Getting it right when budgets are tight: Using optimal expansion pathways to prioritize responses to concentrated and mixed HIV epidemics

Published: October 3, 2017Background: Prioritizing investments across health interventions is complicated by the nonlinear relationship between intervention coverage and epidemiological outcomes. It can be difficult for countries to know which interventions to prioritize for greatest epidemiological impact, particularly when budgets are uncertain. Methods: We examined four case studies of HIV epidemics in diverse settings, each with different characteristics. These case studies were based on public data available for Belarus, Peru, Togo, and Myanmar. The Optima HIV model and software package was used to estimate the optimal distribution of resources across interventions associated with a range of budget envelopes. We constructed “investment staircases”, a useful tool for understanding investment priorities. These were used to estimate the best attainable cost-effectiveness of the response at each investment level. Findings: We find that when budgets are very limited, the optimal HIV response consists of a smaller number of ‘core’ interventions. As budgets increase, those core interventions should first be scaled up, and then new interventions introduced. We estimate that the cost-effectiveness of HIV programming decreases as investment levels increase, but that the overall cost-effectiveness remains below GDP per capita. Significance: It is important for HIV programming to respond effectively to the overall level of funding availability. The analytic tools presented here can help to guide program planners understand the most cost-effective HIV responses and plan for an uncertain future.Robyn M. Stuart, Cliff C. Kerr, Hassan Haghparast-Bidgoli, Janne Estill, Laura Grobicki, Zofia Baranczuk, Lorena Prieto, Vilma Montañez, Iyanoosh Reporter, Richard T. Gray, Jolene Skordis-Worrall, Olivia Keiser, Nejma Cheikh, Krittayawan Boonto, Sutayut Osornprasop, Fernando Lavadenz, Clemens J. Benedikt, Rowan Martin-Hughes, S. Azfar Hussain, Sherrie L. Kelly, David J. Kedziora, David P. Wilso

Scaling up of HIV treatment for men who have sex with men in Bangkok: a modelling and costing study

Background Despite the high prevalence of HIV in men who have sex with men (MSM) in Bangkok, little investment in HIV prevention for MSM has been made. HIV testing and treatment coverage remains low. Through a pragmatic programme-planning approach, we assess possible service linkage and provision of HIV testing and antiretroviral treatment (ART) to MSM in Bangkok, and the most cost-effective scale-up strategy. Methods We obtained epidemiological and service capacity data from the Thai National Health Security Office database for 2011. We surveyed 13 representative medical facilities for detailed operational costs of HIV-related services for sexually active MSM (defined as having sex with men in the past 12 months) in metropolitan Bangkok. We estimated the costs of various ART scale-up scenarios, accounting for geographical accessibility across Bangkok. We used an HIV transmission population-based model to assess the cost-effectiveness of the scenarios. Findings For present HIV testing (23% [95% CI 17–36] of MSM at high risk in 2011) and ART provision (20% of treatment-eligible MSM at high risk on ART in 2011) to be sustained, a US$73·8 million ($51·0 million to $97·0 million) investment during the next decade would be needed, which would link an extra 43 000 (27 900–58 000) MSM at high risk to HIV testing and 5100 (3500–6700) to ART, achieving an ART coverage of 44$55·3 million investment would link an extra 46 700 (30 300–63 200) MSM to HIV testing and 12 600 (8800–16 600) to ART, achieving universal ART coverage of this population by 2022. This increased investment is achievable within present infrastructure capacity. Consequently, an estimated 5100 (3600–6700) HIV-related deaths and 3700 (2600–4900) new infections could be averted in MSM by 2022, corresponding to a 53% reduction in deaths and a 35% reduction in infections from 2012 levels. The expansion would cost an estimated $10 809 (9071–13 274) for each HIV-related death,$14 783 (12 389–17 960) per new infection averted, and $351 (290–424) per disability-adjusted life-year averted. Interpretation Spare capacity in Bangkok's medical facilities can be used to expand ART access for MSM with large epidemiological benefits. The expansion needs increased funding directed to MSM services, but given the epidemiological trends, is probably cost effective. Our modelling approach and outcomes are likely to be applicable to other settings. Funding World Bank Group and Australian National Health and Medical Research Council

Effectiveness and Feasibility of Taxing Salt and Foods High in Sodium: A Systematic Review of the Evidence.

This is a pre-copyedited, author-produced version of an article accepted for publication in Advances in Nutrition, following peer review. The version of record: Rebecca Dodd, Joseph Alvin Santos, Monique Tan, Norm R C Campbell, Cliona Ni Mhurchu, Laura Cobb, Michael F Jacobson, Feng J He, Kathy Trieu, Sutayut Osornprasop, Jacqui Webster, Effectiveness and Feasibility of Taxing Salt and Foods High in Sodium: A Systematic Review of the Evidence, Advances in Nutrition, nmaa067, https://doi.org/10.1093/advances/nmaa067, is available online at: https://doi.org/10.1093/advances/nmaa067Diets high in salt are a leading risk for death and disability globally. Taxing unhealthy food is an effective means of influencing what people eat and improving population health. Although there is a growing body of evidence on taxing products high in sugar, and unhealthy foods more broadly, there is limited knowledge or experience of using fiscal measures to reduce salt consumption. We searched peer-reviewed databases [MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and the Cochrane Database of Systematic Reviews] and gray literature for studies published between January 2000 and October 2019. Studies were included if they provided information on the impact on salt consumption of: taxes on salt; taxes on foods high in salt, and taxes on unhealthy foods defined to include foods high in salt. Studies were excluded if their definition of unhealthy foods did not specify high salt or sodium. We found 18 relevant studies, including 15 studies reporting the effects of salt taxes through modeling (8), real-world evaluation (4), experimental design (2), or review of cost-effectiveness (1); 6 studies providing information relevant to country implementation of salt taxes; and 2 studies reporting stakeholder perceptions toward salt taxation. Although there is some evidence on the potential effectiveness and cost-effectiveness of salt taxation, especially from modeling studies, uptake of salt taxation is limited in practice. Some modeling studies suggested that food taxes can have unintended outcomes such as reduced consumption of healthy foods, or increased consumption of unhealthy, untaxed substitutes. In contrast, modeling studies that combined taxes for unhealthy foods with subsidies found that the benefits were increased. Modeling suggests that taxing all foods based on their salt content is likely to have more impact than taxing specific products high in salt given that salt is pervasive in the food chain. However, the limited experience we found suggests that policy-makers favor taxing specific products

Investment staircase for Myanmar.

<p>Illustrates the relationship between total (optimized) investments in the HIV response (right panel), and the overall outcome in terms of cumulative DALYs from 2017–2030 of that response (left panel; black bars indicate interquartile ranges).</p

Investment staircase for Togo.

<p>Illustrates the relationship between total (optimized) investments in the HIV response (right panel), and the overall outcome in terms of cumulative DALYs from 2017–2030 of that response (left panel; black bars indicate interquartile ranges).</p