WHEN IS PREVENTION BETTER THAN CURE?

This section asks a few questions to generate some answers that address the quality of HIV prevention across sectors in South Africa. From the onset, it is clear that the international funding context raises the following question: How can HIV prevention interventions reduce the incidence of HIV infection and save financial resources in the process?
Indeed, shared experience tells us that available HIV/AIDS funding falls short of the needs of the South African population. Research has shown that international needs are under-resourced by approximately ninety-seven percent. Hiccups in the South African flow of committed Global Funds from national to provincial institutions and diversions from donar commitments compound the situation in 2003. There is increasing competition for material and financial resources and indications of a decline in public confidence in the public health sector.
Solutions may be found in a current trend towards cost-effectiveness evaluations (CEAs) of HIV interventions, including those in the prevention field. You may ask: What are HIV prevention interventions? And: How do we know they work? Prevention interventions, as alternatives to more cost-heavy treatment programs, aim to reduce the incidence of HIV/AIDS, often with a focus on sustained behavioural change. UNAIDS recognises eight HIV prevention interventions. These interventions are listed in Box 1. UNAIDS also sets standards for cost-efficiency and cost-effectiveness of these programmes.

Box 1: Prevention Interventions recognized by UNAIDS

Use: CEA can be used to: evaluate existing programs, sometimes comparatively, to assess pilot stage interventions, or to predict program efficiency and effectiveness through modeling exercises that address the costs of scaling up interventions. CEA measures inputs (financial, human and capital) and outputs (measures of performance as defined by organizations and by researchers). It is important to note that the results of CEA are driven mainly by the assumptions that underlie them, based on micro- and macro-level measures of intervention effectiveness or baseline HIV incidence. Levin (1983) identified core steps in the CEA design that have been developed over time into complex processes that guide CEA.

Method: CEA (1) identifies characteristics of the population under investigation and the epidemiology of HIV/AIDS in that population; (2) describes broad socio-economic and other measures of effectiveness on a macro level; and (3) addresses issues of performance and achievement in relation to the vision, mission and goals of interventions under investigation on a micro-level.

Benefits: When effectively implemented, CEAs can have macro-level impacts on (government) spending decisions. CEAs can also increase awareness of goals, stimulate creative thought on how to achieve goals, focus attention on behavioural change and measurement thereof, and effect qualitative improvements to business or project planning on a micro-level.

What do cost-effectiveness studies in HIV prevention reveal ? CEA provides support to best practice models. For example, CEAs indicate that (1) the prevention benefit is highest if programs are introduced when HIV prevalence is low. Research also emphasizes the (2) greater efficacy of targeted versus non-targeted interventions.

Results further inform on the (3) relative success of HIV prevention interventions that target high risk groups (which include groups characterized by high rates of partner change and STIs) as well as HIV-infected groups. With regards high risk groups, research indicates that (4) program efficacy depends on the mixing patterns of groups and their propensity to engage in risk activity.

Cost-effective behavioural change interventions, particularly those targeting high risk groups, (5) incorporate peer education and measures of changes in STIs in the target population. Analysis has also shown that the (6) cost in VCT interventions could be reduced by increasing the proportion of couples in the target population.

Limitations of existing studies include: the snapshot status of most CEAs, limited focus on the marginal cost of the programme; few comparative studies of alternative forms of one prevention type; and restriction of focus to a few prevention intervention types. There is also a need for assessment of collaborative intervention partnerships that aim to increase available political and economic resources.

Directions: CEAs have a role to play in improving both qualitative and quantitative aspects of service delivery across sectors. Hence, it can be argued that implementers in the CEA field need to: (1) promote multi-disciplinary South African research that investigates the efficacy of prevention interventions across a variety of settings and sectors; (2) devise methods to measure and promote the efficacy of the studied interventions in behavioral change terms; and (3) promote models of intervention that reinforce sustained change through inter alia well-planned participation and communication strategies.

Some of these considerations are being addressed in the Prevent AIDS Network for Cost Effectiveness Analysis (PANCEA) study that the HIVAN networking team is conducting in collaboration with the Institute for Health Policy Studies, University of California. The next issue of share will feature case-specific results of this study. For more information on methods employed in CEA consult HIVAN’s website www.hivan.org.za

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