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HIV Engagement in care

Modelling the scale-down of HIV services in sub-Saharan Africa

19 Sep, 17 | by Leslie Goode, Blogmaster

Search BMJ STI archive, and you will find frequent references to ‘scaling up’, and few – if any – to ‘scaling back’ or ‘scaling down’ (other than Parker/STI).  Who knows if all this may not be about to change, if the US government goes ahead with threats to cut current foreign aid budget ear-marked for HIV by $6.7 billion? How would this affect local HIV programmes?

Walensky & Paltiel  (W&P) model alternative strategies and combinations of strategies for the Republic of South Africa (RSA) and Cote d’Ivoire (CI) to determine which would offer the maximum budgetary return for each year of life lost. Strategies include ‘no new ART’, ‘reduced HIV testing and linking to care’, ‘ART eligibility at a lower CD4 count’, etc.; but all presuppose that commitments to those currently in ART care will be maintained. If scale-back is unavoidable, then it matters how those cuts are implemented; certain combinations of strategies, the authors claim, achieve synergies between strategies such that their combination produces budgetary savings that are greater, per year of life lost, than the total of the two strategies considered separately – for example, ‘late presentation’ and ‘reduced retention’ in RSA. However, ‘no new ART’ turns out to be the strategy that delivers the greatest budgetary savings in an ‘efficient’ manner.

It is hard to gauge the tone of these recommendations – which sound more like a ‘wake-up call’ to the US government than a sober proposal for scale-backs in sub-Saharan countries. Certainly this is not an argument for the long-term cost-effectiveness of any policy for scale-backs, since any short-term savings, they claim, will soon be overtaken by the downstream economic costs of increased HIV transmissions. And even the maximum of savings achievable by these strategies turns out not to exceed 30% of present expenditure. The most efficient alternatives for achieving cuts of 10%-20% will achieve c.$900 and c.$600-900 per every year of life lost in RSA and CI respectively.

In practice, however, it is hard to imagine the necessary cut-backs being achieved in so transparent and rational a manner. At all events, the effect of US cuts to HIV programmes will be presumably be more keenly felt – and will harder to make up for from other (e.g. local) resources – where the proportion of the national HIV budget funded by the US is higher. So, in CI, for example, where 90% of HIV spending comes from international sources, a 10% cut in PEPFAR (President’s Emergency Plan for AIDS Relief) funding would result in a 9% reduction in HIV spending, whereas, in RSA, where most of the funding is self-financed, it would represent a reduction of only 2%. It remains the case, however, that, in absolute terms, that 2% of spending in the RSA is worth $40 million, or double the $20 million saved by the 9% of savings in the CI.

Achieving UNAIDS 90-90-90: More haste less speed?

31 Aug, 17 | by Leslie Goode, Blogmaster

UNAIDS (2014) has set targets for HIV management that seem ambitious, if not unrealistically so  (UNAIDS: 90-90-90): 90% of those living with HIV to know their status; 90% of known HIV+ individuals to undergo ART initiation; 90% of ART+ initiated to achieve viral suppression. A one-year-in report from a large cluster-randomized study of home-based testing and treatment in four Zambian communities, HPTN-071 (Hayes & Fidler (H&F)), recently discussed in this blog (Mountainous challenge of 90-90-90/STI/blogs), suggests that engagement with care may constitute a significant challenge. It gives rates of engagement after six months and one year of care of 42% and 53% respectively. It also confirms what earlier studies (Schwartz & Baral/STIs)  (http://sti.bmj.com/content/early/2016/11/25/sextrans-2016-052773) say about the difficulty of attaining this second target. Estimates as of 2015 for engagement with care in southern and eastern Africa range from 17% to 78% (Wringe & Skovdal/STIs).

Against this somewhat gloomy backdrop, the 2016-17 results from the Swaziland HIV Incidence Measurement Survey (SHIMS2)(http://phia.icap.columbia.edu/wp-content/uploads/2017/07/ZWAZILAND-Factsheet.A4_LR.pdf) from a house-hold based national survey strike a surprisingly hopeful note. 84% of people living with HIV (PLHIV) aged 15 or over report knowing their HIV status; 87.4% of PLHIV knowing their status self-report current use of ART; 91.9% of PLHIV on ART are virally suppressed. Furthermore, rates of response to the survey, at 84.5% (=6,417 eligible households) are impressive. However, PLHIV who are diagnosed but not engaged in care and PLHIV who have become disengaged from care are notoriously difficult to reach (Wringe & Skovdal (STIs)), and likely to be among the non-respondents.

So maybe there is some hope that the UNAIDS targets can be realized by the deadline of 2020 …..

Yet amidst all the anxiety to achieve these targets, a series of qualitative studies reported in the recent supplementary issue of STIs sound a note of caution (STIs: July 2017: 93-3: Understanding the Bottlenecks). This work emphasizes the importance of clients’ personal experiences of health care as a factor in determining likely success in terms of retention in care over time. Among factors likely to have an impact are the painful or disagreeable side-effects from treatment (Renju & Wringe (STIs), or the coercive nature of testing itself (Wringe & Renju (STIs). They also include the attitudes of health-care workers, who are often ‘expert patients’, as well as inappropriate or pressurizing assumptions that test social and moral expectations regarding women’s relationship with men and invoke their moral duty as mothers (Kielmann & Cataldo (STIs). In short, achievement of the benefits of viral suppression requires cooperation of individuals over the longer-term. This in turn depends on trust and good will that are easily forfeited where the pressure to achieve quick results leads health systems to overlook the dimension of personal experience.

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