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Programme Activities to a National Level in Sub-Saharan Africa: Methods and
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II. SCALING-UP OF HIV/AIDS INTERVENTIONS:
WHAT DOES THIS MEAN?
A. Introduction
HIV/AIDS is now the largest
cause of mortality in SSA, accounting for 2.7 million deaths in 1999, more than double the
number of deaths from malaria and one and half times the number of deaths from
tuberculosis (WHO, 2000a). Globally, estimates suggest that at the end of 1999, some 34.3
million people were infected with HIV and 18.8 million people had already died. HIV/AIDS
is now the fourth cause of death in the world. In 1999 alone, there were 5.4 million new
infections. HIV infections are concentrated in the developing world and particularly in
Sub-Saharan Africa, where almost 71% of people with HIV live (UNAIDS, 2000a). The
prevalence in SSA is at epidemic levels, with 22 countries already having adult HIV
prevalence rates of 5% or more, seven countries having an adult prevalence over 15% and 15
countries having prevalence rates of more than 10% among pregnant women. Because of these
high prevalence levels, it is estimated that 10% of all new infections occur in infants,
through mother to child HIV transmission.
Experience from the first
fifteen years of the HIV epidemic has led to many forms of HIV prevention and care
activities being implemented by a range of organizations - including public sector,
private sector and non-governmental organizations (NGOs). Prevention strategies include
different methods to promote behavioral change and condom use (such as peer-education
activities with different sub-groups, mass media campaigns and in-school education);
distribution of male and female condoms (including through social marketing, public sector
distribution and community-based distribution); strengthening of sexually transmitted
disease treatment services; and initiatives to ensure a safe blood supply. There have also
been a number of important recent developments, including short course treatments to
prevent mother-to-child HIV transmission. Care initiatives aim to provide basic care and
support to those living with and affected by HIV/AIDS. These include activities to help
the health sector cope with the increased workload resulting from HIV/AIDS morbidity;
home-based care projects; and initiatives to support community based care and orphan
support. In addition, there have been substantial advancements in the effectiveness of
antiretroviral (ARV) treatment for people infected with HIV. However, the high price of
the drugs and the logistical requirements for delivery of the treatment regimens continue
to pose a significant barrier to wide-spread implementation in SSA.
While there are strong HIV/AIDS
interventions across Africa, few are implemented at a national scale. Likewise, many
people with HIV/AIDS do not have access to even basic drugs, which could dramatically
reduce the burden of a range of common, treatable opportunistic infections. Yet the
experiences of countries such as Uganda and Senegal, which have been successful in
mitigating the epidemic, suggest the importance of a national and coordinated response.
Thus, a key priority in addressing the HIV/AIDS crisis in SSA is rapid expansion of
activities. To do this, a key question is how much would it cost to scale-up different HIV
prevention and care strategies in Sub-Saharan Africa?
B. What
is Scaling up? Definitions and Modeling Approach
This study develops and
discusses a model designed to estimate the costs of scaling-up HIV/AIDS interventions.
Scaling-up refers to increasing the level of coverage of HIV activities from current
levels as well as expanding the type of HIV/AIDS programmes.
Currently, there is very little
information available on the relative cost and likely impact of each programme in
different settings, either individually or in combination. When estimating the costs of
scaling-up activities, there are two challenges: first, to obtain any available costs for
these strategies from the empirical literature and second, to scale-up these costs for
national programmes. Due to the low national coverage of many programmes, even when cost
information is available, it is generally obtained at the individual facility or project
level, operating on a small-scale (e.g. community or district). For this reason, we adopt
a model-based approach (Resource Determination Model) to estimate the required scale of
the programmes and the likely costs for implementing these strategies.1 The Resource Determination Model (RDM) entails the
following steps:
1. Establishing the number of
those who are at risk or in need and will benefit from different HIV/AIDS programmes.
Available demographic, behavioral and epidemiological data are used to determine the size
of the relevant target or population groups which the programmes are designed to reach.
2. Defining the Potential Target
Group and current and future levels of coverage. For most of the programmes, existing
levels of capacity and infrastructure of the health systems will limit the proportion of
the target groups that are currently reached. These limits are reflected in the number of
people that can be currently reached by the programmes. This group is referred to as the
potential target group (PTG). The model incorporates measures of coverage of the PTG for
the base year (2000) and the year 2005. These target levels of coverage reflect what is
thought to be realistically achievable by 2005, given the current low levels of coverage
for many HIV/AIDS-related activities in SSA. Using the PTG and coverage levels, the model
then estimates the increased volume of activity that is required for each intervention in
order to reach the year 2005 coverage targets.
3. Estimation of costs. The
model takes facility or project-level cost data from the published and grey literature to
obtain baseline average costs for the delivery of each health programme (including costs
of personnel, commodities, and capital items). The costs of scaling up interventions are
then estimated based on the current and projected (2005) target levels of coverage. Since
the model estimates costs that are associated with different levels of coverage of PTG,
these cost estimates should always be judged in relation to the PTG, as they depend on the
level of coverage that have been projected to be achieved.
Thus, the extent of scaling-up
activities is achieved by determining the feasible coverage of HIV/AIDS interventions for
each potential target group. The general model that was adopted for scaling-up activities
and estimating their costs is summarized in figure 3.1. The model uses epidemiological,
behavioral, socio-economic, health system and intervention-specific data inputs to
estimate the PTG for each country. The model yields estimates of the costs of scaling-up
prevention and care programmes for some 37 Sub-Saharan African countries. The resulting
cost estimates provide an annual cost of implementing a scaled-up HIV/AIDS programme based
on the overall coverage of the target groups that could be attained by 2005.
However, it is important to note
that some elements of a comprehensive national HIV/AIDS programme such as legal
interventions have not been included in this study. In addition, we have focused upon
estimating the costs of scaling up HIV prevention and care initiatives, given existing
levels of infrastructure and capacity. Without more substantial structural change, such
factors will inevitably affect the overall coverage that can be achieved.
Figure 2.1: Resource
Determination Model
C.
Outline of report
The various components of a
comprehensive HIV/AIDS programme are described in chapter 3. Chapter 4 outlines the
potential target group approach that was followed in order to estimate the cost of
scaling-up HIV/AIDS programmes in Sub-Saharan Africa. The costs of scaling-up HIV/AIDS
programmes are the subject of chapter 5. The essential concept of the potential target
groups (PTG) is discussed in Annex 1. Annex 2 summarizes the source of the unit cost data.
1 As discussed in Kumaranayake and Watts (2000a).
"Scaling up Priority Health Programmemes: A Problem of Constrained
Optimisation."
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