The 'Expanded HIV care in opioid substitution treatment' (EHOST) cluster-randomized, stepped-wedge trial: A study protocol

Geographic variation in the costs of medical care for people living with HIV in British Columbia, Canada

Background

Regional variation in medical care costs can indicate heterogeneity in clinical practice, inequities in access, or inefficiencies in service delivery. We aimed to estimate regional variation in medical costs for people living with HIV (PLHIV), adjusting for demographics and case-mix.

Methods

We conducted a retrospective cohort study using linked health administrative databases of PLHIV, from 2010 to 2014, in British Columbia (BC), Canada. Quarterly health care costs (2018 CAD) were derived from inpatient, outpatient, prescription drugs, antiretroviral therapy (ART), and HIV diagnostics. We used a two-part model with a logit link for the probability of incurring costs, and a log link and gamma distribution for observations with positive costs. We also estimated quarterly utilization rates for hospitalization-, physician billing- and prescription drug-days. Primary variables were indicators of individuals’ Health Service Delivery Area (HSDA). We adjusted cost and utilization estimates for demographic characteristics, HIV-disease progression, and comorbidities.

Results

Our cohort included 9577 PLHIV (median age 45.5 years, 80% male). Adjusted total quarterly costs for all 16 HSDAs were within 20% of the provincial mean, 8/16 for hospitalization costs, 16/16 for physician billing costs and 10/16 for prescription drug costs. Northern Interior and Northeast HSDAs had 38 and 44% lower quarterly non-ART prescription drug costs, and 2 and 5% higher quarterly inpatient costs, respectively.

Conclusions

We observed limited variation in medical care costs and utilization among PLHIV in BC. However, lower levels of outpatient care and higher levels of inpatient care indicate possible barriers to accessing care among PLHIV in the most rural regions of the province.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4391-8) contains supplementary material, which is available to authorized users.

Evaluating the Integrated Methadone and Anti-Retroviral Therapy Strategy in Tanzania Using the RE-AIM Framework

There are an estimated 50,000 people who inject drugs in Tanzania, with an HIV prevalence in this population of 42%. The Integrated Methadone and Anti-Retroviral Therapy (IMAT) strategy was developed to integrate HIV services into an opioid treatment program (OTP) in sub-Saharan Africa and increase anti-retroviral therapy (ART) initiation rates. In this paper, we evaluate the IMAT strategy using an implementation science framework to inform future care integration efforts in the region. IMAT centralized HIV services into an OTP clinic in Dar Es Salaam, Tanzania: HIV diagnosis, ART initiation, monitoring and follow up. A mixed-methods, concurrent design, was used for evaluation: quantitative programmatic data and semi-structured interviews with providers and clients addressed 4 out of 5 components of the RE-AIM framework: reach, effectiveness, adoption, implementation. Results showed high reach: 98% of HIV-positive clients received HIV services; effectiveness: 90-day ART initiation rate doubled, from 41% pre-IMAT to 87% post-IMAT (p < 0.001); proportion of HIV-positive eligible clients on ART increased from 71% pre-IMAT to 98% post-IMAT (p < 0.001). There was high adoption and implementation protocol fidelity. Qualitative results informed barriers and facilitators of RE-AIM components. In conclusion, we successfully integrated HIV care into an OTP clinic in sub-Saharan Africa with increased rates of ART initiation. The IMAT strategy represents an effective care integration model to improve HIV care delivery for OTP clients.

Beyond signal functions in global obstetric care: Using a clinical cascade to measure emergency obstetric readiness

Background

Globally, the rate of reduction in delivery-associated maternal and perinatal mortality has been slow compared to improvements in post-delivery mortality in children under five. Improving clinical readiness for basic obstetric emergencies is crucial for reducing facility-based maternal deaths. Emergency readiness is commonly assessed using tracers derived from the maternal signal functions model.

Objective-method

We compare emergency readiness using the signal functions model and a novel clinical cascade. The cascades model readiness as the proportion of facilities with resources to identify the emergency (stage 1), treat it (stage 2) and monitor-modify therapy (stage 3). Data were collected from 44 Kenyan clinics as part of an implementation trial.

Findings

Although most facilities (77.0%) stock maternal signal function tracer drugs, far fewer have resources to practically identify and treat emergencies. In hypertensive emergencies for example, 38.6% of facilities have resources to identify the emergency (Stage 1 readiness, including sphygmomanometer, stethoscope, urine collection device, protein test). 6.8% have the resources to treat the emergency (Stage 2, consumables (IV Kit, fluids), durable goods (IV pole) and drugs (magnesium sulfate and hydralazine). No facilities could monitor or modify therapy (Stage 3). Across five maternal emergencies, the signal functions overestimate readiness by 54.5%. A consistent, step-wise pattern of readiness loss across signal functions and care stage emerged and was profoundly consistent at 33.0%.

Significance

Comparing estimates from the maternal signal functions and cascades illustrates four themes. First, signal functions overestimate practical readiness by 55%. Second, the cascade’s intuitive indicators can support cross-sector health system or program planners to more precisely measure and improve emergency care. Third, adding few variables to existing readiness inventories permits step-wise modeling of readiness loss and can inform more precise interventions. Fourth, the novel aggregate readiness loss indicator provides an innovative and intuitive approach for modeling health system emergency readiness. Additional testing in diverse contexts is warranted.

Informing Targeted Interventions to Optimize the Cascade of HIV Care Using Cluster Analyses of Health Resource Use Among People Living with HIV/AIDS

Increased awareness of the secondary preventive benefits of antiretroviral treatment (ART) has strengthened the desire to optimize health care systems' response to HIV/AIDS. We identified clusters of health resource utilization (HRU) among people living with HIV (PLHIV) to inform targeted interventions aimed to optimize the cascade of HIV care. Using linked population-level health databases in British Columbia, Canada, we selected two analytic samples of PLHIV with 3 years of follow-up between 2006-2011 that were classified as intermittently retained in care or intermittently engaged in ART, and executed a probabilistic model-based clustering analysis for each sample with 5 and 9 quarterly HRU variables, respectively. We found clear HRU profile differences among both samples with similar HIV-related care: one featured active involvement in non-HIV care, the other little or no health care interaction following linkage to care. Differential reengagement intervention strategies capitalizing on missed opportunities in non-HIV care and further engaging physicians delivering HIV care are needed to optimize the response to the HIV epidemic.

Cost-Effectiveness of the 'One4All' HIV Linkage Intervention in Guangxi Zhuang Autonomous Region, China

BACKGROUND

In Guangxi Zhuang Autonomous Region, China, an estimated 80% of newly-identified antiretroviral therapy (ART)-eligible patients are not engaged in ART. Delayed ART uptake ultimately translates into high rates of HIV morbidity, mortality, and transmission. To enhance HIV testing receipt and subsequent treatment uptake in Guangxi, the Chinese Center for Disease Control and Prevention (CDC) executed a cluster-randomized trial to assess the effectiveness and cost-effectiveness of a streamlined HIV testing algorithm (the One4All intervention) in 12 county-level hospitals.

OBJECTIVE

To determine the incremental cost-effectiveness of the One4All intervention delivered at county hospitals in Guangxi, China, compared to the current standard of care (SOC).

PERSPECTIVE

Health System.

TIME HORIZON

1-, 5-and 25-years.

METHODS

We adapted a dynamic, compartmental HIV transmission model to simulate HIV transmission and progression in Guangxi, China and identify the economic impact and health benefits of implementing the One4All intervention in all Guangxi hospitals. The One4All intervention algorithm entails rapid point-of-care HIV screening, CD4 and viral load testing of individuals presenting for HIV screening, with same-day results and linkage to counselling. We populated the model with data from the One4All trial (CTN-0056), China CDC HIV registry and published reports. Model outcomes were HIV incidence, mortality, costs, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER) of the One4All intervention compared to SOC.

RESULTS

The One4All testing intervention was more costly than SOC (CNY 2,182 vs. CNY 846), but facilitated earlier ART access, resulting in delayed disease progression and mortality. Over a 25-year time horizon, we estimated that introducing One4All in Guangxi would result in 802 averted HIV cases and 1629 averted deaths at an ICER of CNY 11,678 per QALY gained. Sensitivity analysis revealed that One4All remained cost-effective at even minimal levels of effectiveness. Results were robust to changes to a range of parameters characterizing the HIV epidemic over time.

CONCLUSIONS

The One4All HIV testing strategy was highly cost-effective by WHO standards, and should be prioritized for widespread implementation in Guangxi, China. Integrating the intervention within a broader combination prevention strategy would enhance the public health response to HIV/AIDS in Guangxi.