Assessment of the Global Fund-supported procurement and supply chain reforms at the Ethiopian Pharmaceuticals Supply Agency: a mixed-methods study.

OBJECTIVE: The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) partnered with the Ethiopian Pharmaceutical Supply Agency (EPSA) in 2018-2019 to reform procurement and supply chain management (PSCM) procedures within the Ethiopian healthcare system. This assessment sought to determine the impact of the reforms and document the lessons learnt. DESIGN: Mixed-methods study incorporating qualitative and quantitative analysis. Purposive and snowballing sampling techniques were applied for the qualitative methods, and the data collected was transcribed in full and subjected to thematic content analysis. Descriptive analysis was applied to quantitative data. SETTING: The study was based in Ethiopia and focused on the EPSA operations nationally between 2017 and 2021. PARTICIPANTS: Twenty-five Ethiopian healthcare decision-makers and health workers. INTERVENTION: Global Fund training programme for health workers and infrastructural improvements OUTCOMES: Operational and financial measures for healthcare PSCM. RESULTS: The availability of antiretrovirals, tuberculosis and malaria medicines, and other related commodities, remained consistently high. Line fill rate and forecast accuracy were average. Between 2018 and 2021, procurement lead times for HIV and malaria-related orders reduced by 43.0% relative to other commodities that reported an increase. Many interview respondents recognised the important role of the Global Fund support in improving the performance of EPSA and provided specific attributions to the observed successes. However, they were also clear that more needs to be done in specific critical areas such as financing, strategic reorganisation, data and information management systems. CONCLUSION: The Global Fund-supported initiatives led to improvements in the EPSA performance, despite several persistent challenges. To sustain and secure the gains achieved so far through Global Fund support and make progress, it is important that various stakeholders, including the government and the donor community, work together to support EPSA in delivering on its core mandate within the Ethiopian health system.

Ending AIDS as a public health threat by 2030: Time to reset targets for 2025.

Paul De Lay and co-authors introduce a Collection on the design of targets for ending the AIDS epidemic.

Impact of a Family Economic Intervention (Bridges) on Health Functioning of Adolescents Orphaned by HIV/AIDS: A 5-Year (2012-2017) Cluster Randomized Controlled Trial in Uganda.

Objectives. To investigate the long-term impacts of a family economic intervention on physical, mental, and sexual health of adolescents orphaned by AIDS in Uganda.Methods. Students in grades 5 and 6 from 48 primary schools in Uganda were randomly assigned at the school level (cluster randomization) to 1 of 3 conditions: (1) control (n = 487; 16 schools), (2) Bridges (1:1 savings match rate; n = 396; 16 schools), or (3) Bridges PLUS (2:1 savings match rate; n = 500; 16 schools).Results. At 24 months, compared with participants in the control condition, Bridges and Bridges PLUS participants reported higher physical health scores, lower depressive symptoms, and higher self-concept and self-efficacy. During the same period, Bridges participants reported lower sexual risk-taking intentions compared with the other 2 study conditions. At 48 months, Bridges and Bridges PLUS participants reported better self-rated health, higher savings, and lower food insecurity. During the same period, Bridges PLUS participants reported reduced hopelessness, and greater self-concept and self-efficacy. At 24 and 48 months, Bridges PLUS participants reported higher savings than Bridges participants.Conclusions. Economic interventions targeting families raising adolescents orphaned by AIDS can contribute to long-term positive health and overall well-being of these families.Trial Registration. ClinicalTrials.gov registration no. NCT01447615.

Therapeutic Borderlands: Austerity, Maternal HIV Treatment, and the Elusive End of AIDS in Mozambique.

"End of AIDS" requires ambitious testing, treatment, and adherence benchmarks, like UNAIDS' "90-90-90 by 2020." Mozambique's efforts to improve essential maternal/infant antiretroviral treatment (ART) exposes how austerity-related health system short-falls impede public HIV/AIDS service-delivery and hinder effective maternal ART and adherence. In therapeutic borderlands-where household impoverishment intersects with health-system impoverishment-HIV+ women and over-worked care-providers circumnavigate scarcity and stigma. Worrisome patterns of precarious use emerge-perinatal ART under-utilization, delayed initiation, intermittent adherence, and low retention. Ending HIV/AIDS requires ending austerity and reinvesting in a public sector health workforce to ensure universal health coverage as household and community safety nets.

Tackling an emerging epidemic: the burden of non-communicable diseases among people living with HIV/AIDS in sub-Saharan Africa.

Sub-Saharan Africa (SSA) is at a crossroad. Over the last decade, successes in the scale up of HIV care and treatment programs has led to a burgeoning number of people living with HIV (PLHIV) in care. At the same time, an epidemiologic shift has been witnessed with a concomitant rise in non-communicable diseases (NCD) related morbidity and mortality. Against low levels of domestic financing and strained healthcare delivery platforms, the NCD-HIV syndemic threatens to reverse gains made in care of people living with HIV (PLHIV). NCDs are the global health disruptor of the future. In this review, we draw three proposals for low and middle-income countries (LMICs) based on existing literature, that if contextually adopted would mitigate against impending poor NCD-HIV care outcomes. First, we call for an adoption of universal health coverage by countries in SSA. Secondly, we recommend leveraging on comparably formidable HIV healthcare delivery platforms through integration. Lastly, we advocate for institutional-response building through a multi-stakeholder governance and coordination mechanism. Based on our synthesis of existing literature, adoption of these three strategies would be pivotal to sustain gains made so far for NCD-HIV care in SSA.

Analysis of hospitalization expenses of 610 HIV/AIDS patients in Nantong, China.

BACKGROUND: The goal of this study was to describe the expenses related to human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) management and care in Nantong Infectious Disease Hospital from October 2013 through June 2017. METHODS: The information of 610 HIV/AIDS inpatients were collected from the Electronic Medical Record System of the hospital. Univariate and path analysis were employed to evaluate the association between hospitalization expense and its related factors. RESULTS: The average hospitalization expenses per person was 5454 RMB (Renminbi, the currency of China, about $808 USD) and 23,555 RMB (about $3489 USD), respectively for HIV/AIDS patients. The average length of hospital stay was 10.0 ± 5.5 days for HIV patients and 21.7 ± 12.4 days for AIDS patients. For HIV patients, laboratory test fees constituted 37.46% of total expenses; while drug fees accounted for the largest proportion for AIDS patients. Path analysis indicated that the length of hospital stay was the most important factor affecting total expenses (total path coefficient = 0.563 for HIV patients and 0.649 for AIDS patients). Total expenses for HIV-infected females was higher than that of males (total path coefficient = 0.217), and the more complications led to higher expenses for AIDS patients. CONCLUSIONS: Though antiretroviral therapy (ART) is provided for free in China, associated medical care, particularly hospitalizations and fees, continue to drive up the medical costs of patients living with HIV and AIDS. Understanding the factors influencing these costs are crucial for determining policies and strategies that can reduce the economic burden of HIV/AIDS patients in China.

Health sector spending and spending on HIV/AIDS, tuberculosis, and malaria, and development assistance for health: progress towards Sustainable Development Goal 3.

Background: Sustainable Development Goal (SDG) 3 aims to "ensure healthy lives and promote well-being for all at all ages". While a substantial effort has been made to quantify progress towards SDG3, less research has focused on tracking spending towards this goal. We used spending estimates to measure progress in financing the priority areas of SDG3, examine the association between outcomes and financing, and identify where resource gains are most needed to achieve the SDG3 indicators for which data are available. Methods: We estimated domestic health spending, disaggregated by source (government, out-of-pocket, and prepaid private) from 1995 to 2017 for 195 countries and territories. For disease-specific health spending, we estimated spending for HIV/AIDS and tuberculosis for 135 low-income and middle-income countries, and malaria in 106 malaria-endemic countries, from 2000 to 2017. We also estimated development assistance for health (DAH) from 1990 to 2019, by source, disbursing development agency, recipient, and health focus area, including DAH for pandemic preparedness. Finally, we estimated future health spending for 195 countries and territories from 2018 until 2030. We report all spending estimates in inflation-adjusted 2019 US$, unless otherwise stated. Findings: Since the development and implementation of the SDGs in 2015, global health spending has increased, reaching $7·9 trillion (95% uncertainty interval 7·8-8·0) in 2017 and is expected to increase to $11·0 trillion (10·7-11·2) by 2030. In 2017, in low-income and middle-income countries spending on HIV/AIDS was $20·2 billion (17·0-25·0) and on tuberculosis it was $10·9 billion (10·3-11·8), and in malaria-endemic countries spending on malaria was $5·1 billion (4·9-5·4). Development assistance for health was $40·6 billion in 2019 and HIV/AIDS has been the health focus area to receive the highest contribution since 2004. In 2019, $374 million of DAH was provided for pandemic preparedness, less than 1% of DAH. Although spending has increased across HIV/AIDS, tuberculosis, and malaria since 2015, spending has not increased in all countries, and outcomes in terms of prevalence, incidence, and per-capita spending have been mixed. The proportion of health spending from pooled sources is expected to increase from 81·6% (81·6-81·7) in 2015 to 83·1% (82·8-83·3) in 2030. Interpretation: Health spending on SDG3 priority areas has increased, but not in all countries, and progress towards meeting the SDG3 targets has been mixed and has varied by country and by target. The evidence on the scale-up of spending and improvements in health outcomes suggest a nuanced relationship, such that increases in spending do not always results in improvements in outcomes. Although countries will probably need more resources to achieve SDG3, other constraints in the broader health system such as inefficient allocation of resources across interventions and populations, weak governance systems, human resource shortages, and drug shortages, will also need to be addressed. Funding: The Bill & Melinda Gates Foundation.

How were situations of preventive and curative care expenditure for AIDS and medical burden of patients? Research based on "System of Health Accounts 2011".

BACKGROUND: The problem of AIDS response has not only involved public health, but also had a great impact on the family burden.The objective of this study was to estimate the preventive and curative care expenditure(PCE)for AIDS of Hunan Province in 2017 based on System of Health Accounts 2011(SHA2011)by quantity,financing scheme,health provider,health function,and to analyses the factors affecting patients' medical burden. METHODS: Through stratified multi-stage sampling method, 1336 institutions were surveyed to obtain AIDS prevention and control data, and the official data collected from Health Statistical Yearbook, Health Financial Annual Reports and Government Input Monitoring System were used to estimate the AIDS PCE based on SHA2011. Univariate analyses and ordered logistic regression were used to evaluate the factors affecting the medical burden of AIDS patients. RESULTS: The AIDS PCE of Hunan Province in 2017 was 266.67 million, mainly flowed to hospitals and disease prevention and control institutions. The proportions of curative care expenditure(CCE) and prevention expenditure were 51.39 and 48.61% respectively. Prevention expenditure were mainly used for traditional prevention methods. All prevention expenditure and 88.52% of CCE were borne by public financing scheme. Family health expenditure accounted for 11.12% of CCE, but there were still some people with heavy burden of treatment. Non insurance, co-infection and length of stay are risk factors to the total hospitalization expenses(Totalexp)and the out-of-pocket payments(OOPs)(all p < 0.05,OR > 1). Taking the age group under 30 as the reference, the partial regression coefficient of the age group over 60 was statistically significant (OR (Totalexp) = 1.809, OR (OOPs) = 0.30). CONCLUSION: The financing structure of the PCE for AIDS in Hunan Province was relatively stable and the flow of institutions was reasonable. The functional flow of expenditure embodied the principle of "prevention first". China should incorporate oral PrEP into the national guidelines as soon as possible to improve the allocation efficiency of AIDS prevention resources. Meantime, several measures should be taken to reduce the medical burden of AIDS patients, including expanding the scope of government assistance, adjusting insurance compensation measures, increasing the rate of patients participating in insurance,encouraging commercial insurance to join the AIDS insurance system,and controlling length of stay in hospital.

The short-term effects of the implementation of the "Treat All" guidelines on ART service delivery costs in Namibia.

The introduction of "Treat All" (TA) has been promoted to increase the effectiveness of HIV/AIDS treatment by having patients initiate antiretroviral therapy at an earlier stage of their illness. The impact of introducing TA on the unit cost of treatment has been less clear. The following study evaluated how costs changed after Namibia's introduction of TA in April 2017. A two-year analysis assessed the costs of antiretroviral therapy (ART) during the 12 months before TA (Phase I-April 1, 2016 to March 31, 2017) and the 12 months following (Phase II-April 1, 2017 to March 31, 2018). The analysis involved interviewing staff at ten facilities throughout Namibia, collecting data on resources utilized in the treatment of ART patients and analyzing how costs changed before and after the introduction of TA. An analysis of treatment costs indicated that the unit cost of treatment declined from USD360 per patient per year in Phase I to USD301 per patient per year in Phase II, a reduction of 16%. This decline in unit costs was driven by 3 factors: 1) shifts in antiretroviral (ARV) regimens that resulted in lower costs for drugs and consumables, 2) negotiated reductions in the cost of viral load tests and 3) declines in personnel costs. It is unlikely that the first two of these factors were significantly influenced by the introduction of TA. It is unclear if TA might have had an influence on personnel costs. The reduction in personnel costs may have either represented a positive development (fewer personnel costs associated with increased numbers of healthier patients and fewer visits required) or alternatively may reflect constraints in Namibia's staffing. Prior to this study, it was expected that the introduction of TA would lead to a significant increase in the number of ART patients. However, there was less than a 4% increase in the number of adult patients at the 10 studied facilities. From a financial point of view, TA did not significantly increase the resources required in the ten sampled facilities, either by raising unit costs or significantly increasing the number of ART patients.

Assessment of the transport management systems for National Acquired Immunodeficiency Syndrome (AIDS) Council of Zimbabwe Global Fund Round 8 grant sub-recipients and implementing partners, 2014.

INTRODUCTION: during a Global Fund sub-sub recipients (SSRs) and implementing partners (IPs) review meeting for quarter 14 held in September 2013, several reports on mismanagement of vehicles were reported. We were then prompted to assess the transport management systems for the SSRs and IPs. METHODS: we conducted a descriptive cross-sectional study. The study participants were managers, drivers and other personnel involved in transport management. We also assessed the conditions of the vehicles. Data were collected using a questionnaire and checklist. RESULTS: we interviewed ten participants, seven from the IPs and three from the SSRs. Understanding and knowledge on the contents of the Memorandum of Understanding (MOU) which accompanied the vehicles were low. Six out of the ten organisations had operational vehicle policies but had shallow content. Eighteen (18) vehicles were assessed, 16 runners and two non-runners. Fifteen (15/18) of the vehicles did not have valid Zimbabwe National Authority for Road Administration (ZINARA) license discs. Only one (1/18) vehicle had a valid Zimbabwe Broadcasting Cooperation (ZBC) license disc. Of the 18 vehicles, 12 were insured with comprehensive insurance cover. Seven (7/18) of the vehicles were once involved in an accident. All the vehicles were serviced on a quarterly basis. Six (6/18) vehicles had both records of monthly service expenses and fuel returns. All the vehicles had logbooks, but only 8/18 of them were carbonated. Some sections of logbooks were incomplete. CONCLUSION: the transport management systems for the IPs and SSRs were below standard. We recommended the training and capacity building of IPs and SSRs in transport management.

It's politics, stupid! A political analysis of the HIV/AIDS Trust Fund in Uganda.

The role of trust funds in the practice of and the policy discourse on the sustainable financing for health and HIV is growing. However, there is a paucity of political analyses on implementing trust fund arrangements. Drawing on a novel meta-framework - connecting multiple streams and advocacy coalition frameworks to policy cycle models of analysis - to politically analyse HIV financing policy design, adoption and implementation as well as insights from public finance literature, this article critically analyses the politics of the AIDS Trust Fund (ATF) in Uganda. We find that politics was the most fundamental driver for the establishment of the ATF. Whereas HIV financing is inherently both technical and political, enacting the ATF was largely a geopolitical positioning policy instrument that entailed navigating political economy challenges in managing multiple stakeholder groups' politics. With the mandated tax revenues earmarked to capitalise the ATF covering only 0.5% of the annual resource needs, we find a very insignificant potential to contribute to financial sustainability of the national HIV response per se. As good ideas and evidence alone often do not necessarily produce desired results, we conclude that systematic and continuous political analysis can bring meaningful insights to our understanding of political economy dimensions of the ATF as an innovative financing policy instrument, thereby helping drive technically sound health financing policy proposals into practice more effectively. For Uganda, while proponents have invested a considerable amount of hope in the ATF as a source of sustainable domestic funding for the HIV response, substantial work remains to be done to address a number of questions that continue to beguile the current ATF architecture. Regarding global health financing policy, the findings suggest the need to pay attention to the position, power and interests of stakeholders as a powerful lever in health financing policy reforms.

Antiretroviral treatment, government policy and economy of HIV/AIDS in Brazil: is it time for HIV cure in the country?

Brazil is a low-and-middle income country (LMIC) that, despite having a large population and continental dimensions, has been able to successfully fight HIV/AIDS through a number of governmental and societal measures. These included an early response to the epidemic, the development of a universal and free public health system, incisive discussions with pharmaceutical companies to reduce antiretroviral (ARV) drug prices, investments towards the development of generic drugs and compulsory licensing of ARVs. Through such measures, Brazil is among the leading LMIC towards achieving the 90-90-90 UNAIDS goals in the years to come. In this review, we analyze Brazil's progress throughout the HIV/AIDS epidemic to achieve state-of-the-art ARV treatment and to reduce AIDS mortality in the country. The top-quality HIV/AIDS research in Brazil towards HIV prophylactic and functional cure, the next step towards the economic sustainability of the battle against HIV, is also discussed.

Prioritizing HIV/AIDS prevention strategies in Bandung, Indonesia: A cost analysis of three different HIV/AIDS interventions.

BACKGROUND: Indonesia has one of the fastest growing HIV epidemics in Asia, which mainly concentrates within risk groups. Several strategies are available to combat this epidemic, like outreach to Men who have Sex with Men (MSM) and transgender, Harm Reduction Community Meetings (HRCMs) for Injecting Drug Users (IDUs), and Information, Education and Communication (IEC) programs at Maternal & Child Health Posts (MCHPs). Reliable cost data are currently not present, hampering HIV/AIDS priority setting. The aim of this study thus is to assess the societal costs of outreach programs to MSM and transgender, HRCMs for IDUs and IEC at MCHPs in Bandung, Indonesia in 2016. METHODS: The societal costs were collected in Bandung from April until May 2017. Health care costs were collected by interviewing stakeholders, using a micro-costing approach. Non-health care costs were determined by conducting surveys within the target groups of the interventions. RESULTS: The societal costs of the outreach program were US$ 347,199.03 in 2016 and US$ 73.72 per reached individual. Moreover, the cost of HRCM for IDUs were US$ 48,618.31 in 2016 and US$ 365.55 per community meeting. For the IEC program at MCHPs, US$ 337.13 was paid in 2016 and the cost per visitor were US$ 0.51. CONCLUSION: This study provides valuable insights in the costs of outreach to MSM and transgender, HRCMs for IDUs and IEC at MCHPs. Policy makers can use these results in setting priorities within Indonesia. Data on effectiveness of interventions is necessary to make conclusive statements regarding cost-effectiveness and priority of interventions.

Cost-effectiveness of option B+ in prevention of mother-to-child transmission of HIV in Yunnan Province, China.

BACKGROUND: Although Option B+ may be more costly than Options B, it may provide additional health benefits that are currently unclear in Yunnan province. We created deterministic models to estimate the cost-effectiveness of Option B+. METHODS: Data were used in two deterministic models simulating a cohort of 2000 HIV+ pregnant women. A decision tree model simulated the number of averted infants infections and QALY acquired for infants in the PMTCT period for Options B and B+. The minimum cost was calculated. A Markov decision model simulated the number of maternal life year gained and serodiscordant partner infections averted in the ten years after PMTCT for Option B or B+. ICER per life year gained was calculated. Deterministic sensitivity analyses were conducted. RESULTS: If fully implemented, Option B and Option B+ averted 1016.85 infections and acquired 588,01.02 QALYs.The cost of Option B was US$1,229,338.47, the cost of Option B+ was 1,176,128.63. However, when Options B and B+ were compared over ten years, Option B+ not only improved mothers'ten-year survival from 69.7 to 89.2%, saving more than 3890 life-years, but also averted 3068 HIV infections between serodiscordant partners. Option B+ yielded a favourable ICER of $32.99per QALY acquired in infants and $5149per life year gained in mothers. A 1% MTCT rate, a 90% coverage rate and a 20-year horizon could decrease the ICER per QALY acquired in children and LY gained in mothers. CONCLUSIONS: Option B+ is a cost-effective treatment for comprehensive HIV prevention for infants and serodiscordant partners and life-long treatment for mothers in Yunnan province, China. Option B+ could be implemented in Yunnan province, especially as the goals of elimination mother-to-child transmission of HIV and "90-90-90" achieved, Option B+ would be more attractive.

The cost of HIV services at health facilities in Cambodia.

BACKGROUND: Donor funding for HIV/AIDS services is declining in Cambodia, and domestic resources need to be mobilized to sustain and expand these services. However, the cost of delivering HIV/AIDS services is not well studied in Cambodia. This study aims to assess the costs of delivering HIV/AIDS services, identify the major components of costs, and sources of funding. METHODS: Four of the six highest HIV burden provinces were selected at random for this study. Within each province, four health centers and two hospitals were selected for detailed data collection. A mix of top-down and bottom-up methods were used to assess the costs for HIV testing and antiretroviral therapy (ART) from the provider perspective. We assessed the differences in the quantity and prices of inputs between health facilities of the same type to identify cost-drivers. RESULTS: The average cost per visit for HIV testing was $8.92 at health centers and $14.03 at referral hospitals. Differences in the number of visits per staff were the primary determinant of differences in the cost per visit. First-line ART costed about $250 per patient per year, and the number of patients per staff was an important cost driver. Second-line ART costed from $500 to $716 per patient per year, on average, across the types of facilities, with the quantity and mix of second-line antiretroviral drugs being an important cost driver. Inpatient care at referral and provincial hospitals in total represented less than 2 percent of costs of outpatient ART. DISCUSSION: Costs are similar to neighboring countries, but over 50% of the costs of ART are financed by donors. Cambodia now is scaling up social health insurance coverage; the data from this study could serve as one input when setting reimbursement rates for HIV/AIDS services to help ensure that providers are adequately reimbursed for their services.

Management of the Global Fund aid programme in Botswana: challenges and prospects for health services delivery.

This paper examines the institutional management of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) in Botswana. We analyse the often contested roles of the state and non-governmental organisations (NGOs) as recipients of GFATM and partners in extending public health service provision to communities. Of importance is that Botswana's first GFATM grant had to be administratively closed, and the country was not awarded any other grant (especially for HIV/AIDS) until over a decade later. Following this, it is of interest to understand the ways in which institutions manage grant programmes. This article concludes that the "big brother" relationship of the state in relation to NGOs is crippling the critical and constructive effects of these organisations to deliver needed community-based health services in Botswana. GFTAM represents a window of opportunity for creating an effective civil society whose local activities will not be seen as being led covertly by the state. This article contributes to both theory and practice within the scholarship of development aid in Africa. Qualitative research methods were used, including in-depth interviews with public sector policy makers, all GFATM principal and sub-recipients, members of the Country Coordinating Mechanism (CCM) and NGOs.

Why Maximizing Quality-Adjusted Life Years, rather than Reducing HIV Incidence, Must Remain Our Objective in Addressing the HIV/AIDS Epidemic.

With efficacious behavioral, biomedical, and structural interventions available, combination implementation strategies are being implemented to combat HIV/AIDS across settings internationally. However, priority statements from national and international bodies make it unclear whether the objective should be the reduction in HIV incidence or the maximization of health, most commonly measured with quality-adjusted life years (QALYs). Building off a model-based evaluation of HIV care interventions in British Columbia, Canada, we compare the optimal sets of interventions that would be identified using HIV infections averted, and QALYs as the primary outcome in a cost-effectiveness analysis. We found an explicit focus on averting new infections undervalues the health benefits derived from antiretroviral therapy, resulting in suboptimal and potentially harmful funding recommendations.