Articles tagged as "Resources/ Impact/ Development"

Integrating HIV treatment with primary care services

Integrating HIV treatment with primary care outpatient services: opportunities and challenges from a scaled-up model in Zambia.

Topp SM, Chipukuma JM, Chiko MM, Matongo E, Bolton-Moore C, Reid SE., Health Policy Plan. 2013; 4:347-57. doi: 10.1093/heapol/czs065

Background: Integration of HIV treatment with other primary care services has been argued to potentially improve effectiveness, efficiency and equity. However, outside the field of reproductive health, there is limited empirical evidence regarding the scope or depth of integrated HIV programmes or their relative benefits. Moreover, the body of work describing operational models of integrated service-delivery in context remains thin. Between 2008 and 2011, the Lusaka District Health Management Team piloted and scaled-up a model of integrated HIV and general outpatient department (OPD) services in 12 primary health care clinics. This paper examines the effect of the integrated model on the organization of clinic services, and explores service providers' perceptions of the integrated model.

Methods: We used a mixed methods approach incorporating facility surveys and key informant interviews with clinic managers and district officials. On-site facility surveys were carried out in 12 integrated facilities to collect data on the scope of integrated services, and 15 semi-structured interviews were carried out with 12 clinic managers and three district officials to explore strengths and weaknesses of the model. Quantitative and qualitative data were triangulated to inform overall analysis.

Findings: Implementation of the integrated model substantially changed the organization of service delivery across a range of clinic systems. Organizational and managerial advantages were identified, including more efficient use of staff time and clinic space, improved teamwork and accountability, and more equitable delivery of care to HIV and non-HIV patients. However, integration did not solve ongoing human resource shortages or inadequate infrastructure, which limited the efficacy of the model and were perceived to undermine service delivery.

Conclusion: While resource and allocative efficiencies are associated with this model of integration, a more important finding was the model's demonstrated potential for strengthening organizational culture and staff relationships, in turn facilitating more collaborative and motivated service delivery in chronically under-resourced primary healthcare clinics.

Abstract Full-text [free] access

Editor’s notes:  In recent years, there has been much debate about the relative benefits of disease-specific programs vs. broader strengthening of health systems, which may have the potential to improve effectiveness, cost-effectiveness and equity of health care.  

The integrated model in primary care services in this study involved 3 modifications: 1) amalgamation of physical space and patient flow; 2) standardisation of record keeping; 3) introduction of provider-initiated testing and counselling for all attendees.  Integration resulted in a single cadre of health-workers providing care jointly to HIV and OPD patients.

The equitable distribution of material and human resources improved the quality and efficiency of healthcare delivery. This approach provided an opportunity for systems of HIV care to strengthen care for other chronic diseases and healthcare providers were afforded the opportunity to learn different skills.  Shared responsibility of clinic functions improved staff relationships which facilitated more collaborative and motivated service delivery.

However, these advantages cannot offset the absolute underlying problem of limited infrastructural and human resources and weak health financing, which may ultimately make integrated care unsustainable. Hence, while this study demonstrates clear benefits of integration, these macro-level determinants need to be addressed.  The impact of integrated models of healthcare delivery on the quality of medical care merits consideration.   

Africa
Zambia
  • share
0 comments.

Modelling combination prevention: the importance of joint effectiveness assumptions

Combination HIV Prevention: The Value and Interpretation of Mathematical Models.

Walensky RP, Curr HIV/AIDS Rep. 2013 Jun 25. [Epub ahead of print]

Mathematical models of HIV prevention interventions often provide critical insights related to programmatic design and economic efficiency. One recent dynamic model by Long et al. highlights that a combination prevention approach - with testing, treatment, circumcision, microbicides and PrEP - may decrease transmissions by over 60 % and may be very cost-effective in South Africa. In this analysis, the authors introduce the critical concept of joint effectiveness of preventions programs and demonstrate how some programs operate synergistically (HIV screening coupled with early treatment) while others may create redundancies (microbicides coupled with pre-exposure prophylaxis). Whether combination HIV prevention programs perform with additive, multiplicative or maximal effectiveness will be important to consider in anticipation of their combined transmission impact.

Abstract access

Editor’s notes: This commentary highlights important concepts and results from a recent modelling study of combination prevention for HIV in South Africa. A key concept discussed is that of ‘joint effectiveness’, which considers how two or more intervention programmes, might work together in the same population. While multiplicative effectiveness is often assumed, other options are to optimistically assume additive effectiveness, where distinct, non-interacting parts of the population use and benefit from the different interventions, or to conservatively assume maximal effectiveness, where it is the same individuals who use and/or benefit from all of the interventions, substantially reducing the overall impact. The commentary also highlights the synergies and redundancies found in the study between different intervention components, and illustrates how the discounting of future costs and benefits used in this and other cost-effectiveness studies can affect the relative cost-effectiveness of different interventions depending upon when costs are incurred and benefits accrued. These are all important considerations for future modelling and cost-effectiveness studies looking at combination HIV prevention.

Africa
South Africa
  • share
0 comments.

Disproportionately high HIV risk and gender disparity in prevalence among urban poor in Sub-Saharan Africa

The disproportionate high risk of HIV infection among the urban poor in sub-Saharan Africa.

Magadi MA. AIDS Behav. 2013 Jun;17(5):1645-54. doi: 10.1007/s10461-012-0217-y.

The link between HIV infection and poverty in sub-Saharan Africa (SSA) is rather complex and findings from previous studies remain inconsistent. While some argue that poverty increases vulnerability, existing empirical evidence largely support the view that wealthier men and women have higher prevalence of HIV. In this paper, we examine the association between HIV infection and urban poverty in SSA, paying particular attention to differences in risk factors of HIV infection between the urban poor and non-poor. The study is based on secondary analysis of data from the Demographic and Health Surveys from 20 countries in SSA, conducted during 2003-2008. We apply multilevel logistic regression models, allowing the urban poverty risk factor to vary across countries to establish the extent to which the observed patterns are generalizable across countries in the SSA region. The results reveal that the urban poor in SSA have significantly higher odds of HIV infection than urban non-poor counterparts, despite poverty being associated with a significantly lower risk among rural residents. Furthermore, the gender disparity in HIV infection (i.e. the disproportionate higher risk among women) is amplified among the urban poor. The paper confirms that the public health consequence of urban poverty that has been well documented in previous studies with respect to maternal and child health outcomes does apply to the risk of HIV infection. The positive association between household wealth and HIV prevalence observed in previous studies largely reflects the situation in the rural areas where the majority of the SSA populations reside.

Abstract   Full-text [free] access 

Editor’s notes: Evidence on the association between socio-economic position and HIV incidence in sub-Saharan Africa (SSA) has been mixed and appears to be changing over time. Although wealth was previously a predictor of HIV infection, it has recently been suggested that poverty is increasingly driving new infections in mature epidemics, especially in rural areas, where the majority of the population in SSA resides. With high rates of urbanisation both in SSA and globally (according to UNAIDS 2 of every 3 people living with HIV will be living in urban areas by 2030), this article provides important disaggregated evidence of the higher risk of HIV infection among the urban poor as well, and particularly among poor urban women. Even after controlling for sexual behaviour, the results suggest that other structural factors that characterise the environment, in which the urban poor live, such as unemployment, discrimination and violence, may be playing a key role. Interestingly, higher educational attainment was found to be associated with higher HIV risk among the urban poor, while it appeared to be protective among the better-off urban population. This may be pointing towards the ‘inverse equity hypothesis’, discussed in another paper this month (Hargreaves et al.), whereby groups with higher socio-economic position (wealth and/or education) are expected to benefit first from HIV/health interventions, thereby initially widening the gap in health outcomes until the poor catch up. 

Africa
  • share
0 comments.

Towards the elimination of travel restrictions for people living with HIV

HIV-related travel restrictions: trends and country characteristics.

Chang F, Prytherch H, Nesbitt RC, Wilder-Smith A. Glob Health Action. 2013 Jun3;6:20472. doi: 10.3402/gha.v6i0.20472.

Introduction: Increasingly, HIV-seropositive individuals cross international borders. HIV-related restrictions on entry, stay, and residence imposed by countries have important consequences for this mobile population. Our aim was to describe the geographical distribution of countries with travel restrictions and to examine the trends and characteristics of countries with such restrictions.

Methods: In 2011, data presented to UNAIDS were used to establish a list of countries with and without HIV restrictions on entry, stay, and residence and to describe their geographical distribution. The following indicators were investigated to describe the country characteristics: population at mid-year, international migrants as a percentage of the population, Human Development Index, estimated HIV prevalence (age: 15–49), presence of a policy prohibiting HIV screening for general employment purposes, government and civil society responses to having non-discrimination laws/regulations which specify migrants/mobile populations, government and civil society responses to having laws/regulations/policies that present obstacles to effective HIV prevention, treatment, care, and support for migrants/mobile populations, Corruption Perception Index, and gross national income per capita.

Results: HIV-related restrictions exist in 45 out of 193 WHO countries (23%) in all regions of the world. We found that the Eastern Mediterranean and Western Pacific Regions have the highest proportions of countries with these restrictions. Our analyses showed that countries that have opted for restrictions have the following characteristics: smaller populations, higher proportions of migrants in the population, lower HIV prevalence rates, and lack of legislation protecting people living with HIV from screening for employment purposes, compared with countries without restrictions.

Conclusion: Countries with a high proportion of international migrants tend to have travel restrictions – a finding that is relevant to migrant populations and travel medicine providers alike. Despite international pressure to remove travel restrictions, many countries continue to implement these restrictions for HIV-positive individuals on entry and stay. Since 2010, the United States and China have engaged in high profile removals. This may be indicative of an increasing trend, facilitated by various factors, including international advocacy and the setting of a UNAIDS goal to halve the number of countries with restrictions by 2015.

Abstract   Full-text [free] access 

Editor’s notes: Travel restrictions for people living with HIV were adopted by many governments in the early years of the epidemic when little was known about the disease and when there was great fear regarding its spread. This study describes the situation of such restrictions as of 2011, and the geographical distribution of countries with restrictions. Restrictions were present in almost a quarter of WHO countries, with little change in the total of numbers in the past 20 years, despite high profile examples of the US and China removing travel restrictions.  Health practitioners working with mobile populations are well placed to advise and educate individuals who may be affected by these restrictions. Impacts on individual health include an increased risk of interrupted adherence to ARV medication, risk of deportation and detainment, which may limit access to treatment, and risk of psychological stress in travel/immigration process.

  • share
0 comments.

Health system barriers to achieving the potential of integrated service delivery

Integrated maternal and child health services in Mozambique: structural health system limitations overshadow its effect on follow-up of HIV-exposed infants.

Geelhoed D, Lafort Y, Chissale E, Candrinho B, Degomme O. BMC Health Serv Res. 2013 Jun 7;13:207. doi: 10.1186/1472-6963-13-207.

Background: The follow-up of HIV-exposed infants remains a public health challenge in many Sub-Saharan countries. Just as integrated antenatal and maternity services have contributed to improved care for HIV-positive pregnant women, so too could integrated care for mother and infant after birth improve follow-up of HIV-exposed infants. We present results of a study testing the viability of such integrated care, and its effects on follow-up of HIV-exposed infants, in Tete Province, Mozambique.

Methods: Between April 2009 and September 2010, we conducted a mixed-method, intervention-control study in six rural public primary healthcare facilities, selected purposively for size and accessibility, with random allocation of three facilities each for intervention and control groups. The intervention consisted of a reorganization of services to provide one-stop, integrated care for mothers and their children under five years of age. We collected monthly routine facility statistics on prevention of mother-to-child HIV transmission (PMTCT), follow-up of HIV-exposed infants, and other mother and child health (MCH) activities for the six months before (January-June 2009) and 13 months after starting the intervention (July 2009-July 2010). Staff were interviewed at the start, after six months, and at the end of the study. Quantitative data were analysed using quasi-Poisson models for significant differences between the periods before and after intervention, between healthcare facilities in intervention and control groups, and for time trends. The coefficients for the effect of the period and the interaction effect of the intervention were calculated with their p-values. Thematic analysis of qualitative data was done manually.

Results: One-stop, integrated care for mother and child was feasible in all participating healthcare facilities, and staff evaluated this service organisation positively. We observed in both study groups an improvement in follow-up of HIV-exposed infants (registration, follow-up visits, serological testing), but frequent absenteeism of staff and irregular supply of consumables interfered with healthcare facility performance for both intervention and control groups.

Conclusions: Despite improvement in various aspects of the follow-up of HIV-exposed infants, we observed no improvement attributable to one-stop, integrated MCH care. Structural healthcare system limitations, such as staff absences and irregular supply of essential commodities, appear to overshadow its potential effects. Regular technical support and adequate basic working conditions are essential for improved performance in the follow-up of HIV-exposed infants in peripheral public healthcare facilities in Mozambique.

Abstract   Full-text [free] access 

Editor’s notes: Despite rapid advances in the delivery of PMTCT services in many sub-Saharan African countries, the follow-up of HIV-exposed infants until the age of 18 months remains a critical challenge.  This mixed methods, quasi-experimental evaluation study evaluated the viability of providing one-stop, integrated care, its acceptability to healthcare providers, and its effect upon the follow-up of HIV-exposed infants and other MCH services, in the public health system. The intervention consisted of a reorganization of MCH services, to deliver integrated, one-stop consultations for mothers and their children up to 5 years of age. Absence of MCH staff occurred in 16% of months, and stock-outs of HIV testing commodities and MCH drugs occurred in almost half of all months. The improvements in both arms suggests that improving some of the basic working conditions of peripheral MCH staff and ensuring an adequate supply of commodities might be effective ways to improve the follow-up of HIV-exposed infants in peripheral public healthcare facilities in Mozambique. 

Africa
Mozambique
  • share
0 comments.

Increased risk of mortality associated with delayed initiation of ART

Mortality associated with delays between clinic entry and ART initiation in resource-limited settings: results of a transition-state model.

Hoffmann CJ, Lewis JJ, Dowdy DW, Fielding KL, Grant AD, Martinson NA, Churchyard GJ, Chaisson RE. J Acquir Immune Defic Syndr. 2013 May 1;63(1):105-111. doi: 10.1097/QAI.0b013e3182893fb4

To estimate the mortality impact of delay in antiretroviral therapy (ART) initiation from the time of entry into care. A state–transition Markov process model. This technique allows for assessing mortality before and after ART initiation associated with delays in ART initiation among a general population of ART-eligible patients without conducting a randomized trial. We used patient-level data from 3 South African cohorts to determine transition probabilities for pre-ART CD4 count changes and pre-ART and on-ART mortality. For each parameter, we generated probabilities and distributions for Monte Carlo simulations with 1-week cycles to estimate mortality 52 weeks from clinic entry. We estimated an increase in mortality from 11.0% to 14.7% (relative increase of 34%) with a 10-week delay in ART for patients entering care with our pre-ART cohort CD4 distribution. When we examined low CD4 ranges, the relative increase in mortality delays remained similar; however, the absolute increase in mortality rose. For example, among patients entering with CD4 count 50–99 cells per cubic millimeter, 12-month mortality increased from 13.3% with no delay compared with 17.0% with a 10-week delay and 22.9% with a 6-month delay. Delays in ART initiation, common in routine HIV programs, can lead to important increases in mortality. Prompt ART initiation for patients entering clinical care and eligible for ART, especially those with lower CD4 counts, could be a relatively low cost approach with a potential marked impact on mortality.

Abstract access 

Editor’s notes: Prompt initiation of ART in adults eligible for treatment is important to reduce mortality and morbidity, yet in some settings delays remain common. This is one of the first studies to attempt to estimate the impact of such delays on individual risk of mortality by modelling data collated from three well-characterized clinical cohorts in South Africa. A delay of 10 weeks might seem plausible in a routine programme setting and this led to an estimated 34% increased risk of 12-month mortality overall. The absolute impact of treatment delays was not surprisingly greatest for those with lowest CD4+ cell counts suggesting that particular effort should be focused on reducing treatment delays for these groups, perhaps by targeting groups for fast-track ART initiation (as is done in some settings). As health systems and resources in high burden settings continue to be stretched by high patient loads, it will be important to monitor and address delays in ART initiation.

Africa
South Africa
  • share
0 comments.

Dynamic model of active versus passive TB case finding

Identifying dynamic tuberculosis case-finding policies for HIV/TB co-epidemics.

Yaesoubi R, Cohen T. Proc Natl Acad Sci U S A. 2013 Jun 4;110(23):9457-62.

The global tuberculosis (TB) control plan has historically emphasized passive case finding (PCF) as the most practical approach for identifying TB suspects in high burden settings. The success of this approach in controlling TB depends on infectious individuals recognizing their symptoms and voluntarily seeking diagnosis rapidly enough to reduce onward transmission. It now appears, at least in some settings, that more intensified case-finding (ICF) approaches may be needed to control TB transmission; these more aggressive approaches for detecting as-yet undiagnosed cases obviously require additional resources to implement. Given that TB control programs are resource constrained and that the incremental yield of ICF is expected to wane over time as the pool of undiagnosed cases is depleted, a tool that can help policymakers to identify when to implement or suspend an ICF intervention would be valuable. In this article, we propose dynamic case-finding policies that allow policymakers to use existing observations about the epidemic and resource availability to determine when to switch between PCF and ICF to efficiently use resources to optimize population health. Using mathematical models of TB/HIV co-epidemics, we show that dynamic policies strictly dominate static policies that pre-specify a frequency and duration of rounds of ICF. We also find that the use of a diagnostic tool with better sensitivity for detecting smear-negative cases (e.g., Xpert MTB/RIF) further improves the incremental benefit of these dynamic case-finding policies.

Abstract access 

Editor’s notes: There is increasing recognition that to control the HIV-associated TB epidemic settings with high HIV prevalence, especially in southern Africa, that intensive TB case finding (ICF) rather than passive case finding (PCF) may be required. However, this is very resource-intensive and systematic reviews recently conducted by the WHO found weak evidence for an impact at an epidemiological level. Much more research is needed to define whether ICF is feasible, has a population level impact and is economically viable. The present modelling study suggests that dynamic case finding policies that switch between ICF and PCF based on simple inputs such as TB notification rate, budget etc. may provide a more cost-efficient means of case finding.

Avoid TB deaths
  • share
0 comments.

Aid disbursements to reproductive health stable or slightly increasing

Reproductive health priorities: evidence from a resource tracking analysis of official development assistance in 2009 and 2010.

Hsu J, Berman P, Mills A. Lancet. 2013 May 18;381(9879):1772-82.

Background: Information is scarce about the extent to which official development assistance (ODA) is spent on reproductive health to provide childbirth care; support family planning; address sexual health; and prevent, treat, and care for sexually transmitted infections, including HIV. We analysed flows of ODA to reproductive health for 2009 and 2010, assessed their distribution by donor type and purpose, and investigated the extent to which disbursements respond to need. We aimed to provide global estimates of aid to reproductive health, to assess the allocation of resources across reproductive health activities, and to encourage donor accountability in targeting aid flows to those most in need.

Methods: We applied a standard definition of reproductive health across all donors, including a portion of disease-specific activities and health systems development. We analysed disbursements to reproductive health by donor type and purpose (e.g., family planning). We also reported on an indicator to monitor donor disbursements: ODA to reproductive health per woman aged 15-49 years. We analysed the extent to which funding is targeted to countries most in need, proxied by female life expectancy at birth and prevalence of HIV infection in adults.

Findings: Donor disbursements to reproductive health activities in all countries amounted to US$5579 million in 2009 and US$5637 million in 2010-an increase of 1.0%. ODA for such activities in the 74 Countdown priority countries increased more rapidly at 5.3%. More than half of the funding was directed towards prevention, treatment, and care of HIV infection for women of reproductive age (15-49 years of age). On average, ODA to general reproductive health activities amounted to 15.9% and ODA to family planning 7.2%. Aid to reproductive health was heavily dependent on the USA, the Global Fund, the UK, the United Nations Population Fund, and the World Bank.

Interpretation: Donors are prioritising reproductive health, and the slight increase in funding in 2009-10 is welcome, especially in the present economic climate. The large share of such funding for activities related to HIV infection in women of reproductive age affects the amount of ODA received by priority countries. It should thus be distinguished from resources directed to other reproductive health activities, such as family planning, which has been the focus of recent worldwide advocacy efforts. Tracking of donor aid to reproductive health should continue to allow investigation of the allocation of resources across reproductive health activities, and to encourage donor accountability in targeting aid flows to those most in need.

Abstract access 

Editor’s notes: This study analyzes the flows of official development assistance (ODA) to reproductive health in the context of the economic crisis. It is the first resource tracking to cover a more comprehensive set of female reproductive health activities, such as family planning and the treatment of sexually treated infections, including HIV. With a 1% increase in real terms, the study highlights the stability of ODA to reproductive health as promising, although the aggregate masks significant fluctuations by certain donors. Claiming more than half the total aid, funding for HIV activities dominates the package, while the 7.2% for family planning is of concern, given recent commitments. The study also finds that ODA disbursements are closely related to need and that this may even be improving slightly – this is encouraging in terms of the efficiency and effectiveness of aid to women’s health priorities.  

  • share
0 comments.

Delivery of PrEP to populations at highest risk of HIV exposure is most cost-effective strategy

The Cost and Impact of Scaling Up Pre-exposure Prophylaxis for HIV Prevention: A Systematic Review of Cost-Effectiveness Modelling Studies

Gomez GB, Borquez A, Case KK, Wheelock A, Vassall A, et al. (2013). PLoS Med 10(3): e1001401. doi:10.1371/journal.pmed.1001401

Cost-effectiveness studies inform resource allocation, strategy, and policy development. However, due to their complexity, dependence on assumptions made, and inherent uncertainty, synthesising, and generalising the results can be difficult. We assess cost-effectiveness models evaluating expected health gains and costs of HIV pre-exposure prophylaxis (PrEP) interventions. We conducted a systematic review comparing epidemiological and economic assumptions of cost-effectiveness studies using various modelling approaches. The following databases were searched (until January 2013): PubMed/Medline, ISI Web of Knowledge, Centre for Reviews and Dissemination databases, EconLIT, and region-specific databases. We included modelling studies reporting both cost and expected impact of a PrEP roll-out. We explored five issues: prioritisation strategies, adherence, behaviour change, toxicity, and resistance. Of 961 studies retrieved, 13 were included. Studies modelled populations (heterosexual couples, men who have sex with men, people who inject drugs) in generalised and concentrated epidemics from Southern Africa (including South Africa), Ukraine, USA, and Peru. PrEP was found to have the potential to be a cost-effective addition to HIV prevention programmes in specific settings. The extent of the impact of PrEP depended upon assumptions made concerning cost, epidemic context, programme coverage, prioritisation strategies, and individual-level adherence. Delivery of PrEP to key populations at highest risk of HIV exposure appears the most cost-effective strategy. Limitations of this review include the partial geographical coverage, our inability to perform a meta-analysis, and the paucity of information available exploring trade-offs between early treatment and PrEP. Our review identifies the main considerations to address in assessing cost-effectiveness analyses of a PrEP intervention—cost, epidemic context, individual adherence level, PrEP programme coverage, and prioritisation strategy. Cost-effectiveness studies indicating where resources can be applied for greatest impact are essential to guide resource allocation decisions; however, the results of such analyses must be considered within the context of the underlying assumptions made.

Abstract access

Editor’s notes: Some counties are now considering whether to include PrEP in HIV prevention programmes. This paper provides a useful systematic review of cost-effectiveness studies of PrEP, exploring the impact of five key issues raised by policy makers (prioritisation, adherence, behaviour change, toxicity, resistance) on cost-effectiveness estimates. The review identified 7 studies of PrEP cost-effectiveness in southern Africa, and concluded that topical PrEP, in particular, could have a significant impact in South Africa - but needs to be balanced against opportunity costs of other potentially more cost-effective prevention strategies.  The 5 studies in concentrated epidemics in the USA and Peru indicated that, although the impact of PrEP may be substantial, interventions would be unaffordable due to drug costs. In terms of prioritization strategies, those based on self-reported risk behaviours were more cost-effective than those based on prioritization by age group but the costs of identifying and engaging with high risk populations were not taken into consideration.  As expected, behaviour change due to PrEP use and adherence to PrEP, had potentially significant impacts on programme effectiveness. 

  • share
0 comments.

Increasing the impact of male circumcision campaigns

Efficient and equitable HIV prevention: A case study of male circumcision in South Africa.

Verguet S. Cost Eff Resour Alloc. 2013 Jan 4;11(1):1. [Epub ahead of print]

The authors determine efficient, equitable and mixed efficient-equitable allocations of a male circumcision (MC) intervention reducing female to male HIV transmission in South Africa (SA), as a case study of an efficiency-equity framework for resource allocation in HIV prevention. A mathematical model was developed with epidemiological and cost data from the nine provinces of SA. The hypothetical one-year-long MC intervention with a budget of US$ 10 million targeted adult men 15--49 years of age in SA. The intervention was evaluated according to two criteria: an efficiency criterion, which focused on maximizing the number of HIV infections averted by the intervention, and an equity criterion (defined geographically), which focused on maximizing the chance that each male adult individual had access to the intervention regardless of his province. A purely efficient intervention would prevent 4,008 HIV infections over a year. In the meantime, a purely equitable intervention would avert 3,198 infections, which represents a 20% reduction in infection outcome as compared to the purely efficient scenario. A half efficient-half equitable scenario would prevent 3,749 infections, that is, a 6% reduction in infection outcome as compared to the purely efficient scenario. This paper provides a framework for resource allocation in the health sector which incorporates a simple equity metric in addition to efficiency. In the specific context of SA with a MC intervention for the prevention of HIV, incorporation of geographical equity only slightly reduces the overall efficiency of the intervention.

Abstract access 

Editor’s notes: Health planners always have to balance equity (ensuring equal access) and efficiency (the relative impact of a health intervention in different locations or population groups). Economic analyses and other efficiency analyses are important tools for health planning decision making, but are not sufficient, as other issues such as human rights and equal access must be considered.  Even when geographic location is included as a criterion, populations are mobile, and widespread campaigns may also have positive consequences beyond the most immediate measure of success (in this case, more broad-based HIV prevention can be part of male circumcision campaigns) . The analysis provided in this modeling study is useful for public health practitioners and community advocates.

Africa
South Africa
  • share
0 comments.