Cost-effectiveness of the female condom in preventing HIV and STDs in commercial sex workers in rural South Africa

Perceived male partner attitudes toward the female condom predict female university students' use of the female condom

Female and male condoms are the only methods that prevent both sexually transmitted infections (STIs), including HIV, and unintended pregnancy. Despite continuing high STI rates, few studies investigate factors predicting whether women initiating female condom (FC) use sustain use. Using data from a randomized trial, we examined predictors of sustained FC use at five-month follow-up (FU2) among female university students in South Africa who participated in either a one-session, information-only, group-delivered Minimal Intervention or a two-session, group-delivered Enhanced Intervention. In the final multiple logistic regression model, believing one's partner holds positive attitudes toward the FC (aOR = 1.40; p = 0.028), and greater FC use for vaginal sex at previous assessment (aOR) = 1.19; p = 0.008) were associated with greater odds of FC use at FU2. Excluding number of FC-protected occasions at FU1 from the analysis, discussing FC use with partner (aOR = 2.89; p = 0.071) and believing one's partner holds positive attitudes toward the FC (aOR = 1.63; p < 0.001) were associated with greater odds of use at FU2. The FC empowers women to protect themselves from both STIs and unintended pregnancy, but targeted interventions are needed to address men's negative attitudes toward the device. Engaging men as FC champions to support and promote FC use, along with marketing campaigns targeted to men, may expand FC coverage and enhance uptake.

Cost effectiveness of HIV and sexual reproductive health interventions targeting sex workers: a systematic review

Background

Sex workers have high incidences of HIV and other sexually transmitted diseases. Although, interventions targeting sex workers have shown to be effective, evidence on which strategies are most cost-effective is limited. This study aims to systematically review evidence on the cost-effectiveness of sexual health interventions for sex workers on a global level. It also evaluates the quality of available evidence and summarizes the drivers of cost effectiveness.

Methods

A search of published articles until May 2018 was conducted. A search strategy consisted of key words, MeSH terms and other free text terms related to economic evaluation, sex workers and sexual and reproductive health (SRH) was developed to conduct literature search on Medline, Web of Science, Econlit and the NHS Economic Evaluation Database. The quality of reporting the evidence was evaluated using the CHEERS checklist and drivers of cost-effectiveness were reported.

Results

Overall, 19 studies met the inclusion criteria. The majority of the studies were based in middle-income countries and only three in low-income settings. Most of the studies were conducted in Asia and only a handful in Sub-Saharan Africa and Latin America. The reviewed studies mainly evaluated the integrated interventions, i.e. interventions consisted a combination of biomedical, structural or behavioural components. All interventions, except for one, were highly cost-effective. The reporting quality of the evidence was relatively good. The strongest drivers of cost-effectiveness, reported in the studies, were HIV prevalence, number of partners per sex worker and commodity costs. Furthermore, interventions integrated into existing health programs were shown to be most cost-effective.

Conclusion

This review found that there is limited economic evidence on HIV and SRH interventions targeting sex workers. The available evidence indicates that the majority of the HIV and SRH interventions targeting sex workers are highly cost-effective, however, more effort should be devoted to improving the quality of conducting and reporting cost-effectiveness evidence for these interventions to make them usable in policy making. This review identified potential factors that affect the cost-effectiveness and can provide useful information for policy makers when designing and implementing such interventions.

Electronic supplementary material

The online version of this article (10.1186/s12962-018-0165-0) contains supplementary material, which is available to authorized users.

Assessing the Potential Impact of Hormonal-Based Contraceptives on HIV Transmission Dynamics Among Heterosexuals

HIV susceptibility linked to hormonal contraception (HC) has been studied before, but with mixed results. Reports from some of the recent findings have prompted the World Health Organisation to encourage women who use HC to concurrently use condoms in order to prevent HIV infection in the light of possible increased HIV risk of infection associated with hormone-based contraceptives. A two-sex HIV model classifying women into three risk groups consisting of individuals who use condoms, natural methods, and hormone-based contraceptives is formulated and analysed to assess the possible effects of various birth control strategies on the transmission dynamics of the disease. Our model results showed that women who use HC could be key drivers of the epidemic and that their increased infectivity may be critical in driving the epidemic. Women who use hormone-based contraceptives potentially act as a core group from which men get infected and in turn transmit the disease to other population groups. We fitted the model to HIV prevalence data for Zimbabwe reported by UNAIDS and Zimbabwe Ministry of Health and Child Care and used the model fit to project HIV prevalence. Predictions using HIV data for Zimbabwe suggest that a hypothesised increase in susceptibility and infectivity of two-, three-, and fourfold would result in a 25, 50, and 100% increase in baseline HIV prevalence projection, respectively, thus suggesting possible increased disease burden even in countries reporting plausible HIV prevalence declines. Although a possible causal relationship between HIV susceptibility and HC use remains subject of continuing scientific probe, its inclusion as part of birth control strategy has been shown in this study, to possibly increase HIV transmission. If proven, HC use may potentially explain the inordinate spread of HIV within the sub-Saharan Africa region and therefore compel for urgent assessment with a view to reorienting birth control methods in use in settings with generalised epidemics.

Knowledge, attitudes, practices and behaviors associated with female condoms in developing countries: a scoping review

Women in developing countries are at high risk of HIV, sexually transmitted infections, and unplanned pregnancy. The female condom (FC) is an effective dual protective method regarded as a tool for woman’s empowerment, yet supply and uptake are limited. Numerous individual, socioeconomic, and cultural factors influence uptake of new contraceptive methods. We reviewed studies of FC knowledge, attitudes, practices, and behaviors across developing countries, as well as available country-level survey data, in order to identify overarching trends and themes. High acceptability was documented in studies conducted in diverse settings among male and female FC users, with FCs frequently compared favorably to male condoms. Furthermore, FC introduction has been shown to increase the proportion of “protected” sex acts in study populations, by offering couples additional choice. However, available national survey data showed low uptake with no strong association with method awareness, as well as inconsistent patterns of use between countries. We identified a large number of method attributes and contextual factors influencing FC use/nonuse, most of which were perceived both positively and negatively by different groups and between settings. Male partner objection was the most pervasive factor preventing initial and continued use. Importantly, most problems could be overcome with practice and adequate support. These findings demonstrate the importance of accounting for contextual factors impacting demand in FC programming at a local level. Ongoing access to counseling for initial FC users and adopters is likely to play a critical role in successful introduction.

Estimating the hypothetical dual health impact and cost-effectiveness of the Woman's Condom in selected sub-Saharan African countries

BACKGROUND

Female condoms are the only currently available woman-initiated option that offers dual protection from pregnancy and sexually transmitted infections, including HIV. The Woman's Condom is a new female condom designed to provide dual protection and to be highly pleasurable and acceptable.

OBJECTIVE

We sought to estimate the potential dual health impact and cost-effectiveness of a Woman's Condom distribution program in 13 sub-Saharan African countries with HIV prevalence rates >4% among adults aged 15-49 years. We used two separate, publicly available models for this analysis, the Impact 2 model developed by Marie Stopes International and the Population Services International disability-adjusted life years (DALY) calculator program. We estimated the potential numbers of pregnancies and DALYs averted when the Woman's Condom is used as a family planning method and the HIV infections and DALYs averted when it is used as an HIV prevention method.

RESULTS

Programming 100,000 Woman's Condoms in each of 13 countries in sub-Saharan Africa during a 1-year period could potentially prevent 194 pregnancies and an average of 21 HIV infections in each country. When using the World Health Organization CHOosing Interventions that are Cost-Effective (WHO-CHOICE) criteria as a threshold to infer the potential cost-effectiveness of the Woman's Condom, we found that the Woman's Condom would be considered cost-effective.

CONCLUSION

This was a first and successful attempt to estimate the impact of dual protection of female condoms. The health impact is greater for the use of the Woman's Condom as an HIV prevention method than for contraception. Dual use of the Woman's Condom increases the overall health impact. The Woman's Condom was found to be very cost-effective in all 13 countries in our sample.

An action agenda for HIV and sex workers

The women, men, and transgender people who sell sex globally have disproportionate risks and burdens of HIV in countries of low, middle, and high income, and in concentrated and generalised epidemic contexts. The greatest HIV burdens continue to be in African female sex workers. Worldwide, sex workers still face reduced access to needed HIV prevention, treatment, and care services. Legal environments, policies, police practices, absence of funding for research and HIV programmes, human rights violations, and stigma and discrimination continue to challenge sex workers' abilities to protect themselves, their families, and their sexual partners from HIV. These realities must change to realise the benefits of advances in HIV prevention and treatment and to achieve global control of the HIV pandemic. Effective combination prevention and treatment approaches are feasible, can be tailored for cultural competence, can be cost-saving, and can help to address the unmet needs of sex workers and their communities in ways that uphold their human rights. To address HIV in sex workers will need sustained community engagement and empowerment, continued research, political will, structural and policy reform, and innovative programmes. But such actions can and must be achieved for sex worker communities everywhere.

The cost and cost-effectiveness of gender-responsive interventions for HIV: a systematic review

INTRODUCTION

Harmful gender norms and inequalities, including gender-based violence, are important structural barriers to effective HIV programming. We assess current evidence on what forms of gender-responsive intervention may enhance the effectiveness of basic HIV programmes and be cost-effective.

METHODS

Effective intervention models were identified from an existing evidence review ("what works for women"). Based on this, we conducted a systematic review of published and grey literature on the costs and cost-effectiveness of each intervention identified. Where possible, we compared incremental costs and effects.

RESULTS

Our effectiveness search identified 36 publications, reporting on the effectiveness of 22 HIV interventions with a gender focus. Of these, 11 types of interventions had a corresponding/comparable costing or cost-effectiveness study. The findings suggest that couple counselling for the prevention of vertical transmission; gender empowerment, community mobilization, and female condom promotion for female sex workers; expanded female condom distribution for the general population; and post-exposure HIV prophylaxis for rape survivors are cost-effective HIV interventions. Cash transfers for schoolgirls and school support for orphan girls may also be cost-effective in generalized epidemic settings.

CONCLUSIONS

There has been limited research to assess the cost-effectiveness of interventions that seek to address women's needs and transform harmful gender norms. Our review identified several promising, cost-effective interventions that merit consideration as critical enablers in HIV investment approaches, as well as highlight that broader gender and development interventions can have positive HIV impacts. By no means an exhaustive package, these represent a first set of interventions to be included in the investment framework.

Community empowerment and involvement of female sex workers in targeted sexual and reproductive health interventions in Africa: a systematic review

Background

Female sex workers (FSWs) experience high levels of sexual and reproductive health (SRH) morbidity, violence and discrimination. Successful SRH interventions for FSWs in India and elsewhere have long prioritised community mobilisation and structural interventions, yet little is known about similar approaches in African settings. We systematically reviewed community empowerment processes within FSW SRH projects in Africa, and assessed them using a framework developed by Ashodaya, an Indian sex worker organisation.

Methods

In November 2012 we searched Medline and Web of Science for studies of FSW health services in Africa, and consulted experts and websites of international organisations. Titles and abstracts were screened to identify studies describing relevant services, using a broad definition of empowerment. Data were extracted on service-delivery models and degree of FSW involvement, and analysed with reference to a four-stage framework developed by Ashodaya. This conceptualises community empowerment as progressing from (1) initial engagement with the sex worker community, to (2) community involvement in targeted activities, to (3) ownership, and finally, (4) sustainability of action beyond the community.

Results

Of 5413 articles screened, 129 were included, describing 42 projects. Targeted services in FSW ‘hotspots’ were generally isolated and limited in coverage and scope, mostly offering only free condoms and STI treatment. Many services were provided as part of research activities and offered via a clinic with associated community outreach. Empowerment processes were usually limited to peer-education (stage 2 of framework). Community mobilisation as an activity in its own right was rarely documented and while most projects successfully engaged communities, few progressed to involvement, community ownership or sustainability. Only a few interventions had evolved to facilitate collective action through formal democratic structures (stage 3). These reported improved sexual negotiating power and community solidarity, and positive behavioural and clinical outcomes. Sustainability of many projects was weakened by disunity within transient communities, variable commitment of programmers, low human resource capacity and general resource limitations.

Conclusions

Most FSW SRH projects in Africa implemented participatory processes consistent with only the earliest stages of community empowerment, although isolated projects demonstrate proof of concept for successful empowerment interventions in African settings.

Prevalence of knowledge and use of the female condom in South Africa

Male condoms remain a key tool in preventing the spread of HIV and the female condom (FC) holds similar potential. Using data collected through a national cross-sectional population survey that was conducted in 2008, this report investigated the national prevalence of FC knowledge and use by sexually active males and females (n = 7,727) over the age of 15 years in South Africa, followed by a closer examination of the sexually active female population alone. Though knowledge of the FC among sexually active females over the age of 15 years (n = 4,551) was relatively high at 77.75 %, use was low at 7.16 %. The present study found statistically significant associations between knowledge or use of the FC and several demographic variables for females in South Africa. Having heard of the FC was consistently associated with locality, province, age, education level, marital status, and employment status. Use of the FC, however, was only associated with province and age group. Many demographic groups exhibited a high prevalence of knowledge but a low level of use; or conversely, a low prevalence of knowledge but a high level of use compared to their counterparts. Our findings support the need for a rigorous campaign to promote the use of FCs by women and also to increase their availability in public health sector facilities such as government clinics and hospitals in order to improve the chance of women using the FC, a cost-effective device that has the potential to protect both their rights and lives.

Identifying HIV most-at-risk groups in Malawi for targeted interventions. A classification tree model

OBJECTIVES

To identify HIV-socioeconomic predictors as well as the most-at-risk groups of women in Malawi.

DESIGN

A cross-sectional survey.

SETTING

Malawi

PARTICIPANTS

The study used a sample of 6395 women aged 15-49 years from the 2010 Malawi Health and Demographic Surveys.

INTERVENTIONS N/A PRIMARY AND SECONDARY OUTCOME MEASURES

Individual HIV status: positive or not.

RESULTS

Findings from the Pearson χ(2) and χ(2) Automatic Interaction Detector analyses revealed that marital status is the most significant predictor of HIV. Women who are no longer in union and living in the highest wealth quintiles households constitute the most-at-risk group, whereas the less-at-risk group includes young women (15-24) never married or in union and living in rural areas.

CONCLUSIONS

In the light of these findings, this study recommends: (1) that the design and implementation of targeted interventions should consider the magnitude of HIV prevalence and demographic size of most-at-risk groups. Preventive interventions should prioritise couples and never married people aged 25-49 years and living in rural areas because this group accounts for 49% of the study population and 40% of women living with HIV in Malawi; (2) with reference to treatment and care, higher priority must be given to promoting HIV test, monitoring and evaluation of equity in access to treatment among women in union disruption and never married or women in union aged 30-49 years and living in urban areas; (3) community health workers, households-based campaign, reproductive-health services and reproductive-health courses at school could be used as canons to achieve universal prevention strategy, testing, counselling and treatment.

The state of health economic research in South Africa: a systematic review

BACKGROUND

Economic factors are a limiting factor toward the implementation of many health programmes and interventions. Economic evaluation has a great potential to contribute toward cost-effective healthcare delivery in South Africa. Little is known about the characteristics and quality of health economic (including pharmacoeconomic) research in South Africa.

OBJECTIVE AND METHODS

This study assessed the state of health economic (including pharmacoeconomic) research in South Africa. PUBMED, MEDLINE, HealthSTAR, EconLit and PsycINFO databases were searched to identify health economic articles pertaining to South Africa published between 1 January 1977 and 30 April 2010. The searches used the following Medical Subject Headings (MeSH) terms and text words alone and in combination: 'costs', 'health' and 'South Africa'. Our study included only original economic studies/analyses that pertained to South Africa, addressed a health-related topic, and had a statement or word in the title, abstract or keywords that indicated that an economic (including cost) analysis had been conducted. The study only included complete peer-reviewed publications (e.g. abstracts were excluded) that were reported in the English language. Two reviewers independently scored each article in the final sample using the data collection form designed for the study.

RESULTS

In total, 108 studies investigating a wide variety of diseases were included in the study. These articles were published in 39 different journals mostly based outside of South Africa between 1977 and 2010. On average, each article was written by three authors. Most first authors had medical/clinical training and resided in South Africa at the time of publication of their study. Based on a 1-10 scale, with 10 indicating the highest quality, the mean quality score for all studies was 7.59 (SD 1.42) and half of the articles were of good quality (score 8-10) The quality of studies was related to the country in which the journal publishing the article was based (outside South Africa = higher); current residence of the primary author (outside South Africa = higher); method of economic analysis (economic evaluations higher than cost studies); type of data used (secondary higher than primary); primary training of the first author (health economics/pharmacoeconomics = higher); type of medical function (diagnosis = higher); study perspective (societal = higher); primary health intervention (pharmaceuticals = higher); study design (modelling = higher); number of authors (more = higher); and year of publication (more recent = higher) [p ≤ 0.05].

CONCLUSION

Half of the articles were of poor or fair quality. Measures are needed to promote the commissioning of more and better quality health economic and pharmacoeconomic studies in South Africa.

The cost-effectiveness of HIV voluntary counseling and testing in China

China has experienced a dramatic increase in the number of HIV infections. To control the AIDS epidemic, free HIV voluntary counseling and testing has been made available in China. This study compared the cost-effectiveness of this program for 2 populations-the general population and men who have sex with men (MSM), to examine the value for money of this program. A Bernoulli-process model has been used to translate the changes in sexual behaviors to the number of HIV infections averted. Costs are estimated from a societal perspective. The outcomes are measured in terms of the incremental cost per HIV infection averted and the incremental cost per disability-adjusted life-year averted. The study found that the voluntary counseling and testing for the general population is not cost-effective based on the threshold adopted, whereas the same HIV prevention program for MSM is cost-saving. These results suggest that the efficiency of resources used could be substantially improved by appropriately targeting high-risk population groups. Therefore measures should be taken to increase the uptake of this intervention among high-risk groups.

The cost-utility analysis of adult male circumcision for prevention of heterosexual acquisition of HIV in men in sub-Saharan Africa: a probabilistic decision model

OBJECTIVE

The aim of this study was to assess the cost-utility of adult male circumcision (AMC) versus no AMC in the prevention of heterosexual acquisition of HIV in men in sub-Saharan Africa.

METHODS

A decision tree was constructed and parameterized using data from published sources. The economic evaluation was conducted from the perspective of government health care payer. Benefits (disability adjusted life years [DALYs]) and costs were discounted at 3%. Costs were assessed in 2008 US dollars. One-way and probabilistic sensitivity analyses were conducted to assess the stability of the base-case results. The uncertainty surrounding the estimates of cost effectiveness was illustrated through a cost-effectiveness acceptability curve and cost-effectiveness plane.

RESULTS

In the base-case analysis, AMC can be regarded as cost saving because it is associated with higher DALYs gained and lower costs than no AMC. The probability that AMC is cost effective is above 0.96 at a threshold value of $150 and remains high over a wide range of threshold values. Thus, there is very little uncertainty surrounding the decision to adopt AMC for prevention of heterosexual acquisition of HIV in men. The results were found to be sensitive to varying any of the following parameters: DALYs averted, discount, and circumcision efficacy.

CONCLUSIONS

AMC is found to be cost saving. AMC may be seen as a promising new form of strategy for prevention of heterosexual acquisition of HIV in men, but should never replace other known methods of HIV prevention and should always be considered as part of a comprehensive HIV prevention package.

Can medicaid reimbursement help give female condoms a second chance in the United States?

The female condom is the only other barrier contraception method besides the male condom, and it is the only "woman-initiated" device for prevention of sexually transmitted infections. Although studies demonstrate high acceptability and effectiveness for this device, overall use in the United States remains low. The female condom has been available through Medicaid in many states since 1994. We provide the first published summary of data on Medicaid reimbursement for the female condom. Our findings demonstrate low rates of claims for female condoms but high rates of reimbursement. In light of the 2009 approval of a new, cheaper female condom and the recent passage of comprehensive health care reform, we call for research examining how health care providers can best promote consumer use of Medicaid reimbursement to obtain this important infection-prevention device.

Public health evaluation in the twenty-first century: time to see the wood as well as the trees

This paper argues that concepts, methodologies and practices within public health need further development if they are to be sufficient to allow us to develop, undertake and evaluate interventions in the twenty-first century. The public health profession, and the disciplines that contribute to it, maintains the historical focus upon detailed micro analysis (individual and health sector) and not broader macro analysis (societal and system). This brief paper suggests why this is and outlines three challenges it poses: specifying and evaluating outcomes; specifying and understanding complex causal pathways in social interventions and the development of multisector evaluation, to meet information demands from multiple stakeholders. While there is general agreement that public health evaluation needs development, this paper argues that the focus needs to be more upon a broader evaluative space than is currently practiced. There is a need to move beyond primary and secondary health-related effects upon individuals, and focus more on evaluation of the wider range and distribution of direct and indirect effects upon individuals, communities and populations. That is, those involved in public health evaluation need to step back and first consider the wood before focusing in on specific trees.

The costs of a sexually transmitted infection outreach and treatment programme targeting most at risk youth in Tajikistan

Background

Targeted outreach, counselling, and treatment of sexually transmitted infections (STIs) are among the most cost-effective interventions aimed at ameliorating the burden of HIV/STIs. Since many new HIV infections occur in people under the age of 25, youth, and especially most at risk adolescents (MARA), need to be able to access HIV/STI services. Starting in 2006, a programme targeting MARA including outreach, confidential and voluntary counselling and testing, and STI diagnosis and treatment was piloted in three cities in Tajikistan. This study uses data from these pilot sites to estimate the costs of a national programme.

Methods

Cost data were collected from the three pilot sites. Then, the target population and the number of patients receiving specific types of services are calculated for other areas. The unit costs from the pilot sites are multiplied by usage rates to determine the total costs of a national programme. Scenarios were developed to reflect data uncertainty. The government's ability to finance the programme was estimated using Ministry of Health budget data. Further analyses were done for one of the pilot cities where more detailed data were available.

Results

In total, costs were projected for eight programme sites, covering an estimated 8,020 MARA. Operational and variable cost for the programme are projected to be US$ 119,159 (range US$ 104,953 to 151,524) per year. Including annual equivalent cost for capital and start-up items raises this to US$ 137,082 (range: US$ 123,022 to 169,597) per year. The analyses of potential sources of financing for the programme remain inconclusive, but it may take multiple sources of financing to fund the programme.

Conclusion

While the cost-effectiveness of similar programmes have been previously assessed using modelled data, more work needs to be done to assess the costs of new programmes in relation to financial resources available. Full costing should consider cost-savings as well as expenditures. If feasible, the impact of the programme should be monitored over time.

A Bayesian approach to uncertainty analysis of sexually transmitted infection models

OBJECTIVES

To propose a Bayesian approach to uncertainty analysis of sexually transmitted infection (STI) models, which can be used to quantify uncertainty in model assessments of policy options, estimate regional STI prevalence from sentinel surveillance data and make inferences about STI transmission and natural history parameters.

METHODS

Prior distributions are specified to represent uncertainty regarding STI parameters. A likelihood function is defined using a hierarchical approach that takes account of variation between study populations, variation in diagnostic accuracy as well as random binomial variation. The method is illustrated using a model of syphilis, gonorrhoea, chlamydial infection and trichomoniasis in South Africa.

RESULTS

Model estimates of STI prevalence are in good agreement with observations. Out-of-sample projections and cross-validations also show that the model is reasonably well calibrated. Model predictions of the impact of interventions are subject to significant uncertainty: the predicted reductions in the prevalence of syphilis by 2020, as a result of doubling the rate of health seeking, increasing the proportion of private practitioners using syndromic management protocols and screening all pregnant women for syphilis, are 43% (95% CI 3% to 77%), 9% (95% CI 1% to 19%) and 6% (95% CI 4% to 7%), respectively.

CONCLUSIONS

This study extends uncertainty analysis techniques for fitted HIV/AIDS models to models that are fitted to other STI prevalence data. There is significant uncertainty regarding the relative effectiveness of different STI control strategies. The proposed technique is reasonable for estimating uncertainty in past STI prevalence levels and for projections of future STI prevalence.

Women in the time of AIDS: barriers, bargains, and benefits

We comment here on the implications of new HIV prevention technologies (physical and chemical barriers) for women's health and women's rights. Four relevant themes are selected that have emerged in the social and behavioral science literature: structural factors (global and national) limiting the availability of female condoms, control and empowerment with female-initiated HIV prevention technologies, covert use of female-initiated HIV prevention technologies, and male partners as part of the bargain for barriers. There is now a rich and diverse literature on all of these issues, relevant and informative (much is addressed in this issue), which we draw together in this commentary. Discussion of these themes suggests guidelines for policy, research, and action. First, the misconceptions, biases, and prejudices of global and national leaders, including donors, necessitate that we persevere in presenting data to them and engaging them in discussion. Second, we need to support women within their local social contexts to negotiate for their rights, balancing pragmatic approaches to their partners in their initiation of protection, and applying according to each situation as appropriate, a continuum from discretion and clandestine use to deception. Third, men have to be brought in as active participants, and their positive and negative experiences and interests inserted into practices and policies.

Cost-effectiveness of male circumcision for HIV prevention in a South African setting

BACKGROUND

Consistent with observational studies, a randomized controlled intervention trial of adult male circumcision (MC) conducted in the general population in Orange Farm (OF) (Gauteng Province, South Africa) demonstrated a protective effect against HIV acquisition of 60%. The objective of this study is to present the first cost-effectiveness analysis of the use of MC as an intervention to reduce the spread of HIV in sub-Saharan Africa.

METHODS AND FINDINGS

Cost-effectiveness was modeled for 1,000 MCs done within a general adult male population. Intervention costs included performing MC and treatment of adverse events. HIV prevalence was estimated from published estimates and incidence among susceptible subjects calculated assuming a steady-state epidemic. Effectiveness was defined as the number of HIV infections averted (HIA), which was estimated by dynamically projecting over 20 years the reduction in HIV incidence observed in the OF trial, including secondary transmission to women. Net savings were calculated with adjustment for the averted lifetime duration cost of HIV treatment. Sensitivity analyses examined the effects of input uncertainty and program coverage. All results were discounted to the present at 3% per year. For Gauteng Province, assuming full coverage of the MC intervention, with a 2005 adult male prevalence of 25.6%, 1,000 circumcisions would avert an estimated 308 (80% CI 189-428) infections over 20 years. The cost is 181 dollars (80% CI 117-306 dollars) per HIA, and net savings are 2.4 million dollars (80% CI 1.3 million to 3.6 million dollars). Cost-effectiveness is sensitive to the costs of MC and of averted HIV treatment, the protective effect of MC, and HIV prevalence. With an HIV prevalence of 8.4%, the cost per HIA is 551 dollars (80% CI 344-1,071 dollars) and net savings are 753,000 (80% CI 0.3 million to 1.2 million dollars). Cost-effectiveness improves by less than 10% when MC intervention coverage is 50% of full coverage.

CONCLUSIONS

In settings in sub-Saharan Africa with high or moderate HIV prevalence among the general population, adult MC is likely to be a cost-effective HIV prevention strategy, even when it has a low coverage. MC generates large net savings after adjustment for averted HIV medical costs.

Country-wide distribution of the nitrile female condom (FC2) in Brazil and South Africa: a cost-effectiveness analysis

OBJECTIVE

To evaluate the cost-effectiveness and potential impact of expanded female condom distribution.

DESIGN

Cost-effectiveness analysis assessing HIV infections averted annually and incremental cost per HIV infection averted for country-wide distribution of the nitrile female condom (FC2) among sexually active individuals, 15-49 years, with access to publicly distributed condoms in Brazil and South Africa.

RESULTS

In Brazil, expansion of FC2 distribution to 10% of current male condom use would avert an estimated 604 (5-95th percentiles, 412-831) HIV infections at 20,683 US dollars (5-95th percentiles, 13,497-29,521) per infection averted. In South Africa, 9577 (5-95th percentiles, 6539-13,270) infections could be averted, at 985 US dollars (5-95th percentiles, 633-1412) per infection averted. The estimated cost of treating one HIV-infected individual is 21,970 US dollars (5-95th percentiles, 18,369-25,719) in Brazil and 1503 US dollars (5-95th percentiles, 1245-1769) in South Africa, indicating potential cost savings. The incremental cost of expanded distribution would be reduced to 8930 US dollars (5-95th percentiles, 5864-13,163) per infection averted in Brazil and 374 US dollars (5-95th percentiles, 237-553) in South Africa by acquiring FC2s through a global purchasing mechanism and increasing distribution threefold. Sensitivity analyses show model estimates to be most sensitive to the estimated prevalence of sexually transmitted infections, total sexual activity, and fraction of FC2s properly used.

CONCLUSIONS

Expanded distribution of FC2 in Brazil and South Africa could avert substantial numbers of HIV infections at little or no net cost to donor or government agencies. FC2 may be a useful and cost-effective supplement to the male condom for preventing HIV.

Sex-work harm reduction

Sex work is an extremely dangerous profession. The use of harm-reduction principles can help to safeguard sex workers' lives in the same way that drug users have benefited from drug-use harm reduction. Sex workers are exposed to serious harms: drug use, disease, violence, discrimination, debt, criminalisation, and exploitation (child prostitution, trafficking for sex work, and exploitation of migrants). Successful and promising harm-reduction strategies are available: education, empowerment, prevention, care, occupational health and safety, decriminalisation of sex workers, and human-rights-based approaches. Successful interventions include peer education, training in condom-negotiating skills, safety tips for street-based sex workers, male and female condoms, the prevention-care synergy, occupational health and safety guidelines for brothels, self-help organisations, and community-based child protection networks. Straightforward and achievable steps are available to improve the day-to-day lives of sex workers while they continue to work. Conceptualising and debating sex-work harm reduction as a new paradigm can hasten this process.

Expanding safer sex options: introducing the female condom into national programmes

Although the female condom has been introduced into over 90 countries since 1997, it has only been accepted in sexual and reproductive health programmes as a mainstream method in a few. This paper describes introductory strategies developed by Ministries of Health and non-governmental organisations in Brazil, Ghana, Zimbabwe and South Africa, supported by UNAIDS, and the manufacturers of the female condom, which have significantly expanded the number of female condoms being used. These projects have several key similarities: a focus on training for providers and peer educators, face-to-face communication with potential users to equip them with information and skills, an identified target audience, a consistent supply, a long assessment period to gauge actual use beyond the initial novelty phase, and a mix of public and private sector distribution. Female condom programmes require the sanction, leadership and funding of governments and donors. However, the non-governmental and private sectors have also played a major role in programme implementation. To ensure successful introduction of the female condom, it is crucial to involve a range of decision-makers, programme managers, service providers, community leaders and women's and youth groups. The rising cost of inaction and unprotected sex in the spread of HIV and AIDS force us to recognise the high cost of not providing female condoms alongside male condoms in family planning and AIDS prevention programmes.

A comparison of cost-effectiveness of three protocols for diagnosis and treatment of gonococcal and chlamydial infections in women in Africa

BACKGROUND

The cost-effectiveness of different STD diagnosis and treatment approaches has not been evaluated previously.

GOALS

The goals of the study were to compare the cost-effectiveness of "gold standard" care (GS), syndromic management (SM), and mass treatment (MT) protocols for the treatment of cervical gonococcal and chlamydial infections in a hypothetical model of 1 million women in Africa.

STUDY DESIGN

A decision tree model was constructed for each of the protocols. Sensitivity analyses were conducted and 10,000 Monte Carlo simulations were run to test the robustness of the cost-effectiveness estimates to changes in underlying assumptions.

RESULTS

MT with doxycycline for chlamydia was the most cost-effective protocol in terms of cost per cure. SM protocol had the lowest total programmatic costs. For the GS protocol, using azithromycin for chlamydial infections was found to be more cost-effective than using doxycycline. For both the GS and SM protocols, the total cost of the program was most sensitive to the percentage of women seeking STD treatment and the prevalence of non-STD vaginal discharge, whereas the cost of MT was almost exclusively determined by coverage rates.

CONCLUSIONS

No single protocol carries with it all the desired conditions of an optimal cost-effective program. The treatment-seeking behavior, STD prevalence, and coverage of each locale must be evaluated to determine the most cost-effective and highest impact program. MT was found to be the most cost-effective protocol in terms of cost per woman treated when compared with the SM and GS protocols for STDs in women.

Patterns and predictors of female condom use among ethnically diverse women attending family planning clinics

BACKGROUND

The female condom is a viable option for women to protect themselves from HIV infection and other sexually transmitted diseases.

GOAL

The goal was to examine the level of female condom use and factors associated with frequency of use among US women living in San Francisco and Oakland, California.

STUDY DESIGN

Of 238 women recruited from family planning clinics from July 1998 to April 1999, 206 were interviewed at both baseline and 3-month follow-up (a 92% retention rate).

RESULTS

We observed a significant increase in vaginal sexual acts protected by the female condom during the study but no reduction in male condom use. Overall, 82% of women reported using a female condom at least once, but the proportion of sexual acts protected by the female condom was only 17%. Multivariate analyses showed that female condom use was associated with suggesting female condom use to one's partner, less concern about device appearance, and a partner's positive attitude about the female condom.

CONCLUSION

Our data indicate that female condom use supplements male condom use and leads to an increase in protected sex. The results also suggest that attitudinal and communication factors can increase female condom use.

HIV prevention before HAART in sub-Saharan Africa

Data on the cost-effectiveness of HIV prevention in sub-Saharan Africa and on highly active antiretroviral therapy (HAART) indicate that prevention is at least 28 times more cost effective than HAART. We aim to show that funding HAART at the expense of prevention means greater loss of life. To maximise health benefits, the next major increments of HIV funding in sub-Saharan Africa should be devoted mainly to prevention and to some non-HAART treatment and care. Funds should be allocated to HAART primarily for demonstration projects that will help prepare for scaled-up HAART provision following broad population coverage by prevention programmes. UNAIDS and the London School of Hygiene and Tropical Medicine recently estimated that at least US $9.2 billion annually is required to mount an appropriate response to the HIV pandemic, including substantial funding for HAART. To date, US $1.96 billion has been committed to the newly-established UN Global Fund to Fight AIDS, Tuberculosis, and Malaria. It is a moral imperative that expanded programmes to control HIV be implemented without delay, and that the goal of US $9.2 billion or more in annual spending be attained as rapidly as possible. The findings and recommendations of this analysis pertain to the phasing in of additional HIV-related activities during the current period of improved but inadequate funding.