Long-Term Financing Needs for HIV Control in Sub-Saharan Africa in 2015-2050

OBJECTIVES:

To estimate the present value of current and future funding needed for HIV treatment and prevention in 9 sub-Saharan African (SSA) countries that account for 70% of HIV burden in Africa under different scenarios of intervention scale-up. To analyse the gaps between current expenditures and funding obligation, and discuss the policy implications of future financing needs.

DESIGN:

We used the Goals module from Spectrum, and applied the most up-to-date cost and coverage data to provide a range of estimates for future financing obligations. The four different scale-up scenarios vary by treatment initiation threshold and service coverage level. We compared the model projections to current domestic and international financial sources available in selected SSA countries.

RESULTS:

In the 9 SSA countries, the estimated resources required for HIV prevention and treatment in 2015-2050 range from US$98 billion to maintain current coverage levels for treatment and prevention with eligibility for treatment initiation at CD4 count of <500/mm(3) to US$261 billion if treatment were to be extended to all HIV-positive individuals and prevention scaled up. With the addition of new funding obligations for HIV-which arise implicitly through commitment to achieve higher than current treatment coverage levels-overall financial obligations (sum of debt levels and the present value of the stock of future HIV funding obligations) would rise substantially.

CONCLUSIONS:

Investing upfront in scale-up of HIV services to achieve high coverage levels will reduce HIV incidence, prevention and future treatment expenditures by realising long-term preventive effects of ART to reduce HIV transmission. Future obligations are too substantial for most SSA countries to be met from domestic sources alone. New sources of funding, in addition to domestic sources, include innovative financing. Debt sustainability for sustained HIV response is an urgent imperative for affected countries and donors.

Below:  Annual resources required by nine sub-Saharan countries (US$ billions) from 2015 to 2050 (3% discounting).

Below:  Per capita annual resources required by nine sub-Saharan countries ($US) from 2015 to 2050 (3% discounting).

Below:  Total expenditures on HIV from domestic and international sources combined (current US$) in selected sub-Saharan African countries, compared with estimated resource needs for treatment, prevention and structural interventions in 2015 under different coverage levels and eligibility for treatment. EAE, external AIDS expenditure; GEA, Government Expenditure on AIDS; RNE, resource needs estimate. GEA and EAE estimates are from Resch et al 2015.

Full article at:   http://goo.gl/C2PXSW

By:  Atun R¹, Chang AY¹, Ogbuoji O¹, Silva S¹, Resch S¹, Hontelez J¹, Bärnighausen T¹.

¹Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA.

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Social & Clinical Attributes of Patients Who Restart Antiretroviral Therapy in Central & Copperbelt Provinces, Zambia

Background

About 30 % of the patients initiated on antiretroviral therapy in Zambia default treatment. Some of these patients later restart treatment; however, the characteristics of these patients have not been well described and documented. The aim of this study was to describe and document the socio-demographic and clinical characteristics of patients who default and restart antiretroviral therapy, and to determine the socio-demographic characteristics associated with CD4 count response at 6 and 24 months of restarting antiretroviral therapy.

Methods

A longitudinal retrospective analysis was performed on data from 535 adult patients restarting antiretroviral therapy in 2009 and 2010 at five antiretroviral therapy centres in Copperbelt and Central provinces of Zambia. To determine the association between the socio-demographic characteristics and CD4 cell count, quantile regression models were used.

Results

Older age above 45 years was associated with a significantly lower CD4 cell response by 38.1 cells/mm³ compared to the younger age (15–29 years). Patients in formal employment and self-employment gained significantly higher CD4 cells than those unemployed. In addition, baseline CD4 count, type of treatment, WHO staging, total duration on treatment and duration lost to follow-up were found to be strong predictors of CD4 cell count at 6 and 24 months after restarting antiretroviral therapy treatment.

Conclusion

Age and occupation were the only socio-demographic characteristics predicting CD4 count in the patients at 6 months after restarting antiretroviral therapy after adjusting for other confounding clinical variables.  

Below:  Boxplots of Interquartile range of CD4 count at restarting ART, 6 and 24 months after restaring ART

Full article at:  http://goo.gl/8P145h

By:  Chama Mulubwa, Oliver Mweemba, Patrick Katayamoyo, and Hikabasa Halwindi

Department of Public Health, School of Medicine, University of Zambia, PO Box 50110, Lusaka, Zambia

FHI 360, Plot 2374, Farmers Village, ZNFU Complex, Lusaka, Zambia

BMC Public Health. 2016; 16: 289.

Published online 2016 Mar 29. doi:  10.1186/s12889-016-2922-3

Department of Public Health, School of Medicine, University of Zambia, PO Box 50110, Lusaka, Zambia

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In the Interests of Time: Improving HIV Allocative Efficiency Modelling Via Optimal Time-Varying Allocations

Introduction

International investment in the response to HIV and AIDS has plateaued and its future level is uncertain. With many countries committed to ending the epidemic, it is essential to allocate available resources efficiently over different response periods to maximize impact. The objective of this study is to propose a technique to determine the optimal allocation of funds over time across a set of HIV programmes to achieve desirable health outcomes.

Methods

We developed a technique to determine the optimal time-varying allocation of funds (1) when the future annual HIV budget is pre-defined and (2) when the total budget over a period is pre-defined, but the year-on-year budget is to be optimally determined. We use this methodology with Optima, an HIV transmission model that uses non-linear relationships between programme spending and associated programmatic outcomes to quantify the expected epidemiological impact of spending. We apply these methods to data collected from Zambia to determine the optimal distribution of resources to fund the right programmes, for the right people, at the right time.

Results and discussion

Considering realistic implementation and ethical constraints, we estimate that the optimal time-varying redistribution of the 2014 Zambian HIV budget between 2015 and 2025 will lead to a 7.6% (7.3% to 7.8%) decrease in cumulative new HIV infections compared with a baseline scenario where programme allocations remain at 2014 levels. This compares to a 5.1% (4.6% to 5.6%) reduction in new infections using an optimal allocation with constant programme spending that recommends unrealistic programmatic changes. Contrasting priorities for programme funding arise when assessing outcomes for a five-year funding period over 5-, 10- and 20-year time horizons.

Conclusions

Countries increasingly face the need to do more with the resources available. The methodology presented here can aid decision-makers in planning as to when to expand or contract programmes and to which coverage levels to maximize impact.

Below:  The percentage of infections averted between 2015 and 2025 for each of the scenarios shown in Figure 1 compared with a baseline of maintaining 2014 spending. The uncertainty bars were determined by repeating the optimization process 40 times using an ensemble of 40 projections within the uncertainty bounds of the model calibration with an ensemble of 40 cost-outcome curves within their respective uncertainty bounds (see the Supplementary file for figures illustrating the uncertainty in model calibration and the cost-outcome curves).

Below:  Annual spending on VMMC programmes and the associated change in prevalence of circumcised men. In both optimized scenarios (green and blue curves), implementation constraints (where programme scale-up/down is restricted to a maximum of 30% per year) and ethical constraints (where ART and PMTCT funding cannot be decreased) are applied. In the scenario represented by the green curve, total annual spending is fixed at 2014 levels. In this case, a large initial scale-up of the VMMC programme is not attainable because of the limited availability of unreserved funding and restrictions on programme scale-up/down. Thus, the optimal solution does not prioritize this programme. In the scenario represented by the blue curve, total annual spending is optimally determined such that total spending across the 2015 to 2025 period is the same as in all other scenarios. In this case, total annual spending is initially increased to allow for the initial rapid scale-up of the VMMC programme. Although VMMC spending is later rapidly scaled down, the proportion of circumcised men in this scenario remains considerably higher than in other scenarios.

Full article at:   http://goo.gl/PdjqPJ

By:  Andrew J Shattock,§,1 Cliff C Kerr,1,2,3 Robyn M Stuart,1,2,4 Emiko Masaki,5 Nicole Fraser,5 Clemens Benedikt,5Marelize Gorgens,5 David P Wilson,1,2 and Richard T Gray1

¹The Kirby Institute, University of New South Wales, Sydney, Australia

²The Burnet Institute, Melbourne, Australia

³School of Physics, University of Sydney, Sydney, Australia

⁴Department of Mathematical Sciences, University of Copenhagen, Copenhagen, Denmark

⁵The World Bank Group, Washington DC, USA

^§Corresponding author: Andrew J Shattock, The Kirby Institute, University of New South Wales, Level 6, Wallace Wurth Building, Kensington, Sydney, NSW 2052, Australia. Tel: +61 (0)2 9385 0900. (Email: ua.ude.wsnu.ybrik@kcottahsa)

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Integration of HIV Care into Community Management of Acute Childhood Malnutrition Permits Good Outcomes: Lusaka, Zambia

Background

While HIV has had a major impact on health care in southern Africa, there are few data on its impact on acute malnutrition in children in the community. We report an analysis of outcomes in a large programme of community management of acute malnutrition in the south of Lusaka.

Programme Activities and Analysis

Over 3 years, 68,707 assessments for undernutrition were conducted house-to-house, and children with severe acute malnutrition (SAM) or moderate acute malnutrition (MAM) were enrolled into either Outpatient Therapeutic Programme (OTP) or Supplementary Feeding Programme (SFP) respectively. Case records were analysed using tabulation and unconditional logistic regression.

Findings

1,859 children (889 boys, 970 girls; median age 16 months) with MAM (n = 664) or SAM (n = 1,195) were identified. Of 1,796 children whose parents consented to testing, 185 (10.3%) were HIV positive. Altogether 1,163 (62.6%) were discharged as recovered from acute malnutrition. Case fatality while in the programme was 4.2% in children with SAM and 0.5% in those with MAM, and higher in children with HIV infection. In multivariate analysis, HIV, MUAC <11.5cm and the first year of the program all increased mortality. Children with HIV infection who were able to initiate antiretroviral therapy had lower mortality.

Interpretation

Our programme suggests that a comprehensive community malnutrition programme, incorporating HIV care, can achieve low mortality even in a population heavily affected by HIV.

Below:  Flow of children with MAM through the program

Full article at:   http://goo.gl/N84AKd

By:  

Beatrice Amadi, Mercy Imikendu, Milika Sakala, Rosemary Banda 
Department of Paediatrics, University Teaching Hospital, Nationalist Road, Lusaka, Zambia

Beatrice Amadi, Paul Kelly 

Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia

Paul Kelly 

Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, 4 Newark Street, London, United Kingdom

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Retention & Risk Factors for Attrition among Adults in Antiretroviral Treatment Programs in Tanzania, Uganda & Zambia

OBJECTIVES

We assessed retention and predictors of attrition (recorded death or loss to follow-up) in antiretroviral treatment (ART) clinics in Tanzania, Uganda and Zambia.

METHODS

We conducted a retrospective cohort study among adults (≥18 years) starting ART during 2003–2010. We purposefully selected six health facilities per country and randomly selected 250 patients from each facility. Patients who visited clinics at least once during the 90 days before data abstraction were defined as retained. Data on individual and programme level risk factors for attrition were obtained through chart review and clinic manager interviews. Kaplan–Meier curves for retention across sites were created. Predictors of attrition were assessed using a multivariable Cox-proportional hazards model, adjusted for site-level clustering.

RESULTS

From 17 facilities, 4147 patients were included. Retention ranged from 52.0% to 96.2% at 1 year to 25.8%–90.4% at 4 years. Multivariable analysis of ART initiation characteristics found the following independent risk factors for attrition: younger age [adjusted hazard ratio (aHR) and 95% confidence interval (95%CI) = 1.30 (1.14–1.47)], WHO stage 4 ([aHR (95% CI): 1.56 (1.29–1.88)], >10% bodyweight loss [aHR (95%CI) = 1.17 (1.00–1.38)], poor functional status [ambulatory aHR (95%CI) = 1.29 (1.09–1.54); bedridden aHR1.54 (1.15–2.07)], and increasing years of clinic operation prior to ART initiation in government facilities [aHR (95%CI) = 1.17 (1.10–1.23)]. Patients with higher CD4 cell count were less likely to experience attrition [aHR (95%CI) = 0.88 (0.78–1.00)] for every log (tenfold) increase. Sites offering community ART dispensing [aHR (95% CI) = 0.55 (0.30–1.01) for women; 0.40 (0.21–0.75) for men] had significantly less attrition.

CONCLUSIONS

Patient retention to an individual programme worsened over time especially among males, younger persons and those with poor clinical indicators. Community ART drug dispensing programmes could improve retention.

Below:  Kaplan-Meier estimates by site in Tanzania, Uganda and Zambia

Below:  Kaplan-Meier estimates by Community-Based Distribution (CBD) of ARVs in Tanzania, Uganda and Zambia

Full article at:   http://goo.gl/f62sCn

By:  Olivier Koole,1,2 Sharon Tsui,3,4 Fred Wabwire-Mangen,5 Gideon Kwesigabo,6 Joris Menten,2 Modest Mulenga,7Andrew Auld,8 Simon Agolory,8 Ya Diul Mukadi,3 Robert Colebunders,2,9 David R. Bangsberg,10,11 Eric van Praag,3Kwasi Torpey,3 Seymour Williams,8 Jonathan Kaplan,8 Aaron Zee,8 and Julie Denison3,4

¹Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK

²Clinical Sciences Department, Institute of Tropical Medicine, Antwerp, Belgium

³FHI 360, Durham, NC, USA

⁴Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

⁵Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda

⁶Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania

⁷Tropical Diseases Research Centre, Ndola, Zambia

⁸Division of Global AIDS, United States Centers for Disease Control and Prevention, Atlanta, GA, USA

⁹Epidemiology and Social Medicine, University of Antwerp, Antwerp, Belgium

¹⁰Massachusetts General Hospital, Boston, MA, USA

¹¹Harvard Medical School, Boston, MA, USA

Corresponding Author Olivier Koole, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. Tel.: +265 997 680 108; Email: ku.ca.mthsl@elook.reivilo

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Rural-Urban Inequity in Unmet Obstetric Needs and Functionality of Emergency Obstetric Care Services in a Zambian District

Background
Zambia has a high maternal mortality ratio, 398/100,000 live births. Few pregnant women access emergency obstetric care services to handle complications at childbirth. We aimed to assess the deficit in life-saving obstetric services in the rural and urban areas of Kapiri Mposhi district.

Method

A cross-sectional survey was conducted in 2011 as part of the ‘Response to Accountable priority setting for Trust in health systems’ (REACT) project. Data on all childbirths that occurred in emergency obstetric care facilities in 2010 were obtained retrospectively. Sources of information included registers from maternity ward admission, delivery and operation theatre, and case records. Data included age, parity, mode of delivery, obstetric complications, and outcome of mother and the newborn. An approach using estimated major obstetric interventions expected but not done in health facilities was used to assess deficit of life-saving interventions in urban and rural areas.

Results

A total of 2114 urban and 1226 rural childbirths occurring in emergency obstetric care facilities (excluding abortions) were analysed. Facility childbirth constituted 81% of expected births in urban and 16% in rural areas. Based on the reference estimate that 1.4% of childbearing women were expected to need major obstetric intervention, unmet obstetric need was 77 of 106 women, thus 73% (95% CI 71–75%) in rural areas whereas urban areas had no deficit. Major obstetric interventions for absolute maternal indications were higher in urban 2.1% (95% CI 1.60–2.71%) than in rural areas 0.4% (95% CI 0.27–0.55%), with an urban to rural rate ratio of 5.5 (95% CI 3.55–8.76).

Conclusions

Women in rural areas had deficient obstetric care. The likelihood of under-going a life-saving intervention was 5.5 times higher for women in urban than rural areas. Targeting rural women with life-saving services could substantially reduce this inequity and preventable deaths.

Below:  Distribution of health facilities with and without EmONC in Kapiri Mposhi, 2010

Below:  Basic and Comprehensive Emergency Obstetric and Neonatal Care

Full article at:   http://goo.gl/C4S0Hl

By:  

Selia Ng’anjo Phiri, Knut Fylkesnes, Karen Marie Moland

Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway

Selia Ng’anjo Phiri, Knut Fylkesnes

Department of Public Health, School of Medicine, University of Zambia, Lusaka, Zambia

Jens Byskov

Research Unit for Human Parasitology and the Environment, Faculty of Health and Medical Sciences, University of Copenhagen, Dyrlaegevej 100, DK-1870 Frederiksberg C, Copenhagen, Denmark

Torvid Kiserud

Department of Obstetrics and Gynaecology, Haukeland University Hospital, Bergen, Norway

Torvid Kiserud

Department of Clinical Science, University of Bergen, Bergen, Norway

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The Economic Benefits of High CD4 Counts among People Living with HIV/AIDS in Zambia

BACKGROUND:

The economic effects of poor immunologic recovery among HIV-infected patients receiving antiretroviral therapy (ART) in sub-Saharan Africa are not well understood. We examined the relationship between the CD4 counts of patients on long-term ART and employment outcomes in HIV-affected households in Lusaka, Zambia.

METHODS:

Administrative data and a household survey captured information on the clinical records, demographics and employment outcomes of the ART-treated adults and their adult family members (n = 311). Multivariable regression analyses were used to assess relationships between CD4 counts of ART-treated adults and household employment outcomes.

RESULTS:

Patients with a CD4 count of at least 350 cells/µl were 22 percentage points more likely to be engaged in the labor force (P < 0.05) and worked ∼6 more days per month (P < 0.05) and 9 more hours per week (P = 0.05) compared with patients with a CD4 count <350 cells/µl. Non-patient adults in the HIV-affected household had significantly higher labor participation if the patient's CD4 count was ≥500 compared with <500 cells/µl (P < 0.05), but this was not significant for a CD4 ≥350 versus <350.

CONCLUSION:

These findings suggest that interventions to improve or maintain robust immune recovery during ART may confer economic benefits for both HIV-infected individuals and HIV-affected households.

Purchase full article at:   http://goo.gl/ZshgGL

By:  Tirivayi N1, Koethe JR2.

• 1UNU-MERIT (United Nations University), Maastricht 6211 TC, The Netherlands.
• 2Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, TN, USA. 
• J Public Health (Oxf). 2016 Jan 19. pii: fdv199.

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The Adult Prevalence of HIV In Zambia: Results from a Population Based Mobile Testing Survey Conducted in 2013-2014

OBJECTIVE:

To estimate the adult prevalence of HIV among the adult population in Zambia and determine whether demographic characteristics were associated with being HIV positive.

METHODS:

A cross sectional population based survey to asses HIV status among participants aged 15 years and above in a national tuberculosis prevalence survey. Counselling was offered to participants who tested for HIV. The prevalence was estimated using a logistic regression model. Univariate and multivariate associations of social demographic characteristics with HIV were determined.

RESULTS:

Of the 46,099 individuals who were eligible to participate in the survey, 44,761 (97.1 %) underwent pre-test counselling for HIV; out of which 30,605 (68.4 %) consented to be tested and 30, 584 (99.9 %) were tested. HIV prevalence was estimated to be 6.6 %; with females having a higher prevalence than males 7.7 % versus 5.2 %. HIV prevalence was higher among urban than rural residents. The risk of HIV was double among urban dwellers than among their rural counterparts. Being divorced or widowed was associated with a threefold higher risk of being HIV positive than being never married. The risk of being HIV positive was four times higher among those with tuberculosis than those without tuberculosis.

CONCLUSIONS:

HIV prevalence was lower than previously estimated in the country. The burden of HIV showed sociodemographic disparities signifying a need to target key populations or epidemic drivers. Mobile testing for HIV on a national scale in the context of TB prevalence surveys could be explored further in other settings.

Below:  Estimated HIV prevalence by age and sex with uncertainty bounds

Below:  Estimated HIV prevalence by wealth quintile for urban and rural areas with uncertainty bounds

Purchase full article at:   http://goo.gl/IJItN5

By:  Chanda-Kapata P1, Kapata N2, Klinkenberg E3, William N4, Mazyanga L5, Musukwa K6, Kawesha EC4, Masiye F7, Mwaba P4.

• 1Department of Disease Surveillance, Control and Research, Ministry of Health, Lusaka, Zambia ; Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands.
• 2Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands ; Department of Epidemiology and Disease Control, Ministry of Community Development, Mother and Child Health, Lusaka, Zambia.
• 3KNCV Tuberculosis Foundation, The Hague, Netherlands ; Department of Global Health, Academic Medical Center, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands.
• 4Department of Disease Surveillance, Control and Research, Ministry of Health, Lusaka, Zambia.
• 5World Health Organisation, Lusaka, Zambia.
• 6Virology Laboratory, University Teaching Hospital, Lusaka, Zambia.
• 7Department of Economics, University of Zambia, Lusaka, Zambia. 
• AIDS Res Ther. 2016 Jan 19;13:4. doi: 10.1186/s12981-015-0088-1. eCollection 2016.

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