Reassessing HIV prevention

School of Public Health, University of California at Berkeley, Berkeley, CA 94720, USA.
Science (Impact Factor: 31.48). 06/2008; 320(5877):749-50. DOI: 10.1126/science.1153843
Source: PubMed

ABSTRACT The largest investments in AIDS prevention targeted to the general population are being made in interventions where the evidence for large-scale impact is uncertain.

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    • "Over the past three years, diverse developments in global Human Immunodeficiency Virus (HIV) control have fostered greatly increased interest in the use of expanded antiretroviral therapy (ART) for prevention of HIV transmission, and particularly in the cost and costeffectiveness of that strategy. Perhaps foremost has been frustration with the inability of traditional HIV prevention strategies, such as condom distribution and individual-level behavioural interventions, to control the generalised epidemic in many settings [1]. In parallel, several factors have made broad ART use easier to contemplate: simpler-totake pill regimens, lower antiretroviral drug prices (as little as United States [US]$169 per person per year for the World Health Organization [WHO]'s recommended first line of tenofovir/lamivudine/efavirenz [2]), and a rapid expansion of the number of individuals on ART to 5.25 million by the end of 2009 [3]. "
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    ABSTRACT: Recent empirical studies and analyses have heightened interest in the use of expanded antiretroviral therapy (ART) for prevention of HIV transmission. However, ART is expensive, approximately $600 per person per year, raising issues of the cost and cost-effectiveness of ambitious ART expansion. The goal of this review is to equip the reader with the conceptual tools and substantive background needed to understand and evaluate the policy and programmatic implications of cost-effectiveness assessments of ART for prevention. We provide this review in six sections. We start by introducing and explaining basic concepts of health economics as they relate to this issue, including resources, costs, health metrics (such as Disability-Adjusted Life Years), and different types of economic analysis. We then review research on the cost and cost-effectiveness of ART as treatment, and on the cost-effectiveness of traditional HIV prevention. We describe critical issues in the epidemic impact of ART, such as suppression of transmission and the role of the acute phase of infection. We then present a conceptual model for conducting and interpreting cost-effectiveness analyses of ART as prevention, and review the existing preliminary estimates in this area. We end with a discussion of future directions for programmatic demonstrations and evaluation.
    Current HIV research 09/2011; 9(6):405-15. DOI:10.2174/157016211798038542 · 2.14 Impact Factor
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    • "Circumcision has been demonstrated to be efficacious in reducing the risk of HIV transmission in heterosexual males (Auvert et al. 2005; Bailey et al. 2007; Gray et al. 2007). As a result, numerous public health advocacy organizations, including the World Health Organization, have argued for the inclusion of a male circumcision programme as an integral part of any large scale HIV prevention strategy (UNAIDS/WHO 2007; Potts et al. 2008; White et al. 2008). Kenya has since rolled out a nationwide programme to provide safe circumcision for all willing males in the country, while other sub-Saharan countries have taken steps to submit drafts of similar nationwide policies to their parliamentary bodies (UNAIDS 2009). "
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    ABSTRACT: BACKGROUND Circumcision is efficacious in reducing HIV acquisition in heterosexual males. The South Africa government has been reluctant to adopt a national circumcision programme, possibly due to concerns that circumcision may result in decreased condom use. OBJECTIVE To identify the determinants of demand for male circumcision, to examine variations by ethnicity, and to determine whether it is demanded to avoid condom use. METHODS 403 parents and 237 sons in Johannesburg, South Africa, were recruited through a randomized household survey, with oversampling to balance between blacks (n  =  220), 'coloured' (mixed ethnicity) (n  =  202) and whites (n  =  218). The demand for male circumcision was estimated using a conjoint analysis, with each respondent randomly receiving four tasks comparing seven possible benefits-six identified through key informant interviews and one for condom avoidance. Respondents' choices were analysed using logistic regression, including stratified analyses to test for homogeneity. RESULTS Overall, circumcision's beneficial effects on HIV transmission (P  <  0.001), sexually transmitted infection (STI) transmission (P <  0.001), hygiene (P  <  0.05) and sex (P  <  0.05) were identified as determinants of demand, but the condom avoidance hypothesis was rejected as it was 'repulsive' to respondents (P  <  0.001). Consistent results were found for blacks (P  <  0.001) and coloured (P  <  0.001), but not for whites who found condom avoidance attractive (P  <  0.04), a result not explained by variations in wealth, age or paternal circumcision status. CONCLUSIONS Male circumcision programmes should be tailored to accommodate variations in the determinants of demand across the target population. We find that circumcision's protective effect against HIV acquisition in men is the only determinant to be found consistently across all ethnic groups in Johannesburg. We also find that concerns over condom avoidance may have been overstated. This said, male circumcision strategies should reinforce a range of HIV prevention strategies, including condom use, as we find evidence that whites may view circumcision as a means to avoid condom use.
    Health Policy and Planning 10/2010; 26(4):298-306. DOI:10.1093/heapol/czq064 · 3.00 Impact Factor
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    • "The continued high prevalence of HIV in the hyper-epidemics of southern Africa, has led to calls for renewed and re-thought prevention efforts (UNAIDS, 2008, Potts et al., 2008, Merson et al., 2008, Green et al., 2009). The topic of concurrent sexual partnerships has emerged as an important intervention point for HIV prevention in the generalized epidemics of southern Africa (SADC HIV/AIDS Unit -SADC Secretariat, 2006, Soul City Institute Regional Programme, 2008, Parker et al., 2007). "
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