projection is the only scenario that will prevent an increase in expenditures through 2050. This sustained funding projection is highly beneficial for planning for today’s economic recession and donor withdrawals. The recommended model also results in over 50% fewer deaths than baseline and over 20,000 fewer new infections. See Table 3 for a comparison of expenditures and lives saved between the scenarios.

Table 3

The projections demonstrate that a combination of sustained treatment, high prevention efforts, and vaccine deployment are the most cost-effective option for controlling the AIDS epidemic in Namibia. 

Political Economy of Recommended Model
        The recommended funding model balances political pressures from the President’s office, U.S donors, the Ministry of Finance, and the general public. Setting an ART uptake rate goal of 40% rather than the 60% achieved in 2018 may be an area of contention for the President’s office and U.S. Donors. First Lady Monica Geingos is UNAIDS special advocate for young women and adolescent girls, and she has been a strong advocate for expanded treatment (41). She will likely be opposed to any reduction of the fast track program ART expansion. Additionally, the success of the fast track program has received international media coverage and commendation (8, 42). The World Health Organization has celebrated Namibia’s progress towards the 90-90-90 targets. The United States government is also promoting Namibia as a model for expanding treatment in U.S. cities with high levels of HIV transmission, and the city of Atlanta is modeling its outreach efforts after Namibia’s outreach work with young women (8). Any change in HIV investments will likely be noted by these key funding and regulatory bodies. PEPFAR is Namibia’s largest HIV donor, so reducing efforts that have been encouraged and praised by the U.S. may jeopardize donor funding. However, PEPFAR is also pushing Namibia to fund a larger share of HIV services. The agency is likely to accept the evidence for a lower ART goal if it is based on cost-benefit analyses and demonstrates long term reductions in disease transmission. The Minister of Finance and Minister of Health will be able to assure those concerned about treatment reductions that funding will be maintained and treatment will continue at rates far above historical baseline levels.

Although there is intense political pressure to maintain the progress of the fast track effort, there is also pressure for austerity measures within the government. In the current recession environment, government agencies are facing budget reductions that result in scaled back services and high staff turnover (20, 43). Bureaucrats managing budgets for non-health agencies would likely support HIV funding that prioritizes cost-effective investments in prevention over treatment. Funding savings from health could reduce the likelihood that departments managing education, transportation, and defense would see budget cuts.  

Among the general public, the expansion of prevention programs is likely to be well-received. Project DREAMS received positive attention in the national press (40). However, any perceived reductions in spending on treatment may face public backlash. Namibia faces large wealth and health disparities, and efforts to reduce health spending should ensure that vulnerable populations are not disproportionately burdened by funding reallocations. Additionally, the recent “Fishrot Scandal” has weakened public trust in government officials (40). This reduction in trust likely contributed to smaller margins for the Swapo party in recent elections(44).  Highlighting cost-effectiveness and overemphasizing monetary efficiency to the public is not likely to be effective at alleviating public concern over the 40% ART target. The MHSS should assure the public that it will maintain treatment for current patients and continue to initiate treatment well above the historical baseline. A medium treatment, high prevention model best balance cost-effectiveness with political pressures imposed by donors and political figures.

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