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Tlhajoane M, Masoka T, Mpandaguta E, Rhead R, Church K, Wringe A, Kadzura N, Arinaminpathy N, Nyamukapa C, Schur N, Mugurungi O, Skovdal M, Eaton JW, Gregson S. A longitudinal review of national HIV policy and progress made in health facility implementation in Eastern Zimbabwe. Health Res Policy Syst 2018; 16:92. [PMID: 30241489 PMCID: PMC6150955 DOI: 10.1186/s12961-018-0358-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 08/02/2018] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND In recent years, WHO has made major changes to its guidance on the provision of HIV care and treatment services. We conducted a longitudinal study from 2013 to 2015 to establish how these changes have been translated into national policy in Zimbabwe and to measure progress in implementation within local health facilities. METHODS National HIV programme policy guidelines published between 2003 and 2013 (n = 9) and 2014 and 2015 (n = 5) were reviewed to assess adoption of WHO recommendations on HIV testing services, prevention of mother-to-child transmission (PMTCT) of HIV, and provision of antiretroviral therapy (ART). Changes in local implementation of these policies over time were measured in two rounds of a survey conducted at 36 health facilities in Eastern Zimbabwe in 2013 and 2015. RESULTS High levels of adoption of WHO guidance into national policy were recorded, including adoption of new recommendations made in 2013-2015 to introduce PMTCT Option B+ and to increase the threshold for ART initiation from CD4 ≤ 350 cells/mm3 to ≤ 500 cells/mm3. New strategies to implement national HIV policies were introduced such as the decentralisation of ART services from hospitals to clinics and task-shifting of care from doctors to nurses. The proportions of health facilities offering free HIV testing and counselling, PMTCT (including Option B+) and ART services increased substantially from 2013 to 2015, despite reductions in numbers of health workers. Provision of provider-initiated HIV testing remained consistently high. At least one test-kit stock-out in the prior year was reported in most facilities (2013: 69%; 2015: 61%; p = 0.44). Stock-outs of first-line ART and prophylactic drugs for opportunistic infections remained low. Repeat testing for HIV-negative individuals within 3 months decreased (2013: 97%; 2015: 72%; p = 0.01). Laboratory testing remained low across both survey rounds, despite policy and operational guidelines to expand coverage of diagnostic services. CONCLUSIONS Good progress has been made in implementing international guidance on HIV service delivery in Zimbabwe. Further novel implementation strategies may be needed to achieve the latest targets for universal ART eligibility.
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Affiliation(s)
- Malebogo Tlhajoane
- Department for Infectious Disease Epidemiology, Imperial College London, Norfolk Place, London, W2 1PG United Kingdom
| | - Tidings Masoka
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | | | - Rebecca Rhead
- Department for Infectious Disease Epidemiology, Imperial College London, Norfolk Place, London, W2 1PG United Kingdom
| | - Kathryn Church
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Alison Wringe
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Noah Kadzura
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Nimalan Arinaminpathy
- Department for Infectious Disease Epidemiology, Imperial College London, Norfolk Place, London, W2 1PG United Kingdom
| | - Constance Nyamukapa
- Department for Infectious Disease Epidemiology, Imperial College London, Norfolk Place, London, W2 1PG United Kingdom
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Nadine Schur
- Department for Infectious Disease Epidemiology, Imperial College London, Norfolk Place, London, W2 1PG United Kingdom
| | | | - Morten Skovdal
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Jeffrey W. Eaton
- Department for Infectious Disease Epidemiology, Imperial College London, Norfolk Place, London, W2 1PG United Kingdom
| | - Simon Gregson
- Department for Infectious Disease Epidemiology, Imperial College London, Norfolk Place, London, W2 1PG United Kingdom
- Biomedical Research and Training Institute, Harare, Zimbabwe
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Mpinga EK, Kandala NB, Hasselgård-Rowe J, Tshimungu Kandolo F, Verloo H, Bukonda NKZ, Chastonay P. Estimating the Costs of Torture: Challenges and Opportunities. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2015; 13:567-581. [PMID: 26385586 DOI: 10.1007/s40258-015-0196-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Due to its nature, extent and consequences, torture is considered a major public health problem and a serious violation of human rights. Our study aims to set the foundation for a theoretical framework of the costs related to torture. It examines existing challenges and proposes some solutions. Our proposed framework targets policy makers, human rights activists, professionals working in programmes, centres and rehabilitation projects, judges and lawyers, survivors of torture and their families and anyone involved in the prevention and fight against this practice and its consequences. We adopted a methodology previously used in studies investigating the challenges in measuring and valuing productivity costs in health disorders. We identify and discuss conceptual, methodological, political and ethical challenges that studies on the economic and social costs of torture pose and propose alternatives in terms of possible solutions to these challenges. The economic dimension of torture is rarely debated and integrated in research, policies and programmes. Several challenges such as epistemological, methodological, ethical or political ones have often been presented as obstacles to cost studies of torture and as an excuse for not investigating this dimension. In identifying, analysing and proposing solutions to these challenges, we intend to stimulate the integration of the economic dimension in research and prevention of torture strategies.
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Affiliation(s)
- Emmanuel Kabengele Mpinga
- Department of Community Health and Medicine, Faculty of Medicine, Institute of Global Health, University of Geneva, Campus Biotech, Chemin des Mines 9, 1211, Geneva 20, Switzerland.
| | - Ngianga-Bakwin Kandala
- Health Economics and Evidence Synthesis Research Unit, Department of Population Health, Luxembourg Institute of Health (LIH), Strassen, Luxembourg
- Department of Mathematics and Information sciences, Faculty of Engineering and Environment, Northumbria University, Newcastle upon Tyne, UK
| | - Jennifer Hasselgård-Rowe
- Department of Community Health and Medicine, Faculty of Medicine, Institute of Global Health, University of Geneva, Campus Biotech, Chemin des Mines 9, 1211, Geneva 20, Switzerland
| | - Félicien Tshimungu Kandolo
- Departement of Public Health, Epidemiology and Health Systems, Institut Supérieur des Techniques Médicales, Kinshasa, Democratic Republic of Congo
| | - Henk Verloo
- Department of Health Sciences La Source, University of Applied Sciences, Lausanne, Switzerland
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Abstract
An estimated 58 million persons aged 60-plus live in sub-Saharan Africa; by 2050 that number will rise sharply to 215 million. Older Africans traditionally get care in their old age from the middle generation. But in East and Southern Africa, HIV has hollowed out that generation, leaving many older persons to provide care for their children's children without someone to care for him or herself in old age. Simultaneously, the burden of disease among older persons is changing in this region. The result is a growing care deficit. This article examines the existing literature on care for and by older persons in this region, highlighting understudied aspects of older persons' experiences of ageing and care--including the positive impacts of carework, variation in the region and the role of resilience and pensions. We advance a conceptual framework of gendered identities--for both men and women--and intergenerational social exchange to help focus and understand the complex interdependent relationships around carework, which are paramount in addressing the needs of older persons in the current care deficit in this region, and the Global South more generally.
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Affiliation(s)
- Enid Schatz
- a Department of Health Sciences , University of Missouri , Columbia , MO , USA.,b Institute of Behavioral Science , University of Colorado , Boulder , CO , USA.,c MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Janet Seeley
- d Social Science Programme , MRC/UVRI Uganda Research Unit on AIDS , Entebbe , Uganda.,e Department of Global Health and Development , London School of Hygiene and Tropical Medicine , London , UK
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Mazzeo J, Makonese L. Experiences of collaboration, coordination and efficiency in the delivery of HIV/AIDS home-based care in Zimbabwe. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2015; 8:443-53. [PMID: 25875708 DOI: 10.2989/ajar.2009.8.4.8.1045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The difficulties of achieving successful collaboration between stakeholders can lead to uncoordinated and fragmented outcomes for HIV/AIDS programming, which has consequences for the immediate health and livelihood security of the intended beneficiaries. This article examines the collaboration between local, national and international partner organisations in the delivery of and coordination of HIV/AIDS home-based care in Zimbabwe. The purpose of the research was to provide an external assessment of home-based care and to identify the problems that impede the delivery of health resources. Fieldwork was conducted between 2005 and 2008 at rural and peri-urban locations in Zimbabwe, using a combination of informal interviews, focus groups and participant observation. The findings suggest that the delivery of healthcare is impeded by problematic relationships between programme stakeholders-government, non-governmental and community-based. The outcome of poor service delivery is demonstrated to have a direct negative impact on the access to services, quality of care, and health outcomes for programme participants. The methods and findings of this research highlight the use of rapid ethnographic appraisal by social scientists to represent the interests of HIV/AIDS-affected populations in programme and policy design. This approach is crucial in situations such as in Zimbabwe where beneficiaries are less willing to voice their opinions for fear of being cut off from what little assistance is available in case what they say is viewed as uncooperative or noncompliant with a programme's objectives. The findings question the widely held assumption that multisectoral relationships are the most efficient way to deliver services.
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Affiliation(s)
- John Mazzeo
- a Department of Anthropology , DePaul University , 2343 N. Racine Avenue , Chicago , Illinois , 60614 , United States
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O'Brien S, Broom A. The rise and fall of HIV prevalence in Zimbabwe: the social, political and economic context. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2015; 10:281-90. [PMID: 25859797 DOI: 10.2989/16085906.2011.626303] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
For more than 10 years Zimbabwe has experienced social, political and economic instability, including the near collapse in 2008 of its health system. Paradoxically, this period has also seen a fall in estimated HIV prevalence, from 25.6% in 1996 to 13.7% in 2009. This article examines this development in a socio-political and historical context. We focus on the complex interplay of migration, mortality, individual behaviour change, and economic patterns in shaping the presumed epidemiological waning of HIV prevalence in Zimbabwe and explore the evolution and management of the country's HIV/AIDS response. Our assessment of the role that the Zimbabwean state has played in this development leads to the conclusion that a decline in HIV prevalence has been as much an artefact of dire social, political and economic conditions as the outcome of deliberate interventions. Lastly, we propose the need to contextualise available epidemiological data through qualitative research into the social aspects of HIV and the everyday lives of individuals affected by it.
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Affiliation(s)
- Stephen O'Brien
- a School of Social Science , The University of Queensland , Campbell Road , St Lucia Qld , 4072 , Australia
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Aantjes C, Quinlan T, Bunders J. Integration of community home based care programmes within national primary health care revitalisation strategies in Ethiopia, Malawi, South-Africa and Zambia: a comparative assessment. Global Health 2014; 10:85. [PMID: 25499098 PMCID: PMC4279695 DOI: 10.1186/s12992-014-0085-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 11/25/2014] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND In 2008, the WHO facilitated the primary health care (PHC) revitalisation agenda. The purpose was to strengthen African health systems in order to address communicable and non-communicable diseases. Our aim was to assess the position of civil society-led community home based care programmes (CHBC), which serve the needs of patients with HIV, within this agenda. We examined how their roles and place in health systems evolved, and the prospects for these programmes in national policies and strategies to revitalise PHC, as new health care demands arise. METHODS The study was conducted in Ethiopia, Malawi, South Africa and Zambia and used an historical, comparative research design. We used purposive sampling in the selection of countries and case studies of CHBC programmes. Qualitative methods included semi-structured interviews, focus group discussions, service observation and community mapping exercises. Quantitative methods included questionnaire surveys. RESULTS The capacity of PHC services increased rapidly in the mid-to-late 2000s via CHBC programme facilitation of community mobilisation and participation in primary care services and the exceptional investments for HIV/AIDS. CHBC programmes diversified their services in response to the changing health and social care needs of patients on lifelong anti-retroviral therapy and there is a general trend to extend service delivery beyond HIV-infected patients. We observed similarities in the way the governments of South Africa, Malawi and Zambia are integrating CHBC programmes into PHC by making PHC facilities the focal point for management and state-paid community health workers responsible for the supervision of community-based activities. Contextual differences were found between Ethiopia, South Africa, Malawi and Zambia, whereby the policy direction of the latter two countries is to have in place structures and mechanisms that actively connect health and social welfare interventions from governmental and non-governmental actors. CONCLUSIONS Countries may differ in the means to integrate and co-ordinate government and civil society agencies but the net result is expanded PHC capacity. In a context of changing health care demands, CHBC programmes are a vital mechanism for the delivery of primary health and social welfare services.
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Affiliation(s)
- Carolien Aantjes
- Faculty of Earth and Life Sciences: Athena Institute, VU University Amsterdam, De Boelelaan 1085, 1081, HV, Amsterdam, The Netherlands. .,ETC. Foundation, Kastanjelaan 5, Leusden, The Netherlands.
| | - Tim Quinlan
- Faculty of Earth and Life Sciences: Athena Institute, VU University Amsterdam, De Boelelaan 1085, 1081, HV, Amsterdam, The Netherlands. .,Health Economics and HIV/AIDS Research Division, University of KwaZulu-Natal, Westville Campus, University Road, Durban, South-Africa.
| | - Joske Bunders
- Faculty of Earth and Life Sciences: Athena Institute, VU University Amsterdam, De Boelelaan 1085, 1081, HV, Amsterdam, The Netherlands.
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Practicalities and challenges in re-orienting the health system in Zambia for treating chronic conditions. BMC Health Serv Res 2014; 14:295. [PMID: 25005125 PMCID: PMC4094789 DOI: 10.1186/1472-6963-14-295] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 07/02/2014] [Indexed: 11/26/2022] Open
Abstract
Background The rapid evolution in disease burdens in low- and middle income countries is forcing policy makers to re-orient their health system towards a system which has the capability to simultaneously address infectious and non-communicable diseases. This paper draws on two different but overlapping studies which examined how actors in the Zambian health system are re-directing their policies, strategies and service structures to include the provision of health care for people with chronic conditions. Methods Study methods in both studies included semi-structured interviews with government health officials at national level, and governmental and non-governmental health practitioners operating from community-, primary health care to hospital facility level. Focus group discussions were conducted with staff, stakeholders and caregivers of programmes providing care and support at community- and household levels. Study settings included urban and rural sites. Results A series of adaptations transformed the HIV programme from an emergency response into the first large chronic care programme in the country. There are clear indications that the Zambian government is intending to expand this reach to patients with non-communicable diseases. Challenges to do this effectively include a lack of proper NCD prevalence data for planning, a concentration of technology and skills to detect and treat NCDs at secondary and tertiary levels in the health system and limited interest by donor agencies to support this transition. Conclusion The reorientation of Zambia’s health system is in full swing and uses the foundation of a decentralised health system and presence of local models for HIV chronic care which actively involve community partners, patients and their families. There are early warning signs which could cause this transition to stall, one of which is the financial capability to resource this process.
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Ngazimbi EE, Hagedorn WB, Shillingford MA. Counseling Caregivers of Families Affected by HIV/AIDS: The Use of Narrative Therapy. JOURNAL OF PSYCHOLOGY IN AFRICA 2014. [DOI: 10.1080/14330237.2008.10820204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Beck EJ, Fasawe O, Ongpin P, Ghys P, Avilla C, De Lay P. Costs and cost-effectiveness of HIV community services: quantity and quality of studies published 1986-2011. Expert Rev Pharmacoecon Outcomes Res 2014; 13:293-311. [PMID: 23763528 DOI: 10.1586/erp.13.28] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Community services comprise an important part of a country's HIV response. English language cost and cost-effectiveness studies of HIV community services published between 1986 and 2011 were reviewed but only 74 suitable studies were identified, 66% of which were performed in five countries. Mean study scores by continent varied from 42 to 69% of the maximum score, reflecting variation in topics covered and the quality of coverage: 38% of studies covered key and 11% other vulnerable populations - a country's response is most effective and efficient if these populations are identified given they are key to a successful response. Unit costs were estimated using different costing methods and outcomes. Community services will need to routinely collect and analyze information on their use, cost, outcome and impact using standardized costing methods and outcomes. Cost estimates need to be disaggregated into relevant cost items and stratified by severity and existing comorbidities. Expenditure tracking and costing of services are complementary aspects of the health sector 'resource cycle' that feed into a country's investment framework and the development and implementation of national strategic plans.
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Affiliation(s)
- Eduard J Beck
- Office of the Deputy Executive Director, Programme Branch, UNAIDS Secretariat, 20 Avenue Appia, Geneva, Switzerland.
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Mdege ND, Chindove S. Bringing antiretroviral therapy (ART) closer to the end-user through mobile clinics and home-based ART: systematic review shows more evidence on the effectiveness and cost effectiveness is needed. Int J Health Plann Manage 2013; 29:e31-e47. [DOI: 10.1002/hpm.2185] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 03/11/2013] [Accepted: 03/13/2013] [Indexed: 11/05/2022] Open
Affiliation(s)
| | - Stanley Chindove
- Autonomous Medical Stores (SAMES); Ministry of Health; Dili Timor-Leste
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Gwatirisa P, Manderson L. "Living from day to day": food insecurity, complexity, and coping in muTare, Zimbabwe. Ecol Food Nutr 2012; 51:97-113. [PMID: 22455860 DOI: 10.1080/03670244.2012.661328] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
In Zimbabwe, unpredictable conditions associated with structural and institutional factors exacerbated the combined effects of structural violence, economic and political instability, and climate change in the mid 2000s, contributing to widespread food insecurity. Drought, food shortages, and government settlement policy affecting both rural and urban populations has yielded a national human rights crisis. Drawing on ethnographic research conducted in Mutare, southeast Zimbabwe, in 2005-2006, the authors illustrate the flow-on effects of drought and government policy on the livelihoods of households already suffering as a result of the social impacts of AIDS, and how people in a regional city responded to these factors, defining and meeting their basic food needs in diverse ways.
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Affiliation(s)
- Pauline Gwatirisa
- School of Psychology and Psychiatry, Monash University, Caufield East, Victoria, Australia
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Halperin DT, Mugurungi O, Hallett TB, Muchini B, Campbell B, Magure T, Benedikt C, Gregson S. A surprising prevention success: why did the HIV epidemic decline in Zimbabwe? PLoS Med 2011; 8:e1000414. [PMID: 21346807 PMCID: PMC3035617 DOI: 10.1371/journal.pmed.1000414] [Citation(s) in RCA: 123] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Daniel Halperin and colleagues examine reasons for the remarkable decline in HIV in Zimbabwe, in the context of severe social, political, and economic disruption.
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Affiliation(s)
- Daniel T Halperin
- Harvard University School of Public Health, Boston, Massachusetts, USA.
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Ama NO, Seloilwe ES. Estimating the cost of care giving on caregivers for people living with HIV and AIDS in Botswana: a cross-sectional study. J Int AIDS Soc 2010; 13:14. [PMID: 20406455 PMCID: PMC2880016 DOI: 10.1186/1758-2652-13-14] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2009] [Accepted: 04/20/2010] [Indexed: 11/21/2022] Open
Abstract
Background Community home-based care is the Botswana Government's preferred means of providing care for people living with HIV (PLHIV). However, primary (family members) or volunteer (community members) caregivers experience poverty, are socially isolated, endure stigma and psychological distress, and lack basic care-giving education. Community home-based care also imposes considerable costs on patients, their caregivers and families in terms of time, effort and commitment. An analysis of the costs incurred by caregivers in providing care to PLHIV will assist health and social care decision makers in planning the most appropriate ways to meet future service needs of PLHIV and their caregivers. Methods This study estimated the cost incurred in providing care for PLHIV through a stratified sample of 169 primary and volunteer caregivers drawn from eight community home-based care groups in four health districts in Botswana. Results The results show that the mean of the total monthly cost (explicit and indirect costs) incurred by the caregivers was $(90.45 ± 9.08) while the mean explicit cost of care giving was $(65.22 ± 7.82). This mean of the total monthly cost is about one and a half times the caregivers' mean monthly income of $66.00 (± 5.98) and more than six times the Government of Botswana's financial support to the caregivers. In addition, the cost incurred per visit by the caregivers was $15.26, while the total expenditure incurred per client or family in a month was $184.17. Conclusions The study, therefore, concludes that as the cost of providing care services to PLHIV is very high, the Government of Botswana should substantially increase the allowances paid to caregivers and the support it provides for the families of the clients. The overall costs for such a programme would be quite low compared with the huge sum of money budgeted each year for health care and for HIV and AIDS.
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Affiliation(s)
- Njoku O Ama
- Department of Statistics, University of Botswana, Gaborone, Botswana.
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Wringe A, Cataldo F, Stevenson N, Fakoya A. Delivering comprehensive home-based care programmes for HIV: a review of lessons learned and challenges ahead in the era of antiretroviral therapy. Health Policy Plan 2010; 25:352-62. [PMID: 20144935 DOI: 10.1093/heapol/czq005] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Home-based care (HBC) programmes in low- and middle-income countries have evolved over the course of the past two decades in response to the HIV epidemic and wider availability of antiretroviral therapy (ART). Evidence is emerging from small-scale and well-resourced studies that ART delivery can be effectively incorporated within HBC programmes. However, before this approach can be expanded, it is necessary to consider the lessons learned from implementing routine HBC programmes and to assess what conditions are required for their roll-out in the context of ART provision. In this paper, we review the literature on existing HBC programmes and consider the arguments for their expansion in the context of scaling up ART delivery. We develop a framework that draws on the underlying rationale for HBC and incorporates lessons learned from community health worker programmes. We then apply this framework to assess whether the necessary conditions are in place to effectively scale up HBC programmes in the ART era. We show that the most effective HBC programmes incorporate ongoing support, training and remuneration for their workers; are integrated into existing health systems; and involve local communities from the outset in programme planning and delivery. Although considerable commitment has so far been demonstrated to delivering comprehensive HBC programmes, their effectiveness is often hindered by weak linkages with other HIV services. Top-down donor policies and a lack of sustainable and consistent funding strategies represent a formidable threat to these programmes in the long term. The benefits of HBC programmes that incorporate ART care are unlikely to be replicated on a larger scale unless donors and policymakers address issues related to human resources, health service linkages and community preparedness. Innovative and sustainable funding policies are needed to support HBC programmes if they are to effectively complement national ART programmes in the long term.
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Munthree C, Maharaj P. Growing Old in the Era of a High Prevalence of HIV/AIDS: The Impact of AIDS on Older Men and Women in KwaZulu-Natal, South Africa. Res Aging 2010. [DOI: 10.1177/0164027510361829] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite the important consequences that HIV/AIDS is likely to have for older people in South Africa, little empirical work has focused directly on this issue. However, emerging evidence suggests that older people are increasingly affected by the AIDS pandemic. In many households, older people often assume responsibility for the care of those who are sick and/ or dying and for children orphaned by AIDS. This study uses qualitative and quantitative methods to provide insights into the multiple impacts of the HIV/AIDS pandemic on the lives of older men and women. The results show that some older men and women feel at risk of HIV infection because of their caregiving activities. Almost 17% of respondents report that they have ever cared for someone with HIV/AIDS, with the percentage somewhat higher in rural areas. The study found that the impact of HIV/AIDS is substantial and is compounded greatly by gender dynamics in the household.
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Young T, Busgeeth K. Home-based care for reducing morbidity and mortality in people infected with HIV/AIDS. Cochrane Database Syst Rev 2010:CD005417. [PMID: 20091575 DOI: 10.1002/14651858.cd005417.pub2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Home-based care (HBC), to promote quality-of-life and limit hospital care, is used in many countries, especially where public health services are overburdened. OBJECTIVES This review assessed the effects of HBC on morbidity and mortality in those with HIV/AIDS. SEARCH STRATEGY Randomised and controlled clinical trials of HBC including all forms of treatment, care and support offered in the home were included. A highly sensitive search strategy was used to search CENTRAL, MEDLINE, EMBASE, AIDSearch, CINAHL, PsycINFO/LIT. Risk of bias of all trials was assessed. SELECTION CRITERIA All randomised and controlled clinical trials were included of HIV/AIDS positive individuals, adults and children, of any gender, and from any setting. Home-based care, provided by family, lay and/or professional people, including all forms of treatment, care and support offered in the HIV/AIDS positive person's home as compared to hospital or institutional based care DATA COLLECTION AND ANALYSIS Titles, abstracts and descriptor terms of the electronic search results were screened independently by two authors for relevance based on the types of participants, interventions, and study design. Full text articles were obtained of all selected abstracts and an eligibility form was used to determine final study selection. Data extraction and assessment of risk of bias were done independently. Narrative synthesis of results were done. Relevant effect measures and the 95% confidence intervals were reported. MAIN RESULTS Ten studies randomised individuals and trial sizes varied from n=31 to n=549. One study randomised 392 households and enrolled a total of 509 persons with HIV and 1,521 HIV-negative household members. Two ongoing studies were identified. Intensive home-based nursing significantly improved self-reported knowledge of HIV and medications, self-reported adherence and difference in pharmacy drug refill (1 study). Another study, comparing proportion of participants with greater than 90% adherence, found statistically significant differences over time but no significant change in CD4 counts and viral loads. A third study found significant differences in HIV stigma, worry and physical functioning but no differences in depressive symptoms, mood, general health, and overall functioning. Comprehensive case management by trans-professional teams compared to usual care by primary care nurses had no significant difference in quality-of-life after 6-months of follow-up (n=57) and average length of time on service (n=549). Home total parenteral nutrition had no significant impact on overall survival and rate of re-hospitalisation. Two trials comparing computers with brochures/nothing/standard medical care found no significant effect on health status, and decision-making confidence and skill, but a reduction in social isolation after controlling for depression. Two trials evaluating home exercise programmes found opposing results. Home-based safe water systems reduced diarrhea frequency and severity among persons with HIV in Africa. AUTHORS' CONCLUSIONS Studies were generally small and very few studies were done in developing countries. There was a lack of studies truly looking at the effect of home based care itself or looking at significant end points (death and progression to AIDS). However, the range of interventions and HBC models evaluated can assist in making evidence-based decisions about HIV care and support.
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Affiliation(s)
- Taryn Young
- South African Cochrane Centre, Medical Research Council, PO Box 19070, Tygerberg, South Africa, 7505
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Babigumira JB, Sethi AK, Smyth KA, Singer ME. Cost effectiveness of facility-based care, home-based care and mobile clinics for provision of antiretroviral therapy in Uganda. PHARMACOECONOMICS 2009; 27:963-973. [PMID: 19888795 PMCID: PMC3305803 DOI: 10.2165/11318230-000000000-00000] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
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.
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Affiliation(s)
- Joseph B Babigumira
- Pharmaceutical Outcomes Research & Policy Program, Department of Pharmacy, University of Washington, Seattle, WA 98195-7630, USA.
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Akintola O. Defying all odds: coping with the challenges of volunteer caregiving for patients with AIDS in South Africa. J Adv Nurs 2008; 63:357-65. [PMID: 18727763 DOI: 10.1111/j.1365-2648.2008.04704.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM This paper is a report of a study to explore the challenges experienced by volunteer caregivers of people living with HIV/AIDS and the strategies employed in coping with these challenges. BACKGROUND Informal caregiving is associated with stresses that often results in poor health outcomes for caregivers. In South Africa, volunteers play a major role in the provision of care for people living with HIV/AIDS and have been shown to experience burdens as a result of caring. However, little is known about stress and coping among volunteer caregivers. METHODS An ethnographic study was conducted, using observation and in-depth interviews, to collect data with 20 volunteers and other stakeholders in two semi-rural communities in South Africa over a 19-month period in 2002/2003. FINDINGS 'Defying all odds' emerged as the central theme that encompassed the various ways in which volunteer caregivers dealt with the many practical challenges confronting them. These challenges initially posed a threat to volunteering work but were gradually appraised by volunteers as challenges that could be dealt with using various strategies in order to continue providing care. Eight themes highlighting these challenges and the coping strategies employed by volunteers were identified. CONCLUSION A clear understanding of how volunteers deal with challenges of caring for people living with HIV/AIDS can give insight into their weaknesses and strengths and can inform the design of interventions aimed at providing support. Studies are needed to facilitate better understanding of the processes of appraisal of challenges by volunteers and the effectiveness of coping strategies, and to track coping strategies over time.
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Affiliation(s)
- Olagoke Akintola
- School of Psychology, University of KwaZuluNatal, Glenwood, Durban, Kwazulu-Natal, South Africa.
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19
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Gavaza P, Rascati K, Brown C, Lawson K, Mann T. The state of health economic and pharmacoeconomic evaluation research in Zimbabwe: A review. CURRENT THERAPEUTIC RESEARCH 2008; 69:268-85. [PMID: 24692805 PMCID: PMC3969967 DOI: 10.1016/j.curtheres.2008.06.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/07/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Economic evaluation of health care has developed into a substantial body of work, and its contribution to medical decision making is increasingly being recognized. OBJECTIVE The aim of the study was to describe the characteristics and quality of health economic (including pharmacoeconomic) evaluation research studies related to Zimbabwe. METHODS A review of the literature was conducted to identify published health economic evaluation studies related to Zimbabwe. HEED, PubMed, MEDLINE, HealthSTAR, EconLit, and PsycINFO databases and sociological and dissertation abstracts were used to search for economic analyses. The searches used the following terms alone and in combination: costs, budgets, fee, economics, health, pharmacy, pharmacy services, medicines, drugs, health economics, cost-effectiveness, cost-benefit, cost-minimization, cost utility analysis, and Zimbabwe. Only original applied economic evaluations addressing a health-related topic pertaining to Zimbabwe and published in full were included. Two reviewers independently evaluated and scored each study in the final sample using the data collection form designed for the study. RESULTS Fifty-nine studies were identified in the database searches, 18 of which were excluded because they were not about Zimbabwe (3 studies) or were not health related (15). Of the 41 remaining studies, 8 were excluded after further review because they were not original research, 6 because they were not economic analyses, and 1 because it was not about Zimbabwe. The final 26 studies appeared in 13 different journals (based mostly [17 (65%)] outside of Zimbabwe). The mean (SD) number of authors of each study was 3.36 (2.13); most of the authors had medical/clinical training. The number of studies peaked between 1994 and 1997. Based on a 10-point scale, with 10 indicating the highest quality, the mean (SD) quality score for all studies was 5.40 (1.56); 8 of the studies (31%) were considered to be of poor quality (score ≤4). The quality of the studies reviewed was significantly (all, P < 0.05) associated with the country in which the journal was based (non-Zimbabwe = higher), the primary health intervention (services>pharmaceutical interventions), the number of authors (more authors = higher), and year of publication (more recent = higher). CONCLUSION This study indicated that the use of health economic (including pharmacoeconomic) evaluation research in Zimbabwe was low, and 31 % of the studies were of poor quality. More and better quality health economic research in Zimbabwe is warranted.
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Affiliation(s)
| | - Karen Rascati
- The University of Texas at Austin, College of Pharmacy, Austin, Texas
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20
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21
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Waterman H, Griffiths J, Gellard L, O'Keefe C, Olang G, Ayuyo J, Obwanda E, Ogwethe V, Ondiege J. Power brokering, empowering, and educating: the role of home-based care professionals in the reduction of HIV-related stigma in Kenya. QUALITATIVE HEALTH RESEARCH 2007; 17:1028-1039. [PMID: 17928477 DOI: 10.1177/1049732307307524] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
In this article the authors report on how home-based care (HBC) professionals reduce stigmatizing behavior in Kenya. This study was part of an action research project that evaluated the introduction of HBC. HBC professionals coordinate the delivery of HIV/AIDS services at a district level and educate community-based health workers in HBC. Understanding how HBC professionals reduce stigma is crucial to reduce, prevent, and treat HIV/AIDS. Fifty HBC professionals participated in 27 focus group interviews over 18 months. Stigma featured strongly when they discussed barriers to the introduction of HBC. Using sociological theory, the authors organized the data into five themes: Power broking and mobilization, Stigma as a social construction, Community and structural interventions, Educating and training people, and Historical context. The HBC professionals appear to operate at mostly individual and community levels in their efforts to challenge stigma, and in spite of the difficulties they appear to be having some impact.
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Affiliation(s)
- Heather Waterman
- School of Nursing, Midwifery and Social Work, University of Manchester, UK
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22
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Handford C, Tynan A, Rackal JM, Glazier R. Setting and organization of care for persons living with HIV/AIDS. Cochrane Database Syst Rev 2006; 2006:CD004348. [PMID: 16856042 PMCID: PMC8406550 DOI: 10.1002/14651858.cd004348.pub2] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Treating the world's 40.3 million persons currently infected with HIV/AIDS is an international responsibility that involves unprecedented organizational challenges. Key issues include whether care should be concentrated or decentralized, what type and mix of health workers are needed, and which interventions and mix of programs are best. High volume centres, case management and multi-disciplinary care have been shown to be effective for some chronic illnesses. Application of these findings to HIV/AIDS is less well understood. OBJECTIVES Our objective was to evaluate the association between the setting and organization of care and outcomes for people living with HIV/AIDS. SEARCH STRATEGY Computerized searches from January 1, 1980 to December 31, 2002 of MEDLINE, EMBASE, Dissertation Abstracts International (DAI), CINAHL, HealthStar, PsychInfo, PsychLit, Social Sciences Abstracts, and Sociological Abstracts as well as searches of meeting abstracts and relevant journals and bibliographies in articles that met inclusion criteria. Searches included articles published in English and other languages. SELECTION CRITERIA Articles were considered for inclusion if they were observational or experimental studies with contemporaneous comparison groups of adults and/or children currently infected with HIV/AIDS that examined the impact of the setting and/or organization of care on outcomes of mortality, opportunistic infections, use of HAART and prophylaxis, quality of life, health care utilization, and costs for patient with HIV/AIDS. DATA COLLECTION AND ANALYSIS Two authors independently screened abstracts to determine relevance. Full paper copies were reviewed against the inclusion criteria. The findings were extracted by both authors and compared. The 28 studies that met inclusion criteria were too disparate with respect to populations, interventions and outcomes to warrant meta-analysis. MAIN RESULTS Twenty-eight studies were included involving 39,776 study subjects. The studies indicated that case management strategies and higher hospital and ward volume of HIV-positive patients were associated with decreased mortality. Case management was also associated with increased receipt of ARVs. The results for multidisciplinary teams or multi-faceted treatment varied. None of the studies examined quality of life or immunological or virological outcomes. Healthcare utilization outcomes were mixed. AUTHORS' CONCLUSIONS Certain settings of care (i.e. high volume of HIV positive patients) and models of care (i.e. case management) may improve patient mortality and other outcomes. More detailed descriptions of care models, consistent definition of terms, and studies on innovative models suitable for developing countries are needed. There is not yet enough evidence to guide policy and clinical care in this area.
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Affiliation(s)
| | - Anne‐Marie Tynan
- Inner City Health Research UnitSt Michael's Hospital30 Bond StreetToronto, OntarioCanadaM5B 1W2
| | - Julia M Rackal
- St. Michael's HospitalInner City Health Research Unit30 Bond StreetTorontoONCanadaM5B 1W8
| | - Richard Glazier
- St. Michael's HospitalCentre for Research on Inner City Health30 Bond St.TorontoOntarioCanadaM5B 1W8
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McIntyre D, Thiede M, Dahlgren G, Whitehead M. What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts? Soc Sci Med 2005; 62:858-65. [PMID: 16099574 DOI: 10.1016/j.socscimed.2005.07.001] [Citation(s) in RCA: 440] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2004] [Indexed: 11/19/2022]
Abstract
This paper presents the findings of a critical review of studies carried out in low- and middle-income countries (LMICs) focusing on the economic consequences for households of illness and health care use. These include household level impacts of direct costs (medical treatment and related financial costs), indirect costs (productive time losses resulting from illness) and subsequent household responses. It highlights that health care financing strategies that place considerable emphasis on out-of-pocket payments can impoverish households. There is growing evidence of households being pushed into poverty or forced into deeper poverty when faced with substantial medical expenses, particularly when combined with a loss of household income due to ill-health. Health sector reforms in LMICs since the late 1980s have particularly focused on promoting user fees for public sector health services and increasing the role of the private for-profit sector in health care provision. This has increasingly placed the burden of paying for health care on individuals experiencing poor health. This trend seems to continue even though some countries and international organisations are considering a shift away from their previous pro-user fee agenda. Research into alternative health care financing strategies and related mechanisms for coping with the direct and indirect costs of illness is urgently required to inform the development of appropriate social policies to improve access to essential health services and break the vicious cycle between illness and poverty.
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Affiliation(s)
- Diane McIntyre
- Health Economics Unit, University of Cape Town, Cape Town, South Africa.
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Young T, Boulle A, Busgeeth K. Home-based care for reducing morbidity and mortality in people infected with HIV/AIDS. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2005. [DOI: 10.1002/14651858.cd005417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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25
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Ncama BP. Models of Community/Home-Based Care for People Living With HIV/AIDS in Southern Africa. J Assoc Nurses AIDS Care 2005; 16:33-40. [PMID: 16433115 DOI: 10.1016/j.jana.2005.03.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The HIV/AIDS epidemic has placed a large burden on public health facilities in developing countries that are already functioning with limited resources. This has shifted the burden of care to families and communities, because public health services are often stretched beyond their capacities. A number of community/home-based care models and services have evolved in response to this need. This report reviews the most common community- and home-based care models in use as well as the experiences of selected African countries in their use of community/home-based care.
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Bertozzi S, Gutierrez JP, Opuni M, Walker N, Schwartländer B. Estimating resource needs for HIV/AIDS health care services in low-income and middle-income countries. Health Policy 2004; 69:189-200. [PMID: 15212866 DOI: 10.1016/j.healthpol.2003.12.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2003] [Accepted: 12/08/2003] [Indexed: 11/25/2022]
Abstract
As funding mechanisms like the Global Fund for HIV/AIDS, Tuberculosis and Malaria increasingly make funding decisions on the basis of burden of disease estimates and financial need calculations, the importance of reliable and comparable estimating methods is growing. This paper presents a model for estimating HIV/AIDS health care resource needs in low- and middle-income countries. The model presented was the basis for the United Nations' call for US dollars 9.2 billion to address HIV/AIDS in developing countries by 2005 with US dollars 4.4 billion to address HIV/AIDS health care and the rest to deal with HIV/AIDS prevention. The model has since been updated and extended to produce estimates for 2007. This paper details the methods and assumptions used to estimate HIV/AIDS health care financial needs and it discusses the limitations and data needs for this model.
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Affiliation(s)
- Stefano Bertozzi
- Division of Health Economics and Policy, The National Institute of Public Health (INSP), Universidad 655, Cuernavaca, Mexico
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Affiliation(s)
- Ellen Giarelli
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA.
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28
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Affiliation(s)
- John Knodel
- Population Studies Center, Ann Arbor, Michigan 48106-1248, USA.
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29
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Creese A, Floyd K, Alban A, Guinness L. Cost-effectiveness of HIV/AIDS interventions in Africa: a systematic review of the evidence. Lancet 2002; 359:1635-43. [PMID: 12020523 DOI: 10.1016/s0140-6736(02)08595-1] [Citation(s) in RCA: 205] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Evidence for cost-effectiveness of interventions for HIV/AIDS in Africa is fragmentary. Cost-effectiveness is, however, highly relevant. African governments face difficult choices in striking the right balance between prevention, treatment, and care, all of which are necessary to deal comprehensively with the epidemic. Reductions in drug prices have raised the priority of treatment, though treatment access is restricted. We assessed the existing cost-effectiveness data and its implications for value-for-money strategies to combat HIV/AIDS in Africa. METHODS We undertook a systematic review using databases and consultations with experts. We identified over 60 reports that measured both the cost and effectiveness of HIV/AIDS interventions in Africa. 24 studies met our inclusion criteria and were used to calculate standardised estimates of the cost (US$ for year 2000) per HIV infection prevented and per disability-adjusted life-year (DALY) gained for 31 interventions. FINDINGS Cost-effectiveness varied greatly between interventions. A case of HIV/AIDS can be prevented for $11, and a DALY gained for $1, by selective blood safety measures, and by targeted condom distribution with treatment of sexually transmitted diseases. Single-dose nevirapine and short-course zidovudine for prevention of mother-to-child transmission, voluntary counselling and testing, and tuberculosis treatment, cost under $75 per DALY gained. Other interventions, such as formula feeding for infants, home care programmes, and antiretroviral therapy for adults, cost several thousand dollars per infection prevented, or several hundreds of dollars per DALY gained. INTERPRETATION A strong economic case exists for prioritisation of preventive interventions and tuberculosis treatment. Where potentially exclusive alternatives exist, cost-effectiveness analysis points to an intervention that offers the best value for money. Cost-effectiveness analysis is an essential component of informed debate about priority setting for HIV/AIDS.
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Affiliation(s)
- Andrew Creese
- Essential Drugs and Medicines Policy Department, WHO, Geneva, Switzerland.
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30
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Guinness L, Arthur G, Bhatt SM, Achiya G, Kariuki S, Gilks CF. Costs of hospital care for HIV-positive and HIV-negative patients at Kenyatta National Hospital, Nairobi, Kenya. AIDS 2002; 16:901-8. [PMID: 11919492 DOI: 10.1097/00002030-200204120-00010] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To record the costs of hospital care for HIV-positive and -negative patients in Nairobi, and identify costs paid by patients per admission. DESIGN Cost data were collected on inpatients enrolled in a linked clinical study using standardized costing methods. SETTING Kenyatta National Hospital, Nairobi's main district hospital. PATIENTS Consecutive adult medical admissions to one ward over 14 weeks who consented to enrollment; tertiary referrals were excluded. MAIN OUTCOME MEASURE Average length of stay and cost per patient admission. RESULTS The hospital costs of 398 patients (163 HIV positive; 33 with clinical AIDS) were analysed. The mean length of stay was 9.3 days and the mean cost per patient admission was US$163. There was no significant difference in costs or mean lengths of stay between HIV-positive and -negative groups, nor were the costs and lengths of stay for clinical AIDS patients significantly different to those for HIV-positive patients without AIDS. The patient charges paid to the hospital per admission, recorded for 344 patients, were on average US$61; and did not differ by HIV status. CONCLUSION The similar cost patterns for inpatient care irrespective of HIV status or clinical AIDS probably reflects the limited provision of care beyond basic clinical services. Length of stay rather than differing treatment regimes thus appears to be the main cost driver. Private costs of medical care were high and were likely to pressurize households. When resources are limited, the introduction of new, more costly therapies needs careful planning. The study provides cost information for planning care services in resource-poor settings.
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Affiliation(s)
- Lorna Guinness
- Liverpool School of Tropical Medicine, Liverpool, L3 5QA UK
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31
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de Guzman A. Reducing social vulnerability to HIV/AIDS: models of care and their impact in resource-poor settings. AIDS Care 2001; 13:663-75. [PMID: 11571013 DOI: 10.1080/09540120120063287] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
There has been an increasing understanding of the social, economic, cultural and political factors that have shaped the HIV/AIDS epidemic. It has been widely recognized that in order to have effective prevention programmes for HIV/AIDS, the broader determinants of health must be addressed. Concurrently, a deeper understanding of personal and societal vulnerability to HIV/AIDS has emerged. Some prevention efforts have expanded their focus, addressing not only individual risk factors and behaviour, but also social justice and including community mobilization activities to address the wider context of the disease. However, the transition to an expanded approach to mitigating the effects of the HIV/AIDS epidemic has not been complete. There is little evidence that care and support strategies have systematically tried to address these concepts. While the role care plays in prevention is considered vital, viewing models of care in terms of their impact on the social vulnerability of certain groups to HIV/AIDS has been largely neglected. Yet appropriate care programmes that help reduce vulnerability will arguably also make the greatest contribution for prevention. Drawing on examples of the role social vulnerability has played in prevention efforts, this paper evaluates the impact of HIV/AIDS care models on socially vulnerable groups, such as women and children.
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Affiliation(s)
- A de Guzman
- Family Planning International Assistance, Asia and Pacific Regional Office, Bangkok, Thailand.
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Abstract
This review of published studies on the costs of HIV treatment and care describes some of the recent developments that have influenced these costs in industrialised and industrialising countries, especially within the context of changing drug treatments. Some of the different approaches to estimating the economic impact of HIV infection are briefly presented. The methods used to review the literature are described, particularly the criteria of a scoring system that was specifically developed to systematically screen some of the studies identified. The mean review score for studies dealing with direct hospital costs increased significantly (p = 0.003) over the 3 periods analysed (before 1987, 1987 to 1995, and 1996 and beyond), indicating that the overall 'quality' of studies increased over time. All cost estimates, other than those from non-industrialised regions, were converted to 1996 US dollars using country-specific total health expenditure inflaters and country-specific Gross Domestic Product Purchasing Power Parity converters. A summary of hospital cost estimates over time and by region demonstrated that the costs of treating asymptomatic individuals and people with symptomatic non-AIDS increased over the period, but that the costs of treating individuals with AIDS appears to have stabilised since the late 1980s. As fewer studies could be identified on the costs of community and informal care, indirect productivity costs and population cost estimates, and costs of care for children with HIV infection, all of these studies were reviewed without the use of the scoring system. Finally, the discussion explores the evidence on the global costs of HIV in non-industrialised economies and the affordability of HIV treatment and care. Some suggestions for the direction of future HIV costing studies are also presented. A need remains for good quality cost data. Adequate research effort should be directed to improving the scope and quality of information on costs of HIV service provision around the world.
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Affiliation(s)
- E J Beck
- Joint Departments of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada.
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