Spending of HIV resources in Asia and Eastern Europe: systematic review reveals the need to shift funding allocations towards priority populations

Introduction: It is increasingly important to prioritize the most cost-effective HIV interventions. We sought to summarize the evidence on which types of interventions provide the best value for money in regions with concentrated HIV epidemics. Methods: We conducted a systematic review of peer-reviewed and grey literature reporting measurements of cost-effectiveness or cost-benefit for HIV/AIDS interventions in Asia and Eastern Europe. We also collated HIV/AIDS spending assessment data from case-study countries in the region. Results: We identified 91 studies for inclusion, 47 of which were from peer-reviewed journals. Generally, in concentrated settings, prevention of mother-to-child transmission programmes and prevention programmes targeting people who inject drugs and sex workers had lower incremental cost-effectiveness ratios than programmes aimed at the general population. The few studies evaluating programmes targeting men who have sex with men indicate moderate cost-effectiveness. Collation of prevention programme spending data from 12 countries in the region (none of which had generalized epidemics) indicated that resources for the general population/non-targeted was greater than 30% for eight countries and greater than 50% for five countries. Conclusions: There is a misalignment between national spending on HIV/AIDS responses and the most affected populations across the region. In concentrated epidemics, scarce funding should be directed more towards most-at-risk populations. Reaching consensus on general principles of cost-effectiveness of programmes by epidemic settings is difficult due to inconsistent evaluation approaches. Adopting a standard costing, impact evaluation, benefits calculation, analysis and reporting framework would enable cross comparisons and improve HIV resource prioritization and allocation.Andrew P Craig, Hla-Hla Thein, Lei Zhang, Richard T Gray, Klara Henderson, David Wilson, Marelize Gorgens, and David P Wilso

The economics of scaling up: cost estimation for HIV/AIDS interventions.

BACKGROUND: The scaling up of HIV/AIDS programming has been one of the most extensive undertakings in international public health. Yet decision-makers are encountering significant uncertainties about financing and the need to understand programming costs at different scales of delivery. OBJECTIVES: To review the economic methodologies for examining costs and variation by scale. To summarize and synthesize the current evidence related to the provision of HIV/AIDS interventions and scaling up. METHODS: We used a review of economic methodologies to generate a conceptual framework for classifying existing data, looking at both short-run and long-run perspectives. A review of the literature was performed using PubMed and available grey literature. Factors facilitating comparison and generalizability are highlighted. RESULTS: There is growing evidence of scale variation among the costs of HIV/AIDS interventions. Scale variation has been found to explain 26-70% of cost variation across locations for similar interventions. Average costs may become larger or smaller as the volume of services expands, depending on the level of coverage and type of intervention. Key constraints to scaling up include infrastructure investments and cost results need to be interpreted in this light. CONCLUSIONS: Evidence to date suggests that cost efficiencies associated with scale may reflect different ways of delivering services at higher volumes, including lower quality outputs. There is still, however, an extremely limited economic evidence base and mechanisms to integrate economic analyses into routine programme monitoring are recommended