Modelling the impact and cost-effectiveness of the HIV intervention programme amongst commercial sex workers in Ahmedabad, Gujarat, India

MSc Control of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, UK.
BMC Public Health (Impact Factor: 2.26). 02/2007; 7(1):195. DOI: 10.1186/1471-2458-7-195
Source: PubMed


Ahmedabad is an industrial city in Gujarat, India. In 2003, the HIV prevalence among commercial sex workers (CSWs) in Ahmedabad reached 13.0%. In response, the Jyoti Sangh HIV prevention programme for CSWs was initiated, which involves outreach, peer education, condom distribution, and free STD clinics. Two surveys were performed among CSWs in 1999 and 2003. This study estimates the cost-effectiveness of the Jyoti Sangh HIV prevention programme.
A dynamic mathematical model was used with survey and intervention-specific data from Ahmedabad to estimate the HIV impact of the Jyoti Sangh project for the 51 months between the two CSW surveys. Uncertainty analysis was used to obtain different model fits to the HIV/STI epidemiological data, producing a range for the HIV impact of the project. Financial and economic costs of the intervention were estimated from the provider's perspective for the same time period. The cost per HIV-infection averted was estimated.
Over 51 months, projections suggest that the intervention averted 624 and 5,131 HIV cases among the CSWs and their clients, respectively. This equates to a 54% and 51% decrease in the HIV infections that would have occurred among the CSWs and clients without the intervention. In the absence of intervention, the model predicts that the HIV prevalence amongst the CSWs in 2003 would have been 26%, almost twice that with the intervention. Cost per HIV infection averted, excluding and including peer educator economic costs, was USD 59 and USD 98 respectively.
This study demonstrated that targeted CSW interventions in India can be cost-effective, and highlights the importance of replicating this effort in other similar settings.

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    • "We find that the costs of reaching different populations with HIV prevention interventions in the similar settings vary substantially. The costs for all typologies are at the higher end of those found in previous studies in India of both Avahan and HIV prevention delivered by others [11,14-17]. This is likely to be due to the package of services included and the fact that our costs also include expenditures beyond the NGO level, which most previous studies omit. "
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    ABSTRACT: Avahan, the India AIDS Initiative, delivers HIV prevention services to high-risk populations at scale. Although the broad costs of such HIV interventions are known, to-date there has been little data available on the comparative costs of reaching different target groups, including female sex workers (FSWs), replace with 'high risk men who have sex with men (HR-MSM) and trans-genders. Costs are estimated for the first three years of Avahan scale up differentiated by typology of female sex workers (brothel, street, home, lodge based, bar based), HR-MSM and transgenders in urban districts in India: Mumbai and Thane in Maharashtra and Bangalore in Karnataka. Financial and economic costs were collected prospectively from a provider perspective. Outputs were measured using data collected by the Avahan programme. Costs are presented in US$2008. Costs were found to vary substantially by target group. Non-governmental organisations (NGOs) working with transgender populations had a higher mean cost (US $116) per person reached compared to those dealing primarily with FSWs (US $75-96) and MSWs (US $90) by the end of year three of the programme in Mumbai. The mean cost of delivering the intervention to HR-MSMs (US $42) was higher than delivering it to FSWs (US $37) in Bangalore. The package of services delivered to each target group was similar, and our results suggest that cost variation is related to the target population size, the intensity of the programme (in terms of number of contacts made per year) and a number of specific issues related to each target group. Based on our data policy makers and program managers need to consider the ease of accessing high risk population when planning and budgeting for HIV prevention services for these populations and avoid funding programmes on the basis of target population size alone.
    BMC Public Health 12/2011; 11 Suppl 6(Suppl 6):S7. DOI:10.1186/1471-2458-11-S6-S7 · 2.26 Impact Factor
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    • "The World Bank a decade ago as part of its project appraisal for the second national HIV/AIDS control programme of India estimated the cost per DALY saved as US$2.7 for sex worker programmes, US$2.4 for STI management and US$10 for VCT [18]. In another previous report based on data from a sex worker programme during 1999-2003 in Gujarat, the cost per DALY saved was reported as US$5.5 with an uncertainty range of US$3-12 [19]. There are substantial differences between these estimates and ours reported in this paper. "
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    ABSTRACT: Information on cost-effectiveness of the range of HIV prevention interventions is a useful contributor to decisions on the best use of resources to prevent HIV. We conducted this assessment for the state of Andhra Pradesh that has the highest HIV burden in India. Based on data from a representative sample of 128 public-funded HIV prevention programs of 14 types in Andhra Pradesh, we have recently reported the number of HIV infections averted by each type of HIV prevention intervention and their cost. Using estimates of the age of onset of HIV infection, we used standard methods to calculate the cost per Disability Adjusted Life Year (DALY) saved as a measure of cost-effectiveness of each type of HIV prevention intervention. The point estimates of the cost per DALY saved were less than US $50 for blood banks, men who have sex with men programmes, voluntary counselling and testing centres, prevention of parent to child transmission clinics, sexually transmitted infection clinics, and women sex worker programmes; between US $50 and 100 for truckers and migrant labourer programmes; more than US $100 and up to US $410 for composite, street children, condom promotion, prisoners and workplace programmes and mass media campaign for the general public. The uncertainty range around these estimates was very wide for several interventions, with the ratio of the high to the low estimates infinite for five interventions. The point estimates for the cost per DALY saved from the averted HIV infections for all interventions was much lower than the per capita gross domestic product in this Indian state. While these indicative cost-effectiveness estimates can inform HIV control planning currently, the wide uncertainty range around estimates for several interventions suggest the need for more firm data for estimating cost-effectiveness of HIV prevention interventions in India.
    BMC Health Services Research 05/2010; 10(1):117. DOI:10.1186/1472-6963-10-117 · 1.71 Impact Factor
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    • "Work by Fung and colleagues [40] reports on a prevention intervention for commercial sex workers (CSW) comparing changes in sexual behavior and condom use in Ahmedabad City (the seventh largest city in India) in which rates of HIV prevalence are particularly high among CSW. The CE study included four strategies with peer educators: increasing knowledge of HIV/AIDS and STIs, improving STI treatment of CSW and their clients, increasing safer practices, and environment improvement. "
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    ABSTRACT: After more than 25 years, public health programs have not been able to sufficiently reduce the number of new HIV infections. Over 7,000 people become infected with HIV every day. Lack of convincing evidence of cost-effectiveness (CE) may be one of the reasons why implementation of effective programs is not occurring at sufficient scale. This paper identifies, summarizes and critiques the CE literature related to HIV-prevention interventions in low- and middle-income countries during 2005-2008. Systematic identification of publications was conducted through several methods: electronic databases, internet search of international organizations and major funding/implementing agencies, and journal browsing. Inclusion criteria included: HIV prevention intervention, year for publication (2005-2008), setting (low- and middle-income countries), and CE estimation (empirical or modeling) using outcomes in terms of cost per HIV infection averted and/or cost per disability-adjusted life year (DALY) or quality-adjusted life year (QALY). We found 21 distinct studies analyzing the CE of HIV-prevention interventions published in the past four years (2005-2008). Seventeen CE studies analyzed biomedical interventions; only a few dealt with behavioral and environmental/structural interventions. Sixteen studies focused on sub-Saharan Africa, and only a handful on Asia, Latin America and Eastern Europe. Many HIV-prevention interventions are very cost effective in absolute terms (using costs per DALY averted), and also in country-specific relative terms (in cost per DALY measured as percentage of GDP per capita). There are several types of interventions for which CE studies are still not available or insufficient, including surveillance, abstinence, school-based education, universal precautions, prevention for positives and most structural interventions. The sparse CE evidence available is not easily comparable; thus, not very useful for decision making. More than 25 years into the AIDS epidemic and billions of dollars of spending later, there is still much work to be done both on costs and effectiveness to adequately inform HIV prevention planning.
    BMC Public Health 11/2009; 9 Suppl 1(Suppl 1):S5. DOI:10.1186/1471-2458-9-S1-S5 · 2.26 Impact Factor
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