Bridging the Gap: Conference Record [Abstract book, International Conference on AIDS (12th: 1998: Geneva, Switzerland)]

12th World AIDS Conference

Abstracts 44236-44240 983

to manage a research agenda? d) What training do frontline workers need to
integrate research skills into their practice? e) How do we create the structural
changes necessary to develop appropriate criteria for reviewing and funding
community-based research?
Lessons Learned: Community-based action research assists community AIDS
groups in addressing their own research questions, in mobilizing and in evaluating
interventions, however, critical political, methodological, and structural barriers
must be addressed. Community AIDS groups need to continue to dialogue with
each other and the research community to realize the potential for community
action research.
44236 Implications of HIV/AIDS perceptions and behaviours for
the formulation of policies in post-complex emergency
conditions: The case of Bosnia and Herzegovina
Manuel Carballo1 4, Bozo Ljubic2, Z. Puvacic3. 'Route Du Nant-D'avril, 11,
CH-1214 Geneva; 4International Centre for Migration & Health, Geneva,
Switzerland; 2Ministry of Health, Sarajevo; 3National Committee for AIDS
Prevention, Sarajevo, Bosnia
Issues: The need for policies to prevent and cope with HIV/AIDS in the post
emergency phase of the war in Bosnia and Herzegovina has placed special
demands on the Ministry of Health and the National Committee for the Prevention
of AIDS.
Project: In view of the commitment of the national authorities to involving the
population in its decision making process, a national survey was made of the way
in which internally displaced people (IDP), repatriated externally located refugees
(ELR) and non-displaced people (NDP) perceive the problem of HIV/AIDS.
Results: Over 60% of persons surveyed believed that the act of donating blood
was a risk factor for HIV: 62% of ELR and 68% of IDP and NDP. 35% of ELR
and 48% of IDP and NDP believed a moderate to great risk of HIV infection from
use of a public swimming pool. Over 86% believed that AIDS patients should be
treated in hospital as opposed to home and 55% believed that care should be
provided by specially trained medical staff.
Lessons Learned: Misconceptions about HIV transmission risks with respect
to donating blood, and casual contact could constitute a major obstacle to the
capacity of the country to maintain a self-sufficient blood transfusion system,
provide appropriate care for HIV/AIDS patients and avoid unnecessary discrimination. There is a need for increased and focused HIV/AIDS education programs
in populations uprooted and displaced by the recent war.
44237 Sensitisation of health bureaucrats, within city
governments, to the problems faced by men having sex
with men (MSM)
Thanekar Jairaj. 2nd floor, Municipal Eye Hospital, Maulana Shaukat Ali Road,
Mumbai, India
Issues: Effective intervention become highly efficient in preventing controlling
STD/HIV/AIDS in the invisible and stigmat sed, gay community by understanding
their drive for dignity, their needs and facilitating their access to the public health
infrastructure.
Project: Mumbai metro is estimated to have a large invisible gay population
and MSM. The ratio of men to women coming in with clinically diagnosed AIDS is
still hovering around 7 to 1. This epidemiologically points to a large subterranean
unprotected homosexual transmission of HIV. However, the AIDS cell of th Brihanmumbai Mahanagarpalika located and identified groups of gay men and MSM
inspite of their fear of persecution and the general social harrassment they faced.
It is called the HUM SAFAR TRUST. ASHA interacted with them, allowed them
to vocalise their problems and made efforts to address their issues. Sufficient
space has been allotted by the BMC for India's first such official Drop In Centre
for Gay Men and MSM. who have shown confidence to give them autonomous
control of their sexual health and lives and this has boosted the confidence of
the city's neglected gay community resulting in increased co-operation with the
BMC's prevention programme.
Local city governments should take special care to sensitise the health bureauocrats to highly invisible segments of its citizency. Increasing access to
such stigmatised segments, not only controls STD's and HIV but advances, the
constitutional goals of civil society morally to fight the HIV epidemic.
479* / 44238 The cost-effectiveness of prophylaxis for
Mycobacterium avium complex in AIDS
Kenneth Freedberg1, J.A. Scharfstein2, G.R. Seage, III3, E. Losina3,
M.C. Weinstein2, D.E. Craven4, A.D. Paltiel5. 1Boston Medical Center, 91 East
Concord Street, Suite 200, Boston, MA 02118; 2Harvard University School of
Public Health, Boston, MA; 3Boston University School of Public Health, Boston,
MA; 4Boston Medical Center, Boston, MA; 5 Yale University School of Medicine,
New Haven, CT, USA

Objectives: To determine the cost-effectiveness of clinical strategies to prevent
Mycobacterium avium Complex (MAC) in AIDS patients.
Methods: We developed a decision analytic simulation model of advanced
HIV disease to project costs, life expectancy, and cost-effectiveness (C-E) in
discounted US dollars per quality-adjusted life year saved ($/QALY). We utilized
natural history data from the Multicenter AIDS Cohort Study; efficacy and toxicity
data from controlled clinical trials of MAC prophylaxis as well as prophylaxis for

other opportunistic infections, and cost data from the US AIDS Cost and Services
Utilization Survey. The model permitted timing of prophylaxis to be stratified by
CD4 count into four groups (201-300/ul, 101-200/ul, 51-100/ul, - 50/ul), and
allowed combinations of prophylaxis, crossover to second- and third-line agents
for toxicity, and consideration of resistance, adherence, and quality of life. Input
data included the monthly risk of dropping from one CD4 stratum to another
(4.8%-7.2%), prophylaxis efficacy (51.5%-72.0%), and annual MAC prophylaxis
costs ($1,450-$2,450).
Results: The model projects that the average HIV-infected patient with a beginning CD4 count between 201 and 300/ul has total lifetime costs of approximately
$43,000 and a quality-adjusted life expectancy of 45.33 months. If azithromycin
prophylaxis for MAC is begun after the CD4 declines to 50/ul, costs and quality-adjusted survival increase to approximately $44,400 and 45.93 months, respectively, for an incremental cost-effectiveness ratio of $27,000/QALY compared
to no MAC prophylaxis. Other prophylaxis options (i.e., rifabutin, clarithromycin,
and combination therapies) either cost more but offer shorter survival, or have
cost-effectiveness ratios above $230,000/QALY. Sensitivity analysis shows that,
for reasonable assumptions about quality of life, risk of infection, prophylaxis
cost, adherence, and resistance, azithromycin remains the most cost-effective
prophylaxis option.
Conclusions: Azithromycin prophylaxis, begun after the CD4 count has declined to 50/ul, is the most cost-effective MAC prophylaxis strategy with an
incremental cost-effectiveness ratio of $27,000/QALY compared to no MAC prophylaxis. Consistent with the 1997 USPHS/IDSA guidelines, it should be the
first-line prophylaxis option.
542*/44239 Protecting paradise: Tourism and AIDS in the
Dominican Republic
Steven Forsythe1, J. Hasbun2, M. Butler De Lister2. Pembroke Place.
Liverpool, England; 2Fundacion Genesis, Santo Domingo, Dominican Republic
Objectives: This study of the Dominican tourism industry was designed to assess: 1) how HIV/AIDS may affect tourism; 2) how tourists are likely to react to
prevention campaigns; and 3) how tourism may affect the spread of HIV/AIDS.
Methodology: The study involved a review of 3 groups involved in the industry:
1) tourists; 2) hotel staff; and 3) CSWs who work near tourist resorts. To assess
the interrelationships among these groups and assess the risks associated with
AIDS, 6 survey instruments were designed and administered. These instruments
included 738 interviews with tourists, a KABP survey of 239 hotel workers, 100
interviews with entertainment staff at hotels, 8 interviews with hotel managers, a
KABP survey of 381 CSWs, and focus groups discussions with 38 CSWs working
at tourism sites.
Results: A large proportion of tourists don't consider the prevalence of HIV to
be a factor when making their travel plans, and most don't consider themselves
at greater risk of infection while on holiday than at home. Thus the spread of
HIV/AIDS was unlikely to affect the demand for tourism services. The study found
that most tourists would respond positively to an HIV/AIDS prevention campaign
and would not be discouraged from visiting the D.R. because of such campaigns.
Those most receptive to prevention efforts were also those who felt they were at
highest risk. Finally, it was determined that some male and female tourists do engage in sexual encounters with multiple Dominican CSWs and hotel employees.
These encounters represent a risk to the health and economic development of
the D.R., as well as tourists and their other sexual partners.
Conclusions: Based on these findings, it is recommended that in order to minimize the potential social and economic impact of HIV/AIDS in the D.R., prevention
messages need to reach a number of groups which have not yet been adequately
targeted. These groups include tourists, with a special emphasis on "sex tourists",
and hotel employees, with a special emphasis on entertainment staff.
467*/44240 Analysis of unit costs in 23 condom social
marketing programs 1990-1996
Guy Stallworthy. 1120 19th Street, N. W, Suite 600 Washington, DC 20036, USA
Background: Rational allocation of HIV/AIDS prevention resources is limited by
the absence of systematic data on the costs of prevention strategies. This study
is designed to assess levels and trends in costs per condom sold and the role of
critical contextual variables.
Methods: Data on condom sales and total gross program costs were analysed
for condom social marketing programs in 23 countries over the period 1990-1996
(total of 118 program years). Costs included commodities, all local operations,
management, technical assistance and indirect costs. Regression analysis was
used to estimate unit costs by size of population served, age of program, level of
investment, region, and year of intervention, after controlling for other factors.
Results: Cumulative cost per condom sold of $0.08-$0.13 were observed
in six large markets with well-established programs; costs of $0.17-$0.34 were
observed in 13 countries; costs in excess of $0.40 per condom sold were found
under various atypical circumstances. Lower unit costs were observed in countries with populations greater than 50 million and in more mature programs. For

the 23 programs studied, adjusted unit costs fell by 29% between 1990-1992 and
1993-1996 and from $0.52 in the first program year to $0.19 by the sixth year.
Conclusion: The analysis supports the hypotheses that condom social marketing programs become more cost-effective over time and investments to increase
access and demand result in short-term increases in unit costs followed by lower
unit costs as mass consumption is achieved. It can be used as a basis for marginal
cost-effectiveness analysis in resource allocation models.