The cost of community outreach HIV interventions: a case study in Thailand

Background There was an estimated 440,000 people living with HIV in Thailand in 2018. New cases are declining rapidly thanks to successful prevention programs and scaling up of anti-retroviral therapy (ART). Thailand aims to achieve its commitment to end the HIV epidemic by 2030 and implemented a cascade of HIV interventions through the Reach-Recruit-Test-Treat-Retain (RRTTR) program. Methods This study focused on community outreach HIV interventions implemented by Non-Governmental Organizations (NGOs) under the RRTTR program in 27 provinces. We calculated unit cost per person reached for HIV interventions targeted at key-affected populations (KAPs) including men who have sex with men/ transgender (MSM/TG), male sex workers (MSW), female sex workers (FSW), people who inject drugs (PWID) and migrants (MW). We studied program key outputs, costs, and unit costs in variations across different HIV interventions and geographic locations in Thailand. We used these estimates to determine costs of HIV interventions and evaluate economies of scale. Results The interventions for migrants in Samut Sakhon was the least costly with a unit cost of 21.6 USD per person to receive services, followed by interventions for migrants in Samut Prakan 23.2 USD per person reached, MSM/TG in Pratum Thani 26.5USD per person reached, MSM/TG in Nonthaburi 26.6 USD per person reached and, MSM/TG in Chon Buri with 26.7 USD per person. The interventions yielded higher efficiency in large metropolitan and surrounding provinces. Harm reduction programs were the costliest compare with other interventions. There was association between unit cost and scale of among interventions indicating the presence of economies scale. Implementing HIV and TB interventions jointly increased efficiency for both cases. Conclusion This study suggested that unit cost of community outreach HIV and TB interventions led by CSOs will decrease as they are scaled up. Further studies are suggested to follow up with these ongoing interventions for identifying potential contextual factors to improve efficiency of HIV prevention services in Thailand.

“Deadly”, “fierce”, “shameful”: notions of antiretroviral therapy, stigma and masculinities intersecting men’s life-course in Blantyre, Malawi

Background Stigma and masculinity represent persistent barriers in delivering successful HIV interventions to men. Our study examined community perceptions of HIV and anti-retroviral therapy (ART) and their implications for men on ART across the life course in Blantyre, Malawi. Methods Our qualitative study is based on 72 face-to-face semi-structured interviews. Participants were selected purposively and included men on ART (with suppressed and unsuppressed viral loads), adult male community members irrespective of HIV status and other HIV stakeholders such as health personnel and program implementers. Interviews were conducted in Chichewa and English, transcribed verbatim and analyzed thematically in NVivo 12. We applied the socio-ecological model as our theoretical framework as well as a “life-course” perspective. Results Our findings highlight lingering negative perceptions towards ART in general and towards PLHIV irrespective of viral load suppression. With intersecting notions of masculinity and stigma, men’s descriptions of anticipated stigma in their relationships and when visiting health facilities dominated. Stigma was experienced at the personal, interpersonal, facility and community level. Yet, men living with HIV were perceived differently throughout the life-course, with young sexually active men seen as the most stigmatized group and older men seen as drawing resilience from a greater range of masculine norms. Some men of all ages displayed “transformative” masculinities independent of stigma and community expectations. Conclusions We propose the “life-course” as a useful concept for studies on masculinity, HIV and stigma. Considering gendered constructions of “respectable” midlife-older age vis-à-vis younger age, and how they influence stigma as well as uptake and adherence to ART might lead to more targeted services for men that build on “transformative masculinities”.

Could the 2010 HIV outbreak in Athens, Greece have been prevented? A mathematical modeling study

Introduction In 2009 and 2010, Athens, Greece experienced a hepatitis C virus (HCV) and a Human Immunodeficiency Virus (HIV) outbreak among People Who Inject Drugs (PWID), respectively. The HCV outbreak was not detected, while that of HIV was identified in 2011. The integrated HIV-interventions, launched in early 2012, managed to reduce directly the HIV incidence and indirectly the HCV incidence. This study aims to assess what would have been the course of the HIV outbreak and its associated economic consequences if the 2009 HCV outbreak had been detected and integrated interventions had been initiated 1- or 2-years earlier. Methods The model was calibrated to reproduce the observed HIV epidemiological and clinical parameters among PWID of Athens, Greece. We examined the effect of the 1- or 2-years earlier detection scenarios, the 1-year later detection, the non-detection scenario, and compared them to the status quo scenario. Results Cumulative HIV cases, under the status-quo scenario during 2009‐2019, were 1360 (90% Credible intervals: 290, 2470). If the HCV outbreak had been detected 1- or 2- years earlier, with immediate initiation of integrated interventions, 740 and 1110 HIV cases could be averted by 2019, respectively. Regarding the costs, if there was an efficient notification system to detect the HCV outbreak 1 or 2 years earlier, 35.2–53.2 million euros could be saved compared to the status quo by 2019. Conclusions If the HCV outbreak had been detected and promptly addressed, the HIV outbreak would have been prevented and 35.2–53.2 million euros could have been saved.

The Influence of Neighborhood Characteristics on HIV Treatment Outcomes Among Adults: A Scoping Review Protocol

BackgroundThe HIV pandemic has caused enormous suffering and loss of life in the last forty years. Currently more than 34 million people have died as a result of HIV infection and over 37 million people are currently living with HIV. There have been tremendous global efforts to address the HIV pandemic and although significant progress has been made in treatment and prevention of HIV, many people living with HIV still do not have appropriate access to treatment and care. Current HIV interventions have focused more on individual factors than on community level factors. Community level factors influence individual behavior by enhancing or limiting access to- and utilization of HIV care. The objective of this scoping review is to assess and critically examine the association between neighborhood characteristics and outcomes of HIV treatment.Methods The following databases will be searched for studies published on and prior to May 31, 2021: PubMed, PsycINFO, CINAHL, and EMBASE. We will include published full text studies with both experimental and observational study designs that discussed neighborhood characteristics and HIV treatment outcomes. We will exclude abstracts only publications and studies reporting opinion. Data generated from the search will be managed using Mendeley 1.19.8. The review will be conducted using Arskey and Levac’s methodological framework for scoping reviews. A narrative synthesis will be conducted on the included studies. Discussion Sustainability of HIV interventions that focus on individual behaviors rely on the community level factors that influence those individual behaviors. This review will enhance the understanding of the impact of neighborhood characteristics on HIV treatment outcomes among adults, and possibly shed a light on potential points of intervention that will aid in improving ART initiation, ART adherence, and HIV viral load suppression.Scoping Review Registration: OSF 10.17605/OSF.IO/MD89T

The Cost of Community Outreach HIV Interventions in Thailand: A Cohort Study

Background Despite having an estimation of 440000 people living with HIV in 2018, the HIV epidemic in Thailand has become mature and new cases reported have been rapidly declining thanks to its successful prevention programs and scaling up of anti-retroviral therapy (ART). Thailand aimed to achieve its commitment to end the HIV epidemic by 2030 and implemented a cascade of HIV interventions through Reach-Recruit-Test-Treat-Retain (RRTTR) program. Methods This study focused on community-based HIV interventions implemented by Non-Governmental Organizations (NGOs) under RRTTR program in the provinces highly affected by HIV epidemic. We calculated unit cost per person reached for HIV interventions tailored for key-affected populations (KAPs) including men who have sex with men/ transgender (MSM/TG), male sex worker (MSW), female sex worker (FSW), people who inject drug (PWID) and migrant (MW). We studied program outputs, costs, and unit costs in variations across different HIV interventions and geographic locations in Thailand. We used these estimates to evaluate the economies of scale and scope of implementing community-based HIV interventions. Results We analysed a total of 38 community-based HIV interventions in 27 provinces. The average unit cost for a person to received HIV services was 29.7 USD for MSM/TG program, 33.1 USD for MW program, 31.9 USD for FSW program, 36.3 USD for MSW program and 179.1 USD for PWID program. The lowest unit cost per person reached was 21.6 USD for Migrant in Samut Sakhon province while the highest was 324.5 USD for PWID in Samut Prakan. The scattered plots of unit cost per person with polynomial and linear trend line shows the presence of economies of scales. Conclusions This study suggested that community-based HIV interventions led by NGOs in Thailand will only become less costly as they are scaled-up overtime.

Girl-only clubs’ influence on SRH knowledge, HIV risk reduction, and negative SRH outcomes among very young adolescent girls in rural Malawi

Background Early adolescence is an important period to lay the foundation for positive sexual health development that can overcome sexual and reproductive health (SRH) challenges faced by very young adolescents (VYAs) as they reach puberty and sexual debut. In this study, we explored the following questions: first, what are the experiences of VYA girls on DREAMS’ Go Girl club participation? Second, how does club participation influence the VYAs SRH knowledge to reduce their risk for HIV and negative sexual health outcomes? Methods This was a qualitative study in which twenty-three in-depth interviews were conducted with VYA girls aged 12–14 years. These girls were enrolled in girl-only clubs in two rural southern districts in Malawi. The clubs were a part of larger comprehensive HIV prevention project called DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) which provided an evidence-based core package of interventions to VYAs to prevent HIV. Interventions included improved access to key health services, education support, social skills, asset building, and economic strengthening. Narrative inquiry was used to generate first-hand accounts of the girls’ experiences with club participation. Thematic analysis was used to generate themes from the transcribed stories. Results Six main themes were generated: 1) reasons for joining the clubs with desire to learn about SRH as a motivation for joining the clubs.; 2) influence on gender norms and roles whereby participants described a change of gender roles and norms at home; 3) influence on child abuse practices whereby participants reported a decline in child abusive practices at home;4) influence on life skills and social networks whereby participants described learning about networking; 5) support to go back to school whereby out-of-school girls described how economic empowerment of their guardians facilitated their return to school; and 6) influence of clubs on SRH knowledge acquisition and behaviours whereby participants described acquiring knowledge on sexual health issues. Conclusion Girls-only HIV and SRH programs coupled with economic empowerment for their families can be effective in keeping VYA girls in school and improving SRH knowledge and health seeking behavior.

HIV-Related Stigma Research as a Priority at the National Institutes of Health

The National Institutes of Health (NIH) recognizes that, despite HIV scientific advances, stigma and discrimination continue to be critical barriers to the uptake of evidence-based HIV interventions. Achieving the Ending the HIV Epidemic: A Plan for America (EHE) goals will require eliminating HIV-related stigma. NIH has a significant history of supporting HIV stigma research across its Institutes, Centers, and Offices (ICOs) as a research priority. This article provides an overview of NIH HIV stigma research efforts. Each ICO articulates how their mission shapes their interest in HIV stigma research and provides a summary of ICO-relevant scientific findings. Research gaps and/or future opportunities are identified throughout, with key research themes and approaches noted. Taken together, the collective actions on the part of the NIH, in tandem with a whole of government and whole of society approach, will contribute to achieving EHE’s milestones.