Optimizing resource allocation for HIV/AIDS prevention programmes: an analytical framework

Sustainability of the Effects and Impacts of Using Digital Technology to Extend Maternal Health Services to Rural and Hard-to-Reach Populations: Experience From Southwest Nigeria

Background

Nigeria has one of the worst health and development profiles globally. A weak health system, poor infrastructure, and varied socio-cultural factors are cited as inhibitors to optimal health system performance and improved maternal and child health status. eHealth has become a major solution to closing these gaps in health care delivery in low- and middle-income countries (LMICs). This research reports the use of satellite communication (SatCom) technology and the existing 3G mobile network for providing video training (VTR) for health workers and improving the digitization of healthcare data.

Objective

To evaluate whether the expected project outcomes that were achieved at the end-line evaluation of 2019 were sustained 12 months after the project ended.

Methods

From March 2017 to March 2019, digital innovations including VTR and data digitization interventions were delivered in 62 healthcare facilities in Ondo State, southwest Nigeria, most of which lacked access to a 3G mobile network. Data collection for the evaluation combined documents' review with quantitative data extracted from health facility registers, and 24 of the most significant change stories to assess the longevity of the outcomes and impacts of digital innovation in the four domains of healthcare: use of eHealth technology for data management, utilization of health facilities by patients, the standard of care, and staff attitude. Stories of the most significant changes were audio-recorded, transcribed for analysis, and categorized by the above domains to identify the most significant changes 12 months after the project closedown.

Results

Findings showed that four project outcomes which were achieved at end-line evaluation were sustained 12 months after project closedown namely: staff motivation and satisfaction; increased staff confidence to perform healthcare roles; improved standard of healthcare delivery; and increased adoption of eHealth innovations beyond the health sector. Conversely, an outcome that was reversed following the discontinuation of SatCom from health facilities is the availability of accurate and reliable data for decision-making.

Conclusion

Digital technology can have lasting impacts on health workers, patients, and the health system, through improving data management for decision-making, the standard of maternity service delivery, boosting attendance at health facilities, and utilization of services. Locally driven investment is essential for ensuring the long-term survival of eHealth projects to achieve sustainable development goals (SDGs) in LMICs.

Management practices in community-based HIV prevention organizations in Nigeria

Background

Nigeria has one of the largest Human Immunodeficiency Virus (HIV) epidemics in the world. Addressing the epidemic of HIV in such a high-burden country has necessitated responses of a multidimensional nature. Historically, community-based organizations (CBOs) have played an essential role in targeting key populations (eg. men who have sex with men, sex workers) that are particularly burdened by HIV. CBOs are an essential part of the provision of health services in sub-Saharan Africa, but very little is known about the management practices of CBOs that provide HIV prevention interventions.

Methods

We interviewed 31 CBO staff members and other key stakeholders in January 2017 about management practices in CBOs. Management was conceptualized under the classical management process perspective; these four management phases—planning, organizing, leading, and evaluating—guided the interview process and code development. Data analysis was conducted thematically using Atlas.ti software. The protocol was approved by the ethics committees of the National Institute of Public Health of Mexico (INSP), the National Agency for the Control of AIDS in Nigeria (NACA), and the Nigerian Institute for Medical Research (NIMR).

Results

We found that CBOs implement variable management practices that can either hinder or facilitate the efficient provision of HIV prevention services. Long-standing CBOs had relatively strong organizational infrastructure and capacity that positively influenced service planning. In contrast, fledgling CBOs were deficient of organizational infrastructure and lacked program planning capacity. The delivery of HIV services can become more efficient if management practices are taken into account.

Conclusions

The delivery of HIV services by CBOs in Nigeria was largely influenced by inherent issues related to skills, organizational structure, talent retention, and sanction application. These, in turn, affected management practices such as planning, organizing, leading, and evaluating. This study shows that KP-led CBOs are evolving and have strong potentials and capacity for growth, and can become more efficient and effective if attention is paid to issues such as hierarchy, staff recruitment, and talent retention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06494-1.

Efficiency, quality, and management practices in health facilities providing outpatient HIV services in Kenya, Nigeria, Rwanda, South Africa and Zambia

Few studies have assessed the efficiency and quality of HIV services in low-resource settings or considered the factors that determine both performance dimensions. To provide insights on the performance of outpatient HIV prevention units, we used benchmarking methods to identify best-practices in terms of technical efficiency and process quality and uncover management practices with the potential to improve efficiency and quality. We used data collected in 338 facilities in Kenya, Nigeria, Rwanda, South Africa, and Zambia. Data envelopment analysis (DEA) was used to estimate technical efficiency. Process quality was estimated using data from medical vignettes. We mapped the relationship between efficiency and quality scores and studied the managerial determinants of best performance in terms of both efficiency and quality. We also explored the relationship between management factors and efficiency and quality independently. We found levels of both technical efficiency and process quality to be low, though there was substantial variation across countries. One third of facilities were mapped in the best-performing group with above-median efficiency and above-median quality. Several management practices were associated with best performance in terms of both efficiency and quality. When considering efficiency and quality independently, the patterns of associations between management practices and the two performance dimensions were not necessarily the same. One management characteristic was associated with best performance in terms of efficiency and quality and also positively associated with efficiency and quality independently: number of supervision visits to HIV units.

Optimization Models for HIV/AIDS Resource Allocation: A Systematic Review

OBJECTIVE

This study reviews optimization models for human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) resource allocation.

METHODS

We searched 2 databases for peer-reviewed articles published from January 1985 through August 2019 that describe optimization models for resource allocation in HIV/AIDS. We included models that consider 2 or more competing HIV/AIDS interventions. We extracted data on selected characteristics and identified similarities and differences across models. We also assessed the quality of mathematical disease transmission models based on the best practices identified by a 2010 task force.

RESULTS

The final qualitative synthesis included 23 articles that used 14 unique optimization models. The articles shared several characteristics, including the use of dynamic transmission modeling to estimate health benefits and the inclusion of specific high-risk groups in the study population. The models explored similar HIV/AIDS interventions that span primary and secondary prevention and antiretroviral treatment. Most articles were focused on sub-Saharan African countries (57%) and the United States (39%). There was notable variation in the types of optimization objectives across the articles; the most common was minimizing HIV incidence or maximizing infections averted (87%). Articles that utilized mathematical modeling of HIV disease and transmission displayed variable quality.

CONCLUSIONS

This systematic review of the literature identified examples of optimization models that have been applied in different settings, many of which displayed similar features. There were similarities in objective functions across optimization models, but they did not align with global HIV/AIDS goals or targets. Future work should be applied in countries facing the largest declines in HIV/AIDS funding.

A 4D Indicator System of Count, P Rate, G Rate and PG Rate for Epidemiology and Global Health

How to end the HIV/AIDS epidemic is a typical global health question since the impact of HIV/AIDS is global and it cannot be ended without collaborative global effort. In this chapter, a new measurement system is introduced to inform HIV/AIDS control cross the globe. All countries with data available on area size, total population and total number of persons living with HIV (PLWH) were included, yielding a sample of 148 countries. Four indicators, including the total count, population-based p rate, geographic area-based g rate and population and geographic area-based pg rate were used as a 4D system to describe the global HIV epidemic. The total PLWH count provided data informing resource allocation for individual countries to improve HIV/AIDS care; and the top five countries with highest PLWH count were South Africa, Nigeria, India, Kenya, and Mozambique. Information from the remaining three indicators provided a global risk profile of the HIV epidemic, supporting HIV/AIDS prevention programming strategies. Five countries with highest p rates were Swaziland, Botswana, Lesotho, South Africa, and Zimbabwe; five countries with highest g rates were Swaziland, Malawi, Lesotho, Rwanda, and Uganda; and five countries with highest pg rates were Barbados, Swaziland, Lesotho, Malta, and Mauritius. According to pg rates, two HIV hotspots (south and middle Africa and Caribbean region) and one HIV belt across Euro-Asian were identified. In addition to HIV/AIDS, the 4D measurement system can be used to describe morbidity and mortality for many diseases across the globe. We recommend the use of this measurement system in research to address significant global health and epidemiologic issues.

The influence of constraints on the efficient allocation of resources for HIV prevention

OBJECTIVE

To investigate how 'real-world' constraints on the allocative and technical efficiency of HIV prevention programmes affect resource allocation and the number of infections averted.

DESIGN

Epidemiological modelling and economic analyses in Benin, South Africa and Tanzania.

METHODS

We simulated different HIV prevention programmes, and first determined the most efficient allocation of resources, in which the HIV prevention budget is shared among specific interventions, risk-groups and provinces to maximize the number of infections averted. We then identified the efficient allocation of resources and achievable impact given the following constraints to allocative efficiency: earmarking [provinces with budgets fund pre-exposure prophylaxis (PrEP) for low-risk women first], meeting targets [provinces with budgets fund universal test-and-treat (UTT) first] and minimizing changes in the geographical distribution of funds. We modelled technical inefficiencies as a reduction in the coverage of PrEP or UTT, which were factored into the resource allocation process or took effect following the allocation. Each scenario was investigated over a range of budgets, such that the impact reaches its maximum.

RESULTS

The 'earmarking', 'meeting targets' and 'minimizing change' constraints reduce the potential impact of HIV prevention programmes, but at the higher budgets these constraints have little to no effect (approximately 35 billion US$ in Tanzania). Over-estimating technical efficiency can result in a loss of impact compared to what would be possible if technical efficiencies were known accurately.

CONCLUSION

Failing to account for constraints on allocative and technical efficiency can result in the overestimation of the health gains possible, and for technical inefficiencies the allocation of an inefficient strategy.

Poverty as a barrier to antiretroviral therapy access for people living with HIV/AIDS in Kenya

Understanding barriers to access to essential health services is critical for devising effective strategies to improve access and align such strategies with national health and development policy objectives. However, while considerable empirical evidence exists on correlates of HIV prevalence and populations at risk of contracting HIV, there is very little such evidence on access to antiretroviral therapy. This paper addresses this gap through a cross-sectional analysis of coverage of antiretroviral therapy and its correlates across 47 counties in Kenya. It considers health-sector and social factors, and applying instrumental variables to address error-in-variables and reverse-causality issues regarding HIV prevalence. Poverty was the most robust and - statistically and substantially - significant determinant of treatment coverage. The gap in treatment coverage between the poorest and richest counties amounted to about 40 percentage points and has not narrowed between 2012 and 2015. Health sector capacities independently played a role and exacerbated the poverty gap. For Kenya, the results suggest that policies on expanding treatment access need to be differentiated across counties to greatest effect and to align the HIV/AIDS response with national health and social policy objectives. Regarding global HIV/AIDS policies, the findings suggest a need to recognise "people left behind" owing to socio-economic and specifically poverty-related barriers to access to services.

HIV prevention costs and their predictors: evidence from the ORPHEA Project in Kenya

We estimate costs and their predictors for three HIV prevention interventions in Kenya: HIV testing and counselling (HTC), prevention of mother-to-child transmission (PMTCT) and voluntary medical male circumcision (VMMC). As part of the 'Optimizing the Response of Prevention: HIV Efficiency in Africa' (ORPHEA) project, we collected retrospective data from government and non-governmental health facilities for 2011-12. We used multi-stage sampling to determine a sample of health facilities by type, ownership, size and interventions offered totalling 144 sites in 78 health facilities in 33 districts across Kenya. Data sources included key informants, registers and time-motion observation methods. Total costs of production were computed using both quantity and unit price of each input. Average cost was estimated by dividing total cost per intervention by number of clients accessing the intervention. Multivariate regression methods were used to analyse predictors of log-transformed average costs. Average costs were $7 and $79 per HTC and PMTCT client tested, respectively; and $66 per VMMC procedure. Results show evidence of economies of scale for PMTCT and VMMC: increasing the number of clients per year by 100% was associated with cost reductions of 50% for PMTCT, and 45% for VMMC. Task shifting was associated with reduced costs for both PMTCT (59%) and VMMC (54%). Costs in hospitals were higher for PMTCT (56%) in comparison to non-hospitals. Facilities that performed testing based on risk factors as opposed to universal screening had higher HTC average costs (79%). Lower VMMC costs were associated with availability of male reproductive health services (59%) and presence of community advisory board (52%). Aside from increasing production scale, HIV prevention costs may be contained by using task shifting, non-hospital sites, service integration and community supervision.

Getting it right when budgets are tight: Using optimal expansion pathways to prioritize responses to concentrated and mixed HIV epidemics

Background

Prioritizing investments across health interventions is complicated by the nonlinear relationship between intervention coverage and epidemiological outcomes. It can be difficult for countries to know which interventions to prioritize for greatest epidemiological impact, particularly when budgets are uncertain.

Methods

We examined four case studies of HIV epidemics in diverse settings, each with different characteristics. These case studies were based on public data available for Belarus, Peru, Togo, and Myanmar. The Optima HIV model and software package was used to estimate the optimal distribution of resources across interventions associated with a range of budget envelopes. We constructed “investment staircases”, a useful tool for understanding investment priorities. These were used to estimate the best attainable cost-effectiveness of the response at each investment level.

Findings

We find that when budgets are very limited, the optimal HIV response consists of a smaller number of ‘core’ interventions. As budgets increase, those core interventions should first be scaled up, and then new interventions introduced. We estimate that the cost-effectiveness of HIV programming decreases as investment levels increase, but that the overall cost-effectiveness remains below GDP per capita.

Significance

It is important for HIV programming to respond effectively to the overall level of funding availability. The analytic tools presented here can help to guide program planners understand the most cost-effective HIV responses and plan for an uncertain future.

Voluntary Medical Male Circumcision for HIV Prevention in Malawi: Modeling the Impact and Cost of Focusing the Program by Client Age and Geography

Background

In 2007, the World Health Organization (WHO) recommended scaling up voluntary medical male circumcision (VMMC) in priority countries with high HIV prevalence and low male circumcision (MC) prevalence. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), an estimated 5.8 million males had undergone VMMC by the end of 2013. Implementation experience has raised questions about the need to refocus VMMC programs on specific subpopulations for the greatest epidemiological impact and programmatic effectiveness. As Malawi prepared its national operational plan for VMMC, it sought to examine the impacts of focusing on specific subpopulations by age and region.

Methods

We used the Decision Makers’ Program Planning Toolkit, Version 2.0, to study the impact of scaling up VMMC to different target populations of Malawi. National MC prevalence by age group from the 2010 Demographic and Health Survey was scaled according to the MC prevalence for each district and then halved, to adjust for over-reporting of circumcision. In-country stakeholders advised a VMMC unit cost of $100, based on implementation experience. We derived a cost of $451 per patient-year for antiretroviral therapy from costs collected as part of a strategic planning exercise previously conducted in- country by UNAIDS.

Results

Over a fifteen-year period, circumcising males ages 10–29 would avert 75% of HIV infections, and circumcising males ages 10–34 would avert 88% of infections, compared to the current strategy of circumcising males ages 15–49. The Ministry of Health’s South West and South East health zones had the lowest cost per HIV infection averted. Moreover, VMMC met WHO’s definition of cost-effectiveness (that is, the cost per disability-adjusted life-year [DALY] saved was less than three times the per capita gross domestic product) in all health zones except Central East. Comparing urban versus rural areas in the country, we found that circumcising men in urban areas would be both cost-effective and cost-saving, with a VMMC cost per DALY saved of $120 USD and with 15 years of VMMC implementation resulting in lifetime HIV treatment costs savings of $331 million USD.

Conclusions

Based on the age analyses and programmatic experience, Malawi’s VMMC operational plan focuses on males ages 10–34 in all districts in the South East and South West zones, as well as Lilongwe (an urban district in the Central zone). This plan covers 14 of the 28 districts in the country.

Outreach strategies for the promotion of HIV testing and care: closing the gap between health services and female sex workers in Benin

BACKGROUND

Regular voluntary counseling and testing is a key component of the fight against HIV/AIDS. In Benin, the project SIDA-1/2/3 established to decrease HIV/sexually transmitted infection (STIs) among female sex workers (FSWs), implemented a multifaceted intervention, including outreach activities. The objective of this article was to present potential advantages and limitations of 3 categories of outreach interventions designed to increase the use of testing services among FSWs in Benin.

METHODS

This analysis is based on ethnographic fieldwork conducted in Benin from June to December 2012.

RESULTS

Sixty-six FSWs and 24 health care workers were interviewed. Their narratives revealed 3 main factors impeding the development of appropriate HIV testing behavior. These negative elements can be positioned along a continuum of health care behaviors, with each stage of this continuum presenting its own challenges: fear or lack of motivation to use testing services, inaccessibility of care when the decision to go has been made, and a perceived lack of quality in the care offered at the health care center. Many of these needs seem to be addressed in the outreach strategies tested. However, the study also exposed some potential barriers or limitations to the success of these strategies when applied in this specific context, due to social disruption, mobility, access to care, and hard to reach population.

CONCLUSIONS

To increase the use of testing services, an outreach strategy based on community workers or peer educators, along with improved access to testing services, would be well adapted to this context and appreciated by both FSWs and health care workers.

Scaling-up HIV responses with key populations in West Africa

BACKGROUND

Despite decades of HIV responses in pockets of West and Central Africa (WCA), the HIV response with key populations remains an understudied area. Recently, there has been a proliferation of studies highlighting epidemiologic and behavioral data that challenge attitudes of complacency among donors and country governments uncomfortable in addressing key populations.

METHODS

The articles in this series highlight new studies that provide a better understanding of the epidemiologic and structural burden facing key populations in the WCA region and how to improve responses through more effective targeting.

RESULTS

Key populations face pervasive structural barriers including institutional and sexual violence and an intersection of stigma, criminalization, and marginalization as sexual minorities. Despite decades of smaller interventions that have shown the importance of integrated services for key populations, there remains incongruent provision of outreach or testing or family planning pointing to sustained risk. There remains an incongruent resource provision for key populations where they shoulder the burden of HIV and their access to services alone could turn around HIV epidemics within the region.

CONCLUSIONS

These proximal and distal determinants must be addressed in regional efforts, led by the community, and resourced for scale, targeting those most at risk for the acquisition and transmission of HIV. This special issue builds the knowledge base for the region focusing on interventions that remove barriers to service access including treatment uptake for those living with HIV. Better analysis and use of data for strategic planning are shown to lead to more effective targeting of prevention, care, and HIV treatment programs with key populations. These articles further demonstrate the immediate need for comprehensive action to address HIV among key populations throughout the WCA region.

Assessing cost and technical efficiency of HIV prevention interventions in sub-Saharan Africa: the ORPHEA study design and methods

BACKGROUND

Scaling up services to achieve HIV targets will require that countries optimize the use of available funding. Robust unit cost estimates are essential for the better use of resources, and information on the heterogeneity in the unit cost of delivering HIV services across facilities - both within and across countries - is critical to identifying and addressing inefficiencies. There is limited information on the unit cost of HIV prevention services in sub-Saharan Africa and information on the heterogeneity within and across countries and determinants of this variation is even more scarce. The "Optimizing the Response in Prevention: HIV Efficiency in Africa" (ORPHEA) study aims to add to the empirical body of knowledge on the cost and technical efficiency of HIV prevention services that decision makers can use to inform policy and planning.

METHODS/DESIGN

ORPHEA is a cross-sectional observational study conducted in 304 service delivery sites in Kenya, Rwanda, South Africa, and Zambia to assess the cost, cost structure, cost variability, and the determinants of efficiency for four HIV interventions: HIV testing and counselling (HTC), prevention of mother-to-child transmission (PMTCT), voluntary medical male circumcision (VMMC), and HIV prevention for sex workers. ORPHEA collected information at three levels (district, facility, and individual) on inputs to HIV prevention service production and their prices, outputs produced along the cascade of services, facility-level characteristics and contextual factors, district-level factors likely to influence the performance of facilities as well as the demand for HIV prevention services, and information on process quality for HTC, PMTCT, and VMMC services.

DISCUSSION

ORPHEA is one of the most comprehensive studies on the cost and technical efficiency of HIV prevention interventions to date. The study applied a robust methodological design to collect comparable information to estimate the cost of HTC, PMTCT, VMMC, and sex worker prevention services in Kenya, Rwanda, South Africa, and Zambia, the level of efficiency in the current delivery of these services, and the key determinants of efficiency. The results of the study will be important to decision makers in the study countries as well as those in countries facing similar circumstances and contexts.

A systematic review of the effectiveness and cost-effectiveness of peer-based interventions to maintain and improve offender health in prison settings

Background

Offender health is deemed a priority issue by the Department of Health. Peer support is an established feature of prison life in England and Wales; however, more needs to be known about the effectiveness of peer-based interventions to maintain and improve health in prison settings.

Objectives

The study aimed to synthesise the evidence on peer-based interventions in prison settings by carrying out a systematic review and holding an expert symposium. Review questions were (1) what are the effects of peer-based interventions on prisoner health and the determinants of prisoner health?, (2) what are the positive and negative impacts on health services within prison settings of delivering peer-based interventions?, (3) how do the effects of peer-based approaches compare with those of professionally led approaches? and (4) what are the costs and cost-effectiveness of peer-based interventions in prison settings?

Data sources

For the systematic review, 20 electronic databases including MEDLINE, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature and EMBASE were searched from 1985. Grey literature and relevant websites were also searched. To supplement the review findings 58 delegates, representing a variety of organisations, attended an expert symposium, which provided contextual information.

Review methods

Two reviewers independently selected studies using the following inclusion criteria: population – prisoners resident in prisons and young offender institutions; intervention – peer-based interventions; comparators: review questions 3 and 4 compared peer-led and professionally led approaches; outcomes – prisoner health or determinants of health, organisational/process outcomes or views of prison populations; study design: quantitative, qualitative and mixed-methods evaluations. Two reviewers extracted data and assessed validity using piloted electronic forms and validity assessment criteria based on published checklists. Results from quantitative studies were combined using narrative summary and meta-analysis when appropriate; results from qualitative studies were combined using thematic synthesis.

Results

A total of 15,320 potentially relevant papers were identified of which 57 studies were included in the effectiveness review and one study was included in the cost-effectiveness review; most were of poor methodological quality. A typology of peer-based interventions was developed. Evidence suggested that peer education interventions are effective at reducing risky behaviours and that peer support services provide an acceptable source of help within the prison environment and have a positive effect on recipients; the strongest evidence came from the Listener scheme. Consistent evidence from many predominantly qualitative studies suggested that being a peer deliverer was associated with positive effects across all intervention types. There was limited evidence about recruitment of peer deliverers. Recurring themes were the importance of prison managerial and staff support for schemes to operate successfully, and risk management. There was little evidence on the cost-effectiveness of peer-based interventions. An economic model, developed from the results of the effectiveness review, although based on data of variable quality and a number of assumptions, showed the cost-effectiveness of peer-led over professionally led education in prison for the prevention of human immunodeficiency virus (HIV) infection.

Limitations

The 58 included studies were, on the whole, of poor methodological quality.

Conclusions

There is consistent evidence from a large number of studies that being a peer worker is associated with positive health. Peer support services can also provide an acceptable source of help within the prison environment and can have a positive effect on recipients. This was confirmed by expert evidence. Research into cost-effectiveness is sparse but a limited HIV-specific economic model, although based on a number of assumptions and evidence of variable quality, showed that peer interventions were cost-effective compared with professionally led interventions. Well-designed intervention studies are needed to provide robust evidence including assessing outcomes for the target population, economic analysis of cost-effectiveness and impacts on prison health services. More research is needed to examine issues of reach, utilisation and acceptability from the perspective of recipients and those who choose not to receive peer support.

Study registration

This study was registered as PROSPERO CRD42012002349.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Indices to measure risk of HIV acquisition in Rakai, Uganda

Introduction

Targeting most-at-risk individuals with HIV preventive interventions is cost-effective. We developed gender-specific indices to measure risk of HIV among sexually active individuals in Rakai, Uganda.

Methods

We used multivariable Cox proportional hazards models to estimate time-to-HIV infection associated with candidate predictors. Reduced models were determined using backward selection procedures with Akaike's information criterion (AIC) as the stopping rule. Model discrimination was determined using Harrell's concordance index (c index). Model calibration was determined graphically. Nomograms were used to present the final prediction models.

Results

We used samples of 7,497 women and 5,783 men. 342 new infections occurred among females (incidence 1.11/100 person years,) and 225 among the males (incidence 1.00/100 person years). The final model for men included age, education, circumcision status, number of sexual partners, genital ulcer disease symptoms, alcohol use before sex, partner in high risk employment, community type, being unaware of a partner's HIV status and community HIV prevalence. The Model's optimism-corrected c index was 69.1 percent (95% CI = 0.66, 0.73). The final women's model included age, marital status, education, number of sex partners, new sex partner, alcohol consumption by self or partner before sex, concurrent sexual partners, being employed in a high-risk occupation, having genital ulcer disease symptoms, community HIV prevalence, and perceiving oneself or partner to be exposed to HIV. The models optimism-corrected c index was 0.67 (95% CI = 0.64, 0.70). Both models were well calibrated.

Conclusion

These indices were discriminative and well calibrated. This provides proof-of-concept that population-based HIV risk indices can be developed. Further research to validate these indices for other populations is needed.

Empirical evidence of the continuing improvement in cost efficiency of an endoscopic surveillance programme for gastric cancer in Singapore from 2004 to 2010

Background

Endoscopic surveillance has been proven effective in prolonging the survival of gastric cancer (GC) patients. However, there is limited evidence on the cost efficiency of delivering this intervention, especially on a national level in spite of cost efficiency being a major determinant of the actual cost-effectiveness of a cancer prevention programme. The Singapore Gastric Cancer Epidemiology Clinical and Genetic Programme (GCEP) is a demonstration project offering scheduled endoscopy to the Chinese population aged 50 years or older in Singapore. By assessing the cost efficiency of the GCEP, this study aimed to provide empirical evidence on the cost structure and mechanisms underlying cost generation in conducting GC surveillance, thus informing resource allocation and programme budgeting for the Singapore government.

Methods

From a societal perspective, we reported on the direct cost (resource consumption) of conducting endoscopic surveillance through the GCEP network. We retrospectively collected individual-level data of 216 subjects recruited at the National University Hospital, Singapore from 01/04/2004 to 31/10/2010. The Overall Cost, Clinical Cost, GCEP Cost and Personal Cost incurred in serving one subject was computed and discounted as 2004 US dollar (US$) per capita for every year. The Generalized Estimation Equation (GEE) was used to model the data.

Results

All cost indices continuously declined over the 6.5-year costing period. For the total sample, Overall Cost, Clinical Cost, GCEP Cost and Personal Cost declined by 42.3%, 54.1%, 30% and 25.7% respectively. This downward trend existed for age and gender subgroups and the high risk group only with cost reductions varying between 3.5% and 58.4%. The GEE models confirmed statistical significance of the downward trend and of its association with risk profile, where the moderate risk group had cost indices at most 77% of the high risk group.

Conclusions

Our study offered empirical evidence of improved cost efficiency of a surveillance programme for GC in the early phase of programme implementation. Mechanisms such as economies of scale and self-learning were found to be involved in the cost reduction. Our findings highlighted the importance of assessing the cost efficiency and offered valuable insights for future programme budgeting and policy making.

Prevention of Parent to Child Transmission (PPTCT) program data in India: an emerging data set for appraising the HIV epidemic

BACKGROUND

Evidence based resource allocation and decentralized planning of an effective HIV/AIDS response requires reliable information on levels and trends of HIV at national and sub-national geographic levels. HIV sentinel surveillance data from antenatal clinics (HSS-ANC) has been an important data source to assess the HIV/AIDS epidemic in India, but has a number of limitations. We assess the value of Prevention of Parent to Child Transmission (PPTCT) programme data to appraise the HIV epidemic in India.

METHODS/FINDINGS

HIV data from PPTCT sites were compared to HSS-ANC and general population level surveys at various geographic levels in the states of Karnataka, Maharashtra and Andhra Pradesh. Chi-square tests were used to ascertain statistical significance. PPTCT HIV prevalence was significantly lower than HSS-ANC HIV prevalence (0.92% vs. 1.22% in Andhra Pradesh, 0.65% vs. 0.89% in Karnataka, 0.52% vs. 0.60% in Maharashtra, p<0.001 for all three states). In all three states, HIV prevalence from PPTCT centres that were part of the sentinel surveillance was comparable to HSS-ANC prevalence but significantly higher than PPTCT centres that were not part of the sentinel surveillance. HIV prevalence from PPTCT data was comparable to that from general population surveys. In all three states, significant declines in HIV prevalence between 2007 and 2010 were observed with the PPTCT data set. District level analyses of HIV trends and sub-district level analysis of HIV prevalence were possible using the PPTCT and not the HSS-ANC data sets.

CONCLUSION

HIV prevalence from PPTCT may be a better proxy for general population prevalence than HSS-ANC. PPTCT data allow for analysis of HIV prevalence and trends at smaller geographic units, which is important for decentralized planning of HIV/AIDS programming. With further improvements to the system, India could replace its HSS-ANC with PPTCT programme data for surveillance.

Counting the cost of not costing HIV health facilities accurately: pay now, or pay more later

The HIV pandemic continues to be one of our greatest contemporary public health threats. Policy makers in many middle- and low-income countries are in the process of scaling up HIV prevention, treatment and care services in the context of a reduction in international HIV funding due to the global economic downturn. In order to scale up services that are sustainable in the long term, policy makers and implementers need to have access to robust and contemporary strategic information, including financial information on expenditure and cost, in order to be able to plan, implement, monitor and evaluate HIV services. A major problem in middle- and low-income countries continues to be a lack of basic information on the use of services, their cost, outcome and impact, while those few costing studies that have been performed were often not done in a standardized fashion. Some researchers handle this by transposing information from one country to another, developing mathematical or statistical models that rest on assumptions or information that may not be applicable, or using top-down costing methods that only provide global financial costs rather than using bottom-up ingredients-based costing. While these methods provide answers in the short term, countries should develop systematic data collection systems to store, transfer and produce robust and contemporary strategic financial information for stakeholders at local, sub-national and national levels. National aggregated information should act as the main source of financial data for international donors, agencies or other organizations involved with the global HIV response. This paper describes the financial information required by policy makers and other stakeholders to enable them to make evidence-informed decisions and reviews the quantity and quality of the financial information available, as indicated by cost studies published between 1981 and 2008. Among the lessons learned from reviewing these studies, a need was identified for providing countries with practical guidance to produce reliable and standardized costing data to monitor performance, as countries want to improve programmes and services, and have to demonstrate an efficient use of resources. Finally, the issues raised in this paper relate to the provision of all areas of healthcare in countries and it is going to be increasingly important to leverage the lessons learned from the HIV experience and use resources more effectively and efficiently to improve health systems in general.

Knowing your HIV/AIDS epidemic and tailoring an effective response: how did India do it?

Tremendous global efforts have been made to collect data on the HIV/AIDS epidemic. Yet, significant challenges remain for generating and analysing evidence to allocate resources efficiently and implement an effective AIDS response. India offers important lessons and a model for intelligent and integrated use of data on HIV/AIDS for an evidence-based response. Over the past 15 years, the number of data sources has expanded and the geographical unit of data generation, analysis and use for planning has shifted from the national to the state, district and now subdistrict level. The authors describe and critically analyse the evolution of data sets in India and how they have been utilised to better understand the epidemic, advance policy, and plan and implement an increasingly effective, well-targeted and decentralised national response to HIV and AIDS. The authors argue that India is an example of how 'know your epidemic, know your response' message can effectively be implemented at scale and presents important lessons to help other countries design their evidence generation systems.

How much can we gain from improved efficiency? An examination of performance of national HIV/AIDS programs and its determinants in low- and middle-income countries

Background

The economic downturn exacerbates the inadequacy of resources for combating the worldwide HIV/AIDS pandemic and amplifies the need to improve the efficiency of HIV/AIDS programs.

Methods

We used data envelopment analysis (DEA) to evaluate efficiency of national HIV/AIDS programs in transforming funding into services and implemented a Tobit model to identify determinants of the efficiency in 68 low- and middle-income countries. We considered the change from the lowest quartile to the average value of a variable a "notable" increase.

Results

Overall, the average efficiency in implementing HIV/AIDS programs was moderate (49.8%). Program efficiency varied enormously among countries with means by quartile of efficiency of 13.0%, 36.4%, 54.4% and 96.5%. A country's governance, financing mechanisms, and economic and demographic characteristics influence the program efficiency. For example, if countries achieved a notable increase in "voice and accountability" (e.g., greater participation of civil society in policy making), the efficiency of their HIV/AIDS programs would increase by 40.8%. For countries in the lowest quartile of per capita gross national income (GNI), a notable increase in per capita GNI would increase the efficiency of AIDS programs by 45.0%.

Conclusions

There may be substantial opportunity for improving the efficiency of AIDS services, by providing more services with existing resources. Actions beyond the health sector could be important factors affecting HIV/AIDS service delivery.

Limits to evidence-based health policymaking: policy hurdles to structural HIV prevention in Tanzania

Despite the well-documented role of highly co-endemic biological cofactors in facilitating HIV transmission and the availability of comparatively inexpensive tools to control them, cofactor-related interventions are only hesitantly included into African HIV prevention strategies. Against this background, this study analyzes political obstacles to policy-uptake of evidence concerning structural HIV prevention. The data used stem from fieldwork conducted in Tanzania between 2007 and 2009. They include 92 in-depth interviews with key AIDS policymakers and observations of 8 national-level policy meetings. Adopting a political economy perspective, the study shows that 1) assuming cost-aversion as a spontaneous reflex of policymakers is empirically wrong and analytically misleading, 2) that political constituencies induce a path dependence of allocative decisions inconducive to structural prevention, 3) that interventions' political attractiveness depends on the nature of their outputs and the expected temporality of political returns, 4) that policy fragmentation entailed by vertical disease control disfavours the consideration of broader causalities, and 5) that cofactor-based measures are hampered by policymakers' perception of structural prevention as being excessively complex and ultimately tantamount to poverty eradication. Confronting the policy players' reading of the Tanzanian situation with recent and classical literature on evidence-based decision-making and the politics of public health, this paper shows that, far from being strictly evidence-driven, HIV prevention policies result from a politically negotiated aggregation of competing, frequently non-optimizing rationalities. A realistic appraisal of policy processes suggests that the failure to consider the invariably political nature of HIV-related policymaking hampers the formulation of effective, politically informed strategies for positive change. Consequently, developing policy practitioners' understanding of how to effectively engage in evidence-influenced political struggles over priorities might be more instrumental in improving HIV prevention strategies than attempts to sidestep these ineradicably antagonistic controversies though technical decision tools meant to optimize health outcomes via the formulation of 'rational consensus'.

Voluntary medical male circumcision: modeling the impact and cost of expanding male circumcision for HIV prevention in eastern and southern Africa

BACKGROUND

There is strong evidence showing that voluntary medical male circumcision (VMMC) reduces HIV incidence in men. To inform the VMMC policies and goals of 13 priority countries in eastern and southern Africa, we estimate the impact and cost of scaling up adult VMMC using updated, country-specific data.

METHODS AND FINDINGS

We use the Decision Makers' Program Planning Tool (DMPPT) to model the impact and cost of scaling up adult VMMC in Botswana, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, and Nyanza Province in Kenya. We use epidemiologic and demographic data from recent household surveys for each country. The cost of VMMC ranges from US$65.85 to US$95.15 per VMMC performed, based on a cost assessment of VMMC services aligned with the World Health Organization's considerations of models for optimizing volume and efficiencies. Results from the DMPPT models suggest that scaling up adult VMMC to reach 80% coverage in the 13 countries by 2015 would entail performing 20.34 million circumcisions between 2011 and 2015 and an additional 8.42 million between 2016 and 2025 (to maintain the 80% coverage). Such a scale-up would result in averting 3.36 million new HIV infections through 2025. In addition, while the model shows that this scale-up would cost a total of US$2 billion between 2011 and 2025, it would result in net savings (due to averted treatment and care costs) amounting to US$16.51 billion.

CONCLUSIONS

This study suggests that rapid scale-up of VMMC in eastern and southern Africa is warranted based on the likely impact on the region's HIV epidemics and net savings. Scaling up of safe VMMC in eastern and southern Africa will lead to a substantial reduction in HIV infections in the countries and lower health system costs through averted HIV care costs.

Multicity HIV seroprevalence in street youth, Ukraine

We conducted the first systematic, community-based, multicity assessment outside the USA of HIV seroprevalence, risk factors and linkage into clinical services among 929 street youth. After city-wide mapping, we used time-location sampling and randomly selected 74 venues in Odesa, Kyiv and Donetsk, Ukraine. Rapid HIV testing with post-test counselling was offered to all eligible youths aged 15-24 years. Overall, 18.4% (95% confidence interval 16.2-20.2) were HIV positive and 85% had previously unknown status. Rates were identical by sex. Subgroups with highest rates included orphans (26%), youths with histories of exchanging sex (35%), sexually transmitted infections (STIs) (37%), injection drug use (IDU) (42%) and needle sharing (49%). Independent predictors, similar across age groups and city, included being orphaned, time on the street, history of anal sex, STIs, exchanging sex, any drug use, IDU and needle sharing. Two-thirds (68%) of HIV-positive youths were linked to services. This high-risk population has many immediate needs.

Decision making for HIV prevention and treatment scale up: bridging the gap between theory and practice

BACKGROUND

Effectively controlling the HIV epidemic will require efficient use of limited resources. Despite ambitious global goals for HIV prevention and treatment scale up, few comprehensive practical tools exist to inform such decisions.

METHODS

We briefly summarize modeling approaches for resource allocation for epidemic control, and discuss the practical limitations of these models. We describe typical challenges of HIV resource allocation in practice and some of the tools used by decision makers. We identify the characteristics needed in a model that can effectively support planners in decision making about HIV prevention and treatment scale up.

RESULTS

An effective model to support HIV scale-up decisions will be flexible, with capability for parameter customization and incorporation of uncertainty. Such a model needs certain key technical features: it must capture epidemic effects; account for how intervention effectiveness depends on the target population and the level of scale up; capture benefit and cost differentials for packages of interventions versus single interventions, including both treatment and prevention interventions; incorporate key constraints on potential funding allocations; identify optimal or near-optimal solutions; and estimate the impact of HIV interventions on the health care system and the resulting resource needs. Additionally, an effective model needs a user-friendly design and structure, ease of calibration and validation, and accessibility to decision makers in all settings.

CONCLUSIONS

Resource allocation theory can make a significant contribution to decision making about HIV prevention and treatment scale up. What remains now is to develop models that can bridge the gap between theory and practice.

Asia can afford universal access for AIDS prevention and treatment

This paper draws on published reports, data from the Global Fund to Fight AIDS, Tuberculosis, and Malaria and the Asian Development Bank, and analysis by the Commission on AIDS in Asia to estimate financial resources required to achieve universal access for HIV in low-income and middle-income countries of Asia. It explores optimal use of available resources to mount effective response to AIDS in Asia against an uncertain economic climate. Although there is global commitment to tackle the HIV pandemic, available financing falls short of minimum requirements to achieve universal access to prevention and treatment. To support essential HIV priorities in Asia, the Commission on AIDS in Asia estimated annual resource needs to be US$ 3.1 billion. Yet, in 2007, according to one study, estimated total public spending on AIDS in 14 major Asian countries was only US$ 0.9 billion. Hence, scarce resources need to be carefully applied to address the concentrated HIV epidemics in Asia and achieve universal coverage by prioritizing investment in high-impact interventions to maximally avert new infections and deaths, intensifying multisectoral efforts through catalytic financing that mainstreams HIV interventions into existing services, particularly for low-impact prevention programs, and ensuring countries with growing economies mobilize increased amounts of domestic funding to match international financing.

Developing and evaluating comprehensive HIV infection control strategies: issues and challenges

As described elsewhere in this supplement, development of effective methods for prevention of human immunodeficiency virus (HIV) infection has proven to be more challenging than development of effective treatment for the disease. New strategies to control the HIV epidemic are urgently needed; this urgency creates interest in investigation of the possibility of using antiretroviral treatment in combination with other modalities to control the epidemic. This article summarizes current knowledge concerning prevention modalities in the context of the drivers of the HIV epidemic in specific communities, describes challenges in investigating test-and-treat strategies, and proposes research directions for addressing these challenges to investigate the impact of prevention strategies on mitigation of epidemics.

Cost-effectiveness of an intervention to reduce HIV/STI incidence and promote condom use among female sex workers in the Mexico-US border region

BACKGROUND

Previous research demonstrated efficacy of a brief behavioral intervention to reduce incidence of HIV and sexually transmitted infections (STIs) among female sex workers (FSWs) in Tijuana and Ciudad Juarez, Mexico, cities on Mexico's border with the US. We assessed this intervention's cost-effectiveness.

METHODOLOGY AND PRINCIPAL FINDINGS

A life-time Markov model was developed to estimate HIV cases prevented, changes in quality-adjusted life expectancy (QALE), and costs per additional quality-adjusted life year gained (QALY), comparing (in US$2,009) no intervention to a once-only and annual intervention. Future costs and health benefits were discounted annually at 3%. Sensitivity analyses evaluated model robustness. We found that for a hypothetical 1,000 FSWs receiving the once-only intervention, there were 33 HIV cases prevented and 5.7 months of QALE gained compared to no intervention. The additional cost per QALY gained was US$183. For FSWs receiving the intervention annually, there were 29 additional HIV cases prevented and 4.5 additional months of QALE compared to the once-only intervention. The additional cost per QALY was US$1,075. When highly active antiretroviral therapy (HAART) was included in the model, the annual intervention strategy resulted in net savings and dominated both once-only and no intervention strategies, and remained robust across extensive sensitivity analyses. Even when considering clinical benefits from HAART, ignoring added costs, the cost per QALY gained remained below three times the Mexican GDP per capita, and below established cost-effectiveness thresholds.

CONCLUSIONS/SIGNIFICANCE

This brief intervention was shown to be cost-effective among FSWs in two Mexico-US border cities and may have application for FSWs in other resource-limited settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00338845.

The welfare costs of HIV/AIDS in eastern Europe: an empirical assessment using the economic value-of-life approach

Based on the aggregation of individual willingness-to-pay for a statistical life, we calibrate an inter-temporal optimisation model to determine the aggregate welfare loss from HIV/AIDS in 25 Eastern European countries. Assuming a discount rate of 3%, we find a total welfare loss for the whole region that exceeds US $800 billion, approximately 10% of the region's annual GDP between 1995 and 2001. Although prevalence and incidence rates diverge sharply between countries-with central Europe far less affected than major countries in the Commonwealth of Independent States and the Baltics-the epidemic is likely to spread to all countries unless a coherent strategy of prevention and treatment is backed up by substantial increases in healthcare investments. The sheer size of this task and the international nature of the epidemic render this one of the most important current challenges for all of Europe.

The past, present and future of HIV, AIDS and resource allocation

Background

How should HIV and AIDS resources be allocated to achieve the greatest possible impact? This paper begins with a theoretical discussion of this issue, describing the key elements of an "evidence-based allocation strategy". While it is noted that the quality of epidemiological and economic data remains inadequate to define such an optimal strategy, there do exist tools and research which can lead countries in a way that they can make allocation decisions. Furthermore, there are clear indications that most countries are not allocating their HIV and AIDS resources in a way which is likely to achieve the greatest possible impact. For example, it is noted that neighboring countries, even when they have a similar prevalence of HIV, nonetheless often allocate their resources in radically different ways.

These differing allocation patterns appear to be attributable to a number of different issues, including a lack of data, contradictory results in existing data, a need for overemphasizing a multisectoral response, a lack of political will, a general inefficiency in the use of resources when they do get allocated, poor planning and a lack of control over the way resources get allocated.

Methods

There are a number of tools currently available which can improve the resource-allocation process. Tools such as the Resource Needs Model (RNM) can provide policymakers with a clearer idea of resource requirements, whereas other tools such as Goals and the Allocation by Cost-Effectiveness (ABCE) models can provide countries with a clearer vision of how they might reallocate funds.

Results

Examples from nine different countries provide information about how policymakers are trying to make their resource-allocation strategies more "evidence based". By identifying the challenges and successes of these nine countries in making more informed allocation decisions, it is hoped that future resource-allocation decisions for all countries can be improved.

Conclusion

We discuss the future of resource allocation, noting the types of additional data which will be required and the improvements in existing tools which could be made.

Recommendations for increasing the use of HIV/AIDS resource allocation models

BACKGROUND

Resource allocation models have not had a substantial impact on HIV/AIDS resource allocation decisions in spite of the important, additional insights they may provide. In this paper, we highlight six difficulties often encountered in attempts to implement such models in policy settings; these are: model complexity, data requirements, multiple stakeholders, funding issues, and political and ethical considerations. We then make recommendations as to how each of these difficulties may be overcome.

RESULTS

To ensure that models can inform the actual decision, modellers should understand the environment in which decision-makers operate, including full knowledge of the stakeholders' key issues and requirements. HIV/AIDS resource allocation model formulations should be contextualized and sensitive to societal concerns and decision-makers' realities. Modellers should provide the required education and training materials in order for decision-makers to be reasonably well versed in understanding the capabilities, power and limitations of the model.

CONCLUSION

This paper addresses the issue of knowledge translation from the established resource allocation modelling expertise in the academic realm to that of policymaking.

Economic analysis of HIV prevention interventions in Andhra Pradesh state of India to inform resource allocation

OBJECTIVE

To conduct composite economic analysis of HIV prevention interventions to inform efficient utilization of resources in India.

METHODS

We obtained output and economic cost data for the 2005-2006 fiscal year from a representative sample of 128 public-funded HIV prevention programmes of 14 types in Andhra Pradesh state of India. Using data from various sources, we developed a model to estimate the number of HIV infections averted. We estimated the additional HIV infections that could be averted if each intervention reached optimal coverage and the associated cost.

RESULTS

In a year, 9688 HIV infections were averted by public-funded HIV prevention interventions in Andhra Pradesh. Scaling-up interventions to the optimal level would require US$38.8 million annually, 2.8 times the US$13.8 million economic cost in 2005-2006. This could increase the number of HIV infections averted by 2.4-fold, if with higher resources there were many-fold increases in the proportional allocation for programmes for migrant labourers, men who have sex with men and voluntary counselling and testing, and reduction of the high proportion for mass media campaigns to one-third of the 2005-2006 proportion of resource utilization. If the proportions of resource allocation for interventions remained similar to 2005-2006, the higher resources would avert 54% of the additional avertable HIV infections.

CONCLUSION

The recent four-fold increase in public funding for HIV/AIDS control in India should be adequate to scale-up HIV prevention interventions to an optimal level in Andhra Pradesh, but the prevention would be suboptimal if additional investments were not preferentially directed to some particular interventions.