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African Development Forum 2000 AIDS: The Greatest Leadership Challenge |
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Home > Documents
> Costs of Scaling HIV
Programme Activities to a National Level in Sub-Saharan Africa: Methods and
Estimates
PREVIOUS PAGE < CONTENTS > NEXT PAGE III. HIV/AIDS INTERVENTIONSWhile most developing countries have some elements of a comprehensive HIV/AIDS programme, very few have all the components actually in place. Most programmes are typically run on a small scale, consisting of isolated pilot studies, and are generally focused mainly on the health aspects of the epidemic. As a result, these programmes do not have the critical size necessary to have an impact on the course of the HIV/AIDS epidemic. What is a needed is a comprehensive HIV/AIDS programme that covers a wide range of sectors and activities. There is little disagreement about what works to slow the HIV/AIDS epidemic. Sufficient evidence has been accumulated over the last 15 years to identify the components of a comprehensive, multi-sectoral, HIV/AIDS programme.2 The most common interventions that are used in HIV/AIDS prevention and basic care activities are described in the following paragraphs. However, they are not an exhaustive list of all prevention activities that may be undertaken. For example, enabling interventions such as legal changes to safeguard the rights of those affected by HIV/AIDS and the provision of income-generation schemes to reduce the vulnerability of key groups are also not mentioned below. All these elements were left out of the analysis, not because they are unimportant but simply because there is little information on their costs. What are described below are therefore the activities for which information on cost could be obtained. This chapter provides a brief description of the different prevention and care-related activities3. A full description of the average costs that have been used for the model is found in chapter 4 and annex 2. A. HIV prevention activitiesThe following set of HIV prevention activities were considered:
Youth interventionsThere are two main ways in which HIV prevention strategies aim to reach youth: HIV/AIDS school education programmes for youth in schools, and education activities for youth that are not enroled in school. HIV/AIDS school education programmes are most commonly implemented in the government sector, often through additions to the school curriculum. Such projects are often implemented or coordinated by teachers and other school staff. In some settings, a range of services may be provided such as condom provision and STD treatment. Activities within class time may also be complemented by out-of-school and peer-education activities. The average or unit costs in the model correspond to a simple programme with teacher training and provision of basic material for a low-cost scenario; and development of training materials, establishment of a school curriculum and teacher training for the medium-cost scenario. We have assumed that out-of-school youth are reached by peer-education activities, due to the data that were available. Interventions focused on sex workers and their clientsIn general, the main objectives of a peer-education project focusing on commercial sex workers (CSWs) and their clients are to educate CSWs and clients about risks, STD recognition, and condom use. Educational activities may be implemented in locations such as bars, social centres, residences, STD clinics, brothels and truck stops. They may be conducted on a one-to-one basis or organized as group sessions. Peer educators may engage in formal (e.g. educational sessions arranged beforehand) and informal activities (such as discussing HIV/STD transmission with colleagues). IEC (information, education and counseling) materials may or may not be used. Where used, they may range from simple pamphlets, comics and posters, to promotional materials such as T-shirts and bags, to specially produced videos and films. Condoms may be distributed freely or sold as part of cost recovery or a commercial enterprise. Peer CSWs may be volunteers, or salaried staff. Often such interventions are delivered by NGOs. The unit costs correspond to those of NGO peer-education project with formal and informal sessions, including both promotion of condoms and recognition and management of STDs. Strengthening public sector condom distributionPublic sector condom distribution occurs through various outlets such as health facilities and workplaces, depending on the nature of government programmes. They tend to be distributed freely or at a nominal fee through the public sector. Condom quality is often perceived to be low in some settings, and availability may be irregular. Access to such condoms may be limited to opening hours of clinics and other facilities distributing condoms. The average costs used for the estimate are taken from a national programme of public sector condom distribution with free distribution through public channels. Condom social marketingCondom social marketing (CSM) was initially undertaken to market contraceptives socially. More recently, it has been developed as a strategy for HIV/AIDS prevention. The main objective of CSM projects is to increase the availability and use of quality, low-cost condoms and hence, to contribute to preventing the transmission of HIV infection. The aim is also to disseminate messages concerning HIV/AIDS prevention, safe sexual behavior and correct condom use. The unit costs in the model are taken from an analysis of existing CSM costs from an international NGO operating in numerous SSA countries. Strengthening STD treatment servicesSTDs play an important role in facilitating the transmission of HIV infection. Interventions that aim to strengthen STD treatment services can have a substantial impact on HIV transmission (Grosskurth et al 1997). We have included interventions related to STD treatment under prevention, as this is an important intervention to avert HIV infections among those who are HIV negative, as well as treating HIV-positive patients, who have both HIV and STDs. Interventions to strengthen existing STD treatment services often aim to improve the accessibility and effectiveness of existing public and private sector services. The form of project implemented may differ widely among settings. The simplest may focus upon improving basic diagnostics and providing drug prescriptions. Others may include activities such as strengthening the drug supply, counseling, partner notification and condom distribution. The way in which a project is implemented will also be influenced by the way that existing STD treatment services relate to other parts of the health sector. STD services may be established 'horizontally', with services integrated with primary health care services for the general population and with STD patients being seen in general outpatient clinics. Alternatively, they may be established 'vertically', remaining separate from other primary health care services, and with patients being seen in specially designated STD clinics. To improve women's access to STD treatment services, screening and treatment services may also be integrated into other health services commonly used by women - including ante-natal and other reproductive health services. Estimates of costs in the model are based on syndromic management of STD cases and syphilis screening for asymptomatic and symptomatic STDs among antenatal populations. The cost data were taken from interventions to strengthen syndromic management of STDs in the context of existing public sector infrastructure. Voluntary counseling and testing (VCT)A service providing voluntary counseling and testing (VCT) involves pre-test counseling, post-test counseling, and the test itself. Necessary support activities include training of staff and development and distribution of IEC materials. Counseling should be part of any service that involves testing for HIV. The nature of the services provided by VCT may be quite diverse, it may be provided as a free-standing project, or may be integrated in other services (e.g. ante-natal clinics, STD clinics, drug treatment centres, HIV support groups, blood transfusion services). Unit cost data were taken from a range of interventions: the low-cost scenario consists of adding VCT to a hospital; and the medium-cost scenario provides for running a VCT in a free-standing clinic. Workplace interventionsWorkplace interventions may have many aims, including addressing fears and misconceptions about HIV/AIDS, preventing discrimination against people with HIV, promoting safer sexual behavior, and providing condoms and STD treatment services. Commonly education, condom provision and information about STDs may be provided by peer educators recruited from within the workplace. STD treatment services are often integrated into existing health services. However, the extent to which different activities are implemented may differ substantially between employers - depending for example, upon the commitment of the employer, the size of the company and whether the employer already provides health services. Workplace interventions are critical in reaching people whose occupations have been found to have a high risk of HIV transmission such as mining, truckers and the military. The average cost data used in the model are taken from a peer-education intervention within a workplace, including costs for syndromic treatment of STDs and distribution of condoms. Strengthening blood transfusion servicesIt is estimated that between 5% and 10% of HIV infections worldwide are transmitted through the transfusion of infected blood and blood products (WHO 2000b), and great importance is generally placed on the provision of safe blood. In general, this is achieved by testing all blood donations for HIV antibodies before transfusion, and discarding donations that test HIV positive. The main activities undertaken by a blood transfusion service are donor recruitment and selection; collection of blood; screening for a range of diseases; blood processing, storage and distribution; transfusion of blood products; and support activities, such as management, administration and staff training. Interventions to strengthen blood transfusion services may not only focus upon the efficient screening of blood products, but may also include activities to ensure the collection of blood from `low risk' donor populations, ensure a regular supply of blood products, and a reduction in unnecessary blood transfusions. The unit cost of this activity is very reliant on the prevalence of HIV in the donor population. Due to limited information on HIV prevalence among the donor population, this was not factored into the model. The unit cost data are taken from high prevalence settings with national-based blood transfusion systems, where measures have been taken to collect blood from low-risk populations (e.g. adolescents). In such settings, this tends to result in a higher collection cost, but achieve a lower prevalence of HIV in blood collected (so resulting in less blood being discarded). Prevention of mother-to-child-hiv transmission (MTCT)Implementation of this intervention entails counseling and HIV testing of pregnant women, and the delivery of treatment regimen to women testing HIV positive and requesting ARV treatment. Costs are very sensitive to drug prices and the specific regimen being taken. The scenario for administration of these ARV interventions is that women will deliver in facilities and be attended by trained birth attendants, such as midwives. We thus have unit costs for the ARV drug regimen and have also extrapolated for the costs of training staff to provide ARV regimens within health facilities. Interventions may also offer formula milk or replacement-feeding strategies for HIV-positive mothers. The costs of providing a six-months supply of formula milk were included. Mass mediaA mass media strategy entails the development of IEC (information, education and communication) materials and their dissemination to the general population through a variety of media channels. The strategy can be implemented through one or a series of individual campaigns, with varying degrees of sophistication (including the level of pre-testing, method of dissemination and frequency of play). The messages incorporated into such campaigns may vary widely. Costs were based on relatively simple national campaigns in Gabon and Cameroon using a variety of media channels. B. Basic care activitiesGiven the increasing rates of HIV prevalence, the number of people living with HIV/AIDS (PLHA) requiring care throughout their illnesses is substantially increasing. This is complicated by the fact that many do not know their HIV status or are diagnosed relatively close to their death. Thus, much of the care given to PLHA may be based on the treatment of symptoms associated with HIV/AIDS. WHO (1990) provides a clinical staging system to describe the natural history of the HIV infection and AIDS disease. The four stages are:
There is very little information about the rate of disease progression between stages from African countries (Grant et al, 1997; Gilks et al, 1998), due to the limited number of natural history studies in a SSA setting. Even in industrialized countries, disease progression varies. The individual and length of survival with HIV can range from as little as two years to more than 10-15 years. Opportunistic infections (OI) mark the progression of HIV/AIDS and the onset of clinical AIDS. In low-income countries tuberculosis (TB) is the most common OI, occurring in 40-60% of the HIV-infected (World Bank, 1997a). Other common OI in developing countries include bacterial pneumonia, chronic diarrhea, and fungal infections such as cryptoccous. Due to both higher exposure to OI and poor/inadequate health care, in areas where resources are scarce, many people with HIV die early on before full-blown AIDS has developed. Among upper income groups in developing countries, OI similar to those in industrialized countries are also found. Thus, in resource-poor contexts, survival is likely to be shorter. The average length of survival after being infected with HIV may be six to seven years in SSA (Gilks et al, 1998). In a review of African natural history studies, Grant et al (1997) found that the reported median time to AIDS (stage 4) from HIV ranged from 2 to 7.5 years. Shorter times were reported for those with HIV-1 relative to HIV-2. This is much lower than industrialized countries, where, in the absence of treatment, the median time to progression to AIDS is about 10 years. Among symptomatic populations recruited at health facilities (who may be older and sicker), median times to death after a diagnosis of AIDS were very short (2-6 months for HIV-1 and 5-8 months for HIV-2). Again, this is much shorter than the 12-18 months found in industrialized countries. Information about the rate of progression from asymptotic to symptomatic is also limited. Based on seroprevalence, one study suggests that there is a 3-4 year period of being asymptomatic, and then 2 years of being symptomatic (stage 2 and stage 3) before the onset of AIDS for HIV-1 in Uganda (Grant et al, 1997). However, these studies may be biased in terms of length of life and the progression of the disease, as it is unknown when most of the individuals actually became infected. Current monitoring of a cohort of the general population in Uganda has found that eight years into the study only 40% of the people who are HIV positive had developed AIDS, with death occurring 9 to 10 months later (Cohen, 2000). While a more complex approach to modeling care requirements would actually model the progression of disease from stage to stage (e.g. a Markov model), as we are using a prevalence-based approach to the definition of the PTG, we will use a simpler approach. For the purposes of this report, we make three distinctions:
We assume that on average, people live 9 years after becoming infected and that people living with HIV/AIDS (PLHA) are symptomatic for 3 years, and that the onset of AIDS occurs one year before death. The following basic care activities were considered:
Palliative carePalliative care can range from a "total approach to care and support for people who have terminal conditions and are nearing death, or it can be limited to the "relief of pain symptoms such as headache, pain, diarrhea and shortness of breath"(World Bank, 1997a). In this study, we adopt the narrower definition of palliative care. Many of the early infections and many symptoms of HIV-positive patients can be managed adequately, and much relief and comfort can be provided with inexpensive essential drugs that are generally planned to be available through the primary health care system in Africa (Foster, 1991). The costs for palliative care therefore reflect the cost of drugs and treatment of the most common symptoms associated with HIV (fever, cough, diarrhea, skin rashes, headaches, nausea). Clinical management of opportunistic illnessesPeople with HIV infection are vulnerable to infections or other illnesses which take advantage of the opportunity of a weakened immune system. TB is the leading HIV-associated opportunistic disease in developing countries and has been found to cause 30-40% of deaths of HIV-infected people. Effective intervention against OI requires not only the appropriate drug and other medications for a given condition, but also the infrastructure necessary to diagnose the condition, monitor the intervention and counsel the patients (UNAIDS, 1998). Cost estimates reflect the cost of drugs and of the medical care of common symptoms associated with HIV in Africa (such as tuberculosis, oral thrush, and pneumonia/septicemia). They relate to inpatient care and outpatient care. The ability to scale-up clinical management is heavily reliant on existing capacity constraints. These capacity limits may already be reached, given current evidence that 50%-70% of beds in some SSA countries are being used to treat HIV-related illnesses (World Bank, 1997a). As a result, these constraints will limit the scaling-up of clinical management that can be achieved when the HIV prevalence rate is between 15-25%. Prophylaxis for the prevention of opportunistic illnessesInterventions that prevent the occurrence of opportunistic diseases can result in significant gains in life expectancy and the quality of life among people living with HIV. The reason is that HIV-infected people are more susceptible to acquiring TB and recent studies have shown that active TB can cause progression of HIV disease. HIV-infected patients with TB have a shorter survival and a higher tendency to acquire new OI than HIV-infected patients who do not (Bell et al, 1999). TB prophylaxis has been shown to increase the survival of HIV-infected persons at risk of TB (O'Brien and Perriens, 1995). Two interventions have been recommended for wide-spread implementation in SSA: preventive therapy for tuberculosis with isoniazid (INH) and provision of cotrimoxazole. Isoniazid preventive therapy (PT) is recommended as a health-preserving measure for HIV-infected persons at risk of TB (such as those with a positive TB skin test or who are living in areas of endemic TB) (WHO, 1998). Cotrimoxazole (containing antibiotic and sulfa drugs) has also been recommended for use in HIV-symptomatic persons as part of a minimum package of care (UNAIDS 2000b). Common HIV-related infections in SSA that can be prevented by cotrimoxazole (CMX) include bacterial pneumonias and diarrhoeal diseases. While recommended, the feasibility of widespread implementation of prophylaxis for OI remains to be assessed, given significant problems with adherence to a six-month regimen of drugs. This is also compounded by the fact that only a small proportion of people in SSA know their HIV-status. VCT is seen as an entry point for provision of prophylaxis, with individuals having the incentive to be tested, given the possibility of prophylaxis if found to be HIV positive (Kritski, 2000). Cost estimates for delivery of these prophylaxis correspond to activities in a free-standing VCT centre for low-income countries, and delivery of the regimen in outpatient hospital facilities in high-income countries. Home-based care for aids patientsHome-based care has been defined as `any form of care given to sick people in their own homes (Gilks et al, 1998)'. This can involve different groups - for example, people who are chronically sick at an early stage or at the terminal stage of the illness. The delivery of home-based care can be done through the community or through hospital-instituted schemes. The cost estimates come from interventions that tend to have a very low coverage among its target population (less than 10% of the eligible population in Zambia and Zimbabwe). This raises the important issue of what may be the potential of scaling- up these programmes, particularly since the ability of families to provide more care may be limited.4 Reflecting the limited development of hospices in developing countries, there have been no published cost estimates for hospice-based care. In addition, descriptions of the few hospice-type projects in developing countries suggest that they operate in a manner very similar to home-based care. Given this situation, no attempt was made to provide separate cost estimates for hospice care. Care for orphansOrphans (defined as those under 15 who have lost a mother or both parents to AIDS - UNAIDS, 2000) require assistance in a number of ways. Traditionally, the extended family has provided support to orphans. However, this is becoming more difficult given the large number of young adults who are dying (Drew et al, 1998). Estimates of orphan prevalence range from 4.5% of children in medium HIV prevalence areas to more than 12% of children in areas of high HIV prevalence, such as Rakai, Uganda (Foster et al, 1995). The care for orphans is now increasingly falling on adolescent or grand-parent-headed families, and one of the major hurdles facing these families is extreme poverty (Foster et al, 1996). Interventions supporting orphans may provide assistance in the form of adequate food, shelter and school fees through community-based approaches to different family structures (e.g. immediate family, extended family support to elderly/adolescent-headed households or fostering families). The strain of coping with AIDS by the extended family, may also mean that institutional orphanages may be a mode of meeting the basic living requirements of these children. Orphans themselves may be more likely to be HIV positive than non-orphans, especially among those aged less than 5 years (Kamali et al, 1996). The cost data consider both the possibility of orphanages for a small fraction of the orphans, supplemental care for orphans living with extended family in the community, and assistance with school expenses. Psycho-social support and counselingThis includes ongoing counseling for the infected individual, family and community (Gilks et al, 1998). Other forms of counseling associated with HIV testing are assumed to be provided by interventions such as VCT and MTCT interventions. The form of support may be organized in terms of peer-support groups for PLHA. There is no published data related to the costs of these activities, and average cost data has been based on the costs of counseling within the context of VCT. C. TreatmentPrior to 1987, treatment for HIV/AIDS patients consisted of treatment of OI illnesses. Since then the development of ARV drugs which attack the HIV virus itself have led to significant improvements of life expectancy for individuals who are taking the drugs. The ARV drugs are usually taken in combination. The ARV treatment is becoming progressively more complicated as the treatment strategies are rapidly changing (Colebunders et al, 1997). Triple combination therapy, known as Highly Active Anti-Retroviral Therapy (HAART) entails a combination of three different drugs based on an individual's disease progression and response, and has been highly successful. To ensure continuation of benefits, HAART has to be followed for the duration of an individual's life, otherwise relapses will occur. In addition to drugs, HAART requires a range of intensive monitoring (e.g. viral load, blood chemistry, and CD-4 counts) which takes place within a health facility. Often patients have side effects or adverse reactions that require additional clinical management. Barriers to the widespread implementation of ARV treatment in SSA include the price of the drugs, lack of technologies needed to monitor the ARV treatment, lack of trained staff with the knowledge to administer ARVs, and weak health facilities. The largest portion of the cost of HAART relates to the price of drugs themselves, which themselves have been changing rapidly. The average cost data used in the model relate the most recent data on prices as well as the costs of implementing the required technology for monitoring, training of health facility personnel, and strengthening of facilities. These costs are needed for implementing ARV treatment and for undertaking appropriate clinical management of the PTG. D. Institutional strengtheningNo substantial change in infrastructure was assumed. However, estimates are provided of the costs of institutional strengthening to implement scaled-up activities in the context of the existing levels of infrastructure (e.g. what organizational and human skills need to be strengthened in order to use the additional resources). Clearly, the actual cost of institutional strengthening is heavily dependent on the level of existing capacity, which varies substantially from country to country. However, these estimates provide a baseline marker for the level of resources needed to implement national level activities. Costs were therefore differentiated based on a classification of existing HIV/AIDS programme by four levels (very low, low, medium and strong). The classification of countries according to programme strength is shown in chapter 4 and unit cost estimates for institutional strengthening are presented in chapter v. 2 See: "Intensifying Action against HIV/AIDS in Africa: Responding to a Development Crisis". Africa Region, World Bank, 1999. 3 The description of the prevention activities has been adapted from "Costing Guidelines for HIV/AIDS Prevention Strategies." UNAIDS Best Practice Collection. Kumaranayake et al (2000). 4 A survey of care-givers in Zimbabwe showed that on average, they were already spending 2.5 hours per day on care and more when the disease was more advanced (Kerkhoven and Jackson, 1997). PREVIOUS PAGE < CONTENTS > NEXT PAGE
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