Paul Hutchinson, Josh Yukich, Jennifer Wheeler
Tulane University

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Since the onset of the HIV/AIDS epidemic, Behaviour Change
Communication interventions using mass media have been standard components of many countries’ HIV/AIDS prevention and treatment programs.
In spite of their ubiquity, such programs often lack rigorous evaluations because of:
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Challenges in implementing evaluation designs with strong internal and external validity
Program exposure that is frequently beyond the control of researchers
Mass media which may cover entire countries leaving all but a nonrandom sample of the population unexposed to messages.
Even rarer are rigorous evaluations linking costs to programmatic effects, i.e., economic evaluations

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Cohen et al (2004): HIV/AIDS mass media, $2 per person, $18,000 per case prevented per year
Hutton et al (2003): mass media and peer group education of highrisk men and young people, $500 per infection prevented
Kumaranayake et al (2004): $359 per infection averted (needle distribution)
Kincaid and Parker (2008): HIV/ AIDS communication campaign -> reduction of > 700,000 HIV cases averted; lifetime savings in treatment costs US$5.6 billion or annual costs of US$260,000,000
Muirhead, Kumaranayake and Watts (2001), who constructed knowledge, intention, and action scales to assess the costeffectiveness of the 4th Soul City Series but did not make a link to health outcomes.
West (2011): $1,625 / infection averted (Lesotho); $591 / case averted
(South Africa)

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Pakachere Institute for Health & Development Communication ran the OneLove campaign starting in 2008/9 focusing principally on multiple concurrent partnerships (MCP)
 Used print media, radio and television education entertainment and other media messaging
Campaign Objectives:
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To increase uptake of HIV testing and treatment
To reduce risk behaviors associated with HIV transmission
To reduce HIV-related stigma in the youth and adult populations in
Malawi.
Involved a number of partners, including: faith-based community, the private and public sector, non-governmental organisations
(NGOs)
Part of the Regional Programme of the Southern Africa Social and
Behavior Change Communication, which spanned 8 countries
Source: http://www.pakachere.org/group-item/program/one-love/

Objective:
 To collect program-level financial data to estimate the total resources used in developing and delivering the specific mass media interventions of Pakachere over the period 2008-11.
Details:
 Used a narrow programmatic perspective
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 Omitted private household costs / benefits, costs of treatment averted, additional productivity
Overhead costs were apportioned among different interventions (e.g., print media, radio programs and television programs) in proportion to the share of each intervention in total direct costs.
All costs were adjusted for local inflation and calculated in end year
(2011) values.
Converted expenditures from South African Rand to English pounds and US dollars using historical exchange rates gathered from OANDA

Program Items
Print Formative audience research, stakeholder workshops; Development costs (writing, translation, editing, testing); Printing costs (design and reproduction, transportation); Distribution
Radio Research and Audience Reception Evaluation; Development costs
(writing, translation, editing); Production costs (recording, sound effects, Production Manager); Post-production (editing, mixing); Air time
Television Piloting, Development and Production; TV Air time; TV Audience reception; dubbing
Overhead Marketing; Evaluation; Operational Costs (office costs; personnel);
Travel and accommodation; Technical Support; Advocacy

Intervention Amount % of Total
Print
Television
Radio
Total
$ 2,068,555
$ 247,203
$ 655,040
$ 2,970,798
69.6%
8.3%
22.0%
100.0%

Objective
 To ascertain the effects of Pakachere interventions on condom use, HIV testing, and MCP, while controlling for potential confounding influences
Details
 Post-only evaluation comparing outcomes for self-reported exposed and unexposed individuals
 Used data from a nationally representative household survey of 5,149 adults aged 15-49 years.
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 Survey focused on HIV/AIDS-related behaviors and exposure to HIV/AIDS BCC interventions (both Pakachere and other BCC)
Used multivariate regression analysis to attribute observed differences in behaviors to exposure to Pakachere interventions.
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Probit models and propensity score matching
Test for non-random (endogenous) exposure
Used marginal effects from multivariate analyses as measures of changes in behavioral outcomes
Used Markov modeling to translate behavior change into Disability Adjusted
Life Years averted
 Only statistically significant parameters included in the Markov model; otherwise, behavioral parameters set to zero (or equal to the no-intervention scenario)

Measures
OneLove radio: Binary outcome indicating exposure to any OneLove radio shows or
Meet Joe.
One Love booklets: Binary outcome indicating exposure to any of the following:
“Sexual partners and your lives,” “Love and Satisfaction,” “You Haven’t Met Joe,”
Okondedwa athu ndi Moyo wathu, Kukondana ndi Kukwaniritsana
OneLove Television: Binary outcome indicating exposure to any of the following: Love
Stories in the Time of HIV and AIDS, the OneLove talk show, or Untold Stories.
OneLove multimedia: Categorical variable representing intensity of exposure to
OneLove activities. The three levels correspond to the number of media channels through which the respondent was exposed to OneLove interventions, including exposure to OneLove booklets, One Love radio programs, Meet Joe adverts, Love
Stories in the time of HIV, Untold Stories, OneLove talk show. Those coded as low were exposed to one of the following: radio, TV, or booklets. Individuals coded high were exposed to any two media channels.

R i
F
E
N
M j
𝑃
P
𝐻𝐼𝑉−1 𝑖𝑗
= Probability of becoming infected with HIV-1 during a given year
= average HIV-1 prevalence among the population of sex partners of the target population
= risk of HIV-1 transmission per act of unprotected sex (infectivity)
= proportion of sex acts in which a condom is used
= efficacy of condoms at prevention of HIV-1 transmission
= number of sex acts per partner
= average number of sexual partners per person per year
= age group
= risk category of the individual
Source: Sweat, M., S. Gregorich, G. Sangiwa, C. Furlonge, D. Balmer, C. Kamenga, O. Gristead,
T. Coates, “Cost-effectiveness of voluntary HIV-1 counseling and testing in reducing sexual transmission
Of HIV-1 in Kenya and Tanzania,” The Lancet, Vol 356, July 8, 2000.

Parameter Estimate Source
P (HIV adult 15-49 prevalence)
R (infectivity per sex act)
E (condom efficacy)
M (number of partners per year) (Regular Risk 1)
M (number of partners per year) (Regular Risk 2)
M (number of partners per year) (Regular Risk 3)
M (number of partners per year) (Casual Risk 1)
M (number of partners per year) (Casual Risk 2)
M (number of partners per year) (Casual Risk 3)
M (number of partners per year) (Commercial Risk 1)
M (number of partners per year) (Commercial Risk 2)
M (number of partners per year) (Commercial Risk 3)
N (number of sex acts per partner per year) (Regular)
N (number of sex acts per partner per year) (Casual)
N (number of sex acts per partner per year) (CSW)
Percent of Population (Age Group 1)
Percent of Population (Age Group 2)
Percent of Population (Age Group 3)
Percent of Population (Risk Group 1)
Percent of Population (Risk Group 2)
Percent of Population (Risk Group 3)
0.11
0
0
1
66.5
23.8
39.4
0.43
0.33
0.0034
0.95
1
1
1
1
1
0
0.24
0.90
0.07
0.03
UNAIDS
Boily et al
Sweat et al (2000)
Assumption
Assumption
Assumption
Assumption
Assumption
Assumption
Assumption
Assumption
Assumption
PSI DALY Model
PSI DALY Model
PSI DALY Model
Malawi 2008 Census
Malawi 2008 Census
Malawi 2008 Census
Malawi Data
Malawi Data
Assumed

Estimate Source Type of
Parameter
Mortality
Probabilities with
HIV
Parameter
Age Group 1
Age Group 2
Age Group 3
Age specific
Mortality Rates
(per year) under 24 (Age Group 1)
25-34 (Age group 2)
35+ (Age Group 3)
Lifetimes with HIV
(years)
15-24 (Age Group 1)
25-34 (Age Group 2)
35+ (Age group 3)
0.058
0.063
0.073
0.0046
0.0091
0.0119
12
11
9.5
Estimated
Estimated
Estimated
Malawi 2008 Census
Malawi 2008 Census
Malawi 2008 Census
Actuarial Society of
South Africa
Actuarial Society of
South Africa
Actuarial Society of
South Africa

Parameter Estimate Source
Average Number of Sex acts per partner (Regular)
Average Number of Sex acts per partner (Casual)
Average Number of Sex acts per partner (Commercial)
Proportion of sex acts where a condom was used (Risk 1) (F)
Proportion of sex acts where a condom was used (Risk 2)
Proportion of sex acts where a condom was used (Risk 3)
Probability of Condom use with regular partner
Probability of Condom use with casual partner
Probability of Condom use with CSW
Prevalence of HIV-1 among low risk group (Risk 1)
Prevalence of HIV-1 among moderate risk group (Risk 2)
Prevalence of HIV-1 among CSW
P (Risk 1)
P (Risk 2)
P (Risk 3)
E (Condom efficacy)
DALYs Averted per infection averted
Effect of VCT on Condom Use (Odds Ratio)
Baseline VCT
0.11
0.11
0.21
0.95
20
1.69
0.755
66.5
45.15
43.2
0.05
0.20
0.33
0.05
0.62
0.62
0.11
0.11
0.43
Calculated
Calculated
Calculated
Estimated
Estimated
Estimated
Malawi data
Malawi data
Assumed from
Malawi data
UNAIDS
UNAIDS
Est. from UNAIDS and PSI formulation
UNAIDS
UNIADS
Estimated
Sweat et al
Estimated
Denison et al
Malawi Data

$1,60
$1,46
$1,40
$1,20
$1,00
$0,80
$0,60
$0,40
$0,20
$-
$0,46
$0,16
$0,72
Print
N=1,432,303
TV
N=631,470
Radio
N=4,026,211
Multimedia
N=4,061,764

a
0.0000
0.000
0.000
0.000
0.000
0.0000
0.000
0.000
0.0000
0.000
0.000
0.000
a Coefficients are the marginal effects from multivariate regression models controlling for
Endogenous exposure to interventions. Non-zero coefficients represent effects that are statistically
Significant at better than the 5% level.

$30,00
$25,00
$20,00
$15,00
$10,00
$5,00
$-
$15,41
$7,79
$4,27
$2,15
Print TV Radio
$24,08
$11,98
Multimedia
5-Year
10-Year

$60,00
$50,00
$48,16 $48,30
$40,00
$30,82 $29,74
$30,00
$24,08
$20,00
$10,00
$-
$15,41 $15,73
$8,53
$4,27
$8,24
$4,35
$4,10
$2,02 $2,03
Print TV Radio Multimedia
5-Year Doubling Financial Costs
50% reduction in condom use ME 50% reduction in effects on testing

Intervention
VCT
VMMC
Print
Television
Radio
Multimedia
Cost per person
$7-$11
$74-$90
$1.46
$0.40
$0.16
$0.72
Cost per infection averted
$1,315 a
$306-$1,216; b
$176-$3,554 c
$0.77
$0.21
$0.10
$1.20
Cost per
DALY averted
$65.75
$15.30-$60.80
$8.80-$177.70
$15.41
$4.27
$2.02
$24.08
a Behrman and Kohler, (2011); b Njeuhmeli, Forsythe, et al (2011); c Gray, Kigozi et al (2007)

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We are grateful to Esca Scheepers for her comments, suggestions, and guidance with the conceptualization, design, evaluation and analysis. We thank Soul City
Institute colleagues Sue Goldstein, Bongiwe Ndondo, Renay Weiner, and Michael
Jana, who contributed their regional experience to the evaluation. We also thank
Katia Da Silva and Eugene Strydom for compiling the information on the costs of the Soul City program. Data collection for the household survey was led by Susan
Cotts Watkins and Invest in Knowledge Initiative. We would like to thank Susan
Watkins, Senior Research Scientist at the California Center for Population
Research, Peter Fleming, Executive Director of IKI, Mike Dalious, Research
Director of IKI and James Mkandawire, Assistant Research Director. We would also like to thank Stephane Helleringer for designing the sampling scheme and
Kingsley Manda of the National Statistics Office, Malawi for assistance in selecting the sample. Finally, we would like to thank DFID for their support of this evaluation, particularly Petra Nahmias, Anna Seymour, Dirk Mueller, Liz Harmer, and Max Gasteen. Useful comments on earlier drafts have been provided by
Lesong Conteh, Alan Whiteside, Dirk Mueller, Anna Seymour and Jane Bertrand.

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Creese, A., K. Floyd, et al. (2002). "Cost-effectiveness of HIV/AIDS interventions in Africa: a systematic review of the evidence." Lancet 359(9318): 1635-1643.
Denison, J. A., K. R. O'Reilly, et al. (2008). "HIV voluntary counseling and testing and behavioral risk reduction in developing countries: a meta-analysis, 1990--2005." AIDS Behav 12(3): 363-373.
Drummond, M. F., M. J. Sculpher, et al. (2005). Methods for the Economic Evaluation of Health Care
Programmes. Oxford, United Kingdom, Oxford University Press.
Hutton, G., K. Wyss, et al. (2003). "Prioritization of prevention activities to combat the spread of
HIV/AIDS in resource constrained settings: a cost-effectiveness analysis from Chad, Central Africa."
Int J Health Plann Manage 18(2): 117-136.
Kincaid, D. L. and W. Parker (2008). National AIDS Communication Programmes, HIV Prevention
Behaviour, and HIV Infections Averted in South Africa, 2005 Pretoria, South Africa, JHHESA.
Muirhead, D., L. Kumaranayake, et al. (2001). Economically Evaluating the 4th Soul City Series: Costs and Impact on HIV/AIDS and Violence Against Women. Johannesburg, South Africa, Centre for
Health Policy, University of Witswatersrand and Health Policy Unit, London School of Hygiene and
Tropical Medicine.
Sweat, M., S. Gregorich, G. Sangiwa, C. Furlonge, D. Balmer, C. Kamenga, O. Gristead, T. Coates,
“Cost-effectiveness of voluntary HIV-1 counseling and testing in reducing sexual transmission of HIV-
1 in Kenya and Tanzania,” The Lancet , Vol 356, July 8, 2000.
Walker, D. (2003). "Cost and cost-effectiveness of HIV/AIDS prevention strategies in developing countries: is there an evidence base?" Health Policy Plan 18(1): 4-17.
Watkins, S. C., Invest in Knowledge, et al. (2012). External Evaluation of the Southern African Regional Social and
Behaviour Change Communication Programme, as Implemented in Malawi. Zomba, Malawi, Invest in Knowledge.
West, P. (2010). Cost-Effectiveness of Regional HIV and AIDS Behaviour Change Communication (BCC) Programme.