HIV This Week

Nakakeeto ON , Kumaranayake L. The global strategy to eliminate HIV infection in infants and young children: a seven-country assessment of costs and feasibility. AIDS. 2009 May;23(8):987-95.

The objective of this study was to model the feasibility and affordability of the 2001 United Nations General Assembly Special Session on AIDS (UNGASS) goals to reduce mother-to-child transmission of HIV (MTCT) by 50% by 2010 and achieve 80% coverage of interventions to reduce it among women presenting for antenatal care. The cost and human resource needs of prevention of MTCT (PMTCT) and paediatric treatment were modelled for 2007-2015 and compared with the AIDS budgets and available health workforce in Burkina Faso, Cameroon, Cote d’Ivoire, Malawi, Rwanda, United Republic of Tanzania, and Zambia. Interventions used were promotion of family planning to people living with HIV, HIV testing and counselling, antiretroviral treatment to prevent MTCT and for HIV-infected children, and cotrimoxazole prophylaxis for mothers with advanced HIV infection and HIV-exposed children. The cumulative cost from 2007 to 2015 of the intervention in the seven countries combined amounted to US$587 688 291, 86% for PMTCT and 14% for paediatric treatment. Three out of the seven countries - Rwanda, Zambia, and Burkina Faso (almost) - were predicted to have sufficient AIDS funding, but only one - Zambia - was predicted to have also sufficient human resources to scale up the interventions by 2010 and sustain them up to 2015. The cost-effectiveness would be less than US$1150 per infection prevented in fully scaled-up programmes. Scaling up PMTCT will require more funds than currently available in many countries, but human resources appear to be a greater bottleneck than funding. The authors suggest that human resource capacity be assessed when increased funds for PMTCT are requested.

Editors’ note: Although these projections do not include primary prevention of HIV transmission to women of childbearing age, they do include the cost of addressing unmet family planning need among women with HIV who are of reproductive age and living in union. The model also estimated funding requirements to prevent mother-to-child transmission with antiretroviral prophylaxis, treat mothers in need of antiretroviral treatment for 9 months after the birth during breastfeeding, and treat infected children for 2 years. Although commodities (drugs, diagnostics, and supply chain management) represent 81% of the funds required and human resources represent 14%, it is the lack of sufficient numbers of health workers to implement the programme that is a major impediment in 6 of these countries striving to achieve the UNGASS goals of a 50% reduction in the incidence of HIV infection in infants by 2010.

The HIV epidemic continues to be a major issue facing Botswana, with overall adult HIV prevalence estimated to be 25.7 percent in 2007. This paper estimates the cost and impact of the draft Ministry of Health male circumcision strategy using the Decision-Makers' Programme Planning Tool (DMPPT). Demographic data and HIV prevalence estimates from the recent National AIDS Coordinating Agency estimations are used as input to the DMPPT to estimate the impact of scaling-up male circumcision on the HIV epidemic. These data are supplemented by programmatic information from the draft Botswana National Strategy for Safe Male Circumcision, including information on unit cost and program goals. Alternative scenarios were developed in consultation with stakeholders. Results suggest that scaling-up adult and neonatal circumcision to reach 80% coverage by 2012 would result in averting almost 70,000 new HIV infections through 2025, at a total net cost of US$47 million across that same period. This results in an average cost per HIV infection averted of US$689. Changing the target year to 2015 and the scale-up pattern to a linear pattern results in a more evenly-distributed number of male circumcisions required, and averts approximately 60,000 new HIV infections through 2025. Other scenarios explored include the effect of risk compensation and the impact of increasing coverage of general prevention interventions. Scaling-up safe male circumcision has the potential to reduce the impact of HIV in Botswana significantly; program design elements such as feasible patterns of scale-up and inclusion of counselling are important in evaluating the overall success of the program.

Editors’ note: Policy development and programme planning processes for the scale-up of safe male circumcision services for heterosexual men in high HIV prevalence settings are enhanced by the use of this decision-makers’ programme planning tool developed by the Futures Institute in collaboration with UNAIDS. Both Botswana and Namibia have used the tool and several other countries have already or are currently conducting the costing studies that provide key inputs to determine future costs and the impact of male circumcision service scale-up on their HIV epidemics.