Efficient and equitable HIV prevention: A case study of male circumcision in South Africa
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RESEARCH
Open Access
Efficient and equitable HIV prevention: A case study of male circumcision in South Africa Stéphane Verguet
Abstract Background: We determine efficient, equitable and mixed efficient-equitable allocations of a male circumcision (MC) intervention reducing female to male HIV transmission in South Africa (SA), as a case study of an efficiency-equity framework for resource allocation in HIV prevention. Methods: We present a mathematical model developed with epidemiological and cost data from the nine provinces of SA. The hypothetical one-year-long MC intervention with a budget of US$ 10 million targeted adult men 15–49 years of age in SA. The intervention was evaluated according to two criteria: an efficiency criterion, which focused on maximizing the number of HIV infections averted by the intervention, and an equity criterion (defined geographically), which focused on maximizing the chance that each male adult individual had access to the intervention regardless of his province. Results: A purely efficient intervention would prevent 4,008 HIV infections over a year. In the meantime, a purely equitable intervention would avert 3,198 infections, which represents a 20% reduction in infection outcome as compared to the purely efficient scenario. A half efficient-half equitable scenario would prevent 3,749 infections, that is, a 6% reduction in infection outcome as compared to the purely efficient scenario. Conclusions: This paper provides a framework for resource allocation in the health sector which incorporates a simple equity metric in addition to efficiency. In the specific context of SA with a MC intervention for the prevention of HIV, incorporation of geographical equity only slightly reduces the overall efficiency of the intervention. Keywords: Efficiency, Equity, HIV prevention, Male circumcision
Background South Africa has the largest HIV epidemic in the world. In 2009, 5,600,000 people were living with HIV, a 18% prevalence among adults [1]. Specific features of South Africa, including a historically important migrant population, a difficult transition from apartheid that occurred at a critical juncture in the spread of the epidemic [2-4], and even after apartheid, slow government response [5] are relevant to what has been HIV’s explosive spread in the nation. A combination of domestic and international funds totaling US$ 620 million was spent on dealing with the epidemic in 2007 [1], representing a massive allocation for the national health budget.
Correspondence: [email protected] Department of Global Health, University of Washington, 325 9th Avenue, Box 359931, Seattle, WA 98104, USA
Effective HIV prevention has eluded South Africa and sub-Saharan Africa in general. Indeed, worldwide there are few success stories: Thailand with its ‘100% condom’ intervention [6] and Uganda with its ‘ABC approach’ [7] are routinely mentioned. We need to reprioritize strategies for HIV prevention, based on evidence [8], integrated into recently scaled-up treatment [9] and tailored to the local context [1
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