Background: Economic theory and limited empirical data suggest that costs per unit of HIV prevention program output (unit costs) will initially decrease as small programs expand. Unit costs may then reach a nadir and start to increase if expansion continues beyond the economically optimal size. Information on the relationship between scale and unit costs is critical to project the cost of global HIV prevention efforts and to allocate prevention resources efficiently.

IntroductionNumerous barriers to optimal uptake of prevention of mother to child transmission (PMTCT) services occur at community level (i.e., outside the healthcare setting). To achieve elimination of paediatric HIV, therefore, interventions must also work within communities to address these barriers and increase service use and need to be informed by evidence. This paper reviews community-based approaches that have been used in resource-limited settings to increase rates of PMTCT enrolment, retention in care and successful treatment outcomes. It aims to identify which interventions work, why they may do so and what knowledge gaps remain.MethodsFirst, we identified barriers to PMTCT that originate outside the health system. These were used to construct a social ecological framework categorizing barriers to PMTCT into the following levels of influence: individual, peer and family, community and sociocultural. We then used this conceptual framework to guide a review of the literature on community-based approaches, defined as interventions delivered outside of formal health settings, with the goal of increasing uptake, retention, adherence and positive psychosocial outcomes in PMTCT programmes in resource-poor countries.ResultsOur review found evidence of effectiveness of strategies targeting individuals and peer/family levels (e.g., providing household HIV testing and training peer counsellors to support exclusive breastfeeding) and at community level (e.g., participatory women’s groups and home-based care to support adherence and retention). Evidence is more limited for complex interventions combining multiple strategies across different ecological levels. There is often little information describing implementation; and approaches such as “community mobilization” remain poorly defined.ConclusionsEvidence from existing community approaches can be adapted for use in planning PMTCT. However, for successful replication of evidence-based interventions to occur, comprehensive process evaluations are needed to elucidate the pathways through which specific interventions achieve desired PMTCT outcomes. A social ecological framework can help analyze the complex interplay of facilitators and barriers to PMTCT service uptake in each context, thus helping to inform selection of locally relevant community-based interventions.

Context-Highly active anti-retroviral therapy (ART) provides dramatic health benefits for HIVinfected individuals in Africa, and widespread implementation of HAART is proceeding rapidly. Little is known about the cost and cost-effectiveness of HAART programs.Objective-To determine the incremental cost-effectiveness of a home-based HAART program in rural Uganda.Design, setting and patients-Computer-based, deterministic cost-effectiveness model to assess a broad range of economic inputs and health outcomes. From the societal perspective we compared the cost-effectiveness of HAART and cotrimoxazole prophylaxis with cotrimoxazole alone, and with the period before either intervention. Data for 24 months were derived from a trial of HAART in 1,045 patients in Tororo District in eastern Uganda. Costs and outcomes were projected out to 15 years. All costs are in 2004 U.S. dollars.Interventions-First-line HAART regimen consisted of standard doses of stavudine, lamivudine, and either nevirapine or, for clients with active tuberculosis, efavirenz. Second-line therapy consisted of tenofovir, didanosine, and lopinavir/ritonavir. For children, first-line HAART consisted of Correspondence to: Dr. Elliot Marseille, Health Strategies International, 1743 Carmel Drive #26, Walnut Creek, CA 94596, USA, Ph: +1-925-392-4444, emarseille@comcast.net. Conflict of Interest StatementAll authors declare that they have not conflicts of interest to declare. We will provide signed statements to that effect as needed. Contributor shipElliot Marseille (First author): Concept, Design, Parameter estimation, Literature review, Analysis, Writing. Dr. Marseille had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Ethical approvalNo ethical approval was required for this research. NIH Public Access Author ManuscriptAppl Health Econ Health Policy. Author manuscript; available in PMC 2010 July 29. Published in final edited form as:Appl Health Econ Health Policy. 2009 ; 7(4): 229-243. doi:10.2165/11318740-000000000-00000. NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript zidovudine, lamivudine and nevirapine syrup; second-line therapy was stavudine, didanosine and lopinavir/ritonavir.Main outcome measures-HAART program costs, the health benefits accruing to HAART recipients, averted HIV infections in adults and children, and resulting effects on medical care costs.Results-The HAART program standardized for 1,000 patients cost an incremental $1.39 million in its first two years. Compared with cotrimoxazole prophylaxis alone, the program reduced mortality by 87%, and averted 6,861 incremental disability adjusted life-years (DALYs). Benefits accrued from reduced mortality in HIV-infected adults, (67.5% of all benefits), prevention of death in HIVnegative children (20.7%), averted HIV infections in adults (9.1%) and children (1.0%), and improved health status (1.7%). The net program cost, including the medical cost implications of these ...

Screening infants with RHT before DNA-PCR is cost-effective in infants 3 months old or older. Incorporating RHT into early infant testing programs could improve cost-effectiveness and reduce program costs.

Safe water systems (SWSs) have been shown to reduce diarrhea and death. We examined the cost-effectiveness of SWS for HIV-affected households using health outcomes and costs from a randomized controlled trial in Tororo, Uganda. SWS was part of a home-based health care package that included rapid diarrhea diagnosis and treatment of 196 households with relatively good water and sanitation coverage. SWS use averted 37 diarrhea episodes and 310 diarrhea-days, representing 0.155 disability-adjusted life year (DALY) gained per 100 person-years, but did not alter mortality. Net program costs were 5.21 dollars/episode averted, 0.62 dollars/diarrhea-day averted, and 1,252 dollars/DALY gained. If mortality reduction had equaled another SWS trial in Kenya, the cost would have been 11 dollars/DALY gained. The high SWS cost per DALY gained was probably caused by a lack of mortality benefit in a trial designed to rapidly treat diarrhea. SWS is an effective intervention whose cost-effectiveness is sensitive to diarrhea-related mortality, diarrhea incidence, and effective clinical management.

Daily cotrimoxazole prophylaxis for HIV-infected individuals is highly cost-effective in rural Uganda. The use of screening algorithms to identify individuals with advanced HIV disease may result in higher program costs and less favorable cost-effectiveness.

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