title: Effectiveness and Efficiency of Improving HIV Service Provision for Key Populations in Nicaragua.
abstract: OBJECTIVE
  HIV in Nicaragua is concentrated among key populations (KPs) - men who have sex with men, female sex workers, and female transgender - in whom prevalence is 600-4,000 times higher than the general population. The United States Agency for International Development PrevenSida project is aimed at increasing healthy behavior among KPs and people with HIV and improving testing, counseling, and continuity of prevention and treatment by building capacity and improving performance of non-governmental organizations (NGOs) providing services to KPs. We evaluated the cost-effectiveness of PrevenSida's activities.
  
  
  METHODS
  This retrospective observational evaluation used individuals in KPs covered by NGOs receiving assistance from PrevenSida from 2012 to 2014. Cost-effectiveness analysis compared PrevenSida's intervention with business-as-usual. Model inputs were generated from epidemiological modeling and PrevenSida's records.
  
  
  RESULTS
  By 2014, 24 NGOs received grants and technical assistance from PrevenSida with 72,955 people in KPs served at $11.32/person ($9.39-$16.55/person, depending on region). The estimated incremental cost-effectiveness ratio was $50,700/HIV case averted or $2,600/Disability-adjusted Life Year (DALY) averted (95% CI: $1,000-$99,000 and $50-$5,100, respectively).
  
  
  CONCLUSIONS
  PrevenSida distributed about $600,000 in grants and used $230,000 to support 24 NGOs in 2014. Cost-effectiveness from the program perspective compared to no program was slightly over half of GDP per capita per DALY averted, considered highly cost-effective by WHO criteria. Cost and efficiency varied by region, reflecting the number of people in KPs receiving services. Cost-sharing by NGOs improved cost-effectiveness from the program perspective and likely promotes sustainability. Focused interventions for KP service provision organizations can be acceptably efficient in this setting.
authors.affiliation: Research and Evaluation, USAID ASSIST Project, University Research Co., Bethesda, MD, USA; International Health Associate, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Edward Ivor
authors.initials: EI
authors.lastname: Broughton
authors.affiliation: PrevenSida Project, USAID, University Research Co. , Managua , Nicaragua.
authors.forename: Oscar
authors.initials: O
authors.lastname: Nunez
authors.affiliation: PrevenSida Project, USAID, University Research Co. , Managua , Nicaragua.
authors.forename: Rafael
authors.initials: R
authors.lastname: Arana
authors.affiliation: PrevenSida Project, USAID, University Research Co. , Managua , Nicaragua.
authors.forename: Alexey
authors.initials: A
authors.lastname: Oviedo
keywords: HIV infections; Nicaragua; cost efficiency analysis; vulnerable populations