Costs of Scaling HIV Program Activities to a National Level in Sub-Saharan Africa:
Methods and Estimates
ACT africa
A A ID I DS S Ca C am mp pa ai i gn g n T Te ea am m fo f or r A Af f ri r i ca c a
THE WORLD BANK
MARCH 30,2001
Source: UNAIDS 2000
AIDS Campaign Team for Africa (ACTafrica) March 31, 2001
World Bank
Adult Prevalence Rate
15.0% - 36.0%
5.0% - 15.0%
1.0% - 5.0%
0.5% - 1.0%
0.1% - 0.5%
0.0% - 0.1%
not available
TABLE OF CONTENTS
I. Summary . . . .. . . .. . .. . . .. . . .. 1
II. Scaling-Up HIV/AIDS Interventions: What Does it Mean? . . . .. . . . 5
A. Background . . . . . . . .. . . .5
B. What is scaling-up? Definitions and Modeling Approach. . . .. . . . 6
C. Outline of Report. . . 8
III. HIV/AIDS Interventions. . . .. . . .. . . .. . .. . . . .9
A. HIV Prevention Activities. . . . . . .. . . . 9
B. Basic Care Activities . . . . . . 13
C. Treatment . . . .. . . .. . . 17
D. Institutional Strengthening. . . . . . 18
IV. Scaling-Up the Coverage of Potential Target Groups . . . .. . .. . . . 19
A. Definitions of Potential Target Groups . . . 19
B. Coverage of Target Groups: Baseline and Target Levels. . . .. . .. . . . 22
C. Calculation of the Volumes of the Scaled-up Activities Needed to Achieve 2005 Coverage Targets. . . .. . .. .25
V. Costs of Scaling-Up HIV Prevention and Care Activities A. Unit Costs of HIV/AIDS Interventions. . .. . . . . . . . . . . 28
B. Cost of HIV/AIDS Interventions for Sub-Saharan Africa. . . 33
C. Costs of Scaling-up Programs by Countries. . . . . . 37
D. The Benefits of Early Prevention. . . .. . . . . . . 42
E. Policy Implications for Priority Setting. . . 43
Annex 1: The Potential Target Group Approach. . .. . . .. . . . .. 45
Annex 2: Calculation of Unit Cost Data. . . . . . . . . 53
Bibliography: . . . . . . . . . .. . . 62
Acronyms and Abbreviations
AIDS acquired immune deficiency syndrome ANC antenatal care
ARV anti-retroviral CMX Cotrimoxazole
CSW commercial sex worker CSM condom social marketing
ELISA enzyme-linked immunoabsorbent assay GDP gross domestic product
GPA Global Program on AIDS
HAART highly active antiretroviral therapy HIV human immunodeficiency virus
IEC information, education and communication
INH Isoniazid
MTCT mother-to-child-transmission NGO non-governmental organization OI opportunistic illnesses
PLHA people living with HIV/AIDS PLWA people living with AIDS PT preventive TB therapy PTG Potential Target Groups RDM resource determination model SSA Sub-Saharan Africa
STD sexually transmitted disease
TB tuberculosis
UNAIDS Joint United Nations Program on HIV/AIDS
UN United Nations
UNDP United Nations Development Program VCT voluntary counseling and testing WHO World Health Organization
The report was produced by René Bonnel (ACTAfrica). It is based on a report entitled
“Costs of Scaling HIV program Activities to a National Level for Sub-Saharan Africa:
Methods and Estimates", which was prepared by Lilani Kumaranayake and Charlotte Watts, London School of Hygiene and Tropical Medicine, World Bank, 2000, as well as on a model developed by Bernard Schwartlander (UNAIDS) for estimating the cost of care. The report was financed by the HIV/AIDS trust fund provided by the Norwegian Ministry for Foreign Affairs. The assistance of the UNAIDS Secretariat in providing data and valuable comments is gratefully appreciated.
I. SUMMARY
HIV/AIDS continues to have a devastating impact in Sub-Saharan Africa (SSA). Close to 71% of people with HIV/AIDS live in SSA (UNAIDS, 2000a). Life expectancy at birth in Southern Africa, which climbed from 44 years in the early 1950s to 59 years in the early 1990s, is expected to drop back to 40 years sometime between 2005 and 2010, mainly attributed to the result of AIDS. However, while there are strong HIV/AIDS interventions across Africa, few are implemented at a national scale. Yet the experiences of countries like Uganda and Senegal, which have been successful in mitigating the epidemic, suggest the importance of a national and co-ordinated response. Thus, a key priority in addressing the HIV/AIDS crises in SSA is the rapid expansion of activities.
The aim of the approach followed in this document is to provide both a method to present estimates of the cost of scaling-up HIV/AIDS interventions to various levels of coverage.
While providing guidance on the relative resource requirements of different HIV/AIDS interventions, the report does not provide explicit guidance on priority-setting and resource allocation among programs. To do this, one needs also to consider the likely impact and cost-effectiveness of these activities, which are not considered here. The process of choosing which activities to scale up and at which levels depends on several factors, and the analysis of costs is only a component of this process.
This document develops and discusses a resource determination model (RDM) designed to estimate how much would it cost to scale-up different HIV prevention and care strategies to a national level in Sub-Saharan Africa. The model combines cost-studies with detailed information on sexual behavior, condom availability, HIV prevalence and other epidemiological, demographic and health systems. The model yields estimates of the costs of scaling-up ten different HIV prevention and eight care strategies for 37 countries in Sub-Saharan Africa.
What is scaling-up?
Scaling-up is defined in the document as an expansion in the coverage of existing HIV/AIDS interventions as well as an expansion in the type of HIV/AIDS programs that are in place. This has the following implications when considering the cost of scaling-up interventions:
• Scaling-up is a relative concept. It refers to increasing the coverage of target groups by specific HIV/AIDS interventions from one level to another one. For example, scaling-up the prevention of mother to child transmission of HIV/AIDS (MTCT) means increasing the coverage of among pregnant women attending antenatal care. It does not imply that all the population of pregnant women will be covered.
• There are limits to scaling-up activities given existing capacity and infrastructure.
The concept of coverage that underlies the cost estimates presented in this document does not assume additional investment in underlying infrastructure. As a result, the estimated costs of scaling-up HIV/AIDS activities must be discussed with reference to the increase in coverage that is assumed to take place between now and 2005.
Priority-setting
The process of priority-setting entails a strategic planning process. It will depend on factors such as the stage and characteristics of the epidemic, the cost-effectiveness of particular interventions in a setting, and the level of resources, support and implementation capacity that are available within a country.
This report provides estimates of resources, but priority-setting also needs consideration of the impact or effectiveness of the interventions for each setting. Just as information on costs was limited, information on impact and cost-effectiveness is even scarcer. While it is difficult to estimate the impact of prevention strategies, nevertheless one can start to compare comparable outputs between interventions (e.g. the number of condoms distributed and used). Gathering information on this level of intervention outcome is essential for more refinement within the priority-setting and resource allocation process.
Regardless of the stage of the epidemic there is still a need to sustain HIV prevention efforts, even though care needs are becoming more substantial. Ultimately, limiting the transmission of HIV is the long-term solution to mitigating the epidemic. There may be different prevention priorities at different stages of the epidemic. A small sub-set of interventions may be identified as priorities for scaling up and resource mobilization. As the epidemic becomes more generalized, HIV incidence becomes increasingly concentrated amongst youth. Thus interventions for students or out-of school youth become increasingly more important. Resource considerations in such a situation can help how best to reach different sections of the youth population (e.g. how can we reach the greatest number in the cheapest manner) or designing a package of key/essential services.
Given the need to intervene priority-setting also has to consider which activities can be rapidly scaled-up. The task ahead is complex. In the short term, effective activities that can be scaled-up quickly need to be identified. For rapid scaling-up, the potential to use the existing infrastructure to achieve widespread coverage must be maximized. For example, with current enrolment rates a quarter of youths aged 12-16 years could potentially be reached each year through interventions based on secondary schooling.
However, an additional 10% could be reached if prevention activities were also undertaken in the last year of primary school (Watts and Kumaranayake, 1999).
As HIV prevalence rises, there will be increasing costs associated with the higher burden of care that is needed. Thus there will be greater tensions in allocating scarce resources
between prevention and care interventions. This is particularly the case in much of SSA where the HIV epidemic is already generalized
Finally, the substantial potential to use private-sector and informal networks must also not be overlooked. Already in some countries, condoms are transported to rural areas through food-and-beverage distribution systems. More generally, the widespread involvement of different organizations and networks (such as workplaces, unions and religious and community networks) could help to increase the access of different social and geographical groups to specific activities.
The agenda ahead
There is a patchwork of mostly small-scale, prevention and care activities being implemented across SSA by public-sector and private for-profit and non-profit organizations. There is little experience of replication and expansion, so strategic and creative thinking is needed. Overall, intensified action is needed to scale-up effectively and reduce the burden of HIV/AIDS in the following areas:
• Substantial resources need to be mobilized. The estimates developed in this report suggest that if one were to scale-up a wide range of HIV/AIDS interventions, the annual cost would be US$1.5-2.3 billion. Providing antiretroviral therapy (HAART) would add another US$1.5-2.4 billion depending on the prices at which drugs would be available. These estimates are based on relatively conservative estimates of likely coverage that can be achieved by 2005. Despite the devastating impact of HIV in SSA, resources to address HIV/AIDS have been limited compared with those for other priority areas. In 1998, external spending on HIV/AIDS was about US $165 million, less than a third of the $650 million spend on childhood immunization programs (UNICEF, 1999). There is therefore a need to increase resource mobilization and strengthen partnerships to achieve feasible levels of increased coverage.
• Acting early on is essential. There is a substantial body of evidence which shows the importance of acting early to prevent the spread of the epidemic (World Bank 1997a, UNAIDS 1999a). The choice is either to pay a small price now or a much larger price latter on. But few countries can afford the latter. In the case of a typical Sub- Saharan African country with a per capita income of US$300, HIV/AIDS interventions would amount to about 1.3% of GDP when the HIV prevalence rate is less than 5%. But the cost of prevention, care and treatment (including antiretroviral therapy) would represent 10% of GDP once the prevalence rate has reached 30%
(even taking account recent price reductions and assuming that only 10% of the target group would have access). By contrast, countries that invest early on in prevention activities would be able to afford the cost of antiretroviral therapy because the total number of AIDS cases would be much less. In addition to these financial costs, one would need to take into account the broader costs imposed by the HIV epidemic in terms of the loss of young adults in their most productive years (Whiteside and Stover 1997; Stover and Bollinger, 1999).
• Additional investment in health infrastructure may be needed to compensate for the deterioration of existing levels of infrastructure and human capital caused by the HIV/AIDS epidemic. Critical on the care side, is the ability of current health system infrastructure to cope with the growing burden that HIV/AIDS imposes. For example, it has been estimated that a country with a stable 5% HIV prevalence can expect that each year between 0.5 and 1% of its health care providers will die from AIDS. In contrast, a country with a 30% prevalence would lose 3-7% of health workers to the epidemic each year (World Bank, 1997a). About 50-70% of medical beds in large hospitals are taken by patients with HIV-related illnesses. This suggests the need for complementary actions to sustain and expand current levels of infrastructure. In addition, the education sector is also likely to be seriously affected.
A recent survey in Malawi found that the rate of HIV infection among school- teachers was 30% (UNICEF, 1999). This will seriously compromise the ability and sustainability of prevention efforts within schools, where trained teachers have a critical role.
• Specific interventions may be needed for countries that were classified as very low program strength. In some cases, the increase in coverage that can be achieved with the existing infrastructure may be too low. Without additional investment, it may not be feasible to contain the epidemic. In addition, many of these countries face disruptions due to conflict situations. Thus a real question is how to implement activities when there are constraints which are more than limited infrastructure. This has been outside of the current analysis, but is crucial to consider in the implementation of policy.
• Key gaps in information need to be addressed. Knowledge is lacking about the relative quality, efficiency and cost-effectiveness of various interventions as their implementation is scaled-up. It is clear that we cannot wait for better information before implementation, given the need to act quickly. However during implementation, key gaps in information need to be addressed. Thus it is crucial to document the costs, cost-effectiveness and operational learning so that experiences can be shared and successes quickly replicated.
It is our hope that better resource determination will lead to resource mobilization and to hurrying up action for HIV prevention and care for people living with HIV/AIDS.
II. SCALING-UP HIV/AIDS INTERVENTIONS:
WHAT DOES IT MEAN?
A. Introduction
HIV/AIDS is now the largest cause of mortality in SSA, accounting for 2.7 million deaths in 1999, more than double the number of deaths from malaria and one and half times the number of deaths from tuberculosis (WHO, 2000a). Globally, estimates suggest that at the end of 1999, some 34.3 million people were infected with HIV and 18.8 million people had already died. HIV/AIDS is now the fourth cause of death in the world. In 1999 alone, there were 5.4 million new infections. HIV infections are concentrated in the developing world and particularly in Sub-Saharan Africa, where almost 71% of people with HIV live (UNAIDS, 2000a). The prevalence in SSA is at epidemic levels, with 22 countries already having adult HIV prevalence rates of 5% or more, seven countries having an adult prevalence over 15% and fifteen countries having prevalence rates of more than 10% among pregnant women. Because of these high prevalence levels, it is estimated that 10% of all new infections occur in infants, through mother to child HIV transmission.
Experience from the first fifteen years of the HIV epidemic has led to many forms of HIV prevention and care activities being implemented by a range of organizations – including public sector, private sector and Non-Governmental Organizations (NGOs). Prevention strategies include different methods to promote behavioral change and condom use (such as peer education activities with different sub-groups, mass media campaigns and in- school education); distribution of male and female condoms (including through social marketing, public sector distribution and community-based distribution); strengthening of sexually transmitted disease treatment services; and initiatives to ensure a safe blood supply. There have also a number of important recent developments, including short course treatments to prevent mother-to-child HIV transmission. Care initiatives aim to provide basic care and support to those living with and affected by HIV/AIDS. These include activities to help the health sector cope with the increased workload resulting from HIV/AIDS morbidity; home based care projects; and initiatives to support community based care and orphan support. In addition, there have been substantial advancements in the effectiveness of antiretroviral (ARV) treatment for people infected with HIV. However, the high price of the drugs and the logistical requirements for delivery of the treatment regimens continue to pose a significant barrier to wide-spread implementation in SSA.
While there are strong HIV/AIDS interventions across Africa, few are implemented at a national scale. Likewise, many people with HIV/AIDS do not have access to even basic drugs, which could dramatically reduce the burden of a range of common, treatable opportunistic infections. Yet the experiences of countries like Uganda and Senegal, which have been successful in mitigating the epidemic, suggest the importance of a national and coordinated response. Thus, a key priority in addressing the HIV/AIDS crises in SSA is the rapid expansion of activities. To do this, a key question is how much
would it cost to scale-up different HIV prevention and care strategies in Sub-Saharan Africa?
B. What is Scaling up? Definitions and Modeling Approach
This study develops and discusses a model designed to estimate the costs of scaling-up HIV/AIDS interventions. Scaling-up refers to increasing the level of coverage of HIV activities from current levels as well as expanding the type of HIV/AIDS programs.
Currently, there is very little information available on the relative cost and likely impact of each program in different settings, either individually or in combination. When estimating the costs of scaling-up activities there are two challenges: first, to obtain any available costs for these strategies from the empirical literature and second, to scale-up these costs for national programs. Due to the low national coverage of many programs, even when cost information is available, it is generally obtained at the individual facility or project level, operating on a small-scale (e.g. community or district). For this reason, we adopt a model-based approach (Resource Determination Model) to estimate the required scale of the programs and the likely costs for implementing these strategies.1 The Resource Determination Model (RDM) entails the following steps:
1. Establishing the size of those who are at risk or in need and will benefit from different HIV/AIDS programs. Available demographic, behavioral and epidemiological data are used to determine the size of the relevant target or population groups for which the programs are designed to reach.
2. Defining the Potential Target Group and current and future levels of coverage.
For most of the programs, existing levels of capacity and infrastructure of the health systems will limit the proportion of the target groups that can be reached.
These limits are reflected in the number of people that can be currently reached by the programs. This group is referred to as the potential target group (PTG).
The model incorporates measures of coverage of the PTG for the base year (2000) and the year 2005. These target levels of coverage reflect what is thought to be realistically achievable by 2005, given the current low levels of coverage for many HIV/AIDS-related activities in SSA. Using the PTG and coverage levels, the model then estimates the increased volume of activity that is required for each intervention in order to reach the year 2005 coverage targets.
3. Estimation of costs. The model takes facility or project-level cost data from the published and grey literature to obtain baseline average costs for the delivery of each health program (including costs of personnel, commodities, and capital items). The costs of scaling up interventions are then estimated based on the current and projected (2005) target levels of coverage. Since the model estimates costs that are associated with different levels of coverage of PTG,
1As discussed in Kumaranayake and Watts (2000a). “Scaling up Priority Health Programmes: A problem of Constrained Optimisation.”
these cost estimates should always be judged in relation to the PTG, as they depend on the level of coverage that have been projected to be achieved.
Thus, the extent of scaling-up activities is achieved by determining the feasible coverage of HIV/AIDS interventions for each potential target group. The general model that was adopted for scaling-up activities and estimating their costs is summarized in Figure 2.1.
The model uses epidemiological, behavioral, socio-economic, health system and intervention-specific data inputs to estimate the PTG for each country. The model yields estimates of the costs of scaling-up prevention and care programs for some 37 Sub- Saharan African countries. The resulting cost estimates provide an annual cost of implementing a scaled-up HIV/AIDS program based on the overall coverage of the target groups that could be attained by 2005.
However, it is important to note that some elements of a comprehensive national HIV/AIDS program such as legal interventions have not been included in this study. In addition, we have focused upon estimating the costs of scaling up HIV prevention and care initiatives, given existing levels of infrastructure and capacity. Without more substantial structural change, such factors will inevitably affect the overall coverage that can be achieved.
Country-Specific Potential Target Group
Additional Resource Requirements by country and intervention Scaling-Up
Increased coverage of intervention
Intervention-specific Unit Costs
Figure 2.1: Resource Determination Model
Country-Specific Factors Demographic Socio -economic
Health system
Intervention- Specific Factors
Billion $US 2000 Estimates for 37 countries
Country-Specific Factors
Behavioral Epidemiological
C. Outline of Report
The various components of a comprehensive HIV/AIDS program are described in Chapter 3. Chapter 4 outlines the potential target group approach that was followed in order to estimate the cost of scaling-up HIV/AIDS programs in Sub-Saharan Africa. The costs of scaling-up HIV/AIDS programs are the subject of Chapter 5. The essential concept of the potential target groups (PTG) is discussed in Annex 1. Annex 2 summarizes the source of the unit cost data.
III. HIV/AIDS INTERVENTIONS
While most developing countries have some elements of a comprehensive HIV/AIDS program, very few have all the components actually in place. Most programs 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 programs 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 program 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 program.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 safe-guard 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 activities
The following set of HIV prevention activities were considered:
• Youth interventions (in and out-of-school youth)
• Sex worker interventions
• Strengthening public sector condom distribution
• Condom social marketing
• Strengthening Sexually Transmitted Disease (STD) treatment services
• Voluntary counseling and testing (VCT)
• Workplace interventions
• Strengthening blood transfusion services
• Prevention of mother-to-child transmission (MTCT)
• Mass media campaigns
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 have been adapted from “Costing Guidelines for HIV/AIDS Prevention Strategies.” UNAIDS Best Practice Collection. Kumaranayake et al (2000).
Youth Interventions
There are two main ways in which HIV prevention strategies aim to reach youth:
HIV/AIDS school education programs for youth in schools, and education activities for youth that are not enrolled in school. HIV/AIDS school education programs 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 program 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 was available.
Interventions Focused on Sex Workers and their Clients
In 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 centers, 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 for a commercial enterprise. Peer CSWs may be volunteers, or salaried staff. Often such interventions are delivered by NGOs. The unit costs correspond to a NGO peer education project with formal and informal sessions, including both promotion of condoms and recognition and management of STDs.
Strengthening Public Sector Condom Distribution
Public sector condom distribution occurs through various outlets such as health facilities and workplaces, depending on the nature of government programs. 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 for the estimation of costs are taken from a national program of public sector condom distribution with free distribution through public channels.
Condom Social Marketing
Condom social marketing (CSM) was initially undertaken to socially market contraceptives. 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 Services
STDs 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 with 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 between 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 to 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 centers, 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 Interventions
Workplace 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 Services
It is estimated that between 5% and 10% of HIV infections world-wide 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 the HIV prevalence among the donor population, this was not factored this 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)
The implementation of the intervention entails the counseling and HIV testing of pregnant women, and the delivery of the treatment regimen to women testing HIV positive and requesting ARV treatment. The implementation of the intervention entails the counseling and HIV testing of pregnant women, and the delivery of the treatment regimen to women testing HIV positive and requesting 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 also have 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 Media
A 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 Activities
Given 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:
• Stage 1: Asymptomatic
• Stage 2: Progression of HIV with minor symptoms such as weight loss, minor skin and oral problems and herpes zoster
• Stage 3: Onset of more severe symptoms such as tuberculosis (TB), oral candidiasis, and greater than 10% weight loss associated with diarrhea
• Stage 4: Onset of clinical AIDS accompanied by more serious opportunistic infections and illnesses such as advanced TB.
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 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:
• Asymptomatic people
• Symptomatic people (stages 2 and 3)
• People living with AIDS (PLWA) (stage 4).
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 care
• Clinical management of opportunistic infections (OI)
• Prophylaxis for prevention of OI
• Home-based care for AIDS patients
• Care for children
• Support for orphans
• Psycho-social support and counseling
• Treatment with antiretrovirals Palliative Care
Palliative 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 Illnesses
People 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 in-patient 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 Illnesses
Interventions 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 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 wide-spread 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 Patients
Home-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 to scale up these programs, 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, no attempt was made to provide separate cost estimates for hospice care.
Care for Orphans
Orphans (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
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).
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 Counseling
This 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. Treatment
Prior 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 relates the most recent data on prices as well as the costs of the implementing the required technology for monitoring, training of health facility personnel, and strengthening of facilities in order to implement ARV treatment and to undertake appropriate clinical management of the PTG.
D. Institutional Strengthening
No 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 program by four levels (very low, low, medium and strong). The classification of countries according to program strength is shown in Chapter 4 and unit cost estimates for institutional strengthening are presented in Chapter V.
IV. SCALING-UP THE COVERAGE OF POTENTIAL TARGET GROUPS The approach used in the model is to cost HIV/AIDS interventions using country-specific estimates of the potential target groups (PTG) that are to be reached by prevention and care activities. For each intervention considered, a relevant target group is defined using epidemiological, behavioral and intervention-specific data. The concept of a PTG is used to ensure that the scaling-up of interventions is based upon what may be potentially feasible levels of implementation, given current levels of infrastructure and capacity development. Combined with information on project average or unit costs, this approach makes it possible to estimate the costs of scaling-up associated with different levels of coverage.
A. Definition of Potential Target Groups
The definition of the PTG for various HIV/AIDS interventions is shown in Table 4.1. A more detailed discussion of the PTG approach is presented in Annex 1. The RDM allowed for urban and rural differences in the size of the PTG for each country. The interaction between the PTG, the coverage levels and the delivery mode of the intervention will yield the volume of activities that require to be costed when scaling-up.
Details of the coverage levels and calculation of the volume of activities are given in sections B and C.
Table 4.1: Potential Target Groups (PTG) for HIV/AIDS Intervention Activities
Activity/Intervention Potential Target Group Youth Interventions in
school
Male and female youth enrolled in primary schools (age 6-11) Male and female youth enrolled in secondary schools(12-16) Out of school youth Male and female youth aged 6-11 not enrolled in schools
Male and female youth aged 12-16 not enrolled in schools Sex Worker Interventions Sex workers in urban areas
Strengthening Public Sector Condom Distribution
Protection by condoms for all casual sex acts and of sex acts in regular partnerships
(proportion of sex acts in regular partnerships set at 2% for the analysis) Condom Social Marketing
(including the female condom)
Protection by condoms for all casual sex acts and proportion of sex acts in regular partnerships (proportion of sex acts in regular partnerships set at 2% for the analysis)
Men (15-49) with curable symptomatic STDs who have access to health services
Non-pregnant females (15-49) with curable symptomatic STDs who have access to health services
Strengthening STD services
Pregnant women with syphilis and access to health services VCT Current sexually active population
Workplace Interventions HIV prevention activities: all males and females in formal employment STD treatment: same sub-groups as those for strengthening STD services, but limited to those in workplaces that have STD treatment
Condom distribution: the number of sex acts requiring a condom (set at 100% causal and 2% of regular partnerships) for those in formal employment
Strengthening blood transfusion services
Units of blood used in transfusions
Screening (VCT): Pregnant women 15-49 with access to ante-natal services
Prevention of MTCT
ARV treatment for pregnant women testing positive and formula milk for infants
Mass media National campaigns for entire country
Palliative care People who are HIV- infected and symptomatic Clinical management for
opportunistic illnesses
People who are HIV- infected and with access to health services.
Home-based care People who are living with AIDS (PLWA) and access to health services Clinical care for children. Includes palliative care for all children who are HIV positive and
symptomatic, and clinical care for children who are HIV positive and symptomatic with access to health services
Prevention of opportunistic infections (cotrimoxazole and tuberculosis preventive therapy)
People who are HIV-infected and symptomatic and have access to health services
Support for orphans All AIDS orphans less than 15 years old Psycho-social Support;
counseling
People who are HIV- infected and symptomatic
Treatment (HAART) People who are HIV-infected and symptomatic and have access to health services
Figure 4.1: Interaction between the PTG, Coverage and Activities Required to be Costed – The Example of MTCT
Volume of activities to be costed for
MTCT Antenatal population
Intervention: Women offered antiretroviral or feeding intervention (measure of implementation of intervention)
PTG for screening activities:
Women attending antenatal services
Intervention: Women being HIV tested (coverage targets relate to this variable)
PTG for antiretroviral/feeding intervention:
Women testing positive
Intervention: Women taking up regimen (coverage targets relate to this variable)
Figure 4.1 provides an example of how the model defines the PTG and how intervention- specific measures of delivering the intervention and capacity limits will affect the size of the PTG in the case of Mother-To-Child Transmission (MTCT). Since MTCT interventions are primarily provided by secondary and tertiary level health facilities, scaling-up MTCT prevention activities refers to increasing the coverage among pregnant women attending antenatal facilities. There are two interventions related to MTCT that are being costed: screening among the antenatal population who attends antenatal services, and the delivery of antiretroviral/feeding intervention.
In this example, the size of the two PTG reflects capacity constraints, which determine the proportion of women receiving access to and attending antenatal services. What determines the coverage levels is the proportion of the women being tested HIV (and thus knowing their HIV status), and the proportion of women who agree to take the ARV regimen of drugs. The volume of activities to be costed and the corresponding cost estimates relate to the specific coverage targets.
B. Coverage of Target Groups: Baseline and Target Levels
A key constraint that affects the feasible increase in coverage is the level of health infrastructure. Once a certain coverage level of target groups is achieved, further increases in coverage cannot be attained without additional investments in health infrastructure. In the model used for estimating the costs of scaling-up, it was assumed that the increase in coverage would proceed up to the point where no additional investment could be used without additional investments in capacity development and
infrastructure. As this clearly varies by country, the feasible increase in coverage was estimated country by country.
Another important constraint is that the feasible increase in coverage depends on the initial situation of each country. In principle, one would expect that the coverage of target groups by 2005 would be higher in countries where there are already strong HIV/AIDS programs than in countries where existing programs are weak or fragmented.
To take this into account, countries were classified by the strength of their existing HIV/AIDS activities in three categories (very low, low, medium or strong existing program strength). Strong program countries included Uganda and Senegal, countries that have successfully abated the HIV epidemic. Very low strength program countries included a number of countries that are currently in conflict (such as Liberia and Eritrea), or where conflict has only recently abated (such as Somalia). The classification is shown in Table 4.2.
Table 4.2: Estimated Strength of HIV/AIDS Program Activities by Countries
Very Low Low Medium Strong
Angola Benin Botswana Senegal
Congo Burkina Faso Cameroon Uganda
DR Congo Burundi Central African Rep.
Djibouti Chad Cote d’Ivoire
Eritrea Equatorial Guinea Kenya
Ethiopia Gabon Lesotho
Liberia Gambia Malawi
Nigeria Ghana Mauritania
Sierra Leone Guinea Mozambique
Somalia Guinea Bissau Tanzania
Madagascar Namibia
Mali South Africa
Mauritius Swaziland
Niger Zambia
Rwanda Zimbabwe
Togo
Note: Due to a lack of data, estimates were not made for countries in italics.
The potential coverage of current HIV/AIDS interventions that was thought to be feasibly achieved by the year 2005 was projected for each of the HIV/AIDS strategies. Due to the paucity of information regarding current levels of coverage of care activities, baseline coverage estimates for care strategies were not made. Instead, the potential increases in coverage for care that could be achieved between 2000 and 2005 were estimated taking into account the ability of the current health system to absorb a higher level of activity.
Table 4.3: Estimates of Baseline and Target Levels of Coverage for the Year 2005 for HIV/AIDS Interventions by Program Strength
Coverage Estimates for HIV/AIDS Interventions
Baseline coverage estimate 2005 coverage estimate Very
Low
Low Med. Strong Very Low
Low Med. Strong Youth interventions
% required primary teachers trained
5% 5% 10% 20% 40% 50% 60% 60%
% required secondary teachers trained
20% 20% 30% 50% 60% 70% 80% 80%
% out of school youth reached 6 - 11
5% 5% 10% 10% 10% 10% 15% 15%
% out of school youth reached 12 - 15
5% 5% 10% 20% 30% 40% 50% 50%
Interventions focused on sex workers and clients
% sex workers reached by intervention per year
20% 20% 40% 50% 40% 50% 60% 60%
Average consistency of condom use
20% 25% 30% 30% 50% 60% 70% 80%
% condoms female 5% 5% 5% 5% 5% 5% 5% 5%
Increased public sector condom provision
% of sex acts in which public sector condoms used
5% 10% 20% 30% 10% 20% 30% 40%
Condom wastage during storage & distribution
10% 10% 10% 10% 10% 10% 10% 10%
Condom social marketing
% of sex acts in which CSM condoms used
5% 10% 20% 30% 30% 40% 50% 50%
% of CSM condoms provided female
10% 10% 10% 10% 10% 10% 10% 10%
Improving STD management
% male symptomatic STDs treated at clinics
5% 5% 15% 20% 30% 30% 30% 40%
% female symptomatic STDs treated at clinics
5% 5% 15% 20% 30% 30% 30% 40%
% syphilis among ANC women detected & treated
5% 5% 15% 20% 30% 30% 40% 50%
Voluntary counseling and testing Urban coverage sexually
active 15 – 49
1% 1% 1% 1% 5% 5% 5% 5%
Rural coverage sexually active 15 – 49
0% 0% 0% 0% 5% 5% 5% 5%
