Show Me the Money: A Discussion about Investments Needed to Change - - PowerPoint PPT Presentation

Show Me the Money:

A Discussion about Investments Needed to Change STD Rates in the United States

Harrell Chesson

Health Economist Centers for Disease Control and Prevention

National Coalition of STD Directors Annual Meeting Alexandria, VA November 17, 2017

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

“64 percent of all the world's statistics are made up right there on the spot.”

• Todd Snider

Statistician’s Blues

“64 percent of all the world's statistics are made up right there on the spot.” “84 percent of all statisticians truly hate their jobs.”

• Todd Snider

Statistician’s Blues

Budget Category* Budget Funding per capita ($ per person) Total $11.5 billion $35.49 HIV/AIDS $0.8 billion $2.47 STDs $0.16 billion $0.49

* CDC budget estimates (overall and HIV/STD components) adapted from CDC’s FY 2016 Justification of Estimates for Appropriation Committees. Assumes US population of 324 million (www.census.gov).

CDC Budget, Fiscal Year 2016

Budget Category* Budget Funding per capita ($ per person) Total $11.5 billion $35.49 HIV/AIDS $0.8 billion $2.47 STDs $0.16 billion $0.49 Consumption Category** Annual spending Spending per capita (dollars per person) Taco Bell $6.0 billion $18.52 Bottled water $11.8 billion $36.42 Lotteries $69.0 billion $212.96

* * CDC budget estimates (overall and HIV/STD components) are approximated and were adapted from CDC’s FY 2016 Justification of Estimates for Appropriation Committees. ** Spending estimates Taco Bell and Lotteries (2012) were obtained from:http://www.washingtonexaminer.com/six- things-that-americans-spend-more-on-than-the-2014-midterm-elections/article/2555534; Taco Bell estimates are from 2013, and Lottery estimates are for 2012. Spending estimates for bottled water are for 2012 and were obtained from: http://www.businessinsider.com/bottled-water-costs- 2000x-more-than-tap-2013-7. Per capita calculations based on population of 324 million.

CDC Budget, Fiscal Year 2016

Outline

 What has been the impact of STD programs?

• Illustration of STD rates with and without prevention efforts
• User-friendly tool for programs to estimate the economic benefits of

their teams with high chances of winning prevention activities

 What investment is needed to make an appreciable change

in national STD rates?

• Illustration of future STD rates under different funding scenarios

 What is the effect of budget changes?

• User-friendly tool for programs to estimate the health and medical

cost impact of budget cuts, budget increases

6

Outline

 What has been the impact of STD programs?

• Illustration of STD rates with and without prevention efforts
• User-friendly tool for programs to estimate the economic benefits of

their prevention activities

 What investment is needed to make an appreciable change

in national STD rates?

• Illustration of future STD rates under different funding scenarios

 What is the effect of budget changes?

• User-friendly tool for programs to estimate the health and medical

cost impact of budget cuts, budget increases

7

Data examined Main findings

State-level CDC funding allocations for STD and HIV prevention and state-level gonorrhea rates, 1981-19981 Greater amounts of prevention funding in a given year were associated with lower STD/HIV incidence rates in subsequent years State-level syphilis rates and state-level CDC allocation for syphilis elimination activities, 1997-20052 National-level HIV prevention allocations and national-level HIV incidence estimates, 1978- 20064 County-level public health spending and county-level gonorrhea and syphilis rates in California, 2003-20125 Greater amounts of public health spending in a given year were associated with lower gonorrhea and syphilis incidence rates in subsequent years State-level CDC HIV prevention funding (1996- 2003) and HIV testing data from the Behavioral Risk Factor Surveillance System (2003)3 The odds of having been tested for HIV were higher in states with greater amounts of HIV prevention funding

Summary of studies examining impact of STD/HIV prevention funding on STD/HIV-related health outcomes

1 Chesson HW et al., Eval Rev 2005.; 2 Chesson & Owusu-Edusei, Soc Sci Med 2008 ; 3 Linas BP et al., AJPH 2006; 4 Holtgrave & Kates,, Am J Prev Med 2007. 5Gallet

• C. Int Adv Econ Res 2017.

Data examined Main findings

State-level CDC funding allocations for STD and HIV prevention and state-level gonorrhea rates, 1981-19981 Greater amounts of prevention funding in a given year were associated with lower STD/HIV incidence rates in subsequent years State-level syphilis rates and state-level CDC allocation for syphilis elimination activities, 1997-20052 National-level HIV prevention allocations and national-level HIV incidence estimates, 1978- 20064 County-level public health spending and county-level gonorrhea and syphilis rates in California, 2003-20125 Greater amounts of public health spending in a given year were associated with lower gonorrhea and syphilis incidence rates in subsequent years State-level CDC HIV prevention funding (1996- 2003) and HIV testing data from the Behavioral Risk Factor Surveillance System (2003)3 The odds of having been tested for HIV were higher in states with greater amounts of HIV prevention funding

Summary of studies examining impact of STD/HIV prevention funding on STD/HIV-related health outcomes

1 Chesson HW et al., Eval Rev 2005.; 2 Chesson & Owusu-Edusei, Soc Sci Med 2008 ; 3 Linas BP et al., AJPH 2006; 4 Holtgrave & Kates,, Am J Prev Med 2007. 5Gallet

• C. Int Adv Econ Res 2017.

Data examined Main findings

State-level CDC funding allocations for STD and HIV prevention and state-level gonorrhea rates, 1981-19981 Greater amounts of prevention funding in a given year were associated with lower STD/HIV incidence rates in subsequent years State-level syphilis rates and state-level CDC allocation for syphilis elimination activities, 1997-20052 National-level HIV prevention allocations and national-level HIV incidence estimates, 1978- 20064 County-level public health spending and county-level gonorrhea and syphilis rates in California, 2003-20125 Greater amounts of public health spending in a given year were associated with lower gonorrhea and syphilis incidence rates in subsequent years State-level CDC HIV prevention funding (1996- 2003) and HIV testing data from the Behavioral Risk Factor Surveillance System (2003)3 The odds of having been tested for HIV were higher in states with greater amounts of HIV prevention funding

Summary of studies examining impact of STD/HIV prevention funding on STD/HIV-related health outcomes

1 Chesson HW et al., Eval Rev 2005.; 2 Chesson & Owusu-Edusei, Soc Sci Med 2008 ; 3 Linas BP et al., AJPH 2006; 4 Holtgrave & Kates,, Am J Prev Med 2007. 5Gallet

• C. Int Adv Econ Res 2017.

Data examined Main findings

State-level CDC funding allocations for STD and HIV prevention and state-level gonorrhea rates, 1981-19981 Greater amounts of prevention funding in a given year were associated with lower STD/HIV incidence rates in subsequent years State-level syphilis rates and state-level CDC allocation for syphilis elimination activities, 1997-20052 National-level HIV prevention allocations and national-level HIV incidence estimates, 1978- 20064 County-level public health spending and county-level gonorrhea and syphilis rates in California, 2003-20125 Greater amounts of public health spending in a given year were associated with lower gonorrhea and syphilis incidence rates in subsequent years State-level CDC HIV prevention funding (1996- 2003) and HIV testing data from the Behavioral Risk Factor Surveillance System (2003)3 The odds of having been tested for HIV were higher in states with greater amounts of HIV prevention funding

Summary of studies examining impact of STD/HIV prevention funding on STD/HIV-related health outcomes

1 Chesson HW et al., Eval Rev 2005.; 2 Chesson & Owusu-Edusei, Soc Sci Med 2008 ; 3 Linas BP et al., AJPH 2006; 4 Holtgrave & Kates,, Am J Prev Med 2007. 5Gallet

• C. Int Adv Econ Res 2017.

Data examined Main findings

State-level CDC funding allocations for STD and HIV prevention and state-level gonorrhea rates, 1981-19981 Greater amounts of prevention funding in a given year were associated with lower STD/HIV incidence rates in subsequent years State-level syphilis rates and state-level CDC allocation for syphilis elimination activities, 1997-20052 National-level HIV prevention allocations and national-level HIV incidence estimates, 1978- 20064 County-level public health spending and county-level gonorrhea and syphilis rates in California, 2003-20125 Greater amounts of public health spending in a given year were associated with lower gonorrhea and syphilis incidence rates in subsequent years State-level CDC HIV prevention funding (1996- 2003) and HIV testing data from the Behavioral Risk Factor Surveillance System (2003)3 The odds of having been tested for HIV were higher in states with greater amounts of HIV prevention funding

Summary of studies examining impact of STD/HIV prevention funding on STD/HIV-related health outcomes

1 Chesson HW et al., Eval Rev 2005.; 2 Chesson & Owusu-Edusei, Soc Sci Med 2008 ; 3 Linas BP et al., AJPH 2006; 4 Holtgrave & Kates,, Am J Prev Med 2007. 5Gallet

• C. Int Adv Econ Res 2017.

Analysis of state-level gonorrhea rates and STD/HIV prevention funding

 Data: State-level data 1981 to 1998

• 918 observations (18 annual data points for all 50 states and DC)
• Funding amounts
• Reported gonorrhea rates

 Methods: Regression analysis  Findings:

• Greater amounts of prevention funding in a given year were

associated with reductions in gonorrhea incidence rates in subsequent years

• Each dollar of prevention funding per capita was associated with

reductions in gonorrhea of about 2% to 20%

• Results consistent over a variety of robustness tests

Chesson et al., Eval Rev 2005

Includes explanatory variables:

• AIDS mortality rate
• Percent of population aged 15 to 24
• Robbery rate
• Per capita cigarette consumption
• Per capita income
• Poverty rate

200 400 600 800 1000 1200 1970 1975 1980 1985 1990 1995 2000 2005

Number of reported cases

Reported gonorrhea rate

Reported gonorrhea rate (new cases per 100,000) 1970-2005

Chesson, Sex Trans Dis (2006)

200 400 600 800 1000 1200 1970 1975 1980 1985 1990 1995 2000 2005

Number of reported cases

Reported gonorrhea rate Estimated gonorrhea rate without CDC prevention funding

Reported gonorrhea rate (new cases per 100,000) 1970-2005

Chesson, Sex Trans Dis (2006)

• 50%
• 40%
• 30%
• 20%
• 10%

0% 10% 20% 30% 40% 50%

1997 1998 1999 2000 2001 2002 2003 2004 2005

Annual percentage change in reported rate of early syphilis in states that were and were not initially targeted for syphilis elimination

States not targeted Targeted states Year Percentage change

Chesson & Owusu-Edusei, Soc Sci Med 2008.

17

18

5,000 10,000 15,000 20,000 25,000 1994 1996 1998 2000 2002 2004 2006

Number of reported cases Year

Reported cases of P&S syphilis

Reported syphilis cases

P&S: Primary and secondary

19

5,000 10,000 15,000 20,000 25,000 1994 1996 1998 2000 2002 2004 2006

Number of reported cases Year

Reported cases of P&S syphilis With and without syphilis elimination

Reported syphilis cases Reported syphilis cases w/o syphilis elimination funding

P&S: primary and secondary. Calculated by extrapolation of estimates published by Chesson & Owusu-Edusei, Soc Sci Med 2008.

Outline

 What has been the impact of STD programs?

• Illustration of STD rates with and without prevention efforts
• User-friendly tool for programs to estimate the economic benefits of

their prevention activities

 What investment is needed to make an appreciable change

in national STD rates?

• Illustration of future STD rates under different funding scenarios

 What is the effect of budget changes?

• User-friendly tool for programs to estimate the health and medical

cost impact of budget cuts, budget increases

20

Outline

 What has been the impact of STD programs?

• Illustration of STD rates with and without prevention efforts
• User-friendly tool for programs to estimate the economic benefits of

their prevention activities

 What investment is needed to make an appreciable change

in national STD rates?

• Illustration of future STD rates under different funding scenarios

 What is the effect of budget changes?

• User-friendly tool for programs to estimate the health and medical

cost impact of budget cuts, budget increases

29

30

500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 2010 2015 2020 2025

Combined number of reported cases Year

Combined reported cases of chlamydia, gonorrhea, and P&S syphilis

31

500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 2010 2015 2020 2025

Combined number of reported cases Year

Flat funding Assuming recent increases level off

• ver 10 years

Combined reported cases of chlamydia, gonorrhea, and P&S syphilis

32

500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 2010 2015 2020 2025

Combined number of reported cases Year

Flat funding +$162 million annually

Combined reported cases of chlamydia, gonorrhea, and P&S syphilis

33

500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 2010 2015 2020 2025

Combined number of reported cases Year

Flat funding +$162 million annually

Combined reported cases of chlamydia, gonorrhea, and P&S syphilis

+$324 million annually

34

500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 2010 2015 2020 2025

Combined number of reported cases Year

Flat funding +$162 million annually

Combined reported cases of chlamydia, gonorrhea, and P&S syphilis

+$324 million annually +$486 million annually

35

500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 2010 2015 2020 2025

Combined number of reported cases Year

Flat funding +$162 million annually

Combined reported cases of chlamydia, gonorrhea, and P&S syphilis

+$324 million annually +$486 million annually

Where did these estimates come from?

“64 percent of all the world's statistics are made up right there on the spot.”

• Todd Snider

Statistician’s Blues

Outline

 What has been the impact of STD programs?

• Illustration of STD rates with and without prevention efforts
• User-friendly tool for programs to estimate the economic benefits of

their prevention activities

 What investment is needed to make an appreciable change

in national STD rates?

• Illustration of future STD rates under different funding scenarios

 What is the effect of budget changes?

• User-friendly tool for programs to estimate the health and medical

cost impact of budget cuts, budget increases

37

38

S.P.A.C.E. MONKEY 1.0

STD Prevention Allocation Consequence Estimator

Click to Begin

TD) prevention programs to estimate the impact of changes in their budget. roduced by, this spreadsheet reflect the views of the authors and do not nters for Disease Control and Prevention.

39

Size of population served by STD program (all ages) Reported number of chlamydia cases Reported number of gonorrhea cases Reported number of syphilis cases (Primary, secondary, and early latent) Enter information in the white boxes

To begin, we need a little information about your program

Next screen Previous screen

40

Amount of budget decrease Amount of budget increase Enter information in one of the two white boxes below

This tool estimates the effect of a permanent change in your budget. Please enter the change in your budget in the appropriate box below.

Next screen Previous screen

41

Would you like to enter information about Disease Intervention Specialists (DIS) in your program, such as:

• Number of DIS in your program
• Average annual salary per DIS
• Number of STD patients interviewed per DIS per year
• Percentage of STD cases interviewed by DIS

YES N0

42

Input Default value Your value

Leave blank to use the default value

Number of Disease Intervention Specialists (DIS) employed Annual cost per DIS (salary plus fringe benefits)* 73,600 Annual number of STD cases interviewed per DIS 400 Percentage of chlamydia cases interviewed 12% Percentage of gonorrhea cases interviewed 17% Percentage of syphilis cases interviewed (Primary, secondary, and early latent) 89%

For each row in the table below, you can:

• Enter your own value in the white box,

OR

• Leave the white box blank to use the default value.

Next screen Previous screen

43

Year Percentage decrease in STDs due to budget increase Reduction in number of syphilis infections Reduction in number of gonorrhea infections Reduction in number of chlamydia infections Reduction in number

• f STD-

attributable HIV infections Reduction in STD costs Reduction in HIV costs Reduction in total costs (STD + HIV) Year 1 0.00% 0.0 $0 $0 $0 Year 2 0.00% 0.0 $0 $0 $0 Year 3 0.00% 0.0 $0 $0 $0 Year 4 0.00% 0.0 $0 $0 $0 Year 5 0.00% 0.0 $0 $0 $0 Year 6 0.00% 0.0 $0 $0 $0 Year 7 0.00% 0.0 $0 $0 $0 Year 8 0.00% 0.0 $0 $0 $0 Year 9 0.00% 0.0 $0 $0 $0 Year 10 0.00% 0.0 $0 $0 $0 10-year total 0.0 $0 $0 $0 Results: Estimated impact of change in STD prevention funding

See text summary of these results See advanced options Previous screen Return to start

44

Based on published evidence of the impact of STD prevention programs and the cost of STDs, a budget increase of $0 will result in:

• In the first year alone, there will be an estimated decrease of 0 cases of syphilis (range: 0 to 0), 0 cases of gonorrhea (range: 0 to 0), 0

cases of chlamydia (range: 0 to 0), and 0.0 cases of STD-attributable HIV (range: 0.0 to 0.0).

• Over 10 years, there will be an estimated cumulative decrease of 0 cases of syphilis (range: 0 to 0), 0 cases of gonorrhea (range: 0 to 0), 0

cases of chlamydia (range: 0 to 0), and 0.0 cases of STD-attributable HIV (range: 0 to 0).

• Over 10 years, there will be an estimated cumulative decrease in direct medical costs of $0 (range: 0 to 0) due to decreases in STIs and

STI-attributable HIV infections. With a budget increase of $0, positions for disease intervention specialists will be increased, resulting in:

• Additional DIS interviews or effective behavioral counseling for an estimated 0 patients with STDs.
• DIS are public health professionals who work to find people diagnosed with syphilis and other STDs. DIS work to find new cases of the

disease — and to prevent new ones from happening.

• In addition to STDs, DIS fight other disease outbreaks and epidemics, including Ebola, flu, anthrax, and SARS—with additional DIS, we

will be better prepared for emergencies.

• Since an estimated 1 in 4 DIS interviews identifies a new STD case, an estimated 0 people with syphilis, gonorrhea, or chlamydia will

become aware that they are infected, will be more likely to be treated, and will be less likely to spread STDs in their communities.

Results: Estimated impact of change in STD prevention funding

Previous screen

45

ADVANCED OPTIONS MENU

Change one or more of the background assumptions Go back to results Get more information about SPACE MONKEY calculations Change the calculation method See the complete lower bound and upper bound results

SPACE MONKEY calculation methods

Method 1: Historical formula approach Method 2: Disease Intervention Specialist (DIS) approach

Calculate change in budget, per capita Each 1 dollar change in budget per capita changes STD rates by 16% The new STD rate is calculated and phased in

• ver 10 years

Calculate the change in the number of DIS Calculate the change in DIS activities due to the change in DIS Each 10% change in DIS activities changes STD rates by 2% The new STD rate is calculated and phased in over 10 years

The historical formula is based on Chesson et al Eval Rev. 2005;29(1):3-23. The DIS approach is based on Du et al Sex Transm Dis. 2007;34(4):189-194. These methods are described in detail in Chesson, Ludovic, Berruti, and Gift (Sex Transm Dis, forthcoming)

47 Program management & evaluation tools

Summary

 Funding for STD prevention matters

• Analyses of historical, state-level data have demonstrated an

association between prevention funding and subsequent STD rates

• ↑ STD prevention funding, ↓ gonorrhea case rates
• ↑ syphilis elimination funding, ↓ syphilis case rates

 Although the impact of budget changes are difficult to

predict, published studies offer evidence-based estimates

 User-friendly Excel tools available to STD programs

• SPACE MONKEY allows programs to estimate the health and direct

medical cost impact of budget changes

• STIC – Figure allows programs to estimate the direct costs and

productivity losses averted by their program activities

48

For more information please contact 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 STD Prevention

Thank you

HChesson@cdc.gov

Per-capita funding model of syphilis prevention impact

Bottom line: 10 cents per capita of syphilis elimination funding was associated with decreases of 23% in reported rates of early syphilis

Chesson and Owusu-Edusei, Soc Sci Med 2008. Impact of funding shown in slide was adjusted to 2014 US dollars..

50

Per-capita funding model of syphilis prevention impact

 Decreases of 23% in syphilis incidence rates for every $0.10

per capita of prevention funding

 Advantages

• Simple and evidence-based
• Can provide illustrations of the benefits of targeting resources
• Consistent with dynamic transmission models when assuming

declining marginal effect of interventions

 Disadvantages

• Model based on ecological analysis
• Syphilis elimination effort mainly effective in reducing syphilis rates

among heterosexuals

• Approach assumes same marginal impact on syphilis in MSM

51

52

“Several published studies have provided evidence that the amount of resources allocated for the prevention of sexually transmitted diseases (STDs) does indeed have an effect on the incidence of STDs at the population level.1-6 “

• 1. Chesson HW, Harrison P, Scotton CR, Varghese B. Does funding for HIV and sexually transmitted disease prevention

matter? Evidence from panel data. Eval Rev 2005;29(1):3-23.

• 2. Chaulk CP, Zenilman J. Sexually transmitted disease control in the era of managed care: "magic bullet" or "shadow
• n the land"? J Public Health Manag Pract 1997;3(2):61-70.
• 3. Chesson H, Owusu-Edusei K, Jr. Examining the impact of federally-funded syphilis elimination activities in the USA.

Soc Sci Med 2008;67(12):2059-2062.

• 4. Du P, Coles FB, Gerber T, McNutt LA. Effects of partner notification on reducing gonorrhea incidence rate. Sex

Transm Dis 2007;34(4):189-194.

• 5. Brown ST, Wiesner PJ. Problems and approaches to the control and surveillance of sexually transmitted agents

associated with pelvic inflammatory disease in the United States. Am J Obstet Gynecol 1980;138(7 Pt 2):1096-1100.

• 6. Gallet CA. The impact of public health spending on California STD rates. Int Adv Econ Res 2017;23(2):149-159.

Chesson, Ludovic, Berruti, and Gift (Sex Transm Dis, forthcoming)

53

Several published studies have provided evidence that the amount of resources allocated for the prevention of sexually transmitted diseases (STDs) does indeed have an effect on the incidence of STDs at the population level.1-6

• 1. Chesson HW, Harrison P, Scotton CR, Varghese B. Does funding for HIV and sexually transmitted disease prevention

matter? Evidence from panel data. Eval Rev 2005;29(1):3-23.

• 2. Chaulk CP, Zenilman J. Sexually transmitted disease control in the era of managed care: "magic bullet" or "shadow
• n the land"? J Public Health Manag Pract 1997;3(2):61-70.
• 3. Chesson H, Owusu-Edusei K, Jr. Examining the impact of federally-funded syphilis elimination activities in the USA.

Soc Sci Med 2008;67(12):2059-2062.

• 4. Du P, Coles FB, Gerber T, McNutt LA. Effects of partner notification on reducing gonorrhea incidence rate. Sex

Transm Dis 2007;34(4):189-194.

• 5. Brown ST, Wiesner PJ. Problems and approaches to the control and surveillance of sexually transmitted agents

associated with pelvic inflammatory disease in the United States. Am J Obstet Gynecol 1980;138(7 Pt 2):1096-1100.

• 6. Gallet CA. The impact of public health spending on California STD rates. Int Adv Econ Res 2017;23(2):149-159.

Chesson, Ludovic, Berruti, and Gift (Sex Transm Dis, forthcoming)