The reversal of the global gag rule by the Obama administration during the past few weeks means a new dawn for talking about HIV/AIDS prevention activities. It is therefore great timing that a new working paper on the effectiveness of HIV/AIDS prevention health education has been released.

In an update to an much earlier paper on the same topic, Pascaline Dupas from UCLA economics presents the results of a randomized experiment in Kenya that investigates the effectiveness of health prevention education efforts among primary school aged Kenyan teenagers.

Her study actually investigates the effectiveness of two somewhat different prevention interventions. The first, which is basically the strategy adopted by the Kenyan Ministry of Health was based on a strategy of teaching training (training of trainers type set up) focusing on abstinence message (all sex is risky, so avoid it). The second, was a school based, trainer to student type intervention that focused instead on the relative risk of different types of sexual behavior (some sex is riskier than others, so avoid risker sex). She finds that students in schools treated with the latter intervention have a 28% reduced rate of pregnancy (a proxy for unprotected, and hence riskier, sex). She also finds that girls in the treated schools report less sex with older, riskier sexual partners (older partners are more likely to be infected with HIV and are more likely to be wealthier and thus can demand more unprotected sex), and more sex with same age partners (this is also confirmed by younger boys who report more sexual activity). She finds that the government strategy was ineffective and thus prevention efforts may be more effective at reducing the spread of HIV (and potentially unwanted pregnancies) if they focus instead of harm reduction rather than abstinence only messages.

First off, I think this study is great, and always have, as it does shed a lot of light on the effectiveness of health prevention activities in general. However, I think her conclusions may go a bit far. She compares two different messages that are not just different but that are delivered in very different delivery settings. It could be that the delivery mechanism of the teaching training model is simply ineffective and that one needs to think about going straight to the students. We don’t know. Delivery mechanisms are key.

Second, I think she dismisses too much the potential side effects of promoting additional sexual activity among same age partners. Yes, it is true, for the time being this is lower risk, but at what point does this have other effects? The boys in the relative risk treatment group reported a 50% increase in sexual activity and an increase in the number of sexual partners. She also acknowledges in the paper that what happens to the older men who are no longer engaging in as much sex with younger girls? Are they engaging more in sexual activity with commercial sex workers? Are they targeting even younger girls? What are the long-term impacts of such shifts? These spillovers should be considered.

Picky points aside, I think the findings of this study are very significant as it does suggest, if nothing else, that teenagers may be more responsive to prevention messages that involve harm reduction rather than abstinence messages. It also goes to show how important well designed research can be in advancing the evidence base for what we do in global health.

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Paying you to quit

On February 12, 2009, in behavior, economics, risk factors, by Karen Grepin


The result of an interesting randomized study on smoking cessation were just published in the New England Journal. Smoking is the leading preventable cause of premature death in the United States with nearly 438,000 deaths each year directly attributed to this disease. Globally, it is also one of the leading risk factors for death and is on the rise. When you ask American smokers nearly 70% say that they want to quit, but only 2-3% succeed each year in doing so.

In this study, workers at a large company were randomized to receive an incentive to quit smoking. They received $100 for completing of a smoking-cessation program, $250 for remaining smoke free after 6 months, and another $400 for an additional 6 months of remaining smoke free. Most smokers trying to quit relapse within the first few months, so getting people through a year means that there is a good chance they will remain smoke free. To qualify for the incentives, smokers had to be certified smoke free using a biochemical test.

The workers receiving the incentives were almost 10% more likely to be smoke free after one year relative to the control group (who were also able to attend the smoking-cessation program). I have no idea how much a pack of cigarettes goes for these days, but say it is about $5 a pack. On average these people in the program were smoking about a pack a day, or $150 a month or about $1825 a year for cigarettes. In theory, if you have about a 10% additional chance of staying smoke free after one year (and you get the savings for life) we should almost be able to charge people themselves for the service to force them to quit. If you factor in the costs to the employer of lost productivity/sick days/additional health insurance and to the public for the cost of treating these people/second hand smoke, there are some really good reasons why we might want to really seriously consider these types of incentives.

It is this type of research that lead to a site like stickK which allows you to structure your own types of contract with yourself to help you do things that you want to do. Unfortunately, I have a low sensitivity to these types of contracts and unfortunately donated a few hundred bucks last year to the NRA due to my inability to get on the treadmill regularly….but check it out.

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One of my current areas of research, looks at the relationship between funding for HIV/AIDS programs and the delivery of non-targeted health services in sub-Saharan Africa. I find that the disbursements of funding is associated with lower coverage of other health services, including immunizations, and that this effect does not appear to be driven just by the epidemic itself and appears strongest in countries with the lowest density of health workers. I have always argued that these findings suggest that HIV/AIDS funding may be “crowding in” human resources into HIV activities leaving fewer health workers or less capacity for other health activities. Documenting these effects at the country-level, however, has always been challenging and most policy makers are very quick to dismiss “anecdotal reports” of such occurrences.

A recent qualitative study of these mechanims in Zambia by Johanna Hanefeld and Maurice Musheke, certainly support this view. In this study, the authors conducted a series of interviews with key informants at multiple levels of the health sector in Zambia in 2007. They investigate how the strategies employed by the global health initiatives, including PEPFAR and the Global Fund, are addressing the shortage of health workers in Zambia. Referring to these strategies, the authors suggest that:

“… interventions aims to alleviate the human resource shortage in relation to ART, examining their impact at district and provincial level in detail suggests possible negative, unintended consequences.”

They provide some disturbing quotes:

“One senior Ministry of Health official observed, “HIV, TB and malaria have taken almost 90% of our time, not to mention that they have also taken most of our budgetary money to the extent that we have actually neglected what we call noncommunicable diseases”

In Zambia, a great deal of the PEPFAR funds are being channeled in “off-budget” channels, specifically though non-governmental organizations. The authors find that:

“Of the health workers involved in the two public sector sites that started ART in Zambia in 2002 (University Teaching Hospital, Lusaka, and Ndola Central Hospital), including the doctors leading these programmes, the majority have now left the public sector to work for GHI-funded organizations that support the roll-out of ART.”

I think the findings of this study are very important. The authors have done a great job documenting what appears to be happening in Zambia, and likely in other countries as well. Of course, this is not necessarily a bad thing, depending on how one views the gains from one health intervention over the other, but it does raise some important questions. Specifically, to what extent are we willing to accept the negative effects of these initiatives on the rest of the health sector.

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The result of an analysis of the latest round of the British Social Attitudes survey in the UK highlights what I think is one of the key challenges in health system reform. Over the past seven years, the National Health Service (NHS) has undergone extensive reforms, including major changes to the organization of the system and massive increases in public expenditure on the system. The general thinking is that these reforms have done much to improve the quality of services provided and it seems to be showing up in public opinion surveys.

More than half of surveyed Brits report now being satisfied with the NHS, a substantial improvement over the past 25 years, and even a major improvement over the past decade. What is interesting, those who have had recent contact with the system are much more likely to report being satisfied than those who have not, somewhat suggesting that the new improvements are driving this change in public opinion. The highest level of satisfaction was reported about services received from physicians.

However, satisfaction with inpatient services has been falling. It could be that the quality of these services is actually declining, or more likely, linked in part to the increase perception of quality of other health services, expectations of these services are likely rising faster than actual improvements.

You really can’t make everyone happy all of the time…so health reform, even the really well planned and well executed ones, will never be easy.

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When it comes to the development of new drugs and vaccines for global health concerns, diseases that disproportionately affect people living in developing countries receive very little funding for new pharmaceutical products. A recent research article published in PLoS sheds more light on exactly what are the priorities for global health concerns when it comes to development of new products.

The authors find, that in 2007, just over US$2.5 billion was invested for “neglected disease” products. However, funding was mostly devoted for HIV/AIDS, TB, and malaria, which collectively received nearly 80% of the total funding. High DALY burden diseases such as pneumonia and the diarrhoeal illnesses, collectively received less than 6% of total funding. By some people’s definition, HIV/AIDS, TB, and malaria might not even meet the criteria for the definition of “neglected” because in fact they are relatively large burden diseases, have effective treatments currently on market, and have populations that are willing to pay for some drugs at least somewhere in the world. The neglected diseases that most people would agree are truly neglected, appear to remain to be neglected when it comes to new product development.

The other major finding from the study, is that 90% of the funding for “neglected diseases” was largely coming from public and private foundations, meaning that there has been very little increase interest in these concerns among private companies. This is probably not very surprising, and suggests that many of the new initiatives for global health may at least be effective in generating new revenues, albeit from public sources, for neglected diseases. Perhaps a partial victory?

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This week’s Lancet, had an interesting review article of alcohol-use disorders by Marc Schuckit. In this article, he provides a really great summary of the burden of disease associated with the use of alcohol, arguing that some of the most severe effects come from neuropsychiatric disorders associated with the use of alcohol.

The associated editorial provides the following summary of the global burden of disease from alcohol-use disorders:

“Around 2 billion people worldwide consume alcoholic beverages and over 76 million people have alcohol-use disorders. In most parts of the world the burden related to alcohol consumption in terms of morbidity, mortality, and disability is substantial. WHO estimates that the harmful use of alcohol causes about 2·3 million premature deaths per year worldwide (3·7% of global mortality) and is responsible for 4·4% of the global burden of disease. Although there are regional and national differences in levels, patterns, and context of drinking, current trends suggest availability and alcohol consumption will continue to rise.”

The ways in which alcohol affects health are diverse. Alcohol is adversely associated with neuropsychiatric disorders, cardiovascular diseases, cancers, injuries and accidents. It is also believed to be a risk factor for the spread of sexually transmitted diseases, including HIV.

I believe that alcohol-disorder policy research, in particular in a non-developed country setting, has received far too little attention from researchers. It is easier to point to more obvious risk factors such as smoking but to ignore risk factors that are perceived, perhaps incorrectly, to only affect a small subset of the population.

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AllAfrica.com ran a troubling news story this morning about Ghanaian women, living in a rural but well connected area of the country, turning to “prayer camps” rather than seeking necessary prenatal and obstetric services. I had heard some mention of these camps during my visits to Ghana and had heard that people use them as alternative forms of treatment for many conditions. In the story, a women presents at a local hospital in total agony and near death – with week-dead fetus rotting away her insides. This woman had been referred to tertiary medical care weeks prior, but instead attended a prayer camp. Fortunately, she eventually seeks medical treatment at the local hospital and survives her ordeal.

It is not uncommon in many cultures to rely upon faith or religion to help treat or prevent forms of diseases. Meditation, prayer, and other rituals are common around the world. When my husband and I moved to Boston we were tickled that our health plan covered X many annual visits to a Christian Science practitioner (we considered going for the heck of it – moral or spiritual hazard at play?).

But when does it go too far? A local human rights organization, has recently called the practices of such prayer camps, in particular those touting cures for mental illness, as a violation of human rights of people across the country. Last year, the Commonwealth Human Rights Initiative released a report outlining human rights abuses at such camps, describing how “patients” or as they call them “inmates” are:

“….are continuously chained and denied food and adequate shelter.”

In the article, a number of factors are mentioned as reasons why people turn to such camps: lack of supply of practioners, cost of modern treatments, culture, and lack of knowledge. Given the difficulty in trying to address all of these factors, I think this example speaks to the need for more regulation of such practices across the country.

I was incredibly impressed that some of the prayer camps even have their own websites. To sign up, you can visit one of these sites to get more information, although I do not guarantee what you will get…

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There has been a lot of discussion this past week on blogs, newspapers, and among those in the know, about the resignation of Mark Dybul and the fate of the seat he left behind. Names have been floated around who might make a great candidate, and what process should be followed to appoint the new US government HIV/AIDS Czar.

Many have called on Hillary Clinton and the new Obama administration to use an open and consultative process to select a new leader. A prominent group of AIDS activist organizations have called on her to “pursue a innovative, competitive, merit based process“. In an editorial in the Lancet, staff writers also called on the Obama administration to use a “competitive merit-based selection” process. Josh Ruxin in the NYTimes called on her to “choose wisely and by consensus“.

While I certainly agree that whoever is chosen should be well qualified for the job at hand and am a big proponent of openness and transparency, I am a bit worried that this might be taken too far. I am skeptical that consensus is obtainable – it is impossible to please everyone all of the time. And consensus of whom exactly? Would we really build a consultative process that includes all stakeholders from US tax payers, to pharmaceutical companies, to the organizations who have benefited from PEPFAR funds, to patients in the over 100 countries who are touched by PEPFAR funds? A nice idea, but the PEPFAR seat is vacant now, we need someone there now to get new initiatives off the ground and running today. When the Global Fund searched for a new leader a few years back, the process took much longer than planned. Also, by voting in Obama have we not made him and his appointees accountable for the policies of the current administration? Does congress not already have a huge say over the way in which PEPFAR should be run?

Where I think there is a need for greater transparency and consultation is exactly what policies and programs should the PEPFAR program follow. Mark Dybul, appears to have been extremely effective is implementing the programs set by the Bush administration. My criticisms of the PEPFAR program were less about his own ability to execute as opposed to the policies he had as a mandate to implement.

My dream list would be the following: someone who is skilled and knowledgeable about large scale implementation programs, someone who can navigate successfully within the Washington system to build bi-partisan support, someone who is interested in incorporating science and evidence into the development of policies and on-going monitoring to evaluate the effectiveness of these programs, and someone who is able to build the consultative process around establishing what works in which contexts. I would be more afraid if we chose someone who already thinks they know how to make this happen than someone who professes to know less but would be open to hearing new ideas. PEPFAR has the ability to move away from a unilateral program on HIV/AIDS to potentially a very successful bilateral program in the coming years and needs a new strong leader to oversea this process and a heck of a lot of reflection on the mandate of the organization.

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