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Multi-disease prevention campaigns (part 1): integrating HIV into wider public health campaigns

Keith Alcorn
Published: 08 October 2013

Key points

  • Ambitious targets to achieve rapid increases in the coverage of HIV counselling and testing, and of antiretroviral therapy, require innovative approaches to reaching people.
  • Offering HIV counselling and testing as part of larger public health campaigns has shown promising potential in two multi-disease prevention campaigns in western Kenya and Uganda.
  • Integration of disease prevention campaigns has the potential to save money and maximise the value of public health investments.
  • Several neglected tropical diseases are already addressed through integrated treatment campaigns, demonstrating that a variety of disease control areas can work together successfully.
  • Integrated disease prevention campaigns are likely to have the greatest impact when they tackle diseases that are synergistic, such as malaria and HIV. These synergistic effects are likely to vary according to the epidemiology of HIV, malaria and neglected tropical diseases.
  • Integrated disease prevention campaigns may attract community interest through the distribution of prevention commodities such as mosquito nets and water filtration equipment. Campaigns which offer testing for health conditions identified as local health priorities by the community can also attract a high level of community interest.
  • Both approaches have been proven to result in very high uptake of HIV counselling and testing in rural areas, and diagnosis of people living with HIV much earlier in the disease course.
  • Design of integrated disease prevention campaigns requires community involvement in the setting of priorities to ensure successful community mobilisation.
  • Integrated disease prevention campaigns offer an opportunity to expand testing and linkage to care for non-communicable diseases, as well as for HIV. Synergies between infectious diseases and non-communicable diseases, such as between diabetes and tuberculosis, may be worth exploring.
  • Male medical circumcision, syphilis screening and cervical cancer screening are already being considered as elements of future integrated disease prevention campaigns.

Reviewed by Gabriel Chamie, Vivek Jain (University of California San Francisco), Reuben Granich (UNAIDS), Alexandre Doyen (Vestergaard Frandsen) and Judd Walson (University of Washington, Seattle).

This edition of HATIP was kindly supported by Vestergaard Frandsen.

Ambitious targets to scale up the coverage of HIV counselling and testing, and antiretroviral therapy, will require innovations in many aspects of healthcare delivery. This edition of HATIP examines the concept of multi-disease prevention campaigns which target a range of public health issues in a concentrated burst of activity in a locality.

The need for comprehensive responses and more cost-efficient delivery

As international donor spending on health continues to be squeezed there is growing pressure from donors for health programmes to demonstrate greater returns on investment. In part this reflects the growing difficulty that many governments face in justifying overseas aid at a time of domestic budget cuts. But it also reflects the recognition that past investments often missed opportunities for action, and that the previous emphasis on rapid achievement of disease-specific targets may have occurred at the expense of a co-ordinated approach to health.

“Integrated disease prevention campaigns can reduce the costs to donors while doing more with the money,” said Erin Bendavid of Stanford University at an AIDS 2012 satellite meeting on integrated campaigns.

Note the shift in emphasis: Bendavid is talking about “disease prevention” rather than HIV or TB treatment campaigns. In the HIV field the growing emphasis on earlier access to testing and treatment including 'test and treat', which aims to diagnose large numbers of people and link these people to treatment and care before they become severely ill, has fundamentally altered the terms of the debate for low- and middle-income countries. The new 2013 World Health Organization guidelines recommend a move towards earlier treatment at CD4 counts below 500, yet many people with HIV continue to be diagnosed in clinical settings at low CD4 cell counts as a result of presentation with clinical disease.

Prevention of HIV disease requires earlier treatment, as does prevention of transmission. To reach people long before they become sick, and to minimise onward transmission, earlier HIV diagnosis requires more systematic approaches to making HIV testing available in the community, outside clinical settings.

A recently published systematic review and meta-analysis of community-based approaches to HIV testing and counselling found that a range of approaches achieved a high rate of testing and linkage to care, as well as diagnosing people at higher CD4 counts.1

These approaches included door-to-door testing, mobile testing and site-specific testing at churches, workplaces and schools. Door-to-door testing achieved an average uptake of 80%, so it is clearly an effective strategy for achieving a good uptake of voluntary counselling and testing, but is it the most cost-effective use of resources?

A recent comparison of the costs of four different approaches to HIV counselling and testing found costs-per-client (2007 USD) of $19.26 for stand-alone HIV counselling and testing, $11.68 for hospital-based counselling and testing, $13.85 for household-member counselling and testing, and $8.29 for door-to-door counselling and testing.2

So, door-to-door counselling and testing compares favourably with the cost of other methods of offering HIV testing, but there are other considerations regarding cost-efficiency. An integrated disease prevention campaign in western Kenya was able to deliver HIV counselling and testing, condoms, and CD4 cell testing for all persons diagnosed HIV positive, at a cost-per-client of USD12.35 (this cost would fall to USD9.91 if the campaign was scaled up, the researchers estimated).3 Furthermore, the campaign reached 83% of eligible adults in the district in seven days, a very high level of coverage that would not be achievable for door-to-door testing without a substantially increased investment in community health workers to carry it out.

A further limitation of single-disease campaigns relates to incentives and risk perception. People need to be aware that they are at risk in order to seek a diagnosis, and in the case of HIV, high levels of awareness in the population may mask widespread assumptions that HIV is something that happens to other people, or to those in other places, and that absence of illness is proof of good health. The stigma attached to HIV infection and the fear of an HIV diagnosis may also discourage people from testing or from being seen to seek testing.

On the other hand, people may be encouraged to learn their HIV status as a result of free testing for high blood pressure (which may be a paradoxical badge of higher economic status), or by the distribution of long-lasting insecticide-treated nets to protect their families, to give just two examples.

Finally, single-disease campaigns are unlikely to prove a viable way of expanding access to antiretroviral treatment through testing for the 28 million people who need it. Approaches to disease prevention which keep diseases in separate silos fail to achieve economies of scale and keep disease areas in competition, forcing policy makers to choose between HIV, TB, malaria, neglected tropical diseases, rather than exploring ways of using investments to tackle all these areas.

“Multi-disease prevention campaigns provide real hope that with our scarce resources we will be able to keep our promise to reach millions of people with life-saving prevention interventions, said Dr Reuben Granich, UNAIDS Treatment and Care Advisor. “In fact, providing earlier HIV diagnosis and treatment as part of a campaign could end up saving people and the health sector millions of dollars.”

Vertical programmes or integrated disease campaigns?

Almost without exception, the models of community testing evaluated in the systematic review were part of vertical HIV programmes that formed the emergency response in resource-limited settings during the first decade of treatment scale up.

But vertical programmes are increasingly viewed as a bad investment by donors, according to Simon Wright, Head of Child Survival at Save the Children UK, speaking at a recent conference organised by the International Society for Neglected Tropical Diseases (ISNTD). “Policy makers are getting increasingly fed up with hearing from single-disease advocates, about single-disease strategies, and who can’t think in a joined-up way,” he said.

There has been a growing emphasis on the need for integration of HIV-related activities into other programmes, such as TB and maternal-child health, in order to reach people with HIV infection where they are most likely to present for medical care.

The biggest move towards integration has been the shift towards the delivery of HIV treatment and care as part of the package of primary care. It is beyond the scope of this article to explore the challenges and success of this approach, but one limitation is clear: integration into primary care requires a functional primary care system with comprehensive population coverage and, even then, there are things that primary care may not be able to achieve. These include identifying people not currently engaged in care, and promoting disease prevention measures such as condom use and use of long-lasting insecticide-treated nets.

Accordingly, public health practitioners in a variety of settings and disease areas have been considering how campaign approaches to disease prevention might be integrated, in order to achieve economies of scale and synergies of impact.

Integrated disease campaigns: beyond HIV

Integrated campaigns are already happening outside the HIV field and form the core of efforts to tackle neglected tropical diseases. Professor Alan Fenwick of Imperial College, London, director of the Schistosomiasis Control Initiative, points out that in order to achieve the 2020 targets for elimination of many neglected tropical diseases, new strategies rather than new drugs will be needed in order to achieve scale and synergies of action.

Integrated disease prevention campaigns are already a reality in many countries where neglected tropical diseases are a public health priority.

The Rapid-Impact Package for neglected tropical diseases

Disease

Vector

Treatment

Schistosomiasis

Water borne

Praziquantel

Onchocerciasis

Water borne

Ivermectin

Lymphatic

filariasis

Mosquito

Ivermectin or

Albendazole

Soil-based helminths

Soil

Albendazole

Mebendazole

Trachoma

Bacterial

Azithromycin

Schistosomiasis control is increasingly integrated into a package of activities designed to deliver treatment and prevention against a range of neglected tropical diseases that are co-endemic, supported by drug donation programmes run by six pharmaceutical companies. The other diseases are onchocerciasis (river blindness), lymphatic filariasis, soil-transmitted helminths and trachoma. Prevention of these diseases has become integrated through a Rapid-Impact Package which delivers treatment with a combination of four drugs on an annual basis at a cost of approximately US 50 cents per person.

Prevention of all these neglected tropical diseases needs to be supported by vector-based strategies that address both the immediate vectors of transmission – such as mosquitoes – and the environmental and structural factors which give rise to a high burden of disease. These might include clean water, sanitation and hygiene (WASH) interventions as well as measures to reduce mosquito infestation by indoor spraying.

Integrated vector management strategies may also mitigate the unintended consequences of interfering in the very complex ecology of tropical parasites. In the case of lymphatic filariasis, which is spread by mosquitoes, we don’t know whether a reduction in filarae (the parasitic cause) will result in a paradoxical increase in mosquito survival, noted Louise Kelly Hope of the London School of Hygiene and Tropical Medicine during the ISNTD event. “Is elimination a sensible plan or are we removing one species only to make room for another?” asked Dr Mark Booth of the Wolfson Institute at the University of Durham. “Is elimination the best use of resources or will these diseases always bounce back?”

The World Health Organization has recommended integrated vector management for lymphatic filariasis and malaria where both are co-endemic in sub-Saharan Africa and Asia (especially the western Pacific).4 Integrated disease prevention requires both the distribution of long-lasting insecticide-treated nets and treatment of lymphatic filariasis. Mapping of co-endemic areas in order to target areas for integrated intervention will be necessary. This approach of disease mapping is still in its infancy but has huge potential as an additional benefit of integrated disease prevention campaign events.

There is limited evidence that a number of neglected tropical diseases interact with HIV, either by increasing susceptibility to infection or by accelerating disease progression. A systematic review found that treatment of malaria and helminth infections had a modest impact on HIV viral load, but the authors note that “even small changes in plasma HIV-RNA concentrations have been shown to slow HIV disease progression.”5

More importantly, neglected tropical diseases are often endemic in areas where HIV prevalence is also high, and targeting a range of diseases which impose a high burden on the local population is likely to represent a more cost-effective use of resources in most settings.

Several neglected tropical diseases offer potential synergies with HIV and are reviewed in the following sections.

Schistosomiasis, helminth interventions and HIV

Schistosomiasis (bilharzia) is caused by ingesting or bathing in water containing the larvae of schistosoma worms. Subsequent worm infestation can cause damage to the bowel, bladder, kidneys, liver and spleen, and impaired growth in children. Schistosomiasis may also increase the vulnerability of women to HIV infection as a consequence of damage to the genital mucosa. Schistosomiasis can be cleared by treatment with praziquantel in one or two oral doses costing less than US 40 cents per treatment.

Eradication of schistomiasis requires environmental controls in order to eliminate water-dwelling snails that form the natural reservoir for the helminths which cause schistosomiasis.

Mass treatment is concentrated in areas where schistosomiasis is endemic and where it causes a high frequency of symptoms in children.

The Schistosomiasis Consortium for Operational Research and Evaluation (SCORE) is currently evaluating further strategies for the elimination of schistosomiasis.

A wide range of helminths (worm) are also present in the populations affected by schistosomiasis. These may cause anaemia, malnutrition and impaired cognitive development in children. A 2009 Cochrane Review concluded that deworming was associated with significant positive impacts on viral load and CD4 cell counts in adults, and a persuasive body of evidence from population, animal and human studies show that helminth infections reduce responses to childhood vaccines.6, 7 However, a more recent randomised trial conducted in Kenya with support from PEPFAR and US CDC Global AIDS Program failed to show an effect of empiric deworming on HIV disease progression in adults not receiving antiretroviral therapy.8

A different approach to integration of schistosomiasis and HIV disease prevention might focus on the impact of reducing schistosomiasis on HIV acquisition in women. A modelling study using data from a Zimbabwean community intervention which combined provision of clean water, sanitation, and health education with administration of praziquantel to school-aged children suggested that the intervention would be highly cost-effective over a 20-year period.9 “It is important to treat young girls before they become sexually active,” said Professor Alan Fenwick of the Schistosomiasis Control Initiative.

Malaria and HIV

HIV and malaria overlap as endemic diseases in many parts of sub-Saharan Africa, and to a lesser extent in south-east Asia.

People living with HIV are more likely to become infected with malaria,9,10 to suffer higher parasite burden,11 and to have a higher risk of clinical malaria and a higher risk of recurrence, especially at a CD4 count below 200.12, 13

In malaria-endemic settings, several observational cohort studies have shown a significantly greater risk of parasitaemia and clinical malaria among HIV-infected adults, especially among highly immunosuppressed adults.14, 15, 16

In regions of unstable transmission where early immunity is not established, HIV appears to increase the risk of severe malaria, and it is in these regions that the interaction between HIV and malaria may result in the greatest additional burden of disease.17

HIV may particularly exacerbate susceptibility to malaria during pregnancy. A systematic review of the burden of co-infection in pregnant women found that in settings with extremely high HIV prevalence (25 or 40%), 12.7 and 18.8% of malaria cases respectively were attributable to HIV infection.18 For sub-Saharan Africa as a whole, HIV infection was estimated to lead to an additional 505,000 cases of malaria during pregnancy, out of an estimated 10.5 million malaria cases occurring in pregnant women.

Studies have reached varying conclusions about the impact of HIV on malaria in infants and children. While a large cohort study in Uganda failed to find any association between HIV infection or perinatal exposure to HIV and incidence or severity of malaria in children, another study in Uganda in a cohort of children who received blood transfusions found that HIV infection was associated with increased morbidity and all-cause and malaria-related mortality in those children with malaria who developed severe anaemia.19, 20

The latter study highlights perhaps the key area of risk for children: the risk of HIV acquisition as a consequence of a blood transfusion to treat anaemia associated with malaria.

Co-infection with malaria causes a transient but substantial increase in HIV viral load lasting for several months after malaria treatment is successfully concluded.21 In a Ugandan cohort of people living with HIV, people who experienced three or more episodes of malaria in a year had much greater declines in CD4 cell count than people who remained free of malaria (-142 cells).22 Systematic review found conflicting results regarding the impact of malaria on HIV transmission during pregnancy.23 The extent to which malaria contributes to sexual transmission is unclear, but the magnitude of the increase in viral load observed during malarial co-infection is consistent with an increased risk of transmission in people not receiving antiretroviral treatment.

Interventions

A number of interventions in various populations of people living with HIV in east Africa have shown positive benefits of preventing malaria on HIV disease progression and positive benefits of antiretroviral therapy and cotrimoxazole prophylaxis on malaria incidence.

Distribution of long-lasting insecticide-treated nets was associated with a reduced incidence of malaria symptoms and clinical malaria in a prospective study of people with HIV infection not yet eligible for antiretroviral therapy in Kenya, as well as a reduced risk of HIV disease progression as measured by CD4 cell count. Recipients of nets and a water purification device were significantly less likely to reach the CD4 cell threshold for starting treatment (350) during a two-year follow-up period.24

Cotrimoxazole, recommended as prophylaxis against pneumonia and bacterial infections in people with HIV, also protects against malaria, and has been shown to reduce the incidence of malaria by around 70% and mortality by around 40% in HIV-positive adults in a Ugandan cohort study.25

If cotrimoxazole is discontinued in people taking antiretroviral treatment the risk of malaria increases very substantially – a randomised study in Uganda found that after just 120 days off cotrimoxazole, people with HIV had a 28-fold higher risk of developing malaria, indicating the need not only for continuous cotrimoxazole prophylaxis, but also the need for consistent drug supplies and healthcare worker and patient education on the need to use cotrimoxazole consistently in endemic areas.26

Antiretroviral therapy is also strongly associated with a reduced risk of malaria, due in part to improved immunity over time. A cohort study in Uganda found the incidence of malaria was 70% lower in people who received ARVs and cotrimoxazole compared to cotrimoxazole alone. Use of both interventions together with insecticide-treated nets was associated with a 95% reduction in malaria incidence compared to no intervention.27

The use of both cotrimoxazole and insecticide-treated nets combined reduced the risk of malaria in children with HIV by 97% in Uganda.28

In the light of this evidence, there is a strong case for integrating malaria prevention and treatment activities into any community campaign to promote HIV counselling and testing, wherever malaria is present.

Waterborne infectious diseases and HIV

Diarrhoea caused by waterborne infections is a frequent cause of illness in people living with HIV in resource-limited settings, particularly in children (see HATIP 157, April 2010, for a review of the management of diarrhoea in children with HIV). A cohort study conducted in Uganda in the mid-1990s among 1213 people with HIV found that frequency of diarrhoea was strongly associated with lower CD4 cell counts, but failed to show a strong association between diarrhoea and the presence of bacteria or protozoa in the stools of those diagnosed. Cryptosporidial infection was associated with low CD4 cell count.29

However, a randomised study conducted in Uganda by the US Centers for Disease Control Global AIDS Program in 2001-2002 found that a home-based safe water intervention significantly reduced diarrhoea frequency regardless of whether cotrimoxazole prophylaxis was provided, and also reduced the numbers of days of work or school lost due to diarrhoea.30 A subsequent systematic review identified eight studies which measured the effect of water quality interventions on diarrhoea in people living with HIV. Water quality interventions were associated with a 43% reduction in diarrhoea (RR = 0.57, 95% CI 0.38-0.86).31 The authors concluded that the studies were of mixed quality however, with small sample sizes and little measurement of intervention adherence.

A literature review on water safety and the health of people living with HIV published by USAID’s Hygiene Improvement Project in 2007 recommended that:

  • Water treatment kits (including sodium hypochlorite and water storage equipment) should be distributed alongside antiretrovirals.
  • Home-based care programmes should provide covered water vessels with spigots.
  • Hygiene education for people living with HIV and home-based care programmes should include comprehensive information on water safety and storage, handwashing and disposal of waste water and faeces.
  • Access to sufficient quantities of water should be addressed.32

A study of a multi-disease prevention campaign conducted in western Kenya showed that among people living with HIV who received a LifeStraw water filter for home use, the incidence of diarrhoea was reduced by 35%. Furthermore, receipt of a water filter and a long-lasting insecticide-treated net was associated with a significant delay in the need to start antiretroviral treatment among those with CD4 cell counts above 350. This finding suggests that by reducing exposure to waterborne infections, water filtration limits exposure to infectious agents that cause immune activation or infections that cause immunological harm.33

What is the difference between a campaign and a programme?

Campaigns are time-limited events that occur within a specific area as part of a larger public health programme.

“It’s important to understand that campaigns are one modality that can be employed to reach people,” Professor Judd Walson of the University of Washington, Seattle, told HATIP. “We have a successful facility-based intervention – HIV treatment and care – which is very successful. Campaigns are another model.”

Yet facility-based interventions depend on people visiting the facility, and have little reach into the community. Facility-based interventions may work for curative and some preventive interventions, but will have limited preventive impact for endemic infectious diseases like HIV and malaria.

Large community campaigns for diagnosis and disease prevention have a long history, but chiefly as single-disease campaigns. Vaccination campaigns date back to the early 19th century in the form of local and national smallpox vaccination drives.34

One of the first large-scale public health campaigns occurred in the field of tuberculosis. Following the introduction of streptomycin for TB treatment, for example, mass X-ray screening began to be used from the late 1940s to identify people with TB early. One of the largest concentrated campaigns took place in Glasgow in 1957, where 714,915 people were screened in five weeks in a campaign employing 37 mobile X-ray vans, identifying 2842 new TB cases. At the time the city had the highest rate of TB in Western Europe. (See this British Pathé newsreel for further information on the impressive scale of community mobilisation.)

Community campaigns for smallpox eradication provide another important template. Smallpox eradication campaigns “necessarily had to function within existing health service structures and had to take advantage of available resources,” Professor Donald Henderson of Johns Hopkins University Medical School reflected in Mortality and Morbidity Weekly Report in 1999, considering the lessons of previous eradication campaigns. More recently, large-scale campaigns have promoted the distribution and use of insecticide-treated bed nets for malaria prevention.

The World Health Organization and UNICEF have endorsed the strategy of integrating bed net distribution into measles vaccination campaigns. Insecticide-treated bed net distribution has also been integrated with childhood nutrition campaigns. (See this Alliance for Malaria Prevention toolkit for further information on how integrated campaigns have been developed to support distribution of long-lasting insecticide-treated nets.)

Integration of treatment and prevention campaigns against other neglected tropical diseases is less advanced.

In the HIV field, campaign approaches to HIV awareness and prevention, and to HIV counselling and testing, have become widespread. It is not the purpose of this article to review single-disease interventions, beyond noting that HIV testing drives and HIV testing weeks have become a commonplace means of raising awareness of HIV and identifying people with HIV infection. The weakness of this approach is that HIV testing events are by their nature vertical programmes, and as already noted, will only attract people who want to know their HIV status.

Putting it all together

Integration with neglected tropical disease prevention activities is one approach, but many countries are also paying increasing attention to non-communicable diseases. These diseases – heart disease, diabetes, high blood pressure (hypertension), for example – are beginning to impose a large burden on health systems in Africa and Asia, and will eclipse infectious diseases as the main causes of morbidity and mortality in some countries within the next 20 years. (See HATIP 182, October 2011, for a review of the interaction between HIV and non-communicable diseases).

The second edition of this series on integrated disease prevention campaigns will examine how diagnosis and monitoring of diabetes and hypertension were incorporated into a community disease prevention campaign that also involved large-scale HIV testing in Uganda.

Professor Ib Christian Bygbjerg of the University of Copenhagen, who recently highlighted the growing burden of non-communicable diseases in developing countries,35 suggests that integrated disease prevention activities which combine management of infectious and non-communicable diseases should look at the resources and skills required for management when looking at how to effectively combine interventions.

For example, infectious and non-communicable diseases that require long-term monitoring and management, such as HIV and diabetes or leprosy and diabetes, might be managed together. Similarly, direct observation might be employed concurrently in TB treatment programmes to treat TB and to achieve glycaemic control in TB patients diagnosed with diabetes. People with diabetes have an approximately 2.5-fold higher risk of developing active TB. Bi-directional screening programmes have found an elevated prevalence of TB in people diagnosed with diabetes and an elevated prevalence of diabetes in people diagnosed with TB, suggesting opportunities for enhanced case finding of the two diseases.36 Health promotion interventions might also address the fact that smoking is a risk factor for both diseases.

But investigators on both the large multi-disease prevention campaigns incorporating HIV were cautious about the feasibility of incorporating intensified case finding for TB, for reasons that will be explored in more detail in the second article in this series.

Possible elements in integrated disease campaigns

 

Disease

Intervention

Schistosomiasis

Praziquantel

Water filter or treatment kit

Malaria

Longlasting insecticide-treated nets

Cotrimoxazole prophylaxis for HIV+

Treatment of malaria

Waterborne infectious diseases

Water filter or treatment kit

Drug treatment for

schistosomiasis and

onchocerciasis

Rotavirus vaccine for infants

HIV

Counselling and testing

Condom distribution

If HIV+: CD4 count and linkage to care

If HIV+ and CD4<200 – 250: rapid initiation of ART

If HIV+: TB screening

If HIV+: cotrimoxazole

prophylaxis

Medical male circumcision

Cervical cancer

Screening (visual acetic acid / VIA)

Noncommunicable diseases

Blood sugar screening for diabetes

Blood pressure monitoring

Childhood vaccination

Delivery of catch-up immunisations

Introduction of new vaccines eg

rotavirus or pneumococcal vaccine, especially where a single-dose vaccine is available

 

For programmers who want to achieve economies of scale and promote efficiencies in the health system, thinking about how to combine disease prevention interventions inevitably focuses on the questions of cost and organisational efficiency.

“We often think about it from a costing perspective – for example, insecticide-treated nets can be delivered every three years, and so can water filters, so what else can be delivered on the same cycle?” asks Judd Walson of the University of Washington. He is working on a matrix of interventions that can help programmers to identify cycles and potential target populations for combined interventions.

Nevertheless he acknowledges a possible shortcoming of this approach.

“On the flipside, what is going to drive use most effectively? When we asked communities in Western Kenya what they wanted, it was deworming for their kids and bednets. Doing a campaign in a way that makes the community view it as a health benefit may not always align with Ministry of Health programming priorities,” he observed.

“The consumer isn’t the market in terms of paying for these goods, but they are the market in terms of uptake.”

“In an ideal world we would take an approach that I’ve called the public health bazaar, in which we ask the Ministry of Health to come up with five to ten priority interventions, and then go to the community and ask the community about their priorities, and then come up with a list that meets both groups’ needs,” Walson told HATIP.

 “If you erode the confidence of the community [by delivering unwanted interventions] then you undermine the future success of subsequent campaigns. It is a prerequisite to work with the community to be successful,” he went on.

Gabriel Chamie of University of California San Francisco, who led the SEARCH Collaboration campaign combining HIV testing with screening for diabetes and hypertension, agreed that the quality of community consultation is essential to the success of campaign approaches.

“We see community health campaigns as a platform to begin engaging the community as to what they need and to promote community ownership of public health interventions,” he said.

Cost-effectiveness

At AIDS 2012, Stéphane Verguet of the University of Washington presented a cost modelling of the impact of the multi-disease prevention interventions studied in Kenya, assuming they were rolled out to the entire population living with HIV in sub-Saharan Africa. This modelling exercise showed that substantial savings could be achieved in a number of countries as a result of the deferral of antiretroviral therapy.37

Using data from the Kenyan study of the impact of malaria and waterborne disease prevention on HIV disease progression, Verguet and colleagues in the University of Washington Department of Global Health applied these data to a model that incorporated epidemiological and costing data from sub-Saharan Africa. Antiretroviral treatment was estimated to cost US$722 per year and the intervention package was costed at $22 a year.

The model found that for Kenya, a nationwide integrated disease prevention campaign costing $7 million might save $28 million a year in antiretroviral costs, and save 2200 lives from HIV-related death. The model did not incorporate the impact of a nationwide integrated disease prevention campaign on deaths from either malaria or waterborne diseases in the HIV-negative population.

A subsequent publication showed that the intervention was highly cost-effective. The cost per death averted was US$3100 and the cost per disability-adjusted life year (DALY) averted was US$99, making the intervention very affordable for a country like Kenya.38

A nationwide campaign would achieve a similar impact in Mozambique, while in Nigeria, with a much larger population, and a larger numerical HIV burden, a campaign costing $16.7 million would save $67.3 million.

Modelled across the whole of sub-Saharan Africa, universal implementation of an integrated disease prevention campaign would save $402 million in antiretroviral costs, around 8% of the PEPFAR antiretroviral drug budget, Verguet and colleagues estimated.

Furthermore, Stéphane Verguet observed, the implementation of campaigns in rural areas underserved by health services had the potential to reduce inequities in access to services and health care, and to reach the poorest section of the population.

Campaigns – the future

 “In the next two years we will have $9 billion available for re-programming. That allows countries to move funds to high-impact interventions,” said Dr Ade Fakoya, Senior Advisor (HIV & AIDS) at the Global Fund, speaking at the satellite meeting on integrated disease prevention campaigns at AIDS 2012.

Lara Starbinski of the Office of the Global AIDS Coordinator, US State Department, suggested that integrated disease prevention campaign planners ought to look at how circumcision might be integrated into future campaigns. Dr Gabriel Chamie, co-investigator with the SEARCH Collaboration study in Uganda, told HATIP that syphilis screening and referral for circumcision were already being considered for future waves of campaign activity.

“We could go back and do different interventions each year according to the local community’s needs. We need a draw for people to come back each year for repeat testing,” said Gabriel Chamie.

Mikkel Vestergaard, chief executive of Vestergaard Frandsen, manufacturer of the commodities used in the Kenyan disease prevention campaign, said that his team was already looking at how screening for cervical cancer might be integrated into future campaigns.

“When people in the public sector talk about innovation, it’s about innovation in technology rather than innovation in delivery,” he said.

Without innovations in ways of delivering preventive interventions that can achieve large-scale coverage, investments in technological innovations like vaccines, medicines or or other prevention technologies are likely to create a public health landscape of white elephants: expensive projects that fail to make a difference to public health.

Conclusion

 “We’re already thinking about 26 or more million people needing treatment so I think you’re going to be hearing a lot more about these approaches,” said Dr Reuben Granich, now Senior Advisor for Care and Treatment at UNAIDS.

“The individual interventions – safe water, insecticide-treated nets, HIV counselling and testing, cotrimoxazole, antiretroviral therapy – are already recommended by WHO. What’s new is putting them together like this. What’s needed is co-ordination and delivery on a much larger scale,” said Dr Granich.

The next edition of HATIP will review two large multi-disease prevention campaigns, conducted in western Kenya and in Uganda. These campaigns incorporated HIV counselling and testing, but in other respects they differed. What can be learnt from these models, and what do they suggest about the practicalities of combining various interventions?

References

[1] Suthar AB et al. Towards universal voluntary HIV testing and counselling: a systematic review and meta-analysis of community-based approaches. PLoS Medicine 10: e1001496, 2013.

[2] Menzies N et al. The costs and effectiveness of four HIV counseling and testing strategies in Uganda. AIDS 23(3):395-401, 2009.

[3] Kahn J et al. Cost of community integrated prevention campaign for malaria, HIV, and diarrhea in rural Kenya. BMC Health Services Research 11:346, 2011. 

[4] Van den Berg H, Kelly-Hope LA, Lindsay SW Malaria and lymphatic filariasis: the case for integrated vector management. Lancet Infect Dis 13 (1): 89-94, 2013.

[5] Modjarrod K, Vermund S Effect of treating co-infections on HIV-1 viral load: a systematic review. Lancet Infect Dis 10 (7): 455-463, 2010.

[6] Walson JL, Herrin BR, John-Stewart G Deworming helminth co-infected individuals for delaying HIV disease progression. Cochrane Database of Systematic Reviews, 2009. DOI: 10.1002/14651858.CD006419.

[7] Gerens HL, Sangaré LR, Walson JL Integration of deworming into HIV care and treatment: a neglected opportunity. PLoS Neglected Tropical Diseases 6 (7): e1738, 2012.

[8] Walson JL et al. Empiric deworming to delay HIV disease progression in adults with HIV who are ineligible for initiation of antiretroviral treatment (the HEAT study): a multi-site, randomised trial. Lancet Infectious Diseases 12 (12): 925-31, 2012.

[9] Ndeffo Mbah ML et al. Cost-effectiveness of a community-based intervention for reducing the transmission of Schistosoma haematobium and HIV in Africa. PNAS, epub ahead of print, 15 April 2013. doi: 10.1073/pnas.1221396110

[10] Kamya MR et al. Effect of HIV-1 infection on antimalarial treatment outcomes in Uganda: a population-based study. J Infect Dis 193(1):9-15, 2006.

[11] Patnaik P et al. Effects of HIV-1 serostatus, HIV-1 RNA concentration, and CD4 cell count on the incidence of malaria infection in a cohort of adults in rural Malawi. J Infect Dis 192(6):984-91, 2005.

[12] Whitworth J et al. Effect of HIV-1 and increasing immunosuppression on malaria parasitaemia and clinical episodes in adults in rural Uganda: a cohort study. Lancet 356(9235):1051-6, 2000.

[13] Ibid.

[14] Laufer MK et al. Impact of HIV-associated immunosuppression on malaria infection and disease in Malawi. J Infect Dis  193(6):872-8, 2006.

[15] Whitworth J et al. Effect of HIV-1 and increasing immunosuppression on malaria parasitaemia and clinical episodes in adults in rural Uganda: a cohort study. Lancet 356:1051-56, 2000.

[16] French N et al. Increasing rates of malarial fever with deteriorating immune status in HIV-1-infected Ugandan adults. AIDS 15: 899-906, 2001.

[17] Laufer MK  et al. Impact of HIV-associated immunosuppression on malaria infection on malaria infection and disease in Malawi. J Infect Dis 193: 872-8, 2006.

[18] Cohen C et al. Increased prevalence of severe malaria in HIV-infected adults in South Africa. Clin Infect Dis 41: 1631-7, 2005.

[19] Ter Kuile FO et al. The burden of co-infection with human immunodeficiency virus type 1 and malaria in pregnant women in sub-Saharan Africa. Am J Trop Med Hyg 71 (suppl 2) 41-54, 2004.

[20]  Kalyesubula I et al. Effect of malaria infection in human immunodeficiency virus type-1-infected Ugandan children. Pediatr Infect Dis J 16:876-881, 1997.

[21]  Malamba S et al. The effect of HIV on morbidity and mortality in children with severe malarial anaemia. Malaria Journal  6:143. doi:10.1186/1475-2875-6-143, 2007.

[22] Kublin JG et al. Effect of Plasmodium falciparum malaria on concentration of HIV-1-RNA in the blood of adults in rural Malawi: a prospective cohort study. Lancet 365(9455):233-40, 2005.

[23] Mermin J, Lule J, Ekwaru J. Association between malaria and CD4 cell count decline among persons with HIV. J Acquir Immune Defic Syndr 41 (1): 129-30, 2006.

[24] Ter Kuile, op. cit.

[24] Walson JL et al. Evaluation of impact of long-lasting insecticide-treated bed nets and point-of-use water filters on HIV-1 disease progression in Kenya. AIDS (epub ahead of print, 16 Jan 2013).

[25] Mermin J et al. Effect of co-trimoxazole prophylaxis on morbidity, mortality, CD4-cell count, and viral load in HIV infection in rural Uganda. AIDS 364(9443):1428-34, 2004.

[26] Campbell J et al. HIV-infected Ugandans on HAART with CD4 cell counts over 200 cells/mm3 who discontinue cotrimoxazole have increased risk of malaria and diarrhea. 2008 HIV Implementers’ Meeting, Kampala, Uganda, abstract number unlisted.

[27] Mermin J et al. Effect of co-trimoxazole prophylaxis, antiretroviral therapy, and insecticide-treated bednets on the frequency of malaria in HIV-1-infected adults in Uganda: a prospective cohort study. The Lancet 367(9518):1256-61, 2006.

[28] Kamya M et al. Effects of trimethoprim-sulfamethoxazole and insecticide-treated bednets on malaria among HIV-infected Ugandan children. AIDS 21(15):2059-66, 2007.

[29] Brink AK et al. Diarrhea, CD4 counts and enteric infections in a community-based cohort of HIV-infected adults in Uganda. J Infect 45(2):99-106, 2002.

[30] Lule JR et al. Effect of home-based water chlorination and safe storage on diarrhea among persons with human immunodeficiency virus in Uganda. Am J Trop Med Hyg 73(5):926-33, 2005.

[31] Peletz R et al. Water, sanitation and hygiene interventions to improve health among people living with HIV: a systematic review. AIDS 27: 2593-2601, 2013.

[32] Tulenko K, Bery R, Rosenbaum J. Analysis of research on the effects of improved water, sanitation and hygiene on the health of people living with HIV and AIDS and programmatic implications. USAID Hygiene Improvement Project, 2007.

[33] Walson (2013), op. cit.

[34] Stern AM, Markel H The history of vaccines and immunization: familiar patterns, new challenges. Health Affairs 24 (3): 611-21, 2005.

[35] Bygbjerg IB Double burden of noncommunicable and infectious diseases in developing countries. Science 337 (6101): 1499-1501, 2012.

[36] Jeon CY et al. Bi-directional screening for tuberculosis and diabetes: a systematic review. Trop Med Int Health 15 (11): 1300-1314, 2010.

[37] Verguet S et al. Cost savings associated with the provision of a simple care package including long lasting insecticide treated bednets and a point-of-use water filtration device to delay HIV-1 disease progression in Africa. 19th International AIDS Conference, abstract MOPE768, Washington DC, 2012.

[38] Kern E et al. Provision of bednets and water filters to delay HIV-1 progression: cost-effectiveness analysis of a Kenyan multisite study. Trop Med Int Health (epub ahead of print, 2013).

HATIP #206, October 10th 2013

This content was checked for accuracy at the time it was written. It may have been superseded by more recent developments. NAM recommends checking whether this is the most current information when making decisions that may affect your health.