This PHE activity was approved for inclusion in the COP. The PHE tracking ID associated with this activity

is TZ.08.0140.

THIS IS AN ONGOING PHE ACTIVITY. THE ACTIVITY IS UNCHANGED FROM FY 2008.

Title of Study: Comparing Cost-Effectiveness of Three Different Methods of Condom Distribution in

Tanzania: Free Through Public Health Facilities, Traditional Social Marketing and Private-Public Partnership

Expected Timeframe of Study: Two years

Local Co-investigator: Mwanza Research Centre of the Tanzania National Institute for Medical Research

Project Description: Over the past three years, many PEPFAR countries, including Tanzania, have

switched from a traditional model of social marketing HIV-related products (such as male condoms) to a

public-private partnership (PPP) model of shared responsibilities (for warehousing, distribution, etc.)

because of anticipated cost and opportunity benefits. Countries receiving PEPFAR support now need to

identify the most cost-effective interventions for HIV prevention to optimize the use of their own limited

resources. This study seeks to examine the cost-effectiveness of three methods of condom distribution to

high risk groups in Tanzania—free distribution through public health facilities, traditional social marketing,

and private-public partnership—to find ways to increase the cost-effectiveness of each approach and also to

explore the benefits, challenges and strengths of each method in achieving HIV prevention goals.

Evaluation Question: The primary questions are as follows:

1. What is the most cost-effective method of reaching high risk groups with condom interventions in different

segments of the affected population?

2. What are the costs and opportunity benefits associated with the public-private partnership model for

social marketing of HIV-related products as compared with the traditional model of social marketing?

3. What will be the relative saving to USG in using one method versus another?

Methods: Our team will develop a spreadsheet tool using Bernoulli and proportionate change models to

estimate the relative cost-effectiveness for the three HIV prevention interventions designed to change risk

behaviors of individuals—public free distribution of condoms, traditional social marketing, and public-private

partnerships. The team will also conduct sensitivity analyses to assess patterns of the cost-effectiveness

across different populations using various assumptions.

General Approach to Cost-effectiveness Estimation

The overall goal of this study is not to place one approach against another, as each of these complementary

approaches is important and targets different at-risk populations. Instead, the findings will demonstrate

ways to increase the cost-effectiveness of each approach.

The potential for real or perceived bias emanating from AED/T-MARC being involved in implementing the

PPP model in Tanzania will be avoided by collaboration with the Mwanza Research Center, a local research

institution entirely independent of T-MARC's activities. In collaboration with an external consultant, the

Mwanza Research Center staff will collect, analyze and report cost information from the three institutions.

The independent, external economist who will compile cost data and perform the cost effectiveness

analysis, will be made aware of all potential bias including the one of AED/T-MARC being one of the

implementing agencies. The team will work with PSI and GFTAM in selecting the external consultant for

this study.

The cost-effectiveness will be assessed by analyzing program/method costs which will include all resources

(purchased, donated, or volunteered) used to implement the intervention, but excludes any cost incurred by

the participants, unless they are reimbursed. The data will be obtained from financial and operational

reports of the T-MARC Company, Populations Services International (PSI) and The Global Fund to fight

AIDS, Tuberculosis and Malaria (GFATM) program in Tanzania. These are the only three major programs

for which reliable financial and operational costs data exist. The T-MARC project uses the PPP model,

GFATM uses both free distribution and traditional social marketing, and PSI uses traditional social

marketing exclusively.

The total number of HIV infections prevented includes those directly prevented by the intervention (primary

infections) and an estimate of the number of infections prevented in sex partners (secondary infections).

The secondary infections prevented are estimated by considering the prevalence of HIV in the sex partner

pool, multiplied by the number of sex partners and the risk of sexual transmission. The effectiveness of

each method will be estimated by the potential number of HIV infections prevented, and the cost is the

program cost of reaching people with a particular method. The cost-effectiveness ratio is Total program

cost of an intervention/Number of HIV cases prevented = Cost per HIV case prevented.

Estimates of HIV Infections Prevented

The estimate of the number of primary infections prevented will be based on subtraction of an estimate of

the number of HIV infections that would have happened if the prevention program had not been in place

from an estimate of the number of HIV infections that would have happened even with the program in place.

Applying the commonly used mathematical model, the Bernoulli model, each sex act is treated as an

independent event with a small, fixed probability that HIV is transmitted between members of a couple who

are discordant in their HIV status. From this per-act probability, the model then estimates the cumulative

probability that an uninfected individual with given sexual behaviors (number of partners, frequency of sex

acts) would become infected during a specified time period. The number of new HIV cases is determined by

the size of the population with given behaviors, the estimated number of discordant partnerships, and the

cumulative probability of transmission within these partnerships. Parameters measuring the effectiveness of

the interventions, such as changes in condom use or number of sex partners, will be drawn from selected

studies which report the type of condom used and sources of condoms, sexual practices and perception of

risk. We will explore other ways of apportioning the effectiveness based on an early desk review. The study

Activity Narrative: will take into account the potential overlap of activities performed by the three agencies. There are a

number of areas where this overlap is minimal. It is also possible to apportion the effectiveness based on

the volume of condoms distributed, using a mathematical model that controls for overlap in the distribution

and other variables such as distribution systems and behavior change communication intensity.

Estimates of Costs: Each method's costs will be considered as the total cost to the public health system to

implement the intervention. The final parameter to be used will be the program cost per person reached.

Costs will be broken down into capital costs, annualized and discounted across their life span, and recurrent

costs (direct costs of the program, and shared costs, appropriately apportioned using either budget

headings, total volume of product or total sales calls by agents).

The consultant and the Mwanza Center will conduct in-depth interviews with program staff. They will also

review financial reports and costing literature from elsewhere for quality assurance.

Comparisons of Cost-effectiveness and Sensitivity Analyses

We will first calculate the cost-effectiveness of each method using population figures from the Tanzania

AIDS Commission, Demographic Health Surveys (DHS) or data from the Adult Morbidity and Mortality

Project (AMMP). To have some comparability across the methods, we will standardize the duration of effect

to one year (2007) and assume that the effect found at the study end point (if it were less than one year)

would be sustained for one year. If the effect can only be measured at a follow-up time greater than 12

months, we will interpolate the benefit in a linear fashion to estimate the effect after 12 months.

Population of Interest: This will be a retrospective study of costs for the three programs described and will

not involve a traditional sampling strategy.

Information Dissemination Plan: Information dissemination and communication are critical to us and an

Information Resource Center (IRC) is soon to be developed to fulfill this role. The IRC will broker

information and serve as an access point for results. AED/T-MARC will also give presentations and

workshops at national and international AIDS conferences. A local final dissemination meeting will include

a wide audience of government, international organizations, and local organizations concerned with HIV

prevention.

Budget Justification: Staffing: The two-year total is $213,875; a 10 percent rate will add $21,387. This

includes: one pooled AED/T-MARC Company Senior Level Monitoring and Evaluation Staff for 100 days per

year in Years 1 and 2, daily rate $146. Two senior staff, one Economist/cost analyst Consultant and one

field Research Officer from Mwanza Center for 100 days per year for Years 1 and 2. The Economist/cost

analyst has a daily rate of $378 and the Research Officer has a daily rate of $154. A Senior Technical

Advisor will provide technical consultation as needed for 30 days per each year daily rate $1,304.

Travel: $25,840; general office supplies total $3600 at $150 per month plus 4 PDAs and car chargers $660;

additionally, T-MARC charges $750 annually for facilities and computer usage, totalling $1500. T-MARC

charges a 2% fee of $4,580 brings the total required budget to $271,772 for two years. All taxes and

service fees are included in the costs.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16370

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16370 16370.08 U.S. Agency for Academy for 6487 1175.08 $135,000

International Educational

Development Development

Emphasis Areas

Human Capacity Development

Public Health Evaluation

Estimated amount of funding that is planned for Public Health Evaluation $135,656

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.03: