Costs and financing of routine immunization: Approach and selected findings of a multi-country study (EPIC).

BACKGROUND: Few detailed facility-based costing studies of routine immunization (RI) programs have been conducted in recent years, with planners, managers and donors relying on older information or data from planning tools. To fill gaps and improve quality of information, a multi-country study on costing and financing of routine immunization and new vaccines (EPIC) was conducted in Benin, Ghana, Honduras, Moldova, Uganda and Zambia. METHODS: This paper provides the rationale for the launch of the EPIC study, as well as outlines methods used in a Common Approach on facility sampling, data collection, cost and financial flow estimation for both the routine program and new vaccine introduction. Costing relied on an ingredients-based approach from a government perspective. Estimating incremental economic costs of new vaccine introduction in contexts with excess capacity are highlighted. The use of more disaggregated System of Health Accounts (SHA) coding to evaluate financial flows is presented. RESULTS: The EPIC studies resulted in a sample of 319 primary health care facilities, with 65% of facilities in rural areas. The EPIC studies found wide variation in total and unit costs within each country, as well as between countries. Costs increased with level of scale and socio-economic status of the country. Governments are financing an increasing share of total RI financing. CONCLUSIONS: This study provides a wealth of high quality information on total and unit costs and financing for RI, and demonstrates the value of in-depth facility approaches. The paper discusses the lessons learned from using a standardized approach, as well as proposes further areas of methodology development. The paper discusses how results can be used for resource mobilization and allocation, improved efficiency of services at the country level, and to inform policies at the global level. Efforts at routinizing cost analysis to support sustainability efforts would be beneficial.

Social determinants of syphilis in South China: the effect of sibling position on syphilis and sexual risk behaviours.

OBJECTIVE: This study evaluated the relationship between sibling position and sexual risk based on behavioural and syphilis infection data from sexually transmitted infection (STI) patients in South China. DESIGN: A cross-sectional study examining sexual behaviours and syphilis infection. SETTING: 4 STI clinics in the Pearl River Delta of South China. PARTICIPANTS: 1792 Chinese men and women attending STI clinics. PRIMARY OUTCOME MEASURES: STI history, syphilis infection defined as positive non-treponemal and treponemal tests. RESULTS: Among all clinic patients, 824 (46.3%) were first-born, 354 (19.9%) were middle-born and 602 (33.8%) were final-born. Middle-born individuals had a higher percentage of reported STI history (44.7% compared to 34.7%, p<0.001) and syphilis infection (9.7% compared to 4.9%, p=0.01) among men (n=1163) compared to other sibling positions in bivariate analyses, but not in the final multivariate model. The relationship between sibling position and syphilis was independent of income and education level. There was no trend observed between middle-born position and female sexual risk behaviours (n=626). Higher education was significantly associated with syphilis among women and men in respective multivariate models. CONCLUSIONS: This study suggests that middle-born men in China may have an increased sexual risk compared to other sibling positions. As Chinese family and social structures change, a more thorough understanding of how demographic factors influence sexual risk behaviours is needed.

HIV testing and management: findings from a national sample of Asian/Pacific islander men who have sex with men.

OBJECTIVES: We examined reasons for and barriers to participating in HIV voluntary counseling and testing for Asian/Pacific Islander (A/PI) men who have sex with men (MSM) in the U.S. METHODS: We collected data between June 2007 and September 2009 in a study known as Men of Asia Testing for HIV, using a cross-sectional community-based participatory design. This national study was conducted in seven U.S. metropolitan cities through a coalition of seven community-based organizations. RESULTS: Participants included 445 self-identified A/PI MSM aged ≥18 years. Perception of being at risk was the number one reason for testing behaviors. For first-time testers, structural barriers (e.g., language barriers with health professionals) and fear of disclosure (e.g., sexual orientation not known to parents) were deterrents for nontesting in the past. Among previously known HIV-positive men, 22% were not seeing a doctor and 19% were not taking any HIV medications. CONCLUSIONS: HIV testing, care, and treatment policies would be less than optimal without addressing barriers to testing, including stigma related to sexual orientation, among A/PI MSM.

Prior HIV testing among STD patients in Guangdong Province, China: opportunities for expanding detection of sexually transmitted HIV infection.

BACKGROUND: Expanding HIV testing is important among individuals at increased risk for sexual HIV transmission in China, but little is known about prior HIV testing experiences among sexually transmitted disease (STD) patients. METHODS: This cross-sectional study of 1792 outpatients from 6 public STD clinics in Guangdong Province recorded detailed information about ever having been tested for HIV infection in addition to sociodemographic variables, health seeking, clinical STD history, and HIV stigma using a validated survey instrument. RESULTS: A total of 456 (25.4%) of the STD patients in this sample had ever been tested for HIV infection. STD patients who were male, had higher income, more education, were at City A and City C, received STD services at public facilities, had used intravenous drugs, and had a history of an STD were more likely to ever receive an HIV test in multivariate analysis. Low perceived HIV risk was the most common reason for not receiving an HIV test. Only 7.7% of the sample reported fear of discrimination or loss of face as influencing their lack of HIV testing. CONCLUSION: Incomplete prior HIV screening among STD patients in China suggests the need for broadening HIV testing opportunities at STD clinics and similar clinical settings attended by those with increased sexual risk.

Development and implementation of a collaborative, multistakeholder research and practice model on HIV prevention targeting Asian/Pacific Islander men in the United States who have sex with men.

We describe lessons learned from a national HIV prevention research program grounded in community-based participatory research, the Men of Asia Testing for HIV (MATH) Study, which targeted self-identified Asian/Pacific Islander men in the United States who have sex with men. We discuss the genesis of and impetus for the study and then describe its various facets, including accomplishments, challenges, and unanticipated consequences. We conclude with a discussion about the real-world practice of community-based participatory research with respect to the MATH Study in particular and similar research in general.

Intimate partner violence, depression, and alcohol use among a sample of foreign-born Southeast Asian women in an urban setting in the United States.

Intimate partner violence (IPV) is a serious global public health issue. At least one in three women worldwide has been beaten, coerced into sex, or otherwise abused during her lifetime. According to the Bureau of Justice Statistics, more than three women in the United States die every day from physical abuse suffered at the hands of an intimate partner. IPV is defined as violence that occurs within the private sphere, generally between individuals who are related through intimacy, blood, or law. When perpetrated against women, IPV is generally understood to include physical, sexual, and psychological abuse by intimate male partners.

STIs and HIV among men having sex with men in China: a ticking time bomb?

Over the past 10 years, HIV infection rate has increased annually from 30% to 40% in China, resulting in over 700,000 Chinese living with HIV/AIDS by the end of 2007. The Chinese National Medium and Long-Term Strategic Plan for HIV/AIDS Control and Prevention (1998-2010) identifies the men who have sex with men (MSM) population as a high-risk group for HIV infection. The latest statistics show that MSM account for 11.1% of all HIV/AIDS cases in China, an alarming rising rate in a country with one fourth of the world's population. To help expanding the emerging foundation of scientific and empirical data on Chinese MSM, several multidivisional research initiatives have been initiated. For example, the China National Center for AIDS/STD Prevention and Control recently launched a national study targeting above 26,000 MSM in 61 cities in 2008. Other programs, targeted prevention measures for the estimated 5-10 million-Chinese MSM, including stronger promotion of condom use, expanded coverage and quality of HIV prevention activities, increased access to voluntary HIV counseling-and-testing services, and improved access to treatment for sexually transmitted infections. To complement these initiatives, this article aims to provide a comprehensive review and analysis of the (a) scientific and empirical literature (both in English and Chinese) on HIV/sexually tranmitted infection (STI) prevention targeting Chinese MSM, and (b) existing programmatic and policy efforts targeting Chinese MSM at risk for STIs (including HIV). Finally, four recommendations for future endeavors targeting this high-risk group are drawn from the above analyses.

Beyond medical insurance: delayed or forgone care among children in Chinese immigrant families.

While Asian Americans are less likely than most Americans to use health services, little is known about their barriers to pediatric care. This study seeks to describe the prevalence of delayed/forgone pediatric care and its association with parental acculturation status in recent-immigrant Chinese families. Survey data were obtained from 76 families across two community services sites. Half of the surveyed families reported delayed/forgone pediatric care in the previous 12 months. Low-income families in suburban areas reported greater financial burdens, linguistic barriers, and a higher prevalence of delayed/forgone care than low-income families living in downtown area. Middle class immigrant families reported cultural barriers as a reason for delayed/forgone care. Traditional beliefs and not medical insurance were significant predictors of delayed/forgone care. Culturally and linguistically appropriate studies on risk reduction interventions will be needed to address the linguistic and cultural barriers to health care access.

HIV risks among two types of male migrants in Shanghai, China: money boys vs. general male migrants.

OBJECTIVES: To examine HIV/AIDS-related knowledge, attitudes and behaviours among 'money boys' and general male migrants in Shanghai, China. DESIGN: A quantitative cross-sectional design with self-administered paper-and-pencil instruments was used. METHODS: A total of 239 money boys were enrolled using community popular opinion leader and respondent-driven sampling methods, and 100 general male migrants were enrolled through venue-based sampling. RESULTS: Compared to general male migrants, money boys were significantly younger, better educated, more likely to be single, earned a higher income, suffered greater stress, and were less satisfied with life in Shanghai. Both groups had substantial misconceptions about HIV/AIDS, although general male migrants were less well informed. Furthermore, both groups reported low rates of condom use, regardless of who their sexual partners were. Money boys were more likely to use alcohol, had more sexual partners and more casual sex partners, and were more likely to engage in other sexual risks. Moreover, they were likely to be the victims of sexual violence at the hands of their clients. More than half of the money boys had been tested for HIV and 3% self-reported to be HIV-positive, whereas only 1% of the general male migrants had ever been tested and all self-reported to be HIV-negative. Infection with other sexually transmitted diseases was also reported by money boys. CONCLUSIONS: This study suggests an urgent need to implement HIV/AIDS prevention and intervention programs targeting male migrants, especially money boys and their clients. Some recommendations for conducting interventions among the male migrant population in China are suggested.