Handbook of Economic Evaluation of HIV Prevention Programs PDF
Preview Handbook of Economic Evaluation of HIV Prevention Programs
Handbook of Economic Evaluation of HIV Prevention Programs AIDS Prevention and Mental Health Series Editors: David G. Ostrow, M.D., Ph.D. Howard Brown Health Center and Illinois Masonic Medical Center, Chicago, Illinois Jeffrey A. Kelly, Ph.D. Medical College of Wisconsin, Milwaukee, Wisconsin Evaluating HIV Prevention Interventions Joanne E. Mantell, Ph.D., M.S.P.H., Anthony T. DiVittis, M.A., and Marilyn I. Auerbach, A.M.L.S., Dr. P.H. Handbook of Economic Evaluation of HIV Prevention Programs Edited by David R. Holtgrave, Ph.D. Methodological Issues in AIDS Behavioral Research Edited by David G. Ostrow, M.D., Ph.D., and Ronald C. Kessler, Ph.D. Preventing AIDS: Theories and Methods of Behavioral Interventions Edited by Ralph J. DiClemente, Ph.D., and John L. Peterson, Ph.D. Women and AIDS: Coping and Care Edited by Ann O'Leary, Ph.D., and Lorretta Sweet Jemmot, R.N., Ph.D., F.A.A.N. Women at Risk: Issues in the Primary Prevention of AIDS Edited by Ann O'Leary, Ph.D., and Loretta Sweet Jemmott, R.N., Ph.D. A Continuation Order Plan is available for this series. A continuation order will bring delivery of each new volume immediately upon publication. Volumes are billed only upon actual shipment. For further information please contact the publisher. Handbook of Economic Evaluation of HIV Prevention Programs Edited by David R. Holtgrave, Ph.D. Center for AIDS Intervention Research Medical College of Wisconsin Milwaukee, Wisconsin Springer Science+ Business Media, LLC Library of Congress Catalog1ng-1n-Publ1 cation Data Handbook of economic evaluation erf HIV prevention programs / edited by David R. Ho itgrave. p. cm. — (AIDS prevention and mental health) Includes bibliographical references and index. ISBN 978-1-4899-1880-2 1. AIDS (Disease)—Prevention—Cost effectiveness. 2. AIDS (Disease)—Government policy—United States—Cost effectiveness. I. Holtgräve, David R. II. Series. RA644.A25H3665 1998 362. T9697'92—dc21 98-39090 CIP ISBN 978-1-4899-1880-2 ISBN 978-1-4899-1878-9 (eBook) DOI 10.1007/978-1-4899-1878-9 © 1998 Springer Science+Business Media New York Originally published by Plenum Press, New York in 1998 Softcover reprint of the hardcover 1st edition 1998 10 9 8 7 6 5 4 3 2 1 All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher To Lorie Holtgrave, for her encouragement during the hardest moments-she truly made completion of this effort possible; Dr. John Graham, for teaching me policy analysis; Dr. Jim Curran, for showing me policy making; and Buddy and Katie Lynn, for their endless supply of infectious happiness Contributors Paul R. Abramson • Department of Psychology, University of California, Los Angeles, Los Angeles, California 90024 Charles Begley • Center for Health Policy Studies, School of Public Health, The Univer sity of Texas at Houston, Houston, Texas 77030 Heather Cecil • Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research (CAIR), Medical College of Wisconsin, Milwaukee, Wisconsin 53202 Julie Denison. School of Hygiene and Public Health, Johns Hopkins University, Bal timore, Maryland 21205 Wayne J. DiFranceisco • Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research (CAIR), Medical College of Wisconsin, Milwaukee, Wiscon sin 53202 Paul G. Farnham. Department of Economics, Georgia State University, Atlanta, Geor gia 30303; and Division of Prevention Research and Analytic Methods, Epidemiology Program Office, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia 30333 Andrew Fourney - Center for Health Policy Studies, School of Public Health, The University of Texas at Houston, Houston, Texas 77030 Robin D. Gorsky • Late of Division of HIV-AIDS Prevention, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia 30333; and Department of Health Management and Policy, University of New Hampshire, Durham, New Hampshire 03824 Anne Haddix. Prevention Effectiveness Activity, Centers for Disease Control and Pre vention (CDC), Atlanta, Georgia 30333 David R. Hoitgrave • Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research (CAIR), Medical College of Wisconsin, Milwaukee, Wiscon sin 53202 James G. Kahn • Center for AIDS Prevention Studies, Institute for Health Policy Studies, and Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, San Francisco, California 94109 vii viii Contributors Edward H. Kaplan. School of Management, Yale University, New Haven, Connecticut 06520-8200 Jeffrey A. Kelley • Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research (CAIR), Medical College of Wisconsin, Milwaukee, Wisconsin 53202 Robert F. Martin • Department of Economics, University of Chicago, Chicago, Illinois 60637 Anna Johnson Masotti • Center for AIDS Intervention Research (CAIR), Medical Col lege of Wisconsin, Milwaukee, Wisconsin 53202 Paul Masotti. Center for Health Policy Studies, School of Public Health, The University of Texas at Houston, Houston, Texas 77030 Richard L. Melchreit • Connecticut Department of Public Health, Hartford, Connecticut 06134-0308 Edward C. Norton • Department of Health Policy and Administration, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7400 Douglas K. Owens. VA Palo Alto Health Care System, Palo Alto, California 94304; and Section on Medical Informatics, Department of Medicine, and Department of Health Research and Policy, Stanford University, Stanford, California 94305 A. David Paltiel • School of Medicine, Yale University, New Haven, Connecticut 06520 Kathryn A. Phillips • Center for AIDS Prevention Studies (CAPS), University of Califor nia, San Francisco, San Francisco, California 94105 Steven D. Pinkerton • Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research (CAIR), Medical College of Wisconsin, Milwaukee, Wiscon sin 53202 L. Yvonne Stevenson • Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research (CAIR), Medical College of Wisconsin, Milwaukee, Wiscon sin 53202 Aaron A. Stinnett. Department of Health Care Organization and Policy, University of Alabama, Birmingham, Alabama 35294 MichaelD. Sweat. School of Public Hygiene and Public Health, Johns Hopkins Univer sity, Baltimore, Maryland 21205 Mary E. Turk • Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research (CAIR), Medical College of Wisconsin, Milwaukee, Wisconsin 53202 Wendee M. Wechsberg • Research Triangle Institute, Research Triangle Park, North Carolina 27709 Beth Weinstein • Connecticut Department of Public Health, Hartford, Connecticut 06134-0308 Anna Fay Williams. Consultant, Houston, Texas 77005 Preface If resources for HIV prevention efforts were truly unlimited, then this book would be en tirely unnecessary. In a world with limitless support for HIV prevention activities, one would simply implement all effective (or potentially effective) programs without regard to expense. We would do everything useful to prevent the further spread of the virus that has already claimed hundreds of thousands of lives in the United States and millions of lives worldwide. Unfortunately, funding for HIV prevention programs is limited. Even though the amount of available funding may seem quite large (especially in the United States), it is still fixed and not sufficient to meet all needs for such programs. This was very well illustrated in the summer of 1997 when over 500 community-based organizations applied for a combined total of $18 million of HIV prevention funding from the U.S. Centers for Disease Control and Prevention (CDC). Less than one-fifth ofthese organizations received support via this funding mechanism. Hence, although $18 million may seem like a large amount of money at first blush, it is not enough to meet all of the prevention needs that could be addressed by these community-based organizations. This point is true even more generally. In total, U.S. federal support for HIV prevention efforts is measured in the hundreds of millions of dollars per year. These funds are used to support the efforts of state, local, and territorial health departments; national and regional minority organizations; the community-based organizations noted previously; and a wide variety of other governmental and nongovernmental organizations. The programs funded with these monies include HIV counseling and testing services, health education and risk reduction, public information, and other HIV prevention interventions. Of course, even this seemingly large sum is also limited and not sufficient to meet all HIV prevention needs in the United States. Therefore, any use of this money entails an op portunity cost-a dollar spent on one program is a dollar unavailable for others. A decision to spend $100,000 on HIV counseling and testing services in a state might mean that a street outreach program for injection drug users might go unfunded. These resource allocation choices are very real and highly consequential. HIV prevention resource allocation decisions are made in a highly volatile context of politics, activism, science, personal values, and community norms. Some resource alloca tion decisions are made subject to constraints, such as congressional earmarks. Others are made after comprehensively considering the costs and consequences of funding decisions across a variety of communities. To capture the wide diversity of ways in which HIV pre vention allocation decisions are made would require the development of a variety of descriptive models of decision making. This book is focused on one general type of resource allocation decision making. We ix x Preface take as a starting point that HIV prevention resources are limited, that funding one pro gram instead of another can have real effects on the course of the epidemic and on individual morbidity and mortality, and that it is desirable to avert the maximum number of HIV infections possible given a limited set of resources. Indeed, we assume in this book that the major goal of HIV prevention programs is the prevention of HIV infection (a seemingly obvious yet controversial and consequential assumption). We assume that to achieve this goal, it is necessary to balance carefully the relative costs and consequences of HIV prevention efforts. This "balancing act" must be done explicitly (so that the resource allocation process may be transparent to observers and more easily justified), and it must be done carefully and comprehensively. Because of these desiderata, the techniques of cost and cost-effectiveness analysis are useful. Cost analysis allows us to answer the question: What resources does it take to deliver a particular type of HIV prevention intervention to a specific group of clients? Cost-effectiveness analysis allows us to answer the related question: What does it cost to deliver a particular type of HIV prevention intervention to achieve one unit of some outcome measure (e.g., cost per HIV infection averted)? When applied across a variety of HIV prevention intervention types, cost-effectiveness analysis helps us to begin to answer the question: Which HIV prevention interventions are most cost-effective? When applied across a variety of HIV prevention interventions and programs in other disease areas (such as cancer prevention and the treatment of heart disease) and when using a common outcome measure (such as cost per quality-adjusted life-year saved), cost-effectiveness analysis helps us to begin to answer the question: Is HIV prevention a cost-effective expenditure of funds relative to investments in programs in other disease areas? When used with care and skill, the techniques of cost and cost-effectiveness analysis constitute important decision aiding devices to those persons charged with HIV prevention resource allocation. This book is an in-depth discussion of the methods, applications, and utilization of cost and cost-effectiveness analysis in HIV prevention resource allocation decision making. The book is divided into three major sections. The first section, consisting of three chapters, is devoted to the methods of cost and cost-effectiveness analysis. Kathryn Phillips and colleagues provide a detailed definition of some important economic evaluation terms. Further, they provide a brief description of some standards for doing cost and cost effectiveness analysis that have recently been established by a blue-ribbon panel convened by the U.S. Public Health Service. Next, in a pair of chapters Steve Pinkerton and colleagues provide an overview of a methodological framework for doing cost-effectiveness analysis in the context of HIV prevention. They note that calculation of the "cost-utility ratio" depends on four key param eters: program cost, the number of HIV infections prevented, medical costs saved when an HIV infection is prevented, and the number of quality-adjusted life-years saved when an HIV infection is prevented. (When cost-effectiveness analysis is focused on the cost per quality-adjusted life-year saved, it is called "cost-utility analysis.") They describe progress made in identifying methods to estimate each of these four key parameters. An entire chapter is devoted to the special topic of estimating the number of HIV infections prevented by a program that is empirically assessed by behavioral but not biological outcomes. The methodological section of the book provides a relatively brief overview of the methods required to perform HIV prevention cost and cost-effectiveness analyses. It is not a complete tutorial on these topics, although it is a potential guide to further learning on these topics.
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