Spending of HIV resources in Asia and Eastern Europe: systematic review reveals the need to shift funding allocations towards priority populations

Abstract

Introduction: It is increasingly important to prioritize the most cost-effective HIV interventions. We sought to summarize the evidence on which types of interventions provide the best value for money in regions with concentrated HIV epidemics.

Methods: We conducted a systematic review of peer-reviewed and grey literature reporting measurements of cost-effectiveness or cost-benefit for HIV/AIDS interventions in Asia and Eastern Europe. We also collated HIV/AIDS spending assessment data from case-study countries in the region.

Results: We identified 91 studies for inclusion, 47 of which were from peer-reviewed journals. Generally, in concentrated settings, prevention of mother-to-child transmission programmes and prevention programmes targeting people who inject drugs and sex workers had lower incremental cost-effectiveness ratios than programmes aimed at the general population. The few studies evaluating programmes targeting men who have sex with men indicate moderate cost-effectiveness. Collation of prevention programme spending data from 12 countries in the region (none of which had generalized epidemics) indicated that resources for the general population/non-targeted was greater than 30% for eight countries and greater than 50% for five countries.

Conclusions: There is a misalignment between national spending on HIV/AIDS responses and the most affected populations across the region. In concentrated epidemics, scarce funding should be directed more towards most-at-risk populations. Reaching consensus on general principles of cost-effectiveness of programmes by epidemic settings is difficult due to inconsistent evaluation approaches. Adopting a standard costing, impact evaluation, benefits calculation, analysis and reporting framework would enable cross comparisons and improve HIV resource prioritization and allocation.

Keywords: Asia; Eastern Europe; HIV; concentrated epidemics; cost-benefit analyses; cost-effectiveness; programme evaluation; systematic review.

Figure 1

Flowchart indicating inclusion and exclusion of studies (with numbers of studies N) at each stage of the review process.

Figure 2

Point estimates and ranges for ICER divided by per capita GDP. Studies are included here if they reported ICER for an individual country (or if this could be easily calculated), and if the ICER comparator was “no intervention” or “status quo.” Numbers in brackets at the start of a label are the reference number; a name in brackets indicates that the study was received as a personal communication. Study timeframes, where known, are given in brackets at the end of the label. Many studies gave multiple values for a particular ICER, representing variations such as different coverage levels; all values are included in the figure. The ranges are those given in the studies; for the range meaning, see the summary table (Supplementary file 3). For clarity, if a study gave a range but no point estimate, the point estimate was considered to be the midpoint of the range. (A) ICER is cost per life-year saved. (B) ICER is cost per DALY saved. (C) ICER is cost per QALY gained. (D) ICER is cost per HIV infection averted.

Figure 3

Point estimates and ranges for cost per HIV infection averted divided by per capita GDP, where this could be established and where the comparator was “no intervention” or “status quo,” for interventions in India (A) and Thailand (B). Study timeframes, where known, are given in brackets. Many studies gave multiple values for a particular ICER, representing variations such as different coverage levels; all values are included in the figure. The ranges are those given in the studies; for the range meaning, see the summary table (Supplementary file 3). For clarity, if a study gave a range but no point estimate, the point estimate was considered to be the midpoint of the range.

Figure 4

Allocation of 2007–2011 prevention programme spending by country and broad target population group. The “Other vulnerable” category includes programmes targeting unspecified MARPs.