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The Relation of Price of Antiretroviral Drugs and Foreign Assistance with Coverage of HIV Treatment in Africa: Retrospective Study

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Objective To determine the association of reductions in price of antiretroviral drugs and foreign assistance for HIV with coverage of antiretroviral treatment.

Design Retrospective study.

Setting Africa.

Participants 13 African countries, 2003-8.

Main outcome measures A price index of first line antiretroviral therapy with data on foreign assistance for HIV was used to estimate the associations of prices and foreign assistance with antiretroviral coverage (percentage of people with advanced HIV infection receiving antiretroviral therapy), controlling for national public health spending, HIV prevalence, governance, and fixed effects for countries and years.

Results Between 2003 and 2008 the annual price of first line antiretroviral therapy decreased from $1177 (£733; €844) to $96 and foreign assistance for HIV per capita increased from $0.4 to $13.8. At an annual price of $100, a $10 decrease was associated with a 0.16% adjusted increase in coverage (95% confidence interval 0.11% to 0.20%; 0.19% unadjusted, 0.14% to 0.24%). Each additional $1 per capita in foreign assistance for HIV was associated with a 1.0% adjusted increase in coverage (0.7% to 1.2%; 1.4% unadjusted, 1.1% to 1.6%). If the annual price of antiretroviral therapy stayed at $100, foreign assistance would need to quadruple to $64 per capita to be associated with universal coverage. Government effectiveness and national public health expenditures were also positively associated with increasing coverage.

Conclusions Reductions in price of antiretroviral drugs were important in broadening coverage of HIV treatment in Africa from 2003 to 2008, but their future role may be limited. Foreign assistance and national public health expenditures for HIV seem more important in expanding future coverage.

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BMJ
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Eran Bendavid
Grant Miller
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National Survey of Preventive Health Services in US Emergency Departments

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Study objective: We describe the availability of preventive health services in US emergency departments (EDs), as well as ED directors' preferred service and perceptions of barriers to offering preventive services.

Methods: Using the 2007 National Emergency Department Inventory (NEDI)-USA, we randomly sampled 350 (7%) of 4,874 EDs. We surveyed directors of these EDs to determine the availability of

  1. screening and referral programs for alcohol, tobacco, geriatric falls, intimate partner violence, HIV, diabetes, and hypertension;
  2. vaccination programs for influenza and pneumococcus; and
  3. linkage programs to primary care and health insurance.

ED directors were asked to select the service they would most like to implement and to rate 5 potential barriers to offering preventive services.

Results: Two hundred seventy-seven EDs (80%) responded across 46 states. Availability of services ranged from 66% for intimate partner violence screening to 19% for HIV screening. ED directors wanted to implement primary care linkage most (17%) and HIV screening least (2%). ED directors "agreed/strongly agreed" that the following are barriers to ED preventive care: cost (74%), increased patient length of stay (64%), lack of follow-up (60%), resource shifting leading to worse patient outcomes (53%), and philosophical opposition (27%).

Conclusion: Most US EDs offer preventive services, but availability and ED director preference for type of service vary greatly. The maj ority of EDs do not routinely offer Centers for Disease Control and Prevention- recommended HIV screening. Most ED directors are not philosophically opposed to offering preventive services but are concerned with added costs, effects on ED operations, and potential lack of follow- up.

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Annals of Emergency Medicine
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Analyzing Evacuation Versus Shelter-in-Place Strategies After a Terrorist Nuclear Detonation

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Professor Wein received his PhD in Operations Research from Stanford in 1988 and has taught core MBA courses in operations management throughout his entire career, both at MIT's Sloan School of Management from 1988 to 2002 and, since 2002, at Stanford's Graduate School of Business, where he is currently Paul  E. Holden Professor of Management Science. He has also been a Senior Fellow (by courtesy) at FSI since 2003.

Since 2001, Wein has analyzed a variety of homeland security problems. His homeland security work includes four papers in the Proceedings of the National Academy of Sciences: one on an emergency response to a smallpox attack,  a second on an emergency response to an anthrax attack, a third presenting a biometric analysis of the US-VISIT Program, and a fourth analyzing a bioterror attack on the milk supply. He has also published the Washington Post op-ed "Unready for Anthrax" (2003) and the New York Times op-ed "Got Toxic Milk?" (2005) and has written papers on port security, indoor remediation after an anthrax attack, and the detention and removal of illegal aliens.  He was also Editor-in-Chief of Operations Research from 2000 to 2005. Wein has won several awards, including the 1993 Erlang Prize for the outstanding applied probabilist under 35 years of age and the 2002 Koopman Prize for the best paper in military operations research.

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Rebecca Slayton Affiliated Faculty at CISAC, and Lecturer in Science, Technology, and Society Commentator

Lawrence M. Wein

Graduate School of Business
Stanford University
Stanford, CA 94305-5015

(650) 724-1676 (650) 725-0468
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Jeffrey S. Skoll Professor of Management Science
CISAC Affiliated Faculty Member
Wein.jpg PhD

Lawrence Wein is the Jeffrey S. Skoll Professor of Management Science at the Graduate School of Business, Stanford University, and an affiliated faculty member at CISAC. After getting a PhD in Operations Research from Stanford University in 1988, he spent 14 years at the Sloan School of Management at MIT, where he was the DEC Leaders for Manufacturing Professor of Management Science. His research interests include mathematical models in operations management, medicine and biology.

Since 2001, he has analyzed a variety of homeland security problems. His homeland security work includes four papers in Proceedings of the National Academy of Sciences, on an emergency response to a smallpox attack, an emergency response to an anthrax attack, a biometric analysis of the US-VISIT Program, and an analysis of a bioterror attack on the milk supply. He has also published the Washington Post op-ed "Unready for Anthrax" (2003) and the New York Times op-ed "Got Toxic Milk?", and has written papers on port security, indoor remediation after an anthrax attack, and the detention and removal of illegal aliens.

For his homeland security research, Wein has received several awards from the International Federation of Operations Research and Management Science (INFORMS), including the Koopman Prize for the best paper in military operations research, the INFORMS Expository Writing Award, the INFORMS President’s Award for contributions to society, the Philip McCord Morse Lectureship, the Frederick W. Lanchester Prize for best research publication, and the George E. Kimball Medal. He was Editor-in-Chief of Operations Research from 2000 to 2005, and was elected to the National Academy of Engineering in 2009.   

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Lawrence M. Wein Professor of Management Science, Stanford Graduate School of Business; Senior Fellow (by courtesy), Freeman Spogli Institute for International Studies Speaker
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2010 Orientation celebrates FSI's research, educational, and policy endeavors

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FSI's 2010 Fall Orientation welcomed faculty, staff, researchers, and friends of the institute to the new academic year and highlighted the institute's diverse research collaborations, educational programs, and policy engagement.  Presentations on display and in live video offered highlights of the current work of FSI centers and programs on many of the most challenging issues of the day. In his welcoming remarks, FSI Director Coit Blacker emphasized the interdisciplinary, cross-campus nature of FSI's work and thanked the FSI community for their many contributions to new knowledge and new approaches to many of the most pressing issues on today's global agenda.

This year's Orientation attracted the largest turnout to date. On continual display was a slide show capturing research of FSI centers and programs in the field and multi-disciplinary work here at the institute, along with highlights of FSI conferences, lectures, and policy endeavors compiled by FSI's Nora Sweeny.

Among the highlights were the following displays:

  • A presentation by the Center for International Security and Cooperation on the center's research, writing, policy influence, and Track II Diplomacy
  • A display of the many books published by the Walter Shorenstein Asia-Pacific Research Center showing the range of economic, political, and regional issues addressed by APARC scholars, and a photo slideshow of recent events and publications demonstrating the breadth of faculty work bridging the U.S. and Asia
  • A presentation by The Europe Center, newly launched and housed jointly in FSI and the Division of International and Comparative Area Studies, featuring major research areas, visiting scholars, publications, and notable events
  • A presentation by Stanford Health Policy capturing its multidisciplinary work in medicine, law, business, economics, engineering, and psychology
  •  A presentation by the Ford Dorsey Program in International Policy Studies, a two-year interdisciplinary Master's program, which captured the IPS practicum, scholarly concentrations, internships, and careers
  • A presentation by the Program on Energy and Sustainable Development featuring its work on environmental and policy research employing state of the art methodology to examine such issues as renewable energy, natural gas markets, national oil companies, low-income energy services, and climate change policy
  • A presentation by the Program on Food Security and the Environment which addresses hunger, poverty, and environmental degradation. FSE showcased its current research on topics such as solar electrification, food and nutrition security, climate change and conflicts, and evolving U.S. energy policy, as well as its upcoming series on Food Policy, Food Security, and the Environment
  • A presentation by the Stanford Program on International and Cross-Cultural Education, which develops multi-disciplinary curriculum materials on international themes reflecting FSI scholarship. Recent educational projects include a three-part series examining U.S.-South Korean relations, Uncovering North Korea, and Inter-Korean Relations; and a collaboration with TeachAIDS, which works to address and overcome the social and cultural challenges related to HIV/AIDS prevention education through materials offered via the internet and CDs in several languages, http://teachaids.org
  • A presentation featuring the Stanford Global Gateway, a comprehensive directory of Stanford in the world
  • A presentation previewing the vision and mission of the Stanford Center at Peking University, opening Fall 2011

Other highlights included the presentations prepared by Stanford students who worked in the field this past summer. One group worked in China, developing a survey on nutrition and anemia and their effect on learning, with FSI's Scott Rozelle, Director of the Rural Education Action Program. A second group helped Dr. Paul Wise, professor of pediatrics and Stanford Health Policy core faculty member, evaluate prenatal care in the rural highlands of Guatemala.

 

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Scaling Up Circumcision Programs in Southern Africa: The Potential Impact of Gender Disparities and Changes in Condom Use Behaviors on Heterosexual HIV Transmission

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Circumcision significantly reduces female-to-male transmission of HIV infection, but changes in behavior may influence the overall impact on transmission. We sought to explore these effects, particularly for societies where women have less power to negotiate safe sex. We developed a compartmental epidemic model to simulate the population-level impact of various circumcision programs on heterosexual HIV transmission in Soweto. We incorporated gender-specific negotiation of condom use in sexual partnerships and explored post-circumcision changes in condom use. A 5-year prevention program in which only an additional 10% of uncircumcised males undergo circumcision each year, for example, would prevent 13% of the expected new HIV infections over 20 years. Outcomes were sensitive to potential changes in behavior and differed by gender. For Southern Africa, even modest programs offering circumcision would result in significant benefits. Because decreases in male condom use could diminish these benefits, particularly for women, circumcision programs should emphasize risk-reduction counseling.

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AIDS and behavior
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Douglas K. Owens

Second and Third Generation Human Rights in Africa: Workshop #5

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Building on the foundation of 2009-10 workshop Legalizing Human Rights in Africa, the 2010-11 interdisciplinary research workshop will extend the examination of human rights discourse and institutions in Africa to broader questions around second and third generation rights. The workshop will canvas human rights insights from a broad sweep of disciplinary expertise, such as history, science, engineering anthropology, sociology, philosophy, law and political science. The goal of the workshop is to broaden human rights scholarship beyond single disciplinary domains.

Because the field of second and third generation human rights is broad, we have narrowed the discussion topics to the most urgent ones that are well suited to interdisciplinary analysis by anticipated workshop participants. Initial sessions will lay the foundation for the generational framework of human rights in Africa and the recent progression beyond civil and political rights. The workshop will proceed to discuss a wide range of the most significant and timely second and third generation human rights challenges in Africa.

Co-sponsored by the Center on African Studies and the Stanford Humanities Center.

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Board Room, Humanities Center

Richard Goldstone Former Justice of the Constitutional Court of South Africa Speaker
Helen Stacy Moderator
Workshops
Second and Third Generation Rights in Africa

Second and Third Generation Human Rights in Africa: Health equity and AIDS treatment in Africa

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Dr. Katzenstein completed his undergraduate and medical degrees as well as a residency in Internal Medicine and Fellowship training in Infectious Diseases at the University of California San Diego. He continued fellowship training in virology and Infectious Diseases with Dr. Colin Jordan at U.C. Davis, moving to the University of Minnesota to a faculty position in Infectious Disease in 1984. He was a visiting lecturer for two years in the Departments of Medical Microbiology and Medicine at the University University of Zimbabwe as the AIDS epidemic was first recognized in Southern Africa. In 1987, he returned to the U.S. to take up a senior research fellowship at the Center for Biologics Evaluation and Research (CBER) at the Food and Drug Administration in the Vaccine Branch, evaluating early candidate HIV Vaccines and diagnostics. Dr. Katzenstein returned to California in 1989 to work with Dr. Thomas Merigan and the AIDS Clinical Trials Group. He continues an active collaboration with his colleagues in Zimbabwe and Southern Africa in prevention, perinatal transmission and vaccine research. At Stanford, Dr. Katzenstein participates in studies of multiple drugs and drug combinations in Clinical Trials in the U.S. and Europe and is the principal investigator for Stanford's Virology Service Laboratory in the center for AIDS Research. At Stanford he teaches an undergraduate course in Global AIDS, attends on the Infectious Disease service and supervises both laboratory and clinical fellows conducting AIDS Research. He remains actively involved in studies of HIV infection in Zimbabwe, spending 2-3 months a year in Southern Africa.

Professor Katzenstein's research interests include treatment and evaluation of HIV infection in the United States and Europe through the AIDS Clinical Trials Group (ACTG). His international HIV pathogenesis work includes studies in Zimbabwe, South Africa. The lab currently is focused on drug resistance, envelope tropism and the pathogenesis of HIV.

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Encina West 208

Helen Stacy Moderator
David Katzenstein Professor (Research), Medicine - Infectious Diseases; Member, Bio-X Speaker Stanford University
Workshops
Second and Third Generation Rights in Africa

Economic and Social Implications of Population Aging in Asia

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How will population aging impact the economies and social protection systems of Japan, South Korea, China, and India? This colloquium showcases research addressing that question by contributors to a new Shorenstein APARC book, Aging Asia, co-edited by Karen Eggleston and Shripad Tuljapurkar. Dr. Bloom discusses how aging of the baby boom generation, declines in fertility rates, and an increase in life expectancy imply several changes for the economies of the region. Notwithstanding the potential challenges, Bloom argues that population aging may have less of a negative effect on economic growth than some have predicted. Bloom will also discuss the longitudinal aging study in India.

David Bloom is Clarence James Gamble Professor of Economics and Demography at Harvard University, Chair of the Department of Global Health and Population at the Harvard School of Public Health, and Director of Harvard University’s Program on the Global Demography of Aging (funded by the National Institute of Aging). He is Research Associate at the National Bureau of Economic Research, where he serves as a member of three research programs: Labor Studies, Aging, and Health Economics. He co-chairs the Public Policy Committee of the American Foundation for AIDS Research. Bloom received a B.S. in Industrial and Labor Relations from Cornell University in 1976, an M.A. in Economics from Princeton University in 1978, and a Ph.D. in Economics and Demography from Princeton University in 1981.

Philippines Conference Room

David Bloom Clarence James Gamble Professor of Economics and Demography Speaker Harvard University
Seminars

Comparative Effectiveness of HIV Testing and Treatment in Highly Endemic Regions

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BACKGROUND: Universal testing and treatment holds promise for reducing the burden of human immunodeficiency virus (HIV) in sub-Saharan Africa, but linkage from testing to treatment sites and retention in care are inadequate.

METHODS: We developed a simulation of the HIV epidemic and HIV disease progression in South Africa to compare the outcomes of the present HIV treatment campaign (status quo) with 4 HIV testing and treating strategies that increase access to antiretroviral therapy: (1) universal testing and treatment without changes in linkage to care and loss to follow-up; (2) universal testing and treatment with improved linkage to care; (3) universal testing and treatment with reduced loss to follow-up; and (4) comprehensive HIV care with universal testing and treatment, improved linkage to care, and reduced loss to follow-up. The main outcome measures were survival benefits, new HIV infections, and HIV prevalence. 

RESULTS: Compared with the status quo strategy, universal testing and treatment (1) was associated with a mean (95% uncertainty bounds) life expectancy gain of 12.0 months (11.3-12.2 months), and 35.3% (32.7%-37.5%) fewer HIV infections over a 10-year time horizon. Improved linkage to care (2), prevention of loss to follow-up (3), and comprehensive HIV care (4) provided substantial additional benefits: life expectancy gains compared with the status quo strategy were 16.1, 18.6, and 22.2 months, and new infections were 55.5%, 51.4%, and 73.2% lower, respectively. In sensitivity analysis, comprehensive HIV care reduced new infections by 69.7% to 76.7% under a broad set of assumptions.

CONCLUSIONS: Universal testing and treatment with current levels of linkage to care and loss to follow-up could substantially reduce the HIV death toll and new HIV infections. However, increasing linkage to care and preventing loss to follow-up provides nearly twice the benefits of universal testing and treatment alone.

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Archives of Internal Medicine
Authors
Eran Bendavid
Douglas K. Owens
External URL
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