This giving opportunity is a sensitive one. It would be difficult for the US Agency for International Development to proclaim that their number one priority was the provision of condoms to foreign prostitutes, but that is precisely what they should do. In fact, in a backwards step, the US governement requires organizations receiving HIV/AIDS funding to explicitly oppose prostitution. On the other hand The Bill and Melinda Gates Foundation has proven wiser and is replicating the Kolkata Durbar sex worker HIV project to other states in India.
Imagine a terrorist about to detonate a bomb that will kill 100 people that happen to be nearby. How many billions of dollars should the government spend to stop that terrorist? Now imagine a prostitute infected with HIV that will kill 100 clients, as well as the "innocent" spouses of those clients. How much should the government spend to stop them? The answer would seem to be as close to zero as is imaginable. I have searched, and checked with Funders Concerned About AIDS but amongst U.S. NGOs, I am not aware of a single 501(c)3 charitable organization that focuses solely on HIV prevention amongst sex workers, despite this having a huge charitable payoff.
Reported effectiveness of programs for sex workers is:
- above, Nairobi, Kenya, $8-12/case averted
- Modelling the impact and cost-effectiveness of the HIV intervention programme amongst commercial sex workers in Ahmedabad, Gujarat, India, Ahmedabad, India, $56-219/case averted
- Disease Control Priorities Project reports on the cost effectiveness of intervention as $6-68/DALY for an education only programs; however since the prevelance rates are unknown and the targeted groups also include students we do not consider these results any further
- Bill and Melinda Gates Foundation Avahan project, India, $1,200-$10k/case averted (BBC cost of project $258m; Lancet infections prevented over 5 years 26k-208k); project also targets injection drug users, truck drivers
The difference between the effectiveness of the different programs is probably primarily a result of the difference in these countries HIV infection rates. An intervention program will be far more effective when the HIV prevalance rate is high. In Kenya the sex worker HIV prevelance rate is 81% in 1986 to below 50% after 1997 for Nairobi, which we linearly approximate as 67% (circa 1991; the time of the reported Nairobi cost-effectiveness paper), in Ahmedabad the sex worker HIV prevelance rate is 12% (1999). In India overall according to UNAIDS the sex worker HIV prevelance is 4.9% (as retrieved 2011).
HIV prevention
$50-500/case averted
prevent 1 HIV infection
Scaling the Ahmedabad infection rate to that of Kenya gives a $10-39/case averted range. Very roughly scaling the Avahan project using the all of India sex worker infection rate gives $90-$730/case averted. Combining the Kenya, Ahmedabad, and Avahan data, and weighting towards Avahan because it seems more credible, it seems reasonable to assume the actual cost per case averted in an HIV endemic country is probably somewhere in the $50-500/case averted range.
$2m/case averted
4,000 - 40,000 in a HIV endemic population