HIV prevention costs and program scale: data from the PANCEA project in five low and middle-income countries

Elliot Marseille,Mead Over,Alena Peryshkina,Lalit Dandona,Paul Gaist,Joseph Saba,Jerry Coovadia,Christian Pitter,Dmitry Lioznov,Evgeny Krupitsky,Sowedi Muyingo,Mattias Lundberg,Nell Marshall,Nicci Stanley,Stefano Bertozzi ,Sergio Bautista‐Arredondo ,Jo Ann Du Plessis ,Sunil Kumar ,Brandi Y Rollins ,James G Kahn

doi:10.1186/1472-6963-7-108

Abstract

BackgroundEconomic theory and limited empirical data suggest that costs per unit of HIV prevention program output (unit costs) will initially decrease as small programs expand. Unit costs may then reach a nadir and start to increase if expansion continues beyond the economically optimal size. Information on the relationship between scale and unit costs is critical to project the cost of global HIV prevention efforts and to allocate prevention resources efficiently.MethodsThe "Prevent AIDS: Network for Cost-Effectiveness Analysis" (PANCEA) project collected 2003 and 2004 cost and output data from 206 HIV prevention programs of six types in five countries. The association between scale and efficiency for each intervention type was examined for each country. Our team characterized the direction, shape, and strength of this association by fitting bivariate regression lines to scatter plots of output levels and unit costs. We chose the regression forms with the highest explanatory power (R2).ResultsEfficiency increased with scale, across all countries and interventions. This association varied within intervention and within country, in terms of the range in scale and efficiency, the best fitting regression form, and the slope of the regression. The fraction of variation in efficiency explained by scale ranged from 26% – 96%. Doubling in scale resulted in reductions in unit costs averaging 34.2% (ranging from 2.4% to 58.0%). Two regression trends, in India, suggested an inflection point beyond which unit costs increased.ConclusionUnit costs decrease with scale across a wide range of service types and volumes. These country and intervention-specific findings can inform projections of the global cost of scaling up HIV prevention efforts.

Highlights

Economic theory and limited empirical data suggest that costs per unit of HIV prevention program output will initially decrease as small programs expand
Aggregate commitments by major donors such as the Global Fund to Fight Malaria, TB and HIV; the U.S President's Emergency Program for AIDS Relief (PEPFAR); the European Union; and, the Gates Foundation suggest that we have entered an era in which the total funds allocated to stem the HIV epidemic may constitute a significant portion of the amount needed
We found that efficiency increased with scale, across all countries and interventions we examined

Summary

Introduction

Economic theory and limited empirical data suggest that costs per unit of HIV prevention program output (unit costs) will initially decrease as small programs expand. There is wide agreement that an effective response to the global HIV epidemic requires very substantial resources. This consensus has been partially translated into increasing contributions to combat the epidemic [1]. Sound resource allocation and program budgeting, in turn, must rest on a foundation of robust unit cost estimates for the most important prevention modalities in key epidemic and cultural settings. There is a substantial, growing, but still limited body of data on the costs of HIV prevention services [2,3,4,5,6,7,8,9,10,11,12] These data provide a reasonable basis for estimating service costs for some intervention types in some settings, in sub-Saharan Africa.

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Discussion

Conclusion