International AIDS Conference (AIDS 2006)

August 13-18, 2006
Toronto

Abt Associates staff were involved in the following oral presentations and posters.

(Press Release)

Oral Presentations

"Accessing Morphine for HIV/AIDS Pain Management in Zambia" [abstract]
Stella Nkhoma-Mlewa, Abt Associates
Makaria Reynolds, Nadia Khan, and Paurvi Bhatt, formerly with Abt Associates

"HIV Prevention for IDUs in China and Vietnam: The Problem of Inconsistent Policies" [abstract]
Theodore Hammett, Abt Associates
Don Des Jarlais, Baron Edmond de Rothschild Chemical Dependency Institute, Beth Israel Medical Center

"Monitoring HIV/AIDS Financial Flows from Global Initiatives" [abstract]
Tania Dmytraczenko, formerly of Abt Associates
Susna De, Abt Associates

"Policy Implications of the First Systematic Tracking of Financial Flows for HIV/AIDS in Ukraine" [abstract]
Yuriy Chechulin, Abt Associates Consultant
George Gotsadze, International Curatio Foundation
Catherine Chanfreau, formerly of the Abt Associates International Health Division
Liudmila Husak, ICF International HIV/AIDS Alliance in Ukraine
Vinay Saldanha, UNAIDS
Anastasiya Nitsoy, ICF International HIV/AIDS Alliance in Ukraine Consultant
Viktor Galayda, World Bank Consultant
Manjiri Bhawalkar, formerly of Abt Associates
Tania Dmytraczenko, formerly of Abt Associates

Poster Presentations

"Breaking the Cycle of Drug Use, Incarceration, and HIV: Evaluation of HIV Programs and Policies in U.S. Correctional Facilities and Its International Policy" [abstract]
Sofia Kennedy, Abt Associates
Theodore Hammett, Abt Associates
Catherine Chanfreau, formerly of the Abt Associates
Simon Smith, Abt Associates

"The Burden on People Living with HIV/AIDS to Pay for Health Care" [abstract]
Susna De, Abt Associates
Tania Dmytraczenko, formerly of Abt Associates

"Capacity Building for Providing ARVs Within Continuum of Care: A Multi-Country Survey" [abstract]
David Chipanta, Abt Associates
Paurvi Bhatt, formerly with Abt Associates
Nancy Pielemeier, Abt Associates

"Click Here: Testing Advertisements and Messages for Internet Surveys on HIV Risk Behavior" [abstract]
Lisa LeRoy, Abt Associates
Gabriela Garcia, formerly with Abt Associates
Matthew Amsden, formerly with Abt Associates
Eric Rubenstein, Massachusetts Department of Public Health

"Comparative Analysis of Resource Flows for HIV/AIDS in Generalized and Concentrated Epidemic Settings" [abstract]
Susna De, Abt Associates
Tania Dmytraczenko, formerly of Abt Associates

"Culturally Competent HIV Mental Health Care in Minority Communities: Promising Practices from a Center for Mental Health Services (CMHS)/Substance Abuse Mental Health Services Administration (SAMHSA) Demonstration Project" [abstract]
Jim Skinner, Abt Associates
Cristina Booker, Abt Associates

"Emerging Issues in Human Capacity Development in Low Resource Countries: A Comparative Analysis of Cote d'Ivoire, Ethiopia, Kenya, and Zambia" [abstract]
Gilbert Kombe, Abt Associates International Health Division
C. Decker, University Research Company
D. Butera
S Oulai, Ministry of Health and Population, Training & Research, Cote D'Ivoire
Slavea Chankova, Abt Associates International Health Division
Steve Muchiri, Ministry of Health, Planning Unit, Kenya
G Kimani, Ministry of Health, Kenya
David Galaty, Abt Associates International Economic Growth Division
Omer Ahmed, U.S. Agency for International Development,
Priscilla Banda, formerly of Abt Associates International Health Division
Vilepi Mtonga, Central Board of Health, Zambia

"Evidence-Based Planning to Scale Up HIV/AIDS and Sexually Transmitted Infections Services in Low Resource Countries: A Case of Papua New Guinea (PNG)" [abstract]
Gilbert Kombe, Abt Associates International Health Division
John Fieno, Abt Associates consultant
Daoni Esorom, Ministry of Health, New Guinea
Tracey Newburry, Australian Government Overseas Aid Program

"Factors Associated With Adherence to HIV Medications In Homeless or Unstably Housed Persons Living With HIV" [abstract]
Scott Royal, Abt Associates Domestic Health Division
Silvia Cohn, RTI International
Jennafer Kwait, Abt Associates Domestic Health Division
Daniel Kidder, Centers for Disease Control and Prevention
Rich Wolitski, Centers for Disease Control and Prevention
Ron Stall, University of Pittsburgh
Angela Aidala, Columbia University
David Holtgrave, Johns Hopkins University

"From Analysis to Action: Using Human Resource Data for Policy and Program Planning" [abstract]
Nancy Pielemeier, Abt Associates International Health Division
Caytie Decker, University Research Co., Bethesda
Gilbert Kombe, Abt Associates International Health Division
Stephen Musau, Abt Associates International Health Division

"From Knowledge/Attitudes to Practices: M&E for HIV/AIDS Work with Police Officers in Zambia" [abstract]
Stella Nkhoma-Mlewa, Abt Associates International Health Division
Paurvi Bhatt, formerly with Abt Associates International Health Division
Nadia Khan, formerly with Abt Associates International Health Division
David Chipanta, Abt Associates International Health Division
Theodore Hammett, Abt Associates Domestic Health Division

"HIV Medication Use, Adherence, and Disclosure to Family Members Are Associated With Viral Load in Homeless or Unstably Housed HIV-Positive Persons" [abstract]
D.P. Kidder, Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention
S.L. Pals, Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention
R. J. Wolitski, Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention
Scott Royal, Abt Associates Domestic Health Division
R. Stall, University of Pittsburgh, Graduate School of Public Health

"Private Sector Involvement for TB/HIV Prevention in Ethiopia" [abstract]
Tedla Mezemir, IntraHealth, PSP Ethiopia Project, Ethiopia
Yoseph Burka, Abt Associates PSP Ethiopia Project, Ethiopia
Senait Abraham, formerly with Abt Associates International Health Division
Cristina Ruden, Country Director of IntraHealth International.

"Substance Use and Abuse among Homeless People Living with HIV" [abstract]
Ron Stall, University of Pittsburgh
Daniel Kidder, Centers for Disease Control and Prevention
Angela Aidala, Columbia University
K. Henny
Scott Royal, Abt Associates Domestic Health Division
M. Friedman
M. Marshal
C. Courtney-Quirk
David Holtgrave, Johns Hopkins University
Rich Wolitski, Centers for Disease Control and Prevention

"Substance Use, Sexual Risk-Taking and HIV Treatment Adherence among Homeless People Living with HIV" [abstract]
Ron Stall, University of Pittsburgh, Graduate School of Public Health
Daniel Kidder, Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention
Angela Aidala, Columbia University
M. Friedman, University of Pittsburgh, Graduate School of Public Health
M. Marshal, University of Pittsburgh, Graduate School of Public Health
K. Henny, Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention
Scott Royal, Abt Associates Domestic Health Division
C. Courtney-Quirk, Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention
David Holtgrave, Johns Hopkins University
Rich Wolitski, Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention

"Tracking HIV/AIDS Resource Flows in St. Vincent and Grenadine" [abstract]
Del Hamilton, Director, National AIDS Secretariat, St. Vincent and the Grenadines
Also: Ann DeRoche, Yvonne Bonadie, Tim Powell-Jackson

"The Value of a Network Approach HIV/AIDS Health Systems Research" [abstract]
Kate Stillman, Abt Associates International Health Division
Sara Bennett, formerly with Abt Associates
Nancy Pielemeier, Abt Associates International Health Division

For additional information: XVI International AIDS Conference

Abstract: Accessing Morphine for HIV/AIDS Pain Management in Zambia

Issues: The WHO estimates 50% of PLWHA will suffer from severe, chronic pain. Yet access to essential drugs for treatment of severe pain (i.e., morphine) is severely limited in most developing countries. Unavailability of morphine and legal restrictions on prescription limit the appropriate medical response to pain faced by millions of PLWHA globally.

Description: The USAID-funded Support to the HIV/AIDS Response in Zambia (SHARe) project is working to improve the HIV/AIDS policy environment, including access to essential pain medication. Working with policy makers in the Ministry of Health and the Drug Enforcement Commission (DEC), SHARe is complementing the efforts of palliative care organizations and hospices in reviewing Zambia's legal barriers preventing morphine from reaching those in need. Activities include educational efforts to dispel myths about medical morphine, analysis of import and distribution regulations, facilitating dialogue between health and drug enforcement officials, and addressing issues of pain and palliative care in the community. Encouraging the DEC to re-evaluate policies and legislation hindering access to morphine is critical. SHARe is documenting and applying best practices for morphine access, based on similar work implemented in Uganda and elsewhere.

Lessons learned: Results indicate great need to simplify the complex regulations surrounding who is permitted to administer morphine and under what circumstances. Working with advocacy groups (hospice and PLWHA organizations) is key to engaging a broad coalition. This unique policy issue highlights the need for open, cross-sector dialogue between health and policy officials and the community.

Recommendations: Simplified legislation is needed to address the legal constraints to access, and medical education and training on morphine prescription and implications must be implemented. Civil society should recognize the importance of pain relief in the broader scope of palliative care and integrate it into other HIV/AIDS interventions to address comprehensive treatment and care needs of PLWHA.

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Abstract: HIV Prevention for IDUs in China and Vietnam: The Problem of Inconsistent Policies

Issues: To be optimally successful, HIV prevention programs for IDUs require a consistently supportive policy and legal environment. Prevention programs have been threatened by hostile policies in some areas with serious HIV epidemics among IDUs, including Russia and Eastern Europe.

Description: Since 2002 we have carried out a Cross-Border HIV Prevention Project for IDUs in Guangxi Province, China and Lang Son Province, Vietnam. Interventions include peer education, provision of sterile needles/syringes both directly and through pharmacy vouchers, and collection of used needles/syringes. Government documents in both countries explicitly endorse harm reduction strategies including needle/syringe exchange. Through regular meetings and community education, the Cross-Border Project has secured and maintained the approval and support of government leaders and key agencies such as the police.

Lessons learned: Since implementation of the Cross-Border Project, HIV prevalence among IDUs has stabilized or declined and HIV incidence has dropped by one-third. However, in both countries there is continuing strong support for a law enforcement approach to drug use and HIV/AIDS that centers on arrest and incarceration of IDUs. China detained 273,000 drug users in 2004 and Vietnam has >60,000 drug users confined in rehabilitation centers. In our project sites, police crackdowns on IDUs have become more severe since 2004. Even though police have never directly interfered with the interventions, the continuing crackdowns threaten IDU participation, which may mean that IDUs are more likely to share needles/syringes. This inconsistent policy environment, epitomized in China's announcement of a "People's War on drugs and HIV/AIDS," may encourage but then undermine community-based HIV prevention for IDUs.

Recommendations: Multisectoral training and policy analysis are needed to harmonize law and policy and forge a truly enabling environment in which HIV prevention interventions for IDUs can achieve their best effects.

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Abstract: Monitoring HIV/AIDS Financial Flows from Global Initiatives

Background: Unprecedented increases in funding to fight the HIV/AIDS pandemic in recent years have largely flowed through new global and bilateral initiatives — The Global Fund, the World Bank's MAP, and the U.S. President's Emergency Plan. Though the Three One's Initiative attempts to harmonize M&E efforts, each global initiative is using its own M&E framework for reporting by grant recipients. Additionally, national AIDS strategies often set their own targets, and countries are encouraged to report on core indicators for implementation of the UNGASS Declaration of Commitment. Financial indicators are conspicuously absent from most M&E frameworks.

Methods: The international classification of health accounts — a methodology vetted through over 30 years of use in more than 50 countries — is adapted to track the flow of HIV/AIDS funds. The origins of funds are identified, as well as allocation to specific program and service delivery components of interest to global and bilateral initiatives, and national strategic plans. Estimates of spending by program/ treatment categories are presented for seven countries — with generalized and concentrated-epidemics — across three regions from 1998 to 2004.

Results: In most cases, funds were not allocated according to the spending priorities established in national strategic plans. Further, though the principal of additionality has been met in many countries, increases in government spending on HIV/AIDS are relatively small, as is the reduction of the burden of financing on households. Meeting bilateral and global output targets would require significant increases in funding and/or improvement in the effectiveness of country-level disbursements.

Conclusions: As HIV/AIDS funds increasingly flow from external sources to NGOs, the ability of government to exercise stewardship over prevention and care is challenged. As demonstrated by the experiences of the governments of Kenya, Malawi, Rwanda, Ukraine, Vietnam, Zambia, and Zimbabwe, developing systems to track the flow of resources against program objectives can be a powerful tool in guiding HIV/AIDS policy.

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Abstract: Breaking the Cycle of Drug Use, Incarceration, and HIV: Evaluation of HIV Programs and Policies in U.S. Correctional Facilities and Its International Policy

Issues: Correctional facilities present an important opportunity to reach marginalized groups (e.g., injection drug users) that are critical in the HIV/AIDS epidemic in the U.S. and Eastern Europe and Central Asia (ECA). In the US, about one fourth of people living with HIV/AIDS pass through correctional facilities annually. Two recent studies examined HIV/AIDS policies and programs for inmates and releasees. This U.S. experience is relevant in the ECA, where HIV rates in prisons are also many times higher than in the total population.

Description: The 2005 Survey of Infectious Diseases in U.S. Correctional Facilities assessed HIV/AIDS screening, treatment, and support policies; 46/50 state prison systems responded. The 1999-2005 Corrections Demonstration Project (CDP) sought to improve post-release participation in HIV/AIDS and other services through pre-release discharge planning and community case management to 2,103 HIV-infected inmates.

Lessons learned: The Survey showed that all systems offer HIV testing (mandatory in 17 states) and provide some HAART regimens (71% initiate treatment at CD4 counts >300). HIV/AIDS support groups are not widely available — one third of systems offer groups led by various providers. The CDP evaluation (n=406) showed that connecting to case management, medical, and substance abuse services in the first month after release is important. Clients who did not seek services that month were less likely to connect to them later.

Recommendations: These studies further support the theory that the period of incarceration serves as a public health opportunity: a time to identify people with HIV, engage them in community-standard treatment both inside the facility and after release, and offer effective HIV prevention and support services. In regions where a large proportion of people living with HIV/AIDS are incarcerated, policies to reduce HIV transmission must include the development, evaluation, and institutionalization of HIV prevention and care interventions for inmates and releasees to ensure their connection to mainstream healthcare and support.

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Abstract: The Burden on People Living with HIV/AIDS to Pay for Health Care

Background: Given the recent surge in global funding for HIV/AIDS, there is enormous pressure on stakeholders to monitor the flow of funds. Of particular value is data on the ultimate beneficiaries of these resources, a critical indicator of the effectiveness of current resource allocation arrangements. However, in most endemic countries, very few data on beneficiaries are available. Thus, policymakers are often poorly equipped when deciding how to optimally invest resources to reach populations in greatest need. One way to determine whether those in need are benefiting from HIV investments is to examine the burden of financing on people living with HIV/AIDS (PLWHA).

Methods: To track PLWHA expenditures, two approaches were used: 1) targeted PLWHA expenditure surveys; and 2) the addition of expenditure questions to ongoing surveillance efforts — such as the Demographic Health Survey Plus (that includes biomarkers for HIV/AIDS). This paper presents findings from such surveys conducted in Kenya, Rwanda, Zambia, Ukraine, and Vietnam.

Results: HIV positive individuals pay between 3 and 7 times more out-of-pocket (OOP) for health care (mainly for opportunistic infection treatment) compared to the general population. In generalized epidemic settings, HIV positive women spend the same or less OOP for health care. This is noteworthy because in the general population, women are bigger consumers of health care overall, due to childbirth, etc. The PLWHA findings may reflect lower health care utilization rates by HIV positive women. In concentrated epidemic settings, due to the prevailing mechanism of transmission through intravenous drug use, HIV positive men spend more than women. Across the countries, the wealthiest quintiles spend 4 to 9 times more on health care than the poorest quintiles, which upon closer investigation reflects inequities in utilization.

Conclusions: The comparative analysis findings highlight disparities with respect to treatment expenditures among different PLWHA populations. Such information can inform resource allocation and policymakers' targeting decisions.

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Abstract: Culturally Competent HIV Mental Health Care in Minority Communities: Promising Practices from a Center for Mental Health Services (CMHS)/Substance Abuse Mental Health Services Administration (SAMHSA) Demonstration Project

Issues: Culturally competent programmatic approaches to mental health are crucial to service delivery to people living with HIV/AIDS (PLWHA) and mental illness in underserved racial/ethnic minority communities. Non-governmental community-based organizations (CBOs) that provide integrated services to those with co-morbidities have a distinct advantage when services are delivered with cultural competence by providers who understand the importance of meeting clients where they are. In doing so, providers empower clients to collaboratively manage their mental health treatment.

Description: This presentation will review promising and culturally competent practices learned from the Mental Health HIV Services Collaborative (MHHSC), funded by CMHS/SAMHSA, to enhance culturally competent mental health services to PLWHA in underserved communities. Twenty U.S. CBOs provide such services in traditional and non-traditional settings (approximately 1,500 clients/year: 50% African-American, 30% Hispanic/Latino[a], 17% White, and 2% Native American). Over half (51%) of MHHSC clients have multiple mental health diagnoses, and 50% of those have co-occurring substance use disorders.

Lessons learned: Promising MHHSC practices include culturally and linguistically relevant clinical approaches; diverse staffing models; mobile treatment services; untangling co-occurring conditions; integration of traditional health beliefs in treatment planning; acknowledging the importance of spirituality, and the impact of trauma and domestic violence; and use of consumer feedback to enhance services, training models, and client recruitment and retention. Sexual values clarification, identified as a necessary exploration for clinicians, proved essential for connecting with clients non-judgmentally.

Recommendations: Successfully engaging underserved PLWHA in mental health care with cultural competence requires tailored capacity-building, strategic planning, and organizational sanctioning. All of the above are necessary to enhance the delivery of culturally competent HIV and mental health services to a population already stigmatized and distrustful of the system. MHHSC surveys, site-specific client satisfaction surveys, and post-training evaluations support the need for, and benefits of, ongoing clinical training that emphasizes cultural competence.

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Abstract: Capacity Building for Providing ARVs within Continuum of Care: A Multi-Country Survey

Background: Though there is increased scaling up of ARV provision within a continuum of care framework, little effort is being directed at the capacity needs that such undertakings require. Yet capacity is a prerequisite to effectively providing care. That capacity means different things to different people adds further complexity to the level and quality of capacity development and service provision. This study seeks to develop a definition of capacity to assist in identifying capacity needs required in providing ARVs as part of a continuum of care.

Description: We develop a definition of capacity in three steps, namely: (1) review of key literature, (2) focus group discussions with HIV/AIDS program leaders about the definition arising from the literature review, and (3) validation and modification of the definition of capacity through self-administered electronic surveys to more than 100 HIV/AIDS projects around the world.

Lessons learned: We define capacity in providing ARVs within a continuum of care as a chain linking six interdependent elements: human resources, organization, organizational culture, sector, legal political environment, and social mobilization. We find the following key points. Capacity-building definition among the respondents revolves around knowledge transfer and human capital accumulation in organization management, accountability, and technical know-how. Capacity to deliver ARV within a continuum of care involves mobilization of different partners around VCT and its collateral activities, and suitable policy regulatory institutions and environment to ensure supply and demand of quality services.

Recommendations: Follow-up work includes surveying country capacity needs to provide ARVs. The country capacity needs survey results would provide policy-makers with understanding of capacity weaknesses that need to be addressed, including identifying the most effective entry point in capacity building — whether knowledge transfer and human capital accumulation, institutions, or a legal and social environment that supports or constrains the provision of ARV.

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Abstract: Click Here: Testing Advertisements and Messages for Internet Surveys on HIV Risk Behavior

Background: The Internet is a popular vehicle for men having sex with men (MSM) to find sex partners. Researchers want to use the Web to recruit these Internet users to participate in surveys about health behavior. The Massachusetts Department of Public Health (MDPH) is participating in a CDC pilot test of the feasibility of conducting HIV Risk Surveillance using the Internet.

Methods: We conducted four focus groups and 21 individual interviews with MSM Internet users (total n=41) to test messages and visual images intended to motivate MSM to click on an advertisement and then take a survey on HIV risk behavior. Five different concept banner ads were shown to participants for their reactions, as well as web pages explaining the survey and encouraging participation.

Results: 88% of participants described themselves as "experienced" users of the Internet. The majority had had an in-person encounter with someone they initially met online. Most participants had visited manhunt.com, gay.com, and friendster.com; sites under consideration for recruiting survey respondents, as well as 16 other sites of interest to MSM. The primary goal of the ads was to attract attention on a busy Web page and entice the potential respondent to click through to a survey page and complete the survey. Each ad had its advocates and detractors, suggesting that rotating the ads in a short timeframe would increase the click-through rate. Focus group participants also wanted the purpose of the ads (to take a survey) to be explicit. They recommended: simpler web pages, confidentiality assurances earlier on, a "hide survey" button, explicit language about the survey topics (e.g., sex not health), and a shorter questionnaire.
Conclusions: Our research informs the field how to design ads and Web pages for health surveys targeted at MSM. We will show the before and after advertisements and Web pages in the presentation.

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Abstract: Factors Associated with Adherence to HIV Medications in Homeless Or Unstably Housed Persons Living With HIV

Background: Some research suggests that adherence to HIV treatment is lower among persons living with HIV who are homeless or unstably housed. This study investigates the association of adherence with access to health care, mental health, substance use, and attitudes toward HIV treatment.

Methods: Participants were 644 homeless or unstably housed HIV positive persons enrolled in the Housing and Health Study, a study conducted in three cities across the U.S. Using baseline data and controlling for gender, race, age, and education, we examined associations between self-reported 2- and 7-day adherence and access to health care, mental health, substance use, and attitudes toward HIV medical therapy.

Results: Of the 644 participants, 431 (69%) were currently taking HIV medications, with 354 (82%) reporting >90% adherence. Overall, 22% and 27% of participants reported missing at least one dose over the past 2 and 7 days, respectively. Being younger (OR=2.27, 95% CI=1.44, 3.59), male (OR=2.14, CI=1.28, 3.70), reporting problems accessing health care (OR=1.67, CI=1.07, 2.62), scoring poorer on SF-36 mental component summary measure (OR=0.93, CI=0.88, 0.97), and having greater risk for depression based on the CES-D (OR=1.06, CI=1.03, 1.09) were associated with missing at least one dose over 7 days. Further, alcohol use problems (OR=2.05, CI=1.22, 3.44), recent drug use (OR=1.63, CI=1.04, 2.56) and lower scores measuring attitude toward HIV medical therapy (OR=0.95, CI=0.89, 1.00) were also associated with missing at least one dose in the same time period. Similar associations were observed for 2-day adherence.

Conclusions: Our data suggest that overall adherence to HIV medications in this population is similar to in other groups. Coexisting problems of access to health care, poor mental health, and substance use, along with poorer attitudes toward treatment, are associated with increased likelihood of missing doses. Comprehensive models of HIV care that include a continuum of medical and social services are essential for treating this population.

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Abstract: Policy Implications of the First Systematic Tracking of Financial Flows for HIV/AIDS in Ukraine

Background: Ukraine has the most severe HIV/AIDS epidemic in Europe. Appropriate monitoring is necessary to support evidence-based policy decision-making and the requirements of donors who are important financiers of the HIV/AIDS response. The Ukraine National Health Accounts HIV/AIDS Subanalysis 2003-2004 is the country's first attempt to systematically track HIV/AIDS financial flows.

Methods: The International Classification of Health Accounts was adapted to the Ukrainian context to organize HIV/AIDS financial flows from public, private, and donor sources to financing agents, providers, and functions. Data were collected through the official statistical system, available HIV studies, and expert interviews. The methodology used in the data collection and partitioning was developed and agreed upon by a multi-sector national working group (government, NGOs, etc.).

Households are the main HIV/AIDS financiers. Household expenditures occur out-of-pocket and are not mobilized in pre-paid risk pools, thus creating financial barriers to access. Moreover, PLWHA spent 5.43 times more on curative care than did the general population. There is significant and growing dependence on external finances, with expectations for future public replacement. While all HIV/AIDS spending rose in absolute terms, increased donor financing caused relative decreases in household and public shares. Donor funds function independently from public financing. Spending on ART increased from 3.8% to 7.5% out of total HIV/AIDS expenditures. Compared to countries with similar epidemics Ukraine devotes a smaller share for preventive/collective services.

Conclusions: The government should increase public spending, with a major focus on targeted prevention to provide equitable access to HIV-related care and prevent epidemic generalization. Adequate allocations are necessary to support the strategy of universal access to ART. More donor funds should be channeled through public financing agents ensuring ongoing HIV programs' sustainability.

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Abstract: Comparative Analysis of Resource Flows for HIV/AIDS In Generalized and Concentrated Epidemic Settings

Background: Perhaps more critical than the amount invested to fight HIV/AIDS is how funds are invested to deliver a well-coordinated response. This necessitates a thorough understanding of the current organization and financing of national HIV/AIDS services (including public, private, and donor aspects). In this regard, policymakers in endemic countries face a paucity of data, which increases the risk of inappropriate allocation of funds, as well as possible suspension of donor funding. This paper examines National Health Accounts (NHA) expenditure findings from countries facing generalized epidemics (Kenya, Malawi, Rwanda, Zambia) and concentrated epidemics (Vietnam, Ukraine, St. Vincent and Grenadines).

Methods: NHA is a routinely used policy tool for tracking national spending on health care. Extension of its framework allows specific examination of spending on HIV/AIDS. This extension involves compilation of data from donors, nongovernmental organizations, companies, government ministries, insurance programs, providers, and people living with HIV/AIDS (PLWHA).

Results: Findings from generalized epidemic settings showed that the resource envelope for HIV/AIDS was quite substantial, accounting for sizeable portions of overall health spending (15-43%). Although donor financing accounted for the largest share (mainly for prevention), PLWHA still paid for at least half of all medical care services, particularly for opportunistic infection (OI) treatment (particularly during the pre-Global Fund era). Government HIV investments often fell behind PLWHA contributions. In concentrated epidemic settings, HIV/AIDS resources were targeted to specific population groups and concentrated on prevention (and testing) of high-risk behaviors (over 50% of all expenditures).

Conclusions: Generalized epidemic countries invest a sizeable share of HIV resources on mass prevention efforts, and more recently on treatment for HIV itself, the effect of which has not yet been felt by PLWHA who spend largely on OI treatment services. In concentrated epidemic settings, policymakers are focusing on containing the spread of HIV by investing in prevention and diagnosis.

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Abstract: Emerging Issues in Human Capacity Development in Low Resource Countries: A Comparative Analysis of Cote d'Ivoire, Ethiopia, Kenya, and Zambia

Background: Many countries are currently exploring ways of mobilizing large numbers of nurses, counselors, midwives, laboratory technicians, and other health workers to meet major targets such as PEPFAR and MDGs. Despite the known constraint of human capacity, few countries have conducted comprehensive assessments to obtain an accurate estimate of the available stock of health care workers. This paper presents key findings from comprehensive assessments conducted in Cote d'Ivoire, Ethiopia, Kenya, and Zambia.

Method: Primary data on human resources were collected from health facilities, Ministries of Health, and other sources, to quantify the existing and required human capacity to achieve national and international targets. Furthermore, a review of HR policies and regulations was conducted. Data were analyzed using STATA.

Results: First, an overall shortage of health workers (especially doctors) exists across all four countries. Second, based on the current HR situation, these countries will not be able to reach national, PEPFAR, and MDG targets. Third, attrition among doctors and nurses presents a major constraint. In both Ethiopia and Zambia, the attrition rates for doctors in the public sector are extremely high (9.6% and 9.8% respectively). Fourth, the distribution of staff is skewed towards urban areas. For example, 64% of doctors and 74% of pharmacists in the public sector work in the capital region of Cote d'Ivoire. Finally, countries were taking steps to address the issues raised in the assessments through policy change. The governments of Kenya and Zambia have declared human capacity development (HCD) a major priority for their countries, and Zambia is developing a costed five-year HCD plan.

Conclusion: Data show that most countries will not achieve national and international targets unless their current HCD issues are immediately addressed. The global community should assist by supporting HCD assessments, and help to develop policies and strategies to address the immediate causes contributing to the HR shortage.

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Abstract: Evidence-Based Planning to Scale Up HIV/AIDS and Sexually Transmitted Infections Services in Low Resource Countries: A Case of Papua New Guinea (PNG)

Background: In Papau New Guinea (PNG), as in many low-resource countries, there is a growing need to understand the costs and resource requirements for scaling up HIV/AIDS and STI services. However, discussions about the costs and resource requirements are frequently taking place in the absence of comprehensive information. The purpose of this study was to provide a comprehensive analysis of the costs required to provide HIV/AIDS and STI services in the public sector. The study attempts to answer three interrelated policy questions: What is the total cost of providing HIV/AIDS and STI services? How will these costs change over the next five years? What are the major cost drivers?

Methods: The framework used to estimate the costs of providing HIV/AIDS and STI services was based on the HIV/AIDS and STI Costing (HASC) Model developed by Abt Associates Inc. The data were entered to obtain the model estimates of the costs of providing these two services over the next five years.

Results: This study has four findings. First, the provision of antiretroviral therapy (ART) is the cornerstone of this program and represents by far the largest programmatic cost. ART services will cost about $1.03 million over five years and constitute about 2.4 percent of public expenditure on health. Second, the annual per-patient cost of ARV drugs is high. PNG is spending $300 per patient/year, or double what most countries in Africa and Asia are paying. Third, there is a severe shortage of human resources to scale up services. Fourth, the current spending of 2.5 percent of the total HIV/AIDS budget on HIV/AIDS monitoring and evaluation/surveillance is inadequate.

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Abstract: From Analysis to Action: Using Human Resource Data for Policy and Program Planning

Issues: Human resource shortages are increasingly recognized as a critical impediment to achieving HIV/AIDS control objectives in highly impacted countries. In spite of this recognition, countries vary in their response to the issue. Some countries have hesitated to act in the absence of current human resources for health (HRH) data, other countries have not acted even when data are available, while others have moved ahead in spite of the lack of reliable information. The authors investigated the reasons for action or lack of action at the country level, looking particularly at the importance of current country-level HRH data, on the probability of policy or program action.

Description: The authors conducted key informant interviews in a sample of countries receiving GFATM and PEPFAR funds to determine a) whether data had been collected on HRH within the last three years and how these data were collected, including the degree of local participation; b) the use of these data or of other available data in policy and program design; and c) what policy and program actions had been taken and their link data availability and use.

Lessons learned: Availability of current country-level data, as well as local ownership of the data, increases the probability of use of these data in policy development and program planning. While lack of good human resource data, or low level of involvement of policy and program planners in data generation, do not necessarily impede development of HR policies and programs, the probability of such action is lower than in situations where policy and program staff are involved in generating data highlighting the issue.

Recommendations: Country-led HRH assessments should be undertaken in countries highly impacted by HIV/AIDS with human resource shortages, to accelerate actions to improve availability of HRH.

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Abstract: From Knowledge/Attitudes to Practices: M&E for HIV/AIDS Work with Police Officers in Zambia

Background: Empirical evidence indicates that uniformed personnel are seriously affected by HIV/AIDS. While HIV/AIDS education, prevention, and care programs have been mounted for police, few programs have monitored their impact on police's legal and ethical practices in the context of HIV/AIDS. The Support to HIV/AIDS Response (SHARe) project in Zambia systematically monitored the impact of its training program for police.

Methods: SHARe in conjunction with Zambia AIDS Law Research and Advocacy Network (ZARAN) conducted 20 three-day workshops reaching more than 300 police officers across Zambia. The workshops covered HIV/AIDS facts, HIV/AIDS occupational and personal risks, universal precautions, stigma and discrimination, and the role of police officers in protecting human rights in the context of HIV/AIDS. A KAP survey was administered at the beginning and end of each workshop.

Results: The findings indicated an increase in police officers' HIV/AIDS knowledge. Before the workshops 86% of police officers could identify three main ways through which HIV is transmitted. This increased to 99% with insignificant differences between genders. Knowledge on human rights and ethics in the context of HIV/AIDS increased after the training from 70% to 95%. 70% were not in favor of HIV+ officers going for peacekeeping missions because of perceptions that such officers would fall ill during the missions before the workshops; this changed to 90% in favor after the workshops.

Conclusions: KAP scores were high before the workshops. They increased further after the workshops, suggesting a shift in additional work on police policies while recognizing the importance of repetition and reinforcement of KAP work. Further suggestions included formalizing AIDS policies for police, supporting the police victims support unit, and applying the police code of ethics in the context of HIV/AIDS. Another suggestion was to support the monitoring and evaluation of peer education campaigns that officers have initiated as a result of the workshops.

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Abstract: HIV Medication Use, Adherence, and Disclosure to Family Members Are Associated With Viral Load in Homeless or Unstably Housed HIV-Positive Persons

Background: Homeless people living with HIV or AIDS (PLWHA) face many obstacles to receiving appropriate HIV care that affects their health. This study investigates the association of viral load with health care, HIV medication, and HIV disclosure variables among homeless or unstably housed PLWHA.

Methods: Participants were 641 homeless/unstably housed PLWHA in three cities across the U.S. who were interviewed and tested for viral load and CD4 levels. Multiple logistic regression analyses examined the relationships of detectable viral load with sociodemographic, health care, and other variables.

Results: Respondents were mostly male (68%), black (79%), and single (69%), with a mean age of 41 years. A third (33%) of the sample was not on any HIV antiretroviral medications (ARVs), 11% were on ARVs but not HAART, 40% were on HAART and 100% adherent over past two days, and 15% were on HAART but <100% adherent. Viral load levels were detectable (400 viral copies/ml) for 68% of participants. Logistic regression analyses indicated that detectable viral load was associated with medication use and adherence and HIV status disclosure to family members. Compared with being on HAART and 100% adherent, detectable viral load was associated with not being on ARVs (AOR=13.25, 95% CI=6.90, 25.43), being on ARVs but not HAART (AOR=2.61, CI=1.32, 5.16), and being on HAART but <100% adherent (AOR=1.89, CI=1.08, 3.30). Those who had disclosed their HIV status to 100% of their family members (AOR=0.52, CI=0.30, 0.91) and to 50% to 99% of their family (AOR=0.29, CI=0.12, 0.66) were less likely to have detectable viral loads than those who had disclosed to <50% of their family.

Conclusions: Disclosing HIV status to family members may be a protective factor for HIV progression among homeless/unstably housed PLWHA. Homeless PLWHA are in need of social support and better care to achieve undetectable viral load levels.

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Abstract: Private Sector Involvement for TB/HIV Prevention in Ethiopia

Background: The authors conducted an assessment of 26 companies across five geographic regions of Ethiopia from March to June 2005, to design a workplace HIV/AIDS program with the objective of expanding knowledge of, and access to, affordable, high-quality private sector HIV/AIDS and TB services.

Methods: To collect information the assessment applied a performance improvement approach, using quantitative and qualitative methods. Qualitative data were gathered by interviewing managers and HIV focal persons of the organizations to understand HIV/AIDS-related issues in the workplace. Quantitative data were collected, including the availability of social groups and resources and/or budget for HIV/AIDS activities in the workplace. The information was analyzed using SPSS software.

Results: The assessment found that all but one of the 26 companies assessed had an onsite clinic (96%). Four had some TB/HIV initiatives (15%), but none provided TB/HIV services. The lack of private sector HIV/TB services was attributed to the absence of relevant policy dialogue.
The assessment resulted in the creation of partnerships among MOH, NGOs, and the private sector, and organization of dialogue workshops that involved government officials, the business sector, and NGOs. This dialogue resulted in the formation of a National PPM-DOTS Agency (Private Public Mix, Directly Observed Treatment Short Course). A National Workplace TB/HIV Forum was established to advise the project and facilitate policy dialogue.

Conclusions: Program outputs included trainings for private providers, prophylaxis therapies, and TB treatments offered in the workplace, improving the lives of 400,000 workers and families. Private sector involvement in TB/HIV control is cost-effective and offers the best strategy to increase national efforts to fight the epidemic. The commercial sector, as the common site for a client's first visit, is the best way to ensure positive client uptake, minimal rate of default, and a high rate of prophylaxis and treatment.

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Abstract: Tracking HIV/AIDS Resource Flows in St. Vincent and Grenadine

Background: The HIV/AIDS epidemic poses a significant threat to the Caribbean region. This region has the second highest infection rate in the world, with an estimated 440,000 HIV positive people. In an effort to inform the implementation of their HIV/AIDS strategy and to measure results against expenditures, the country seeks to understand the financial flows for HIV/AIDS. It is an opportune time for St. Vincent and Grenadine (SVG) to analyze the baseline situation before the forthcoming influx of external funding and scaling up of HIV/AIDS services.

Methods: SVG has adopted the National Health Accounts (NHA) framework to measure HIV/AIDS health expenditures and their flows. By analyzing expenditure data from various entities in conjunction with health utilization information, estimates were obtained on the total resource envelope for HIV/AIDS in 2004. Flows between different entities were analyzed to identify the sources of finance, and service-providers and their uses.

Results: In 2004, total health expenditure on HIV/AIDS in SVG was estimated at US$0.56 million (EC$1.52 million), accounting for 0.14% of GDP, which is equivalent to US$9.6 per capita based on purchasing-power parity (PPP). Expenditure on ARV treatment, including the cost of outpatient visits and drugs, was US$258 (PPP) per person living with HIV/AIDS. The focus of efforts to combat HIV/AIDS is oriented slightly towards prevention. Of total HIV/AIDS funds, 54% were spent on preventive activities, 40% on care and treatment, and the remainder on administration. 81% of this expenditure was funded publicly and the rest privately.

Conclusions: The NHA HIV/AIDS subanalysis was conducted when SVG received no external funding. In 2005 there have been large influxes of funds from the World Bank and the GFATM. The institutionalization of the NHA process to monitor financial flows for HIV/AIDS means these funds can be tracked in the future to ensure that policy priorities are adequately and appropriately financed.

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Abstract: The Value of a Network Approach HIV/AIDS Health Systems Research

Issues: Stakeholders within the global health community struggle to understand how best to achieve rapid and widespread results in combating HIV/AIDS without causing detrimental effects on other health priorities such as child health. Little research has been done on the effects of large disease-specific financing mechanisms on broader health systems. In 2003, following the creation of the Global Fund to Fight AIDS, TB and Malaria, a Systemwide Effects of the Fund (SWEF) Research Network was created to tackle this important question. The SWEF Network — a collaborative network of Southern and Northern partners — seeks to understand how GF resources, as well as other significant HIV/AIDS funding sources, affect broader country health systems.

Description: The SWEF Network was established to answer important and sensitive research questions using a collaborative approach among varied partners. The rationale for this approach was to engage international and developing country partners, to improve comparability of findings across multiple studies, and to facilitate exchange among partners to strengthen the global lessons learned from collective findings.

Lessons learned: Taking a network approach to conducting this research provided value added. For example, through consultative processes, the Network collectively developed a core research protocol for implementing country studies. Thus, findings were largely comparable, strengthening the overall bearing of issues identified. Constraints to the approach included limitations in funding for coordination among network members, and differences in timing and scale among studies due to varying donor requirements.

Recommendations: While there is value in conducting research using a collaborative approach, coordinate across multiple partners requires additional time and resources. Some transaction costs may be counteracted by the ability to alleviate sensitivities surrounding findings given the involvement of multiple partners. Future efforts to address important and sensitive research topics, especially regarding the impact of HIV/AIDS programs, may benefit from collaborative approaches that may strengthen the influence of findings.

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Abstract: Substance Use, Sexual Risk-Taking and HIV Treatment Adherence among Homeless People Living with HIV

Background: Substance use and AIDS intertwine in many ways. Substance use among HIV-seropositive individuals may facilitate high-risk sex and/or poor adherence to HIV treatment, factors that may be especially prevalent among seropositive homeless individuals.

Methods: This study reports substance use and abuse profiles from baseline data collected in 2004/5 by the Housing and Health (H&H) Study, a large-scale (n=644) study of homeless/unstably housed HIV+ individuals from Baltimore, MD, Chicago, IL, and Los Angeles, CA. High-risk sexual behavior was defined as unprotected vaginal or anal sex with a person of known negative or unknown HIV status; substance use was defined as any use during the previous 90 days; medication non-adherence was defined as missing any doses during the past two days.

Results: Participants who used drugs were significantly more likely to be non-adherent than were non-users: marijuana (30% vs.17% non-adherent, p < .05); crack cocaine (32% vs. 16% non-adherent, p < .05) or heroin (34% vs. 15% non-adherent, p < .05). Substance users were more likely to have had unsafe sex if they used 2+ drugs (26% vs. 12% unsafe, p < .001), were IDU (36% vs. 15% unsafe, p < .01), used powder cocaine (26% vs. 13% unsafe, p < .01), used crack cocaine (26% vs. 13% unsafe, p < .01), or used sedatives (33% vs. 12% unsafe, p < .05). 19% of those who were non-adherent also had unsafe sex.

Conclusions: Substance use is associated with both elevated levels of high-risk sex and lower rates of treatment adherence among homeless/unstably housed HIV+ people. Providers should assess the possibility that substance use is associated with HIV risk within this population, and refer patients as possible to substance abuse treatment. Findings ways to disentangle the substance use and HIV epidemics among HIV homeless people is a pressing issue in both AIDS prevention and treatment.

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Abstract: Substance Use and Abuse among Homeless People Living with HIV

Background: Continued substance abuse may be especially damaging to the health of homeless HIV-positive individuals, as it could: make them more vulnerable to other health problems such as violence/victimization, interfere with HAART adherence, and/or facilitate high-risk sex. Despite these possibilities, relatively little is known of substance use profiles in this population.

Methods: This paper reports substance use and abuse profiles from the 2004/5 baseline data collection of the Housing and Health Study, a large-scale (n=644) study of homeless/unstably housed HIV+ individuals from Baltimore, MD, Chicago, IL, and Los Angeles, CA.

Results: Substance use during the previous 90 days is common in this population:

1=Gay/Bi men significantly different from heterosexual men; 2=Gay/Bi men significantly different from women; *p < .05 **p < .01

Comparisons across these three groups did not yield significant statistical differences in measures of alcohol abuse (26% overall), drug abuse (16% overall), or IDU (4% overall).

Conclusions: Substance use and abuse are highly prevalent among homeless HIV-seropositive individuals. Providers should be aware that this is a population in which the epidemics of substance use and HIV have intertwined in an intimate way, and be prepared to address both health issues in tandem.

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