How to sell a condom? The impact of demand creation tools on male and female condom sales in resource limited settings

Despite condoms being cheap and effective in preventing HIV, there remains an 8billion shortfall in condom use in risky sex-acts. Social marketing organisations apply private sector marketing approaches to sell public health products. This paper investigates the impact of marketing tools, including promotion and pricing, on demand for male and female condoms in 52 countries between 1997 and 2009. A static model differentiates drivers of demand between products, while a dynamic panel data estimator estimates their short- and long-run impacts. Products are not equally affected: female condoms are not affected by advertising, but highly affected by interpersonal communication and HIV prevalence. Price and promotion have significant short- and long-run effects, with female condoms far more sensitive to price than male condoms. The design of optimal distribution strategies for new and existing HIV prevention technologies must consider both product and target population characteristics

Review of costing methods in national HIV strategic planning documents — An Equitable Financing report

Stagnating HIV funding means efficient resource allocation is increasingly vital for an effective HIV response. Strategic planning documents (SPDs), including investment cases, national strategic plans (NSPs), and their respective resource-needs estimates, are central to this aim. This study reviewed SPD costing methods to identify common methodological strengths, weaknesses and gaps, with a view to improving national planning and budgeting and promoting transparency. Latest costed SPDs from nine countries were reviewed using purposive sampling, including six costed NSPs and four investment cases. Cost estimates were extracted and evaluated for transparency and validity using the Global Health Cost Consortium checklist. SPD narratives, and their respective costings and primary data sources, were compared to evaluate alignment in the scope of interventions and for appropriate adaptation to settings and programmatic contexts. Across all SPDs, a total of 426 cost estimates were extracted, categorized and compared with SPD narratives and source data. Costs were adapted from existing unit cost estimates in the literature (n = 101, 24%), estimated using ingredients-based costing (IBC) (n = 279, 65%) or unstated (n = 46, 11%). When literature sources were publicly accessible (n = 50, 50%), two-thirds of the corresponding estimates were found, of which half matched in activity scope. When examining peer-reviewed literature sources, primary cost literature was found to be robust for prevention interventions and testing and treatment, but sparse for the remaining four service areas. Of the 279 IBC estimates, 38% presented itemized inputs. Within the NSP subsample of SPD, a tenth (11%) included some interventions that were not included in their costings. Among the 256 costed interventions in NSPs (Figure 1), 63% of estimates defined specific activities, of which 91% matched with NSP intervention details and 72% had sufficient detail to assess. Within the NSP subsample of SPDs, a 44% information gap was found between NSPs and their respective costings. A tenth (11%) of interventions specified in NSPs were not included in their costings. Among the 256 costed interventions (Figure 1), 8% did not match in scope with NSP intervention details and 25% of cost estimates had insufficient details to assess scope alignment. This review identifies methodological strengths and weaknesses in SPD costings and identifies opportunities to improve future costings of national HIV planning documents. Although analysts make very good use of existing data sources, lack of empirical cost data and adaptation to specific settings often make IBC necessary to generate appropriate setting- and time-specific cost estimates. As formal guidance on how to do this does not exist, the approaches taken differ. Overall, there are no formalized templates or standards for reporting the full set of adaptations and assumptions for unit costs, rendering the estimates hard to interpret, and missing the opportunity to build on these unit costs to adapt them for future iterations and other settings. This review recommends that bespoke guidance on generating cost estimates for SPDs be developed, including a reporting checklist to institutionalize transparent reporting of methods. This reporting checklist and the resulting cost estimates could be submitted to a live public database that can be scrutinized, adapted and used for costings elsewher

Modelling the effect of market forces on the impact of introducing human immunodeficiency virus pre‐exposure prophylaxis among female sex workers

Pre-exposure prophylaxis (PrEP) to prevent human immunodeficiency virus (HIV) enables female sex workers (FSWs) to protect themselves from HIV without relying on clients using condoms. Yet, because PrEP reduces HIV risk, financial incentives to not use condoms may lead to risk compensation: reductions in condom use and/or increases in commercial sex, and may reduce the price of unprotected sex. In this analysis, we integrate market forces into a dynamic HIV transmission model to assess how risk compensation could change the impact of PrEP among FSWs and clients. We parameterise how sexual behavior may change with PrEP use among FSWs using stated preference data combined with economic theory. Our projections suggest the impact of PrEP is sensitive to risk compensatory behaviors driven by changes in the economics of sex work. Condom substitution could reduce the impact of PrEP on HIV incidence by 55%, while increases in the frequency of commercial sex to counter decreases in the price charged for unprotected sex among PrEP users could entirely mitigate the impact of PrEP. Accounting for competition between PrEP users and nonusers exacerbates this further. Alternative scenarios where increases in unprotected sex among PrEP users are balanced by decreases in non-PrEP users have the opposite effect, resulting in PrEP having much greater impact. Intervention studies need to determine how HIV prevention products may change the economics of sex work and provision of unprotected sex to enable a better understanding of their impact

Cost-Effectiveness of Introducing the SILCS Diaphragm in South Africa.

BACKGROUND: Though South Africa has high contraceptive use, unintended pregnancies are still widespread. The SILCS diaphragm could reduce the number of women with unmet need by introducing a discreet, woman-initiated, non-hormonal barrier method to the contraceptive method mix. METHODS: A decision model was built to estimate the impact and cost-effectiveness of the introduction of the SILCS diaphragm in Gauteng among women with unmet need for contraception in terms of unintended and mistimed pregnancies averted, assuming that the available contraceptives on the market were not a satisfying option for those women. Full costs were estimated both from a provider's and user's perspective, which also accounts for women's travel and opportunity cost of time, assuming a 5% uptake among women with unmet contraceptive need. The incremental cost-effectiveness ratio is computed at five and 10 years after introduction to allow for a distribution of fixed costs over time. A probabilistic sensitivity analysis was conducted to incorporate decision uncertainty. RESULTS: The introduction of the SILCS diaphragm in Gauteng could prevent an estimated 8,365 unintended pregnancies and 2,117 abortions over five years, at an annual estimated cost of US$55 per woman. This comes to a cost per pregnancy averted of US$153 and US$171 from a user's and provider's perspectives, respectively, with slightly lower unit costs at 10 years. Major cost drivers will be the price of the SILCS diaphragm and the contraceptive gel, given their large contribution to total costs (around 60%). CONCLUSIONS: The introduction of the SILCS diaphragm in the public sector is likely to provide protection for some women for whom current contraceptive technologies are not an option. However to realize its potential, targeting will be needed to reach women with unmet need and those with likely high adherence. Further analyses are needed among potential users to optimize the introduction strategy

Modelling the effect of market forces on the impact of introducing HIV pre-exposure prophylaxis among female sex workers

HIV pre-exposure prophylaxis (PrEP) enables female sex workers (FSWs) to protect themselves from HIV without relying on clients using condoms. Yet, because PrEP reduces HIV risk, financial incentives to not use condoms may lead to risk compensation: reductions in condom use and/or increases in commercial sex, and may reduce the price of unprotected sex. In this analysis, we integrate market forces into a dynamic HIV transmission model to assess how risk compensation could change the impact of PrEP among FSWs and clients. We parameterise how sexual behaviour may change with PrEP use among FSWs using stated preference data combined with economic theory. Our projections suggest the impact of PrEP is sensitive to risk compensatory behaviours driven by changes in the economics of sex work. Condom substitution could reduce the impact of PrEP on HIV incidence by 55%, while increases in the frequency of commercial sex to counter decreases in the price charged for unprotected sex among PrEP users could entirely mitigate the impact of PrEP. Accounting for competition between PrEP users and non-users exacerbates this further. Alternative scenarios where increases in unprotected sex among PrEP users are balanced by decreases in non-PrEP users have the opposite effect, resulting in PrEP having much greater impact. Intervention studies need to determine how HIV prevention products may change the economics of sex work and provision of unprotected sex to enable a better understanding of their impact

The costs of accessible quality assured syphilis diagnostics: informing quality systems for rapid syphilis tests in a Tanzanian setting.

OBJECTIVES: To determine the costs of Rapid Syphilis Test (RSTs) as compared with rapid plasma reagin (RPR) when implemented in a Tanzanian setting, and to determine the relative impact of a quality assurance (QA) system on the cost of RST implementation. METHODS: The incremental costs for RPR and RST screening programmes in existing antenatal care settings in Geita District, Tanzania were collected for 9 months in subsequent years from nine health facilities that varied in size, remoteness and scope of antenatal services. The costs per woman tested and treated were estimated for each facility. A sensitivity analysis was constructed to determine the impact of parameter and model uncertainty. FINDINGS: In surveyed facilities, a total of 6362 women were tested with RSTs compared with 224 tested with RPR. The range of unit costs was $1.76-$3.13 per woman screened and $12.88-$32.67 per woman treated. Unit costs for the QA system came to $0.51 per woman tested, of which 50% were attributed to salaries and transport for project personnel. CONCLUSIONS: Our results suggest that rapid syphilis diagnostics are very inexpensive in this setting and can overcome some critical barriers to ensuring universal access to syphilis testing and treatment. The additional costs for implementation of a quality system were found to be relatively small, and could be reduced through alterations to the programme design. Given the potential for a quality system to improve quality of diagnosis and care, we recommend that QA activities be incorporated into RST roll-out

Managing men: women's dilemmas about overt and covert use of barrier methods for HIV prevention.

Women in sub-Saharan Africa are at high risk of HIV infection and may struggle to negotiate condom use. This has led to a focus on the development of female-controlled barrier methods such as the female condom, microbicides and the diaphragm. One of the advantages of such products is their contribution to female empowerment through attributes that make covert use possible. We used focus groups to discuss covert use of barrier methods with a sample of South African women aged 18-50 years from Eastern Johannesburg. Women's attitudes towards covert use of HIV prevention methods were influenced by the overarching themes of male dislike of HIV and pregnancy prevention methods, the perceived untrustworthiness of men and social interpretations of female faithfulness. Women's discussions ranged widely from overt to covert use of barrier methods for HIV prevention and were influenced by partner characteristics and previous experience with contraception and HIV prevention. The discussions indicate that challenging gender norms for HIV prevention can be achieved in quite subtle ways, in a manner that suits individual women's relationships and previous experiences with negotiation of either HIV or pregnancy prevention

A health decision analytical model to evaluate the cost-effectiveness of female genital schistosomiasis screening strategies: The female genital schistosomiasis SCREEN framework.

Female genital schistosomiasis is a chronic gynaecological disease caused by the waterborne parasite Schistosoma (S.) haematobium. It affects an estimated 30-56 million girls and women globally, mostly in sub-Saharan Africa where it is endemic, and negatively impacts their sexual and reproductive life. Recent studies found evidence of an association between female genital schistosomiasis and increased prevalence of HIV and cervical precancer lesions. Despite the large population at risk, the burden and impact of female genital schistosomiasis are scarcely documented, resulting in neglect and insufficient resource allocation. There is currently no standardised method for individual or population-based female genital schistosomiasis screening and diagnosis which hinders accurate assessment of disease burden in endemic countries. To optimise financial allocations for female genital schistosomiasis screening, it is necessary to explore the cost-effectiveness of different strategies by combining cost and impact estimates. Yet, no economic evaluation has explored the value for money of alternative screening methods. This paper describes a novel application of health decision analytical modelling to evaluate the cost-effectiveness of different female genital schistosomiasis screening strategies across endemic settings. The model combines a decision tree for female genital schistosomiasis screening strategies, and a Markov model for the natural history of cervical cancer to estimate the cost per disability-adjusted life-years averted for different screening strategies, stratified by HIV status. It is a starting point for discussion and for supporting priority setting in a data-sparse environment