Sergio Bautista-Arredondo

Making HIV prevention programmes work

Even after 25 years of experience, HIV prevention programming remains largely deficient. We identify four areas that managers of national HIV prevention programmes should reassess and hence refocus their efforts-improvement of targeting, selection, and delivery of prevention interventions, and optimisation of funding. Although each area is not wholly independent from one another, and because each country and epidemic context will require a different balance of time and funding allocation in each area, we present the current state of each dimension in the global HIV prevention arena and propose practical ways to remedy present deficiencies. Insufficient data for intervention effectiveness and country-specific epidemiology has meant that programme managers have operated, and continue to operate, in a fog of uncertainty. Although priority must be given to the improvement of prevention methods and the capacity for the generation and use of evidence to improve programme planning and implementation, uncertainty will remain. In the meantime, however, we argue that prevention programming can be made much more effective by use of information that is readily available.

Optimizing resource allocation for HIV/AIDS prevention programmes: an analytical framework.

Introduction:Although investment in HIV/AIDS prevention has increased worldwide, it remains uncertain how the additional resources can be most efficiently allocated to maximize the number of infections averted, especially at the country, regional and local levels. Methods:Data from developing countries in Africa, Asia and Latin America were reviewed on the allocation of HIV/AIDS prevention funds in relation to the prevalence of infection, as well as budgetary allocations for specific population groups at high risk of infection, such as sex workers, intravenous drug users and men who have sex with men. The variation in unit costs of voluntary counselling and testing in five countries was also examined. Results:Evidence was found of three distinct sources of inefficiency in the allocation of HIV/AIDS prevention resources: inefficiency in the mix of interventions selected; inefficient targeting of key populations; and technical inefficiency in the production of HIV prevention services. Conclusion:A general conceptual framework for evaluating the efficiency of HIV/AIDS prevention programmes at the country, regional and local levels is proposed. This framework stresses three equally important components of programme efficiency: cost-effectiveness (the choice of the mix of interventions); targeting (the choice of the mix of target populations); and technical efficiency (the delivery of prevention services at least cost).

Using provider performance incentives to increase HIV testing and counseling services in Rwanda

Paying for performance provides financial rewards to medical care providers for improvements in performance measured by utilization and quality of care indicators. In 2006, Rwanda began a pay for performance scheme to improve health services delivery, including HIV/AIDS services. Using a prospective quasi-experimental design, this study examines the schemes impact on individual and couples HIV testing. We find a positive impact of pay for performance on HIV testing among married individuals (10.2 percentage points increase). Paying for performance also increased testing by both partners by 14.7 percentage point among discordant couples in which only one of the partners is an AIDS patient.

Economic impact of antiretroviral therapy prescription decisions in the context of rapid scaling-up of access to treatment: lessons from Mexico

Background:Mexico started scaling-up access to antiretroviral treatment in the late 1990s. Even though the Mexican Health System enrolled patients at impressive speed, in the initial years important aspects of the quality of care were overlooked. Objective:To describe antiretroviral prescribing and adherence practices in Mexico during initial scaling-up of antiretroviral treatment in comparison to national treatment guidelines and to estimate the associated economic cost. Methods:Eleven public sector hospitals provided detailed patient chart data. Monthly observations formed the basis of scenarios aligned by calendar month and by month before and after initiation of triple therapy. The scenarios varied by extent of prescription refill, adherence levels, and compliance with national treatment guidelines. Results:Antiretroviral therapy prescription practices were largely inconsistent with published guidelines. Non-recommended combinations were prescribed to between 54 and 79% patients-months per year. Additionally, more than 50% of patients experienced four to 13 changes in treatment. Modeling of the economic impact of treatment practices showed that it would have been possible to effectively treat the same number of patients at the same or lower cost per patient. Conclusions:In addition to dispensing drugs, countries scaling-up antiretroviral therapy must find ways to ensure consistent drug supply, appropriate prescription practices and effective levels of adherence. Failing to do so will seriously reduce treatment effectiveness, greatly increasing the cost per unit of health benefit. With very low levels of effective adherence patients may even be harmed and the spread of multi-drug resistant virus facilitated.

Learning effect of a conditional cash transfer programme on poor rural women’s selection of delivery care in Mexico

BACKGROUND The Mexican programme Oportunidades/Progresa conditionally transfers money to beneficiary families. Over the past 10 years, poor rural women have been obliged to attend antenatal care (ANC) visits and reproductive health talks. We propose that the length of time in the programme influences womens preferences, thus increasing their use not only of services directly linked to the cash transfers, but also of other services, such as clinic-based delivery, whose utilization is not obligatory. OBJECTIVE To analyse the long-term effect of Oportunidades on womens use of antenatal and delivery care. METHODOLOGY 5051 women aged between 15 and 49 years old with at least one child aged less than 24 months living in rural localities were analysed. Multilevel probit and logit models were used to analyse ANC visits and physician/nurse attended delivery, respectively. Models were adjusted with individual and socio-economic variables and the localitys exposure time to Oportunidades. Findings On average women living in localities with longer exposure to Oportunidades report 2.1% more ANC visits than women living in localities with less exposure. Young women aged 15-19 and 20-24 years and living in localities with longer exposure to Oportunidades (since 1998) have 88% and 41% greater likelihood of choosing a physician/nurse vs. traditional midwife for childbirth, respectively. Women of indigenous origin are 68.9% less likely to choose a physician/nurse for delivery care than non-indigenous women. CONCLUSIONS An increase in the average number of ANC visits has been achieved among Oportunidades beneficiaries. An indirect effect is the increased selection of a physician/nurse for delivery care among young women living in localities with greater exposure time to Oportunidades. Disadvantaged women in Mexico (indigenous women) continue to have less access to skilled delivery care. Developing countries must develop strategies to increase access and use of skilled obstetric care for marginalized women.

Factors influencing global antiretroviral procurement prices

BackgroundAntiretroviral medicines (ARVs) are one of the most costly parts of HIV/AIDS treatment. Many countries are struggling to provide universal access to ARVs for all people living with HIV and AIDS. Although substantial price reductions of ARVs have occurred, especially between 2002 and 2008, achieving sustainable access for the next several decades remains a major challenge for most low- and middle-income countries. The objectives of the present study were twofold: first, to analyze global ARV prices between 2005 and 2008 and associated factors, particularly procurement methods and key donor policies on ARV procurement efficiency; second, to discuss the options of procurement processes and policies that should be considered when implementing or reforming access to ARV programs.MethodsAn ARV-medicines price-analysis was carried out using the Global Price Reporting Mechanism from the World Health Organization. For a selection of 12 ARVs, global median prices and price variation were calculated. Linear regression models for each ARV were used to identify factors that were associated with lower procurement prices. Logistic regression models were used to identify the characteristics of those countries which procure below the highest and lowest direct manufactured costs.ResultsThree key factors appear to have an influence on a countrys ARV prices: (a) whether the product is generic or not; (b) the socioeconomic status of the country; (c) whether the country is a member of the Clinton HIV/AIDS Initiative. Factors which did not influence procurement below the highest direct manufactured costs were HIV prevalence, procurement volume, whether the country belongs to the least developed countries or a focus country of the United States Presidents Emergency Plan For AIDS Relief.ConclusionOne of the principal mechanisms that can help to lower prices for ARV over the next several decades is increasing procurement efficiency. Benchmarking prices could be one useful tool to achieve this.

Is the HIV Epidemic Stable among MSM in Mexico? HIV Prevalence and Risk Behavior Results from a Nationally Representative Survey among Men Who Have Sex with Men

Background Recent evidence points to the apparent increase of HIV prevalence among men who have sex with men (MSM) in different settings with concentrated epidemics, including the Latin American region. In 2011, Mexico implemented an ambitious HIV prevention program in all major cities, funded by the Global Fund to Fight Aids, Tuberculosis and Malaria. The program was intended to strengthen the prevention response for the most at risk populations: MSM and injecting drug users. This paper presents the HIV prevalence results of a nationally representative baseline survey in 24 Mexican cities throughout the 5 regions in the country and reports the socio-demographic and sexual risk behaviors that predict the probability of infection. Methods The survey was implemented in two phases. We first identified and characterized places where MSM gather in each city and then conducted in a second phase, a seroprevalence survey that included rapid HIV testing and a self-administered questionnaire. The prevalence of HIV was estimated by adjusting for positive predicted value. We applied a probit model to estimate the probability of having a positive result from the HIV test as a function of socio-demographic characteristics and self-reported sexual risk behaviors. Results We found an overall HIV prevalence among MSM gathering in meeting points of 16.9% [95% CI: 15.6–18.3], significantly higher than previously reported estimates. Our regression results suggest that the risk of infection increases with age, with the number of sexual partners, and among those who play a receptive sexual role, and the risk decreases with higher education. Discussion Our findings suggest a higher HIV prevalence among MSM than previously acknowledged and that a significant regional variability exist throughout the country. These two findings combined, signal an important dynamic in the epidemic that should be better understood and promptly addressed with strong prevention efforts targeted at key populations.

Costing of scaling up HIV/AIDS treatment in Mexico

OBJECTIVE To determine the net effect of introducing highly active antiretroviral treatment (HAART) in Mexico on total annual per-patient costs for HIV/AIDS care, taking into account potential savings from treatment of opportunistic infections and hospitalizations. MATERIAL AND METHODS A multi-center, retrospective patient chart review and collection of unit cost data were performed to describe the utilization of services and estimate costs of care for 1003 adult HIV+ patients in the public sector. RESULTS HAART is not cost-saving and the average annual cost per patient increases after initiation of HAART due to antiretrovirals, accounting for 90% of total costs. Hospitalizations do decrease post-HAART, but not enough to offset the increased cost. CONCLUSIONS Scaling up access to HAART is feasible in middle income settings. Since antiretrovirals are so costly, optimizing efficiency in procurement and prescribing is paramount. The observed adherence was low, suggesting that a proportion of these high drug costs translated into limited health benefits.

A Cross-Sectional Study of Prisoners in Mexico City Comparing Prevalence of Transmissible Infections and Chronic Diseases with That in the General Population

Objectives To describe patterns of transmissible infections, chronic illnesses, socio-demographic characteristics and risk behaviors in Mexico City prisons, including in comparison to the general population, to identify those currently needing healthcare and inform policy. Materials and Methods A cross-sectional study among 17,000 prisoners at 4 Mexico City prisons (June to December 2010). Participation was voluntary, confidential and based on informed consent. Participants were tested for HIV, Hepatitis B & C, syphilis, hypertension, obesity, and, if at risk, glucose and cholesterol. A subset completed a questionnaire on socio-demographic characteristics and risk behaviors. Positive results were delivered with counseling and treatment or referral. Results 76.8% (15,517/20,196) of men and 92.9% (1,779/1,914) of women participated. Complete data sets were available for 98.8%. The following prevalence data were established for transmissible infections: HIV 0.7%; syphilis: Anti-TP+/VDRL+ 2.0%; Hepatitis B: HBcAb 2.8%, HBsAg 0.15%; Anti-HCV 3.2%. Obesity: 9.5% men, 33.8% women. Compared with national age- and sex-matched data, the relative prevalence was greater for HIV and syphilis among women, HIV and Hepatitis C in men, and all infections in younger participants. Obesity prevalence was similar for women and lower among male participants. The prevalence of previously diagnosed diabetes and hypertension was lower. Questionnaire data (1,934 men, 520 women) demonstrated lower educational levels, increased smoking and substance use compared to national data. High levels of non-sterile tattooing, physical abuse and histories of sexual violence were found. Conclusion The study identified that health screening is acceptable to Mexico City prisoners and feasible on a large-scale. It demonstrated higher prevalence of HIV and other infections compared to national data, though low rates compared to international data. Individual participants benefited from earlier diagnosis, treatment and support. The data collected will also enable the formulation of improved policy for this vulnerable group.

Costo-efectividad de políticas para el tamizaje de cáncer de mama en México

Objective. Generate cost-effectiveness information to allow policy makers optimize breast cancer (BC) policy in Mexico. Material and methods. We constructed a Markov model that incorporates four interrelated processes of the disease: the natural history; detection using mammography; treatment; and other competing-causes mortality, according to which 13 different strategies were modeled. Results. Strategies (starting age, % of coverage, frequency in years)= (48, 25, 2), (40, 50, 2) and (40, 50, 1) constituted the optimal method for expanding the BC program, yielding 75.3, 116.4 and 171.1 thousand pesos per life-year saved, respectively.Conclusions: The strategies included in the optimal method for expanding the program produce a cost per life-year saved of less than two times the GNP per capita and hence are cost-effective according to WHO Commission on Macroeconomics and Health criteria.