No Time to Lose Getting More from HIV Prevention (2001) / Chapter Skim
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Allocating Resources
Allocating Resources
Pages 26-49
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From page 26... ...
. Further, the Committee examined the implicit strategies that appear to currently drive the investment of HIV prevention dollars, and we compared the results of those investments to the results that might have been achieved if those same resources had been allocated based on the new goal that we propose in this report, that is, preventing as many new HIV infections as possible.
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From page 27... ...
Still, it is unrealistic to expect that all federal prevention funds will be redirected to interventions that are shown to be the most cost-effective in Throughout this chapter, the Committee uses the terms "HIV prevention programs," "HIV prevention interventions," or "HIV prevention activities" to refer to publicly sponsored actions intended to prevent new HIV infections. Sometimes the Committee discusses specific interventions (such as needle exchange or HIV counseling and testing)
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From page 28... ...
Community Planning Groups, comprised of representatives from groups of people at risk for HIV infection and of providers of HIV prevention services, advise these state and local health departments in setting their priorities and in making programmatic and resource allocation decisions (Valdiserri et al., 1995; Kaplan, 1998; Kaplan and Pollack, 1998~. Similarly, SAMHSA distributes Substance Abuse Prevention and Treatment (SAPT)
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From page 29... ...
Further, the strategy that results from these cumulative decisions can best be described as "proportionality." For the most part, federal HIV prevention funds and CDC funds in particular3The CARE Act primarily funds HIV treatment services, but also funds some prevention services.
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From page 30... ...
It begins with an objective criterion of need: observed AIDS cases. While proportionality may be useful for allocating funds for AIDS treatment, it has serious limitations, including the fact that it is an inadequate marker of need for prevention services.
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From page 31... ...
As an alternative to proportionality, the Committee recommends that prevention funds be allocated to reach populations at highest risk and to support programs that are cost-effective. Both aims are necessary to support a strategy of preventing the greatest number of new infections within budget constraints.
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From page 32... ...
framework will also point decision makers to areas where data are lacking and further research is warranted. In the absence of this framework, policy makers will continue to use the same decision rules that previously have failed in the past to maximize the number of HIV infections averted.
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From page 33... ...
The use of such techniques in conjunction with the new surveillance approach recommended by the Committee could enable reasonably accurate estimates of HIV incidence by state and area. For examples of attempts to estimate the number of HIV infections averted by interventions, see Holtgrave (1998)
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From page 34... ...
Implementing Needle Exchange Programs Injection drug users (IDUs) may account for an estimated 50 percent of new HIV infections (Holmberg, 1996)
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From page 35... ...
USING EPIDEMIC IMPACT AS A MEASURE OF SUCCESS In the examples above, data exist to make reasonably accurate estimates of both the impact of the intervention on new HIV infections, or the "epidemic impact," and the cost of each new infection averted. Such clear evidence rarely is available.
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From page 36... ...
However, from the standpoint of averting HIV infections, 90 percent of all acts of anal intercourse were unprotected before the intervention while, following the intervention, 80 percent of all such acts were unprotected. Basic principles of epidemiology suggest that the incidence of new HIV infections among receptive partners will be proportional to both HIV prevalence among insertive partners and the rate of unprotected anal intercourse (Anderson and May, 1991; Kahn, 1996~.
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From page 37... ...
A STRATEGIC VISION FOR HIV PREVENTION INVESTMENTS The Committee recommends that CDC and other federal agencies supporting HIV prevention programs adopt a more strategic decision making process for allocating prevention funds. The Committee has already discussed the advantage of allocating funds on the basis of epidemic impact rather than proportionality.
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From page 38... ...
The Committee believes that allocation decisions regarding public HIV prevention money represent the single most important set of HIV prevention decisions made. The Committee has focused on the number of HIV infections prevented as the best metric for evaluating alternative HIV prevention resource allocation decisions.7 To the extent that there are additional benefits from these programs (e.g., decreases in drug use or in the incidence of sexually transmitted diseases)
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From page 39... ...
Assume further that, in this location, the annual rate of new infections absent any intervention is equal to five new HIV infections per 100 IDUs per year, and that the program is able to reduce the annual rate of new infections by 20 percent. The result of spending $300,000 would be to reach 750 injectors (since that is the maximum that can be reached)
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40 co x co o 5v)
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From page 41... ...
As previously noted, the CDC's HIV prevention funding now follows a pattern of proportionality to AIDS cases. Since AIDS cases appear to be used as a surrogate for HIV incidence when allocating funds, the Committee represents the agency's current policy as proportionality to the rate of new HIV infections.
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From page 42... ...
For each scenario, the upper line reflects epidemic impact using the Committee's recommendation to fund allocation on the basis of estimated HIV infection rates. The lower line illustrates the epidemic impact assuming the current proportional allocation formula.
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From page 43... ...
_.,.~~~ Optimistic Base '-'-'-'''a 1 1 1 Pessimistic O' ~ 0 200 400 600 800 1,000 HIV Prevention Budget (million $) FIGURE 3.5 Annual infections prevented: cost-effective versus proportional allocation.
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From page 44... ...
This scenario seems a more realistic portrait of what might be expected if investment in improved prevention programs were combined with the cost-effective allocation of prevention funds. At the Committee's touchstone funding level of $412 million, this investment scenario would see the prevention of roughly 5,060 infections under optimal allocation (compared to 3,900 infections prevented in the base case via optimal allocation)
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From page 45... ...
The Committee acknowledges that other values will and should play a role in HIV prevention policy. However, it is important that the cost of those values (in terms of prevented HIV infections forgone)
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From page 46... ...
A second example illustrates the cost of placing constraints on available HIV prevention programs based on values that punish socially proscribed behaviors. If needle exchange programs linked to drug treatment were allowed to enter the portfolio of federally funded HIV prevention programs, then the number of new infections prevented at the $412 million investment level is estimated to increase from 3,900 to 5,300 in the base case.l° The estimated difference of 1,400 prevented infections can be viewed as the human cost imposed by the ban on needle exchange.
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From page 47... ...
2000. Methods for systematic reviews of economic evaluations for the Guide to Community Preventive Services.
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From page 48... ...
1997. Updates of cost of illness and quality of life estimates for use in economic evaluations of HIV prevention programs.
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From page 49... ...
In Holtgrave DR (Ed.) , Handbook of Economic Evaluation of HIV Prevention Programs.
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