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Preventing HIV as core business. Debbie Muirhead Andrew Van Zyl Aurum Institute for Health Research. Outline of presentation. The treatment take over Economics of HIV prevention Why a prevention focus should be at the core of our business HIV response - costs

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preventing hiv as core business

Preventing HIV as core business

Debbie Muirhead

Andrew Van Zyl

Aurum Institute for Health Research

outline of presentation
Outline of presentation
  • The treatment take over
  • Economics of HIV prevention
    • Why a prevention focus should be at the core of our business HIV response - costs
    • Cost effectiveness of differing prevention interventions – the evidence
  • HIV prevention in the workplace
    • Creating a workplace evidence base and guiding investment
  • Discussion
    • Examples of HIV prevention packages from represented companies
    • Discussion of core ideas and ways of carrying action forward
the treatment takeover
The treatment takeover



STI treatment














Trial based research

Pilot community projects

Private sector roll out

Government roll out


  • Innovative – interest
  • Tangible results
    • Know it works
    • Rapid, consistent,
  • Funding opportunities
  • Keeping up with practice
    • Business
  • Visiblility
    • Particularly in business
    • Opportunities for public private partnership
  • Real benefit to VCTees for participation
treatment works
Treatment works
  • Costs are minimal in context of payroll
  • Decline in absenteeism immediate and sustained
  • Returns in decreased health care utilisation where a large component of HR costs are substantial
why invest in prevention
Why invest in prevention
  • When largely unknown what works?
  • Costs of one HIV positive worker whether ART or not can be substantial
  • Prevention costs a small proportion and benefits spread across entire workforce
  • Timing may avoid large HIV related expenditures
    • Pension fund and medical scheme contributions
incident cost of infection
Incident Cost of Infection
  • Quantify the additional costs to the firm of an HIV positive and AIDS sick employee
    • Individual level analysis
  • Determine the timing of the costs
  • Weight by likelihood of separation
  • Weight by proportion in each job grade
  • Calculate the Net Present Value of these costs
  • This is the incident cost of infection:

The Value of Preventing New Infections

incident cost calculations
Incident Cost Calculations
  • The incident cost is the present value of the future ‘differential’ costs that will be incurred
  • This is done for each job grade
cumulative cost of infection
Cumulative Cost of Infection

Costs are inflated into the future and then discounted. The above represents an example of one category of worker in one company

formulating a business case
Formulating a business case
  • Can quantify the cost of one infection
  • Can estimate the likely impact of prevention programmes
  • Can then determine cost effectiveness
  • But, this is difficult to do, time consuming and has ethical and other obstacles
  • The cost of infection is generally high enough to warrant even a relatively inefficient prevention programme
cost effectiveness of prevention interventions
Cost effectiveness of prevention interventions
  • Difficult to quantify
    • Long follow up often means modelling used
    • Need HIV incidence – test / retest but then over what period
    • Behavioural change used as marker but self report and modelled to final HIV transmission reduction
    • Many concurrent interventions makes attributability difficult (plea for randomised trials)
    • Effects may be into future and therefore discounting can bias against prevention
  • Measures used
    • Cost per HIV transmission averted
    • Cost per quality adjusted life year gained
    • Cost per DALY averted (most used for comparison in developing countries)


Behavioural change communication

Counselling & Testing

Exposure Prophylaxis

Barrier methods (Male & Female Condoms)





CERVICAL BARRIERS (Vaginal Diaphragms)



BARRIER METHODS (Male & Female Condoms)




education behaviour change communication
Education / Behaviour Change Communication
  • Work at various levels to facilitate change
    • Providing information not enough
    • Stigma (management – including perceptions of care programmes & employees – role models)
    • Risk factors associated with living circumstances / community / society – programmes should be multilevel
  • Cost effective?
    • Fixed cost high coverage resulting in low cost per person reached
    • Reported relative high cost effectiveness results from many assumptions and modelling (Cost per DALY averted of $3)
    • CE studies of implemented programmes show much lower cost effectiveness than modelled estimates ($300 - $1400 per DALY averted)
    • Key as part of a package of interventions
    • Changes in knowledge, attitude and intention often result but little returns to incidence in well designed studies to date found
voluntary counselling testing
Voluntary Counselling & Testing
  • Two recent and good articles on testing in the workplace (Corbett et al 2006, Corbett et al 2007)
  • Need to link to basic HIV care
  • On-site testing had far greater uptake than vouchers for external testing (51.1% vs 4.3%)
  • HIV positive individuals less likely to test
  • VCT did not provide prevention benefit to HIV negatives (same behaviour after as previous)
  • Some suggestion (US, Zimbabwe) that intensive rapid testing had negative behavioural consequences
  • Need to more carefully consider outcomes from differing VCT strategies in the workplace
beware prevalence vct results
Beware – prevalence ≠ VCT results
  • In a company of 5000 employees, 20% true HIV prevalence. All equate to an uptake over over 60%
barrier methods sti treatment
Barrier methods & STI treatment
  • Barrier methods
    • Male condom
      • large reductions in tranmission but behaviour change key
    • Female condom
      • low take up
      • CE estimated in South Africa of $985 per infection averted
  • STI treatment
    • Reduction in incidence of 40% reported in one well known trial (Grosskurth et al, 1995)
    • In implementation setting in SA HIV incidence reduced by 3.1%
    • Coverage key in implementation setting
    • Cost per DALY averted $3 - $80
mtct pep
  • MTCT
    • Short course ARV reduction in HIV incidence in infants of approx 37% - 47%
    • Cost per HIV infection averted of $900 (SA) - $2517 (8 African countries) and DALY averted of $30 (SA) - $84 (8 African countries)
    • Important role in worforce particularly if own health services or internal medical aid
  • PEP
    • Post occupational exposure – 70- 90% reduction in HIV seroconversion
    • More difficult to quantify post sexual assualt
    • Cost effectiveness depends on coverage - $ 31,000 per HIV transmission averted
  • Chemical products applied
  • vaginally to prevent HIV infection
    • Kill or inactivate HIV
    • Stop the virus entering cells
    • Enhance the body’s normal defense mechanisms
    • Inhibit HIV replication
  • Benefits
    • Female-initiated
    • Active against other STIs
    • Possible contraceptive actions
  • Six ongoing clinical trials

Ref: *Tsai C-C, et al. Science 1995: 270:1197-1199; **Veazey RS et al.

  • Thought to be partial explanation for HIV rate differences between Western Africa and ESA
  • Evidence from earliest trial publication noted reduction in transmission women to men of 60% (Orange Farm SA)
  • Two other RCTs showed 53% reduction (Kisumu Kenya) and 51% (Rakai, Uganda)
  • 2 year followup (hence post operation reduction unlikely to drive such large impacts)
  • 2 studies showed no behavioural risk increase
  • CE SA – estimated $181 per HIV infection averted (Kahn et al, 2006)
  • Some more conservative estimates do not outweigh strong support
  • Role in workforce? – Providing access and education
hiv prevention ce summary
HIV prevention CE summary
  • Very little work done in workforce setting
  • Testing – mixed results in terms of HIV prevention intervention but important as entrance to other HIV programmes
  • Education – difficult to change behaviour. Important as facilitator alongside other interventions. Targeted interventions key
  • MTCT, STI treatment similar and high cost effectiveness – important in settings where have control over health service provision
  • Circumcision – very important new HIV prevention push
  • Little work done on condom distribution promotion alone – low CE for female condom currently due to lack of uptake
business innovation in hiv prevention
Business innovation in HIV prevention
  • Incentives
    • Role of incentives to promote health behaviour – already done to a large degree but need evaluation
  • Efficiency
    • Tracking of costs of implementing differing prevention interventions in a workforce setting but include number of people covered
  • Test and retesting – follow up easier but stakeholder objections
  • Support of enabling community programmes where expertise exists such as microfinance
  • Trying differing approaches in different units – natural communities
creating an evidence base in the workplace
Creating an evidence base in the workplace
  • What works
    • Little known on effectiveness and cost effectiveness of HIV prevention interventions at work
    • Requires baseline information and ongoing on sexual behaviour
    • Where multi-site business can consider scaling up different HIV prevention intervention in each site
  • Guiding investments
    • Cost effectiveness analysis of cost per infection averted
    • Need to consider package of interventions
    • High cost of infection in workforce could mean even poorly targeted programmes are cost saving
  • Packages of HIV prevention in represented companies
  • Innovation in business HIV prevention

Auvert B, Taljaard D, Lagarde E et al (2005) Randomized controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 Trial. PLoS Medicine 2:e298

Bailey RC, Moses S, Parker CB et al (2007) Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet; 369 pp 643-56.

Christofides N, Muirhead D, Jewkes R et al (2006) Inlcuding post-exposure prophylaxis to prevent HIV/AIDS into post sexual assualt health services in South Africa: Costs and cost effectiveness of user preferred approaches to provision. Report to DoH & Unicef (accessed on SA MRC website)

Corbett E, Makamure B, Cheung Y et al (2007) HIV incidence during a cluster-randomized trial of two strategies providing voluntary counselling and testing at the workplace, Zimbabwe. AIDS; 21; pp 483-389

Corbett E, Dauya E, Matambo R (2006) Uptake of Workplace HIV counselling and Testing: A Cluster_Randomised Trial in Zimbabwe. PLoS Medicine. 3(7) e238

Creese A, Floyd K, Alban A, Guiness L (2002) Cost-effectiveness of HIV/AIDS interventions in Africa: a systematic review of the evidence. Lancet 359: 1635-42


Dowdy DW, Sweat MD, Holtgrave DR (2006) Country-wide distribution of the nitrile female condom (FC2) in Brazil and South Africa: a cost-effectiveness analysis

Gilson L, Mkanje R, Grosskurth H et al (1997) Cost-effectiveness of improved treatment services for sexually transmitted diseases in preventing HIV-1 infection in Mwanza Region, Tanzania. Lancet; 350; 1805-9

Gray RH, Kigozi G, Serwadda D et al (2007) Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet; 369; 657-66.

Grosskurth H, Mosha F, Todd J et al (1995) Impact of improved tre4atment of sexually transmitted diseases on HIV infection in rural Tanzania: a randomised controlled trial. Lancet; 346; 530-6.

Hogan D, Baltussen R, Hayashi C et al (2005) Cost effectiveness anlaysis of strategies to combat HIV/AIDS in developing countries. BMJ, dol:10.1136/bmj.38643.368692.68

Kahn JG, Marseille E, Auvert B(2006) Cost-Effectiveness of Male Circumcision for HIV Prevention in a South African Setting. PLoS Medicine; 3 (12) e517.

Quigley MA, Kamali A, Kinsman J et al (2004) The impact of attending a behavioural intervention on HIV incidence in Masaka, Uganda. AIDS; 18: pp 2055-2063.

references cont
References (cont)

Sweat M, Kerrigan D, Moreno L(2006) Cost-effectiveness of environmental-structural communication interventions for HIV prevention in the female sex industry in the Dominican Republic. J Health Communication; 11 Supp 2; 123-42

Sweat MD, O’Reilly KR, Schmid GP, et al (2004) Cost-effectiveness of nevirapine to prevent mother to child HIV transmission in eight African countries. AIDS 18 pp 1661-1671

Vickerman P, Terris-Prestholt F, Delany S et al (2006) Are targeted HIV prevention activities cost-effective in high prevalence settings? Results from a sexually transmitted infection treatment project for sex workers in Johannesburg, South Africa. Sex Transm Dis 33 (10 supp) pp S122-32

Williams BG, Lloyd-Smith JO, Gouws E(2006) The Potential Impact of Male Circumcision on HIV in Sub-Saharan Africa. PLoS Medicine; 3 (7) e262

Wilkinson D, Floyd K & Gilks CF (2000) National and provincial estimated costs and cost effectiveness of a programme to reduce mother to child HIV transmission in South Africa. SAMJ 90 (8) pp 794-8.