An action agenda for HIV and sex workers.

The women, men, and transgender people who sell sex globally have disproportionate risks and burdens of HIV in countries of low, middle, and high income, and in concentrated and generalised epidemic contexts. The greatest HIV burdens continue to be in African female sex workers. Worldwide, sex workers still face reduced access to needed HIV prevention, treatment, and care services. Legal environments, policies, police practices, absence of funding for research and HIV programmes, human rights violations, and stigma and discrimination continue to challenge sex workers' abilities to protect themselves, their families, and their sexual partners from HIV. These realities must change to realise the benefits of advances in HIV prevention and treatment and to achieve global control of the HIV pandemic. Effective combination prevention and treatment approaches are feasible, can be tailored for cultural competence, can be cost-saving, and can help to address the unmet needs of sex workers and their communities in ways that uphold their human rights. To address HIV in sex workers will need sustained community engagement and empowerment, continued research, political will, structural and policy reform, and innovative programmes. But such actions can and must be achieved for sex worker communities everywhere.

Is there scope for cost savings and efficiency gains in HIV services? A systematic review of the evidence from low- and middle-income countries.

OBJECTIVE: To synthesize the data available--on costs, efficiency and economies of scale and scope--for the six basic programmes of the UNAIDS Strategic Investment Framework, to inform those planning the scale-up of human immunodeficiency virus (HIV) services in low- and middle-income countries. METHODS: The relevant peer-reviewed and "grey" literature from low- and middle-income countries was systematically reviewed. Search and analysis followed Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. FINDINGS: Of the 82 empirical costing and efficiency studies identified, nine provided data on economies of scale. Scale explained much of the variation in the costs of several HIV services, particularly those of targeted HIV prevention for key populations and HIV testing and treatment. There is some evidence of economies of scope from integrating HIV counselling and testing services with several other services. Cost efficiency may also be improved by reducing input prices, task shifting and improving client adherence. CONCLUSION: HIV programmes need to optimize the scale of service provision to achieve efficiency. Interventions that may enhance the potential for economies of scale include intensifying demand-creation activities, reducing the costs for service users, expanding existing programmes rather than creating new structures, and reducing attrition of existing service users. Models for integrated service delivery--which is, potentially, more efficient than the implementation of stand-alone services--should be investigated further. Further experimental evidence is required to understand how to best achieve efficiency gains in HIV programmes and assess the cost-effectiveness of each service-delivery model.

Costs and efficiency of integrating HIV/AIDS services with other health services: a systematic review of evidence and experience.

OBJECTIVES: To review the literature on the potential efficiency gains of integrating HIV services with other health services. DESIGN: Systematic literature review. Search of electronic databases, manual searching and snowball sampling. Studies that presented results on cost, efficiency or cost-effectiveness of integrated HIV services were included, focusing on low- and middle-income countries. Evidence was analysed and synthesised through a narrative approach and the quality of studies assessed. RESULTS: Of 666 citations retrieved, 46 were included (35 peer reviewed and 11 from grey literature). A range of integrated HIV services were found to be cost-effective compared with 'do-nothing' alternatives, including HIV services integrated into sexual and reproductive health services, integrated tuberculosis/HIV services and HIV services integrated into primary healthcare. The cost of integrated HIV counselling and testing is likely to be lower than that of stand-alone counselling and testing provision; however, evidence is limited on the comparative costs of other services, particularly HIV care and treatment. There is also little known about the most efficient model of integration, the efficiency gain from integration beyond the service level and any economic benefit to HIV service users. CONCLUSIONS: In the context of increasing political commitment and previous reviews suggesting a strong public health argument for the integration of HIV services, the authors found the evidence on efficiency broadly supports further efforts to integrate HIV services. However, key evidence gaps remain, and there is an urgent need for further research in this area.

Knowledge of, attitudes towards, and practices relating to child-spacing methods in northern Burkina Faso.

This study was carried out to document current trends in knowledge of, attitudes towards, and practices relating to traditional and modern child-spacing methods in a remote area in northern Burkina Faso. Information on sexual abstention, weaning, and contraception was elicited from 296 women of reproductive age, involving 413 postpartum intervals. A number of older women and key informants were also interviewed. The findings depicted significant diversity in that durations of individual postpartum sexual abstinence varied between 40 days and 3 years, with shorter durations associated with stricter adherence to Islamic beliefs and, possibly, a trend towards a less collective and, for the family unit, more labour intensive, agro-pastoral subsistence economy. Although durations of amenorrhoea were relatively short at between (median) 9 and 11 months, they determined the length of non-susceptible periods in almost 90% of cases. The median timing of weaning was stable at 24 months across all three main ethnic groups. However, changes in the frequency and type of complementary feeds may have impacted on the duration of amenorrhoea. Both demand for modem contraception and contraceptive prevalence (< 1%) were very low. The creation of new child-spacing norms and the promotion of modern contraceptive methods are likely to be successful in areas like this one only, if the population can be sensitized to the idea that Islam does not necessarily discourage contraception.