Introduction With limited resources, attaining maximal average health service coverage can be at odds with maximising equity which attempts to promote greater reach among underserved populations. In this study, we examined the trade-offs in immunisation coverage levels and equity for children under 5 years of age in Pakistan across various subpopulations who can be targeted with different combinations of immunisation service modalities.Methods We conducted a detailed costing exercise across 16 geographically and demographically diverse districts in Pakistan. These data were the basis for (a) technical efficiency benchmarking via Data Envelopment Analysis to identify potential efficiency gains by location, delivery model and cost ingredient; (b) allocative efficiency optimisation modelling to understand how resource allocations could be optimised and to devise recommended budget allocations and operational metrics. Finally, the hypothetical overall efficiency gains attainable were estimated if available resources were allocated with the optimal emphases, and if service delivery models operated at productivity levels at the benchmarked frontier of efficiency.Results Benchmarking suggests that ~44% of delivery models are running efficiently and 37% are highly inefficient. While coverage and equity are usually at odds, surprisingly, the optimisation modelling revealed that substantial improvements in equity between subpopulations does not necessarily cost very much in overall immunisation coverage: theoretically, equity can be achieved while still attaining close to maximal immunisation coverage. Overall, analyses suggest greater emphases should be placed on outreach delivery models which particularly target rural areas and slum populations.Conclusion The unit cost differentials within districts are not sufficiently large for there to be a large reduction in potential Fully Immunised Children coverage if one focuses on maximising equity. However, reallocations of programme budgets can have a significant impact on equity outcomes, particularly at current low spending amounts. Therefore, it is recommended to address equity as the key objective in national immunisation programming.

Pakistan faces a formidable challenge in eliminating the polio virus from the country. With transmission of the polio virus substantially slowing in the Africa region, the only two countries worldwide with ongoing endemic polio transmission may soon be Pakistan and Afghanistan. A substantial number of the polio cases or infant paralysis occurring in Afghanistan is linked to cross-border transmission from Pakistan. The ongoing cycle of polio infection is not just a tragedy for the children of Pakistan, it is a global public health emergency constituting one of the final barriers to permanently eradicating polio. This paper demonstrates clear economic benefits and efficacy of the National Immunization Support Project (NISP), which is financing interventions in terms of DALYs saved, and establishes that this approach is affordable and economically effective with a high rate of return. In addition to increased investment, the effectiveness of the Expanded Program on Immunization can be enhanced by improving the capacity building of health professionals, as well as by improving logistics of program interventions to reach marginalized populations, remote areas, and pockets of resistance. An increased financial investment alone will be insufficient to address the root causes of persistent under-coverage of immunization in Pakistan. It is imperative that ample attention and resources be diverted to strengthen the procurement systems, local and provincial management capacity, and reporting mechanisms, among other capacity improvements.

The HIV epidemic amongst men who have sex with men (MSM) in Bangkok is substantial. The population size of MSM in Bangkok is 120,000-250,000, with approximately one-third (33.5 percent) considered high-risk, characterized by their young age, multiple partnerships, frequent unprotected anal intercourse, and sexual activities around MSM hotspots. In metropolitan Bangkok, HIV prevalence among MSM reportedly increased from 21 percent to 28 percent between 2000 and 2012. The Thai Working Group of Estimation and Projection (2013) projected an estimate of 39,000 new HIV infections would occur in Thailand during 2012-2016, based on the AIDS Epidemic Model (AEM). MSM will account for 44 percent of these new HIV cases, and 25-30 percent of these infections will likely to occur in Bangkok. In 2011, the United Nations held a high-level meeting on HIV/AIDS where they adopted the ambitious epidemiological targets of the United Nations Political Declaration on HIV/AIDS (UNPD), to be met by 2015. Attaining these specific targets would lead to substantial progress towards ending AIDS. UNAIDS has also been prioritizing the “Getting to Zero” initiative (“Zero new HIV infections. Zero AIDS-related deaths. Zero discrimination.”). The Bangkok Metropolitan Administration (BMA) recently responded with the “Bangkok: Getting to Zero” initiative, which strategizes an increased focus on prevention amongst MSM in the city. The clinical trial, HPTN052, demonstrated a 96 percent reduction of HIV transmission among heterosexual discordant couples who received ART. “Treatment as prevention” has become an increasingly accepted strategy to prevent new infections. A cost-effectiveness analysis comparing current levels of investment in targeted HIV prevention interventions for MSM in Bangkok (including treatment), with scenarios of increased coverage, would provide evidence to shape efficient national and metropolitan strategies. A return-on-investment analysis would provide an economic rationale to finance this strategy in allocating sufficient resources to address the epidemic at the most appropriate scale. Demonstration by the study that a significant reduction in transmission (including potential elimination) are both feasible and cost effective, may galvanize global political support.

Background Despite the high prevalence of HIV in men who have sex with men (MSM) in Bangkok, little investment in HIV prevention for MSM has been made. HIV testing and treatment coverage remains low. Through a pragmatic programme-planning approach, we assess possible service linkage and provision of HIV testing and antiretroviral treatment (ART) to MSM in Bangkok, and the most cost-effective scale-up strategy.Methods We obtained epidemiological and service capacity data from the Thai National Health Security Office database for 2011. We surveyed 13 representative medical facilities for detailed operational costs of HIV-related services for sexually active MSM (defined as having sex with men in the past 12 months) in metropolitan Bangkok. We estimated the costs of various ART scale-up scenarios, accounting for geographical accessibility across Bangkok. We used an HIV transmission population-based model to assess the cost-effectiveness of the scenarios.Findings For present HIV testing (23% [95% CI 17-36] of MSM at high risk in 2011) and ART provision (20% of treatment-eligible MSM at high risk on ART in 2011) to be sustained, a US$73.8 million ($51.0 million to $97.0 million) investment during the next decade would be needed, which would link an extra 43 000 (27 900-58 000) MSM at high risk to HIV testing and 5100 (3500-6700) to ART, achieving an ART coverage of 44% for MSM at high risk in 2022. An additional $55.3 million investment would link an extra 46 700 (30 300-63200) MSM to HIV testing and 12 600 (8800-16600) to ART, achieving universal ART coverage of this population by 2022. This increased investment is achievable within present infrastructure capacity. Consequently, an estimated 5100 (3600-6700) HIV-related deaths and 3700 (2600-4900) new infections could be averted in MSM by 2022, corresponding to a 53% reduction in deaths and a 35% reduction in infections from 2012 levels. The expansion would cost an estimated $10 809 (9071-13 274) for each HIV-related death, $14783 (12 389-17960) per new infection averted, and $351 (290-424) per disability-adjusted life-year averted.Interpretation Spare capacity in Bangkok's medical facilities can be used to expand ART access for MSM with large epidemiological benefits. The expansion needs increased funding directed to MSM services, but given the epidemiological trends, is probably cost effective. Our modelling approach and outcomes are likely to be applicable to other settings.

Introduction: Sex workers have endured a high burden of HIV infection in and across HIV epidemics. A comprehensive, community empowerment-based HIV prevention intervention emphasizes sex worker organization and mobilization to address HIV risk and often includes community-led peer education, condom distribution, and other activities. Meta-analysis of such interventions suggests a potential 51% reduction in inconsistent condom use. Mathematical modeling exercises provide theoretical insight into potential impacts of the intervention on HIV incidence and burden in settings where interventions have not yet been implemented.Methods: We used a deterministic model, Goals, to project the impact on HIV infections when the community empowerment interventions were scaled up among female sex workers in Kenya, Thailand, Brazil, and Ukraine. Modeling scenarios included expansion of the comprehensive community empowerment-based HIV prevention intervention from baseline coverage over a 5-year period (5-65% in Kenya and Ukraine; 10-70% in Thailand and Brazil), while other interventions were held at baseline levels. A second exercise increased the intervention coverage simultaneously with equitable access to ART for sex workers. Impacts on HIV outcomes among sex workers and adults are observed from 20122016 and, compared to status quo when all interventions are held constant.Results: Optimistic but feasible coverage (65%-70%) of the intervention demonstrated a range of impacts on HIV: 220 infections averted over 5 yrs. among sex workers in Thailand, 1,830 in Brazil, 2,220 in Ukraine, and 10,800 infections in Kenya. Impacts of the intervention for female sex workers extend to the adult population, cumulatively averting 730 infections in Thailand to 20,700 adult infections in Kenya. Impacts vary by country, influenced by HIV prevalence in risk groups, risk behaviors, intervention use, and population size.Discussion: A community empowerment approach to HIV prevention and access to universal ART for female sex workers is a promising human rights-based solution to overcoming the persistent burden of HIV among female sex workers across epidemic settings.

No AccessNov 2012Pakistan Case StudyAuthors/Editors: https://doi.org/10.1596/9780821397763_CH04View ChaptersAboutPDF (0.6 MB) ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookTwitterLinked In Abstract: Reports that Pakistan has a concentrated HIV epidemic, with sustained transmission occurring in specific high-risk groups, including people who inject drugs (PWID), who are estimated to contribute between 15 to 32 percent of HIV incidence by 2015. Needle and Syringe Programs (NSP) and outreach response over 2005–2007 suggest several factors contributing to a lack of HIV prevalence reduction, including (1) short duration of interventions, (2) movement of PWID between cities with differing intervention coverage, (3) problems in targeting interventions toward all age brackets, and (4) lack of an integrated, combination approach, such as HIV Counseling and Testing (HCT). With NSP and HCT for PWID at 60 percent coverage by 2015, proportion­ate access for PWID in Antiretroviral Therapy (ART) scale-up, and Medically Assisted Therapy (MAT) scaled up to 20 percent of opiate-dependent PWID, Pakistan can reduce new infections nationally among PWID by 33 percent compared to 2011 levels. Previous chapterNext chapter FiguresreferencesRecommendeddetails View Published: November 2012ISBN: 978-0-8213-9776-3e-ISBN: 978-0-8213-9777-0 Copyright & Permissions Related RegionsSouth AsiaRelated CountriesPakistanRelated TopicsGenderHealth Nutrition and PopulationPrivate Sector Development KeywordsADULT POPULATIONAIDS EPIDEMICBLOOD PRODUCTSCONDOMCONDOM USEDRUGSEPIDEMICHIVMIGRANTSNATIONAL AIDSNEW INFECTIONSPOPULATION SIZEREFUGEESREPRODUCTIVE AGESEXSEX WORKERSEX WORKERSSEXUAL BEHAVIORSPOUSESURBAN CENTERS PDF DownloadLoading ...

No AccessNov 2012Ukraine Case StudyAuthors/Editors: https://doi.org/10.1596/9780821397763_CH03View ChaptersAboutPDF (0.5 MB) ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookTwitterLinked In Abstract: Reports that Ukraine’s HIV epidemic remains concentrated, with less evidence of sustained transmission in the general, low-risk heterosexual population, but transmission continues in high-risk groups such as people who inject drugs (PWID), female sex workers (FSW), their clients, and men who have sex with men (MSM) as well as secondary transmission to sexual partners of PWID and regular partners of commercial sex work clients. Ukraine has made progress in scaling up outreach services, including Needle and Syringe Programs (NSP) for PWID, but further progress requires raising the coverage of Medically Assisted Therapy (MAT), HIV Counseling and Testing (HCT), and Antiretroviral Therapy (ART). If Ukraine increases coverage for NSP to 75 percent and HCT for PWID to 60 percent, with proportionate provision of ART to PWID and 15 percent coverage of MAT among opiate-dependent PWID, it can reduce new infections by 34 percent compared to 2011 status quo levels of coverage. Previous chapterNext chapter FiguresreferencesRecommendeddetails View Published: November 2012ISBN: 978-0-8213-9776-3e-ISBN: 978-0-8213-9777-0 Copyright & Permissions Related RegionsEurope and Central AsiaRelated CountriesUkraineRelated TopicsHealth Nutrition and Population KeywordsCOMMERCIAL SEXCOMMERCIAL SEX WORKDRUG ADDICTIONDRUGSEPIDEMICHIVHIV INFECTIONMINISTRY OF HEALTHMORTALITYMOTHERMOTHER-TO-CHILDMOTHER-TO-CHILD TRANSMISSIONRISKY SEXUAL BEHAVIORSSEXSEX WITH MENSEX WORKERSSEXUAL PARTNERSSEXUAL RISKURBAN AREASWORKING-AGE POPULATION PDF downloadLoading ...