Kazakhstan can achieve ambitious HIV targets despite expected donor withdrawal by combining improved ART procurement mechanisms with allocative and implementation efficiencies
Kazakhstan can achieve ambitious HIV targets despite expected donor withdrawal by combining improved ART procurement mechanisms with allocative and implementation efficiencies
Andrew J. Shattock 0
Irina Petrenko 1
Lolita Ganina 1
Sherrie L. Kelly
Robyn M. Stuart 0
Cliff C. Kerr 0
David P. Wilson 0
Richard T. Gray 0
0 The Kirby Institute, University of New South Wales , Sydney , Australia , 2 The World Bank Group, Washington DC, United States of America, 3 Joint United Nations Programme on HIV/AIDS , Geneva , Switzerland , 4 United Nations Development Programme , Istanbul Regional Hub, Istanbul , Turkey
1 Republican Center for Prevention and Control of AIDS, Almaty, Kazakhstan, 6 The Burnet Institute , Melbourne , Australia , 7 Department of Mathematical Sciences, University of Copenhagen , Copenhagen , Denmark , 8 School of Physics, University of Sydney , Sydney , Australia , 9 The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva , Switzerland
We used the Optima model to project future scenarios of the HIV epidemic in Kazakhstan
that varied in future antiretroviral treatment unit costs and management expenditureÐtwo
areas identified for potential cost-reductions. We determined optimal allocations across HIV
programs to satisfy either national targets or ambitious targets. For each scenario, we
considered two cases of future HIV financing: the 2014 national budget maintained into the
future and the 2014 budget without current international investment.
Kazakhstan can achieve its national HIV targets with the current budget by (1) optimally
reallocating resources across programs and (2) either securing a 35% [30%±39%] reduction
in antiretroviral treatment drug costs or reducing management costs by 44% [36%±58%] of
2014 levels. Alternatively, a combination of antiretroviral treatment and management
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
Funding: This study was funded by the World Bank
Group and the Australian National Health and
Medical Research Council (APP1064192 and
APP1086540, both awarded to DPW). The World
Bank Group also provided support in the form of
salaries for CB and EM. The Kirby Institute at
UNSW Australia is funded by the Australian
Editor: Ravindra K Gupta, UCL, UNITED KINGDOM
Despite a non-decreasing HIV epidemic, international donors are soon expected to
withdraw funding from Kazakhstan. Here we analyze how allocative, implementation, and
technical efficiencies could strengthen the national HIV response under assumptions of future
Government, Department of Health and Ageing.
The views expressed in this publication do not
necessarily represent the position of the Australian
Government. As members of the study team, CB
and EM (employed by the World Bank Group)
supported the project by engaging with the
Kazakhstan HIV sector and requesting data from
the national Ministry of Health. They did not have
any additional role in the study design, data
collection and analysis, decision to publish, or
preparation of the manuscript beyond what is
specified in the Author Contributions Statement.
Competing interests: The commercial affiliation
with the World Bank Group does not alter our
adherence to PLOS ONE policies on sharing data
reductions could be sufficient. Furthermore, Kazakhstan can achieve ambitious targets of
halving new infections and AIDS-related deaths by 2020 compared to 2014 levels by
attaining a 67% reduction in antiretroviral treatment costs, a 19% [14%±27%] reduction in
management costs, and allocating resources optimally.
With Kazakhstan facing impending donor withdrawal, it is important for the HIV response to
achieve more with available resources. This analysis can help to guide HIV response
planners in directing available funding to achieve the greatest yield from investments. The key
changes recommended were considered realistic by Kazakhstan country representatives.
Many countries are experiencing downward trends in their HIV epidemics after 10±15 years
of large global investment [1±4]. However, some countries now face international donor
withdrawal despite non-decreasing epidemics [
]. Kazakhstan has recently experienced a decrease
in HIV funding from international donors after achieving upper-middle-income country
status in 2006 [
]. In future, international aid for HIV is likely to be completely withdrawn for
Kazakhstan. Although the government has increased domestic funding for the national
], in 2012 20% of spending still came from international donors [
Currently Kazakhstan's gross domestic product (GDP) per capita exceeds $12,000 USD.
This surpasses many countries in the Eastern Europe and Central Asia (EECA) region, and
suggests Kazakhstan is in a stronger position to fund its HIV response (Fig 1). However, this
economic advantage is diminished by costs of procuring antiretroviral drugs (ART) being
greater than other countries in the region, exceeding the EECA average (of countries for which
recent data are available) by 110% (Fig 1). This high cost of HIV treatment is primarily driven
by the exclusion of the Kazakhstan government from voluntary licence agreements that
pharmaceutical companies negotiate with generic drug manufacturers due to Kazakhstan's
uppermiddle-income country status [
]. Central Asia±along with Europe±experiences the highest
cost of donor-funded ART when procured from originator companies, but also the least
expensive when procured from generic manufacturers [
], highlighting the importance for
countries in these regions to have access to the generic ART market. Such high treatment
costs in the future would likely hinder the attainment of Kazakhstan's HIV targetsÐespecially
after donor withdrawal. However, it is believed that future costs of ART can be substantially
reduced through the more efficient pooled procurement processes of the United Nations and
the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) [
Like other former Soviet Union republics, Kazakhstan had an exploding HIV epidemic
amongst people who inject drugs during the 1990s [12±14]. This epidemic was driven by a
high proportion of adults living in towns along major drug trafficking routes injecting drugs
(up to 10% of the population) [
]. Since 2000, the epidemic has accelerated, with new HIV
infections increasingly reported amongst heterosexual partners of people who inject drugs,
female sex workers and their clients, men who have sex with men, prison inmates, and
]. By 2011, heterosexual infections had surpassed injecting drug use as the
primary mode of HIV transmission [
]. There were an estimated 20,000 people living with
HIV in Kazakhstan in 2013 . As of 2013, the estimated HIV prevalence among people who inject drugs was 8%, among prison inmates 3%, female sex workers 1.5%, and men who have
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Fig 1. Gross domestic product per capita, ART unit costs, and key HIV/AIDS program spending data in selected EECA countries. This figure
highlights key HIV-related spending data from selected countries in the Eastern Europe and Central Asia region. Only countries for which data were
available are illustrated. The pie charts represent total HIV spending in 2014, and the bar graphs represent national gross domestic product (GDP) per
capita and ART unit costs. The red text within the parentheses represents the proportion of the respective national budget consumed by management
sex with men 1.2% [
]. The priorities of the national strategic plan [
] are to stabilize the
epidemic by increasing public awareness of HIV prevention, targeting key populations at higher
risk of transmission, continuing to provide access to treatment, and virtually eliminating
mother-to-child transmission [
Within an HIV response, funding is required for critical enablers to support treatment and
prevention programs. These ªindirectº costs include management, coordination, enabling
environment, training, and capacity building expenditures. In Kazakhstan, these indirect costs
consumed 58% of the 2014 HIV budget, with 29% of the overall budget allocated to
management costs. This proportional allocation to management programs in Kazakhstan is much
higher than many countries in the EECA region (Fig 1). Similar findings have previously been
reported by Forsythe et al [
]. Whilst this could partially be due to potential differences in
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accounting definitions, with staff and infrastructure costs either categorized within indirect or
program costs, there is likely to exist opportunities to reduce management costs in Kazakhstan
through implementation efficiencies. Obtaining efficiency gains in essential management
programs would provide extra funds for prevention and treatment, allowing Kazakhstan to
achieve more with its current resources.
Here we used mathematical modeling to explore the potential impact of three types of effi
ciency gains with respect to Kazakhstan's national targets. The impact of funding the most
cost-effective programs to an optimal level (known as allocative efficiency), decreasing the unit
cost of treatment programs (technical efficiency), and increasing the productivity of indirect
programs and overhead costs (implementation efficiency) [
] are simultaneously considered.
We further investigated if ambitious targets could be achieved with such efficiencies.
We conducted an allocative efficiency analysis using the Optima HIV model [
]. We modeled
the interactions, HIV transmissions, and transitions within the general population and key
populations using 12 distinct population groups: the general population segregated by sex and
age (0±14 years, 15±49 years, and 50+ years), female sex workers and their clients, people who
inject drugs (segregated by sex), men who have sex with men, and prison inmates.
Demographic, behavioral, and biological data required to inform the model were collected from
national vital statistics [
], integrated bio-behavioral surveillance  and routine
program records. Model projections based on these inputs were calibrated to align the model
output with empirical epidemiological data collected from integrated bio-behavioral surveillance
] and data from registers of HIV testing and counseling services. Details of the model
calibration process are presented in the Supplementary Material (S1 and S2 Figs). The data used
to inform the model were primarily collected by Kazakhstan representatives attending an
allocative efficiency workshop held in November 2014 in Yerevan, Armenia.
Nine ªdirectº HIV prevention and treatment programs were modeled by defining
relationships between program spending and relevant transmission-related outcomes. The programs
modeled were female sex worker and client prevention programs, men who have sex with men
prevention programs, programs for people who inject drugs, needle-syringe programs, opiate
substitution therapy (OST), mass media programs, HIV testing and counseling programs,
prevention of mother-to-child-transmission (PMTCT), and antiretroviral therapy (ART). Along
with the aforementioned behavioral and epidemiological data, these spending-versus-outcome
relationships were informed by unpublished annual HIV/AIDS national budgets and program
expenditure data. We present the full set of relationships with associated uncertainties in S3
As described in Kazakhstan's national strategic plan, the priorities of the national HIV/
AIDS response are to contain the epidemic within key populations, to restrict overall popula
tion prevalence to 0.2%-0.6%, and to prevent mother-to-child transmission (MTCT). We
translated these goals into quantified targets within the Optima model. The Kazakhstan
allocative efficiency study group interpreted the epidemic targets to mean no further increases in
annual newly-acquired sexual and injecting HIV infections and no further increases in annual
AIDS-related deaths by 2020 compared to 2014 levels. Prevention of MTCT is assumed to
mean virtual elimination of mother-to-child-transmission as defined by UNAIDS [
Ambitious targets were further defined as 50% reductions in annual new sexual- and injecting-related transmissions, a 50% reduction in annual AIDS-related deaths, and virtual elimination of mother-to-child transmission, all by 2020.
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The annual HIV budget required for Kazakhstan to achieve their national targets should
2014 allocations be scaled up proportionally was determined. This was achieved by
incrementally increasing the allocation to each program proportionally (and hence varying associated
model inputs as defined by the cost-outcome relationships) and simulating the model to assess
whether the epidemiological outcomes satisfied the targets. Both the additional cost and
epidemiological gain of this increase in spending were compared to a `status-quo' scenario of
continuing 2014 spending policies for 6 years from 2015±2020.
A series of scenarios were then simulated to determine whether Kazakhstan could achieve
their national targetsÐor further, the ambitious targetsÐby 2020 under assumptions of future
efficiency gains and total HIV budget. For each scenario, three types of efficiency gains were
considered: 1) gains in allocative efficiency through optimally redistributing direct funds, 2)
gains in implementation efficiency through reducing management costs (with surplus funds
re-allocated to direct programs), and 3) gains in technical efficiency through reducing ART
procurement costs. Technical efficiencies of prevention programs were not considered.
Through discussions with country representatives, reductions in future ART costs of up to
60%-70% were identified to be plausible, as were 20%-25% reductions in management costs.
In order to fully scope the space of potential cost reductions, we considered (in percentage
point increments) reductions in ART costs from 0% to 80%, and reductions in management
costs from 0% to 50%. A scenario was simulated for each pairwise combination of ART cost
reduction and management cost reduction, with the budget for direct programs in each
scenario being optimized through a formal mathematical optimization algorithm [
uses the cost-outcome relationships) representing maximal allocative efficiency. Two levels of
future HIV financing were considered for each simulated scenario. The future annual HIV
budget available was restricted to either a) 2014 levels of funding (where international funds
would be replenished from domestic sources), or b) 2014 levels without international donor
funding. In the second case, we assume that the 20% of the total budget currently sourced
from international donors [
] is withdrawn proportionally from direct and indirect programs.
By simulating scenarios for each combination of implementation efficiency gain and ART
cost reduction assumption, we were able to identifyÐfor both assumptions of future total HIV
budgetÐthe scenarios for which the national and ambitious targets were attained when direct
funds were optimally allocated. We then identified one key scenario that achieved a desirable
outcome (that is, achievement of national or ambitious targets) whilst still being considered
realistic in terms of the efficiency gains required. By comparison with status-quo, this key
scenario was analyzed in terms of newly-acquired HIV infections averted and AIDS-related
In the absence of optimal allocative, implementation, and technical efficiencies a 32% [27%
42%] increase in HIV budget would be required to achieve Kazakhstan's national targets if the
current allocation to direct programs is scaled up proportionally. Whilst an estimated 4,090
newly-acquired HIV infections and 2,950 AIDS-related deaths would be averted by 2020
compared to status-quo spending, an additional $75.1 million [$63.7m-$96.38m] would be
required, assuming indirect costs remain fixed at $21.8 million a year.
With no additional annual spending, Kazakhstan can achieve their national targets if either
a 44% [36%-58%] reduction in management costs or a 35% [30%-39%] decrease in ART unit
costs can be secured, and by also optimally allocating available resources. Alternatively, the
same targets could be achieved by combining smaller implementation efficiency gains and
ART cost reductions whilst also allocating funds optimally (Fig 2A). For example, optimal
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Fig 2. Contour plot of thresholds to achieve national and ambitious targets with varying levels of management cost reductions and treatment
cost reductions. This figure illustrates the estimated reduction in management costs and treatment costs required to achieve i) national targets (light grey
region), and ii) ambitious targets (dark grey region) should the annual budget be restricted to a) 2014 levels (Fig 2A), or b) 2014 levels without international
donor funding (Fig 2B). The colored contours show the thresholds for percentage reductions in both newly acquired HIV infections and AIDS-related
deaths by 2020 compared to 2014 levels. The `no increase' contour is the threshold for satisfying the national targets (and is hence the border for the light
grey region), whilst the `50% decrease' contour satisfies the ambitious targets (and is hence the border for the dark grey region). In each simulation, the
proportion of the budget dedicated to direct programs is optimally distributed across programs to minimize incidence, minimize deaths, and virtually
allocative efficiency with a 20% decrease in the future cost of ART combined with a 21%
[15%29%] reduction in management costs is estimated to be sufficient to achieve the national
targets. The light grey area of Fig 2A illustrates the combination of efficiency gains that are
estimated to lead to Kazakhstan achieving their national targets should 2014 spending levels
remain available. With no additional annual resources, Kazakhstan could further fully achieve
the ambitious targets by: (1) securing at least a 51% [49%-56%] reduction in ART costs, (2)
increasing the proportion of the total budget allocated to direct programs by reducing
management costs, and (3) optimally allocating available resources across treatment and prevention
programs. The dark grey area of Fig 2A illustrates the corresponding combination of efficiency
gains estimated to achieve the ambitious targets.
Should the total annual HIV budget be reduced by 20% due to international donor with
drawal without replacement from domestic sources, our results indicate a 35% decrease in
ART costs would need to be combined with a 32% [26%-36%] reduction in management costs
and optimal allocative efficiency for national targets to be realized (Fig 2B). Further, if
substantial implementation efficiency gains (at least 24% [19%-31%] reductions in management
costs), substantial technical efficiency gains (at least 70% [64%-74%] reductions in future ART
unit costs), and also optimal allocative efficiency are attained, we estimate Kazakhstan could
achieve the ambitious targets without replenishing funds currently sourced from international
donors (Fig 2B), i.e. with only 80% of the 2014 HIV budget applied through to 2020.
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Fig 3. Allocations to programs under the status-quo scenario and the realistic scenario to achieve ambitious targets. This figure illustrates the
2014 allocation to HIV programs in Kazakhstan, alongside the optimal distribution of funds under the realistic scenario to achieve ambitious targets. This
bar illustrates the `best-fit' result, whilst uncertainty bounds around the program allocations are presented in Table 1 and S4 Fig.
Of the array of results that achieved the ambitious targets, the scenario of attaining a 67%
reduction in the cost of ART along with a 19% [14%-27%] reduction in management costs
(with the current national budget distributed optimally across programs) was identified as
being realistic by country representatives and key stakeholders. Henceforth, we refer to this
scenario as the `realistic scenario to achieve ambitious targets'. The optimally allocated
distribution of funds under this realistic scenario is illustrated in Fig 3 alongside the 2014 allocations
of the status-quo scenario. Uncertainty bounds around the optimal allocation of funds in the
realistic scenario to achieve ambitious targets are presented Table 1 and S4 Fig.
In the realistic scenario that achieves the ambitious targets, more funds were directed to
programs for key populations than currently allocated: coverage for female sex worker and
client prevention programs increased from 78% to 90% [85%-94%], prevention programs for
men who have sex with men from 8% to 19% [17%-19%], programs for people who inject
drugs from 19% to 51% [41%-54%], and needle-syringe programs from 51% to 57%
[55%58%]. Program coverage also increased for OST (from 0.2% to 0.8% [0.2%-1.1%]) and PMTCT
programs (from 75% to 86% [84%-90%]), although coverage of mass media programs
decreased from 14% to 6% [0%-13%]. ART coverage (where those diagnosed with a CD4
count of <500 cells per cubic millimeter of blood are eligible [
]) increased from 47% in the
status-quo scenario to >90% under the realistic scenario to achieve ambitious targets. Due to
the assumed decrease in the cost of ART procurement in this scenario, the annual cost of such
a program is less ($7.5 million in 2015) than for the status-quo scenario ($8.1 million in 2015).
In addition, with a 19% [14%-27%] reduction in management costs obtained through implementation efficiencies, the percentage of total HIV budget consumed by indirect costs from 2015±2020 is reduced from 56% to 51% [49%-53%] under the realistic scenario to achieve
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82% [81% - 82%]
47% [46% - 49%]
ambitious targets compared to the status-quo scenario. A summary of these results is presented
in Table 1.
Our results indicate that annual newly-acquired sexual- and injecting-related HIV infections and AIDS-related deaths will increase in 2020 from 2014 levels under the baseline statusquo (Fig 4). In contrast, annual newly-acquired sexual- and injecting-related infections are projected to decrease by 50% and 63%, respectively, under the realistic scenario of achieving
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Fig 4. Epidemiological outcomes under the status-quo scenario and realistic scenario to achieve ambitious targets in 2020 compared to 2014.
This figure illustrates the corresponding epidemiological outcomes that are estimated to arise by implementing the allocations presented in Fig 3
(statusquo scenario, and the optimized realistic scenario to achieve ambitious targets) between 2015 and 2020. In each sub chart, the first column represents the
value of the indicator in 2014.
ambitious targets. AIDS-related deaths are estimated to decrease by 71% under this scenario.
Virtual elimination of mother-to-child-transmission would also be achieved in the ambitious
targets scenario, which was not the case when status-quo spending was projected. This
translates to an estimated 5,500 newly-acquired HIV infections and 4,220 AIDS-related deaths
being averted under the realistic scenario to achieve ambitious targets compared to the
statusquo scenario between 2015 and 2020. Due to the epidemiological impact of the realistic
scenario to achieve ambitious targets, future treatment liabilities decrease and, over time, the cost
of the HIV response begins to decrease accordingly; so much so that between 2015 and 2020
the total cumulative cost of the ambitious targets scenario is estimated to be $4.5 million less
($227.4 million) than the status-quo scenario ($231.9 million).
The Government of Kazakhstan has moved to increase domestic responsibility of the HIV
budget over recent years; between 2007±2011 the domestic share of ART funding increased
from 7% to 100% [
]. Many other countries have already implemented, or are soon likely to
require, a similar transition from international to domestic sources to finance their national
HIV responses [
]. Historically, however, there has often been delays between external
funding withdrawal and domestic funding scale up [
]. Amongst other factors, this may be due to
withstanding political sensitivities surrounding key-affected populations such as people who
inject drugs, female sex workers, and men who have sex with men [
]. In this context of
domestic responsibility for key-affected population programs, a recent success story has
emerged from Croatia. Following large scale external support between 2003±2006, primarily
from GFATM, Croatia has since transitioned to a fully domestically-financed response, and
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has further scaled up key programs [
]. A key factor in Croatia's successful transition to
domestic financing was the cooperation between the government and non-government
organizations to target resources to otherwise marginalized populations [
]. Kazakhstan itself has
also achieved some success in transitioning funding for key-affected populations.
Our modeling results indicate that by continuing the current HIV intervention strategy
Kazakhstan will likely have more annual newly-acquired infections and AIDS-related deaths
in 2020 than 2014. In the absence of allocative, implementation, and technical efficiencies,
we estimate that a 32% increase in total HIV budget would be required to achieve national
targets. Alternatively, our modeling findings suggest the same targets could be satisfied with
no increase in budget by reallocating funding to focus on programs for key-affected
populations, reducing management costs, reducing ART procurement costs and consequently
increasing treatment coverage. More ambitious epidemiological targets could also be
attained without additional overall resourcing. Our results suggest that Kazakhstan could
potentially reduce new HIV-infections and AIDS-related deaths by 50% of 2014 levels by
2020 even without replenishment of 20% of the HIV budget expected to be withdrawn.
However, such an outcome would require substantial implementation efficiency gains and very
large reductions in ART costs beyond the levels deemed reasonable by country
representatives and key stakeholders.
Allocative efficiency studies have been carried out in many countries to highlight potential
inefficiencies in current investment approaches [33±39]. A recent study of the concentrated
epidemic in Sudan concluded that reallocating resources from un-targeted general population
programs to treatment programs, prevention programs of female sex workers, and prevention
programs for men who have sex with men could result in substantial epidemiological gains
]. In light of these findings, the Sudanese government has since shifted funding priorities
to closer align with the findings of the study [
]. Within the EECA region, Armenia has
undertaken several studies to assess the allocative efficiency of their HIV response [
and have used the evidence to advocate for resources to be targeted towards cost-effective
programs for key-affected populations such as short-term labour migrants [
As with all mathematical modeling studies, it is important that our findings be interpreted
with an appreciation of the inherent assumptions. We assumed that it is possible for ART costs
to be reduced by up to 80%. Whether such reductions in treatment costs are plausible in
Kazakhstan is debatable. A 2012 analysis found that implementing partners in Mozambique
were able to reduce the mean unit cost of ART by 45% between 2009 and 2011 by adjusting
inefficient service delivery models [
]. Along with more efficient drug procurement via the
UN and GFATM systems, several other factors may synergistically contribute to reduce future
costs of ART in Kazakhstan. Tenofovir Disoproxil Fumarate (TDF)±a nucleotide reverse
transcriptase inhibitor commonly used in fixed-dose combination ART±is due to expire in 2017
]. Typically, both originator and generic drug prices decrease as associated patents near
], hence it is likely that the cost of purchasing current combinations of ART will
decrease in the near future. Further, trials have shown that by optimizing antiretroviral
dosages such that any negative effect on viral suppression is negligible can help to cut the cost of
HIV treatment. A number of dose optimization trials which compared the virological efficacy
of a reduced dose versus standard dose of an antiretroviral drug have recently been completed
], finding that several antiretroviral agents show no difference in virological suppression
rates across the different dosages. The implication of reduced antiretroviral dosages on the
cost of treatment programs could potentially be substantial.
Our analyses consider efficiency gains in both direct and indirect programs. As an indirect cost that absorbs a large portion of national funding that cannot be mathematically optimized due to its unquantifiable effect on epidemiological outcomes, we assume that management
10 / 15
costs can be reduced whilst still allowing for essential functions to be maintained. A 2012
study of the HIV response in Ukraine estimated that costs associated with program staff could
be reduced on average by 18% whilst maintaining the same level of outputs [
]. In this paper,
we focus on a scenario that incorporates a ~20% reduction of management costs; a selection
that was made in line with national expert opinion as it was deemed to be realistically
attainable. We further consider scenarios that assume management costs are able to be reduced by
up to 50% of 2014 levels without detrimental effect on the direct treatment and prevention
programs that such spending supports. Such results are included to indicate what
epidemiological gains may be attainable if such efficiency gains can be achieved. However, additional
setting-specific work is needed to focus on specific implementation efficiency analyses to
understand the plausibility and potential impact of such spending cuts. Further, our results
assume that achieving the instant scale up and scale down of treatment and prevention
programs to optimal levels is plausible. In reality, this may not be the case as certain logistical,
ethical, and political constraints may exist that slow or even prevent the scale up of programs to
Our modeling findings suggest that Kazakhstan will not be able to substantially reduce new
infections and deaths unless coverages of key prevention and treatment services are scaled up.
Achieving the proposed high coverage of effective ART will require extensive demand
generation and adherence support. Among people who inject drugs, access to OST has been shown
to substantially improve adherence to antiretroviral therapy [
], and is thus likely to be an
essential condition for a successful treatment program amongst this risk group. Additional
outreach support programs may also be required to increase access and adherence to ART for
key population groups such as female sex workers, men who have sex with men, and people
who inject drugs.
Faced with impending donor withdrawal and a non-decreasing HIV epidemic, it will
become increasingly important for Kazakhstan's HIV response to achieve more with limited
available resources. This analysis can help to guide policy makers in directing available
resources to achieve the greatest yield from HIV investments, and ultimately turn the tide of
the national epidemic.
S1 Fig. Calibration of Optima to the HIV epidemic in Kazakhstan. Using all available
demographic, epidemiological, behavioral, and clinical data we calibrated Optima to the HIV
epidemic in Kazakhstan between 2000 and 2014. This was achieved by varying input parameters
within their uncertainty bounds such that model projections were within the uncertainty
bounds of empirical data on population group prevalence, number of new diagnoses per year,
and the number of people on treatment. On inspection, the Optima outputs of HIV
prevalence, number of people living with HIV, and number of AIDS-related deaths were found to
be similar in magnitude and trend to estimates produced by the Spectrum model. Generally,
Optima closely matches the available HIV prevalence and treatment data. The early female sex
worker prevalence data was deemed to be less reliable than post-2006 data by the Kazakhstan
country team, and the apparent downward trend of female sex worker prevalence was not
believed to be accurate. As such, we favored the more recent female sex worker prevalence
data and the clients of sex worker prevalence data during the calibration process. Dark grey
discs represent available data for HIV prevalence. The dark grey lines attached to these discs
represent uncertainty bounds. The solid pink curve is the best fitting simulation, and the
shaded pink region shows the range of the uncertainty simulations.
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S2 Fig. Calibration of model to ART scale-up data in Kazakhstan. Black discs represent
available data for the number of people on first and subsequent lines of anti-retroviral
treatment. The solid pink curve is the best fitting simulation and the shaded pink region represents
the range of uncertainty simulations.
S3 Fig. Relationships between program costs and associated programmatic outcomes for
the range of programs and target populations modelled. These curves are the result of
combining the intermediate cost-coverage and coverage-outcome relationships for each
programmatic outcome. These relationships were defined during a workshop held in November 2014
in Yerevan, Armenia, which was co-hosted by the Global Fund to Fight AIDS, Tuberculosis
and Malaria, UNAIDS, the United Nations Development Program, the World Bank, and
various other partners. This process was conducted by the Optima HIV modelling team in
consultation with Kazakhstan country representatives and other stake holders. In several cases, the
magnitude of the programmatic outcome data was not trusted by the Kazakhstan country
team, and adjustments to the curves were made accordingly. The Kazakhstan country
representatives approved the set of curves presented here during the workshop. Black discs
represent available program spending verses program-related outcome data. The solid curve is the
best estimate cost-outcome curve, and the shaded region represents the range of uncertainty
considered in the each of the cost-outcome relationships.
S4 Fig. Uncertainty around optimal allocations. An uncertainty analysis was undertaken to
determine how uncertainties in both model calibration and cost-outcome relationships
impacted on allocation recommendations. Forty baseline model simulations were sampled
from an ensemble of projections within the uncertainty bounds of the model calibration, as
were 40 samples of each of the cost-outcome relations within their respective uncertainty
bounds. Here we present the impact of such uncertainty on optimal allocations and associated
coverages under different assumptions of future ART cost reduction. In each case, the
ambitious targets defined in the manuscript are fully achieved. The blue dots represent the optimal
allocations obtained from the analysis of the `best-estimate' model calibration and
cost-outcome curves. The blue shaded regions represent the range of uncertainty in the optimal
allocations. The red dots and red shaded region represent the best-estimate and uncertainty optimal
program coverages associated with the optimal program allocations. Subfigure A shows the
impact of uncertainty on optimal allocations and associated coverages when future ART costs
are reduced by 67% (a 3-fold reduction). In subfigure B future ART costs are fixed at 2014
levels, and in subfigure C future ART are reduced by 80% (a 5-fold reduction). The program
specific coverages corresponding to optimal spending patterns are very similar in each of these
cases. This phenomenon, along with the consistently tight uncertainty bounds around the
best-fit optimal result, suggests that these optimal coverage recommendations for achieving
the ambitious targets are a robust finding.
The views expressed in this publication do not necessarily represent the position of the Austra
lian Government. The findings, interpretations, and conclusions expressed in this work are
those of the authors and do not necessarily reflect the views of The World Bank, its Board of
Executive Directors, or the governments they represent.
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Conceptualization: DPW EM MM CH SZ TV.
Data curation: PD AB IP LG CB AJS.
Formal analysis: AJS.
Funding acquisition: EM MM CH SZ.
Investigation: AJS PD AB IP LG CB.
Methodology: CCK DPW RMS AJS RTG SLK CB EM.
Project administration: DPW EM MM CH SZ.
Software: CCK RMS AJS RTG SLK.
Supervision: RTG DPW MM CH SZ EM.
Validation: AJS DPW CB.
Visualization: AJS RTG DPW.
Writing ± original draft: AJS RTG DPW.
Writing ± review & editing: AJS RTG DPW PD AB CB IP LG SLK RMS CCK TV SZ CH MM EM.
13 / 15
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