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Quantitative Evaluation of HIV Prevention Programs

Quantitative Evaluation of HIV Prevention Programs

Edward H. Kaplan
Ron Brookmeyer
Copyright Date: 2002
Published by: Yale University Press
Pages: 352
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  • Book Info
    Quantitative Evaluation of HIV Prevention Programs
    Book Description:

    How successful are HIV prevention programs? Which HIV prevention programs are most cost effective? Which programs are worth expanding and which should be abandoned altogether? This book addresses the quantitative evaluation of HIV prevention programs, assessing for the first time several different quantitative methods of evaluation.The authors of the book include behavioral scientists, biologists, economists, epidemiologists, health service researchers, operations researchers, policy makers, and statisticians. They present a wide variety of perspectives on the subject, including an overview of HIV prevention programs in developing countries, economic analyses that address questions of cost effectiveness and resource allocation, case studies such as Israel's ban on Ethiopian blood donors, and descriptions of new methodologies and problems.

    eISBN: 978-0-300-12822-2
    Subjects: Health Sciences

Table of Contents

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  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. Foreword
    (pp. ix-x)
    Donald L. Thomsen Jr.

    In 1974, the Societal Institute of the Mathematical Sciences (SIMS) held what turned out to be the first in a series of Research Application Conferences (RACs) for the purpose of exploring in depth selected societal fields in light of their receptivity to mathematical/statistical analysis. The RACs were well received and have been held every two to three years ever since, going on now for over twenty-five years and coinciding with the twenty-fifth anniversary of sims. Societal fields which have benefited from this kind of attention include energy, human exposure, and health topics such as AIDS; human exposure covers a wide...

  4. Introduction
    (pp. 1-10)
    Edward H. Kaplan and Ron Brookmeyer

    The epidemic of human immunodeficiency virus (HIV), the cause of the acquired immune deficiency syndromes (AIDS), has led to the infection of an estimated 58 million people worldwide, 22 million of whom have already died (Merson and Dayton, Chapter 1, this volume). HIV and AIDS have reduced life expectancies by more than 10 years in hard hit countries such as Burkina Faso and Côte d’Ivoire, and by 22 years in Zimbabwe.¹ The impact of this epidemic reaches beyond those directly infected with HIV. Children with HIV-infected parents become orphans, while networks of friends and families suffer as loved ones become...

  5. Part I: Evaluating HIV Prevention Programs:: Context and Concepts

    • Chapter 1 Overview of HIV Prevention Programs in Developing Countries
      (pp. 13-31)
      Michael H. Merson and Julia M. Dayton

      In this chapter we review the global epidemiology of HIV infection, particularly in developing countries. We summarize what has been learned about the efficacy of behavioral and medical interventions to prevent HIV infection in these countries, and offer a few ideas about how modeling could assist in planning public health prevention programs.

      The United Nations Combined AIDS Program (UNAIDS) estimates that as of the end of 2000 a total of 57.9 million adults and children worldwide have been infected by HIV. About 36.1 million of these individuals have already died from AIDS, and 21.8 million are still living with HIV....

    • Chapter 2 Implications of Economic Evaluations for National HIV Prevention Policy Makers
      (pp. 32-54)
      David R. Holtgrave and Steven D. Pinkerton

      The course of HIV prevention programming in the United States is driven by policy makers at the local, state, and federal levels. But, unlike most public health programs in other disease areas, a formal mechanism—known as HIV prevention community planning—is available for HIV-infected and HIV-affected community members to participate in the HIV prevention decision making process by becoming members of their local community planning groups.¹,² These groups are charged with analyzing the course of the epidemic in their jurisdiction; assessing and prioritizing prevention needs; and identifying science-based HIV prevention interventions to meet these needs. The HIV prevention community...

    • Chapter 3 Statistical Issues in HIV Prevention
      (pp. 55-78)
      Ron Brookmeyer

      In the past two decades we have accumulated considerable knowledge about the pathogenesis of the human immunodeficiency virus (HIV) and treatment of the HIV-infected individual. Nevertheless, there remains considerable uncertainty about the type and characteristics of effective public health control programs to prevent new HIV infections from occurring. Indeed, new HIV infections continue to occur at an alarming rate, particularly in developing countries. Furthermore, no phase III vaccine trial has yet been completed. This chapter is concerned with some of the statistical issues that arise in the quantitative evaluation of HIV prevention programs. The objective is to review statistical issues...

    • Chapter 4 Epidemiological Issues in the Evaluation of HIV Prevention Programs
      (pp. 79-94)
      Nancy S. Padian and Stephen C. Shiboski

      In this chapter, we discuss the contribution of epidemiological methods to the development of HIV prevention strategies and policy. First, we consider the importance of study design and the precedence of randomized controlled trials (RCTS) in influencing policy makers. The limitations of this study design are discussed, specifically with reference to practical considerations in implementation of RCTS and the urgency of critical public health concerns, the importance of compliance to the intervention or treatment being evaluated in the RCTS, the importance of measurement of compliance, and finally, the ability to generalize results from RCTS to the larger community. Next, in...

  6. Part II: Cost-Effectiveness and Resource Allocation

    • Chapter 5 Difficult Choices, Urgent Needs: Optimal Investment in HIV Prevention Programs
      (pp. 97-117)
      Margaret L. Brandeau

      Recent advances in treatment for human immunodeficiency virus (HIV) have significantly reduced the death rate from acquired immunodeficiency syndrome (AIDS) in the United States.¹ However, HIV prevention continues to be a significant problem. The estimated number of incident HIV cases in the United States has remained constant at about 40,000 cases per year for the past several years.² Fewer new cases are occurring among white homosexual men, but more new cases are occurring among women, injection drug users, and minorities.

      Although millions of dollars are spent annually on HIV prevention in the United States and other industrialized nations, resources for...

    • Chapter 6 Methadone Treatment as HIV Prevention: Cost-Effectiveness Analysis
      (pp. 118-142)
      Harold Pollack

      As AIDS enters its third decade of public consciousness, domestic HIV prevention has changed from a crisis response to a frightening outbreak to a mature set of programs that compete for scarce public funds. In such an environment, practitioners face new pressure to critically evaluate ongoing HIV prevention efforts. More openly than in the past, sympathetic policy makers demand rigorous evaluation to allocate resources across competing interventions, and even between HIV prevention and other public health concerns.

      The transformation of AIDS policy presents dangers, but the passage of time provides welcome opportunity to document the costs and benefits of HIV-prevention...

    • Chapter 7 Costs and Benefits of Imperfect HIV Vaccines: Implications for Vaccine Development and Use
      (pp. 143-172)
      Douglas K. Owens, Donna M. Edwards and Ross D. Shachter

      In less than 20 years, 47 million people have been infected with the human immunodeficiency virus (HIV).¹ New HIV infections now occur at a rate of about 16,000 per day worldwide.¹ Approximately 14 million people have died from HIV infection—2.5 million died in 1998 alone.¹ The HIV pandemic now ranks as one of the worst epidemics in history, taking its place alongside bubonic plague and in-fluenza which caused devastating losses of human life. The introduction of highly active antiretroviral therapy has prolonged survival with HIV infection,² but the high cost of these drugs puts them out of reach of...

  7. Part III: Case Studies

    • Chapter 8 Harm Reduction in Rome: A Model-Based Evaluation of Its Impact on the HIV-1 Epidemic
      (pp. 175-188)
      Massimo Arcà, Teresa Spadea, Giulia Cesaroni, Marina Davoli, Annette D. Verster and Carlo A. Perucci

      In August 1994, the Lazio Region Health Authority in Italy started a two-year pilot harm reduction program (HRP) aimed at contacting drug users currently not in treatment and reducing the health risks related to injecting drugs. The integrated program, implemented in the city of Rome, involved street outreach, needle exchange programs, distribution of condoms, information and counseling, first aid (for overdose), drop-in centers for day and night care, and referral to methadone maintenance treatment.

      In two years of activity, three outreach units made 148,000 contacts, 87% of which were with 5047 different drug users. About 200,000 sterile syringes and more...

    • Chapter 9 Evaluating Israel’s Ethiopian Blood Ban
      (pp. 189-201)
      Edward H. Kaplan

      In January 1996, the Israeli dailyMa’arivreported that donations to Israel’s national blood supply from Ethiopian immigrants were routinely discarded without informing the donors. Blood bank physicians adopted this policy in response to the factor-of-fifty higher prevalence of hiv among Ethiopian immigrants relative to the rest of the Israeli population. Revelation of this exclusion policy resulted in a violent protest by 10,000 Ethiopian immigrants, accounting for onesixth of the 60,000 Ethiopians living in Israel at that time, in which 70 persons were injured.¹,²,³ Subsequently, a committee chaired by former Israeli President Yitzhak Navon was formed to conduct an of-ficial...

    • Chapter 10 Feeding Strategies for Children of HIV-Infected Mothers: Modeling the Trade-Off Between HIV Infection and Non-HIV Mortality
      (pp. 202-220)
      James G. Kahn, Elliot Marseille and Joseph Saba

      Each year, approximately half a million infants worldwide acquire the human immunodeficiency virus (HIV) from their mothers, according to the United Nations Combined aids Program (UNAIDS). The risk of transmission from mother to child varies up to 50% in breastfeeding populations.¹ Much transmission occurs in utero and intra partum, but risk during breastfeeding itself is about 14% on average, and higher with long duration breastfeeding.²,³ Mother-to-child HIV transmission risk is largely avoidable through the use of perinatal antiretroviral therapy and formula feeding.4These strategies are widely used in the developed world.5

      In many countries hardest hit by the AIDS epidemic,...

  8. Part IV: New Methods for New Problems

    • Chapter 11 Design of HIV Trials for Estimating External Effects
      (pp. 223-240)
      Tomas Philipson

      This chapter examines the statistical inference problems associated with external effects for the purpose of evaluating and designing hiv prevention trials. It reports on the application to vaccination trials of some results reported in Philipson,¹ which discusses more generally the topic of external effects in the canonical evaluation framework. In this framework, a set of treatments are randomly assigned, and the impact of these treatments on a defined outcome is studied. In this evaluation problem, the paper defines an external effect to operate when the treatment assignments of other individuals affect the outcome of a given individual. The key aspect...

    • Chapter 12 Estimation of Vaccine Efficacy for Prophylactic HIV Vaccines
      (pp. 241-259)
      Ira M. Longini Jr., Michael G. Hudgens and M. Elizabeth Halloran

      The current generation of prophylactic human immunodeficiency virus (HIV) vaccines are now in phase III vaccine trials. In this chapter, we use simulations to explore the feasibility of measuring different important protective effects of these vaccines in a particular population structure. The simulation population is motivated by a cohort of injecting drug users (IDUS) in Bangkok, Thailand,¹,² in which a phase III trial of the recombinant envelope protein vaccine glycoprotein (gp) 120 is now in the field.³

      HIV vaccines could have at least three important protective effects: (a) they could reduce the susceptibility to infection of vaccinated people, that is,...

    • Chapter 13 Health Policy Modeling: Epidemic Control, HIV Vaccines, and Risky Behavior
      (pp. 260-289)
      Sally Blower, Katia Koelle and John Mills

      The HIV epidemic, which was first recognized in the early 1980s, became one of the great health crises of the late twentieth century. The United Nations Combined AIDS Program (UNAIDS) estimates that globally 16,000 HIV infections occur every day, and that there are more than 33 million persons infected.¹ As many as 40 million persons were infected by the year 2000; this is a global prevalence approaching 1%. The majority of HIV cases (perhaps 95%) are in citizens of the developing world.¹ Although antiretroviral chemotherapy can control HIV infection in an individual, at least temporarily, the cost and complexity of...

    • Chapter 14 Development and Validation of a Serologic Testing Algorithm for Recent HIV Seroconversion
      (pp. 290-304)
      Glen A. Satten, Robert S. Janssen, Susan Stramer and Michael P. Busch

      Owing to the long incubation period from infection to AIDS, researchers often ignore the fact that infection with HIV, the onset of infectivity, and a detectable antibody response on standard screening assays are not simultaneous. The time at which HIV antibody is first detectable in peripheral blood using an enzyme-linked immunoassay (EIA) can vary by manufacturer and generation of test (first-generation tests were replaced by second-generation tests in 1987, and thirdgeneration tests or combination HIV-1/HIV-2 tests became available in 1992). Typically the differences in onset of detectability are fairly small. For example, DNA PCR can detect HIV infection on average...

    • Chapter 15 Issues in Quantitative Evaluation of Epidemiologic Evidence for Temporal Variability of HIV Infectivity
      (pp. 305-330)
      Stephen C. Shiboski and Nancy S. Padian

      Much recent attention has focused on the implications of possibly increased HIV transmission from individuals in the primary phase of infection for epidemic development and the design of prevention programs. The following quotations from articles illustrate this:

      The pattern of high contagiousness during the primary infection followed by a large drop in infectiousness may explain the pattern of epidemic spread seen in male homosexual cohorts in the early years of the epidemic.¹

      The relatively short interval of high viral load during early infection followed by a long period of low viral load, suggests a special window of time during which...

  9. Index
    (pp. 331-335)