An Assessment of Family Planning Decision Makers' and Advocates' Needs and Strategies in Three East African Countries.

CONTEXT: Despite decades of evidence-based advocacy for family planning in developing countries, research on how decision makers perceive and respond to such efforts is lacking. METHODS: A literature review yielded 10 peer-reviewed journal articles published between 1999 and 2012 on decision makers' needs for and experiences with health advocacy and evidence. Two sets of questions about family planning research and advocacy-one for decision makers and another for advocates-were developed from emerging themes and used in structured interviews with 68 key informants in Ethiopia, Kenya and Malawi. RESULTS: Decision makers reported understanding family planning's value and confirmed that advocacy had helped to spur recent favorable shifts in government support of family planning. Key informants stressed that advocacy messages and formats must be tailored to the needs and interests of particular audiences to be effective. Messages must also consider barriers to decision makers' support for family planning: constituents' negative attitudes; fear that increased adherence to family planning will shrink the size and influence of specific voting blocs and ethnic groups; and competing economic, social, cultural, religious and political priorities. Decision makers reported valuing the contributions of international family planning organizations and donors, but were more comfortable receiving advocacy messages from local sources. CONCLUSIONS: According to decision makers, sustained and strategic family planning advocacy developed and delivered by culturally attuned national actors, with support from international actors, can diminish barriers to government support for family planning.

Cost drivers for voluntary medical male circumcision using primary source data from sub-Saharan Africa.

BACKGROUND: As voluntary medical male circumcision (VMMC) programs scale up, there is a pressing need for information about the important cost drivers, and potential efficiency gains. We examine those cost drivers here, and estimate the potential efficiency gains through an econometric model. METHODS AND FINDINGS: We examined the main cost drivers (i.e., personnel and consumables) associated with providing VMMC in sub-Saharan Africa along a number of dimensions, including facility type and service provider. Primary source facility level data from Kenya, Namibia, South Africa, Tanzania, Uganda, and Zambia were utilized throughout. We estimated the efficiency gains by econometrically estimating a cost function in order to calculate the impact of scale and other relevant factors. Personnel and consumables were estimated at 36% and 28%, respectively, of total costs across countries. Economies of scale (EOS) is estimated to be eight at the median volume of VMMCs performed, and EOS falls from 23 at the 25th percentile volume of VMMCs performed to 5.1 at the 75th percentile. CONCLUSIONS: The analysis suggests that there is significant room for efficiency improvement as indicated by declining EOS as VMMC volume increases. The scale of the fall in EOS as VMMC volume increases suggests that we are still at the ascension phase of the scale-up of VMMC, where continuing to add new sites results in additional start-up costs as well. A key aspect of improving efficiency is task sharing VMMC procedures, due to the large percentage of overall costs associated with personnel costs. In addition, efficiency improvements in consumables are likely to occur over time as prices and distribution costs decrease.

Costs and impacts of scaling up voluntary medical male circumcision in Tanzania.

BACKGROUND: Given the proven effectiveness of voluntary medical male circumcision (VMMC) in preventing the spread of HIV, Tanzania is scaling up VMMC as an HIV prevention strategy. This study will inform policymakers about the potential costs and benefits of scaling up VMMC services in Tanzania. METHODOLOGY: The analysis first assessed the unit costs of delivering VMMC at the facility level in three regions-Iringa, Kagera, and Mbeya-via three currently used VMMC service delivery models (routine, campaign, and mobile/island outreach). Subsequently, using these unit cost data estimates, the study used the Decision Makers' Program Planning Tool (DMPPT) to estimate the costs and impact of a scaled-up VMMC program. RESULTS: Increasing VMMC could substantially reduce HIV infection. Scaling up adult VMMC to reach 87.9% coverage by 2015 would avert nearly 23,000 new adult HIV infections through 2015 and an additional 167,500 from 2016 through 2025-at an additional cost of US$253.7 million through 2015 and US$302.3 million from 2016 through 2025. Average cost per HIV infection averted would be US$11,300 during 2010-2015 and US$3,200 during 2010-2025. Scaling up VMMC in Tanzania will yield significant net benefits (benefits of treatment costs averted minus the cost of performing circumcisions) in the long run-around US$4,200 in net benefits for each infection averted. CONCLUSION: VMMC could have an immediate impact on HIV transmission, but the full impact on prevalence and deaths will only be apparent in the longer term because VMMC averts infections some years into the future among people who have been circumcised. Given the health and economic benefits of investing in VMMC, the scale-up of services should continue to be a central component of the national HIV prevention strategy in Tanzania.

A syndemic analysis of alcohol use and sexual risk behavior among tourism employees in Sosúa, Dominican Republic.

The Dominican Republic has high rates of HIV infection and alcohol consumption. Unfortunately, little research has been focused on the broader sources of the synergy between these two health outcomes. We draw on syndemic theory to argue that alcohol consumption and sexual risk behavior are best analyzed within the context of culture and economy in Caribbean tourism spaces, which produce a synergy between apparently independent outcomes. We sampled 32 men and women working in the tourism industry at alcohol-serving establishments in Sosúa, Dominican Republic. Interviewees described alcohol consumption as an implicit requirement of tourism work, tourism industry business practices that foster alcohol consumption, and an intertwining relationship between alcohol and sexual commerce. The need to establish relationships with tourists, combined with the overconsumption of alcohol, contributed to a perceived loss of sexual control, which participants felt could impede condom use. Interventions should incorporate knowledge of the social context of tourism areas to mitigate the contextual factors that contribute to HIV infection and alcohol consumption among locals.