Articles tagged as "Close the resource gap"

HIV and gay men and other men who have sex with men: an expanding and underfunded epidemic

Financing the response to HIV among gay men and other men who have sex with men: case studies from eight diverse countries.

Grosso A, Ryan O, Tram KH, Baral S. Glob Public Health. 2015 Dec;10(10):1172-84. doi: 10.1080/17441692.2015.1043314. Epub 2015 Jul 3.

Despite reductions in the number of new HIV infections globally, the HIV epidemic among men who have sex with men (MSM) is expanding. This study characterises financing of HIV programmes for MSM and the impact of criminalisation on levels of funding, using data from five countries that criminalise same-sex sexual practices (Ethiopia, Mozambique, Guyana, India and Nigeria) and three that do not (China, Ukraine and Vietnam). For each country, all publicly available documents from the Global Fund to Fight AIDS, Tuberculosis and Malaria for approved HIV/AIDS grants in Rounds 5-9 and Country Operational Plans detailing investments made through the President's Emergency Plan for AIDS Relief (PEPFAR) from US fiscal year (FY) 2007-2009 were examined. Eleven of 20 HIV proposals to the Global Fund contained programmes for MSM totalling approximately $40 million or 6% of proposed budgets. In six countries providing activity-level data on MSM programming, PEPFAR funding that served this population and others ranged from $23.3 million in FY2007 to $35.4 million in FY2009, representing 0.5-25.9% of overall, non-treatment funding over this period. Countries that criminalise same-sex sexual practices spend fewer resources on HIV programmes serving MSM. However, they also show consistent underfunding of programmes serving MSM regardless of context or geography.

 Abstract access

Editor’s notes: Despite encouraging indicators on the reduction of new HIV infections worldwide, the epidemic among gay men and other men who have sex with men continues to grow. This is due to both biological and structural factors. With many governments failing to take responsibility for this at-risk population, funding for gay men and other men who have sex with men-specific programmes often comes from international donors. This study looks at Global Fund and PEPFAR financing of programmes for gay men and other men who have sex with men, comparing funding availability and services offered both in settings where homosexuality is criminalised and settings where it is not.

The study finds that most proposed funding focuses on behaviour change communication, and less frequently on improving sexual health services, community outreach and education. Nations that criminalise homosexuality allocated about 2% of funding towards gay men and other men who have sex with men services, while countries without punitive measures allocated close to 7%. Importantly, both were felt to be inadequately small sums of money in relation to the size of the epidemic. Key stakeholder interviews from criminalising countries suggest that legal restrictions make it more difficult to provide services focused on gay men and other men who have sex with men. Although, little is known about the degree to which gay men and other men who have sex with men access services focused on the general population. The authors also note that countries that criminalise homosexuality may request funds for gay men and other men who have sex with men believing that donors will look favourably on budgets that include these activities. After receiving funds, these countries may re-programme activities, reducing or removing these focussed programmes.

There is comparatively little research done on HIV and gay men and other men who have sex with men in low- and middle-income countries, in particular in African settings. This article contributes to an expanding literature on the subject and raises questions about the role that international donors should play in ensuring an equitable access to services, particularly in the context of reprogramming. This highlights how real impact on the incidence of HIV among gay men and other men who have sex with men requires both demand generation and accountability in equal measure.

Africa, Asia, Europe, Latin America
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Expanding ART access: increasing costs

The HIV treatment gap: estimates of the financial resources needed versus available for scale-up of antiretroviral therapy in 97 countries from 2015 to 2020.

Dutta A, Barker C, Kallarakal A. PLoS Med. 2015 Nov 24;12(11):e1001907. doi: 10.1371/journal.pmed.1001907. eCollection 2015.

Background: The World Health Organization (WHO) released revised guidelines in 2015 recommending that all people living with HIV, regardless of CD4 count, initiate antiretroviral therapy (ART) upon diagnosis. However, few studies have projected the global resources needed for rapid scale-up of ART. Under the Health Policy Project, we conducted modeling analyses for 97 countries to estimate eligibility for and numbers on ART from 2015 to 2020, along with the facility-level financial resources required. We compared the estimated financial requirements to estimated funding available.

Methods and findings: Current coverage levels and future need for treatment were based on country-specific epidemiological and demographic data. Simulated annual numbers of individuals on treatment were derived from three scenarios: (1) continuation of countries' current policies of eligibility for ART, (2) universal adoption of aspects of the WHO 2013 eligibility guidelines, and (3) expanded eligibility as per the WHO 2015 guidelines and meeting the Joint United Nations Programme on HIV/AIDS "90-90-90" ART targets. We modeled uncertainty in the annual resource requirements for antiretroviral drugs, laboratory tests, and facility-level personnel and overhead.

We estimate that 25.7 (95% CI 25.5, 26.0) million adults and 1.57 (95% CI 1.55, 1.60) million children could receive ART by 2020 if countries maintain current eligibility plans and increase coverage based on historical rates, which may be ambitious. If countries uniformly adopt aspects of the WHO 2013 guidelines, 26.5 (95% CI 26.0 27.0) million adults and 1.53 (95% CI 1.52, 1.55) million children could be on ART by 2020. Under the 90-90-90 scenario, 30.4 (95% CI 30.1, 30.7) million adults and 1.68 (95% CI 1.63, 1.73) million children could receive treatment by 2020. The facility-level financial resources needed for scaling up ART in these countries from 2015 to 2020 are estimated to be US$45.8 (95% CI 45.4, 46.2) billion under the current scenario, US$48.7 (95% CI 47.8, 49.6) billion under the WHO 2013 scenario, and US$52.5 (95% CI 51.4, 53.6) billion under the 90-90-90 scenario. After projecting recent external and domestic funding trends, the estimated 6-y financing gap ranges from US$19.8 billion to US$25.0 billion, depending on the costing scenario and the U.S. President's Emergency Plan for AIDS Relief contribution level, with the gap for ART commodities alone ranging from US$14.0 to US$16.8 billion. The study is limited by excluding above-facility and other costs essential to ART service delivery and by the availability and quality of country- and region-specific data.

Conclusions: The projected number of people receiving ART across three scenarios suggests that countries are unlikely to meet the 90-90-90 treatment target (81% of people living with HIV on ART by 2020) unless they adopt a test-and-offer approach and increase ART coverage. Our results suggest that future resource needs for ART scale-up are smaller than stated elsewhere but still significantly threaten the sustainability of the global HIV response without additional resource mobilization from domestic or innovative financing sources or efficiency gains. As the world moves towards adopting the WHO 2015 guidelines, advances in technology, including the introduction of lower-cost, highly effective antiretroviral regimens, whose value are assessed here, may prove to be "game changers" that allow more people to be on ART with the resources available.

Abstract Full-text [free] access

Editor’s notes: This is a complex and important paper that seeks to understand the financial requirements necessary to: a) continue countries’ current policies of eligibility for ART, b) roll out universal adoption of certain aspects of WHO 2013 eligibility guidelines, and c) expand eligibility as per WHO 2015 guidelines and meeting the Joint United Nations Programme on HIV/AIDS ‘90-90-90’ targets.

The authors estimated the number of adults and children eligible for and receiving HIV treatment, as well as the cost of providing ART in 97 countries across six regions, covering different income levels. They estimated that 25.7 million adults and 1.57 million children could receive ART by 2020 if countries maintain the current eligibility strategies. If countries adopted WHO 2013 eligibility guidelines, 26.5 million adults and 1.53 million children would be on ART by 2020, and if they adopted the 90-90-90 scenario, 30.4 million adults and 1.68 million children could receive treatment by then. The financial resources necessary for this scale up are estimated to be US$ 45.8 billion under current eligibility, US$ 48.7 billion under WHO 2013 scenario and US$ 52.5 billion under the 90-90-90 scenario. The estimated funding gap for the six year period ranges between US$ 20 and US$ 25 billion. In this study, the costs of commodities were taken directly from data collated by other organisations.  No empirical cost estimates of service delivery were made.  Nor was there an attempt to understand the cost implications of the development synergies and social and programme enablers that may be needed to increase the number of people living with HIV knowing their status.  The new WHO recommendations need to be actively pursued if we are to meet targets, rather than passively continuing with “business as usual”. 

Nonetheless, the findings of this study highlight the gap between guidelines written by WHO and very real programmatic obstacles on the ground. There is evidence to suggest that universal test-and-treat strategies could lead to substantially improved health outcomes at the population level, as well as potentially being cost-saving in the long-term. However, as the authors have illustrated, it would require increased levels of funding. What needs to be explored further now is how to overcome the logistical hurdles of rolling out such an initiative. Changing systems and practices is costly and takes time. Health workers will have to be retrained, data collection strategies will have to be revised. Expanding treatment may also mean increasing the number of health staff working on this initiative, which has an opportunity cost that may reverberate in other parts of the health system. Substantially altering health service provision, particularly in weak health systems, may have knock-on effects with unexpected and unintended consequences.

WHO guidelines serve a vital purpose of giving us a goal to aim for. But studies like this one help us know if and how we can get there. 

Africa, Asia, Europe, Latin America, Oceania
Algeria, Angola, Armenia, Azerbaijan, Bahamas, Bangladesh, Barbados, Belarus, Belize, Benin, Bhutan, Bolivia, Botswana, Bulgaria, Burkina Faso, Burundi, Cambodia, Cameroon, Central African Republic, Chad, China, Comoros, Côte d'Ivoire, Cuba, Democratic Republic of the Congo, Djibouti, Dominican Republic, Egypt, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Georgia, Ghana, Guatemala, Guinea, Guinea-Bissau, Guyana, Haiti, Honduras, India, Indonesia, Iran (Islamic Republic of), Jamaica, Kazakhstan, Kenya, Kyrgyzstan, Lao People's Democratic Republic, Lesotho, Liberia, Madagascar, Malawi, Malaysia, Mali, Mauritania, Mauritius, Moldova, Mongolia, Morocco, Mozambique, Myanmar, Namibia, Nepal, Nicaragua, Niger, Nigeria, Pakistan, Papua New Guinea, Philippines, Republic of the Congo, Romania, Russia, Rwanda, Senegal, Serbia and Montenegro, Sierra Leone, Somalia, South Africa, Sri Lanka, Sudan, Suriname, Swaziland, Tajikistan, Thailand, Togo, Trinidad and Tobago, Tunisia, Uganda, Ukraine, United Republic of Tanzania, Uzbekistan, Viet Nam, Yemen, Zambia, Zimbabwe
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More savings, more hope, and more HIV-preventive attitudes among vulnerable adolescent youth

Effect of savings-led economic empowerment on HIV preventive practices among orphaned adolescents in rural Uganda: results from the Suubi-Maka randomized experiment.

Jennings L, Ssewamala FM, Nabunya P. AIDS Care. 2015 Nov 7:1-10. [Epub ahead of print]

Improving economic resources of impoverished youth may alter intentions to engage in sexual risk behaviors by motivating positive future planning to avoid HIV risk and by altering economic contexts contributing to HIV risk. Yet, few studies have examined the effect of economic-strengthening on economic and sexual behaviors of orphaned youth, despite high poverty and high HIV infection in this population. Hierarchal longitudinal regressions were used to examine the effect of a savings-led economic empowerment intervention, the Suubi-Maka Project, on changes in orphaned adolescents' cash savings and attitudes toward savings and HIV-preventive practices over time. We randomized 346 Ugandan adolescents, aged 10-17 years, to either the control group receiving usual orphan care plus mentoring (n = 167) or the intervention group receiving usual orphan care plus mentoring, financial education, and matched savings accounts (n = 179). Assessments were conducted at baseline, 12, and 24 months. Results indicated that intervention adolescents significantly increased their cash savings over time (b = $US12.32, +/-1.12, p < .001) compared to adolescents in the control group. At 24 months post-baseline, 92% of intervention adolescents had accumulated savings compared to 43% in the control group (p < .001). The largest changes in savings goals were the proportion of intervention adolescents valuing saving for money to buy a home (DeltaT1-T0 = +14.9, p < .001), pursue vocational training (DeltaT1-T0 = +8.8, p < .01), and start a business (T1-T0 = +6.7, p < .01). Intervention adolescents also had a significant relative increase over time in HIV-preventive attitudinal scores (b = +0.19, +/-0.09, p < .05), most commonly toward perceived risk of HIV (95.8%, n = 159), sexual abstinence or postponement (91.6%, n = 152), and consistent condom use (93.4%, n = 144). In addition, intervention adolescents had 2.017 significantly greater odds of a maximum HIV-prevention score (OR = 2.017, 95%CI: 1.43-2.84). To minimize HIV risk throughout the adolescent and young adult periods, long-term strategies are needed to integrate youth economic development, including savings and income generation, with age-appropriate combination prevention interventions.

Abstract access 

Editor’s notes: This study contributes to the small but growing evidence on the effectiveness of economic strengthening activities for HIV prevention and treatment outcomes. It used a cluster randomised experimental design to evaluate the impact of a savings-led economic empowerment programme for orphaned adolescents on savings behaviour, as well as sexually protective attitudes. The authors report a significant and large impact on cash savings, as well as an increase in HIV-preventive attitudinal scores. This is particularly promising given the need to address the multiple needs of adolescent youth to promote their healthy transition to adulthood.

It is important to note that this study considered attitudinal outcomes, rather than biological or even reported behavioural ones. There are considerable limitations to such measures that often do not reflect actual sexual behaviours. Also, given the significant additional cost and economic benefits of the savings component in the programme arm, a key question remains, namely how incrementally cost-effective it is in achieving HIV and economic development goals. 

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Early treatment initiation reduces costs in Indonesia

Costs of HIV/AIDS treatment in Indonesia by time of treatment and stage of disease.

Siregar AY, Tromp N, Komarudin D, Wisaksana R, van Crevel R, van der Ven A, Baltussen R. BMC Health Serv Res. 2015 Sep 30;15(1):440. doi: 10.1186/s12913-015-1098-3.

Background: We report an economic analysis of Human Immunodeficiency Virus (HIV) care and treatment in Indonesia to assess the options and limitations of costs reduction, improving access, and scaling up services.

Methods: We calculated the cost of providing HIV care and treatment in a main referral hospital in West Java, Indonesia from 2008 to 2010, differentiated by initiation of treatment at different CD4 cell count levels (0-50, 50-100, 100-150, 150-200, and >200 cells/mm3); time of treatment; HIV care and opportunistic infections cost components; and the costs of patients for seeking and undergoing care.

Discussion: Before antiretroviral treatment (ART) initiation, costs were dominated by laboratory tests (>65 %), and after initiation, by antiretroviral drugs (≥60 %). Average treatment costs per patient decreased with time on treatment (e.g. from US$580 per patient in the first 6 month to US$473 per patient in months 19-24 for those with CD4 cell counts under 50 cells/mm3). Higher CD4 cell counts at initiation resulted in lower laboratory and opportunistic infection treatment costs. Transportation cost dominated the costs of patients for seeking and undergoing care (>40 %).

Conclusions: Costs of providing ART are highest during the early phase of treatment. Costs reductions can potentially be realized by early treatment initiation and applying alternative laboratory tests with caution. Scaling up ART at the community level in certain high prevalence settings may improve early uptake, adherence, and reduce transportation costs.

Abstract  Full-text [free] access

Editor’s notes: There is a growing evidence base on the costs of HIV treatment and care, however much of the evidence to date is from sub-Saharan African settings. A review conducted by Siapka et al. in 2014 found 31 studies reporting unit costs for antiretroviral therapy, only 10 of which were outside of Africa and only four of which were set in Asia and the Pacific. This study provides necessary evidence on ART costs in Indonesia. This will be important for Indonesian policy makers as they seek to scale up HIV treatment - especially in the context of recent guideline reforms for ART provision.

Findings from this study largely confirm what has been found elsewhere. Antiretroviral drug costs are primary cost drivers, followed closely by treatment of opportunistic infections. Costs of ART provision are therefore highest during the treatment initiation phase, and drop off as people are established on care. For the same reason, this study also found that costs for treating people with a CD4 count > 200 were significantly lower than costs for treating people with a CD4 count < 200. 

Unit costs per person per year range from $1699 to $2346. This is higher than previously published costs from studies in Thailand, Viet Nam and India, as reported by Siapka et al. It is difficult to tell whether it is representative of ART costs generally in Indonesia as this is the first study reporting costs from this country. 

The authors note that delivering HIV treatment at the community level may reduce costs. It is difficult to tell from the results of this study whether this is indeed the case, as costs are estimated for only one health facility (the largest public referral hospital in West Java province). However, it poses an interesting question for further research. Further evidence on costs for provision of HIV treatment and care across a variety of settings in Indonesia would improve policy relevance and help decision-makers identify potential avenues for improving efficiency.

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Workplace provision of ART: potentially cost-saving in high prevalence settings

The impact of company-level ART provision to a mining workforce in South Africa: a cost-benefit analysis.

Meyer-Rath G, Pienaar J, Brink B, van Zyl A, Muirhead D, Grant A, Churchyard G, Watts C, Vickerman P. PLoS Med. 2015 Sep 1;12(9):e1001869. doi: 10.1371/journal.pmed.1001869. eCollection 2015.

Background: HIV impacts heavily on the operating costs of companies in sub-Saharan Africa, with many companies now providing antiretroviral therapy (ART) programmes in the workplace. A full cost-benefit analysis of workplace ART provision has not been conducted using primary data. We developed a dynamic health-state transition model to estimate the economic impact of HIV and the cost-benefit of ART provision in a mining company in South Africa between 2003 and 2022.

Methods and findings: A dynamic health-state transition model, called the Workplace Impact Model (WIM), was parameterised with workplace data on workforce size, composition, turnover, HIV incidence, and CD4 cell count development. Bottom-up cost analyses from the employer perspective supplied data on inpatient and outpatient resource utilisation and the costs of absenteeism and replacement of sick workers. The model was fitted to workforce HIV prevalence and separation data while incorporating parameter uncertainty; univariate sensitivity analyses were used to assess the robustness of the model findings. As ART coverage increases from 10% to 97% of eligible employees, increases in survival and retention of HIV-positive employees and associated reductions in absenteeism and benefit payments lead to cost savings compared to a scenario of no treatment provision, with the annual cost of HIV to the company decreasing by 5% (90% credibility interval [CrI] 2%-8%) and the mean cost per HIV-positive employee decreasing by 14% (90% CrI 7%-19%) by 2022. This translates into an average saving of US$950 215 (90% CrI US$220 879-US$1.6 million) per year; 80% of these cost savings are due to reductions in benefit payments and inpatient care costs. Although findings are sensitive to assumptions regarding incidence and absenteeism, ART is cost-saving under considerable parameter uncertainty and in all tested scenarios, including when prevalence is reduced to 1%-except when no benefits were paid out to employees leaving the workforce and when absenteeism rates were half of what data suggested. Scaling up ART further through a universal test and treat strategy doubles savings; incorporating ART for family members reduces savings but is still marginally cost-saving compared to no treatment. Our analysis was limited to the direct cost of HIV to companies and did not examine the impact of HIV prevention policies on the miners or their families, and a few model inputs were based on limited data, though in sensitivity analysis our results were found to be robust to changes to these inputs along plausible ranges.

Conclusions: Workplace ART provision can be cost-saving for companies in high HIV prevalence settings due to reductions in healthcare costs, absenteeism, and staff turnover. Company-sponsored HIV counselling and voluntary testing with ensuing treatment of all HIV-positive employees and family members should be implemented universally at workplaces in countries with high HIV prevalence.

Abstract  Full-text [free] access

Editor’s notes: HIV-associated diseases generally hit adults at the prime of their working life, which in turn takes a heavy economic toll on private companies. The infection increases rates of absenteeism, labour force turnover and costs of company operations. HIV care has been provided by mining companies in South Africa since 2002 (before the provision of ART in the public sector). Although the cost and cost-effectiveness of public sector HIV provision in South Africa has been estimated, the cost and impact of ART provision at the workplace level has not been establish. This paper explores cost and impact of both HIV and ART in a mining company in South Africa.

A dynamic Markov health-state transition model, the Workplace Impact Model (WIM), was developed to evaluate both the past and future impact and costs of introducing ART into the workforce from the perspective of the employer. Two scenarios are explored: no ART provision, and scale-up of ART provision in the workforce. Costs and impacts are projected over a 20-year period starting in 2003.

The results illustrate that as ART coverage increases, there are increases in survival and employee retention, as well as reductions in absenteeism and benefit payments. These lead to cost savings compared to the no ART provision scenario. Annual cost of HIV to the company dropped by 5% and the mean cost per HIV-positive employee decreased by 14%. The biggest savings are due to reductions in benefit payment for death and ill-health retirement and in the cost of employee healthcare use. Importantly, the finding that ART is cost-saving is robust to the uncertainty around the model parameters as well as to other changes in the assumptions made in the model.

This paper is very strong due to the nuances built into the model, as well as due to the quality and precision of the data used. The model takes into account different factors associated to workforce profile, HIV progression, health effects of ART initiation, age groups, and job grade categories, to mention a few. It also includes CD4 progression data from the specific population for every trimester from 2003-2010. Additionally, it includes company-specific bottom-up cost data on the costs of providing ART (medications, monitoring costs, etc.). The potential policy implications, namely that it is cost-saving for employers to provide HIV care, is a substantial one. Provision of services by private companies may not only make business sense, they may also provide a respite to public sector HIV service provision programmes.

It would be interesting to see how these findings relate to other industries. Different industries have different features. Mining, for example, is a labour-intensive, high profit industry. Others are not. Understanding the costs and effects in other types of companies, and whether ART provision remains cost-saving, would be worthwhile in order to create more specific policy guidelines. 

South Africa
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A combination approach – the most impactful mechanism to reduce new HIV cases in Nigeria

Modelling the impact and cost-effectiveness of combination prevention amongst HIV serodiscordant couples in Nigeria.

Mitchell KM, Lepine A, Terris-Prestholt F, Torpey K, Khamofu H, Folayan MO, Musa J, Anenih J, Sagay AS, Alhassan E, Idoko J, Vickerman P. AIDS. 2015 Sep 24;29(15):2035-44. doi: 10.1097/QAD.0000000000000798.

Objective: To estimate the impact and cost-effectiveness of treatment as prevention (TasP), pre-exposure prophylaxis (PrEP) and condom promotion for serodiscordant couples in Nigeria.

Design: Mathematical and cost modelling.

Methods: A deterministic model of HIV-1 transmission within a cohort of serodiscordant couples and to/from external partners was parameterized using data from Nigeria and other African settings. The impact and cost-effectiveness were estimated for condom promotion, PrEP and/or TasP, compared with a baseline where antiretroviral therapy (ART) was offered according to 2010 national guidelines (CD4 <350 cells/µl) to all HIV-positive partners. The impact was additionally compared with a baseline of current ART coverage (35% of those with CD4 <350 cells/µl). Full costs (in US $2012) of programme introduction and implementation were estimated from a provider perspective.

Results: Substantial benefits came from scaling up ART to all HIV-positive partners according to 2010 national guidelines, with additional smaller benefits of providing TasP, PrEP or condom promotion. Compared with a baseline of offering ART to all HIV-positive partners at the 2010 national guidelines, condom promotion was the most cost-effective strategy [US $1206/disability-adjusted-life-year (DALY)], the next most cost-effective intervention was to additionally give TasP to HIV-positive partners (incremental cost-effectiveness ratio US $1607/DALY), followed by additionally giving PrEP to HIV-negative partners until their HIV-positive partners initiate ART (US $7870/DALY). When impact was measured in terms of infections averted, PrEP with condom promotion prevented double the number of infections as condom promotion alone.

Conclusions: The first priority intervention for serodiscordant couples in Nigeria should be scaled up ART access for HIV-positive partners. Subsequent incremental benefits are greatest with condom promotion and TasP, followed by PrEP.

Abstract  Full-text [free] access

Editor’s notes: Despite large reductions in incident HIV infections, Nigeria still has the second largest epidemic globally. Only 35% of  eligible individuals (under NIgerian guidelines) receive antiretroviral treatment. A mathematical model was developed describing HIV-1 transmission between serodiscordant heterosexual partnerships and to/from external partners. The impact and cost-effectiveness of pre-exposure prophylaxis (PrEP), Treatment as Prevention (TasP) and condom promotion for serodiscordant couples was estimated. Two baseline scenarios were used. The first was offering ART at 2010 national guidelines (CD4+<350cells/µl) to all positive individuals. The second assumed current ART coverage (35%) among eligible HIV positive partners.

Scaling up current ART has the greatest impact, and is the most cost effective method for reducing new HIV infections in Nigeria, averting 15% of infections over 20 years. This equated to 35% of all infections under the strategy with the highest impact, which included TasP, long-term PrEP and condom promotion, and 73% of DALYs. The results were most strongly influenced by assumptions around frequency of sex within partnerships, per-act transmission rates, programme efficacy and dropout rates. As more resources become available, after giving ART to all eligible individuals, condom promotion was the next most cost-effective approach. In terms of DALYS averted however, TasP was more likely to be the most cost-effective initial programme.

The study illustrates that the first priority in Nigeria should be scaling up ART to all individuals who are already eligible under Nigerian guidelines from its current level of 35%. Condom promotion within serodiscordant couples was also predicted to be highly cost-effective. Additionally, initiating treatment regardless of CD4 count was predicted to bring about substantial and highly cost-effective additional gains in DALYs averted.

The authors illustrate that combination approaches are important in this setting and should be considered for future programme policy.

condoms, treatment
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Food insecurity among people living with HIV in the United States: time for structural level policy changes?

Food insecurity, chronic illness, and gentrification in the San Francisco Bay Area: an example of structural violence in United States public policy.

Whittle HJ, Palar K, Hufstedler LL, Seligman HK, Frongillo EA, Weiser SD. Soc Sci Med. 2015 Aug 20;143:154-161. doi: 10.1016/j.socscimed.2015.08.027. [Epub ahead of print]

Food insecurity continues to be a major challenge in the United States, affecting 49 million individuals. Quantitative studies show that food insecurity has serious negative health impacts among individuals suffering from chronic illnesses, including people living with HIV/AIDS (PLHIV). Formulating effective interventions and policies to combat these health effects requires an in-depth understanding of the lived experience and structural drivers of food insecurity. Few studies, however, have elucidated these phenomena among people living with chronic illnesses in resource-rich settings, including in the United States. Here we sought to explore the experiences and structural determinants of food insecurity among a group of low-income PLHIV in the San Francisco Bay Area. Thirty-four semi-structured in-depth interviews were conducted with low-income PLHIV receiving food assistance from a local non-profit in San Francisco and Alameda County, California, between April and June 2014. Interview transcripts were coded and analysed according to content analysis methods following an inductive-deductive approach. The lived experience of food insecurity among participants included periods of insufficient quantity of food and resultant hunger, as well as long-term struggles with quality of food that led to concerns about the poor health effects of a cheap diet. Participants also reported procuring food using personally and socially unacceptable strategies, including long-term dependence on friends, family, and charity; stealing food; exchanging sex for food; and selling controlled substances. Food insecurity often arose from the need to pay high rents exacerbated by gentrification while receiving limited disability income-a situation resulting in large part from the convergence of long-standing urban policies amenable to gentrification and an outdated disability policy that constrains financial viability. The experiences of food insecurity described by participants in this study can be understood as a form of structural violence, motivating the need for structural interventions at the policy level that extend beyond food-specific solutions.

Abstract access 

Editor’s notes: Studies in the United States of America have demonstrated a high prevalence of food insecurity among low-income people living with HIV. Despite this high prevalence, little is known about the precise structural mechanisms by which food insecurity is distributed across low and high income participants, particularly among people living with HIV. This paper begins to fill that knowledge gap.  Using in-depth interviews among a group of low-income people living with HIV residing in the San Francisco Bay area, this study sought to investigate questions around how food insecurity manifests among certain groups in the population. Three themes relevant to the lived experience of food insecurity emerged from the interviews. The first being periods of significant food shortage where hunger or the anticipation of hunger was a serious source of anxiety for participants. The second was around the perceived poor quality of food where participants were unable to afford a diet that they believed to be sufficiently healthy. They considered this to be detrimental to both their general and HIV-associated health. This led to a third theme: participants using a multitude of resourceful strategies in order to procure food. Some of the strategies they found personally uncomfortable or they perceived as socially unacceptable. A relevant theme around structural determinants of food security that also emerged was the disparity between rent payments and the disability income which participants received. In particular, rising rents due to an influx of people who benefited from the technology boom, alongside gentrification taking place in the San Francisco area made it particularly difficult for low income people living with HIV to afford to live in the city. In order to be able to purchase food which they considered as high priority they would have to ration their money and avoid buying items they considered as less of a necessity (for example, entertainment, travel or toiletries). This is particularly exacerbated by the issue of monthly disability payments being low relative to the cost of living. The findings presented in this paper suggest certain structural activities in order to prevent the adverse effects of food insecurity such as sexual risk, sub-optimal ART adherence and poor clinical outcomes for people living with HIV. There were two suggested measures. The first was protecting vulnerable populations from the market effects of urban regeneration through better state subsidies in housing. The second was helping state-dependent individuals afford an adequate and sufficiently healthy diet by reassessing the amount disbursed through the disability income.

In summary, the authors describe low-income people living with HIV participants who often found themselves pushed into situations of indignity, shame and poor health by large-scale economic forces beyond their control. Without funds to purchase food with adequate nutritional content, they often fell into absolute hunger or had poor diets that prompted concerns about their physical health. Despite the United States of America being a high income country with one of the highest GDP per capita, food insecurity continues to be a challenge. Only broad structural approaches with policy changes can help chronically ill and vulnerable individuals escape both indignities and negative health consequences of food insecurity in the 21st century. 

Northern America
United States of America
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In which settings is Xpert® MTB/RIF and LED microscopy screening for Tuberculosis for people living with HIV cost-effective?

Screening for tuberculosis among adults newly diagnosed with HIV in sub-Saharan Africa: a cost-effectiveness analysis.

Zwerling AA, Sahu M, Ngwira LG, Khundi M, Harawa T, Corbett EL, Chaisson RE, Dowdy DW. J Acquir Immune Defic Syndr. 2015 Sep 1;70(1):83-90. doi: 10.1097/QAI.0000000000000712.

Objective: New tools, including light-emitting diode (LED) fluorescence microscopy and the molecular assay Xpert® MTB/RIF, offer increased sensitivity for tuberculosis (TB) in persons with HIV but come with higher costs. Using operational data from rural Malawi, we explored the potential cost-effectiveness of on-demand screening for TB in low-income countries of sub-Saharan Africa.

Design and methods: Costs were empirically collected in 4 clinics and in 1 hospital using a microcosting approach, through direct interview and observation from the national TB program perspective. Using decision analysis, newly diagnosed persons with HIV were modeled as being screened by 1 of the 3 strategies: Xpert®, LED, or standard of care (ie, at the discretion of the treating physician).

Results: Cost-effectiveness of TB screening among persons newly diagnosed with HIV was largely determined by 2 factors: prevalence of active TB among patients newly diagnosed with HIV and volume of testing. In facilities screening at least 50 people with a 6.5% prevalence of TB, or at least 500 people with a 2.5% TB prevalence, Xpert® is likely to be cost-effective. At lower prevalence-including that observed in Malawi-LED microscopy may be the preferred strategy, whereas in settings of lower TB prevalence or small numbers of eligible patients, no screening may be reasonable (such that resources can be deployed elsewhere).

Conclusions: TB screening at the point of HIV diagnosis may be cost-effective in low-income countries of sub-Saharan Africa, but only if a relatively large population with high prevalence of TB can be identified for screening.

Abstract access 

Editor’s notes: This study provides guidance on when screening people newly diagnosed with HIV for tuberculosis (TB) using Xpert® MTB/RIF or LED microscopy is likely to be cost-effective. Previous studies suggest that both TB screening technologies may be cost-effective, but that cost-effectiveness will depend on how tests are implemented. In highly resource constrained settings, the affordability of TB screening, particularly using Xpert® MTB/RIF, remains a concern. It therefore may not be feasible to place screening equipment at all locations, and more guidance is required on the types of setting where these investments may have the most benefit.

The study finds that two factors are particularly important in the choice of TB screening at any specific site. First, the authors find that test volumes are critical to cost-effectiveness. This finding supports earlier studies from South Africa prior to Xpert® MTB/RIF roll-out – that suggest that ‘economies of scale’ drive the unit costs per test. The authors of this study add to this previous evidence by providing a detailed example from a low income setting. Second, on the effect side, TB prevalence is found to be a key driver of cost-effectiveness.

The authors provide an illustration of a simple approach and model that can be used by countries to select the different TB screening tests required. It should be noted however, that the authors are not able to fully consider some factors that may have an important impact on the cost-effectiveness of TB screening, due to data scarcity. For example, the extent and speed to which people are appropriately treated for TB under each option (including the standard of care). This has been shown to be an important consideration in other studies investigating the cost-effectiveness of Xpert® MTB/RIF. It should also be noted that the study determines cost-effectiveness using an approach that may not fully reflect financial constraints. Therefore additional analyses, using local data, are still required before applying the study’s results in different settings.  

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HIV self-testing: A cost-saving approach?

Assessment of the potential impact and cost-effectiveness of self-testing for HIV in low-income countries.  

Cambiano V, Ford D, Mabugu T, Napierala Mavedzenge S, Miners A, Mugurungi O, Nakagawa F, Revill P, Phillips A. J Infect Dis. 2015 Aug 15;212(4):570-7. doi: 10.1093/infdis/jiv040. Epub 2015 Mar 12.

Background: Studies have demonstrated that self-testing for human immunodeficiency virus (HIV) is highly acceptable among individuals and could allow cost savings, compared with provider-delivered HIV testing and counseling (PHTC), although the longer-term population-level effects are uncertain. We evaluated the cost-effectiveness of introducing self-testing in 2015 over a 20-year time frame in a country such as Zimbabwe.

Methods: The HIV synthesis model was used. Two scenarios were considered. In the reference scenario, self-testing is not available, and the rate of first-time and repeat PHTC is assumed to increase from 2015 onward, in line with past trends. In the intervention scenario, self-testing is introduced at a unit cost of $3.

Results: We predict that the introduction of self-testing would lead to modest savings in healthcare costs of $75 million, while averting around 7000 disability-adjusted life-years over 20 years. Findings were robust to most variations in assumptions; however, higher cost of self-testing, lower linkage to care for people whose diagnosis is a consequence of a positive self-test result, and lower threshold for antiretroviral therapy eligibility criteria could lead to situations in which self-testing is not cost-effective.

Conclusions: This analysis suggests that introducing self-testing offers some health benefits and may well save costs.

Abstract  Full-text [free] access

Editor’s notes: In low-income countries 50% of people living with HIV are unaware of their HIV-status. Some barriers to diagnosis are associated with provider-based models and could potentially be overcome by introducing self-testing strategies. The cost of self-testing is expected to be lower than that of provider-based testing. However, self-testing may have a lower sensitivity, may necessitate provider-based diagnosis confirmation and may lead to lower linkages to care, among other potential disadvantages. This study assesses the cost-effectiveness of introducing self-testing in Zimbabwe over a 20-year time frame.

Two scenarios are modelled using an individual-based stochastic model of HIV transmission and infection progression and treatment: 1) a reference case where self-testing is not introduced, with continuous reliance on provider-based testing and 2) following self-testing introduction. Cost and health outcomes were compared.

The study suggests that introduction of self-testing would lead to a 7% higher proportion tested for HIV compared to the reference scenario. Also, it would lead to a cost reduction of 2.6% (USD 75 million) and to 7000 DALYs averted in a 20-year period. However, the costs and effects depend on a range of factors and in some scenarios (such as in situations of inadequate links to the care and treatment cascade) self-testing could result in worse outcomes than in the reference case. Sensitivity analyses illustrate that key determinants of the magnitude of health gains include the cost of self-testing, the initial level of HIV diagnosis and ART coverage, and self-testing availability.

This study contains some exciting findings that could lead to the use of resources more effectively. However, associated research needs to be carried out to ensure that the introduction of self-testing yields the greatest benefit. More work needs to be done in determining the cost of distribution and management of self-testing, as well as exploring the community acceptance. Further, given the importance of linkages to care, research on self-testing should be embedded into the larger literature around health system strengthening. 

HIV testing
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Agricultural and microfinance programmes might be part of the mix to achieve the virologic suppression goal

Shamba Maisha: randomized controlled trial of an agricultural and finance intervention to improve HIV health outcomes in Kenya.

Weiser SD, Bukusi EA, Steinfeld RL, Frongillo EA, Weke E, Dworkin SL, Pusateri K, Shiboski S, Scow K, Butler LM, Cohen CR. AIDS. 2015 Jul 23. [Epub ahead of print]

Objectives: Food insecurity and HIV/AIDS outcomes are inextricably linked in sub-Saharan Africa. We report on health and nutritional outcomes of a multisectoral agricultural intervention trial among HIV-infected adults in rural Kenya.

Design: This is a pilot cluster randomized controlled trial.

Methods: The intervention included a human-powered water pump, a microfinance loan to purchase farm commodities, and education in sustainable farming practices and financial management. Two health facilities in Nyanza Region, Kenya were randomly assigned as intervention or control. HIV-infected adults 18 to 49 years old who were on antiretroviral therapy and had access to surface water and land were enrolled beginning in April 2012 and followed quarterly for 1 year. Data were collected on nutritional parameters, CD4 T-lymphocyte counts, and HIV RNA. Differences in fixed-effects regression models were used to test whether patterns in health outcomes differed over time from baseline between the intervention and control arms.

Results: We enrolled 72 and 68 participants in the intervention and control groups, respectively. At 12 months follow-up, we found a statistically significant increase in CD4 cell counts (165 cells/µl, P < 0.001) and proportion virologically suppressed in the intervention arm compared with the control arm (comparative improvement in proportion of 0.33 suppressed, odds ratio 7.6, 95% confidence interval: 2.2-26.8). Intervention participants experienced significant improvements in food security (3.6 scale points higher, P < 0.001) and frequency of food consumption (9.4 times per week greater frequency, P = 0.013) compared to controls.

Conclusion: Livelihood interventions may be a promising approach to tackle the intersecting problems of food insecurity, poverty and HIV/AIDS morbidity.

Abstract access 

Editor’s notes: There is compelling evidence of a vicious cycle between food insecurity and HIV transmission, morbidity and mortality. Studies have been finding alarmingly high rates of moderate and severe food insecurity among ART initiates in east Africa, at least 70%. At a time when the world is aiming to achieve the 90-90-90 targets, (90% of HIV positive individuals knowing their status, 90% of people being on ART and 90% of people on ART being virally suppressed) and thus increase viral suppression to 90%, among people on antiretroviral therapy, it is clear that the effectiveness and efficiency of treatment will depend on how food insecurity is addressed, within and/or alongside the HIV programme.

In this pilot study in Kenya, the authors report on an agricultural and microfinance programme provided to food-insecure adults living with HIV, who had access to farming land and surface water. Study participants were mainly established patients who had been on ART for an average of 2.8 years. The study finds a significant increase in CD4 cell counts (165 cells/mm3) and a comparative increase in the proportion of patients with virologic suppression, of 33%. In addition, significant improvements were found on the food security scale. These included the diversity and frequency of food consumption, as well as increases in BMI, despite no significant changes in food expenditures. However, it is important to note that the programme and control samples were unbalanced, with the programme group starting with higher food insecurity and a lower proportion of virologic suppression. Moreover, with only two sites, the study could not separate the programme effects from cluster-level variables, underscoring the need for a larger cluster RCT to confirm these findings.

Although this is a pilot RCT with a small sample size and other limitations, it provides promising evidence that a multi-sectoral agricultural and microfinance programme can have direct effects on ART outcomes, as well as impacting on food insecurity and nutrition outcome measures. While previous studies have reported on the effects of food assistance for people on ART, this study is an important addition to the evidence, as it is one of the first to report on a potentially sustainable agricultural-microfinance programme. Also, by measuring multiple outcomes across sectors, it allows for a more balanced appraisal of the programmes societal benefits, rather than only considering its HIV dividend. 

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