Costs of Scaling HIV Programme Activities to a National Level in Sub-Saharan Africa: Methods and Estimates

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Annex 1 (continued)

Table A.1. Data Input Parameters and Data Sources for RDM

A. HIV-prevention interventions and PTG

1. Youth interventions

The model estimates the cost of providing HIV-prevention education to urban and rural youth, in- and out-of-school.¹¹ There are two PTG: all youth enroled in primary and secondary schools; and all youth who are out-of-school between 6 and 16 years of age. Tertiary education is excluded. Coverage assumptions relate to the proportion of the required number of primary and secondary teachers that need to be trained, and the proportion of out-of-school youth aged 6-11 and 12-16 who are reached.

Country-specific data are used to estimate the size of the male and female primary and secondary school age populations who are in and out-of-school. Due to low school enrolment rates in many countries, the overall number of out-of-school youth is quite large. It is assumed that in-school education is provided by teachers, with the potential number of teachers needing to be trained being estimated using inputs describing the teacher-student ratios in primary and secondary schools, and the proportion of teachers required to be trained.¹² Out-of-school education is assumed to be provided by peer educators.

2 . Interventions focused on sex workers and their clients

A key objective of these interventions is generally to promote condom use among sex workers and their clients, and the early treatment of STDs. The PTG is all sex workers in urban areas. Coverage assumptions relate to the proportion of commercial sex workers reached, and the average consistency of condom use achieved by them.

Demographic information is used to estimate the size of the urban female population aged 15-49 in the year 2000. We assume that 4% of urban women sell sex, based on estimates from Zimbabwe and Cameroon (Watts, 1999 and Mangtani, 1996). The average number of condoms per year required by a sex worker was estimated on the basis of the average number of sex acts per woman per year. This is fixed at a value of 200 in the model.¹³ It was assumed that 5% of the condoms used are female condoms for the analysis. We recognize that focusing solely on urban commercial sex work excludes some other settings where commercial sex work is often common (such as around military bases, and on major trucking routes). More detail was not included as country-specific information on commercial sex outside urban areas was not found.¹⁴ For this reason, we have used a relatively high estimate of the percentage of urban women selling sex.

4. Strengthening public sector condom distribution

In many countries, the overall per-capita number of condoms distributed is low (UNAIDS, 1997). In the model, the number of condoms required for strengthened systems of condom distribution (either through the public or private sector) is the number required to provide protection in all causal sex acts and 2% of sex acts within regular partnerships. This gives a low estimate of the number of condoms required, as ideally for HIV-prevention, higher levels of condom use should be promoted. However, the 2% value is based on the estimated levels of condom use in regular partnerships documented in Demographic and Health Surveys, and it reflects the practical difficulties associated with achieving high levels of condom use in regular partnerships.

The number of people aged 15 - 49 in regular and/or casual partnerships was estimated by assuming that 80% of men aged 15 - 49 are in regular partnerships.¹⁵ The average proportion of men aged 15 - 49 having casual partnerships was derived from country data (based upon UNAIDS 1998b). Where such data were not available, we used the mean of the values provided by UNAIDS for sub-Saharan Africa. Estimates of the overall number of condoms required are obtained by assuming that, on average, men and women have 100 sex acts per year in regular partnerships (as is often used in family planning literature), and 25 sex acts per year in casual partnerships.

In estimating the total number of condoms that need to be supplied, 10% of condom wastage (either during storage or distribution) was included. This figure is derived from analysis in Zambia (Goodman and Watts, 1995). The model assumes that only male condoms are being distributed by the public sector. Coverage assumptions describe the proportion of the total number of condoms required that are provided by the public sector.

5. Condom social marketing

The PTG for condom social marketing (CSM) is the same as for strengthening public sector condom distribution¹⁶. Coverage assumptions are related to the proportion of the overall condoms provided by CSM. The model includes the increased provision of the female condom through CSM channels, and the proportion of female condoms is set at 10%.

6. Strengthening STD treatment services

The PTG for the strengthened STD treatment are treatable, symptomatic STD episodes among men and non-pregnant women who have access to health services; and pregnant women with syphilis, who have access to ante-natal health services. Coverage assumptions relate to the proportion of treatable symptomatic STDs among men and women with access to health services¹⁷, that are treated in clinics (in urban and rural locations), and the proportion of syphilis cases among women attending ante-natal services that are identified and treated.

Country-specific estimates of the annual incidence of treatable STDs episodes for males and females in urban and rural locations were obtained from Gerbase (personal communication).¹⁸ Only passive case detection and syndromic management are assumed for STD episodes among men and non-pregnant women. But, it was assumed that pregnant women having access to antenatal services would be screened and treated. A fixed proportion of these STDs was assumed to be symptomatic (60% for males and 40% for females). The proportion of the treatable STD episodes that could potentially be treated was estimated from the levels of urban and rural access to health services, and the proportion of urban and rural women attending ante-natal services. To estimate the number of syphilis infections occurring in antenatal populations (also taken from Gerbase et al 1999), the antenatal syphilis prevalence rates were applied to the total number of ANC attendees per year.

7. Voluntary counseling and testing (VCT)

The PTG consists of the proportion of adults aged 15-49 who are sexually active (taken as 90% for the analysis). Since VCT is also provided within the context of MTCT interventions, the size of the PTG for VCT also includes those that could potentially be tested when attending ANC services. To avoid double-counting, this group is ascribed to MTCT costs, and not included in the VCT cost calculations. However, the coverage assumptions are for the proportion of sexually active adults receiving VCT services in urban and rural locations (including through MTCT services).

8. Workplace interventions

The PTG is obtained by: a) estimating the number of condoms required by men and women in the urban and rural formal sector; and b) estimating the total number of treatable STD episodes among people employed in the formal sector, and who have access to workplace STD treatment services. Coverage inputs describe the proportion of people in formal sector employment who have access to workplace HIV/AIDs prevention (and condom promotion) activities; and the proportion of formal sector employees whose employers provide STD treatment services¹⁹.

The methodology consists of estimating the labour force aged 15 - 49 and the proportions of the formal sector workforce in agriculture, industry and services²⁰. These data are then used to estimate the condoms that are required by people in the formal sector, and the overall burden of treatable symptomatic STD episodes that could potentially be treated through workplace interventions.

9. Strengthening blood transfusion services

Interventions to strengthen blood transfusion services aim to reduce the estimated 5-10% of HIV infections in developing countries that are transmitted through the provision of infected blood products. The PTG is all blood used for transfusion. Estimates of the annual volume of safe blood required are based on the assumption that 2.2 units of blood would be required per 1,000 people (Barraclough et al, 2000). Coverage assumptions relate to the proportion of all blood used in transfusion that has been HIV tested in urban and rural areas.

10. Prevention of mother-to-child-HIV transmission (MTCT)

Recent trials have demonstrated the efficacy of the provision of oral ARV treatments to avert mother-to-child HIV transmission. In most countries, the delivery of the short course takes place in a tertiary-level health facility. Because it is necessary to provide the drugs at health facilities, the PTG for HIV counseling and testing are women with access to antenatal care. Country-specific inputs describing the HIV prevalence among the urban and rural antenatal populations are used to estimate the proportion testing positive, receiving the treatment regimen, and taking infant formula milk. For the calculations the proportion of HIV-positive mothers accepting treatment and taking infant formula milk are fixed at 90% and 50% respectively (Pazvakavambwa, 1999). The coverage inputs describe the proportion of pregnant women delivering in health facilities that are HIV tested and offered an MTCT interventions in urban and rural locations.

11. Mass media

The potential target group for mass media activities is the population with access to different forms of media. However, we assume that the cost of a mass media campaign does not depend on the size of the PTG or the intervention coverage. Instead, the intensity of the intervention varies, and so the coverage estimate describes the annual number of campaigns.

B. Care and treatment interventions

The PTG for the different care activities considered is described in the paragraphs below. Country-specific estimates of the number of people living with HIV/AIDS (PLHA) are obtained by multiplying the average number of AIDS deaths in the 15-49 age group by three in order to obtain the number of people who are HIV-positive and symptomatic. Individuals are assumed to be symptomatic for three years before their death and the last year they are in stage 4 of the illness. This is likely to underestimate the current numbers who are HIV-infected in settings where the HIV prevalence has risen rapidly. For care related to health systems (palliative care, prevention and management of OI, and treatment), the modeling of the PTG follows a similar structure to the UNAIDS care model (UNAIDS Secretariat, 2000).

1. Palliative care

As we assume that people are symptomatic for three years (including the last year of life), the size of the PTG for palliative care is 3 times the number of adults who are have died from AIDS in 1999. This group is described as symptomatic PLHA. Coverage inputs describe the proportion of HIV-infected and symptomatic individuals with access to palliative care.

2. Clinical management of opportunistic illnesses

We assume that people who are symptomatic will require clinical management of opportunistic infections. The PTG for this group is symptomatic PLHA with access to health services. Coverage describes the proportion of symptomatic PLHA with access to health services, who have access to clinical management of opportunistic illnesses.

3. Prevention of OI.

This PTG is similar to those who require clinical management.

4. Care for children

We assume that: (a) one-third of children born to HIV-positive mothers in health facilities are HIV-infected (based on the findings of the Working Group on Mother-To-Infant Transmission of HIV (1995)); (b) their average life expectancy is six years following birth; and (c) they are symptomatic for three years. The size of the PTG for palliative care is then three times the number of AIDS deaths in children aged 0-15 in 1999, and clinical management is provided to the group who have access to formal health services. The coverage describes the proportion of symptomatic HIV-infected infants with access to health services who have access to palliative care.

5. Home-based care for AIDS patients

Home-based care is part of a continuum of comprehensive care including access to clinical management. Home-based care is assumed to be provided to people with HIV/AIDS in the last two years of life. Consequently, the size of the PTG is estimated as twice the number of AIDS deaths aged 15-49 in 1999.

6. Care for orphans

The PTG is the total number of surviving orphans aged 15 or less (UNAIDS Secretariat). Some 5% of orphans are assumed to reside in institutions.

7. Psycho-social support and counseling

These interventions encompass "psychosocial support, promoting positive living and helping individuals make informed decision on HIV testing, planning for the future and behavioural changes, and involving sexual partners in such decisions." The PTG is the same as for palliative care, PLHA who are symptomatic.

8. Treatment

This is the same PTG as for clinical management of OI.

C. Measuring access to health services

One way in which current capacity constraints are incorporated in the model is through their effects on access to health services. In order to measure this access a composite indicator was created based on the urban and rural access to health facilities, DOTs case detection rates, births attended by health personnel and % of children under 12 months who are immunized. This composite indicator is calculated as the mid-point of the range of these indicators. This approach is similar to the UNAIDS Care Model (UNAIDs Secretariat, 2000)

11 We assume the same level of enrolment between urban and rural populations. Due to the lack of detailed data for the age group 0-15, we assume that 1/3 are between 0-5, 1/3 between 6-11 and 1/3 are between 12-15. We also assume that ½ are male and ½ are female.

12 The steps in the estimation process were: (a) estimate the size of the urban and rural male and female populations aged 6-11 and 12-15 using demographic inputs; (b) estimate the total number in each of these age groups enroled in primary and secondary schools; (c) use the totals from (a) and (b) to estimate the number of youth not enroled in school; (d) estimate the number of teachers using pupil-teacher ratios. There were some countries where the primary and/or secondary school enrolment was listed at over 100% (because of older cohorts attending school). In these cases, we assumed that the enrolment was 100%. In reality, it is likely that in many settings, the proportion of 6 - 11s and 12 - 15s is less than 100%.

13 We did not find data on the average number of sex acts per sex worker per year (with clients). It was assumed that CSWs have 4 sex acts per week, for 50 weeks per year.

14 A detailed review of the literature to obtain country specific estimates was beyond the scope of this study.

15 Based upon data from Tanzania.

16 Because the target levels of distribution are low, there will not be substantial `double counting' between the different interventions (such as between public sector and CSM condom distribution).

17 Discussed in section C of the annex.

18 Summary statistics are presented in Gerbase et al (1999).

19 For the calculations, the proportion of condoms provided by workplace interventions was fixed at 60%. The proportion of male and female STD episodes that are treated was set at 80% and 60% respectively.

20 It is assumed that agricultural workers are based in rural areas, and that industry and service workers are based in urban areas. The proportion of male and female workers in urban and rural locations was estimated from country data on the male/female ratio in urban settings. The STD figures are derived from the methods discussed in section j

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