Articles tagged as "Resources/ Impact/ Development"

Integrating HIV, malaria and diarrhoea prevention is far more efficient than vertical programmes

Scaling up integrated prevention campaigns for global health: costs and cost-effectiveness in 70 countries. 

Marseille E, Jiwani A, Raut A, Verguet S, Walson J, Kahn JG. BMJ Open. 2014 Jun 26;4(6):e003987. doi: 10.1136/bmjopen-2013-003987.

Objective: This study estimated the health impact, cost and cost-effectiveness of an integrated prevention campaign (IPC) focused on diarrhoea, malaria and HIV in 70 countries ranked by per capita disability-adjusted life-year (DALY) burden for the three diseases.

Methods: We constructed a deterministic cost-effectiveness model portraying an IPC combining counselling and testing, cotrimoxazole prophylaxis, referral to treatment and condom distribution for HIV prevention; bed nets for malaria prevention; and provision of household water filters for diarrhoea prevention. We developed a mix of empirical and modelled cost and health impact estimates applied to all 70 countries. One-way, multiway and scenario sensitivity analyses were conducted to document the strength of our findings. We used a healthcare payer's perspective, discounted costs and DALYs at 3% per year and denominated cost in 2012 US dollars.

Primary and secondary outcomes: The primary outcome was cost-effectiveness expressed as net cost per DALY averted. Other outcomes included cost of the IPC; net IPC costs adjusted for averted and additional medical costs and DALYs averted.

Results: Implementation of the IPC in the 10 most cost-effective countries at 15% population coverage would cost US$583 million over 3 years (adjusted costs of US$398 million), averting 8.0 million DALYs. Extending IPC programmes to all 70 of the identified high-burden countries at 15% coverage would cost an adjusted US$51.3 billion and avert 78.7 million DALYs. Incremental cost-effectiveness ranged from US$49 per DALY averted for the 10 countries with the most favourable cost-effectiveness to US$119, US$181, US$335, US$1 692 and US$8 340 per DALY averted as each successive group of 10 countries is added ordered by decreasing cost-effectiveness.

Conclusions: IPC appears cost-effective in many settings, and has the potential to substantially reduce the burden of disease in resource-poor countries. This study increases confidence that IPC can be an important new approach for enhancing global health.

Abstract  Full-text [free] access

Editor’s notes: Increasingly governments and policy makers are seeking to identify how to invest resources most effectively, to achieve multiple health and development outcomes. This paper presents a cost-effectiveness analysis of an integrated campaign to prevent diarrhoea, malaria and HIV.  

They developed a model to estimate the cost per disability adjusted life year (DALY) averted by this intervention, across 70 countries with high disease burden, assuming 15% coverage. The authors categorise countries by income level and their opportunity index (i.e. the opportunity to avert DALYs by having a high disease burden). The findings suggest that an integrated prevention campaign (IPC) could cost as little as US$7 per DALY averted in Guinea-Bissau, a low income, high opportunity country. As would be expected, the contribution of the different IPC components varied by country, depending on their relative disease burdens. This suggests that further focusing of activities within countries may further improve efficiency.

The model was also used to consider potential roll out strategies across counties. For this, countries were grouped into blocks of 10, and ordered with increasing incremental-cost effectiveness. The authors suggest that reaching the top 40 countries with IPC, even at just 15% coverage, could achieve far greater health benefits, with a substantially lower budget, than requested under PEPFAR for antiretroviral therapy alone.

This paper provides further evidence of the need for a more integrated approach to improve population health across disease areas.

Africa, Asia, Europe, Latin America
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Does land ownership by women reduce HIV risk?

Women's land ownership and risk of HIV infection in Kenya

Muchomba FM, Wang JS, Agosta LM. Soc Sci Med. 2014 Aug;114:97-102. doi: 10.1016/j.socscimed.2014.05.055. Epub 2014 Jun 2.

Theory predicts that land ownership empowers women to avoid HIV acquisition by reducing their reliance on risky survival sex and enhancing their ability to negotiate safer sex. However, this prediction has not been tested empirically. Using a sample of 5 511 women working in the agricultural sector from the 1998, 2003 and 2008-09 Kenya Demographic and Health Surveys, we examined the relationship between women's land ownership and participation in transactional sex, multiple sexual partnerships and unprotected sex, and HIV infection status. We controlled for demographic characteristics and household wealth, using negative binomial and logistic regression models. Women's land ownership was associated with fewer sexual partners in the past year (incidence rate ratio, 0.98; 95% confidence interval [CI], 0.95-1.00) and lower likelihood of engaging in transactional sex (odds ratio [OR], 0.67; 95% CI: 0.46-0.99), indicators of reduced survival sex, but was not associated with unprotected sex with casual partners (OR, 0.64; 95% CI, 0.35-1.18) or with unprotected sex with any partner among women with high self-perceived HIV risk (OR, 1.02; 95% CI, 0.57-1.84), indicating no difference in safer sex negotiation. Land ownership was also associated with reduced HIV infection among women most likely to engage in survival sex, i.e., women not under the household headship of a husband (OR, 0.40; 95% CI, 0.18-0.89), but not among women living in husband-headed households, for whom increased negotiation for safer sex would be more relevant (OR, 1.74; 95% CI, 0.92-3.29). These findings suggest that reinforcing women's land rights may reduce reliance on survival sex and serve as a viable structural approach to HIV prevention, particularly for women not in a husband's household, including unmarried women and female household heads.

Abstract access 

Editor’s notes: A range of social and economic factors influence the degree to which individuals and communities are vulnerable to HIV infection. In some settings, a lack of land ownership has been shown to increase women’s risk of partner violence. This paper assessed whether women who own land have lower HIV risk. For single women or women in female-headed households, land ownership was associated with a reduced risk of HIV infection. Interestingly, lower HIV risk didn’t appear to be associated with an increased ability to negotiate safer sex practices, but rather arise from women's reduced economic reliance on high-risk sexual partnerships. The findings also suggest that women's own access to land had a greater influence on their HIV risk than household-level wealth, suggesting that household level wealth is not the same as wealth owned by women. Although the analysis is of cross-sectional data, and so causality cannot be established, the findings suggest that increasing women’s ownership of land may provide a structural mechanism to reduce women’s HIV vulnerability. This contributes to the increasing body of evidence that points to the potentially important role that economic empowerment programmes may play in helping to reduce women’s vulnerability to HIV.

Africa
Kenya
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Refusal bias in HIV prevalence estimates from nationally-representative surveys: small overall effects may conceal substantial bias for certain subgroups

Refusal bias in the estimation of HIV prevalence.

Janssens W, van der Gaag J, Rinke de Wit TF, Tanovic Z. Janssens W, van der Gaag J, Rinke de Wit TF, Tanović Z. Demography. 2014 May 2. [Epub ahead of print]

In 2007, UNAIDS corrected estimates of global HIV prevalence downward from 40 million to 33 million based on a methodological shift from sentinel surveillance to population-based surveys. Since then, population-based surveys are considered the gold standard for estimating HIV prevalence. However, prevalence rates based on representative surveys may be biased because of nonresponse. This article investigates one potential source of nonresponse bias: refusal to participate in the HIV test. We use the identity of randomly assigned interviewers to identify the participation effect and estimate HIV prevalence rates corrected for unobservable characteristics with a Heckman selection model. The analysis is based on a survey of 1 992 individuals in urban Namibia, which included an HIV test. We find that the bias resulting from refusal is not significant for the overall sample. However, a detailed analysis using kernel density estimates shows that the bias is substantial for the younger and the poorer population. Nonparticipants in these subsamples are estimated to be three times more likely to be HIV-positive than participants. The difference is particularly pronounced for women. Prevalence rates that ignore this selection effect may be seriously biased for specific target groups, leading to misallocation of resources for prevention and treatment.

Abstract access 

Editor’s notes: Refusal bias in HIV prevalence estimates from nationally representative surveys has been a contested issue ever since UNAIDS made a downward revision of its estimates to accommodate the evidence from such surveys. Most authors nowadays agree that an adjustment of estimates based on unobserved characteristics – for example, prior knowledge of one’s HIV status – is necessary. The Heckman sample selection model with the interviewer identities as the instrumental variable is often used for that. Results from Heckman models have not always been conclusive however, and this study is no exception. The authors take the lack of significant bias as a starting point for exploring the characteristics of nonparticipants and their relative contribution to HIV prevalence estimates in greater detail. They conclude that even though the impact of refusal on national-level HIV prevalence estimates may be small, it could lead to substantial downward bias of HIV prevalence estimates for certain subgroups, in this case women, younger individuals and the poor.

Africa
Namibia
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Real-world costing of HIV treatment in Zambia highlights difference between national guidelines and actual resource use

Retention in care, resource utilization, and costs for adults receiving antiretroviral therapy in Zambia: a retrospective cohort study.

Scott CA, Iyer HS, McCoy K, Moyo C, Long L, Larson BA, Rosen S. BMC Public Health. 2014 Mar 31;14(1):296. doi: 10.1186/1471-2458-14-296.

Background: Of the estimated 800 000 adults living with HIV in Zambia in 2011, roughly half were receiving antiretroviral therapy (ART). As treatment scale up continues, information on the care provided to patients after initiating ART can help guide decision-making. We estimated retention in care, the quantity of resources utilized, and costs for a retrospective cohort of adults initiating ART under routine clinical conditions in Zambia.

Methods: Data on resource utilization (antiretroviral [ARV] and non-ARV drugs, laboratory tests, outpatient clinic visits, and fixed resources) and retention in care were extracted from medical records for 846 patients who initiated ART at ≥15 years of age at six treatment sites between July 2007 and October 2008. Unit costs were estimated from the provider's perspective using site- and country-level data and are reported in 2011 USD.

Results: Patients initiated ART at a median CD4 cell count of 145 cells/μL. Fifty-nine percent of patients initiated on a tenofovir-containing regimen, ranging from 15% to 86% depending on site. One year after ART initiation, 75% of patients were retained in care. The average cost per patient retained in care one year after ART initiation was $243 (95% CI, $194-$293), ranging from $184 (95% CI, $172-$195) to $304 (95% CI, $290-$319) depending on site. Patients retained in care one year after ART initiation received, on average, 11.4 months' worth of ARV drugs, 1.5 CD4 tests, 1.3 blood chemistry tests, 1.4 full blood count tests, and 6.5 clinic visits with a doctor or clinical officer. At all sites, ARV drugs were the largest cost component, ranging from 38% to 84% of total costs, depending on site.

Conclusions: Patients initiate ART late in the course of disease progression and a large proportion drop out of care after initiation. The quantity of resources utilized and costs vary widely by site, and patients utilize a different mix of resources under routine clinical conditions than if they were receiving fully guideline-concordant care. Improving retention in care and guideline concordance, including increasing the use of tenofovir in first-line ART regimens, may lead to increases in overall treatment costs.

 Abstract  Full-text [free] access

Editor’s notes: This article highlights the importance of conducting ‘real-world’ economic evaluations for HIV-related services.  The authors found that practical implementation of national policy was not universal. This finding had important implications on the observed retention in care and cost of providing services. The observed use of some resources, e.g. drugs, for people retained in care, were lower than expected, while the number of clinical consultations was higher than recommended in the guidelines. These findings suggest that it may not be appropriate to assume that guidelines and practice will be identical for the purposes of programme planning and budgeting.  

Africa
Zambia
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Efavirenz dose reduction could help scale up antiretroviral therapy access

Efficacy of 400 mg efavirenz versus standard 600 mg dose in HIV-infected, antiretroviral-naive adults (ENCORE1): a randomised, double-blind, placebo-controlled, non-inferiority trial.

ENCORE1 Study Group. Lancet. 2014 Feb 7. pii: S0140-6736(13)62187-X. doi: 10.1016/S0140-6736(13)62187-X. [Epub ahead of print]

Background: The optimum dose of key antiretroviral drugs is often overlooked during product development. The ENCORE1 study compared the efficacy and safety of reduced dose efavirenz with standard dose efavirenz in combination with tenofovir and emtricitabine as first-line treatment for HIV infection. An effective and safe reduced dose could yield meaningful cost savings.

Methods: ENCORE1 is a continuing non-inferiority trial in HIV-1-infected antiretroviral-naive adults in 38 clinical sites in 13 countries. Participants (plasma HIV-RNA >1000 log10 copies per mL, CD4 T-cell count 50-500 cells per µL) were randomly assigned by a computer-generated sequence with a blocking factor of four (stratified by clinical site and by screening viral load) to receive tenofovir plus emtricitabine with either a reduced daily dose (400 mg) or a standard dose (600 mg) of efavirenz. Participants, physicians, and all other trial staff were masked to treatment group. The primary endpoint was the difference in proportions of participants with plasma HIV-RNA of less than 200 copies per mL at 48 weeks. Treatment groups were regarded as non-inferior if the lower limit of the 95% CI for the difference in viral load was less than -10% by modified intention-to-treat analysis. Adverse events were summarised by treatment.

Findings: The modified intention-to-treat analysis consisted of 630 patients (efavirenz 400=321; efavirenz 600=309). 32% were women; 37% were African, 33% were Asian, and 30% were white. The mean baseline CD4 cell count was 273 cells per µL (SD 99) and median plasma HIV-RNA was 4.75 log10 copies per mL (IQR 0.88). The proportion of participants with a viral load below 200 copies per mL at week 48 was 94.1% for efavirenz 400 mg and 92.2% for 600 mg (difference 1.85%, 95% CI -2.1 to 5.79). CD4 T-cell counts at week 48 were significantly higher for the 400 mg group than for the 600 mg group (mean difference 25 cells per µL, 95% CI 6-44; p=0.01). We recorded no difference in grade or number of patients reporting adverse events (efavirenz 400=89.1%, efavirenz 600=88.4%; difference 0.75%, 95% CI -4.19 to 5.69; p=0.77). Study drug-related adverse events were significantly more frequent in the 600 mg group than in the 400 mg group (146% [47] vs 118 [37]), difference -10.5%, 95% CI -18.2 to -2.8; p=0.01) and significantly fewer patients with these events stopped treatment (400 mg=6 [2%], 600 mg=18 [6%], difference -3.96%, 95% CI -6.96 to -0.95; p=0.01).

Interpretation: Our findings suggest that a reduced dose of 400 mg efavirenz is non-inferior to the standard dose of 600 mg, when combined with tenofovir and emtricitabine during 48 weeks in ART-naive adults with HIV-1 infection. Adverse events related to the study drug were more frequent with 600 mg efavirenz than with 400 mg. Lower dose efavirenz should be recommended as part of routine care.

Abstract access

Editor’s notes: Nearly 10 million people in low- and middle-income countries were receiving antiretroviral therapy (ART) by the end of 2012, with plans to expand coverage to 15 million by 2015. Several challenges must be overcome if this target is to be achieved. One of the most pertinent of these is how to fund this expansion in the current economic climate. Significant progress has already been made in reducing the cost of first-line drugs. The authors of this paper propose an alternative approach to lowering drug costs, namely dose reduction.

Evidence supporting the 600mg dose of efavirenz used in clinical practice is weak, with no difference found in the proportion of patients achieving viral suppression in the original dose finding trials of 200mg, 400mg and 600mg (unpublished). This trial in ART-naive individuals found that 400mg was non-inferior to 600mg of efavirenz in terms of viral suppression over 48 weeks of follow-up. Findings were similar when stratified by ethnic group (African, Asian, other) and body mass index, both factors which influence drug concentrations. Furthermore, fewer patients on 400mg reported adverse events which were related to efavirenz, and fewer patients with drug-related side effects on this dose stopped efavirenz. These promising results support a dose reduction strategy. However, longer term outcomes need to be evaluated and efficacy studies in patients with tuberculosis are needed before the 400mg dose is recommended for use in routine clinical practice. Certainly, if drug companies agree to manufacture this dose at scale, preferably in fixed-dose combination tablets, cost-savings could be considerable.  

Africa, Asia, Europe, Latin America
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The do’s and don’ts for human resource strategies as external financing makes its exit: lessons from Namibia

Confronting 'scale-down': Assessing Namibia's human resource strategies in the context of decreased HIV/AIDS funding.

Cairney LI, Kapilashrami A. Glob Public Health. 2014 Jan-Feb;9(1-2):198-209. doi: 10.1080/17441692.2014.881525. Epub 2014 Feb 6.

In Namibia, support through the Global Fund and President’s Emergency Plan for AIDS Relief has facilitated an increase in access to HIV and AIDS services over the past 10 years. In collaboration with the Namibian government, these institutions have enabled the rapid scale-up of prevention, treatment and care services. Inadequate human resources capacity in the public sector was cited as a key challenge to initial scale-up; and a substantial portion of donor funding has gone towards the recruitment of new health workers. However, a recent scale-down of donor funding to the Namibian health sector has taken place, despite the country’s high HIV and AIDS burden. With a specific focus on human resources, this paper examines the extent to which management processes that were adopted at scale-up have proven sustainable in the context of scale-down. Drawing on data from 43 semi-structured interviews, we argue that human resources planning and management decisions made at the onset of the country’s relationship with the two institutions appear to be primarily driven by the demands of rapid scale-up and counter-productive to the sustainability of interventions.

Abstract access 

Editor’s notes: Some countries graduate to higher income categories and become ineligible for funding from major donors, such as the Global Fund and PEPFAR. As this happens, it is increasingly important to draw lessons on how to manage this transition from international to domestic financing and ownership. Using the case of human resource management, this study underscores the need to establish exit strategies early on. It also emphasises the need to ensure the integration of management processes within government systems. These are deemed necessary if high service coverage rates are to be maintained. The case study documents how additional health professionals were recruited at higher salaries than government salaries through a parallel recruitment system.  This was done in order to meet the needs of service scale-up. However, that approach led to an unsustainable situation. Sudden salary cuts jeopardised service continuity and the expectation that these staff would be absorbed on to the government payroll. There appears to be a trade-off between certain structures to enable rapid scale-up and programme sustainability. These ought to be planned for at an early stage of funding partnerships.   

Africa
Namibia
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Integrated routine screening for syphilis and HIV in antenatal care is cost-effective in China

Cost-effectiveness of integrated routine offering of prenatal HIV and syphilis screening in China.

Owusu-Edusei, K., Jr. Tao, G. Gift, T. L. Wang, A. Wang, L. Tun, Y. Wei, X. Wang, L. Fuller, S. Kamb, M. L. Bulterys, M. Sex Transm Dis. 2014 Feb;41(2):103-10. doi: 10.1097/OLQ.0000000000000085.

Background: In China, recent rises in syphilis and HIV cases have increased the focus on preventing mother-to-child transmission of these infections. We assess the health and economic outcomes of different strategies of prenatal HIV and syphilis screening from the local health department's perspective.

Methods: A Markov cohort decision analysis model was used to estimate the health and economic outcomes of pregnancy using disease prevalence and cost data from local sources and, if unavailable, from published literature. Adverse pregnancy outcomes included induced abortion, stillbirth, low birth weight, neonatal death, congenital syphilis in live-born infants, and perinatal HIV infection. We examined 4 screening strategies: no screening, screening for HIV only, for syphilis only, and for both HIV and syphilis. We estimated disability-adjusted life years (DALYs) for each health outcome using life expectancies and infections for mothers and newborns.

Results: For a simulated cohort of 10 000 pregnant women (0.07% prevalence for HIV and 0.25% for syphilis; 10% of HIV-positives were coinfected with syphilis), the estimated costs per DALY prevented were as follows: syphilis-only, $168; HIV-and-syphilis, $359; and HIV-only,    $5 636. The estimated incremental cost-effectiveness ratio if an existing HIV-only strategy added syphilis screening (i.e., move from the HIV-only strategy to the HIV-and-syphilis strategy) was $140 per additional DALY prevented.

Conclusions: Given the increasing prevalence of syphilis and HIV among pregnant women in China, prenatal HIV screening programs that also include syphilis screening are likely to be substantially more cost-effective than HIV screening alone and prevent many more adverse pregnancy outcomes.

Abstract access 

Editor’s notes: This study uses a Markov cohort model to estimate the cost-effectiveness of combined HIV and syphilis screening in antenatal care, as compared to HIV-only screening, syphilis-only screening, or no screening. This is the first study to examine cost-effectiveness of antenatal syphilis screening in China. This is particularly interesting as existing studies modelling the cost-effectiveness of syphilis screening in antenatal care have largely focused on settings with high syphilis prevalence amongst pregnant women, such as sub-Saharan Africa. This study found that even in a low syphilis prevalence setting, combined HIV/syphilis screening is substantially cost-effective at $359 per DALY averted, and more cost-effective than HIV-only screening.

Asia
China
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Unconditional cash transfers delays age of sexual debut among orphans and vulnerable children in Kenya

The government of Kenya's cash transfer program reduces the risk of sexual debut among young people age 15-25.

Handa S, Halpern CT, Pettifor A3, Thirumurthy H. PLoS One 2014; 9(1):e85473.

The aim of this study is to assess whether the Government of Kenya's Cash Transfer for Orphans and Vulnerable Children (Kenya CT-OVC) can reduce the risk of HIV among young people by postponing sexual debut. The program provides an unconditional transfer of US$ 20 per month directly to the main caregiver in the household. An evaluation of the program was implemented in 2007-2009 in seven districts. Fourteen Locations were randomly assigned to receive the program and fourteen were assigned to a control arm. A sample of households was enrolled in the evaluation in 2007. We revisited these households in 2011 and collected information on sexual activity among individuals between 15-25 years of age. We used logistic regression, adjusted for the respondent's age, sex and relationship to caregiver, the age, sex and schooling of the caregiver and whether or not the household lived in Nairobi at baseline, to compare rates of sexual debut among young people living in program households with those living in control households who had not yet entered the program. Our results, adjusted for these covariates, show that the program reduced the odds of sexual debut by 31 percent. There were no statistically significant effects on secondary outcomes of behavioral risk such as condom use, number of partners and transactional sex. Since the CT-OVC provides cash to the caregiver and not to the child, and there are no explicit conditions associated with receipt, these impacts are indirect, and may have been achieved by keeping young people in school. Our results suggest that large-scale national social cash transfer programs with poverty alleviation objectives may have potential positive spillover benefits in terms of reducing HIV risk among young people in Eastern and Southern Africa.

Abstract Full-text [free] access

Editor’s notes: There is growing interest in the potential to use social protection and/or poverty alleviation mechanisms to reduce adolescent’s HIV risk. Current evidence comes largely from pilot or localized experiments, involving different programme parameters and target populations. This paper presents the findings from a large-scale evaluation of the Kenya Cash Transfer for Orphans and Vulnerable Children (Kenya CT-OVT) programme. Findings show that the activity reduced the relative odds of sexual debut among young people aged 15–25 by 31%, with larger impacts among females (42%) than males (26%).  Importantly, this impact was achieved despite the payment being paid to the caregiver rather than to the child, having no explicit focus on HIV, or having any form of conditionality (such as school attendance) associated with the payment. Further research is needed to better understand the pathways underlying this impact. However, the results add to the growing evidence base that addressing upstream structural drivers of risk, including poverty, can reduce HIV risk behaviours. The findings are particularly important also, given that similar, large-scale social protection programmes are currently operating across many countries in east and southern Africa.

Africa
Kenya
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Provider-initiated partner notification of HIV is potentially cost-effective in sub-Saharan Africa

Cost-effectiveness of provider-based HIV partner notification in urban Malawi.

Rutstein SE, Brown LB, Biddle AK, Wheeler SB, Kamanga G, Mmodzi P, Nyirenda N, Mofolo I, Rosenberg NE, Hoffman IF, Miller WC. Health Policy Plan 2014 Jan;29(1):115-26. doi: 10.1093/heapol/czs140. Epub 2013 Jan 15.

Provider-initiated partner notification for HIV effectively identifies new cases of HIV in sub-Saharan Africa, but is not widely implemented. Our objective was to determine whether provider-based HIV partner notification strategies are cost-effective for preventing HIV transmission compared with passive referral. We conducted a cost-effectiveness analysis using a decision-analytic model from the health system perspective during a 1-year period. Costs and outcomes of all strategies were estimated with a decision-tree model. The study setting was an urban sexually transmitted infection clinic in Lilongwe, Malawi, using a hypothetical cohort of 5 000 sex partners of 3 500 HIV-positive index cases. We evaluated three partner notification strategies: provider notification (provider attempts to notify indexes' locatable partners), contract notification (index given 1 week to notify partners then provider attempts notification) and passive referral (index is encouraged to notify partners, standard of care). Our main outcomes included cost (US dollars) per transmission averted, cost per new case identified and cost per partner tested. Based on estimated transmissions in a 5 000-person cohort, provider and contract notification averted 27.9 and 27.5 new infections, respectively, compared with passive referral. The incremental cost-effectiveness ratio (ICER) was $3 560 per HIV transmission averted for contract notification compared with passive referral. Provider notification was more expensive and slightly more effective than contract notification, yielding an ICER of $51 421 per transmission averted. ICERs were sensitive to the proportion of partners not contacted, but likely HIV positive and the probability of transmission if not on antiretroviral therapy. The costs per new case identified were $36 (provider), $18 (contract) and $8 (passive). The costs per partner tested were $19 (provider), $9 (contract) and $4 (passive). We conclude that, in this population, provider-based notification strategies are potentially cost-effective for identifying new cases of HIV. These strategies offer a simple, effective and easily implementable opportunity to control HIV transmission.

Abstract access 

Editor’s notes: Partner notification of HIV status is a way to identify new HIV cases and prevent transmission. Provider-initiated partner notification has had success in high-income countries, but is not widely implemented in sub-Saharan Africa. This study is the first cost-effectiveness analysis of provider-initiated partner notification in sub-Saharan Africa. The authors use a decision-tree model based on trial data from Malawi, to identify the incremental cost-effectiveness of provider notification, and contract notification, against the current standard of care (passive referral). 

The findings of this study indicate that provider referral may be a cost-effective and affordable way to identify new HIV cases and link patients to care earlier. The cost per infection averted as compared to passive referral ($3 560 for contract notification and $4 106 for provider notification) compares favourably with that of using nevirapine for prevention of mother-to-child transmission of HIV. Further research into the possible costs of adverse outcomes from provider notification (including dissolution of partnership or violence) is needed.

Africa
Malawi
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Gender, structural determinants and vulnerability

A critical analysis of Peru's HIV grant proposals to the Global Fund. 

Cáceres CF, Amaya AB, Sandoval C, Valverde R. Glob Public Health. 2013 Dec;8(10):1123-37. doi: 10.1080/17441692.2013.861859

Peru has applied to six of the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) rounds for funding, achieving success on four occasions. The process of proposal development has, however, been criticised, especially concerning the use of evidence, relevance/consistency and performance indicators. We aimed to analyse the Peruvian Global Fund proposals according to those dimensions, providing feedback to improve future local efforts and inform global discussions around Global Fund procedures. We analysed the content of four HIV-focused proposals (rounds 2, 5, 6 and 8) regarding epidemic context, needs identification and prioritisation and monitoring and evaluation systems. Peruvian proposals submitted after round 1 were described as resulting from collaborative inputs involving formerly unrepresented sectors, principally 'vulnerable populations'. However, difficulties arose regarding the amount and quality of evidence about the epidemiological context; limited consideration of social determinants of the epidemic; lack of theory-driven interventions, and little synergy across projects and the inclusion of weak monitoring and evaluation systems, with poor indicators and measurement procedures. Prioritising the development of analytical and technical skills to generate Global Fund proposals would enhance the country's capacity to produce and utilise evidence, improve the technical-political interface, strengthen information systems and lead to more informed decision making and accountability.

Abstract access 

Editor’s notes: This is a useful paper that dissects one country’s Global Fund proposals over 10 years (2002-2012) to assess the use of evidence, the consistency and appropriateness of proposed activities and the adequacy of its monitoring and evaluation framework. Although only one country, Peru, is scrutinised in this paper, many of the findings will be relevant to the development and implementation of Global Fund proposals in other countries.

It was encouraging to learn that the use of evidence improved over time. However the lack of appropriate surveillance data meant that proposals were not always found to be evidence-based. The paper highlights in particular the need to use epidemiological evidence that is related to specific population sub-categories to address “vulnerability” and ensure that interventions are effectively targeted.

Consistency and continuity across proposals was sometimes lacking, possibly reflecting the Global Fund’s mechanistic funding process via “rounds”. The paper notes that at times, programmes could appear to be a juxtaposition of activities rather than a well thought out comprehensive strategy. It would be interesting to see whether the Global Fund's new funding model based on the national HIV/AIDS strategy in the future leads to a more continuous and consistent flow of activities.

Another key point in the paper is the inadequacy of the proposals’ monitoring and evaluation (M&E) framework to monitor grants and evaluate results. As the paper notes, the information system will need to be strengthened for the M&E to deliver a more evidence based strategy.

Latin America
Peru
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