Recommendations for increasing the use of HIV/AIDS resource allocation models

Background

Resource allocation models have not had a substantial impact on HIV/AIDS resource allocation decisions in spite of the important, additional insights they may provide. In this paper, we highlight six difficulties often encountered in attempts to implement such models in policy settings; these are: model complexity, data requirements, multiple stakeholders, funding issues, and political and ethical considerations. We then make recommendations as to how each of these difficulties may be overcome.

Results

To ensure that models can inform the actual decision, modellers should understand the environment in which decision-makers operate, including full knowledge of the stakeholders' key issues and requirements. HIV/AIDS resource allocation model formulations should be contextualized and sensitive to societal concerns and decision-makers' realities. Modellers should provide the required education and training materials in order for decision-makers to be reasonably well versed in understanding the capabilities, power and limitations of the model.

Conclusion

This paper addresses the issue of knowledge translation from the established resource allocation modelling expertise in the academic realm to that of policymaking.

     

More than just talk: the framing of transactional sex and its implications for vulnerability to HIV in Lesotho, Madagascar and South Africa

Background

Despite massive scale up of funds from global health initiatives including the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and other donors, the ambitious target agreed by G8 leaders in 2005 in Gleneagles to achieve universal access to HIV/AIDS treatment by 2010 has not been reached. Significant barriers to access remain in former Soviet Union (FSU) countries, a region now recognised as a priority area by policymakers. There have been few empirical studies of access to HIV/AIDS services in FSU countries, resulting in limited understanding and implementation of accessible HIV/AIDS interventions. This paper explores the multiple access barriers to HIV/AIDS services experienced by a key risk group-injecting drug users (IDUs).

Methods

Semi-structured interviews were conducted in two FSU countries-Ukraine and Kyrgyzstan-with clients receiving Global Fund-supported services (Ukraine n = 118, Kyrgyzstan n = 84), service providers (Ukraine n = 138, Kyrgyzstan n = 58) and a purposive sample of national and subnational stakeholders (Ukraine n = 135, Kyrgyzstan n = 86). Systematic thematic analysis of these qualitative data was conducted by country teams, and a comparative synthesis of findings undertaken by the authors.

Results

Stigmatisation of HIV/AIDS and drug use was an important barrier to IDUs accessing HIV/AIDS services in both countries. Other connected barriers included: criminalisation of drug use; discriminatory practices among government service providers; limited knowledge of HIV/AIDS, services and entitlements; shortages of commodities and human resources; and organisational, economic and geographical barriers.

Conclusions

Approaches to thinking about universal access frequently assume increased availability of services means increased accessibility of services. Our study demonstrates that while there is greater availability of HIV/AIDS services in Ukraine and Kyrgyzstan, this does not equate with greater accessibility because of multiple, complex, and interrelated barriers to HIV/AIDS service utilisation at the service delivery level. Factors external to, as well as within, the health sector are key to understanding the access deficit in the FSU where low or concentrated HIV/AIDS epidemics are prevalent. Funders of HIV/AIDS programmes need to consider how best to tackle key structural and systemic drivers of access including prohibitionist legislation on drugs use, limited transparency and low staff salaries within the health sector.     

The past,present and future of HIV,AIDS and resource allocation

Background

How should HIV and AIDS resources be allocated to achieve the greatest possible impact? This paper begins with a theoretical discussion of this issue, describing the key elements of an "evidence-based allocation strategy". While it is noted that the quality of epidemiological and economic data remains inadequate to define such an optimal strategy, there do exist tools and research which can lead countries in a way that they can make allocation decisions. Furthermore, there are clear indications that most countries are not allocating their HIV and AIDS resources in a way which is likely to achieve the greatest possible impact. For example, it is noted that neighboring countries, even when they have a similar prevalence of HIV, nonetheless often allocate their resources in radically different ways.These differing allocation patterns appear to be attributable to a number of different issues, including a lack of data, contradictory results in existing data, a need for overemphasizing a multisectoral response, a lack of political will, a general inefficiency in the use of resources when they do get allocated, poor planning and a lack of control over the way resources get allocated.

Methods

There are a number of tools currently available which can improve the resource-allocation process. Tools such as the Resource Needs Model (RNM) can provide policymakers with a clearer idea of resource requirements, whereas other tools such as Goals and the Allocation by Cost-Effectiveness (ABCE) models can provide countries with a clearer vision of how they might reallocate funds.

Results

Examples from nine different countries provide information about how policymakers are trying to make their resource-allocation strategies more "evidence based". By identifying the challenges and successes of these nine countries in making more informed allocation decisions, it is hoped that future resource-allocation decisions for all countries can be improved.

Conclusion

We discuss the future of resource allocation, noting the types of additional data which will be required and the improvements in existing tools which could be made.

     

HIV in the Middle East and North Africa: priority, culture, and control

Objectives

This study aimed to assess the priority of HIV/AIDS in the Middle East and North Africa region and compare it with other regions. This review examines the social, cultural and religious features of HIV in the region, and considers their influence on perception of risk and approaches to control, such as condom use and antiretroviral therapy.

Methods

We screened a wide range of sources for comprehensive and reliable data; the search of PubMed, ISI Web of Science, ScienceDirect, and grey literature databases were unrestricted by language and year of publication.

Results

Studies of HIV/AIDS in the region are limited, especially studies of social aspects of HIV/AIDS and their relevance for control. Findings suggest low condom use across the region among high-risk groups, and the general population, and low antiretroviral therapy uptake among people with HIV/AIDS.

Conclusions

The review indicates gaps in the literature and needs for more academic engagement and political commitment. Cultural norms have notable implications for HIV control, which are discussed, considering implications for the priority, prevention, treatment, and control of HIV/AIDS.     

HIV/AIDS und Aussieder aus der ehemaligen Sowjetunion

Background

Ethnic German resettlers from the former Soviet Union are one of the biggest immigrant groups to Germany. Some come from countries with a comparably high prevalence of human immunodeficiency virus (HIV), such as Ukraine and the Russian Federation. However, no data are available concerning this group’s knowledge or attitudes regarding HIV and acquired immunodeficiency syndrome (AIDS).

Methods

In this study, 927 ethnic German resettlers in the federal state of Bavaria, Germany, were questioned in a multicentre survey through an anonymous mail-in questionnaire.

Results

Of the 927, 37.3% participated in the survey. HIV/AIDS was rated as an important or very important topic by 81.7% of the respondents, and 62.3% felt well informed or very well informed about it. Intravenous drug users (89.2%), commercial sex workers (78%), and men who have sex with men (76%) were mentioned as risk groups for HIV/AIDS. Syringes/needles (97%), vaginal (82.5%), anal (65.1%), and oral (50%) sexual intercourse were cited as HIV transmission routes. Condom use (91.6%) and use of disposable syringes/needles (79.9%) were chosen as HIV prevention measures.

Conclusions

Respondents showed an acceptable HIV/AIDS knowledge level, but knowledge regarding sexual transmission routes was not always sufficient; information about conventional HIV prevention measures reaches few ethnic German resettlers.     

Access to and perceptions towards water,sanitation and hygiene: a case of HIV/AIDS affected and non-affected households in rural Uganda

Aim

To explore the water, sanitation and hygiene (WASH) access and perceptions among households with people living with HIV/AIDS (affected households) as compared to households without people living with HIV/AIDS (non-affected households).

Methods

This was a cross-sectional study that was conducted in the rural districts of Mpigi and Gomba. The study used a sample of 450 respondents with 222 from HIV/AIDS affected and 228 from HIV/AIDS non-affected households.

Results

Majority of respondents had improved water sources although most of these sources were beyond 2 km from households. Respondents from HIV/AIDS-affected households were four times more likely to have ever used a chemical water disinfectant locally known as “water guard”. Additionally, affected households were twice more likely to mention having clean containers for storing drinking water and twice more likely to report boiling water for drinking. No significant differences in presence of latrines for affected and non-affected households were reported. Households with a perception that fetching water takes a lot of time were more likely to buy water from vendors.

Conclusions

Access to improved water sources in short distances with a round trip water collection time of 30 min as recommended by WHO/UNICEF is still a challenge in this region. Good water practices were reported more in HIV/AIDS-affected households. A perception that fetching water takes a lot of time is significantly associated with buying water from vendors. Sleeping in own house is significantly associated with household presence of latrines.     

Multilateral, regional, and national determinants of policy adoption: the case of HIV/AIDS legislative action

Objectives

This article examines the global legislative response to the HIV/AIDS epidemic with a particular focus on how policies were diffused internationally or regionally, or facilitated internally.

Methods

This article uses event history analysis combined with multinomial logit regression to model the legislative response of 133 countries.

Results

First, the results demonstrate that the WHO positively influenced the likelihood of a legislative response. Second, the article demonstrates that development bank aid helped to spur earlier legislative action. Third, the results demonstrate that developed countries acted earlier than developing countries. And finally, the onset and severity of the HIV/AIDS epidemic was a significant influence on the legislative response.

Conclusion

Multilateral organizations have a positive influence in global policy diffusion through informational advocacy, technical assistance, and financial aid. It is also clear that internal stressors play key roles in legislative action seen clearly through earlier action being taken in countries where the shock of the onset of HIV/AIDS occurred earlier and earlier responses taken where the epidemic was more severe.     

Availability of indicators of migration in the surveillance of HIV, tuberculosis and hepatitis B in the European Union – a short note

Background and aim

Data regarding infectious diseases in migrant populations in Europe are scarce. We aimed to assess whether information on migration status is collected in countries of the European Union (EU) as part of their national surveillance systems for major infectious diseases (HIV/AIDS, tuberculosis (TB) and hepatitis B infection).

Methods

Using different electronic sources we collected information about whether indicators of migration status were collected in national infectious diseases surveillance systems in European countries.

Results

Of 27 EU countries, migration status was recorded in all 27 countries for TB surveillance (100%), in 22 countries for HIV (~82%) and in 23 countries for AIDS (~85%). Eight of 20 countries (40%) recorded migration status in hepatitis B surveillance systems. The most commonly recorded indicator of migration status was country of birth. Among countries which conducted migrant specific surveillance, country of birth was collected in ~82% of TB, ~86% of HIV, and ~83% of AIDS surveillance systems. Other indicators of the migration status were ethnicity (used in HIV and AIDS surveillance) and citizenship (TB surveillance).

Conclusion

We showed differences in how migration status is recorded in surveillance systems from European countries. This was especially true for tuberculoses and hepatitis B, whereas data collection as part of HIV/AIDS surveillance was nearly uniform. These results suggest the need for a more uniform reporting of migration status as part of infectious disease surveillance in EU countries.     

Sources of evidence in HIV/AIDS care: pilot study comparing family physicians and AIDS service organization staff

Background

The improvement of the quality of the evidence used in treatment decision-making is especially important in the case of patients with complicated disease processes such as HIV/AIDS for which multiple treatment strategies exist with conflicting reports of efficacy. Little is known about the perceptions of distinct groups of health care workers regarding various sources of evidence and how these influence the clinical decision-making process. Our objective was to investigate how two groups of treatment information providers for people living with HIV/AIDS perceive the importance of various sources of treatment information.

Methods

Surveys were distributed to staff at two local AIDS service organizations and to family physicians at three community health centres treating people living with HIV/AIDS. Participants were asked to rate the importance of 10 different sources of evidence for HIV/AIDS treatment information on a 5-point Likert-type scale. Mean rating scores and relative rankings were compared.

Results

Findings suggest that a discordance exists between the two health information provider groups in terms of their perceptions of the various sources of evidence. Furthermore, AIDS service organization staff ranked health care professionals as the most important source of information whereas physicians deemed AIDS service organizations to be relatively unimportant. The two groups appear to share a common mistrust for information from pharmaceutical industries.

Conclusions

Discordance exists between medical "experts" from different backgrounds relating to their perceptions of evidence. Further investigation is warranted in order to reveal any effects on the quality of treatment information and implications in the decision-making process. Possible effects on collaboration and working relationships also warrant further exploration.     

Harm reduction and law enforcement in Vietnam: influences on street policing

Background and rationale

The HIV epidemic in Vietnam has from its start been concentrated among injecting drug users. Vietnam instituted the 2006 HIV/AIDS Law which includes comprehensive harm reduction measures, but these are unevenly accepted and inadequately implemented. Ward police are a major determinant of risk for IDUs, required to participate in drug control practices (especially meeting quotas for detention centres) which impede support for harm reduction. We studied influences on ward level police regarding harm reduction in Hanoi to learn how to better target education and structural change.

Methods

After document review, we interviewed informants from government, NGOs, INGOs, multilateral agencies, and police, using semi-structured guides. Topics covered included perceptions of harm reduction and the police role in drug law enforcement, and harm reduction training and advocacy among police.

Results

Police perceive conflicting responsibilities, but overwhelmingly see their responsibility as enforcing drug laws, identifying and knowing drug users, and selecting those for compulsory detention. Harm reduction training was very patchy, ward police not being seen as important to it; and understanding of harm reduction was limited, tending to reflect drug control priorities. Justification for methadone was as much crime prevention as HIV prevention. Competing pressures on ward police create much anxiety, with performance measures based around drug control; recourse to detention resolves competing pressures more safely. There is much recognition of the importance of discretion, and much use of it to maintain good social order. Policy dissemination approaches within the law enforcement sector were inconsistent, with little communication about harm reduction programs or approaches, and an unfounded assumption that training at senior levels would naturally reach to the street.

Discussion

Ward police have not been systematically included in harm reduction advocacy or training strategies to support or operationalise legalised harm reduction interventions. The practices of street police challenge harm reduction policies, entirely understandably given the competing pressures on them. For harm reduction to be effective in Vietnam, it is essential that the ambiguities and contradictions between laws to control HIV and to control drugs be resolved for the street-level police.     

The value of effective public tuberculosis treatment: an analysis of opportunity costs associated with multidrug resistant tuberculosis in Latvia

Background

We 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.

Methods

We present a mathematical model 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.

Results

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.

Conclusions

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.     

Gesundheits?konomische Evaluation bei Leistungen f��r Senioren

Background

Demographic change and accretive health service utilization result in an increasing need of rational criteria for resource allocation. Health economic evaluation is seen as an explicit and transparent option, to be preferred to more controversial criteria like age-based rationing.

Aims

This article pursues the question of whether the application of health economic evaluation especially in the field of prevention and health promotion is as egalitarian as assumed and not more disadvantageous for the elderly than for younger people.

Results

Resource allocation following health economic evaluation can be age dependent. But this is consistent with admissible normative positions whereas implicit age rationing is not. When based on methodologically sound concepts without substituting more arbitrary forms of rationing, health economic evaluation can therefore be regarded as an allocation mechanism that induces welfare gains.     

A cost-based equity weight for use in the economic evaluation of primary health care interventions: case study of the Australian Indigenous population

Background

Efficiency and equity are both important policy objectives in resource allocation. The discipline of health economics has traditionally focused on maximising efficiency, however addressing inequities in health also requires consideration. Methods to incorporate equity within economic evaluation techniques range from qualitative judgements to quantitative outcomes-based equity weights. Yet, due to definitional uncertainties and other inherent limitations, no method has been universally adopted to date. This paper proposes an alternative cost-based equity weight for use in the economic evaluation of interventions delivered from primary health care services.

Methods

Equity is defined in terms of 'access' to health services, with the vertical equity objective to achieve 'equitable access for unequal need'. Using the Australian Indigenous population as an illustrative case study, the magnitude of the equity weight is constructed using the ratio of the costs of providing specific interventions via Indigenous primary health care services compared with the costs of the same interventions delivered via mainstream services. Applying this weight to the costs of subsequent interventions deflates the costs of provision via Indigenous health services, and thus makes comparisons with mainstream more equitable when applied during economic evaluation.

Results

Based on achieving 'equitable access', existing measures of health inequity are suitable for establishing 'need', however the magnitude of health inequity is not necessarily proportional to the magnitude of resources required to redress it. Rather, equitable access may be better measured using appropriate methods of health service delivery for the target group. 'Equity of access' also suggests a focus on the processes of providing equitable health care rather than on outcomes, and therefore supports application of equity weights to the cost side rather than the outcomes side of the economic equation.

Conclusion

Cost-based weights have the potential to provide a pragmatic method of equity weight construction which is both understandable to policy makers and sensitive to the needs of target groups. It could improve the evidence base for resource allocation decisions, and be generalised to other disadvantaged groups who share similar concepts of equity. Development of this decision-making tool represents a potentially important avenue for further health economics research.     

Herausforderungen der HIV-Pr?vention f��r Migranten

Background

Approximately 30% of new HIV infections in Germany occur among immigrants. HIV prevention thus needs to be better tailored to immigrant communities.

Methods

A survey of the 118 members of the national association of AIDS service organizations (Deutsche AIDS-Hilfe e.V.) was conducted to assess their experiences in providing HIV prevention services to immigrants. The survey is part of a participatory research project (PaKoMi). The analysis focuses on the challenges described by the AIDS service organization (ASO).

Results

A total of 90 ASO participated in the survey (return rate 76%). The great majority (89%) provide HIV prevention services to immigrants. More than half (53%) state a need for further action to improve prevention services to immigrants in their locality. Only a small minority (10%) are satisfied with the level of communal cooperation among local actors on this issue. Major challenges in providing HIV prevention services to immigrants include: intercultural challenges in dealing with cultural differences and taboos, lack of resources, limited access of ASOs to immigrant communities, language barriers, stigmatization processes, and practical and conceptual challenges resulting from the complex needs and multilayered problems of those immigrant groups who are most at risk for HIV/AIDS.

Conclusions

To better manage the challenges described by the ASOs, the participation of immigrant communities in HIV prevention and the cooperation of health and social service providers with community-based immigrant organizations should be improved. Given the social structural factors and legal issues which contribute to the specific vulnerability and increased HIV risks of immigrants, the concept of ??structural prevention?? seems appropriate which conceptualizes HIV prevention as health promotion in the broader social context.     

Public-private partnerships to build human capacity in low income countries: findings from the Pfizer program

Background

The ability of health organizations in developing countries to expand access to quality services depends in large part on organizational and human capacity. Capacity building includes professional development of staff, as well as efforts to create working environments conducive to high levels of performance. The current study evaluated an approach to public-private partnership where corporate volunteers give technical assistance to improve organizational and staff performance. From 2003 to 2005, the Pfizer Global Health Fellows program sent 72 employees to work with organizations in 19 countries. This evaluation was designed to assess program impact.

Methods

The researchers administered a survey to 60 Fellows and 48 Pfizer Supervisors. In addition, the team conducted over 100 interviews with partner organization staff and other key informants during site visits in Uganda, Kenya, Ghana, South Africa and India, the five countries where 60% of Fellows were placed.

Results

Over three-quarters of Fellowships appear to have imparted skills or enhanced operations of NGOs in HIV/AIDS and other health programs. Overall, 79% of Fellows reported meeting all or most technical assistance goals. Partner organization staff reported that the Fellows provided training to clinical and research personnel; strengthened laboratory, pharmacy, financial control, and human resource management systems; and helped expand Partner organization networks. Local staff also reported the Program changed their work habits and attitudes. The evaluation identified problems in defining goals of Fellowships and matching Organizations with Fellows. Capacity building success also appears related to size and sophistication of partner organization.

Conclusion

Public expectations have grown regarding the role corporations should play in improving health systems in developing countries. Corporate philanthropy programs based on "donations" of personnel can help build the organizational and human capacity of frontline agencies delivering health services. More attention is needed to measure and compare outcomes of international volunteering programs, and to identify appropriate strategies for expansion.     

AIDS-Prävention mit sozial benachteiligten Kindern in der Republik Südafrika

Background

Approximately two-thirds of the worldwide population infected with the human immunodeficiency virus (HIV) are currently living in the sub-Saharan region. The need for increased prevention is not controversial, but preventive efforts are undertaken mainly in relation to adolescents and adults.

Target group and methods

This study deals with a life-skills programme on HIV/AIDS for socially disadvantaged children of primary school age in an informal settlement of the Stellenbosch municipal area in the Western Cape province of the Republic of South Africa. The programme was outlined and evaluated using a questionnaire within a quasi-experimental design with an intervention and a control group and four measuring time points each.

Results

For the children in the intervention group, the results indicate a significant increase in knowledge about HIV and AIDS between the pretest and the posttest. In the subsequent measurements, however, the knowledge values decreased back to the initial level.

Conclusion

The reasons for this lack of sustainability are discussed with regard to the children’s unique socioeconomic and sociocultural life situation. Perspectives for further prevention efforts can be derived.     

Eine rationale Strategie f��r Pr?vention und Gesundheitsf?rderung

Background

Prevention and health promotion can improve the performance of the health care system. However, the numerous interventions in Germany show a lack of evidence base and inexplicit responsibilities.

Aims

On the basis of knowledge about quality assurance, effectiveness, and target groups, we deduce criteria for a rational prevention strategy. Obstacles to the implementation of a rational prevention strategy are described.

Results

Empirically proven health inequalities provide indications of outcome measures. Effectiveness of interventions should be analyzed and compared in a competitive context.

Conclusion

Concerning the institutional setting, we recommend a prevention trust which regulates planning, controlling, and financing of the interventions in terms of an evidence-based care plan.