Preventing HIV in injection drug users: exploring the tradeoffs between interventions

Injection drug users (IDUs) transmit the human immunodeficiency virus (HIV) via both needle sharing and sex. Available interventions for this population have varying costs and effectiveness and focus on different risk behaviors. In this analysis, we look at two interventions. One is inexpensive, broad-based and provides modest risk reductions (street outreach (SO)); the other is narrowly focused, expensive and relatively effective (methadone maintenance). This analysis explores the effects of population risk behavior, intervention effectiveness, intervention costs, and decision constraints when allocating funds between these two interventions to maximize effectiveness. We develop a model of the spread of HIV, dividing IDUs into susceptibles (uninfected) and infectives, and separately portraying sex and injection risk. We simulate the epidemic in New York City for time periods from the mid-1980s to the early 1990s, and incorporate the behavioral effects of two interventions performed singly or in combination to find the allocation that maximizes the number of infections averted in the IDUs and their noninjecting sex partners, assuming interventions have increasing marginal costs. We find that the optimal allocation nearly always involves spending the maximum allowable amount on SO. This result is largely insensitive to variations in risk parameters, intervention efficacy, or cost. The model's structure, however, makes clear that many factors contribute to this insensitivity, namely the scope of the interventions, the dual drug/sex nature of HIV risk in the population, the asymmetry of sexual risk for men and women, and the potential benefits to nonIDUs.     

Legalistic organizational responses to catastrophic illness: The effect of stigmatization on reactions to HIV/AIDS

The HIV/AIDS epidemic has focused increased attention on catastrophic illnesses in the workplace, and because of the stigmas associated with HIV/AIDS, it raises three primary concerns for organizations: (1) organizational avoidance of legal sanctions and litigation; (2) the maintenance of organizational legitimacy; and (3) organizational protection of employee rights. Although many organizations adopt legalistic responses to cope with these concerns, the analysis presented in this article suggests that while legalistic approaches function well to protect organizational interests in terms of both legal liability and legitimacy, the are only partially able to protect employee rights. Drawing upon the limited literature on HIV/AIDS in the workplace, this article presents an agenda for future research on organizational responses to HIV/AIDS.     

Strengthening capacity for sustainable livelihoods and food security through urban agriculture among HIV and AIDS affected households in Nakuru,Kenya

The promotion and support of urban agriculture (UA) has the potential to contribute to efforts to address pressing challenges of poverty, under nutrition and sustainability among vulnerable populations in the growing cities of sub-Saharan Africa (SSA). This may be especially relevant for HIV/AIDS-affected individuals in SSA whose agricultural livelihoods are severely disrupted by the devastating effects of the disease on physical productivity and nutritional well-being. This paper outlines the process involved in the conception, design and implementation of a project to strengthen technical, environmental, financial and social capacity for UA among HIV-affected households in Nakuru, Kenya. Key lessons learned are also discussed. The first has been the value of multi-stakeholder partnerships, representing a broad range of relevant experience, knowledge and perspectives in order to address the complex set of issues facing agriculture for social purposes in urban settings. A second is the key role of self-help group organizations, and the securing of institutional commitments to support farming by vulnerable persons affected by HIV-AIDS is also apparent. Finally, the usefulness of evaluative tools using mixed methods to monitor progress towards goals and identify supports and barriers to success are highlighted.     

AIDing contraception: HIV and recent trends in abortion

Using a difference-in-differences estimation framework and state-level data, we investigate the potential role of HIV/AIDS in contributing to declining abortion utilization in the United States. Our results suggest that the perceived risk of HIV contraction negatively affected unwanted pregnancies. Specifically, a 10% increase in HIV incidence is associated with 0.34–1.1% fewer abortions per live births, an effect that can account for at least one-tenth of the sharp decline in abortions observed from the early 1980s to mid-1990s.     

Modelling the cost-effectiveness of nevirapine triple combination therapy and dual combination therapy for the treatment of HIV disease in the United Kingdom

Summary

Recent advances in HIV antiretroviral therapy together with limited budgets have forced payers to look for evidence that new combinations provide good value for money. Using a public financing perspective, two Markov models are employed to evaluate the first-year outcomes and costs and the long-term cost-effectiveness of adding nevirapine (NVP) to dual combination therapy with zidovudine (ZDV) and didanosine (ddI) in the United Kingdom.

First-year medical care savings are estimated to be £2,122 (103.8% of NVP cost). In the longer term, NVP/ZDV/ddI therapy yields £6,186 per life year saved (costs discounted at 6%). The model is moderately sensitive only to duration of therapy effects and the therapy initiation time. These model estimates suggest that policy makers may expect to observe superior initial health outcomes and substantial medical cost savings during the first year of therapy, as well as acceptable long-term cost-effectiveness, when NVP/ZDV/ddI is used in place of dual therapy.