A report on the Zimbabwe Antiretroviral Therapy (ART) programme progress towards achieving MGD6 target 6B: achievement and challenges

Zimbabwe's target to achieve Universal Access to treatment for HIV and AIDS, was severely affected by a decade long economic recession that threatened to reverse all the country's social and economic indicators. Despite these challenges, by September 2010, 282,916 adults and children (47.7% of those in need of treatment) were on treatment at 509 sites countrywide since national scale up started. ART services are predominantly offered through the public sector, with the private sector being an untapped potential resource for ART services for the future. Challenges of skilled and adequately trained human resources have hindered progress towards service availability. Providing access to children in particular has been constrained by lack of clinical mentorship for health workers, weak systems for support supervision, and inadequate HIV diagnostic services especially for children under 18 months and challenges with follow up of the HIV-exposed infants. Though the country has not met its target of Universal Access by 2010, significant progress has been made with over a 30-fold increase in service availability.

[Impact of access to antiretroviral therapy in Côte d'Ivoire]

In 1998 UNAIDS implemented the national drug access initiative (DAI) in Côte d'Ivoire. The Ivorian government took the DAI over in 2000 with the support of the Global Fund and Presidential Emergency Program For AIDS Relief (PEPFAR). The ensuing affordability of antiretroviral therapy (ART), medical staff training, and healthcare equipment allowed Ministry of Health to improve HIV care throughout the country. Since 2008 ART and follow-up monitoring have been free of charge for people living with HIV/AIDS (PLWHA). In January 2009 a total of 57,833 PLWHA received ART and follow-up at 274 HIV care centers. Use of ART has improved the life expectancy of PLWHA. However morbidity and mortality remained high during the first year of ART implementation with respective frequencies of 5-10% person-year (PY) and 2-3% PY. Morbidity was mainly related to infectious disease (tuberculosis and bacteriaemia) and earlier onset of adverse events (AE). In most cases ART has been well tolerated. The main adverse effects have been anemia, neuropathy, skin toxicity and liver enzyme elevation. The incidence of stage 3/4 AE has been low (< 2 %PY). Although overall compliance has been good (<80%), data among children and adults suggest the need for further work to reinforce support mechanisms. Convincing results have been obtained in the management of PLWHA. Nevertheless greater funding and commitment must be given to management of opportunistic infections and side effects and to development of nutrition support services.

Planning for posttrial access to antiretroviral treatment for research participants in developing countries

Despite recognition of the importance of posttrial access to antiretroviral therapy (ART), the implementation process has not been studied. We examined whether the National Institutes of Health (NIH) guidance document was being implemented in NIH-funded ART trials conducted in developing countries between July 2005 and June 2007. All of the 18 studies we identified had posttrial access plans for trial participants. More than 70% had specific mechanisms for posttrial access, but none guaranteed long-term sponsor funding after the trials. The plans reflected variation in local contexts and the uncertainty of predicting local conditions in the long term. The strength of the NIH guidance document may be that it encourages investigators to formulate plans in advance and to work with other stakeholders to provide access to ART.

Clinical and financial burdens of secondary level care in a public sector antiretroviral roll-out setting (G. F. Jooste Hospital)

BACKGROUND

Antiretroviral therapy (ART) is being extended across South Africa. While efforts have been made to assess the costs of providing ART via accredited service points, little information is available on its downstream costs, particularly in public secondary level hospitals.

OBJECTIVES

To determine the cost of care for inpatients and outpatients at a dedicated antiretroviral referral unit treating and caring for antiretroviral-related conditions in a South African peri-urban setting; to identify key epidemiological cost drivers; and to examine the associated clinical and outcome data.

METHODS

A prospective costing study on 48 outpatients and 25 inpatients was conducted from a health system perspective. Incremental economic costs and clinical data were collected from primary sources at G. F. Jooste Hospital, Cape Town, over a 1-month period (March 2005).

RESULTS

Incremental cost per outpatient was R1 280, and per inpatient R5 802. Costs were dominated by medical staff costs (62% inpatient and 58% outpatient, respectively). Infections predominated among diagnoses and costs--55% and 67% respectively for inpatients, and 49% and 54% respectively for outpatients. Most inpatients and outpatients were judged by attending physicians to have improved or stabilised as a result of treatment (52% and 59% respectively).

CONCLUSIONS

The costs of providing secondary level care for patients on or immediately preceding ART initiation can be significant and should be included in the government's strategic planning: (i) so that the service can be expanded to meet current and future needs; and (ii) to avoid crowding out other secondary level health services.

Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model

BACKGROUND

Roughly 3 million people worldwide were receiving antiretroviral therapy (ART) at the end of 2007, but an estimated 6.7 million were still in need of treatment and a further 2.7 million became infected with HIV in 2007. Prevention efforts might reduce HIV incidence but are unlikely to eliminate this disease. We investigated a theoretical strategy of universal voluntary HIV testing and immediate treatment with ART, and examined the conditions under which the HIV epidemic could be driven towards elimination.

METHODS

We used mathematical models to explore the effect on the case reproduction number (stochastic model) and long-term dynamics of the HIV epidemic (deterministic transmission model) of testing all people in our test-case community (aged 15 years and older) for HIV every year and starting people on ART immediately after they are diagnosed HIV positive. We used data from South Africa as the test case for a generalised epidemic, and assumed that all HIV transmission was heterosexual.

FINDINGS

The studied strategy could greatly accelerate the transition from the present endemic phase, in which most adults living with HIV are not receiving ART, to an elimination phase, in which most are on ART, within 5 years. It could reduce HIV incidence and mortality to less than one case per 1000 people per year by 2016, or within 10 years of full implementation of the strategy, and reduce the prevalence of HIV to less than 1% within 50 years. We estimate that in 2032, the yearly cost of the present strategy and the theoretical strategy would both be US$1.7 billion; however, after this time, the cost of the present strategy would continue to increase whereas that of the theoretical strategy would decrease.

INTERPRETATION

Universal voluntary HIV testing and immediate ART, combined with present prevention approaches, could have a major effect on severe generalised HIV/AIDS epidemics. This approach merits further mathematical modelling, research, and broad consultation.

Cost effectiveness of facility-based care, home-based care and mobile clinics for provision of antiretroviral therapy in Uganda

Stakeholders in HIV/AIDS care currently use different programmes for provision of antiretroviral therapy (ART) in Uganda. It is not known which of these represents the best value for money. To compare the cost effectiveness of home-based care (HBC), facility-based care (FBC) and mobile clinic care (MCC) for provision of ART in Uganda. Incremental cost-effectiveness analysis was performed using decision and Markov modeling of adult AIDS patients in WHO Clinical Stage 3 and 4 from the perspective of the Ugandan healthcare system. The main outcome measures were cost (year 2008 values), life expectancy in life-years (LY) and the incremental cost-effectiveness ratio (ICER) measured as cost per QALY or LY gained over 10 years. Ten-year mean undiscounted life expectancy was lowest for FBC (3.6 LY), followed by MCC (4.3 LY) and highest for HBC (5.3 LY), while the mean discounted QALYs were also lowest for FBC (2.3), followed by MCC (2.9) and highest for HBC (3.7). The 10-year mean costs per patient were lowest for FBC ($US3212), followed by MCC ($US4782) and highest for HBC ($US7033). The ICER was lower for MCC versus FBC ($US2241 per LY and $US2615 per QALY) than for HBC versus MCC ($US2251 per LY and $US2814 per QALY). FBC remained cost effective in univariate and probabilistic sensitivity analyses. FBC appears to be the most cost-effective programme for provision of ART in Uganda. This analysis supports the implementation of FBC for scale-up and sustainability of ART in Uganda. HBC and MCC would be competitive only if there is increased access, increased adherence or reduced cost.

The double burden of disease in developing countries: the Mexican experience

OBJECTIVE

To present the challenges arising from the double burden of disease in developing countries, focusing on the case of Mexico, and to propose a strategy for addressing these challenges.

METHODOLOGY/APPROACH

Mortality and morbidity data are presented for selected countries and groups of diseases. Specific examples of the pressures faced by the public health services in Mexico to provide and finance treatment for communicable and non-communicable diseases are used to illustrate the extent of the challenges in the context of a country with limited resources.

FINDINGS

Public health systems in developing countries face strong pressure to provide and finance treatment for both communicable and non-communicable diseases, inevitably producing competition among diseases and conditions and requiring trade-offs between equity and efficiency goals.

IMPLICATIONS FOR POLICY

In developing countries, addressing the challenges presented by the double burden of disease requires a multidisciplinary approach to develop and strengthen the policymaking process. This involves the use of analytical tools applied to each stage of the planning cycle, in particular the use of an explicit priority setting process together with monitoring and assessment to strengthen decision making under limited resources.

The Brazilian experiment: HIV drugs for all

The World Health Organization Joint Report of 2007 (WHO/UNAIDS/UNICEF) estimated that in developing world economies, 2 million people with HIV/AIDS were being treated with antiretroviral drugs (ARVs) out of the 7 million needing treatment. The ongoing political and humanistic movement in Brazil highly relates to health care provision, especially to treatment of the HIV/AIDS epidemic. "Compulsory licensing" (patent breaking) was used by Brazil to manufacture and import HIV/AIDS drugs. The Brazilian government provided top-of-the-line antiretroviral drugs in the form of HAART (highly active antiretroviral therapy) to all needing treatment for HIV/AIDS. Subsequently, the international community found Brazil as an eager "poster child" in the universal access movement for HIV/AIDS drugs. However, can this program of justice and humanity in Brazil be feasible when applied to the HIV/AIDS epidemic in other developing world countries? It is worth exploring.

Standardized patients for HIV/AIDS training in resource-poor settings: the expert patient-trainer

This article presents a unique approach to HIV/AIDS training in resource-poor settings that incorporates the use of standardized patients (SPs). Integrated Management of Adolescent and Adult Illness (IMAI) is a World Health Organization health systems strengthening initiative with a strong emphasis on training health workers in the management of common diseases and conditions. In IMAI, SPs are called Expert Patient-Trainers (EPTs) to emphasize their role in the training of health workers. EPTs were first used in IMAI training in Uganda in 2004. Since then, the method has been adopted by a number of other countries in Africa, Latin America, and Asia. EPTs are usually recruited from groups of people living with HIV/AIDS. In the classroom, EPTs discuss living with HIV and help participants understand HIV as it affects patients. Course participants spend approximately two hours per day in "skill stations," multiple-station assessments consisting of one-on-one encounters with EPTs. In each encounter, the health worker interacts with an EPT portraying a standardized case. Instructions on how to portray each case provide only broad outlines of the major clinical and counseling points; the EPT is expected to use his or her own life experiences to fill in emotional details. Course facilitators noted that health workers were often initially skeptical about EPTs, but this generally turned to enthusiasm after participating in the skill stations. EPTs benefited from the sense of being part of the training team, the satisfaction of improving the skills of health workers, and learning more about their illness.

Lessons learned from a paying antiretroviral therapy service in the public health sector at Kamuzu Central Hospital, Malawi: 1-year experience

BACKGROUND

In October 2001, a paying antiretroviral therapy service was introduced at a Central Hospital in Malawi using stavudine 40 mg/lamivudine 150 mg/nevirapine 200 mg (triomune). The objective of this study was to determine characteristics of patients seeking antiretroviral therapy, retention in care, clinical outcomes, and outlines for program improvement.

METHODS

Retrospectively, all patients seeking anti-retroviral therapy initiation (October 2001 to October 2002; follow-up through April 2003) were evaluated for laboratory results, retention in care, toxicity, and mortality. Hazard ratios for factors associated with dropout were determined.

RESULTS

Of 757 patients seeking evaluation, 625 began treatment. Documented mortality rate was 61 of 757. Total dropout rate was 50%. Factors associated with dropout include CD4 count <50 cells/mm(3) and Kaposi's sarcoma. Twenty-seven of 625 patients discontinued therapy for toxicity.

CONCLUSIONS

The paying antiretroviral therapy program showed an unacceptable dropout rate associated with advanced baseline disease. Severe toxicity rate was low. Areas for improved program performance include lower cost, wide and earlier access to antiretroviral therapy, and targeted retention strategies.

Policy making and roles of health technology assessment

The processes of policy development and implementation in the public sector are complex and dynamic as several actors with different interests are involved. To pursue their benefits, these individual and organizational participants compete with each other and those with a relatively high degree of power can lead the policy decisions. Results of and recommendations derived from economic evaluation and other forms ofhealth technology assessment (HTA) are expected to have an important role in policy making and professional practice. However, it appears that on many occasions, such scientific evidence is neglected. Complex calculations, arbitrary assumptions, debatable choices of whose perspectives to pursue, difficult-to-understand methods, research designs and underlying philosophy/concepts, and time-consuming processes are claimed as key factors discouraging policy makers and practitioners from making use of HTA findings. Ethical considerations and the perception that HTA-based clinical guidelines undermine professional autonomy are also crucial.

The association of adherence to antiretroviral therapy with healthcare utilization and costs for medical care

BACKGROUND

The association between antiretroviral adherence, healthcare utilization and medical costs has not been well studied.

OBJECTIVE

To examine the relationship of adherence to antiretroviral medications to healthcare utilization and healthcare costs.

METHODS

A retrospective cohort study was conducted using data from 325 previously antiretroviral medication-naive HIV-infected individuals initiating first antiretroviral therapy from 1997 through 2003. The setting was an inner-city safety net hospital and HIV clinic in the US. Adherence was assessed using pharmacy refill data. The average wholesale price was used for prescription costs. Healthcare utilization data and medical costs were obtained from the hospital billing database, and differences according to quartile of adherence were compared using analysis of variance (ANOVA). Multivariate logistic regression was used to assess predictors of higher annual medical costs. Sensitivity analyses were used to examine alternative antiretroviral pricing schemes. The perspective was that of the healthcare provider, and costs were in year 2005 values.

RESULTS

In 325 patients followed for a mean (+/- SD) 3.2 (1.9) years, better adherence was associated with lower healthcare utilization but higher total medical costs. Annual non-antiretroviral medical costs were $US 7,612 in the highest adherence quartile versus $US 10,190 in the lowest adherence quartile. However, antiretroviral costs were significantly higher in the highest adherence quartile ($US 17,513 vs $US 8,690), and therefore the total annual medical costs were also significantly higher in the highest versus lowest adherence quartile ($US 25,125 vs $US 18,880). In multivariate analysis, for every 10% increase in adherence, the odds of having annual medical costs in the highest versus lowest quartile increased by 87% (odds ratio 1.87; 95% CI 1.45, 2.40). In sensitivity analyses, very low antiretroviral prices (as seen in resource-limited settings) inverted this relationship - excellent adherence was cost saving.

CONCLUSION

Better adherence to antiretroviral medication was associated with decreased healthcare utilization and associated costs; however, because of the high cost of antiretroviral therapy, total medical costs were increased. Combination antiretroviral therapy is known to be cost effective; lower antiretroviral costs may make it cost saving as well.

2007 costs and coverage of antiretrovirals under Medicare Part D for people with HIV/AIDS living in North Carolina

BACKGROUND

Effective January 1, 2006 Medicare Part D became a new source of prescription drug coverage for people with HIV/AIDS in the United States. The implementation of Part D has affected access to antiretrovirals for people with HIV/AIDS. In North Carolina, access can be difficult because of the state's struggling safety net programs and the growing HIV-infected populations among Blacks and in poor rural counties. This analysis examines Medicare Part D antiretroviral coverage in 2007 for beneficiaries with HIV/AIDS in North Carolina, particularly those who did not qualify as dual eligibles or for a full low-income subsidy.

METHODS

Data describing program coverage were obtained from the Web site www.medicare.gov and descriptive analyses were performed to assess changes in antiretroviral coverage in Part D prescription drug plans in North Carolina.

RESULTS

Most of the 26 antiretrovirals are covered in some way by 76 North Carolina prescription drug plans. There may be variability in coverage however associated with (a) antiretroviral classification within formularies; (b) drug premiums; (c) whether premiums can be waived; (d) annual deductibles; and (e) whether coverage is provided in the "doughnut hole."

LIMITATIONS

The data may not reflect actual patterns of drug use and realized access to the drugs. The findings are limited to antiretroviral coverage in North Carolina's Part D offerings but could be generalized to other states with similar prescription drug plan costs and coverage.

CONCLUSION

These concerns continue to pose significant challenges to accessing antiretrovirals for Part D beneficiaries with HIV/AIDS in North Carolina. Variability demonstrated within prescription drug plans will continue, and beneficiaries with HIV/AIDS who do not qualify as dual eligibles or for low-income subsidies will need to evaluate these issues when selecting a prescription drug plan in future enrollment periods.