The Value of Reducing HIV Stigma

Presenter: Robert Brent (Fordham University. Economics)
Theme: Methodology
Abstract (492 words)

Abstract: Rationale: Globally, by the end of 2011 there were 34.0 million people living with HIV/AIDS. With 2.5 million new cases of HIV and 1.7 million AIDS deaths, the HIV epidemic is still on the rise. UN Secretary General, Ban Ki-Moon (2008) states that stigma is a chief reason why the AIDS epidemic continues to devastate societies worldwide. He argues that because of stigma people do not get tested and, if tested, do not seek treatment. So HIV transmission increases greatly because of the existence of stigma. If one could obtain estimates of how beneficial it would be in monetary terms to reduce HIV stigma then one could decide how much resources should be devoted to interventions that would lead to the reduction of HIV stigma. Objectives: The main objective of this paper is to show how the value of reductions in HIV stigma could be obtained by estimating the utility function and finding the marginal rate of substitution (MRS) between stigma and income. Although we will be focusing on HIV stigma reduction, it is important to recognize that stigma is a widespread phenomenon that affects access to services in many branches of the health care field. Our methods could be adapted to apply to valuing any type of stigma reduction. Methodology: We used happiness as our utility measure and happiness is increasingly being used to evaluate outcomes of economic policies, see Graham (2009). We used a recursive estimation framework whereby stigma first determined income and then the income-influenced stigma determined utility. Three different expressions for the MRS are derived and each of these leads to an alternative estimation method. To illustrate how our framework can be used we applied it to a sample of elderly people living in NYC with HIV. Data: Data for the study are related to the 2006 survey by the AIDS Community Research Initiative of America (ACRIA). This is a self-reported data set of 914 individuals with HIV in New York City. We used from this data set information on happiness (life satisfaction on a scale with 1 as the minimum and 10 as the maximum), income adequacy (ranging from $22,281 to $68,026) and HIV stigma (using the Berger scale ranging from 40 to 160). Conclusions: The total value of stigma reduction is rather large at around $1,000 per unit. The challenge to evaluators of HIV policies is to come up with interventions that impact stigma. It is unlikely that HIV stigma can be completely reduced, which for our measure was 120 points. However, interventions should be able to be identified that reduce stigma by a few points, say five. Our study can be used to value the benefits, which would be $5,000. Estimating the costs of the intervention then would allow an Economic Evaluation to be undertaken. Whether one uses an educational program, a job training scheme or anti-discriminatory regulation, one now has an estimate of how much resources should be devoted to implementing these interventions.

Biographical Details:

Currently (since 1995), Professor of Economics at Fordham University, Bronx, NY 10458.
Specializes in Cost-Benefit Analysis for policies in Developed and Developing Countries. Recent research related to evaluating interventions for HIV/AIDS.

Key Terms: HIV Stigma, Marginal Rate of Substitution (MRS), Older Adults
Author (1): Robert J. Brent (Fordham University. Economics)

An economic assessment of decentralizing anti-retroviral services from hospitals to primary health care centers in Nigeria: A matched difference-in-difference analysis

Presenter: Elaine Baruwa (Abt Associates, Inc.. International Health Division)
Theme: Application
Abstract (492 words)

Nigeria launched a ‘hub and spoke’ decentralization pilot in March 2010 for the provision of anti-retroviral therapy (ART). In this program, stable ART patients at hospitals (hubs) were downward referred to primary health care centers (spokes) for the continued provision of ART. The rationale for decentralization was to relieve congestion at the hospital level and to provide better access to care for patients not living near the hospital. The program may also save resources by moving care from more expensive hospitals to less expensive health centers. USAID’s Health Systems 20/20 project performed a costing study of ‘hub and spoke’ services. The objectives of this study are to compare the cost of ART care provided through the two levels of care, and understand the implications of cost differences for scale up of the ‘hub and spoke’ model. The study adopts a government perspective, with an analytic horizon including one year pre- and one year post-decentralization. Data were collected from facilities and patient records from Kaduna and Cross Rivers States. In Cross Rivers, data were extracted for 198 decentralized patients from four spoke sites and 200 non-decentralized patients from the hub site. These numbers were 285 and 243 respectively for the five spoke and one hub sites in Kaduna. Non-decentralized patients were matched to decentralized patients by date of ART initiation. Comparisons between patients before and after decentralization were made to assess changes in the receipt of care; difference-in-difference assessment was done between the two groups to assess differences in the receipt of care and the cost of care due to decentralization. Selected decentralized and non-decentralized patients had similar profiles in terms of age, CD4 counts, and sex when they initiated ART and again at the time when decentralized patients were referred to spoke sites, indicating a reasonable match between the comparison groups. Both groups had more visits and fewer missed visits in the year after decentralization, suggesting that decentralization may have improved access for both sets of patients. Decentralized patients had a greater decline in the number laboratory tests post-decentralization than their counterparts (p<0.05). However, fewer than the recommended number of laboratory tests was being conducted across all patients even before decentralization. Decentralized patients’ average cost of ART care was $355 per person per year in the year before decentralization and $388 after decentralization (p=0.51). For patients staying at the hospitals, these costs were $316 per person per year before decentralization and $447 after (p<0.01). In the difference-in-difference analysis, the increase in cost for non-decentralized patients was greater than that for decentralized patients (p<0.05). Decentralization of ART services appears to increase access to general ART care, but may limit access to ART laboratory services for decentralized patients. Decentralization is also likely to result in greater efficiency in the delivery of services, especially as health centers take on a greater number of patients. This study is limited by not including costs incurred above the facility level, such as training, or costs borne by patients.

Biographical Details:

Key Terms: HIV, Decentralization, Efficiency, Costing
Authors (2): Elaine Baruwa (Abt Associates, Inc.. International Health Division) and Ben Johns (Abt Associates, Inc.. International Health Division)

Funding Sources: USAID's Health Systems 20/20 Project

Examining the links between staff flexibility, workload, and service delivery in the context of SRH and HIV service integration: a case study of selected government facilities in Kenya

Presenter: Sedona Sweeney (London School of Hygiene & Tropical Medicine. Department of Global Health and Development)
Theme: Application
Abstract (429 words)

Background: There is a great deal of interest in integrating HIV and sexual reproductive health (SRH) services in low-income countries. It is often assumed that integration can improve service access and quality while reducing the cost of service delivery. Economic theory also indicates that integration could provide a greater flexibility of use of human resources, potentially improving the efficiency of health services. On the other hand, integration often requires reorganization of existing service delivery models and health workers may be concerned about increases in workload. We therefore examine the variation in staff orientation to different tasks and workload in integrated HIV/SRH care, and explore how this may be linked to unit costs. Methods: As part of the Integra Initiative in Kenya, cost and output data were collected in 11 government health facilities supported by a project aiming to enable the integration of HIV and SRH services through training, management support and the provision of resources. Baseline data was collected for the financial year 2008-09, and endline data was collected for 2010-11. Unit costs per visit and per episode of care were estimated for family planning (FP) and provider-initiated HIV counselling and testing (PITC) services. Staff time was allocated as a percentage of clinical staff full-time equivalency (FTE) according to service mix and time use. We assessed the level of task orientation based on the number of different types of health services routinely provided by one clinical staff member. Results: From baseline to endline, flexibility in the range of services provided increased among clinical staff across facilities integrating FP and PITC (increasing from 3.8 services to 5.2 services per staff member). The effect on staff time, however, varied. District hospitals and sub-district hospitals saw minimal change in the amount of total staff time spent on FP and PITC, however health centres saw a large increase in total staff time (total FTE increased by 90%). These health centres did not see an increase in workload on individual staff members resulting from the integration, as additional staff were hired in as Kenya expanded its health workforce. The total number of PITC services delivered increased by 17%, however the number of FP services fell by 6% keeping the overall number of services delivered relatively constant. Further work is currently underway to examine the relationship between multi-tasking, service delivery and unit cost. Conclusion: Our initial results suggest that while support to enable integration can increase the multi-tasking of staff, this does not necessarily reduce the amount of time spent providing services. Further work is on-going to examine the impact of multi-tasking on service efficiency.

Key Terms: integration, human resources, HIV

Authors (6): Sedona Sweeney (London School of Hygiene and Tropical Medicine. Department of Global Health and Development) , Carol Dayo Obure (London School of Hygiene and Tropical Medicine. Department of Global Health and Development) , Anna Vassall (London School of Hygiene and Tropical Medicine. Department of Global Health and Development) , Christine Michaels-Igebokwe (London School of Hygiene and Tropical Medicine. Department of Global Health and Development) , Fern Terris-Prestholt (London School of Hygiene and Tropical Medicine. Department of Global Health and Development) and The Integra Team ( . )

Funding Sources: This work was supported by a grant from the Bill and Melinda Gates Foundation.

How effective are cash transfer programmes among Children affected and infected with HIV?: An Evaluation study from South India

Presenter: Edwin Sam Asirvatham (AIDS Prevention and Control Project. Voluntary Health Services)
Theme: Application
Abstract (433 words)

Background In India, children affected and infected with HIV are primarily from the poor households and they are deprived of basic needs in terms of food, basic health care, shelter and education. The government of Tamil Nadu responded to this situation by developing the first cash transfer program in India for the children infected and affected by HIV to address the children’s education, nutrition, medical and socioeconomic needs. This was operationalized through an Orphan and Vulnerable Children (OVC) Trust with a corpus fund of $1million. Objectives The objective of the study was to assess the effectiveness of this cash transfer program in achieving its intended purposes. Methods The study was undertaken in 10 districts that were selected from four clusters of districts in Tamil Nadu state. Out of the 655 beneficiaries, a sample of 153 beneficiaries was selected using the probability to proportionate size method from each district. Interviews were conducted using a semi-structured interview schedule. The caretakers were interviewed for children below 15 years. Biometric markers (hemoglobin and CD4) of children on ART were collected from medical records. The latest available data before the cash transfer programme and latest available data during the interviews were taken for comparison. Results Among study participants, 73% of them were HIV infected and the remaining were affected children; around 37% were double orphans, 53% were paternal orphans and 10% were maternal orphans; majority were (63.4%) from rural areas and the average age was 11.46 years. 30% of the children were under the care of their grandparents. The average age of the care givers was 44 years (Range: 20 to 85 years). Food expenditure was considered as the primary household expenditure for 89% of the respondents. The household income is positively correlated with food consumption (r=.607; p<.001) indicating less scope for other basic needs. The cash transfer programmes disbursed an average amount of INR 2617(USD 52). Most interviewees reported improvement in school attendance (98%) and performance (94%) that included high marks and participation in extracurricular activities. Around 42% reported an improvement in the food consumption pattern. Among children on ART (81), both mean hemoglobin level (10.04 mg to 10.76 mg; p<.001) and mean CD4 level (738.75 to 1014.34; p<0.01) increased significantly. Conclusion The findings provide evidence related to the effectiveness of cash transfer program among children especially in supporting their education. This program has contributed in restoring their childhood and this model can be replicated in other similar situation/area. However, the program was able to reach only a low proportion of eligible beneficiaries. It is imperative to scale up the program by adopting appropriate resource mobilization initiatives.

Key Terms: Cash Transfer Programmes, Effectiveness, Children Infected with HIV
Authors (2): Edwin Sam Asirvatham (AIDS Prevention and Control Project. Voluntary Health Services) and Bimal Charles (AIDS Prevention and Control Project. Voluntary Health Services)

Funding Sources: Nil