Articles tagged as "Resources/ Impact/ Development"

Task-shifting reduces costs for early infant male circumcision

Comparative cost of early infant male circumcision by nurse-midwives and doctors in Zimbabwe.

Mangenah C, Mavhu W, Hatzold K, Biddle AK, Ncube G, Mugurungi O, Ticklay I, Cowan FM, Thirumurthy H. Glob Health Sci Pract. 2016 Jul 13;4 Suppl 1:S68-75. doi: 10.9745/GHSP-D-15-00201. Published online 2016 Jul 2.

Background: The 14 countries that are scaling up voluntary male medical circumcision (VMMC) for HIV prevention are also considering early infant male circumcision (EIMC) to ensure longer-term reductions in HIV incidence. The cost of implementing EIMC is an important factor in scale-up decisions. We conducted a comparative cost analysis of EIMC performed by nurse-midwives and doctors using the AccuCirc device in Zimbabwe.

Methods: Between August 2013 and July 2014, nurse-midwives performed EIMC on 500 male infants using AccuCirc in a field trial. We analyzed the overall unit cost and identified key cost drivers of EIMC performed by nurse-midwives and compared these with costing data previously collected during a randomized noninferiority comparison trial of 2 devices (AccuCirc and the Mogen clamp) in which doctors performed EIMC. We assessed direct costs (consumable and nonconsumable supplies, device, personnel, associated staff training, and waste management costs) and indirect costs (capital and support personnel costs). We performed one-way sensitivity analyses to assess cost changes when we varied key component costs.

Results: The unit costs of EIMC performed by nurse-midwives and doctors in vertical programs were US$38.87 and US$49.77, respectively. Key cost drivers of EIMC were consumable supplies, personnel costs, and the device price. In this cost analysis, major cost drivers that explained the differences between EIMC performed by nurse-midwives and doctors were personnel and training costs, both of which were lower for nurse-midwives.

Conclusions: EIMC unit costs were lower when performed by nurse-midwives compared with doctors. To minimize costs, countries planning to scale up EIMC should consider using nurse-midwives, who are in greater supply than doctors and are the main providers at the primary health care level, where most infants are born.

Abstract  Full-text [free] access 

Editor’s notes: The evidence behind the efficacy for male circumcision in HIV prevention has been proven beyond a reasonable doubt, and 14 countries with a high HIV prevalence are currently scaling up voluntary medical male circumcision. To improve future HIV prevention, WHO and UNICEF also recommend that early infant male circumcision be performed within the first 60 days of life in countries with a high HIV prevalence. In countries such as Zimbabwe, an acute shortage of human resources for health has the potential to hinder scale-up of early infant male circumcision.  However, with new devices such as the AccuCirc® , early infant male circumcision can be performed without advanced surgical skills – raising the potential for task shifting as a way to alleviate pressure on human resources.  

This study compares the unit cost of early infant male circumcision using the AccuCirc® , as performed by doctors and by nurse-midwives. Nurse-midwives on average took a longer time to complete a circumcision (average 18 minutes) as compared to doctors (average 16 minutes).  However, the reductions in salary costs offset this increased time, reducing the unit cost of early infant male circumcision overall. Integrating early infant male circumcision into a public health facility (as compared to a vertical programme) would further reduce the costs. 

This study suggests that countries seeking to scale up early infant male circumcision should consider task shifting as a way to reduce costs. Task shifting does pose the risk of increasing workload for lower-level personnel; more nurse-midwives will need to be trained to cope with additional responsibilities to avoid over-burdening existing personnel. However, this is a promising solution to enable scale-up of early infant male circumcision quickly and affordably in settings such as Zimbabwe.

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Immediate initiation of HIV treatment is cost-effective, but needs a large portion of health system spending

Changing HIV treatment eligibility under health system constraints in sub-Saharan Africa: Investment needs, population health gains, and cost-effectiveness.

Hontelez JA, Chang AY, Ogbuoji O, Vlas SJ, Barnighausen T, Atun R. AIDS. 2016 Jun 29. [Epub ahead of print]

Objective: We estimated the investment need, population health gains, and cost-effectiveness of different policy options for scaling-up prevention and treatment of HIV in the 10 countries that currently comprise 80% of all people living with HIV in sub-Saharan Africa (Ethiopia, Kenya, Malawi, Mozambique, Nigeria, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe).

Design: We adapted the established STDSIM model, to capture the health system dynamics: demand-side and supply-side constraints in the delivery of antiretroviral treatment (ART).

Methods: We compared different scenarios of supply-side (i.e. health system capacity) and demand-side (i.e. health seeking behavior) constraints, and determined the impact of changing guidelines to ART eligibility at any CD4 cell count within these constraints.

Results: Continuing current scale-up would require US$178 billion by 2050. Changing guidelines to ART at any CD4 cell count is cost-effective under all constraints tested in the model, especially in demand-side constrained health systems because earlier initiation prevents loss to follow-up of patients not yet eligible. Changing guidelines under current demand-side constraints would avert 1.8 million infections at US$208 per life-year saved.

Conclusions: Treatment eligibility at any CD4 cell count would be cost-effective, even under health system constraints. Excessive loss to follow up and mortality in patients not eligible for treatment can be avoided by changing guidelines in demand-side constrained systems. The financial obligation for sustaining the AIDS response in sub-Saharan Africa over the next 35 years is substantial, and requires strong, long-term commitment of policy makers and donors to continue to allocate substantial parts of their budgets.

Abstract access

Editor’s notes: Recent WHO guidelines recommend that everyone who is diagnosed as HIV positive should be allowed to start treatment immediately, a change to the former guideline where their CD4 count (a measure of disease progression) was the main criteria for starting treatment. This paper uses a model to look at the costs and benefits of changing to this immediate treatment regimen in the sub-Saharan African countries most affected by the epidemic. The authors find that allowing all HIV people living with HIV to access treatment is cost-effective, and this finding does not change when the model assumptions are varied. However, the impact of this change on the health system budgets in these countries is very substantial, and the authors suggest that a large commitment is necessary from policymakers and donors to sustain this response as short-term spending will not be enough to make an impact.

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Viral load testing is more cost-effective than CD4 testing

Laboratory monitoring of antiretroviral therapy for HIV infection: cost-effectiveness and budget impact of current and novel strategies.

Ouattara EN, Robine M, Eholie SP, MacLean RL, Moh R, Losina E, Gabillard D, Paltiel AD, Danel C, Walensky RP, Anglaret X, Freedberg KA. Clin Infect Dis. 2016 Jun 1;62(11):1454-62. doi: 10.1093/cid/ciw117. Epub 2016 Mar 1.

Background: Optimal laboratory monitoring of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) remains controversial. We evaluated current and novel monitoring strategies in Cote d'Ivoire, West Africa.

Methods: We used the Cost-Effectiveness of Preventing AIDS Complications -International model to compare clinical outcomes, cost-effectiveness, and budget impact of 11 ART monitoring strategies varying by type (CD4 and/or viral load [VL]) and frequency. We included "adaptive" strategies (biannual then annual monitoring for patients on ART/suppressed). Mean CD4 count at ART initiation was 154/µL. Laboratory test costs were CD4=$11 and VL=$33. The standard of care (SOC; biannual CD4) was the comparator. We assessed cost-effectiveness relative to Cote d'Ivoire's 2013 per capita GDP ($1500).

Results: Discounted life expectancy was 16.69 years for SOC, 16.97 years with VL confirmation of immunologic failure, and 17.25 years for adaptive VL. Mean time on failed first-line ART was 3.7 years for SOC and <0.9 years for all routine/adaptive VL strategies. VL failure confirmation was cost-saving compared with SOC. Adaptive VL had an incremental cost-effectiveness ratio (ICER) of $4100/year of life saved compared with VL confirmation and increased the 5-year budget by $310/patient compared with SOC. Adaptive VL achieved an ICER <1x GDP if second-line ART and VL costs simultaneously decreased to $156 and $13, respectively.

Conclusions: VL confirmation of immunologic failure is more effective and less costly than CD4 monitoring in Cote d'Ivoire. Adaptive VL monitoring reduces time on failing ART, is cost-effective, and should become standard in Cote d'Ivoire and similar settings.

Abstract access 

Editor’s notes: Monitoring whether or not people are able to effectively use HIV antiretroviral therapy (ART) to supress viral load is important to maintaining individual and population health. There are two ways to monitor whether or not people are able to adhere to ART, assessing CD4 cell count or viral load. These tests require different amounts of expensive laboratory resources. This paper explores 11 ways in which ART regimens can be monitored in Cote d’Ivoire to assess the potential impact and cost-effectiveness of different strategies compared to current care (twice-yearly CD4 tests). The authors estimate that adding viral load failure confirmation to current practice would be cost saving. Adaptive viral load monitoring is found to be cost-effective. This approach involves decreasing monitoring from twice-annually to annually among people who present with suppressed viral loads for one year. In many countries, viral load monitoring is not generally available. This research is important because it illustrates that viral load monitoring strategies can be cost saving compared to CD4 counts, in line with WHO recommendations. 

Côte d'Ivoire
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Taking account of the human factor when introducing new technology – a cautionary tale

Unintended adverse consequences of electronic health record introduction to a mature universal HIV screening program.

Medford-Davis LN, Yang K, Pasalar S, Pillow MT, Miertschin NP, Peacock WF, Giordano TP, Hoxhaj S. AIDS Care. 2016 May;28(5):566-73. doi: 10.1080/09540121.2015.1127319. Epub 2016 Jan 5.

Early HIV detection and treatment decreases morbidity and mortality and reduces high-risk behaviors. Many Emergency Departments (EDs) have HIV screening programs as recommended by the Centers for Disease Control and Prevention. Recent federal legislation includes incentives for electronic health record (EHR) adoption. Our objective was to analyze the impact of conversion to EHR on a mature ED-based HIV screening program. A retrospective pre- and post-EHR implementation cohort study was conducted in a large urban, academic ED. Medical records were reviewed for HIV screening rates from August 2008 through October 2013. On 1 November 2010, a comprehensive EHR system was implemented throughout the hospital. Before EHR implementation, labs were requested by providers by paper orders with HIV-1/2 automatically pre-selected on every form. This universal ordering protocol was not duplicated in the new EHR; rather it required a provider to manually enter the order. Using a chi-squared test, we compared HIV testing in the 6 months before and after EHR implementation; 55 054 patients presented before, and 50 576 after EHR implementation. Age, sex, race, acuity of presenting condition, and HIV seropositivity rates were similar pre- and post-EHR, and there were no major patient or provider changes during this period. Average HIV testing rate was 37.7% of all ED patients pre-, and 22.3% post-EHR, a 41% decline (p < 0.0001), leading to 167 missed new diagnoses after EHR. The rate of HIV screening in the ED decreased after EHR implementation, and could have been improved with more thoughtful inclusion of existing human processes in its design.

Abstract access

Editor’s notes: The introduction of Electronic Health Records is beneficial for sharing patient information between health care providers in large health care settings. However, as the authors of this paper illustrate with this thoughtful case study, the introduction of electronic health records in some settings may worsen rather than improve care. In this case, the electronic health record system which was introduced did not faithfully mimic the manual system it replaced. HIV-screening which had previously been an ‘opt out’ option for laboratory testing, became an ‘opt-in’ option in the new system.  As a result, testing rates went down. Interestingly, a similar electronic system was introduced in another hospital nearby. The effect on testing rates was noticed there and a manual workaround put in place. The nursing director in that institution ‘was a very strong personal advocate and champion for the HIV screening programme there’.  The authors point to the importance of testing new systems carefully and checking for unintended consequences on patient care.

Northern America
United States of America
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Comparing the performance of different community-based measures of viral load as correlates for HIV incidence

Community viral load, antiretroviral therapy coverage, and HIV incidence in India: a cross-sectional, comparative study.

Solomon SS, Mehta SH, McFall AM, Srikrishnan AK, Saravanan S, Laeyendecker O, Balakrishnan P, Celentano DD, Solomon S, Lucas GM. Lancet HIV. 2016 Apr;3(4):e183-90. doi: 10.1016/S2352-3018(16)00019-9. Epub 2016 Mar 11.

Background: HIV incidence is the best measure of treatment-programme effectiveness, but its measurement is difficult and expensive. The concept of community viral load as a modifiable driver of new HIV infections has attracted substantial attention. We set out to compare several measures of community viral load and antiretroviral therapy (ART) coverage as correlates of HIV incidence in high-risk populations.

Methods: We analysed data from a sample of people who inject drugs and men who have sex with men, who were participants of the baseline assessment of a cluster-randomised trial in progress across 22 cities in India ( number NCT01686750). We recruited the study population by use of respondent-driven sampling and did the baseline assessment at 27 community-based sites (12 for men who have sex with men and 15 for people who inject drugs). We estimated HIV incidence with a multiassay algorithm and calculated five community-based measures of HIV control: mean log10 HIV RNA in participants with HIV in a community either engaged in care (in-care viral load), aware of their status but not necessarily in care (aware viral load), or all HIV-positive individuals whether they were aware, in care, or not (population viral load); participants with HIV in a community with HIV RNA more than 150 copies per mL (prevalence of viraemia); and the proportion of participants with HIV who self-reported ART use in the previous 30 days (population ART coverage). All participants were tested for HIV, with additional testing in HIV-positive individuals. We assessed correlations between the measures and HIV incidence with Spearman correlation coefficients and linear regression analysis.

Findings: Between Oct 1, 2012, and Dec 19, 2013, we recruited 26 503 participants, 12 022 men who have sex with men and 14 481 people who inject drugs. Median incidence of HIV was 0.87% (IQR 0.40-1.17) in men who have sex with men and 1.43% (0.60-4.00) in people who inject drugs. Prevalence of viraemia was more strongly correlated with HIV incidence (correlation 0.81, 95% CI 0.62-0.91; p<0.0001) than all other measures, although correlation was significant with aware viral load (0.59, 0.27-0.79; p=0.001), population viral load (0.51, 0.16-0.74; p=0.007), and population ART coverage (-0.54, -0.76 to -0.20; p=0.004). In-care viral load was not correlated with HIV incidence (0.29, -0.10 to 0.60; p=0.14). With regression analysis, we estimated that to reduce HIV incidence by 1 percentage point in a community, prevalence of viraemia would need to be reduced by 4.34%, and ART use in HIV-positive individuals would need to increase by 19.5%.

Interpretation: Prevalence of viraemia had the strongest correlation with HIV incidence in this sample and might be a useful measure of the effectiveness of a treatment programme.

Abstract access    

Editor’s notes: The ideal metric of impact for a programme looking at the prevention benefits of treatment would be the reduction in HIV incidence in the target population. Incidence is however very difficult to measure. ‘Community viral load’ has been proposed as an alternative. However its estimation using data collected either in a routine clinical setting or from a cohort study can suffer from bias, due to the population included not being representative of the wider population of people living with HIV.

This paper describes a study among gay men and other men who have sex with men and people who inject drugs carried out at 27 sites in India. Participants were recruited using respondent-driven sampling (in which respondents recruit their peers to produce a generally representative sample of hard-to-reach populations). At each site incidence was estimated using a multi-assay algorithm designed to identify seroconversion occurring approximately within the last six months. Five community-based measures of viral load were measured at each site. Of these, the prevalence of HIV viraemia (i.e. the proportion of the population with a viral load greater than 150 copies per mL), was most strongly associated with HIV incidence, while mean viral load among people in-care was not associated. This latter finding is important if a case-based surveillance approach using only data collected at clinics is to be used to estimate incidence. Population ART coverage, a measure of the proportion of the site participants on ART was also strongly correlated with incidence. As this can be measured through a simple questionnaire, rather than lab-based assays, it could be an easily and cheaply obtainable correlate for incidence, albeit one potentially prone to response bias.

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Strengthening PMTCT implementation through systems engineering

Impact of a systems engineering intervention on PMTCT service delivery in Cote d'Ivoire, Kenya, Mozambique: a cluster randomized trial.

Rustagi AS, Gimbel S, Nduati R, Cuembelo MF, Wasserheit JN, Farquhar C, Gloyd S, Sherr K, with input from the SST. J Acquir Immune Defic Syndr. 2016 Apr 14. [Epub ahead of print]

Background: Efficacious interventions to prevent mother-to-child HIV transmission (PMTCT) have not translated well into effective programs. Prior studies of systems engineering applications to PMTCT lacked comparison groups or randomization.

Methods: Thirty-six health facilities in Cote d'Ivoire, Kenya, and Mozambique were randomized to usual care or a systems engineering intervention, stratified by country and volume. The intervention guided facility staff to iteratively identify and then rectify barriers to PMTCT implementation. Registry data quantified coverage of HIV testing during first antenatal care visit, antiretrovirals (ARVs) for HIV-positive pregnant women, and screening HIV-exposed infants (HEI) for HIV by 6-8 weeks. We compared the change between baseline (January 2013-January 2014) and post-intervention (January-March 2015) periods using t-tests. All analyses were intent-to-treat.

Results: ARV coverage increased 3-fold (+13.3 percentage points [95% CI: 0.5, 26.0] in intervention vs. +4.1 [-12.6, 20.7] in control facilities) and HEI screening increased 17-fold (+11.6 [-2.6, 25.7] in intervention vs. +0.7 [-12.9, 14.4] in control facilities). In pre-specified sub-group analyses, ARV coverage increased significantly in Kenya (+20.9 [-3.1, 44.9] in intervention vs. -21.2 [-52.7, 10.4] in controls; p=0.02). HEI screening increased significantly in Mozambique (+23.1 [10.3, 35.8] in intervention vs. +3.7 [-13.1, 20.6] in controls; p=0.04). HIV testing did not differ significantly between arms.

Conclusions: In this first randomized trial of systems engineering to improve PMTCT, we saw substantially larger improvements in ARV coverage and HEI screening in intervention facilities compared to controls, which were significant in pre-specified sub-groups. Systems engineering could strengthen PMTCT service delivery and protect infants from HIV.

Abstract access

Editor’s notes: Systems engineering is an interdisciplinary approach to optimise complex processes or systems. In this randomised trial of a systems engineering approach to improving prevention  of mother-to-child HIV transmission programmes, the study programme was a five-step, iterative package of systems analysis and quality improvement tools. In lay terms, the systems engineering activity helped facility staff understand implementation barriers to prevention of mother-to-child transmission programme service delivery, identify bottlenecks and patient dropout along the cascade and develop a facility-specific microintervention to address these issues. This was then repeated in a quality improvement iterative cycle with the overall aim to improve the flow of mother-infant pairs through the prevention of mother-to-child HIV transmission cascade. Study findings suggest that a systems engineering approach could markedly increase antiretroviral therapy coverage and HIV-exposed infant screening in prevention of mother-to-child HIV transmission programmes.  Further studies evaluating a systems engineering approach in the context of programmatic HIV care, especially in resource-poor settings, are required.

Côte d'Ivoire, Kenya, Mozambique
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Pilot integration of HIV and nutrition services shows great potential for health impact

Outcomes and cost-effectiveness of integrating HIV and nutrition service delivery: pilots in Malawi and Mozambique.

Bergmann JN, Legins K, Sint TT, Snidal S, Group UR, Amor YB, McCord GC. AIDS Behav. 2016 Apr 19. [Epub ahead of print]

This paper provides the first estimates of impact and cost-effectiveness for integrated HIV and nutrition service delivery in sub-Saharan Africa. HIV and undernutrition are synergistic co-epidemics impacting millions of children throughout the region. To alleviate this co-epidemic, UNICEF supported small-scale pilot programs in Malawi and Mozambique that integrated HIV and nutrition service delivery. We use trends from integration sites and comparison sites to estimate the number of lives saved, infections averted and/or undernutrition cases cured due to programmatic activities, and to estimate cost-effectiveness. Results suggest that Malawi's program had a cost-effectiveness of $11-29/DALY, while Mozambique's was $16-59/DALY. Some components were more effective than others ($1-4/DALY for Malawi's Male motivators vs. $179/DALY for Mozambique's One stop shops). These results suggest that integrating HIV and nutrition programming leads to a positive impact on health outcomes and should motivate additional work to evaluate impact and determine cost-effectiveness using an appropriate research design.

Abstract access

Editor’s notes: This paper presents outcomes and cost-effectiveness of a variety of programmes intended to facilitate integration of HIV treatment and care services with community management of acute malnutrition (CMAM) services in Malawi and Mozambique. In Malawi, programmes included SMS reminders to encourage attendance and adherence, “male motivators” who encouraged men to be involved in children’s health, and child health passports. In Mozambique, programmes included one-stop shops where children could access HIV-associated and vaccination services. Flowcharts to facilitate referral between HIV and nutrition services were also tried. Difference in difference estimates indicate substantial improvements in child health outcomes, and cost-effectiveness estimates are in line with other services. The programmes were funded by UNICEF, and not designed for research purposes. The authors therefore acknowledge some limitations in the external validity of their findings.  This paper should be taken as proof of concept rather than a final word on the effectiveness or cost-effectiveness of these activities. However, these preliminary estimates illustrate that there is great potential in facilitating integration of these two services.  Further research into integration of nutritional support services with HIV services is necessary.

Malawi, Mozambique
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An innovative method to evaluate community support for children: Using existing datasets

How effective is help on the doorstep? A longitudinal evaluation of community-based organisation support. 

Sherr L, Yakubovich AR, Skeen S, Cluver LD, Hensels IS, Macedo A, Tomlinson M. PLoS One. 2016 Mar 11;11(3):e0151305. doi: 10.1371/journal.pone.0151305. eCollection 2016.

Community-based responses have a lengthy history. The ravages of HIV on family functioning has included a widespread community response. Although much funding has been invested in front line community-based organisations (CBO), there was no equal investment in evaluations. This study was set up to compare children aged 9-13 years old, randomly sampled from two South African provinces, who had not received CBO support over time (YC) with a group of similarly aged children who were CBO attenders (CCC). YC baseline refusal rate was 2.5% and retention rate was 97%. CCC baseline refusal rate was 0.7% and retention rate was 86.5%. 1848 children were included—446 CBO attenders compared to 1402 9-13 year olds drawn from a random sample of high-HIV prevalence areas. Data were gathered at baseline and 12-15 months follow-up. Standardised measures recorded demographics, violence and abuse, mental health, social and educational factors. Multivariate regression analyses revealed that children attending CBOs had lower odds of experiencing weekly domestic conflict between adults in their home (OR 0.17; 95% CI 0.09, 0.32), domestic violence (OR 0.22; 95% CI 0.08, 0.62), or abuse (OR 0.11; 95% CI 0.05, 0.25) at follow-up compared to participants without CBO contact. CBO attenders had lower odds of suicidal ideation (OR 0.41; 95% CI 0.18, 0.91), fewer depressive symptoms (B = -0.40; 95% CI -0.62, -0.17), less perceived stigma (B = -0.37; 95% CI -0.57, -0.18), fewer peer problems (B = -1.08; 95% CI -1.29, -0.86) and fewer conduct problems (B = -0.77; 95% CI -0.95, -0.60) at follow-up. In addition, CBO contact was associated with more prosocial behaviours at follow-up (B = 1.40; 95% CI 1.13, 1.67). No associations were observed between CBO contact and parental praise or post-traumatic symptoms. These results suggest that CBO exposure is associated with behavioural and mental health benefits for children over time. More severe psychopathology was not affected by attendance and may need more specialised input.

Abstract  Full-text [free] access 

Editor’s notes: This study is novel in both its research question and its methodology. The study aims to assess whether receipt of support from community-based organisations (CBOs) impacts the mental and social well-being of children in high HIV prevalence areas. The CBOs studied include many different organisations with diverse services, giving the study the benefit of assessing the overall impact of a combination of small, motivated groups. This helps lend credibility to CBOs and to convince policymakers and funders to support small-scale CBOs.

In terms of methodology, the study utilises two longitudinal datasets from southern Africa to explore the study aims. One survey is from a study of children affected by HIV served by CBOs, while the other is from a study of children affect by HIV without CBO support. There are some limitations to using two different studies, most especially unclear comparability and, in this case, lack of control data to adjust for possible differences, for example on socio-economic status or how HIV specifically affected the child. Despite these, this paper has striking results, and is an innovative effort to improve our understanding of the impact of CBOs on children’s well-being and should spur further creativity in impact evaluation methods.

South Africa
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The conundrum of future funding for HIV – who pays and how?

Long-term financing needs for HIV control in sub-Saharan Africa in 2015-2050: a modelling study. 

Atun R, Chang AY, Ogbuoji O, Silva S, Resch S, Hontelez J, Barnighausen T. BMJ Open. 2016 Mar 6;6(3):e009656. doi: 10.1136/bmjopen-2015-009656.

Objectives: To estimate the present value of current and future funding needed for HIV treatment and prevention in 9 sub-Saharan African (SSA) countries that account for 70% of HIV burden in Africa under different scenarios of intervention scale-up. To analyse the gaps between current expenditures and funding obligation, and discuss the policy implications of future financing needs.

Design: We used the Goals module from Spectrum, and applied the most up-to-date cost and coverage data to provide a range of estimates for future financing obligations. The four different scale-up scenarios vary by treatment initiation threshold and service coverage level. We compared the model projections to current domestic and international financial sources available in selected SSA countries.

Results: In the 9 SSA countries, the estimated resources required for HIV prevention and treatment in 2015-2050 range from US$98 billion to maintain current coverage levels for treatment and prevention with eligibility for treatment initiation at CD4 count of <500/mm3 to US$261 billion if treatment were to be extended to all HIV-positive individuals and prevention scaled up. With the addition of new funding obligations for HIV–which arise implicitly through commitment to achieve higher than current treatment coverage levels–overall financial obligations (sum of debt levels and the present value of the stock of future HIV funding obligations) would rise substantially.

Conclusions: Investing upfront in scale-up of HIV services to achieve high coverage levels will reduce HIV incidence, prevention and future treatment expenditures by realising long-term preventive effects of ART to reduce HIV transmission. Future obligations are too substantial for most SSA countries to be met from domestic sources alone. New sources of funding, in addition to domestic sources, include innovative financing. Debt sustainability for sustained HIV response is an urgent imperative for affected countries and donors

Abstract  Full-text [free] access 

Editor’s notes: The authors of this interesting paper use the most up-to-date cost and coverage data to provide a range of estimates for future treatment financing obligations. Epidemiological parameters are included to fit the Goals model and key prevention services such as ‘prevention of mother-to-child HIV transmission’ and ‘voluntary medical male circumcision’ are also included.

Financing needs for the nine countries are estimated by varying treatment initiation threshold (everyone initiated on treatment versus initiation at CD4 of <500cells/mm3) and/or coverage level for prevention and treatment (‘current’ levels and a ‘scale up’ scenario). The authors also attempt to assess both the ethics and the cost of different approaches.

For all scenarios, there is a steady decline in proportion of treatment costs and an increase in the proportion of prevention costs. This apparent contradiction is largely because there will be fewer individuals on treatment over time but prevention costs rise because they are mostly invested in non-infected populations, which increases with population growth.

In the nine countries, estimated resources required for HIV prevention and treatment from 2015-2050 will be large. This is increased further when human resources and supplies increase at the rate of GDP per capita.

However, there is undoubtedly an ethical responsibility to not only continue financing people receiving ART, but, that the responsibility extends to people in equal need who are not on treatment. The ethics is underpinned by the evidence. This illustrates how ‘front-loading’ investments in HIV scale-up now to ensure high levels of coverage, will significantly reduce future HIV incidence and prevalence. 

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Spatial analysis methods to improve localised estimates of HIV prevalence

Evaluation of geospatial methods to generate subnational HIV prevalence estimates for local level planning.

Anderson SJ, Subnational Estimates Working Group of the HIVMC. AIDS. 2016 Feb 25. [Epub ahead of print]

Objective: There is evidence of substantial subnational variation in the HIV epidemic. However, robust spatial HIV data are often only available at high levels of geographic aggregation and not at the finer resolution needed for decision making. Therefore, spatial analysis methods that leverage available data to provide local estimates of HIV prevalence may be useful. Such methods exist but have not been formally compared when applied to HIV.

Design/methods: Six candidate methods - including those used by UNAIDS to generate maps and a Bayesian geostatistical approach applied to other diseases- were used to generate maps and subnational estimates of HIV prevalence across three countries using cluster level data from household surveys. Two approaches were used to assess the accuracy of predictions: (1) internal validation, whereby a proportion of input data is held back (test dataset) to challenge predictions, (2) comparison with location specific data from household surveys in earlier years.

Results: Each of the methods can generate usefully accurate predictions of prevalence at unsampled locations, with the magnitude of the error in predictions similar across approaches. However, the Bayesian geostatistical approach consistently gave marginally the strongest statistical performance across countries and validation procedures.

Conclusions: Available methods may be able to furnish estimates of HIV prevalence at finer spatial scales than the data currently allow. The subnational variation revealed can be integrated into planning to ensure responsiveness to the spatial features of the epidemic. The Bayesian geostatistical approach is a promising strategy for integrating HIV data to generate robust local estimates.

Abstract access  

Editor’s notes: Data from intensively monitored populations indicates that large differences in HIV prevalence can be seen across small geographic spaces. Understanding these localised spatial variations within a generalised epidemic can enable HIV programme resources to be used most effectively. However the data required for such localised estimation are often lacking. As a result modelling strategies must be used to predict local variation based on the best available data.

This study compares six different geospatial methods of estimating local HIV prevalence. The methods can be categorised by whether or not they use ancillary information such as road networks to improve their predictions and also whether they generated continuously changing prevalence surfaces (like map contours) or gave discrete estimates for geographic sub-regions e.g. districts.

While all methods produced reasonable overall levels of performance, those using a Bayesian geostatistical approach illustrated marginally better predictive accuracies. The levels of accuracy appeared more dependent on the national prevalence than the choice of model used.

The authors conclude by setting out a strategy for improvement of the models, principally through integrating additional data from sources such as antiretroviral therapy and prevention of mother-to-child transmission programmes, antenatal clinic surveys and case based reporting. 

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