Vassall Anna, Chandrashekar Sudhashree, Pickles Michael, Beattie Tara S, Shetty Govindraj, Bhattacharjee Parinita, Boily Marie-Claude, Vickerman Peter, Bradley Janet, Alary Michel, Moses Stephen, Watts Charlotte
London School of Hygiene and Tropical Medicine, London, United Kingdom.
London School of Hygiene and Tropical Medicine, London, United Kingdom; St John's Research Institute, Bangalore, India.
PLoS One. 2014 Oct 21;9(10):e110562. doi: 10.1371/journal.pone.0110562. eCollection 2014.
Most HIV prevention for female sex workers (FSWs) focuses on individual behaviour change involving peer educators, condom promotion and the provision of sexual health services. However, there is a growing recognition of the need to address broader societal, contextual and structural factors contributing to FSW risk behaviour. We assess the cost-effectiveness of adding community mobilisation (CM) and empowerment interventions (eg. community mobilisation, community involvement in programme management and services, violence reduction, and addressing legal policies and police practices), to core HIV prevention services delivered as part of Avahan in two districts (Bellary and Belgaum) of Karnataka state, Southern India.
An ingredients approach was used to estimate economic costs in US$ 2011 from an HIV programme perspective of CM and empowerment interventions over a seven year period (2004-2011). Incremental impact, in terms of HIV infections averted, was estimated using a two-stage process. An 'exposure analysis' explored whether exposure to CM was associated with FSW's empowerment, risk behaviours and HIV/STI prevalence. Pathway analyses were then used to estimate the extent to which behaviour change may be attributable to CM and to inform a dynamic HIV transmission model.
The incremental costs of CM and empowerment were US$ 307,711 in Belgaum and US$ 592,903 in Bellary over seven years (2004-2011). Over a 7-year period (2004-2011) the mean (standard deviation, sd.) number of HIV infections averted through CM and empowerment is estimated to be 1257 (308) in Belgaum and 2775 (1260) in Bellary. This translates in a mean (sd.) incremental cost per disability adjusted life year (DALY) averted of US$ 14.12 (3.68) in Belgaum and US$ 13.48 (6.80) for Bellary--well below the World Health Organisation recommended willingness to pay threshold for India. When savings from ART are taken into account, investments in CM and empowerment are cost saving.
Our findings suggest that CM and empowerment is, at worst, highly cost-effective and, at best, a cost-saving investment from an HIV programme perspective. CM and empowerment interventions should therefore be considered as core components of HIV prevention programmes for FSWs.
大多数针对女性性工作者的艾滋病预防措施都集中在个人行为改变上，包括同伴教育、推广使用避孕套以及提供性健康服务。然而，人们越来越认识到需要解决导致女性性工作者危险行为的更广泛的社会、环境和结构因素。我们评估了在印度南部卡纳塔克邦的两个地区（贝拉里和贝尔高姆），将社区动员和赋权干预措施（如社区动员、社区参与项目管理和服务、减少暴力以及解决法律政策和警察行为问题）添加到作为“阿瓦汉”项目一部分提供的核心艾滋病预防服务中的成本效益。
采用成分法从艾滋病项目的角度估算2011年美元价值的社区动员和赋权干预措施在七年期间（2004 - 2011年）的经济成本。通过两阶段过程估算在避免感染艾滋病方面的增量影响。“暴露分析”探讨了接触社区动员是否与女性性工作者的赋权、危险行为以及艾滋病/性传播感染患病率相关。然后使用路径分析来估算行为改变可能归因于社区动员的程度，并为动态艾滋病传播模型提供信息。
在七年期间（2004 - 2011年），贝尔高姆的社区动员和赋权的增量成本为307,711美元，贝拉里为592,903美元。在七年期间（2004 - 2011年），通过社区动员和赋权避免感染艾滋病的平均（标准差，sd.）数量估计在贝尔高姆为1257例（308例），在贝拉里为2775例（1260例）。这意味着在贝尔高姆每避免一个伤残调整生命年（DALY）的平均（sd.）增量成本为14.12美元（3.68美元），在贝拉里为13.48美元（6.80美元），远低于世界卫生组织为印度建议的支付意愿阈值。如果将抗逆转录病毒治疗的节省考虑在内，对社区动员和赋权的投资是节省成本的。
我们的研究结果表明，从艾滋病项目的角度来看，社区动员和赋权干预措施，往坏里说是具有很高的成本效益，往好里说是节省成本的投资。因此，社区动员和赋权干预措施应被视为针对女性性工作者的艾滋病预防项目的核心组成部分。
