A risky business
Authors: Zoë Mullan
Journal: The Lancet Global Health (2014)

In a world full of seemingly intractable problems, health-related and otherwise, knowing where to start or what to prioritise can be daunting. One of the principles by which to allocate scarce medical resources is to focus on the worst off—ie, the sickest. In a prevention context, this might translate to the most at risk. The diverse research articles in this month's issue follow this philosophy.In their analysis of Demographic and Health Surveys from 54 low-income and middle-income countries, Rishi Caleyachetty and colleagues estimate the prevalence of tobacco use (both smoked and smokeless) in pregnant women. These individuals are doubly at risk. First, their status as pregnant clearly puts them in a category where harm is at its maximal. The damage caused by maternal tobacco use in terms of pregnancy complications, stillbirth, prematurity, low birthweight, and sudden infant death syndrome hardly needs repeating. But women of childbearing age in low-income and middle-income countries, pregnant or not, are also at risk because—as a potential “growth market”—they are firmly in the cross-hairs of Big Tobacco. Caleyachetty and colleagues' finding of a low overall prevalence of tobacco use in pregnant women from these countries (around 2·6%) should be taken as a baseline from which to work hard to improve, and not a reassuring confirmation of a non-issue.High-risk groups were the target of the south Indian HIV prevention programme, Avahan. Implemented across six states between 2004 and 2008, the intervention involved services such as peer-led outreach, education, and condom distribution; free treatment of sexually transmitted infections (STIs); and free supplies of condoms and STI drugs. The aim was to prevent HIV infection among female sex workers and their clients, men who have sex with men, and injecting drug users. A previous study in this journal demonstrated the population-level effectiveness of the programme; Anna Vassall and colleagues now reveal that it was also good value for money. The researchers estimate a mean incremental cost per disability-adjusted life-year averted of $46. As Elliot Marseille and James Kahn state in their accompanying Comment, this figure is “roughly on par with the provision of insecticide-treated bednets to prevent malaria; diarrhoeal disease prevention with the promotion of hygiene practices; volunteer paramedic training in emergency care; and the provision of childhood immunisation against tuberculosis, diphtheria, polio, and measles”. It is a welcome affirmation of the cost-effectiveness of targeted population prevention of HIV.Finally, to an unwitting group at high risk of transmitting hepatitis C virus (HCV). Egypt has the highest prevalence of HCV infection in the world. 15% of people aged 15–59 years are estimated to be infected, mainly as a result of contaminated medical equipment used to give mass treatment for schistosomiasis in the 1960–80s. The current transmission status is unknown, as is whether the present national control strategy is likely to be effective. A modelling study by Romulus Breban and colleagues indicates that, without treatment, the HCV epidemic in Egypt is self-sustaining—ie, transmission would continue even after all those originally infected died. The drivers of this sustained transmission, the model suggests, are individuals who undergo more than the mean number of medical injections per year and who pass on the virus via suboptimal safety practices within health-care facilities. Simulations indicate that the present screening and subsidised treatment strategy, which only covers Ministry of Health and Population facilities (and thus only 30% of the population), will not interrupt transmission. What is likely to be most effective is a strategy that targets the high-risk group of multiple injectors within 2·5 years of chronic infection. Will the Egyptian Government take heed? Breban speculates about this in a linked podcast.Being aware of what puts us at risk is a basic prerequisite of any programme to help us mitigate those risks. But what if we don't trust the people who are identifying them? What if we suspect them of being part of the problem? Consider the situation in west Africa where a terrible breakdown in trust seems to be thwarting efforts to contain the spread of Ebola. In his blog post, Francis Omaswa, who led Uganda's response to the previously largest outbreak, outlines his recipe for regaining trust. He recommends harnessing the media via regular in-person press conferences, and recruiting community leaders in control efforts. That communication and societal involvement is key to risk reduction is hardly revelatory. But when medical resources are scarce, or a crisis emerges, they can be forgotten weapons in the armamentarium. In a world full of seemingly intractable problems, health-related and otherwise, knowing where to start or what to prioritise can be daunting. One of the principles by which to allocate scarce medical resources is to focus on the worst off—ie, the sickest. In a prevention context, this might translate to the most at risk. The diverse research articles in this month's issue follow this philosophy. In their analysis of Demographic and Health Surveys from 54 low-income and middle-income countries, Rishi Caleyachetty and colleagues estimate the prevalence of tobacco use (both smoked and smokeless) in pregnant women. These individuals are doubly at risk. First, their status as pregnant clearly puts them in a category where harm is at its maximal. The damage caused by maternal tobacco use in terms of pregnancy complications, stillbirth, prematurity, low birthweight, and sudden infant death syndrome hardly needs repeating. But women of childbearing age in low-income and middle-income countries, pregnant or not, are also at risk because—as a potential “growth market”—they are firmly in the cross-hairs of Big Tobacco. Caleyachetty and colleagues' finding of a low overall prevalence of tobacco use in pregnant women from these countries (around 2·6%) should be taken as a baseline from which to work hard to improve, and not a reassuring confirmation of a non-issue. High-risk groups were the target of the south Indian HIV prevention programme, Avahan. Implemented across six states between 2004 and 2008, the intervention involved services such as peer-led outreach, education, and condom distribution; free treatment of sexually transmitted infections (STIs); and free supplies of condoms and STI drugs. The aim was to prevent HIV infection among female sex workers and their clients, men who have sex with men, and injecting drug users. A previous study in this journal demonstrated the population-level effectiveness of the programme; Anna Vassall and colleagues now reveal that it was also good value for money. The researchers estimate a mean incremental cost per disability-adjusted life-year averted of $46. As Elliot Marseille and James Kahn state in their accompanying Comment, this figure is “roughly on par with the provision of insecticide-treated bednets to prevent malaria; diarrhoeal disease prevention with the promotion of hygiene practices; volunteer paramedic training in emergency care; and the provision of childhood immunisation against tuberculosis, diphtheria, polio, and measles”. It is a welcome affirmation of the cost-effectiveness of targeted population prevention of HIV. Finally, to an unwitting group at high risk of transmitting hepatitis C virus (HCV). Egypt has the highest prevalence of HCV infection in the world. 15% of people aged 15–59 years are estimated to be infected, mainly as a result of contaminated medical equipment used to give mass treatment for schistosomiasis in the 1960–80s. The current transmission status is unknown, as is whether the present national control strategy is likely to be effective. A modelling study by Romulus Breban and colleagues indicates that, without treatment, the HCV epidemic in Egypt is self-sustaining—ie, transmission would continue even after all those originally infected died. The drivers of this sustained transmission, the model suggests, are individuals who undergo more than the mean number of medical injections per year and who pass on the virus via suboptimal safety practices within health-care facilities. Simulations indicate that the present screening and subsidised treatment strategy, which only covers Ministry of Health and Population facilities (and thus only 30% of the population), will not interrupt transmission. What is likely to be most effective is a strategy that targets the high-risk group of multiple injectors within 2·5 years of chronic infection. Will the Egyptian Government take heed? Breban speculates about this in a linked podcast. Being aware of what puts us at risk is a basic prerequisite of any programme to help us mitigate those risks. But what if we don't trust the people who are identifying them? What if we suspect them of being part of the problem? Consider the situation in west Africa where a terrible breakdown in trust seems to be thwarting efforts to contain the spread of Ebola. In his blog post, Francis Omaswa, who led Uganda's response to the previously largest outbreak, outlines his recipe for regaining trust. He recommends harnessing the media via regular in-person press conferences, and recruiting community leaders in control efforts. That communication and societal involvement is key to risk reduction is hardly revelatory. But when medical resources are scarce, or a crisis emerges, they can be forgotten weapons in the armamentarium. Avahan and the cost-effectiveness of “prevention as prevention”Avahan, the India AIDS Initiative funded by the Bill & Melinda Gates Foundation, is one of the largest HIV prevention programmes targeted to populations at high risk of infection. The initiative operated across 22 districts and committed US$258 million from 2004 to 2009, reaching 154 425 individuals. Through work with non-governmental organisations (NGOs), and a focus on peer-led interventions, it offered a package of services that included risk-reduction education, access to condoms, screening and treatment for sexually transmitted infection, and referral to clinical services as appropriate. Full-Text PDF Open AccessTobacco use in pregnant women: analysis of data from Demographic and Health Surveys from 54 low-income and middle-income countriesOverall, tobacco use in pregnant women in LMICs was low; however high prevalence estimates were noted in some LMICs. Prevention and management of tobacco use and exposure to second-hand smoke in pregnancy is crucial to protect maternal and child health in LMICs. Full-Text PDF Open AccessCost-effectiveness of HIV prevention for high-risk groups at scale: an economic evaluation of the Avahan programme in south IndiaThis study provides evidence that the investment in targeted HIV prevention programmes in south India has been cost effective, and is likely to be cost saving if a commitment is made to provide ART to all that can benefit from it. Policy makers should consider funding and sustaining large-scale targeted HIV prevention programmes in India and beyond. Full-Text PDF Open AccessEffect of preventive and curative interventions on hepatitis C virus transmission in Egypt (ANRS 1211): a modelling studyTargeting preventive and curative interventions to individuals with high rates of medical injections in Egypt would result in a greater reduction the spread of HCV than would untargeted allocation. Such an approach might prove beneficial in other resource-limited countries with health-care-driven epidemics. Full-Text PDF Open AccessAssessment of the population-level effectiveness of the Avahan HIV-prevention programme in South India: a preplanned, causal-pathway-based modelling analysisThis is the first assessment of Avahan to account for the causal pathway of the intervention, that of changing risk behaviours in female sex workers and high-risk men who have sex with men to avert HIV infections in these groups and the general population. The findings suggest that substantial preventive effects can be achieved by targeted behavioural HIV prevention initiatives. Full-Text PDF Open Access