Making HIV Prevention Programs Work Lancet HIV Prevention
- Slides: 16
Making HIV Prevention Programs Work Lancet HIV Prevention Series XVII International AIDS Conference Mexico City, August 2008 Stefano M Bertozzi Marie Laga Sergio Bautista-Arredondo Alex Cautinho
The glass half empty • • • 25 years of prevention efforts for an easily preventable disease Billions of dollars spent 2. 7 million new infections/year in 2007 What is wrong? Three obvious options: 1. Available interventions not sufficiently effective 2. Poor implementation of available interventions 3. Not enough spent on prevention • All are true
1) Available interventions not sufficiently effective Insufficient knowledge: • Biomedical: Continue research efforts: vaccines, microbicides, Pe. EP, etc. • Behavioral: Expand research efforts: • -- e. g. learn from the empirical behavioral research done by private sector marketers; develop mass mobilization interventions for high prevalence settings; refine tailored interventions for key populations • Structural: Expand research efforts • how to change the drivers in different settings?
2) Poor implementation of available interventions • WHAT: Combination of interventions not matched to the characteristics of the national/local epidemic
Source of New HIV Infections by Region
Percent Coverage of Prevention Interventions
2) Poor implementation of available interventions • WHAT: Combination of interventions not matched to the characteristics of the national/local epidemic – KNOWLEDGE GAP: Effectiveness of different interventions in different settings • WHO/WHERE: Interventions not targeted to the right people: – age, sex, sub-group, location – KNOWLEDGE GAP: Expected incidence patterns -- better epi, better tools • HOW: Programs poorly managed: – high costs, low quality, low coverage
Programs poorly managed: Enormous variation in unit costs Cost per VCT Completed (unit cost) $1000 Mexico Uganda Russia India South Africa $100 $1 0 10 1000 10, 000 Annual Clients Completing VCT (scale)
Programs poorly managed: Enormous variation in unit costs Cost per VCT Completed (unit cost) $1000 Mexico Uganda Russia India South Africa $100 $1 0 10 1000 10, 000 Annual Clients Completing VCT (scale)
Programs poorly managed: Enormous variation in unit costs Cost per VCT Completed (unit cost) $1000 Mexico Uganda Russia India South Africa $100 $1 0 10 1000 10, 000 Annual Clients Completing VCT (scale)
2) Poor implementation of available interventions • WHAT: Combination of interventions not matched to the characteristics of the national/local epidemic – KNOWLEDGE GAP: Effectiveness of different interventions in different settings • WHO/WHERE: Interventions not targeted to the right people: – age, sex, sub-group, location – KNOWLEDGE GAP: Expected incidence patterns -- better epi, better tools • HOW: Programs poorly managed: – high costs, low quality, low coverage – DATA GAP: provider-level cost, quality & coverage • CAPACITY GAP CRITICAL TO ALL ABOVE
3) Not enough spent on prevention • How much should a country spend on prevention?
Optimal Scale for National HIV Prevention Program? Cost Per Marginal HIV Infection Prevented Mexico B A South Africa Competing National Priorities $0. 50 $10 $ Per Capita on HIV Prevention
Recommendations • Continue to invest in vaccines & microbicide development • Develop new technologies to measure HIV incidence and software/tools to model epidemic behavior • Innovate & experiment with new behavioral and structural prevention approaches • LEARN WHILE DOING -- incorporate impact evaluations throughout programs with uncertain effectiveness
Recommendations (2) • Invest in education, not just training -- generate excess capacity to analyze/plan, to implement, to manage, & to evaluate • Tie funding to performance • fund via the most efficient mechanism (e. g. WB, GF, bilateral) • fund the most efficient implementors, whether US-based or not; private, governmental or NGO; without pointless shackles (e. g. prostitution pledges) • We need to generate new knowledge, collect better data, and strengthen our capacity to use data to manage more effectively • but none of those are excuses for not doing more and better with the people and tools we currently have
sbertozzi@insp. mx MLaga@itg. be sbautista@insp. mx acoutinho@idi. co. ug
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