Evaluating AVAHAN's design, implementation and impact: lessons learned for the HIV Prevention Community

Estimating the cost of HIV services for key populations provided by the LINKAGES program in Kenya and Malawi

BACKGROUND

Data remain scarce on the costs of HIV services for key populations (KPs). The objective of this study was to bridge this gap in the literature by estimating the unit costs of HIV services delivered to KPs in the LINKAGES program in Kenya and Malawi. We estimated the mean total unit costs of seven clinical services: post-exposure prophylaxis (PEP), pre-exposure prophylaxis (PrEP), HIV testing services (HTS), antiretroviral therapy (ART), sexually transmitted infection (STI) services, sexual and reproductive health (SRH) services, and management of sexual violence (MSV). These costs take into account the costs of non-clinical services delivered alongside clinical services and the pre-service and above-service program management integral to the LINKAGES program.

METHODS

Data were collected at all implementation levels of the LINKAGES program including 30 drop-in-centers (DICs) in Kenya and 15 in Malawi. This study was conducted from the provider's perspective. We estimated economic costs for FY 2019 and cost estimates include start-up costs. Start-up and capital costs were annualized using a discount rate of 3%. We used a combination of top-down and bottom-up costing approaches. Top-down methods were used to estimate the costs of headquarters, country offices, and implementing partners. Bottom-up micro-costing methods were used to measure the quantities and prices of inputs used to produce services in DICs. Volume-weighted mean unit costs were calculated for each clinical service. Costs are presented in 2019 United States dollars (US$).

RESULTS

The mean total unit costs per service ranged from US$18 (95% CI: 16, 21) for STI services to US$635 (95% CI: 484, 785) for PrEP in Kenya and from US$41 (95% CI: 37, 44) for STI services to US$1,240 (95% CI 1156, 1324) for MSV in Malawi. Clinical costs accounted for between 21 and 59% of total mean unit costs in Kenya, and between 25 and 38% in Malawi. Indirect costs-including start-up activities, the costs of KP interventions implemented alongside clinical services, and program management and data monitoring-made up the remaining costs incurred.

CONCLUSIONS

A better understanding of the cost of HIV services is highly relevant for budgeting and planning purposes and for optimizing HIV services. When considering all service delivery costs of a comprehensive HIV service package for KPs, costs of services can be significantly higher than when considering direct clinical service costs alone. These estimates can inform investment cases, strategic plans and other budgeting exercises.

Programmatic Mapping: Providing Evidence for High Impact HIV Prevention Programs for Female Sex Workers

Programmatic mapping (PM) is a rapid and efficient mechanism to develop size estimates of key populations including female sex workers (FSWs) and geolocate them at physical locations in a systematic and scientific manner. At the macro level, this information forms the basis for allocating program resources, setting performance targets, and assess coverage. At a micro level, PM data provide specific information on hot spots, estimates of FSWs at those spots, and hot spot typology and days and times of operation, all of which provides targeted service delivery strategies. This information can provide a reliable platform to plan HIV prevention and treatment services to considerable scale and intensity. Above all, the entire PM process requires deep involvement of FSWs, which increases community ownership of the data and can lead to an increased uptake of services. Despite a few limitations, the approach is versatile and can be used in varied country contexts to generate important information about sex work and its dynamics. In this paper, we describe experiences and lessons learned from using evidence generated from PM of FSWs in multiple countries to develop HIV prevention programs at scale.

HIV prevention and care services for female sex workers: efficacy of a targeted community-based intervention in Burkina Faso

INTRODUCTION

Although interventions to control HIV among high-risk groups such as female sex workers (FSW) are highly recommended in Africa, the contents and efficacy of these interventions are unclear. We therefore designed a comprehensive dedicated intervention targeting young FSW and assessed its impact on HIV incidence in Burkina Faso.

METHODS

Between September 2009 and September 2011 we conducted a prospective, interventional cohort study of FSW aged 18 to 25 years in Ouagadougou, with quarterly follow-up for a maximum of 21 months. The intervention combined prevention and care within the same setting, consisting of peer-led education sessions, psychological support, sexually transmitted infections and HIV care, general routine health care and reproductive health services. At each visit, behavioural characteristics were collected and HIV, HSV-2 and pregnancy were tested. We compared the cohort HIV incidence with a modelled expected incidence in the study population in the absence of intervention, using data collected at the same time from FSW clients.

RESULTS

The 321 HIV-uninfected FSW enrolled in the cohort completed 409 person-years of follow-up. No participant seroconverted for HIV during the study (0/409 person-years), whereas the expected modelled number of HIV infections were 5.05/409 person-years (95% CI, 5.01-5.08) or 1.23 infections per 100 person-years (p=0.005). This null incidence was related to a reduction in the number of regular partners and regular clients, and by an increase in consistent condom use with casual clients (adjusted odds ratio (aOR)=2.19; 95% CI, 1.16-4.14, p=0.01) and with regular clients (aOR=2.18; 95% CI, 1.26-3.76, p=0.005).

CONCLUSIONS

Combining peer-based prevention and care within the same setting markedly reduced the HIV incidence among young FSW in Burkina Faso, through reduced risky behaviours.

HIV Programs for Sex Workers: Lessons and Challenges for Developing and Delivering Programs

There is evidence that HIV prevention programs for sex workers, especially female sex workers, are cost-effective in several contexts, including many western countries, Thailand, India, the Democratic Republic of Congo, Kenya, and Zimbabwe. The evidence that sex worker HIV prevention programs work must not inspire complacency but rather a renewed effort to expand, intensify, and maximize their impact. The PLOS Collection "Focus on Delivery and Scale: Achieving HIV Impact with Sex Workers" highlights major challenges to scaling-up sex worker HIV prevention programs, noting the following: sex worker HIV prevention programs are insufficiently guided by understanding of epidemic transmission dynamics, situation analyses, and programmatic mapping; sex worker HIV and sexually transmitted infection services receive limited domestic financing in many countries; many sex worker HIV prevention programs are inadequately codified to ensure consistency and quality; and many sex worker HIV prevention programs have not evolved adequately to address informal sex workers, male and transgender sex workers, and mobile- and internet-based sex workers. Based on the wider collection of papers, this article presents three major clusters of recommendations: (i) HIV programs focused on sex workers should be prioritized, developed, and implemented based on robust evidence; (ii) national political will and increased funding are needed to increase coverage of effective sex worker HIV prevention programs in low and middle income countries; and (iii) comprehensive, integrated, and rapidly evolving HIV programs are needed to ensure equitable access to health services for individuals involved in all forms of sex work.

Cost-effectiveness of HIV prevention for high-risk groups at scale: an economic evaluation of the Avahan programme in south India

BACKGROUND

Avahan is a large-scale, HIV preventive intervention, targeting high-risk populations in south India. We assessed the cost-effectiveness of Avahan to inform global and national funding institutions who are considering investing in worldwide HIV prevention in concentrated epidemics.

METHODS

We estimated cost effectiveness from a programme perspective in 22 districts in four high-prevalence states. We used the UNAIDS Costing Guidelines for HIV Prevention Strategies as the basis for our costing method, and calculated effect estimates using a dynamic transmission model of HIV and sexually transmitted disease transmission that was parameterised and fitted to locally observed behavioural and prevalence trends. We calculated incremental cost-effective ratios (ICERs), comparing the incremental cost of Avahan per disability-adjusted life-year (DALY) averted versus a no-Avahan counterfactual scenario. We also estimated incremental cost per HIV infection averted and incremental cost per person reached.

FINDINGS

Avahan reached roughly 150 000 high-risk individuals between 2004 and 2008 in the 22 districts studied, at a mean cost per person reached of US$327 during the 4 years. This reach resulted in an estimated 61 000 HIV infections averted, with roughly 11 000 HIV infections averted in the general population, at a mean incremental cost per HIV infection averted of $785 (SD 166). We estimate that roughly 1 million DALYs were averted across the 22 districts, at a mean incremental cost per DALY averted of $46 (SD 10). Future antiretroviral treatment (ART) cost savings during the lifetime of the cohort exposed to HIV prevention were estimated to be more than $77 million (compared with the slightly more than $50 million spent on Avahan in the 22 districts during the 4 years of the study).

INTERPRETATION

This study provides evidence that the investment in targeted HIV prevention programmes in south India has been cost effective, and is likely to be cost saving if a commitment is made to provide ART to all that can benefit from it. Policy makers should consider funding and sustaining large-scale targeted HIV prevention programmes in India and beyond.

FUNDING

Bill & Melinda Gates Foundation.

An assessment of an HIV prevention intervention among people who inject drugs in the states of Manipur and Nagaland, India

BACKGROUND

The present study describes an assessment of a large-scale intervention, "Avahan", using an evaluation framework that assesses the program coverage, changes in injection patterns, condom use, and STI and HIV prevalence among People Who Inject Drugs (PWID) in two states of India - Manipur and Nagaland.

METHODS

Program monitoring data and results from two rounds of a cross sectional biological and behavioural surveys in 2006 (Round 1) and 2009 (Round 2) were used. The sample included 839 and 860 PWIDs from Manipur and 821 and 829 PWIDs from Nagaland in Round 1 and Round 2 respectively for current analysis. Bivariate and multivariate analyses were done to measure the changes in behavioural and biological outcomes between the two rounds and to examine the association between programme exposure and behavioural outcomes.

RESULTS

In Manipur, about 77% of the PWIDs were contacted by the peer educators/outreach workers every month and about 18% of the PWIDs visited the clinic every month by March 2010. In Nagaland, however, the proportion of PWIDs visiting the clinic monthly remained low (11% in March 2010). PWIDs in both states were more likely to report 'consistent safe injection practice in the last six months' in Round 2 compared to Round 1 (Manipur: adjusted odds ratio (aOR): 1.88, 95% confidence intervals (CI): 1.46-2.43; Nagaland: aOR: 2.35, 95% CI: 1.86-2.80) PWIDs were also more likely to report consistent condom use with regular partners in Round 2. The prevalence of Hepatitis B virus (HBV) increased in Round 2 in Manipur (11% vs 6%, p<0.001) and Nagaland (8% vs 6%, p=0.05). The prevalence of Hepatitis C virus (HCV) was high and did not change, either in Manipur (67.3% vs 69.9%, p=0.42) and Nagaland (14.7% vs 15.1%, p=0.82). Similarly, the prevalence of HIV did not change significantly between the two Rounds either in Manipur (27.8% in Round 1 vs 29.2% in Round 2, p=0.59) or in Nagaland (1.2% in Round 1 and 1.6% in Round 2 of the IBBA, p=0.82).

CONCLUSION

Improvements in safe injection practices and consistent condom use with regular partners suggest effectiveness of prevention efforts. However, increase in HBV prevalence and non-decline in HCV and HIV prevalence in both the states also underscore the need to continue and intensify targeted interventions (such as Hepatitis B vaccination, needle exchange programmes, condom distribution) for long term risk reduction among PWID population.

Assessment of the population-level effectiveness of the Avahan HIV-prevention programme in South India: a preplanned, causal-pathway-based modelling analysis

BACKGROUND

Avahan, the India AIDS initiative of the Bill & Melinda Gates Foundation, was a large-scale, targeted HIV prevention intervention. We aimed to assess its overall effectiveness by estimating the number and proportion of HIV infections averted across Avahan districts, following the causal pathway of the intervention.

METHODS

We created a mathematical model of HIV transmission in high-risk groups and the general population using data from serial cross-sectional surveys (integrated behavioural and biological assessments, IBBAs) within a Bayesian framework, which we used to reproduce HIV prevalence trends in female sex workers and their clients, men who have sex with men, and the general population in 24 South Indian districts over the first 4 years (2004-07 or 2005-08 dependent on the district) and the full 10 years (2004-13) of the Avahan programme. We tested whether these prevalence trends were more consistent with self-reported increases in consistent condom use after the implementation of Avahan or with a counterfactual (assuming consistent condom use increased at slower, pre-Avahan rates) using a Bayes factor, which gave a measure of the strength of evidence for the effectiveness estimates. Using regression analysis, we extrapolated the prevention effect in the districts covered by IBBAs to all 69 Avahan districts.

FINDINGS

In 13 of 24 IBBA districts, modelling suggested medium to strong evidence for the large self-reported increase in consistent condom use since Avahan implementation. In the remaining 11 IBBA districts, the evidence was weaker, with consistent condom use generally already high before Avahan began. Roughly 32700 HIV infections (95% credibility interval 17900-61600) were averted over the first 4 years of the programme in the IBBA districts with moderate to strong evidence. Addition of the districts with weaker evidence increased this total to 62800 (32000-118000) averted infections, and extrapolation suggested that 202000 (98300-407000) infections were averted across all 69 Avahan districts in South India, increasing to 606000 (290000-1 193000) over 10 years. Over the first 4 years of the programme 42% of HIV infections were averted, and over 10 years 57% were averted.

INTERPRETATION

This is the first assessment of Avahan to account for the causal pathway of the intervention, that of changing risk behaviours in female sex workers and high-risk men who have sex with men to avert HIV infections in these groups and the general population. The findings suggest that substantial preventive effects can be achieved by targeted behavioural HIV prevention initiatives.

FUNDING

Bill & Melinda Gates Foundation.

Community action to end paediatric HIV infections

Virtual prevention of HIV transmission from parents to children is possible. This is cause for hope and renewed energy for prevention in general. The Global Plan is the most concerted and ambitious plan to date to protect children and to promote their care. But the inspiring and much appreciated global targets cannot be achieved, nor will they be realized in spirit in addition to form, without joint action between health services, affected women, their partners, families and communities and the wider society. In turn, this engagement is only possible under enabling political, legal, material and social conditions. Much has already been achieved, and community engagement can everywhere be seen in efforts to increase demand, to supply services and to create and improve enabling environments. Some of these initiatives are highly organized and expansive, with demonstrated success. Others are local but essential adjuncts to health services. The nature of this engagement varies because the challenges are different across countries and parts of countries. To be sustained and effective, community action must simultaneously be inclusive and supportive for those people who are affected, it must be appreciated and assigned a place within the broad systemic response, and it must promote and defend social justice.