HIV This Week

H W Reynolds, B Janowitz, R Wilcher, W Cates. Contraception to prevent HIV-positive births: current contribution and potential cost savings in PEPFAR countries. Sex. Transm. Inf. 2008;84;ii49-ii53

Reynolds et al aimed to estimate the number of HIV-positive births currently prevented by contraceptive use in the President’s Emergency Plan for AIDS Relief (PEPFAR) focus countries and to estimate the first year cost savings to each country if unintended and unwanted HIV-positive births were prevented via contraceptive use rather than providing antiretroviral prophylaxis for HIV-positive pregnant women (prevention of mother-to-child transmission services). Data from publicly available sources yielded estimates of (1) contraceptive and HIV prevalence; (2) the number of women of reproductive age; (3) the number of annual births to HIV-infected women; (4) the rates of pregnancy and vertical HIV transmission; (5) the proportions of unintended and unwanted births; and (6) the cost per HIV-positive birth averted by family planning and prevention of mother-to-child transmission services. The number of HIV-positive births currently averted by contraceptive use and the number of unwanted and unintended HIV-positive births are the product of these estimates. Cost savings are the difference in the costs of family planning and prevention of mother-to-child transmission services. The study found that the annual number of unintended HIV-positive births currently averted by contraceptive use ranges from 178 in Guyana to over 120,000 in South Africa. The minimum annual cost savings to prevent just the unwanted HIV-positive births ranges from $26,000 in Vietnam to over $2.2 million in South Africa. The authors concluded that contraception is already having an important effect on reducing the number of infant HIV infections. This contribution could be strengthened by additional efforts to provide contraception to HIV-infected women who do not wish to become pregnant. Moreover, the effect of contraception can be achieved at a cost savings compared with prevention of mother-to-child transmission services.

Editors’ note: Despite low contraceptive prevalence rates, contraception is already preventing many unintended HIV-positive births. Contraception helps women with HIV delay pregnancy until they are emotionally and physically ready and can access appropriate antenatal and safe delivery care, as well as antiretroviral regimens. Important cost savings could be incurred if more women living with HIV were able to prevent mistimed or unwanted pregnancy in the first place rather than interrupting mother-to-child transmission through antiretroviral prophylaxis. Cost-effective compared with other approaches to prevent mother-to-child transmission, family planning really is the best-kept secret of HIV prevention.

Auvert B, Marseille E, Korenro§mp EL, Lloyd-Smith J, Sitta R, Taljaard D, Pretorius C, Williams B, Kahn JG. Estimating the resources needed and savings anticipated from roll-out of adult male circumcision in Sub-Saharan Africa. PLoS ONE. 2008;3(8):e2679.

Trials in Africa indicate that medical adult male circumcision reduces the risk of HIV by 60%. Medical adult male circumcision may avert 2 to 8 million HIV infections over 20 years in sub-Saharan Africa and cost less than treating those who would have been infected. This paper estimates the financial and human resources required to roll out medical adult male circumcision and the net savings due to reduced infections. Auvert and colleagues developed a model which included costing, demography, and HIV epidemiology and used it to investigate 14 countries in sub-Saharan Africa where the prevalence of male circumcision was lower than 80% and HIV prevalence among adults was higher than 5%, in addition to Uganda and the Nyanza province in Kenya. The authors assumed that the roll-out would take 5 years and lead to a male circumcision prevalence among adult males of 85%. They also assumed that surgery would be done as it was in the trials. They calculated public program cost, number of full-time circumcisers and net costs or savings when adjusting for averted HIV treatments. Costs were in USD, discounted to 2007. 95% percentile intervals (95% PI) were estimated by Monte Carlo simulations. In the first 5 years the number of circumcisers needed was 2 282 (95% PI: 2 018 to 2 959), or 0.24 (95% PI: 0.21 to 0.31) per 10,000 adults. In years 6-10, the number of circumcisers needed fell to 513 (95% PI: 452 to 664). The estimated 5-year cost of rolling out medical adult male circumcision in the public sector was $919 million (95% PI: 726 to 1 245). The cumulative net cost over the first 10 years was $672 million (95% PI: 437 to 1,021) and over 20 years there were net savings of $2.3 billion (95% PI: 1.4 to 3.4). The authors conclude that a rapid roll-out of medical adult male circumcision in sub-Saharan Africa requires substantial funding and a high number of circumcisers for the first five years. These investments are justified by medical adult male circumcision’s substantial health benefits and the savings accrued by averting future HIV infections. Lower ongoing costs and continued care savings suggest long-term sustainability.

Editors’ note: This modelling optimistically assumes that the proportion of men circumcised in these 15 countries plus Nyanza Province, Kenya will rise from a range of 0 to 70% (in 2007 the number of uncircumcised males aged 15 to 49 was 30.5 million) to 85% in five years. This would require very high demand for services as well as unprecedented capacity for well-trained, adequately equipped, health care personnel to meet that demand safely. Although relevant costs were contained in the modelling, the cost of HIV testing and counselling was not, with the authors stating that it ‘may not be required by many male circumcision programmes’. WHO/UNAIDS advise health professionals to recommend voluntary HIV testing to all individuals seeking male circumcision services. Asymptomatic HIV-positive men and healthy men of unknown serostatus who do not wish to be tested should not be refused circumcision unless there are medical contraindications. However, consistent with provider-initiated testing policies, men requesting circumcision should be given the opportunity to learn their HIV status.

Morin SF, Morfit S, Maiorana A, Aramrattana A, Goicochea P, Mutsambi JM, Robbins JL, Richards TA. Building community partnerships: case studies of Community Advisory Boards at research sites in Peru, Zimbabwe, and Thailand. Clin Trials. 2008;5(2):147-56.

Differences in resources, knowledge, and infrastructure between countries initiating and countries hosting HIV prevention research trials frequently yield ethical dilemmas. Community Advisory Boards have emerged as one strategy for establishing partnerships between researchers and host communities to promote community consultation in socially sensitive research. Morin and co-authors undertook to understand the evolution of Community Advisory Boards and community partnerships at international research sites conducting HIV prevention trials. Three research sites of the HIV Prevention Trials Network (HPTN) were selected to include geographical representation and diverse populations at risk for HIV exposure - Lima, Peru; Chitungwiza, Zimbabwe; and Chiang Mai, Thailand. Data collection included review of secondary data, including academic publications and site-specific progress reports; observations at the research sites; face-to-face interviews with Community Advisory Boards members, research staff, and other key informants; and focus groups with study participants. Rapid assessment techniques were used for data analysis. The authors found that two of the three Community Advisory Boards developed new strategies for community representation in response to new studies. All three Community Advisory Boards expanded their original function and became advocates for broader community interests beyond HIV prevention. The participation and input of community representatives, in response to critical incidents that occurred at the sites over the past five years, helped to solidify partnerships between researchers and communities. In terms of limitations the authors point out that Rapid Assessment is an exploratory methodology designed to provide an understanding of a situation based on the integration of multiple data sources, collected within a short period of time, without a formal examination of transcribed and coded data. Case studies, as a method, are meant to draw out what can be learned from a single case but are not, in the scientific sense, generalizable. They conclude that in developing countries, Community Advisory Boards can be dynamic entities that enhance the HIV research process, assist in responding to issues involving research ethics, and prepare communities for HIV research.

Editors´note: This assessment of changes in community advisory board conduct and roles over a five year period found that at each site a conflict or challenge arose in which the views and assistance of community advisory board members became not only valuable to the research team but also important for the future success of the research. These conflicts or challenges generated substantial interactions of mutual benefit as issues were debated which led to a more genuine partnership. Community advisory boards clearly can be dynamic entities striving to better represent and advocate for the communities.

Djomand G, Metch B, Zorrilla CD, Donastorg Y, Casapia M, Villafana T, Pape J, Figueroa P, Hansen M, Buchbinder S, Beyrer C; for the 903 Protocol Team. The HVTN Protocol 903 Vaccine Preparedness Study: Lessons Learned in Preparation for HIV Vaccine Efficacy Trials. J Acquir Immune Defic Syndr. 2008;48(1):82-9 2008

Successful recruitment and retention of HIV-uninfected at-risk participants are essential for HIV vaccine efficacy trials. A multicountry vaccine preparedness study was started in 2003 to assess enrolment and retention of HIV-negative high-risk participants, and to assess their willingness to participate in future vaccine efficacy trials. HIV-negative high-risk adults were recruited in the Caribbean, in Southern Africa, and in Latin America, and were followed for 1 year. Participants included men who have sex with men, heterosexual men and women, and female sex workers. History of sexually transmitted infections and sexual risk behaviours were recorded with HIV testing at 0, 6, and 12 months, and willingness to participate in future vaccine trials was recorded at 0 and 12 months. Recruitment, retention, and willingness to participate in future trials were excellent at 3 of the 6 sites, with consistent declines in risk behaviours across cohorts over time. Although not powered to measure seroincidence, HIV seroincidence rates per 100 person-years (95% confidence interval [CI]) were as follows: 2.3 (95% CI: 0.3 to 8.2) in Botswana, 0.5 (95% CI: 0 to 2.9) in the Dominican Republic, and 3.1 (95% CI: 1.1 to 6.8 ) in Peru. The HIV Vaccine Trials Network 903 study helped to develop clinical trial site capacity, with a focus on recruitment and retention of high-risk women in the Americas, and improved network and site expertise about large-scale HIV vaccine efficacy trials.

Editors´note: Finding populations with sufficient risk for HIV infection to support the seroincidence demands of trials is a start but they must also have high rates of retention for there to be adequate power to confirm or refute the study’s hypothesis. Even participating in a study to assess enrolment, retention, and HIV incidence can lead to declines in risk behaviour and HIV incidence, above those already happening in the overall general population. Such a positive effect of being studied is sometimes called the Hawthorne Effect.

Hughes S, L Cuffe R, Lieftucht A, Garrett Nichols W. Informing the selection of futility stopping thresholds: case study from a late-phase clinical trial. Pharm Stat. 2008 Mar 27 [Epub ahead of print]

In an environment where (i) potential risks to subjects participating in clinical studies need to be managed carefully, (ii) trial costs are increasing, and (iii) there are limited research resources available, it is necessary to prioritize research projects and sometimes re-prioritize if early indications suggest that a trial has low probability of success. Futility designs allow this reprioritization to take place. This paper reviews a number of possible futility methods available and presents a case study from a late-phase study of an HIV therapeutic, which utilized conditional power-based stopping thresholds. The two most challenging aspects of incorporating a futility interim analysis into a trial design are the selection of optimal stopping thresholds and the timing of the analysis, both of which require the balancing of various risks. The paper outlines a number of graphical aids that proved useful in explaining the statistical risks involved to the study team. Further, the paper outlines a decision analysis undertaken which combined expectations of drug performance with conditional power calculations in order to produce probabilities of different interim and final outcomes, and which ultimately led to the selection of the final stopping thresholds.

Editors´note: Early indications that a trial has low probability of success - with success defined as confirming or refuting the trial hypothesis - can lead to the stopping of a trial for futility. Although this saves resources, stopping a trial prior to its conclusion because its key endpoints will not be met makes it impossible to determine whether results for secondary endpoints would have generated useful hypotheses for future investigation. It is important to decide up front what the stopping rules will be with respect to all endpoints and understand the consequences and anticipate them.

Ryan M, Griffin S, Chitah B, Walker AS, Mulenga V, Kalolo D, Hawkins N, Merry C, Barry MG, Chintu C, Sculpher MJ, Gibb DM. The cost-effectiveness of cotrimoxazole prophylaxis in HIV-infected children in Zambia. AIDS. 2008;22(6):749-57.

Ryan and colleagues aimed to assess the cost-effectiveness of cotrimoxazole prophylaxis in HIV-infected children in Zambia, as implementation at the local health centre level has yet to be undertaken in many resource-limited countries despite recommendations in recent updated World Health Organization (WHO) guidelines. A probabilistic decision analytical model of HIV progression in children based on the CD4 cell percentage (CD4%) was populated with data from the placebo-controlled Children with HIV Antibiotic Prophylaxis trial that had reported a 43% reduction in mortality with cotrimoxazole prophylaxis in HIV-infected children aged 1-14 years. Unit costs (US$ in 2006) were measured at University Teaching Hospital, Lusaka. Cost-effectiveness, expressed as cost per life-year saved; cost per quality adjusted life-year saved; and cost per disability adjusted life-year averted, was calculated across a number of different scenarios at tertiary and primary healthcare centres. Cotrimoxazole prophylaxis was associated with incremental cost-effectiveness ratios of US$72 per life-year saved, US$94 per quality adjusted life-year saved, and US$53 per disability adjusted life-year averted, i.e. substantially less than a cost-effectiveness threshold of US$1019 per outcome (gross domestic product per capita, Zambia 2006). Incremental cost-effectiveness ratios of US$5 or less per outcome demonstrate that cotrimoxazole prophylaxis is even more cost-effective at the local healthcare level. The intervention remained cost-effective in all sensitivity analyses including routine haematological and CD4% monitoring, varying starting age, AIDS status, cotrimoxazole formulation, efficacy duration, and discount rates. Cotrimoxazole prophylaxis in HIV-infected children is an inexpensive low technology intervention that is highly cost-effective in Zambia, strongly supporting the adoption of WHO guidelines into essential healthcare packages in low-income countries.

Editors´note: Along with other factors, cost-effectiveness analyses can inform decision-making on competing priorities. In this case, highly cost-effective cotrimoxazole in children with HIV infection is life-saving, simple, well–tolerated and inexpensive. It is a key element of pre-antiretroviral treatment care and part of the HIV chronic care package. The gap between World Health Organisation guidance and actual practice at the country level in sub-Saharan Africa needs to close rapidly for all children with HIV infection.

Dandona L, Kumar SG, Ramesh YK, Rao MC, Marseille E, Kahn JG, Dandona R. BMC Health Serv Res. 2008;8:26. Outputs, cost and efficiency of public sector centres for prevention of mother to child transmission of HIV in Andhra Pradesh, India.

Prevention of mother to child transmission is an important part of the effort to control HIV. PMTCT services are mostly provided at public sector government hospitals in India. Systematic data on the cost and efficiency of providing prevention of mother-to-child transmission services in India are not available readily for further planning. Cost and output data were collected at 16 sampled prevention of mother to child transmission centres in the south Indian state of Andhra Pradesh using standardized methods. The services provided were analysed, and the relation of unit cost of services with scale was assessed. In the 2005-2006 fiscal year, 125,073 pregnant women received prevention of mother to child transmission services at the 16 centres (range 2,939 to 20,896, median 5,679). The overall HIV positive rate among those tested was 1.67%. Of the total economic cost, the major components were personnel (47.3%) and recurrent goods (31.7%). For the 16 prevention of mother-to-child transmission centres, the average economic cost per post-HIV-test counselled pregnant woman was Indian Rupees (INR) 98.9 (US$ 2.23), ranging 2.7-fold from INR 71.4 (US$ 1.61) to INR 189.9 (US$ 4.29). The economic cost per mother-neonate pair who received nevirapine had a higher variation, ranging 41-fold for the 16 centres from INR 4,354 (US$ 98 ) to INR 179,175 (US$ 4,047), average INR 10,210 (US$ 231), with very high unit cost at some centres where HIV prevalence among pregnant women and the total volume of services were both low. Scale had a significant inverse relation with both of the unit costs, per post-HIV-test counselled pregnant woman and per mother-neonate pair who received nevirapine. In addition, HIV prevalence among pregnant women had a significant inverse relation with unit cost per mother-neonate pair who received nevirapine. Although the variation between prevention of mother-to-child transmission centres for unit cost per post-HIV-test counselled pregnant woman was modest that per mother-neonate pair receiving nevirapine was over 40-fold. The extremely high unit cost for each mother-neonate pair receiving nevirapine at some centres suggests that the new approach of combining prevention of mother to child transmission services with voluntary counselling and testing services that has recently been started in India could potentially offer better efficiency.

Editors’ note: An inverse relationship between unit cost and scale makes common sense. The piece that is missing in the equation is how many pregnancies in these 16 prevention of mother-to-child transmission centres were unplanned and unwanted. Integrating these services with voluntary counselling and testing services makes more than economical sense if fertility counselling is offered to all men and women testing HIV-positive.

Msisha WM, Kapiga SH, Earls FJ, Subramanian SV. Place matters: multilevel investigation of HIV distribution in Tanzania. AIDS. 2008;22(6):741-8.

Msisha and colleagues aimed to examine the extent to which the regional and neighborhood distribution of HIV in Tanzania is caused by the differential distribution of individual correlates and risk factors, using nationally representative, cross-sectional data on 12,522 women and men aged 15-49 years from the 2003-2004 Tanzanian AIDS Indicator Survey. Three-level multilevel binary logistic regression models were specified to estimate the relative contribution of regions and neighborhoods to the variation in HIV seroprevalence. Spatial distribution of individual correlates (and risk factors) of HIV do not explain the neighborhood and regional variation in HIV seroprevalence. Neighborhoods and regions accounted for approximately 14 and 6% of the total variation in HIV. HIV prevalence ranged from 1.8% (Kigoma) to 6.7% (Iringa) even after adjusting for the compositional make-up of these regions. An inverse association was observed between log odds of being HIV positive and neighborhood poverty [odds ratio (OR) 0.24, 95% confidence interval (CI) 0.09-0.61] and regional poverty (OR 0.97, 95% CI 0.95-0.99). The study provides evidence for independent contextual variations in HIV, above and beyond that which can be ascribed to geographical variations in individual-level correlates and risk factors. The authors emphasize the need to adopt both a group-based and a place-based approach, as opposed to the dominant high-risk group approach, for understanding the epidemiology of HIV as well as for developing HIV intervention activities.

da Silva ZJ, Oliveira I, Andersen A, Dias F, Rodrigues A, Holmgren B, Andersson S, Aaby P. Changes in prevalence and incidence of HIV-1, HIV-2 and dual infections in urban areas of Bissau, Guinea-Bissau: is HIV-2 disappearing? AIDS. 2008;22(10):1195-202.

Da Silva and colleagues aimed to assess the changes in HIV prevalence and incidence between 1996 and 2006 in urban areas of Bissau, using a cross-sectional survey of 384 randomly selected houses within a community-based follow-up study of HIV-1 and HIV-2. A total of 3242 individuals aged at least 15 years were eligible for inclusion. Participants were interviewed about behavioural and socio-economic factors and had a blood sample drawn. A total of 2548 individuals were tested for antibodies to HIV-1 and HIV-2, of whom 649 had taken part in a similar survey in 1996. With 0.5% HIV dual reactions included, the overall HIV-1 prevalence was 4.6% (118 out of 2548 ) and the HIV-2 prevalence was 4.4% (112 out of 2548). The prevalence of HIV-1 increased more for women than men especially in the 25-34-year age group. HIV-2 prevalence decreased below 45 years of age but not for individuals more than 45 years old. The incidence rate between 1996 and 2006 was 0.5 per 100 person-years for HIV-1 and 0.24 per 100 person-years for HIV-2. Compared with a previous period from 1987 to 1996, the incidence of HIV-2 is declining whereas no significant increase in the incidence of HIV-1 was observed. The present study shows an increasing prevalence of HIV-1 and a decreasing prevalence of HIV-2 in Guinea-Bissau. HIV is generally a bigger problem for women. Despite the general decline in prevalence, HIV-2 may continue as an infection in older people, especially women.

Kyobutungi C, Ziraba AK, Ezeh A, Ye Y. The burden of disease profile of residents of Nairobi’s slums: Results from a Demographic Surveillance System. Popul Health Metr. 2008;6(1):1 [Epub ahead of print]

With increasing urbanization in sub-Saharan Africa and poor economic performance, the growth of slums is unavoidable. About 71% of urban residents in Kenya live in slums. Slums are characteristically unplanned, underserved by social services, and their residents are largely underemployed and poor. Recent research shows that the urban poor fare worse than their rural counterparts on most health indicators, yet much about the health of the urban poor remains unknown. This study aims to quantify the burden of mortality of the residents in two Nairobi slums, using a Burden of Disease approach and data generated from a Demographic Surveillance System. Data from the Nairobi Urban Health and Demographic Surveillance System collected between January 2003 and December 2005 were analysed. Core demographic events in the Nairobi Urban Health and Demographic Surveillance System including deaths are updated three times a year; cause of death is ascertained by verbal autopsy and cause of death is assigned according to the ICD 10 classification. Years of Life Lost due to premature mortality were calculated by multiplying deaths in each subcategory of sex, age group, and cause of death, by the Global Burden of Disease standard life expectancy at that age. The overall mortality burden per capita was 205 years of life lost /1,000 person years. Children under the age of five years had more than four times the mortality burden of the rest of the population, mostly due to pneumonia and diarrhoeal diseases. Among the population aged five years and above, HIV and tuberculosis accounted for about 50% of the mortality burden. Slum residents in Nairobi have a high mortality burden from preventable and treatable conditions. It is necessary to focus on these vulnerable populations since their health outcomes are comparable to or even worse than the health outcomes of rural dwellers who are often the focus of most interventions.

Hunter M. The changing political economy of sex in South Africa: the significance of unemployment and inequalities to the scale of the AIDS pandemic. Soc Sci Med. 2007;64(3):689-700.

Between 1990 and 2005, HIV prevalence rates in South Africa jumped from less than 1% to around 29%. Important scholarship has demonstrated how racialized structures entrenched by colonialism and apartheid set the scene for the rapid unfolding of the AIDS pandemic, like other causes of ill-health before it. Of particular relevance is the legacy of circular male-migration, an institution that for much of the 20th century helped to propel the transmission of sexually transmitted infections among black South Africans denied permanent urban residence. But while the deep-rooted antecedents of AIDS have been noted, less attention has been given to more recent changes in the political economy of sex, including those resulting from the post-apartheid government’s adoption of broadly neo-liberal policies. As an unintentional consequence, male migration and apartheid can be seen as almost inevitably resulting in AIDS, a view that can disconnect the pandemic from contemporary social and economic debates. Combining ethnographic, historical, and demographic approaches, and focusing on sexuality in the late apartheid and early post-apartheid periods, this article outlines three interlinked dynamics critical to understanding the scale of the AIDS pandemic: (1) rising unemployment and social inequalities that leave some groups, especially poor women, extremely vulnerable; (2) greatly reduced marital rates and the subsequent increase of one person households; and (3) rising levels of women’s migration, especially through circular movements between rural areas and informal settlements/urban areas. As a window into these changes, the article gives primary attention to the country’s burgeoning informal settlements–spaces in which HIV rates are reported to be twice the national average–and to connections between poverty and money/sex exchanges.

Editors´note: Political economy analyses help conceptualise HIV as a symptom of ‘structural violence’ with sex as a mode of transmission. Housing, employment, and social equality are clearly linked to HIV, both historically and contemporarily, and help explain the striking scale of the South African epidemic. This article, which suggests ways to reconfigure the response to AIDS around a more politically enabling agenda, makes for thought-provoking reading.

Kang M, Dunbar M, Laver S, Padian N. University of California Programme in Women’s Health, University of California-San Francisco, 50 Beale Street, San Francisco, CA 94105, USA. Maternal versus paternal orphans and HIV/STI risk among adolescent girls in Zimbabwe. AIDS Care. 2008;20(2):214-7.

The AIDS epidemic has contributed to a drastic increase in the number of orphans in Zimbabwe. Orphans (whether orphaned by AIDS or other causes) have been shown to have economic and educational disadvantages as well as poor reproductive health outcomes. Kang and colleagues recruited a convenience sample of 200 girls in a peri-urban area of Zimbabwe to examine the impact of orphan status (compared to non-orphans) on household composition, education, risk behaviour, pregnancy and prevalent HIV and HSV-2 infection. In the study population, maternal orphans were more likely to be in households headed by themselves or a sibling, to be sexually active, to have had a sexually transmitted infection, to have been pregnant and to be infected with HIV. Paternal orphans were more likely to have ever been homeless and to be out of school. The findings suggest that maternal care and support is important for HIV prevention. This finding corroborates previous research in Zimbabwe and has implications for intervention strategies among orphan girls.

Editors´note: Because of recruitment methodology, these results are not generalizable, however they do provide food for thought. Although paternal orphanhood had more of an impact on household financial stability and orphaned girls’ educational attainment, the loss of a mother affected behavioural risk and biological outcomes (HIV, HSV-2). Keeping mothers alive helps reduce sexual risk in adolescent girls. How would orphaned adolescent girls in Zimbabwe benefit from support and mentoring by women in their communities?

Bock J, Johnson. Grandmothers’ Productivity and the HIV/AIDS Pandemic in sub-Saharan Africa. J Cross Cult Gerontol. 2008 Jan 8.

The human immunodeficiency virus (HIV) pandemic has left large numbers of orphans in sub-Saharan Africa. Botswana has an HIV prevalence rate of approximately 40% in adults. Morbidity and mortality are high, and in a population of a 1.3 million there are nearly 50,000 children who have lost one or both parents to HIV. The extended family, particularly grandparents, absorbs much of the childrearing responsibilities. This creates large amounts of additional work for grandmothers especially. The embodied capital model and the grandmother hypothesis are both derived from life history theory within evolutionary ecology, and both predict that one important factor in the evolution of the human extended family structure is that post-reproductive individuals such as grandmothers provide substantial support to their grandchildren’s survival. Data collected in the pre-pandemic context in a traditional multi-ethnic community in the Okavango Delta of Botswana are analyzed to calculate the amount of work effort provided to a household by women of different ages. Results show that the contributions of older and younger women to the household in term of both productivity and childrearing are qualitatively and quantitatively different. These results indicate that it is unrealistic to expect older women to be able to compensate for the loss of younger women’s contributions to the household, and that interventions be specifically designed to support older women based on the type of activities in which they engage that affect child survival, growth, and development.

Editors’ note: This study found that grandmothers are unable to substitute their labour for that of younger women lost to the family because of the energy intensity (strength and stamina) required for grain-processing. Further, the more time they allocate to food production, the less time they have for seeking and processing traditional wild foods that provide high levels of micronutrients and phytochemicals. They also can no longer produce traditional craft items such as the baskets, fishing implements, and tools essential to the productivity of all members of the household. Critically, their grandchildren have no means to acquire the skills and knowledge about traditional activities from them that are key to their long-term survival. Interventions to compensate for lost labour should support grandmothers in pursuing their traditional roles and activities.

This paper estimates the impact of antiretroviral therapy on days harvesting tea per month for tea-estate workers in Kenya. Such information is needed to assess the potential economic benefits of providing treatment to working adults. Data for this analysis come from company payroll records for 59 HIV-infected workers and a comparison group of all workers assigned to the same work teams (reference group, n = 1992) for a period covering 2 years before and 1 year after initiating antiretroviral therapy. Mean difference tests were used to obtain overall trends in days harvesting tea by month. A difference in difference approach was used to estimate the impact of HIV on days working in the pre-antiretroviral therapy period. Information on likely trends in the absence of the therapy was used to estimate the positive impacts on days harvesting tea over the initial 12 months on antiretroviral therapy. No significant difference existed in days plucking tea each month until the ninth month before initiating antiretroviral therapy, when workers worked -2.79 fewer days than references (15% less). This difference grew to 5.09 fewer days (27% less) in the final month before initiating antiretroviral therapy. After 12 months on antiretroviral therapy, Larson and colleagues conservatively estimate that workers worked at least twice as many days in the month than they would have in the absence of antiretroviral therapy. In conclusion treatment had a large, positive impact on the ability of workers to undertake their primary work activity, harvesting tea, in the first year on antiretroviral therapy.

Editors’ note: This study found that tea pluckers placed on antiretroviral treatment worked 7.5 to 9.5 days more harvesting tea in month 12 than they would have worked in the absence of antiretroviral treatment. A large cohort and a longer period of follow-up are required to determine the impact of antiretroviral treatment on work performance over the long term but these are promising initial findings.

Micheloud D, Berenguer J, Bellón JM, Miralles P, Cosin J, de Quiros JC, Conde MS,Muñoz-Fernández MA, Resino S. Negative influence of age on CD4+ cell recovery after highly active antiretroviral therapy in naive HIV-1-infected patients with severe immunodeficiency. J Infect. 2008 ;56(2):130-6.

Micheloud and colleagues aimed to study the effect of age on several outcomes among 187 antiretroviral-naive infected patients who started highly active antiretroviral therapy (HAART) with <or=200 CD4(+)/microl. The authors carried out a retrospective study to determine the hazard ratio (HR) to reach an outcome in patients who experienced a change from the baseline in CD4(+) counts of at least +100, +200, +300, +400 and +500 cells/microl at any moment during the follow-up and the odds ratio (OR) of achieving and maintaining a CD4(+) value above a certain setpoint during at least 6, 12 or 18 months. The adjusted HR for an increase of +400 CD4(+)/microl and +500 CD4(+)/microl were 1.3 (95% CI: 1.1; 1.5) and 1.3 (95% CI: 1.1; 1.6) times slower for each additional 5 years of age at baseline. In addition, for every 5 years of extra age, the adjusted OR to achieve an absolute CD4(+) cell count >500/microl at 6, 12 and 18 months after the initiation of HAART were 2.2 (95% CI: 1.5; 3.2), 1.8 (95% CI: 1.2; 2.6), and 1.8 (95% CI: 1.2; 2.9) times less likely, respectively. The authors also found that patients >or=45 years old had worse complete CD4(+) recovery (CD4(+)>500 cells/microl) than patients <45 years old. in conclusion, the CD4(+) recovery after HAART is a prolonged and continuous process which extends for several years. Age at baseline is inversely correlated with the magnitude and speed of CD4(+) recovery among HIV-1 infected patients.

Editors’ note: Older age at the time of HIV acquisition is associated with faster disease progression. This study found that increasing age was associated with slower CD4 count recovery after initiation of antiretroviral treatment and a lower likelihood of reaching an absolute CD4 count of 500. This suggests that older people may benefit from earlier initiation of antiretroviral treatment before CD4 counts reach 200.

The aim of this study was to estimate the outcome and cost-effectiveness per life-year-gained (LYG) of first-, second- and third-line non-nucleoside reverse transcriptase inhibitors (NNRTI) versus protease inhibitor (PI) containing highly active antiretroviral therapy regimens. Hospital care costs (2002 US dollars discounted 3.5% per annum) were linked to treatment failure times. Results show that the median time-to-treatment failure for first-line (nucleoside reverse transcriptase inhibitors) 2NRTIs + NNRTI was substantially longer than that for 2NRTIs + PI (boosted), 2NRTIs + PI and 2NRTIs + 2PIs, whereas for second- and third-line they were similar. Comparing first-line 2NRTIs + NNRTI with 2NRTIs + PI (boosted) cost per LYG was US$ 12,375; US$ 12,139 per LYG when compared with 2NRTIs + PI and US$ 2948 per LYG when compared with 2NRTIs + 2PIs. For second-line cost per LYG comparing 2NRTIs + NNRTI with 2NRTIs + PI (boosted) was US$ 19,501; US$ 18,364 per LYG when compared with 2NRTIs + PI and cost-saving when compared with 2NRTIs + 2PIs. For third-line cost per LYG comparing 2NRTIs + NNRTI with 2NRTIs + PI(boosted) was US$ 2708; US$ 11,559 per LYG when compared with 2NRTIs + PI and cost-saving when compared with 2NRTIs + 2PIs. In conclusion, first-line 2NRTIs + NNRTI was cost-effective or cost-saving when compared with PI-containing regimens for all lines of therapy. Such information is required by clinicians and managers of HIV services to make appropriate treatment decisions based on clinical and financial grounds, and given the increasing number of people living with HIV, such information will become more important over time.

Editors’ note: In low- and middle–income countries, the standard first-line therapy recommended by the WHO public health approach contains a backbone of two nucleoside reverse transcriptase inhibitors (NRTI) and one non-nucleoside reverse transcriptase inhibitor (2 nukes and 1 non-nuke). Until now, the outcome and cost-effectiveness of such regimens compared to protease inhibitor (PI) containing regimens have not been studied. Although the setting for this study is a high-income country, the 2 nukes-1 non-nuke first-line, second-line, and third-line regimens were either cost-effective or cost-saving. Of note is the much longer median time to treatment failure for people on these first-line regimens compared to those containing protease inhibitors, a finding of direct relevance for low- and middle-income countries.

Samb B, Celletti F, Holloway J, Van Damme W, De Cock KM, Dybul M. Rapid expansion of the health workforce in response to the HIV epidemic. N Engl J Med. 2007; 357(24):2510-4.

The World Health Organization (WHO) estimates that there is now a global deficit of more than 4 million trained health workers. The shortages in health workers are critical in 57 countries, mostly in sub-Saharan Africa and parts of Asia. The situation is further exacerbated by the direct effect of the human immunodeficiency virus (HIV) on health workers in resource-constrained countries in which the disease is epidemic. Poor working conditions and low pay conspire with the risks of occupational transmission and the stress of working in communities devastated by the HIV epidemic to drive up rates of attrition. In countries with the highest rate of HIV, leading causes of attrition are the morbidity and mortality caused by HIV itself. In Botswana, 17% of the health workers died from diseases related to AIDS from 1999 to 2005. The “Treat, Train, Retrain” global effort aims to prevent HIV among health workers and to treat those who are infected, to expand the workforce by training new people and by making more efficient use of the current pool of human resources for health, and to retain skilled staff. Possibly the most challenging imperative to expand the health workforce is the need for “task shifting”, the process of delegation in which tasks are moved, where appropriate, from more to less specialized health workers. Reorganizing the force in this way allows more efficient use of available human resources and quickly expands the overall human resource pool. Although such programs are in their early days, there is evidence of success. In South Africa, care models that shift many medical tasks to nurses were found to be feasible, acceptable to patients, and potentially more affordable. After 6 months of follow-up, outcomes such as virologic suppression, adherence, and retention of patients at sites with doctors were similar to those at sites without doctors where there was adequate supervision. The process of delegation can further extended from health professionals to community members. Adopting new models for the delivery of health services requires political and financial commitment. Governments, as well as international and bilateral agencies, will need to recognize and allow systems that train and deploy nonphysicians, including community-level workers and patients living with HIV in health care delivery. Although research is needed in these areas, sufficient data are already available to support a prompt scale-up of HIV prevention, care, and treatment through task shifting to save as many lives as quickly as possible.

Editors’ note: Although the term “task shifting” is new, the experience of task substitution has been documented since the 1970s in a variety of settings, often as a measure to enhance quality and reduce cost rather than as an emerging response to scarcity. Task shifting works best when standardized protocols, appropriate training, ongoing supervisory support, and a meaningful career pathway support it.

Ickovics JR. « Bundling » HIV prevention: Integrating services to promote synergistic gain. Prev Med 2007; 46 (3):222-5.

Bundling is defined as the aggregation of services to increase effectiveness (i.e., creating synergy of effort). Ickovics and colleagues aimed to review the utilization and potential benefits of bundling in its application to HIV prevention. A review of the literature was conducted to provide a broad perspective on the concept of bundling and specific examples of bundling in HIV prevention. Benefits, challenges, and directions were considered. To be effective, bundling must offer strategic advantage: greater value, less cost. It provides an opportunity to target multiple risk behaviours simultaneously for synergistic gain. Technological advances including rapid HIV tests permit non-invasive sampling in clinical and non-clinical settings. Bundling of HIV prevention provides an opportunity to reach high-risk persons who are asymptomatic and/or may not otherwise seek care by eliminating barriers to prevention. In conclusion, programmes that work must be implemented and innovative approaches considered to stem the AIDS epidemic; bundling provides one such opportunity to create an efficient paradigm targeting multiple risk behaviours simultaneously.

Editors’ note: Bundling goods or services in business is done to increase profitability with customers benefiting from integrated value-added services, one-stop shopping, and lower prices. In HIV prevention, what gets bundled together, how and how much are important to programme effectiveness-it is high time to create synergy and secondary gain through thoughtful bundling.

Mishra V, Arnold F, Otieno F, Cross A, Hong R. Education and nutritional status of orphans and children of HIV-infected parents in Kenya. AIDS Educ Prev. 2007;19(5):383-95.

Mishra and colleagues examined whether orphaned and fostered children and children of HIV-infected parents are disadvantaged in schooling, nutrition, and health care. The authors analyzed data on 2,756 children aged 0-4 years and 4,172 children aged 6-14 years included in the 2003 Kenya Demographic and Health Survey, with linked anonymous HIV testing, using multivariate logistic regression. Results indicate that orphans, fostered children, and children of HIV-infected parents are significantly less likely to attend school than non-orphaned/non-fostered children of HIV-negative parents. Children of HIV-infected parents are more likely to be underweight and wasted, and less likely to receive medical care for ARI and diarrhoea. Children of HIV-negative single mothers are also disadvantaged on most indicators. The findings highlight the need to expand child welfare programs to include not only orphans but also fostered children, children of single mothers, and children of HIV-infected parents, who tend to be equally, if not more, disadvantaged.

Editors’ note: Recognition of the vulnerability of children who have not been orphaned by AIDS led to the acronym ‘OVC’ (orphans and vulnerable children) which casts the net more widely. Child welfare programmes that include all disadvantaged children are more likely to mitigate the effects of the epidemic on children while preventing HIV from getting a toehold in the next generation.

Chatterjee and colleagues examine whether maternal HIV disease stage during pregnancy and child malnutrition are associated with child mortality in a prospective cohort study in Tanzania. Indicators of disease stage were assessed for 939 HIV-infected women during pregnancy and at delivery, and children’s anthropometric status was obtained at scheduled monthly clinic visits after delivery. Children were followed up for survival status until 24 months after birth. Advanced maternal HIV disease during pregnancy (CD4 count <350 vs. >or=350 cells/mm) was associated with increased risk of child mortality through 24 months of age (hazard ratio [HR] = 1.74, 95% confidence interval [CI]: 1.32 to 2.30). CD4 count <350 cells/mm was also associated with an increased risk of death among children who remained HIV-negative during follow-up (HR = 2.00, 95% CI: 1.36 to 2.94). Low maternal haemoglobin concentration and child undernutrition were related to an increased risk of mortality in this cohort of children. The authors conclude that low maternal CD4 cell count during pregnancy is related to increased risk of mortality in children born to HIV-infected women. Care and treatment for HIV disease, including highly active antiretroviral therapy to pregnant women, could improve child survival. Prevention and treatment of undernutrition in children remain critical interventions in settings with high HIV prevalence.

Editors’ note: The association between mothers’ advanced disease stage and child mortality is complex. Such mothers may transit a more virulent virus strain, may transmit other infections, may not provide as strong passive immunity to their offspring (across the placenta during pregnancy and in breast milk during breastfeeding), and may have reduced parenting capacity due to anaemia, fatigue, and HIV-related disease. To increase child survival in high HIV prevalence areas, integration of maternal and child health programmes with antiretroviral treatment programmes can help prevent and treat childhood malnutrition, while addressing the maternal anaemia and opportunistic infections that can undermine parenting capacity.

Rosen S, Feeley F, Connelly P, Simon J. The private sector and HIV/AIDS in Africa: taking stock of 6 years of applied research. AIDS 2007;21 Suppl 3:S41-51.

Until recently, little was known about the costs of the HIV epidemic to businesses in Africa or about business responses to the epidemic.  This paper synthesizes the results of a set of studies conducted between 1999 and 2006. Data for the studies included were drawn from human resource, financial, and medical records of 16 large companies and from 7 surveys of small, medium-sized, and large companies in South Africa, Uganda, Kenya, Zambia, Ethiopia, and Rwanda. The estimated workforce HIV prevalence ranged from 5 to 37%. The average cost per employee lost to AIDS varied from 0.5 to 5.6 times the average annual compensation of the employee affected. Labour cost increases were estimated at 0.6-10.8% but exceeded 3% at only two of 14 companies. Antiretroviral treatment at a cost of US$360/patient per year was found to have positive financial returns for most but not all companies. Managers of small and medium-sized enterprises (SME) reported low HIV-related employee attrition, little concern about the impacts of HIV, and relatively little interest in taking action. HIV was estimated to increase the average operating costs of small and medium-sized enterprises by less than 1%. In conclusion, for most companies, HIV is causing a moderate increase in labour costs, with costs determined mainly by HIV prevalence, employee skill level, and employment policies. Treatment of HIV-positive employees is a good investment for many large companies. Small companies have less capacity to respond to workforce illness and little concern about it. Research on the effectiveness of workplace interventions is needed.

Editors’ note: This synthesis suggests that well-designed interventions can achieve the double benefit of reducing costs to employers while improving the welfare of individual employees. Small and medium-sized companies face business challenges such as power failures, unpredictable taxes, and political instability, and are unable to benefit from economies of scale. Their HIV workplace programmes require support from business associations or external funders for HIV prevention activities and must rely on governments and non-governmental organizations for healthcare provision.

Koenig SP, Riviere C, Leger P, Severe P, Atwood S, Fitzgerald D, Pape JW, Schackman BR. The cost of antiretroviral therapy in Haiti. Cost Eff Resour Alloc. 2008; 14;6(1):3.

Koenig and colleagues determined direct medical costs, overhead costs, societal costs, and personnel requirements for the provision of antiretroviral therapy (ART) to patients with AIDS in Haiti. The authors examined data from 218 treatment-naive adults who were consecutively initiated on ART at the GHESKIO Center in Port-au-Prince, Haiti between December 23, 2003 and May 20, 2004 and calculated costs and personnel requirements for the first year of ART. The mean total cost of treatment per patient was $US 982 including $US 846 in direct costs, $US 114 for overhead, and $US 22 for societal costs. The direct cost per patient included generic ART medications $US 355, lab tests $US 130, nutrition $US 117, hospitalizations $US 62, pre-ART evaluation $US 58, labour $US 51, non-ART medications $US 39, outside referrals $US 31, and telephone cards for patient retention $US 3. Higher treatment costs were associated with hospitalization, change in ART regimen, TB treatment, and survival for one year.  The authors estimate that 1.5 doctors and 2.5 nurses are required to treat 1000 patients in the first year after initiating ART. Initial ART treatment in Haiti costs approximately $US 1,000 per patient per year. With generic first-line antiretroviral drugs, only 36% of the cost is for medications. Patients who change regimens are significantly more expensive to treat, highlighting the need for less-expensive second-line drugs. There may be sufficient health care personnel to treat all HIV-infected patients in urban areas of Haiti, but not in rural areas. New models of HIV care are needed for rural areas using assistant medical officers and community health workers.

Editors’ note: Costing studies such as this one provide key information for programme management and budgeting, as well as hard data to feed into national, regional, and global cost estimates. Equity in treatment scale-up in Haiti and elsewhere will depend on keeping costs for first-and-second-line antiretroviral drugs low and developing innovative task-shifting scenarios for rural areas.

Bärnighausen T, Hosegood V, Timaeus IM, Newell ML. The socioeconomic determinants of HIV incidence: evidence from a longitudinal, population-based study in rural South Africa. AIDS. 2007 Nov;21 Suppl 7:S29-38.

Knowledge of the effect of socioeconomic status on HIV infection in Africa stems largely from cross-sectional studies. Cross-sectional studies suffer from two important limitations: two-way causality between socioeconomic status and HIV serostatus and simultaneous effects of socioeconomic status on HIV incidence and HIV-positive survival time. Both problems are avoided in longitudinal cohort studies. Bärnighausen and colleagues  used data from a longitudinal HIV surveillance and a linked demographic surveillance in a poor rural community in KwaZulu-Natal, South Africa, to investigate the effect of three measures of socioeconomic status on HIV incidence: educational attainment, household wealth categories (based on a ranking of households on an assets index scale) and per capita household expenditure. Their sample comprised of 3325 individuals who tested HIV-negative at baseline and either HIV-negative or -positive on a second test (on average 1.3 years later). In multivariable survival analysis, one additional year of education reduced the hazard of acquiring HIV by 7% (P = 0.017) net of sex, age, wealth, household expenditure, rural vs. urban/periurban residence, migration status and partnership status. Holding other factors equal, members of households that fell into the middle 40% of relative wealth had a 72% higher hazard of HIV acquisition than members of the 40% poorest households (P = 0.012). Per capita household expenditure did not significantly affect HIV incidence (P = 0.669). The authors conclude that although poverty reduction is important for obvious reasons, it may not be as effective as anticipated in reducing the spread of HIV in rural South Africa. In contrast, their results suggest that increasing educational attainment in the general population may lower HIV incidence.

Editors’ note: In early stages of the epidemic, higher education may increase HIV risk due, in part, to higher numbers of sexual partners. As HIV epidemics mature, the highly educated may adopt risk-reducing behaviours more quickly, possibly because they are more empowered to negotiate safer sex. This longitidinal study in a poor South Africa community provides strong support for structural interventions to keep children in school, with each additional year reducing HIV risk. The higher HIV prevalence seen among members of households falling in the middle 40% of relative wealth underscores findings from other studies suggesting that the relationship between HIV and poverty/wealth is complex.

Mishra V, Assche SB, Greener R, Vaessen M, Hong R, Ghys PD, Boerma JT, Van Assche A, Khan S, Rutstein S.  HIV infection does not disproportionately affect the poorer in sub-Saharan. Africa AIDS. 2007 Nov;21 Suppl 7:S17-28.

Wealthier populations do better than poorer ones on most measures of health status, including nutrition, morbidity and mortality, and healthcare utilization. This study examines the association between household wealth status and HIV serostatus to identify what characteristics and behaviours are associated with HIV infection, and the role of confounding factors such as place of residence and other risk factors. Data are from eight national surveys in sub-Saharan Africa (Kenya, Ghana, Burkina Faso, Cameroon, Tanzania, Lesotho, Malawi, and Uganda) conducted during 2003-2005. Dried blood spot samples were collected and tested for HIV, following internationally accepted ethical standards and laboratory procedures. The association between household wealth (measured by an index based on household ownership of durable assets and other amenities) and HIV serostatus is examined using both descriptive and multivariate statistical methods. In all eight countries, adults in the wealthiest quintiles have a higher prevalence of HIV than those in the poorer quintiles. Prevalence increases monotonically with wealth in most cases. Similarly for cohabiting couples, the likelihood that one or both partners is HIV infected increases with wealth. The positive association between wealth and HIV prevalence is only partly explained by an association of wealth with other underlying factors, such as place of residence and education, and by differences in sexual behaviour, such as multiple sex partners, condom use, and male circumcision. Mishra and colleagues conclude that in sub-Saharan Africa, HIV prevalence does not exhibit the same pattern of association with poverty as most other diseases. HIV programmes should also focus on the wealthier segments of the population.

Editors’ note: HIV clearly disproportionately affects the poor in sub-Saharan Africa when they do become infected; however, the poor appear to be at lower risk of HIV infection in the first place. This eight country study found that wealth, defined as higher household economic status, is associated with higher HIV prevalence among adult men and women. Qualitative research is needed to better understand why wealthier people who tend to be more educated, have a greater knowledge of HIV prevention methods, access health care, and use condoms more, still have higher HIV prevalence. Higher mobility and concurrent partnerships may be creating risky sexual networks for the virus to travel.

Dionisio D  , Khanna AK, Nicolaou S , Raghavan V, Juneja S, Sengupta A,   Messeri D. For-profit policies and equitable access to antiretroviral drugs in resource-limited countries. Future HIV Therapy January 2008, Vol. 2, No. 1, Pages 25-36.

Unaffordable prices continue to obstruct access to antiretroviral drugs in income-constrained countries. This article explores the fitness of a multi-pronged, incentive-bound, WHO-mediated voluntary license strategy for attuning research, innovation, profit and equitable access to antiretrovirals in under-served markets. The potential of the model was investigated by examining: the predictable effect on current regulatory practices (trade-related aspects of intellectual property rights [TRIPS] and TRIPS-plus measures); the expected benefits, either in terms of equity or safeguarding of the generic and brand name manufacturer’s interests; the interplay dynamics with drug trading policies of deeply concerned countries (China, India, countries in the EU, USA, Brazil, South Africa and Thailand); and the suitability for helping plants for generic antiretrovirals, including home plants in Sub-Saharan Africa, undertake research and development partnerships encompassing innovation, technological catch-up, exploitation of TRIPS flexibilities, as well as raised marketing power and an increase in domestic employment. The explored strategy, although far from being the ideal solution, looks like it would be reliable to help expand equitable and sustainable access to appropriate antiretrovirals in resource-limited populations, as long as it entwines with the WHO’s brokerage. It should also boost know-how, technology transfer, innovation, research and development, as well as national industry plant development and penetration of the wealthy and under-served markets by generic drug enterprises.

Editors’ note: The advantage and dynamics of voluntary licensing agreements between multinational brand-name corporations and generic manufacturers are described in this paper which provides specific examples [Bristol-Myers Squibb and Aspen Pharmacare (sub-Saharan Africa) and Emcure (India); Tibotec Pharmaceuticals and Aspen Pharmacare (sub-Saharan Africa); Roche and Addis Pharmaceutical Factory (Ethiopia) and Varichem Pharmaceuticals (Zimbabwe)]. The authors argue that WHO should play a brokering role in this confluence of interest to secure low priced drugs and expanded access to antiretroviral medications through voluntary licensing agreements.

Vijayaraghavan A, Efrusy MB, Mazonson PD, Ebrahim O, Sanne IM, Santas CC. Cost-effectiveness of alternative strategies for initiating and monitoring Highly Active Antiretroviral Therapy in the developing world. J Acquir Immune Defic Syndr 2007 Sep 1;46(1):91-100.

The objective was to determine the cost-effectiveness of initiating and monitoring highly active antiretroviral therapy (HAART) in developing countries according to developing world versus developed world guidelines. The design was a Lifetime Markov model incorporating costs, quality of life, survival, and transmission to sexual contacts. Vijayaraghavan and colleagues evaluated treating patients with HIV in South Africa according to World Health Organization (WHO) ”3 by 5” guidelines (treat CD4 counts </=200 cells/mm3 patients with AIDS, and monitor CD4 cell counts every 6 months) versus modified WHO guidelines that incorporate the following key differences from developed world guidelines: treat CD4 counts </=350 cells/mm3 viral loads >100,000 copies/mL, and monitor CD4 cell counts and viral load every 3 months. Incorporating transmission to partners (excluding indirect costs), treating patients according to developed versus developing world guidelines increased costs by US $11,867 and increased life expectancy by 3.00 quality-adjusted life-years (QALYs), for an incremental cost-effectiveness of $3956 per QALY. Including indirect costs, over the duration of the model, there are net cost savings to the economy of $39.4 billion, with increased direct medical costs of $60.5 billion offset by indirect cost savings of $99.9 billion. Treating patients with HIV according to developed versus developing world guidelines is highly cost-effective and may result in substantial long-term savings.

Editors’ note: This unusual study compares the health and economic impacts of implementing treatment guidelines for the developed world (US Department of Health and Human Services) versus guidelines for the developing world (WHO) in South Africa. Initiating treatment at a higher CD4 cell count and using viral load tests to identify treatment failure more quickly so that regimens can be switched have both survival and quality of life benefits. That this modelling predicted a net savings to the economy of $39 billion over the next 38 years is perhaps surprising. It emphasizes the importance of indirect cost savings (primarily resulting from socially and economically productive years of life saved for index patients and their sexual partners) in countering direct medical costs, which are themselves staggering.

Floyd S, Crampin AC, Glynn JR, Madise N, Mwenebabu M, Mnkhondia S, Ngwira B, Zaba B, Fine PE. The social and economic impact of parental HIV on children in northern Malawi: Retrospective population-based cohort study. AIDS Care 2007;19:781-90.

From population-based surveys in the 1980s in Karonga district, northern Malawi, 197 ‘index individuals’ were identified as HIV-positive. 396 HIV-negative ‘index individuals’ were selected as a comparison group. These individuals, and their spouses and children, were followed up in 1998-2000. 582 of 593 index individuals were traced. 487 children of HIV-positive, and 1493 children of HIV-negative, parents were included in analyses. Rates of paternal, maternal, and double orphanhood among children with one or both parents HIV-positive were respectively 6, 8, and 17 times higher than for children with HIV-negative parents. Around 50% of children living apart from both parents had a grandparent as their guardian; for most of the rest the guardian was an aunt, uncle, or sibling. There were no child-headed households. Almost all children aged 6-14 were attending primary school. There was no evidence that parental HIV affected primary school attainment among children <15 years old. Children of HIV-positive parents were less likely to have attended secondary school than those of HIV-negative parents. The extended family has mitigated the impact of orphanhood on children, but interventions to reduce the incidence of orphanhood, and/or which strengthen society’s ability to support orphans, are essential, especially as the HIV epidemic matures and its full impact is felt.

Editors’ note: Although it is encouraging that primary school enrolment in Malawi is not measurably affected by parental HIV infection, effects are being seen on secondary school attendance. The diminishing horizon of education and employment prospects for many orphans then limits the opportunities for their own children – the next generation. Counteracting these intergenerational effects can preserve social capital and social cohesion and build resilience to HIV.

Dasinger LK, Speiglman R. Homelessness prevention: the effect of a shallow rent subsidy program on housing outcomes among people with HIV or AIDS. AIDS Behav 2007;26(2):128-139.

This paper presents results of an evaluation of Project Independence (PI), a shallow rent subsidy program with services coordination support for very low income people with HIV or AIDS who live in Alameda County in the San Francisco Bay Area. By providing a small rental subsidy to eligible individuals and their families who are already stably housed, the philosophy of the program is to prevent homelessness before it starts. The housing outcomes of 185 PI clients were compared to those of 218 people who were not enrolled in the program but were presumed eligible for it, controlling for sociodemographic, HIV disease, and behavioural health characteristics. Using survival analysis techniques, non-program participants were found to be more likely to leave their rental housing at any given point in time compared to PI program participants. After one year of follow-up, while 99% of PI clients remained stably housed in their program-subsidized rental unit, only 32% of comparison group clients were still in rental housing. At two years, 96% of PI participants remained independently housed, compared to only 10% of non-participants. The success of the program suggests that Project Independence should be replicated and evaluated in other jurisdictions where a relatively high incidence and prevalence of HIV is combined with a lack of affordable housing for low income households.

Editors’ note: HIV infection can become impoverishing as it progresses. Those who are on very low incomes are particularly vulnerable to losing their housing. This intervention of a small rental subsidy was an investment which reaped large dividends for fully 96% of the 185 participants who received it. Two years later they were still stably housed - an effective mitigation tool addressing a social consequence of being poor and having HIV infection.