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BACKGROUND: One critical element to optimize funding decisions involves the cost and efficiency implications of implementing alternative program components and configurations. Program planners, policy makers and funders alike are in need of relevant, strategic data and analyses to help them plan and implement effective and efficient programs. Contrary to widely accepted conceptions in both policy and academic arenas, average costs per service (so-called unit costs) vary considerably across implementation settings and facilities. The objective of this work is twofold: 1) to estimate the variation of VMMC unit costs across service delivery platforms (SDP) in Sub-Saharan countries, and 2) to develop and validate a strategy to extrapolate unit costs to settings for which no data exists. METHODS: We identified high-quality VMMC cost studies through a literature review. Authors were contacted to request the facility-level datasets (primary data) underlying their results. We standardized the disparate datasets into an aggregated database which included 228 facilities in eight countries. We estimated multivariate models to assess the correlation between VMMC unit costs and scale, while simultaneously accounting for the influence of the SDP (which we defined as all possible combinations of type of facility, ownership, urbanicity, and country), on the unit cost variation. We defined SDP as any combination of such four characteristics. Finally, we extrapolated VMMC unit costs for all SDPs in 13 countries, including those not contained in our dataset. RESULTS: The average unit cost was 73 USD (IQR: 28.3, 100.7). South Africa showed the highest within-country cost variation, as well as the highest mean unit cost (135 USD). Uganda and Namibia had minimal within-country cost variation, and Uganda had the lowest mean VMMC unit cost (22 USD). Our results showed evidence consistent with economies of scale. Private ownership and Hospitals were significant determinants of higher unit costs. By identifying key cost drivers, including country- and facility-level characteristics, as well as the effects of scale we developed econometric models to estimate unit cost curves for VMMC services in a variety of clinical and geographical settings. CONCLUSION: While our study did not produce new empirical data, our results did increase by a tenfold the availability of unit costs estimates for 128 SDPs in 14 priority countries for VMMC. It is to our knowledge, the most comprehensive analysis of VMMC unit costs to date. Furthermore, we provide a proof of concept of the ability to generate predictive cost estimates for settings where empirical data does not exist.

Understanding the costs of health interventions is critical for generating budgets, planning and managing programs, and conducting economic evaluations to use when allocating scarce resources. Here, we utilize techniques from the hedonic pricing literature to estimate the characteristics of the costs of social and behavior change communication (SBCC) interventions, which aim to improve health-seeking behaviors and important intermediate determinants to behavior change. SBCC encompasses a wide range of interventions including mass media (e.g., radio, television), mid media (e.g., community announcements, live dramas), digital media (e.g., short message service/phone reminders, social media), interpersonal communication (e.g., individual or group counseling), and provider-based SBCC interventions focused on improving provider attitudes and provider-client communication. While studies have reported on the costs of specific SBCC interventions in low- and middle-income countries, little has been done to examine SBCC costs across multiple studies and interventions. We use compiled data across multiple SBCC intervention types, health areas, and low- and middle-income countries to explore the characteristics of the costs of SBCC interventions. Despite the wide variation seen in the unit cost data, we can explain between 63 and 97 percent of total variance and identify a statistically significant set of characteristics (e.g., health area) for media and interpersonal communication interventions. Intervention intensity is an important determinant for both media and interpersonal communication, with costs increasing as intervention intensity increases; other important characteristics for media interventions include intervention subtype, target population group, and country income as measured by per capita Gross National Income. Important characteristics for interpersonal communication interventions include health area, intervention subtype, target population group and geographic scope. [ABSTRACT FROM AUTHOR]

Background: Most low- and middle-income countries have limited access to cost data that meets the needs of health policy-makers and researchers in health intervention areas including HIV, tuberculosis, and immunization. Unit cost repositories (UCRs)—searchable databases that systematically codify evidence from costing studies—have been developed to reduce the effort required to access and use existing costing information. These repositories serve as public resources and standard references, which can improve the consistency and quality of resource needs projections used for strategic planning and resource mobilization. UCRs also enable analysis of cost determinants and more informed imputation of missing cost data. This report examines our experiences developing and using seven UCRs (two global, five country-level) for cost projection and research purposes. Discussion: We identify advances, challenges, enablers, and lessons learned that might inform future work related to UCRs. Our lessons learned include: (1) UCRs do not replace the need for costing expertise; (2) tradeoffs are required between the degree of data complexity and the useability of the UCR; (3) streamlining data extraction makes populating the UCR with new data easier; (4) immediate reporting and planning needs often drive stakeholder interest in cost data; (5) developing and maintaining UCRs requires dedicated staff time; (6) matching decision-maker needs with appropriate cost data can be challenging; (7) UCRs must have data quality control systems; (8) data in UCRs can become obsolete; and (9) there is often a time lag between the identification of a cost and its inclusion in UCRs. Conclusions: UCRs have the potential to be a valuable public good if kept up-to-date with active quality control and adequate support available to end-users. Global UCR collaboration networks and greater control by local stakeholders over global UCRs may increase active, sustained use of global repositories and yield higher quality results for strategic planning and resource mobilization. [ABSTRACT FROM AUTHOR]

The HIV/AIDS epidemic continues to be a major issue facing Botswana, with overall adult HIV prevalence estimated to be 25.7 percent in 2007. This paper estimates the cost and impact of the draft Ministry of Health male circumcision strategy using the UNAIDS/WHO Decision‐Makers' Programme Planning Tool (DMPPT). Demographic data and HIV prevalence estimates from the recent National AIDS Coordinating Agency estimations are used as input to the DMPPT to estimate the impact of scaling‐up male circumcision on the HIV/AIDS epidemic. These data are supplemented by programmatic information from the draft Botswana National Strategy for Safe Male Circumcision, including information on unit cost and program goals. Alternative scenarios were developed in consultation with stakeholders. Results suggest that scaling‐up adult and neonatal circumcision to reach 80% coverage by 2012 would result in averting almost 70,000 new HIV infections through 2025, at a total net cost of US$47 million across that same period. This results in an average cost per HIV infection averted of US$689. Changing the target year to 2015 and the scale‐up pattern to a linear pattern results in a more evenly‐distributed number of MCs required, and averts approximately 60,000 new HIV infections through 2025. Other scenarios explored include the effect of risk compensation and the impact of increasing coverage of general prevention interventions. Scaling‐up safe male circumcision has the potential to reduce the impact of HIV/AIDS in Botswana significantly; program design elements such as feasible patterns of scale‐up and inclusion of counselling are important in evaluating the overall success of the program., Background The HIV/AIDS epidemic continues to be a major issue facing Botswana, with overall adult HIV prevalence estimated to be 25.7% in 2007 [1]. As an add‐on strategy to augment [...]

Abstract Background How should HIV and AIDS resources be allocated to achieve the greatest possible impact? This paper begins with a theoretical discussion of this issue, describing the key elements of an "evidence-based allocation strategy". While it is noted that the quality of epidemiological and economic data remains inadequate to define such an optimal strategy, there do exist tools and research which can lead countries in a way that they can make allocation decisions. Furthermore, there are clear indications that most countries are not allocating their HIV and AIDS resources in a way which is likely to achieve the greatest possible impact. For example, it is noted that neighboring countries, even when they have a similar prevalence of HIV, nonetheless often allocate their resources in radically different ways. These differing allocation patterns appear to be attributable to a number of different issues, including a lack of data, contradictory results in existing data, a need for overemphasizing a multisectoral response, a lack of political will, a general inefficiency in the use of resources when they do get allocated, poor planning and a lack of control over the way resources get allocated. Methods There are a number of tools currently available which can improve the resource-allocation process. Tools such as the Resource Needs Model (RNM) can provide policymakers with a clearer idea of resource requirements, whereas other tools such as Goals and the Allocation by Cost-Effectiveness (ABCE) models can provide countries with a clearer vision of how they might reallocate funds. Results Examples from nine different countries provide information about how policymakers are trying to make their resource-allocation strategies more "evidence based". By identifying the challenges and successes of these nine countries in making more informed allocation decisions, it is hoped that future resource-allocation decisions for all countries can be improved. Conclusion We discuss the future of resource allocation, noting the types of additional data which will be required and the improvements in existing tools which could be made.

Background: There is strong evidence showing that voluntary medical male circumcision (VMMC) reduces HIV incidence in men. To inform the VMMC policies and goals of 13 priority countries in eastern and southern Africa, we estimate the impact and cost of scaling up adult VMMC using updated, country-specific data. Methods and Findings: We use the Decision Makers' Program Planning Tool (DMPPT) to model the impact and cost of scaling up adult VMMC in Botswana, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, and Nyanza Province in Kenya. We use epidemiologic and demographic data from recent household surveys for each country. The cost of VMMC ranges from US$65.85 to US$95.15 per VMMC performed, based on a cost assessment of VMMC services aligned with the World Health Organization's considerations of models for optimizing volume and efficiencies. Results from the DMPPT models suggest that scaling up adult VMMC to reach 80% coverage in the 13 countries by 2015 would entail performing 20.34 million circumcisions between 2011 and 2015 and an additional 8.42 million between 2016 and 2025 (to maintain the 80% coverage). Such a scale-up would result in averting 3.36 million new HIV infections through 2025. In addition, while the model shows that this scale-up would cost a total of US$2 billion between 2011 and 2025, it would result in net savings (due to averted treatment and care costs) amounting to US$16.51 billion. Conclusions: This study suggests that rapid scale-up of VMMC in eastern and southern Africa is warranted based on the likely impact on the region's HIV epidemics and net savings. Scaling up of safe VMMC in eastern and southern Africa will lead to a substantial reduction in HIV infections in the countries and lower health system costs through averted HIV care costs. Please see later in the article for the Editors' Summary., Introduction Three randomized controlled trials have shown that voluntary medical male circumcision (VMMC) reduces heterosexual HIV acquisition in men by up to 60% [1-3]. On the basis of these trial [...]

In 2011 a new Investment Framework was proposed that described how the scale-up of key HIV interventions could dramatically reduce new HIV infections and AIDS-related deaths in low and middle income countries by 2015. This framework included ambitious coverage goals for prevention and treatment services for 2015, resulting in a reduction of new HIV infections by more than half, in line with the goals of the declaration of the UN High Level Meeting in June 2011. However, the approach suggested a leveling in the number of new infections at about 1 million annually—far from the UNAIDS goal of ending AIDS by 2030. In response, UNAIDS has developed the Fast-Track approach that is intended to provide a roadmap to the actions required to achieve this goal. The Fast-Track approach is predicated on a rapid scale-up of focused, effective prevention and treatment services over the next 5 years and then maintaining a high level of programme implementation until 2030. Fast-Track aims to reduce new infections and AIDS-related deaths by 90% from 2010 to 2030 and proposes a set of biomedical, behavioral and enabling intervention targets for 2020 and 2030 to achieve that goal, including the rapid scale-up initiative for antiretroviral treatment known as 90-90-90. Compared to a counterfactual scenario of constant coverage for all services at early-2015 levels, the Fast-Track approach would avert 18 million HIV infections and 11 million deaths from 2016 to 2030 globally. This paper describes the analysis that produced these targets and the estimated resources needed to achieve them in low- and middle-income countries. It indicates that it is possible to achieve these goals with a significant push to achieve rapid scale-up of key interventions between now and 2020. The annual resources required from all sources would rise to US$7.4Bn in low-income countries, US$8.2Bn in lower middle-income countries and US$10.5Bn in upper-middle-income-countries by 2020 before declining approximately 9% by 2030. [ABSTRACT FROM AUTHOR]

The AIDS pandemic will enter its fiftieth year in 2031. Despite much progress, there are thirty-three million infected people worldwide, and 2.3 million adults were newly infected in 2007. Without a change in approach, a major pandemic will still be with us in 2031. Modeling carried out for the AIDS 2031 project suggests that funding required for developing countries to address the pandemic could reach $35 billion annually by 2031- three times the current level. Even then, more than a million people will still be newly infected each year. However, wise policy choices focusing on high-impact prevention and efficient treatment could cut costs by half. Investments in new prevention tools and major behavior- change efforts are needed to spur more rapid advances. Existing donors, middle-income countries with contained epidemics, philanthropists, and innovative financing could help bridge the likely funding gap. [ABSTRACT FROM AUTHOR]