Outputs, cost and efficiency of public sector centres for prevention of mother to child transmission of HIV in Andhra Pradesh, India

<p>Abstract</p> <p>Background</p> <p>Prevention of mother to child transmission (PMTCT) is an important part of the effort to control HIV. PMTCT services are mostly provided at public sector government hospitals in India. Systematic data on the cost and efficiency of providing PMTCT services in India are not available readily for further planning.</p> <p>Methods</p> <p>Cost and output data were collected at 16 sampled PMTCT centres in the south Indian state of Andhra Pradesh using standardized methods. The services provided were analysed, and the relation of unit cost of services with scale was assessed.</p> <p>Results</p> <p>In the 2005–2006 fiscal year, 125,073 pregnant women received PMTCT services at the 16 centres (range 2,939 to 20,896, median 5,679). The overall HIV positive rate among those tested was 1.67%. Of the total economic cost, the major components were personnel (47.3%) and recurrent goods (31.7%). For the 16 PMTCT centres, the average economic cost per post-HIV-test counselled pregnant woman was Indian Rupees (INR) 98.9 (US$2.23), ranging 2.7-fold from INR 71.4 (US$ 1.61) to INR 189.9 (US$4.29). The economic cost per mother-neonate pair who received nevirapine had a higher variation, ranging 41-fold for the 16 centres from INR 4,354 (US$ 98) to INR 179,175 (US$4,047), average INR 10,210 (US$ 231), with very high unit cost at some centres where HIV prevalence among pregnant women and the total volume of services were both low. Scale had a significant inverse relation with both of the unit costs, per post-HIV-test counselled pregnant woman and per mother-neonate pair who received nevirapine. In addition, HIV prevalence among pregnant women had a significant inverse relation with unit cost per mother-neonate pair who received nevirapine.</p> <p>Conclusion</p> <p>Although the variation between PMTCT centres for unit cost per post-HIV-test counselled pregnant woman was modest that per mother-neonate pair receiving nevirapine was over 40-fold. The extremely high unit cost for each mother-neonate pair receiving nevirapine at some centres suggests that the new approach of combining PMTCT services with voluntary counselling and testing services that has recently been started in India could potentially offer better efficiency.</p

Brief Communication: Economic Comparison of Opportunistic Infection Management With Antiretroviral Treatment in People Living With HIV/AIDS Presenting at an NGO Clinic in Bangalore, India

<p>Abstract</p> <p>Context</p> <p>Highly active antiretroviral treatment (HAART) usage in India is escalating. With the government of India launching the free HAART rollout as part of the "3 by 5" initiative, many people living with HIV/AIDS (PLHA) have been able to gain access to HAART medications. Currently, the national HAART centers are located in a few district hospitals (in the high- and medium-prevalence states) and have very stringent criteria for enrolling PLHA. Patients who do not fit these criteria or patients who are too ill to undergo the prolonged wait at the government hospitals avail themselves of nongovernment organization (NGO) services in order to take HAART medications. In addition, the government program has not yet started providing second-line HAART (protease inhibitors). Hence, even with the free HAART rollout, NGOs with the expertise to provide HAART continue to look for funding opportunities and other innovative ways of making HAART available to PLHA. Currently, no study from Indian NGOs has compared the direct and indirect costs of solely managing opportunistic infections (OIs) vs HAART.</p> <p>Objective</p> <p>Compare direct medical costs (DMC) and nonmedical costs (NMC) with 2005 values accrued by the NGO and PLHA, respectively, for either HAART or exclusive OI management.</p> <p>Study design</p> <p>Retrospective case study comparison.</p> <p>Setting</p> <p>Low-cost community care and support center - Freedom Foundation (NGO, Bangalore, south India).</p> <p>Patients</p> <p>Retrospective analysis data on PLHA accessing treatment at Freedom Foundation between January 1, 2003 and January 1, 2005. The HAART arm included case records of PLHA who initiated HAART at the center, had frequent follow-up, and were between 18 and 55 years of age. The OI arm included records of PLHA who were also frequently followed up, who were in the same age range, who had CD4+ cell counts < 200/microliter (mcL) or an AIDS-defining illness, and who were not on HAART (solely for socioeconomic reasons). A total of 50 records were analyzed. Expenditures on medication, hospitalization, diagnostics, and NMC (such as food and travel for a caregiver) were calculated for each group.</p> <p>Results</p> <p>At 2005 costs, the median DMC plus NMC in the OI group was 21,335 Indian rupees (Rs) (mean Rs 24,277/-) per patient per year (pppy) (US $474). In the HAART group, the median DMC plus NMC was Rs 18,976/- (mean Rs 21,416/-) pppy (US$421). Median DMC plus NMC pppy in the OI arm was Rs 13623.7/- paid by NGO and Rs 1155/- paid by PLHA. Median DMC and NMC pppy in the HAART arm were Rs 1425/- paid by NGO and Rs 17,606/- paid by PLHA.</p> <p>Conclusion</p> <p>Good health at no increased expenditure justifies providing PLHA with HAART even in NGO settings.</p

The costs of HIV prevention for different target populations in Mumbai, Thane and Bangalore.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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

HIV reactivity trends in a tertiary care teaching hospital in Himachal Pradesh: a ten-year ICTC based retrospective analysis

Background: Despite being a low HIV prevalence nation, India has the third largest number of PLHAs in the world. The study aimed to explore the prevalence, pattern of socio-demographic and epidemiological distribution among HIV sero-positive patients in this part of Himachal Pradesh. Objective was to estimate the prevalence of HIV infection among the clients who had attended the ICTC for a period of ten years, i.e. from 2008 to 2017.Methods: A retrospective descriptive analysis of secondary data from the National AIDS control program from the year 2008 through 2017 was done.Results: Overall prevalence of HIV positivity amongst the clients attending the centre was observed to be 2.1%. Out of the total 55610 clients tested for HIV infection, 40.4% were male, 25.4% were female (excluding ANCs) and 34.2% were Ante-natal cases. Overall, seropositivity was higher among males (58%) than females (40%). However, amongst the groups, higher prevalence has been observed to be present in the females (3.3%) over males (3%) and Ante-natal cases (0.12%). Belonging to the female sex [OR 1.99 (95% CI: 1.77-2.24)] and male sex [OR 2.07 (95% CI: 1.84- 2.33)] had higher odds of having HIV sero-positivity than Ante-natal cases [OR 0.04 (95% CI: 0.02-0.05)]. Heterosexual route of transmission was the major route seen in 70.1%. Maximum HIV seropositivity was in the age group of 25 - 34 years (35.4%).Conclusions: The trends over the last 10 years show no steady pattern. Hence, there is a need for scaled up and sustained efforts focused on the males of reproductive age group for the prevention and control of HIV infection

Size estimation of injecting drug users (IDU) using multiplier method in five Districts of India

The HIV epidemic in Manipur, the highest HIV prevalence state of India, is primarily driven by injecting drug use. Reliable estimate of population size of injecting drug users (IDU) is critical for aiding HIV prevention program in the state to combat drug driven HIV epidemic. The study described multiplier method, an indirect technique of estimation of IDU size in five districts of Manipur, India making use of existing records of rapid intervention and care (RIAC) programs. Number of IDUs who accessed RIAC services during the past 12 months was taken as the benchmark data for the size estimation. The benchmark data were then multiplied by the inverse of the proportion of the IDUs who reported having accessed RIAC services during the same period to derive the sizes of IDU population in each study districts. The estimated sizes of IDU population in five districts were: 7353 (95% CI: 6759-8123) in Imphal West, 5806 (95% CI: 5635-6054) in Imphal East, 3816 (95% CI: 3571-4139) in Thoubal, 2615 (95% CI: 2528-2731) in Churachandpur and 2137 (95% CI: 1979-2343) in Bishenpur district. Multiplier method seems to be a feasible indirect technique which can be applied to estimate of IDU population using existing data from intervention programs in settings like Manipur where reliable size estimation of IDU population is lacking

HIV Seroprevalence among Tuberculosis Patients in India, 2006–2007

BACKGROUND: Little information exists regarding the burden of HIV among tuberculosis patients in India, and no population-based surveys have been previously reported. A community-based HIV prevalence survey was conducted among tuberculosis patients treated by the national tuberculosis control programme to evaluate the HIV prevalence among tuberculosis patients in India. METHODOLOGY/PRINCIPAL FINDINGS: Fifteen districts (total population: 40.2 million) across 8 states were stratified by HIV prevalence in antenatal clinic HIV surveillance sites and randomly selected. From December 2006 to May 2007, remnant serum was collected from patients' clinical specimens taken after 2 months of anti-tuberculosis treatment and subjected to anonymous, unlinked HIV testing. Specimens were obtained and successfully tested for 5,995 (73%) of 8,217 tuberculosis patients eligible for the survey. HIV prevalence ranged widely among the 15 surveyed districts, from 1% in Koch Bihar, West Bengal, to 13.8% in Guntur, Andhra Pradesh. HIV infection was 1.3 times more likely among male TB patients than among female patients. Relative to smear-positive tuberculosis, HIV infection was 1.4 times more likely among smear-negative patients and 1.3 times more likely among extrapulmonary patients. In 4 higher-HIV prevalence districts, which had been previously surveyed in 2005-2006, no significant change in HIV prevalence was detected. CONCLUSIONS: The burden of HIV among tuberculosis patients varies widely in India. Programme efforts to implement comprehensive TB-HIV services should be targeted to areas with the highest HIV burden. Surveillance through routine reporting or special surveys is necessary to detect areas requiring intensification of TB-HIV collaborative activities

Impact of targeted interventions on heterosexual transmission of HIV in India

<p>Abstract</p> <p>Background</p> <p>Targeted interventions (TIs) have been a major strategy for HIV prevention in India. We evaluated the impact of TIs on HIV prevalence in high HIV prevalence southern states (Tamil Nadu, Karnataka, Andhra Pradesh and Maharashtra).</p> <p>Methods</p> <p>A quasi-experimental approach was used to retrospectively compare changes in HIV prevalence according to the intensity of targeted intervention implementation. Condom gap (number of condoms required minus condoms supplied by TIs) was used as an indicator of TI intensity. Annual average number of commercial sex acts per female sex worker (FSW) reported in Behavioral Surveillance Survey was multiplied by the estimated number of FSWs in each district to calculate annual requirement of condoms in the district. Data of condoms supplied by TIs from 1995 to 2008 was obtained from program records. Districts in each state were ranked into quartiles based on the TI intensity. Primary data of HIV Sentinel Surveillance was analyzed to calculate HIV prevalence reductions in each successive year taking 2001 as reference year according to the quartiles of TI intensity districts using generalized linear model with logit link and binomial distribution after adjusting for age, education, and place of residence (urban or rural).</p> <p>Results</p> <p>In the high HIV prevalence southern states, the number of TI projects for FSWs increased from 5 to 310 between 1995 and 2008. In high TI intensity quartile districts (n = 30), 186 condoms per FSW/year were distributed through TIs as compared to 45 condoms/FSW/year in the low TI intensity districts (n = 29). Behavioral surveillance indicated significant rise in condom use from 2001 to 2009. Among FSWs consistent condom use with last paying clients increased from 58.6% to 83.7% (p < 0.001), and among men of reproductive age, the condom use during sex with non-regular partner increased from 51.7% to 68.6% (p < 0.001). A significant decline in HIV and syphilis prevalence has occurred in high prevalence southern states among FSWs and young antenatal women. Among young (15-24 years) antenatal clinic attendees significant decline was observed in HIV prevalence from 2001 to 2008 (OR = 0.42, 95% CI 0.28-0.62) in high TI intensity districts whereas in low TI intensity districts the change was not significant (OR = 1.01, 95% CI 0.67-1.5).</p> <p>Conclusion</p> <p>Targeted interventions are associated with HIV prevalence decline.</p

Prevalence of viral (HBV, HCV and HIV) co-infections among apparently healthy blood donors in Ranchi, Jharkhand, India

Background: Apparently healthy blood donors may carry double viral co-infections that might be more fatal than viral mono-infection for the donor himself as well as recipient later on.Methods: All blood samples were screened for HIV-I and II (4th generation kit), HBV and HCV (3rd generation kit) by using chemiluminescence technique (Manufacturer- Abbott, Model-Architect i 1000SR).Results: On screening of 41307 blood units, 829 (2.0%) donors were found positive for one of the viral infection (HBV, HCV and HIV). Highest prevalence was for HBV (417 donors- 1.0%) followed by HCV (324 donors- 0.78 %) and HIV (88 donors- 0.21 %).Conclusions: Apparently healthy blood donors might carry, life threatening, double viral co-infections in their blood. Failure to diagnose and treat co-infection at an early stage results in serious complications and sequelae. For safe blood transfusion all blood units should be tested for compatibility and TTI’s with reduction in unnecessary blood transfusion

Use of Technology in Segregating Occupational risks of Migrant and linking them with Services: Experiences from National AIDS Control Program for Migrants

Background: The migrant intervention in India was initiated during the National AIDS Control Program (NACP) Phase-2 (2002-2007). Even by the end of NACP Phase-3 (2010-11); the service uptake among migrants remained very low (14% referred for HIV testing, of which only 37% were tested). USAID PHFI-PIPPSE project in collaboration with the National AIDS Control Organization (NACO) developed a unique system called Migrant Service Delivery System (MSDS) to capture migrants profile with respect to their risk profile and to provide tailor made services to them.Description: MSDS is a web-based system, designed and implemented to increase service uptake among migrants through evidence based planning. 110 destination migrants Targeted Intervention (TI) from 11 states were selected for study with varied target populations in terms of occupations; to understand occupation related risk behaviors amongst the migrants. Occupation wise registration data of high risk vulnerable migrants were analyzed through MSDS for the period April 2014-June 2016. Analysis was made on specific indicators amongst these occupational groups to understand the risk behavior and their vulnerability to HIV and STI.Lessons Learned: Out of total migrants workers enrolled in MSDS HIV rate is found to be highest amongst Auto-Rickshaw (18.66%) followed by daily wage laborers (14.46%), loom workers (10.73%), industrial workers (10.04%) and construction workers (7.93%). With 45.14% positivity, industrial workers are found to be most vulnerable to Sexually Transmitted Infections (STIs) amongst all occupational categories followed by loom workers (16.28%), skilled worker (Furniture, Jeweler)(7.14%), daily wage laborers (5.45%) .Conclusion/Next Steps: MSDS is an effective tool to assess migrants’ risk and their vulnerability to HIV for designing evidence informed program. This system calls for a replication across all destination TIs by NACO for differential strategies for different occupation groups to ensure better yield through scientific planning of intervention among high risk and high vulnerable migrants.

Managerial Challenges in Addressing HIV/AIDS: Gujarat State AIDS Control Society (GSACS)

The spread of HIV/AIDS is not merely a problem of public health; it is also an economic, political, and social challenge that threatens to hinder decades of progress in different parts of Gujarat. There is an urgent need to significantly scale-up public health interventions that work to make a meaningful impact. While NGOs and community based organizations have a critical role to play in implementing these interventions amongst the various population groups, the government must shoulder the overall responsibility for planning, coordinating, mobilizing, and facilitating the various HIV/AIDS prevention, care and treatment services in the state. Generally, the departments of HIV/AIDS are dominated by doctor-managers who lack training in management. This working paper was developed with objective of enhancing the skills of the program implementers. In this paper, in first three chapters we describe the overall situation of HIV/AIDS globally and nationally. Major challenges in managing sentinel surveillance, behavior surveillance, targeted interventions and its subcomponents have been described in chapter four. Issues related to integration of HIV/AIDS activities with reproductive health has also been discussed in the chapter. In chapter five, we present a few case studies from Gujarat State AIDS Control Society. These cases focus on the managerial issues in the following areas: Project Management, Blood Bank Management, VCTC/ICTC Management, Behavioral Surveillance and MIS for Targeted Interventions. These case studies bring out the ground level realities and can help participants develop insights for better management of the HIV/AIDS programme.