HİV ve AIDS için tıbbi araç gereç eksikliği: kenya’da kaynak ihtiyaçlarının belirlenmesi ve unaıds’in antiretroviral ilaçların artmasına yönelik 90-90-90 hedefleri HIV and AIDs Commodity Gap: An Estimate of resource needs and envelop under the UNAIDs 90-90-90 targets towards ART scale up in Kenya

Introduction: Kenya has committed to reaching UNAIDS’ ambitious 90-90-90 targets by 2019. Attainment of these goals will require increasing the number of patients on ART from the current 871,000 (as of June 2015) to 1.4 million by June 2019. This will translate to increased demand for commodities (Antiretroviral [ARVs], rapid test kits, lab commodities [viral load, early detection, and CD4]) and a highly responsive health system that are essential for the realization of these targets. Given that in the past Kenya has had significant HIV Resource gap, it not clear how adherence to the current WHO guideline will affect this gap together with targets sustainability. Methodology and Results: The costing approach involved obtaining and inputting demographic, HIV prevalence data into the HIV Resource Needs, Map and Gap model (HRNMG), obtaining the targets for the different interventions in the plan and inputting them in the model based on the guideline cut-offs, collecting and estimating unit costs of different activities for input into the model and finally inputting the financial data into model. The total financial requirement for ARVs is US$168 million in FY 2015/16, and rises to US$305 million in FY 2018/19. The resource gap for ARVs increases from US$23 million in FY 2015/16 to US$160 million in FY 2018/19. Conclusion and Recommendation: The achievement of the first and second 90-90-90 targets will require an increase in the number of test kits, ARVs, and laboratory commodities used for patient monitoring. The estimated resource needs has not shown any reduction in the future which suggests that realization of the 90-90-90 targets requires a major refocus on resource sustainability options by both government and other stake holders. One such option would be to obtain the required resources through Domestic Resource Mobilization (DRM) to bridge the resource gap for HIV commodities and place the HIV response on a more sustainable path. Kenya would also uphold agreements that would call for a lower cost of ARTs drugs through pushing for changes in the current WTO agreements on Trade-Related Aspect of Intellectual Property Rights (TRIPS) flexibilities.


INTRODUCTION
The Kenya AIDS Strategic Framework 2014/15-2018/19 (KASF) is the overarching strategic document guiding the HIV response in Kenya's devolved system of governance. The implementation of KASF goals will contribute to the achievement of Vision 2030 targets by ensuring universal access to comprehensive HIV prevention, treatment, and care (see Ministry of Health (MOH), 2014). Kenya has also committed to reaching 1 Palladium group, 2 Clinton health access initiative; 3  Although these goals could be realized under the current guidelines, or under a test-and-treat approach, it is paramount that reaching these goals in the context of current funding constraints will require three targeted interventions.
First, Identification of the 90 per cent of the total HIV population which implies intensifying scale-up of innovative testing strategies for targeted groups as an entry point to maximizing the identification of HIVpositive persons while minimizing the number of tests conducted. Second, Treatment of the 90 per cent of the identified which implies access to ART for 81 percent of HIV-positive persons (90% identified, and 90% initiated to ART treatment from the point-ofdiagnosis) and Third, Suppression of HIV to the 90 percent of the treated. This implies targeted support for adherence and retention in the first 12 months of ART, and access to viral load monitoring for measurement of CD4 count.
Attainment of these goals will require increasing the number of patients on ART from the current 871,000 (as of June 2015) to 1.4 million 1 by June 2019. This will translate to increased demand for commodities (antiretroviral [ARVs], rapid test kits, lab commodities [viral load, early detection, and CD4]) that are essential for the realization of these targets. Since commodities are the key cost drivers in HIV programming, it is critical to estimate their costs and any resulting financial gaps to guide policy discussions on scaling up for achievement of 90-90-90 targets by FY 2018/19. Specifically the achievement of the first and second 90-90-90 targets will require an increase in the number of test kits, ARVs, and laboratory commodities used for patient monitoring. Since the second 90 is already defined as 81 percent of PLHIV on ART, patient targets are not only based on country eligibility guidelines, but also on the number of PLHIV. Thus, the number of patients requiring ART at 90-90-90 is 1.4 million. If Kenya moves to test-and-treat then achievement of the second 90 is more assured, as more people will be initiated in ART per year.
The only factor that will vary is the mix of patients by CD4. Under test-and-treat, a portion of patients on ART will be those with CD4 >500, while under the current guidelines the patients on treatment are those with CD4<500. However, it should be noted that the speed of convergence at the set targets is higher with test-and-treat than under current guidelines, as the number put on treatment will be higher because they are not limited by a CD4 cut-off.
Several resource gaps for HIV programs have been estimated in the past (see MOH, 2015). This brief attempts to harmonize the methodologies used in estimating HIV commodity gaps in the past. To do so, major stakeholders (Clinton Health Access Initiative, National AIDS & STI Control Programme, and National AIDS Control Council) were consulted in arriving at the assumption and targets used in the resource-gap estimation model. In this model, two scenarios are considered: financial needs for key commodities under the current guidelines, and a more ambitious "scale-up" scenario. In addition to harmonizing the way Kenya estimates HIV commodities gaps, the model will also support the mobilization of resources toward attaining the 90-90-90 targets.

Methodology
The resource requirements estimation was aligned with the Kenyan ART and HTC national guidelines, which specify ART regimens, testing algorithm and strategies. The broad commodity needs considered are ARVs, test kits and laboratory commodities. The estimation of the financial resources to support the implementation was done using HIV Resource Needs, Map and Gap (HRNMG) which in builds Resource Needs Model (RNM). The HRNMG is a modification of RNM to accommodate resource mapping and gaps. The costing approach involved four steps.
Step one consisted of obtaining and inputting demographic, HIV prevalence data into the model. The second step involved obtaining the targets for the different interventions in the plan and inputting them in the model based on the guideline cut-offs. The third step consisted of collecting and estimating unit costs of different activities for input into the model. The fourth step involved in putting the financial data into the model.
In the costing analysis, the resource needs are a function of the population in need of the service or intervention, the unit cost of the intervention and the coverage rate. These are estimated on an annual basis and summed across the period to give an indication of the likely costs of providing ART, HTC and laboratory commodities as per the set country targets. The estimated cost per activity was computed by the following formula:

Cost per activity or service (Ksh) = population x coverage target x unit cost.
The difference between the estimated resource need and the resource available (available resource envelop) is the resource gap that need to be meant.

Data
The data used for this analysis contains commodity quantities from the national HIV forecasting and quantification process (MOH and NASCOP, 2015). This quantification was conducted based on a combination of morbidity-and consumption-based methods. The ARV quantities were computed on a consumption basis, while lab commodities were determined from morbidity estimates. Viral load tests were calculated based on population estimates and targeted scaleup by the national program. Finally, HIV testing and counseling (HTC) estimates included assumptions of progressively reduced testing by the national program by shifting toward more targeted strategies over the next three years (MOH and NASCOP, 2015).
Funding data was collected from several sources, including the Global Fund to Fight AIDS, Tuberculosis and Malaria's grant allocation for Kenya; the Country Operational Plan (COP 15) for PEPFAR; other development partners (through a questionnaire); and the Government of Kenya (from printed and Medium-Term Expenditure Framework estimates).

Ethical consideration
No ethical committee approval was needed for this study as the data used in this research was obtained from public use data set.  Table 1). The main driver of this increase is the rise in total costs for ARVs, driven by an increase of over 45 percent in the number of patients on treatment (871,000 in FY 2014/15 to 1.4 million in FY 2018/19). By FY 2018/19, available funding will be enough to cover only 51 percent of the need for key HIV commodities.

ARVs
As shown in Figure 1,

Testing Kits
The need for HIV testing kits is US$12 million for FY 2015/16, which reduces to US$6 million by FY 2018/19. There is no current gap for testing kits and, with the resources available, the need will be met by FY 2018/19 2 (see Figure 2). 2 Negative gaps in figure 2, represent surplus as a results of the reduced HIV testing targets brought about by targeted testing.   The Key policy option then would be to obtain the required resources through Domestic Resource Mobilization (DRM) to bridge the resource gap for HIV commodities and place the HIV response on a more sustainable path. Other options could include engaging in international trade agreements under the world trade organization that will boost manufacturing of HIV generic drugs in the country with a target of lowering the cost of drugs which has been the key component to the growing HIV funding gap and, coming up with a deliberate long term strategy of engaging the private sector at financing some key area of HIV prevention cost .One such way would be for the government to offer some tax concession to companies engaging in community work that focus on HIV prevention and care.