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Exploring New Policy Questions in HIV/AIDS Treatment

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  • More demand for research
  • Questions related to treatment, adherence, and prevention
  • HIV/AIDS research with country partners in Rwanda

August 1, 2008— With more funding for large-scale treatment programs for HIV/AIDS, research on emerging policy questions related to treatment is increasingly in demand.

In tandem with programs designed to step up access to anti-retroviral therapy (ART) and to deliver treatment through public-private partnerships, World Bank researchers are collecting and analyzing new treatment-related data to uncover evidence that could shape future health policy and improve the design of HIV/AIDS treatment programs.

With continued funding—the World Bank alone has committed $1.5bn to over 30 Sub-Saharan African countries since 2000—and improved knowledge through research, the ultimate goal is to prevent further spread of the disease and to ensure its progress from being a “silent killer” to being widely treatable.

Here are some of the key policy questions that World Bank HIV/AIDS research is attempting to address:

Why is treating HIV so important?  

HIV/AIDS affects most adults in their prime, limiting their ability to work and provide for family members and contributing to high rates of premature death in developing countries.

World Bank research has already shown significant impacts of HIV/AIDS and of adult mortality on poverty and living standards, orphanhood, and education in the developing countries most affected by the disease. 

Redoubling efforts to treat HIV patients appears to have a ripple effect, benefitting not only individuals, but also all those who depend on them. 

Treating HIV/AIDS isn’t only about counting the number of lives saved, critical as that is,” said Elizabeth King, manager of the Human Development and Public Services team in the Bank’s Development Research Group “It’s also about improving the quality of life of those infected with the disease and the lives of the family members who share in carrying the burden of HIV/AIDS.

What determines adherence to HIV treatment?

Patients receiving education about ARV drugs
Patients at the Rubona and Rusatira
Health Center receiving education
about ARV drugs

Adhering to treatment is crucial for its effectiveness; it also prevents patients developing resistance to the drugs.  Through new household surveys, World Bank researchers are now trying to identify what factors determine adherence to ART.

In addition, researchers are using health facility surveys to measure treatment quality.  Healthcare service delivery could also have an impact on ART adherence and the welfare of patients and their families.

Longitudinal household surveys of HIV/AIDS patients and health facilities are in progress in Rwanda, Burkina Faso, Ghana, Mozambique, Kenya, South Africa, and India. 

Many of these baseline surveys are ongoing or are completed, as seen in this timeline, but the complete story won’t be clear until the follow-up surveys, now in the field, are completed.

Does treatment availability make people less cautious about protection?

HIV/AIDS treatment is now more widely available in Africa. What impact does the availability of treatment have on prevention and on the future behavior of patients, family members, and society?

The “disinhibition” hypothesis (or treatment optimism) has been seen in vulnerable groups in some developed countries. Some groups appear to have become less cautious about HIV transmission as treatment becomes more accessible and living with HIV/AIDS is more accepted in the mainstream.

A major question that Bank researchers are studying is the link between scaling up treatment and the type of prevention steps that may be required. Efforts may need to include increasing prevention education campaigns along with access to treatment.

"While access to treatment and its ultimate success are important, we also need to find out what works in terms of prevention,” said David Wilson, lead health specialist in the World Bank's Global HIV/AIDS program. “Researchers are trying to identify and evaluate various innovative methods to strengthen prevention efforts and the most effective prevention messages for youth.

Has AIDS funding affected the quality of healthcare service delivery?

It is widely believed that the large amount of money given for HIV treatment has helped improve the capacity of the health system in general,” said Damien de Walque, Economist in the Bank’s Development Research Group, “but some will claim that other diseases have been neglected.

To ascertain the real picture, health facility surveys include questions about all other services, and exit interviews with patients both with HIV/AIDS as well as other diseases. 

An evaluation currently being carried out in Rwanda tests whether “performance-based contracting”—a form of funding that links performance with payments received for completed work—can enhance the effectiveness of service delivery and thus ultimately improve the health status of HIV-positive patients.

This is an important policy question, as this form of funding is becoming more popular and is being increasingly used in Rwanda’s health sector.

Data from this evaluation will help inform the Implementation Completion Report for the Rwanda HIV/AIDS Project which piloted the contracting approach for HIV/AIDS services,” said Miriam Schneidman, Senior Health Specialist in the World Bank’s Africa Region.  “Evaluations are critical to assessing the impact of our operational work.

HIV/AIDS treatment research in Rwanda

School boy in Africa
"[My son] is always the first in
his class with 95% marks. He is
no longer sickly."
-- A HIV+ Rwandan mother who
lost her husband to AIDS

Without the Rwandan government’s widely available treatment program, this HIV+ mother and son might not have been spared. Both are on regular medication and receive nutritional support.

In addition to testing whether performance-based contracts improve HIV+ patients’ health status, the household survey in Rwanda has also gathered data to study the impact of ART on patients and household members.

In an attempt to document the precise impact of ART on family welfare, researchers are collecting data on labor market and household socioeconomic indicators, self-reported and perceived adherence to treatment, attitudes and perception regarding anti-retroviral treatment, activities of daily living of all patients, mental health questions of all patients, sexual history, and knowledge regarding risk for HIV/AIDS and STDs.

When comparing the life of a household with one or more HIV patients to one without, the analysis, done jointly with the Commission Nationale de Lutte contre le Sida in Rwanda (CNLS) finds that households with HIV patients:

  • Spend more time in health facilities
  • Are more likely to have another death in the family in the last five years,
  • Are more likely to have had to sell assets
  • Spend more for health care and transportation
  • Had less sex in the last 12 months and used condoms more often

“The time spent on health services is time lost for economic production, and the money spent for health care and transportation and the sale of assets is a sign of impoverishment,” said Dr Agnès Binagwaho, Executive Secretary of the CNLS in Rwanda.

“It is important to continue to place the fight against HIV/AIDS at the heart of the struggle against poverty and for economic development. This study in Rwanda has reinforced our strategy in that direction,” she said.

HIV studies inherently take a long time to complete. The results of these surveys will be available in 2008/2009, and the full analysis should be available by the end of 2010.

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