ASAP Regional Training on Epidemiological and Economic Tools for HIV/AIDS Strategic Planning S P Optimizing HIV/AIDS prevention programs: towards multidimensional allocative efficiency Sergio Bautista Paola Gadsden Stefano M Bertozzi
HIV/AIDS Prevention Resources Consensus about the importance of increasing investment in prevention How? Which interventions? For whom? Implemented how? 2
Today Until now, the discussion regarding optimal resource allocation for HIV prevention has focused on two dimensions: Allocation among interventions Allocation among subpopulations 3
Dimension 1: Allocation among interventions To interventions that produce the greatest value for money Cost-effectiveness Analysis (CEA) 1993, World Development Report Investing in Health Disease Control Priorities in Developing Countries (1993) Disease Control Priorities in Developing Countries (2006) 4
HIV/AIDS Prevention and Care Stefano M. Bertozzi, MD, PhD Director, Health Economics and Evaluation, National Institute of Public Health, Mexico; Part-time faculty CIDE and University of California, Berkeley Nancy S. Padian, PhD, MPH Professor, Obstetrics, Gynecology & Reproductive Sciences Associate Director for Research, Global Health Sciences and AIDS Research Institute: University of California, San Francisco Thanks to David Wilson, World Bank for many of these slides
Dimension 1: Allocation among interventions Y Comparison of two different interventions in the same subpopulation Benefit Y2 Y1 Intervention VCT Intervention IEC X1 Investment X 6
Dimension 2: Allocation among subpopulations To subpopulations at greatest risk of acquiring and/or transmitting HIV infection 7
Subpopulations: Unified Prevention Theory Prevention Interventions Low Level Key Populations Concentrated General Population Generalized Low Generalized High Low HIV PREVALENCE High 8
Dimension 2: Allocation among subpopulations Y Comparison of the same intervention in two different subpopulations Benefit Y1 Street-based Sex Workers Y2 Brothel-based Sex Workers X1 Investment X 9
Evidence of performance in these two dimensions? 10
3 Information for Dimension 1 Low-level Concentrated Generalized Generalized Intervention epidemic epidemic low-level high-level Blood safety 1 study found 1 study found 4 studies found 2 studies found ART to reduce MTCT 2 studies found 3 studies found 3 studies found Sterile injection 1 study found 2 studies found 1 study found 1 study found 3 5 8 VCT 1 study found 2 studies found Peer-based programs 4 studies found 4 studies found STI treatment 3 studies found 1 study found School-based education Harm reduction for IDU ART for prevention and postexposure prophylaxis Condom promotion, distribution and IEC Condom social marketing Surveillance IEC Abstinence education MTCT, feeding substitution Drug substitution for IDU Universal precautions Vaccines Behavior change those HIV+ 1 study found 2 studies found 1 study found 1 study found 1 study found No cost-effectiveness studies found Source: Bertozzi SM, Padian N, Wegbreit J. et al. 2006. HIV/AIDS prevention and treatment. In: DCP2 11
Dimension 1: Example Allocation of resources to interventions 100% IEC Condoms VCT STI PMTCT Blood Safety Other 80% 60% 40% 20% 0% Mauritania (0.6%) Madagascar (0.9%) Ghana (4.6%) Burkina (7.2%) Cameroon (7.2%) Uganda (10%) Mozambique (14.5%) Zambia (20%) Source: World Bank. 2005. Review of National HIV/AIDS Strategies for Countries Participating in the World Bank s Africa Multi-Country AIDS Program (MAP). Concentrated Generalized Low Generalized High 12
Information needs for Dimension 2 Epidemiological surveillance Behavioral surveillance Country specific 13
Dimension 2: Example Coverage of subpopulations by region (2003) IDU Sex Workers MSM Prisoners Children living on the street 100% Primary Students Secondary Students 80% 60% 40% 20% 0% Africa Eastern Mediterranean Eastern Europe Americas South-East Asia Western Pacific All Reporting Countries Source: USAID, et al. 2004. Coverage of selected services for HIV/AIDS prevention, care and support in low and middle income countries in 2003. Less than 20% of coverage: IDU, SW, MSM 14
Interventions (1) 15 Subpopulations (2)
Optimal Allocation Framework 100 % There are different combinations of allocative efficiency that produce the same health result Subpopulations Isobenefit curve 2 0 % 100 % Interventions Isobenefit curve 1 16
Interventions (1) 17 Subpopulations (2) Inputs (3)
Dimension 3: Management of service delivery Optimal combination of inputs used to produce a given intervention Cost-effectiveness analysis typically assumes constant (optimal?) efficiency of implementation across sites A cost-effective intervention may turn out to be very cost-ineffective if implemented inefficiently 18
Management of service delivery 19
Dimension 3: Management of service delivery Y Not all implementations of VCT intervention are at its efficiency frontier Y2 Intervention VCT Y1 Benefit Investment X1 X 20
Information needs for Dimension 3 Monitoring performance at the level of the facility Characteristics of best performers Technological Organizational 21
1,000 Scale and Average Unit Cost of VCT programs in 5 countries US$ Average Unit Costs 100 10 1 1 10 100 1,000 10,000 100,000 Annual clients receiving VCT Mexico Uganda Russia India South Africa Source: Preliminary analysis of PANCEA data. Unpublished data. 2006 22
1,000 Scale and Average Unit Cost of VCT programs in 5 countries US$ Average Unit Costs 100 10 1 1 10 100 1,000 10,000 100,000 Annual clients receiving VCT Mexico Uganda Russia India South Africa Source: Preliminary analysis of PANCEA data. Unpublished data. 2006 23
1,000 Scale and Average Unit Cost of VCT programs in 5 countries US$ Average Unit Costs 100 10 1 1 10 100 1,000 10,000 100,000 Mexico Annual clients receiving VCT Source: Preliminary analysis of PANCEA data. Unpublished data. 2006 24
Optimal Allocation Framework 100 Inputs (3) 100 Subpopulations (2) Optimal allocation C 0 Interventions (1) 100 B A 25
Optimal Allocation Framework Optimal allocation Inputs (3) Subpopulations (2) Interventions (1) 26
Allocation Costs -- Subpopulations Cost of Allocation Cultural costs lnformation costs 0 Allocation efficiency 100 % among subpopulations 27
Allocation Costs -- Interventions Cost of Allocation Cultural costs lnformation costs 0 Allocation efficiency 100 % among interventions 28
Allocation Costs -- Inputs Cost of Allocation Cultural costs lnformation costs 0 Allocation efficiency 100 % among inputs 29
Summary Three dimensions to achieve allocative efficiency in prevention: Allocation among interventions Allocation among subpopulations Allocation for efficient service delivery Not independent In combination determine the level of effectiveness of an allocation decision 30
Summary The 3 rd has been largely ignored and it may well be the one where the marginal return to investment in improving efficiency is greatest Importance of Strategic plans that are well linked to operational plans and effective program management Improving overall efficiency is possible by improving efficiency in one dimension Consideration of relative costs of improving efficiency in each of the dimensions 31
sbautista@insp.mx pgadsden@insp.mx sbertozzi@insp.mx