Costs and economies of scale in the accelerated program for prevention of mother-to-child transmission of HIV in Zimbabwe

BACKGROUND

Despite a growing body of literature on HIV service costs in sub-Saharan Africa, only a few studies have estimated the facility-level cost of prevention of Mother-to-Child Transmission (PMTCT) services, and even fewer provide insights into the variation of PMTCT costs across facilities. In this study, we present the first empirical costs estimation of the accelerated program for the prevention of mother-to-child transmission of HIV in Zimbabwe and investigate the determinants of heterogeneity of the facility-level average cost per service. To understand such variation, we explored the association between average costs per service and supply-and demand-side characteristics, and quality of services. One aspect of the supply-side we explore carefully is the scale of production-which we define as the annual number of women tested or the yearly number of HIV-positive women on prophylaxis.

METHODS

We collected rich data on the costs and PMTCT services provided by 157 health facilities out of 699 catchment areas in five provinces in Zimbabwe for 2013. In each health facility, we measured total costs and the number of women covered with PMTCT services and estimated the average cost per woman tested and the average cost per woman on either ARV prophylaxis or ART. We refer to these facility-level average costs per service as unitary costs. We also collected information on potential determinants of the variation of unitary costs. On the supply-side, we gathered data on the scale of production, staff composition and on the types of antenatal and family planning services provided. On the demand side, we measured the total population at the catchment area and surveyed eligible pairs of mothers and infants about previous use of HIV testing and prenatal care, and on the HIV status of both mothers and infants. We explored the determinants of unitary cost variation using a two-stage linear regression strategy.

RESULTS

The average annual total cost of the PMTCT program per facility was US$16,821 (median US$8,920). The average cost per pregnant woman tested was US$80 (median US$47), and the average cost per HIV-positive pregnant woman initiated on ARV prophylaxis or treatment was US$786 annually (median US$420). We found substantial heterogeneity of unitary costs across facilities regardless of facility type. The scale of production was a strong predictor of unitary costs variation across facilities, with a negative and statistically significant correlation between the two variables (p<0.01).

CONCLUSIONS

These findings are the first empirical estimations of PMTCT costs in Zimbabwe. Unitary costs were found to be heterogeneous across health facilities, with evidence consistent with economies of scale.

Rates and determinants of HIV-attributable mortality among rural female sex workers in Northern Karnataka, India

Female sex workers (FSWs) have among the highest rates of HIV infection in India. However, little is known about their HIV-specific mortality rates. In total, 1561 FSWs participated in a cohort study in Karnataka. Outcome data (mortality) were available on 1559 women after 15 months of follow-up. To gather details on deaths, verbal autopsy (VA) questionnaires were administered to key informants. Two physicians reviewed the VA reports and assigned underlying causes of death. Forty-seven deaths were reported during the follow-up (overall mortality rate was 2.44 per 100 person-years), with VA data available on 45 women. Thirty-five (75.6%) of these women were known to be HIV-positive, but only 42.5% were on antiretroviral therapy (ART). Forty deaths were assessed to be HIV-related, for an HIV-attributable mortality rate of 2.11 deaths per 100 person-years. Absence of a current regular partner (incidence rate ratio: 2.79; 95% confidence interval [CI]: 1.39-5.60) and older age (1.06; 1.01-1.11) were associated with increased HIV-attributable mortality. Reported duration in sex work was not related to HIV-attributable mortality. We found a high HIV-related mortality rate among this cohort of FSWs; nearly 10 times that of national mortality rates among women of a similar age group. Older age, but not reported duration in sex work, was associated with increased mortality, and suggests HIV acquisition prior to self-reported initiation into sex work. Despite significant efforts, there remain considerable gaps in HIV prevention near or before entry into sex work, as well as access and uptake of HIV treatment among FSWs.

High-risk sex among mobile female sex workers in the context of jatras (religious festivals) in Karnataka, India

Jatras (religious festivals) represent venues for female sex workers (FSWs) to meet potential clients in an environment of anonymity. Data from a survey conducted among 1499 mobile FSWs in Karnataka, India were analysed using bivariate and multivariate analysis. Overall, 31% of mobile FSWs reported attending jatras in the previous year. Women who sold sex at jatras tended to practice sex work in public places, in their own homes or on highways. Jatra attendees reported lower condom use with their last commercial sexual partners at their usual places of sex work. Jatra-related mobility was a significant predictor of non-condom use at their usual place of residence, after controlling for sociodemographic, sex work-related, HIV vulnerability and programme exposure variables. Moreover, only 13% of FSWs used condoms consistently at jatras. Condom availability and accessibility at jatras should be a priority for HIV prevention programmes, and such programmes should make efforts to introduce outreach activities at jatras.

Study on possible deleterious effects induced in white mice and rabbits by prolonged administration of polidin in different concentrations

There were investigated possible deleterious effects induced in white mice and rabbits by prolonged administration of polidin in different concentrations, as well as of polidin associated with membrane fraction of Klebsiella pneumoniae. In the experimental model used all the animals evolved normally presenting some transient blood modifications which occurred after administration of comparatively much higher doses than those usually administered in man. There were not noticed significant macroscopical and microscopical modifications at the level of the organs sampled from mice. The pregnant female mice treated along one month with doses, proportionally 1000 times higher than those used in human therapy, presented some pathological aspects, which disappeared on cessation of therapy with the biological. These animals were not affected by abortions and the experiment proved the absence of some teratogenic effects connected to polidin administration. The prolonged polidin administration also acted as an immunostimulant of the natural and acquired defense system.