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One of our major goals for 2017 is “intervention prioritization,” our work to assess a large number of programs (interventions) as potential GiveWell priority programs we’d be interested in recommending charities working on.

Summary

This post will provide a brief overview of our intervention work this year, focusing on the interim and full intervention reports we’ve published in 2017.

Programs we plan to continue investigating:

• Sayana® Press
• Antiretroviral Therapy to Treat HIV/AIDS
• SMS Reminders for Vaccination
• Surgery to Repair Obstetric Fistula
• Interventions to Promote Handwashing

Programs we decided not to prioritize additional research on:

• Distribution of Eyeglasses in Developing Countries
• Oral Pre-exposure Prophylaxis (PrEP) for HIV

Intervention prioritization process

We aim to do low-intensity research on a large number of promising interventions as part of our intervention prioritization work. We typically start by spending a few hours assessing a program before deciding whether to move forward with a more intense (say, 20-40 hour) “interim intervention report.” If the program looks promising following an interim intervention report, we’ll move on to a full intervention report, which generally involves about 80-200 total hours of work. We may do additional research after this point, as well, as we did with David Roodman’s research on deworming, one of GiveWell’s priority programs, last year.

Priority programs

This section will discuss programs we have researched in 2017 and see as promising.

Sayana® Press

Sayana® Press is an injectable contraceptive in a prefilled single-use package. We decided to look into Sayana® Press after a charity described the program to us as a potential GiveWell priority program. Sayana® Press seemed promising because community health workers or recipients themselves may be able to administer it, which could make it a viable contraceptive for women without regular access to health facilities. Sayana® Press, a single injection of which is intended to provide protection for three months, also requires less frequent adherence than daily birth control pills. Our initial estimate suggests that family planning programs involving Sayana® Press have the potential to be be in the same range of cost-effectiveness as our current top charities.

After this review, we prioritized initial investigation of charities that work on family planning programs.

Read our report on Sayana® Press here.

Antiretroviral Therapy to Treat HIV/AIDS

Antiretroviral therapy (ART) refers to using a combination of drugs to treat (not cure) human immunodeficiency virus (HIV) to increase life expectancy for those who have the disease and to reduce HIV transmission rates. We prioritized investigating ART as we learned that it had become more cost-effective (due to falling prices) and because of our perception that despite significant funding for ART, funding gaps remain. If that were the case, we’d be interested in identifying giving opportunities that demonstrate they are filling such gaps, similar to how the GiveWell top charity the Against Malaria Foundation works in the insecticide-treated net space.

We’re in the process of having conversations with charities that implement ART programs to better understand whether a funding gap for direct delivery of ART exists. If there is room to fund marginal direct ART delivery, our key question will be around patient adherence rates to treatment when charities implement this program. We will want to see strong monitoring from charities to demonstrate that outcome.

Read our report on ART here.

SMS Reminders for Vaccination

We’re trying to grow the pipeline of potential future GiveWell top charities through our GiveWell Incubation Grant program. We funded Charity Science Health with an Incubation Grant for its program to send Short Message Service (SMS) messages to caregivers’ cell phones to remind them of upcoming vaccination dates for young children. We decided to investigate SMS reminders for vaccination as part of our ongoing review into Charity Science Health’s work and our impression that this intervention had the potential to be highly cost-effective.

The available randomized controlled trial (RCT) evidence on the program, upon which GiveWell generally places high weight, varies quite a bit and we’re hesitant to generalize from the findings. We don’t expect to recommend SMS reminders for vaccination based on the existing evidence. In order to recommend Charity Science Health as a top charity, we would likely require additional independent evidence for the program or an RCT of Charity Science Health’s program in particular.

Read our report on SMS reminders for vaccination here.

Surgery to Repair Obstetric Fistula

In 2016 and 2017, we decided to revisit the evidence for promising corrective surgery programs, including the evidence for surgery to repair obstetric fistula.

An obstetric fistula is an abnormal opening between the vagina and bladder or rectum that typically results from prolonged obstructed labor. Our impression is that fistula can have a very negative impact on well-being and that some obstetric fistulas may be repaired with surgery.

We have a number of open questions about this intervention, including the success of surgery in (a) closing the fistula and (b) leading to improved psychosocial outcomes. Fistula management programs may also involve other activities, such as outreach to women with fistula, training surgeons, and counseling. We would like to better understand the impact of these activities on improving life outcomes as well as their cost.

We are working with IDinsight to closely examine a Fistula Foundation program to better understand the cost-effectiveness of this work. If the cost-effectiveness appears to be in the range of our other priority programs, we will then work with IDinsight to identify organizations with which they can develop improved monitoring to help us answer our remaining questions about patient outcomes.

Read our report on surgery to repair obstetric fistula here. We have also published a blog post on our work in this space.

Interventions to Promote Handwashing

We understand that washing hands can remove pathogens that transmit infectious diseases. We investigated a variety of interventions intended to promote handwashing, including hygiene education and the distribution of posters and leaflets.

We looked for RCTs of the impact of handwashing on reducing diarrhea, pneumonia, and worm infections, as well as the impact handwashing might have on improving nutrition (via reducing diarrhea). While we did see some evidence of a reduction in diarrhea incidence and pneumonia, we have not seen strong evidence for the impact of promoting handwashing on worm infections or nutrition indicators. Research was conducted on a variety of approaches to promote handwashing and the results were heterogeneous, such that we couldn’t draw generalizable conclusions from the literature.

To consider groups working on handwashing promotion for a potential GiveWell recommendation, we would need to learn more about their individual activities and monitoring, which could also give us better information with which to assess their cost-effectiveness.

Read our report on interventions to promote handwashing here.

Other programs considered

Distribution of Eyeglasses in Developing Countries

We reviewed the evidence for providing free or subsidized eyeglasses to individuals with poor vision. We saw some evidence that offering free corrective eyeglasses to children has some effect on test scores; we did not find strong evidence assessing whether distributing eyeglasses increased economic productivity in the short or long run. We decided not to move forward with our research and do not consider the distribution of eyeglasses a GiveWell priority program. If we were to come to the conclusion that increasing test scores reliably led to improved life outcomes, we would likely revisit our conclusion about eyeglasses interventions.

Read our report on eyeglasses distribution here.

Oral Pre-exposure Prophylaxis (PrEP) for HIV

Oral pre-exposure prophylaxis (PrEP) is the use of antiretroviral drugs by HIV-negative individuals to prevent HIV acquisition. We think the evidence that PrEP reduces HIV acquisition rates among high-risk individuals is strong, but we have not found evidence that large-scale charity programs have successfully increased PrEP coverage rates in sub-Saharan Africa. Our latest cost-effectiveness estimate for this program suggests that PrEP programs are less cost-effective than voluntary medical male circumcision (VMMC) for preventing new HIV infections, though there are a few key parameters about which we’re uncertain. We are not planning to prioritize additional work on this program at this time, but would revisit our conclusion if charities provided us with information that could substantially change our cost-effectiveness estimate for PrEP programs.

Read our full report on oral pre-exposure prophylaxis to prevent HIV here.

Conclusion

Reviewing a large number of interventions is a major research priority for GiveWell in 2017. A separate post will discuss our “intervention prioritization” work in detail.