HIV interventions will not reach those who need them without increased efficiencies, review says

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While noting that HIV service delivery can’t be increased to needed levels with reduced resources, authors of a systematic review published in the July World Health Organization Bulletin say more efficient use of existing resources will be critical to making meaningful reductions in prevalence and infection rates. That includes cost reductions achieved through economies of both scale and scope, but also includes savings realized through improved client retention, service provision by nurses and community health workers, reductions in prices for second-line antiretroviral treatments that will be needed by increasing numbers of HIV patients in low- and lower-middle-income coutnries, and by overall strengthened and better functioning health systems. At the same time, authors of the systematic review of evidence from low- and middle-income countries point to a paucity of large scale studies on cost reduction outcomes, including impacts on the quality of services. In the few instances in which costs and services were looked at together, authors noted, drops in costs brought drops in quality.

Authors whittled down 131 articles examining HIV intervention costs to 82 that were accessible and included sufficient data. The studies included data on costs per unit and per patient of HIV interventions that include testing, counseling, and antiretroviral treatment, focused efforts to reach populations facing the highest risks and lowest access to services, condom distribution, efforts to prevent infants from acquiring HIV and keep their mothers alive, medical circumcision and behavior change communications. Authors noted that economies of scale — reductions in individual costs through increases in the numbers of people served — could be realized by increasing demand and reducing attrition. They also noted that the potential for “diseconomies of scale” should not be ruled out. Providing HIV services in combination with other health services yielded economies of scope for HIV services, but in some cases raised the costs of the accompanying services.

Some cost reductions are likely to come with time, as programs adapt to the needs of their environments and clients, authors indicate. Medicine and technology innovations are likely to bring savings as well, they note. Continued and needed cost efficiencies, though, they conclude will require the collaboration of HIV and general health system policy makers.

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