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Rosen S, Blokhina E, Truong V, Bereznicka A, Gnatienko N, Quinn E, Lioznov D, Krupitsky E, Michals A, Lunze K, Samet JH. Comparative costs and potential affordability of a multifaceted intervention to improve treatment outcomes among people with HIV who inject drugs in Russia: economic evaluation of the LINC-II randomized controlled trial. J Int AIDS Soc 2024; 27:e26208. [PMID: 38403887 PMCID: PMC10895073 DOI: 10.1002/jia2.26208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 12/23/2023] [Indexed: 02/27/2024] Open
Abstract
INTRODUCTION The LINC-II randomized controlled trial in St. Petersburg, Russia for HIV-positive adults who inject drugs found that a multi-component intervention including initiation of antiretroviral therapy (ART) during admission to an addiction hospital, strengths-based case management and naltrexone significantly increased 12-month HIV viral suppression and ART retention. We conducted a comparative cost analysis to determine if the 12-month cost of the intervention is affordable within the current Russian health system. METHODS We used LINC-II trial records and questionnaire responses to calculate the resources utilized by each participant in the study, including inpatient days, medications, laboratory tests, outpatient consultations, case manager interactions and opioid medication treatment. Quantities of resources utilized were multiplied by unit costs for each resource estimated from the service fee or price lists used by the study facilities for each specific service delivered. We report the average cost/study primary (viral suppression at 12 months) or secondary (retention in care at 12 months) outcome/participant in 2021 USD and compare costs between study arms. RESULTS The trial enrolled 225 participants (111 intervention, 114 control) between September 2018 and December 2020. Viral suppression, non-suppression and missing suppression results were 28% and 14%, 49% and 37%, and 31% and 41% for the control and intervention arms, respectively. Retention results were 35% and 51% for the control and intervention arms, respectively. The average cost per study participant was $2714 in the control arm and $4342 in the intervention arm. The average cost per participant virally suppressed at 12 months was $3662 (control) and $6355 (intervention). The average cost per participant retained at 12 months was $4050 (control) and $5448 (intervention). For those retained, the cost difference between the arms was comprised of opioid treatment (35%), case management (31%), outpatient visits (18%) and additional days of ART (12%). CONCLUSIONS The LINC-II intervention increased the cost of care for HIV-positive people who inject drugs in Russia significantly, but some components of the intervention, particularly earlier initiation of ART and case management, may be justifiable due to their success in reaching a challenging subgroup of the population in need. CLINICAL TRIAL NUMBER NCT03290391.
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Affiliation(s)
- Sydney Rosen
- School of Public HealthBoston UniversityBostonMassachusettsUSA
- Health Economics and Epidemiology Research OfficeWits Health ConsortiumFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Elena Blokhina
- Pavlov First State Medical UniversitySt. PetersburgRussian Federation
| | - Ve Truong
- Clinical Addiction Research and Education (CARE) UnitSection of General Internal MedicineDepartment of MedicineBoston Medical CenterBostonMassachusettsUSA
| | - Agata Bereznicka
- Clinical Addiction Research and Education (CARE) UnitSection of General Internal MedicineDepartment of MedicineBoston Medical CenterBostonMassachusettsUSA
| | - Natalia Gnatienko
- Clinical Addiction Research and Education (CARE) UnitSection of General Internal MedicineDepartment of MedicineBoston Medical CenterBostonMassachusettsUSA
| | - Emily Quinn
- Biostatistics and Epidemiology Data Analytics CenterBoston University School of Public HealthBostonMassachusettsUSA
| | - Dmitry Lioznov
- Pavlov First State Medical UniversitySt. PetersburgRussian Federation
- Smorodintsev Research Institute of InfluenzaSt. PetersburgRussian Federation
| | - Evgeny Krupitsky
- Pavlov First State Medical UniversitySt. PetersburgRussian Federation
- V.M. Bekhterev National Medical Research Center for Psychiatry and NeurologySaint PetersburgRussian Federation
| | - Amy Michals
- Biostatistics and Epidemiology Data Analytics CenterBoston University School of Public HealthBostonMassachusettsUSA
| | - Karsten Lunze
- Clinical Addiction Research and Education (CARE) UnitSection of General Internal MedicineDepartment of MedicineBoston Medical CenterBostonMassachusettsUSA
- Section of GeneralInternal MedicineDepartment of MedicineBoston University School of MedicineBostonMassachusettsUSA
| | - Jeffrey H. Samet
- Clinical Addiction Research and Education (CARE) UnitSection of General Internal MedicineDepartment of MedicineBoston Medical CenterBostonMassachusettsUSA
- Section of GeneralInternal MedicineDepartment of MedicineBoston University School of MedicineBostonMassachusettsUSA
- Department of Community Health SciencesBoston University School of Public HealthBostonMassachusettsUSA
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Antoniak S, Chasela CS, Freiman MJ, Stopolianska Y, Barnard T, Gandhi MM, Liulchuk M, Tsenilova Z, Viktor T, Dible J, Wose Kinge C, Akpan F, Minior T, Sigwebela N, Mohamed S, Barralon M, Marange F, Cavenaugh C, Horst CV, Antonyak S, Xulu T, Chew KW, Sanne I, Rosen S. Treatment outcomes and costs of a simplified antiretroviral treatment strategy for hepatitis C among Hepatitis C Virus and Human Immuno deficiency Virus co-infected patients in Ukraine. JGH Open 2022; 6:894-903. [PMID: 36514496 PMCID: PMC9730727 DOI: 10.1002/jgh3.12839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 10/12/2022] [Accepted: 10/21/2022] [Indexed: 11/18/2022]
Abstract
Background and Aim To demonstrate the use of a standard dose of ledipasvir (LDV) and sofosbuvir (SOF), with or without ribavirin, to treat hepatitis C and hepatitis C/HIV co-infection in Ukraine. Methods Eligible HCV viraemic adults from two clinics in Kyiv were treated with LDV/SOF with or without weight-based ribavirin for 12 weeks. Clinical assessments were performed at screening and at week 24, and as needed; treatment was dispensed every 4 weeks. The primary outcome was sustained virologic response (SVR) 12 weeks after treatment, with analysis by intention to treat. Cost per patient was estimated in USD (2018) over the 24-week period. Results Of 868 patients included in the study and initiated on therapy, 482 (55.5%) were co-infected with HIV. The common genotypes were 1 (74.1%) and 3 (22%). Overall, SVR was achieved in 831 of the 868 patients (95.7%). SVR in patients with hepatitis C alone and hepatitis C/HIV co-infection was 98.4% and 93.6%, respectively. Adverse events were infrequent and usually mild. Using generic medication, cost per patient was estimated at US$680. Conclusion A standard dose of LDV and SOF, with ribavirin as per protocol, resulted in good outcomes for patients with both hepatitis C alone and co-infected with hepatitis C/HIV. Program costs in Ukraine were modest using generic medication.
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Affiliation(s)
| | - Charles S Chasela
- Right to CarePretoriaSouth Africa
- Department of Epidemiology and Biostatistics, Faculty of Health Sciences, School of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
| | | | | | - Tetiana Barnard
- United States Agency for International DevelopmentWashingtonDistrict of ColumbiaUSA
| | - Malini M Gandhi
- David Geffen School of Medicine at University of California Los AngelesLos AngelesCaliforniaUSA
| | - Maria Liulchuk
- Public Health Centre of Ministry of Healthcare of UkraineKyivUkraine
| | | | | | - Jeri Dible
- United States Agency for International DevelopmentWashingtonDistrict of ColumbiaUSA
| | | | | | - Thomas Minior
- United States Agency for International DevelopmentWashingtonDistrict of ColumbiaUSA
| | | | - Sofiane Mohamed
- Advanced Biological Laboratories (ABL)Luxembourg CityLuxembourg
| | | | | | - Clint Cavenaugh
- United States Agency for International DevelopmentWashingtonDistrict of ColumbiaUSA
| | | | - Svitlana Antonyak
- Gromashevsky Research Institute of Epidemiology and Infectious DiseasesMedical Academy of Sciences of UkraineKyivUkraine
| | | | - Kara W Chew
- David Geffen School of Medicine at University of California Los AngelesLos AngelesCaliforniaUSA
| | - Ian Sanne
- Right to CarePretoriaSouth Africa
- Wits HIV Research Unit, Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Sydney Rosen
- Boston UniversityBostonMassachusettsUSA
- Health Economics and Epidemiology Research OfficeWits Health Consortium, Faculty of Health Sciences, University of the WitwatersrandJohannesburgSouth Africa
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Guthrie T, Muheki C, Rosen S, Kanoowe S, Lagony S, Greener R, Miot J, Balidawa H, Kiggundu J, Calnan J, Dejene S, Xulu T, Sigwebela N, Long LC. Similar costs and outcomes for differentiated service delivery models for HIV treatment in Uganda. BMC Health Serv Res 2022; 22:1315. [PMID: 36329450 PMCID: PMC9635081 DOI: 10.1186/s12913-022-08629-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 09/15/2022] [Indexed: 11/06/2022] Open
Abstract
This cost-outcome study estimated, from the perspective of the service provider, the total annual cost per client on antiretroviral therapy (ART) and total annual cost per client virally suppressed (defined as < 1000 copies/ml at the time of the study) in Uganda in five ART differentiated service delivery models (DSDMs). These included both facility- and community-based models and the standard of care (SOC), known as the facility-based individual management (FBIM) model. The Ministry of Health (MOH) adopted guidelines for DSDMs in 2017 and sought to measure their costs and outcomes, in order to effectively plan for their resourcing, implementation, and scale-up. In Uganda, the standard of care (FBIM) is considered as a DSDM option for clients requiring specialized treatment and support, or for those who select not to join an alternative DSDM. Note that clients on second-line regimes and considered as “established on treatment” can join a suitable DSDM. Using retrospective client record review of a cohort of clients over a two-year period, with bottom-up collection of clients’ resource utilization data, top-down collection of above-delivery level and delivery-level providers’ fixed operational costs, and local unit costs. Forty-seven DSDMs located at facilities or community-based points in the four regions of Uganda were included in the study, with 653 adults on ART (> 18 years old) enrolled in a DSDM. The study found that retention in care was 98% for the sample as a whole [96–100%], and viral suppression, 91% [86-93%]. The mean cost to the provider (MOH or NGO implementers) was $152 per annum per client treated, ranging from $141 to $166. Differences among the models’ costs were largely due to clients’ ARV regimens and the proportions of clients on second line regimens. Service delivery costs, excluding ARVs, other medicines and laboratory tests, were modest, ranging from $9.66–16.43 per client per year. We conclude that differentiated ART service delivery in Uganda achieved excellent treatment outcomes at a cost similar to the standard of care. While large budgetary savings might not be immediately realized, the reallocation of “saved” staff time could improve health system efficiency and with their equivalent or better outcomes and large benefits to clients, client-centred differentiated models would nevertheless add great societal value.
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Hoffman RM, Moyo C, Balakasi KT, Siwale Z, Hubbard J, Bardon A, Fox MP, Kakwesa G, Kalua T, Nyasa-Haambokoma M, Dovel K, Campbell PM, Tseng CH, Pisa PT, Cele R, Gupta S, Benade M, Long L, Xulu T, Sanne I, Rosen S. Multimonth dispensing of up to 6 months of antiretroviral therapy in Malawi and Zambia (INTERVAL): a cluster-randomised, non-blinded, non-inferiority trial. LANCET GLOBAL HEALTH 2021; 9:e628-e638. [PMID: 33865471 DOI: 10.1016/s2214-109x(21)00039-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Facility-based, multimonth dispensing of antiretroviral therapy (ART) for HIV could reduce burdens on patients and providers and improve retention in care. We assessed whether 6-monthly ART dispensing was non-inferior to standard of care and 3-monthly ART dispensing. METHODS We did a pragmatic, cluster-randomised, unblinded, non-inferiority trial (INTERVAL) at 30 health facilities in Malawi and Zambia. Eligible participants were aged 18 years or older, HIV-positive, and were clinically stable on ART. Before randomisation, health facilities (clusters) were matched on the basis of country, ART cohort size, facility type (ie, hospital vs health centre), and region or province. Matched clusters were randomly allocated (1:1:1) to standard of care, 3-monthly ART dispensing, or 6-monthly ART dispensing using a simple random allocation sequence. The primary outcome was retention in care at 12 months, defined as the proportion of patients with less than 60 consecutive days without ART during study follow-up, analysed by intention to treat. A 2·5% margin was used to assess non-inferiority. This study is registered with ClinicalTrials.gov, NCT03101592. FINDINGS Between May 15, 2017, and April 30, 2018, 9118 participants were randomly assigned, of whom 8719 participants (n=3012, standard of care group; n=2726, 3-monthly ART dispensing group; n=2981, 6-monthly ART dispensing group) had primary outcome data available at 12 months and were included in the primary analysis. The median age of participants was 42·7 years (IQR 36·1-49·9) and 5774 (66·2%) of 8719 were women. The primary outcome was met by 2478 (82·3%) of 3012 participants in the standard of care group, 2356 (86·4%) of 2726 participants in the 3-monthly ART dispensing group, and 2729 (91·5%) of 2981 participants in the 6-monthly ART dispensing group. After adjusting for clustering, for retention in care at 12 months, the 6-monthly ART dispensing group was non-inferior to the standard of care group (percentage-point increase 9·1 [95% CI 0·9-17·2]) and to the 3-monthly ART dispensing group (5·0% [1·0-9·1]). INTERPRETATION Clinical visits with ART dispensing every 6 months was non-inferior to standard of care and 3-monthly ART dispensing. 6-monthly ART dispensing is a promising strategy for the expansion of ART provision and achievement of HIV treatment targets in resource-constrained settings. FUNDING US Agency for International Development.
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Affiliation(s)
- Risa M Hoffman
- Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA.
| | | | | | | | - Julie Hubbard
- Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
| | - Ashley Bardon
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
| | - Matthew P Fox
- Department of Epidemiology, School of Public Health, Boston University, Boston, MA, USA; Department of Global Health, School of Public Health, Boston University, Boston, MA, USA; Department of Paediatrics, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Thokozani Kalua
- Department of HIV and AIDS, Malawi Ministry of Health, Lilongwe, Malawi
| | | | - Kathryn Dovel
- Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
| | - Paula M Campbell
- Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
| | - Chi-Hong Tseng
- Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
| | - Pedro T Pisa
- Department of Paediatrics, University of the Witwatersrand, Johannesburg, South Africa; Right to Care South Africa, Centurion, South Africa
| | - Refiloe Cele
- Department of Paediatrics, University of the Witwatersrand, Johannesburg, South Africa
| | - Sundeep Gupta
- Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
| | - Mariet Benade
- Department of Global Health, School of Public Health, Boston University, Boston, MA, USA
| | - Lawrence Long
- Department of Global Health, School of Public Health, Boston University, Boston, MA, USA; Department of Paediatrics, University of the Witwatersrand, Johannesburg, South Africa
| | - Thembi Xulu
- Right to Care South Africa, Centurion, South Africa
| | - Ian Sanne
- Right to Care South Africa, Centurion, South Africa
| | - Sydney Rosen
- Department of Global Health, School of Public Health, Boston University, Boston, MA, USA; Department of Paediatrics, University of the Witwatersrand, Johannesburg, South Africa
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Fast-track treatment initiation counselling in South Africa: A cost-outcomes analysis. PLoS One 2021; 16:e0248551. [PMID: 33735206 PMCID: PMC7971492 DOI: 10.1371/journal.pone.0248551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 03/01/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction In 2016, under its new National Adherence Guidelines (AGL), South Africa formalized an existing model of fast-track HIV treatment initiation counselling (FTIC). Rollout of the AGL included an evaluation study at 24 clinics, with staggered AGL implementation. Using routinely collected data extracted as part of the evaluation study, we estimated and compared the costs of HIV care and treatment from the provider’s perspective at the 12 clinics implementing the new, formalized model (AGL-FTIC) to costs at the 12 clinics continuing to implement some earlier, less formalized, model that likely varied across clinics (denoted here as early-FTIC). Methods This was a cost-outcome analysis using standard methods and a composite outcome defined as initiated antiretroviral therapy (ART) within 30 days of treatment eligibility and retained in care at 9 months. Using patient-level, bottom-up resource-utilization data and local unit costs, we estimated patient-level costs of care and treatment in 2017 U.S. dollars over the 9-month evaluation follow-up period for the two models of care. Resource use and costs, disaggregated by antiretroviral medications, laboratory tests, and clinic visits, are reported by model of care and stratified by the composite outcome. Results A total of 350/343 patients in the early-FTIC/AGL-FTIC models of care are included in this analysis. Mean/median costs were similar for both models of care ($135/$153 for early-FTIC, $130/$151 for AGL-FTIC). For the subset achieving the composite outcome, resource use and therefore mean/median costs were similar but slightly higher, reflecting care consistent with treatment guidelines ($163/$166 for early-FTIC, $168/$170 for AGL-FTIC). Not surprisingly, costs for patients not achieving the composite outcome were substantially less, mainly because they only had two or fewer follow-up visits and, therefore, received substantially less ART than patients who achieved the composite outcome. Conclusion The 2016 adherence guidelines clarified expectations for the content and timing of adherence counseling sessions in relation to ART initiation. Because clinics were already initiating patients on ART quickly by 2016, little room existed for the new model of fast-track initiation counseling to reduce the number of pre-ART clinic visits at the study sites and therefore to reduce costs of care and treatment. Trial registration Clinical Trial Number: NCT02536768.
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Min Thaung Y, Chasela CS, Chew KW, Minior T, Lwin AA, Sein YY, Drame N, Marange F, van der Horst C, Thwin HT, Freiman MJ, Gandhi MM, Bijl M, Wose Kinge C, Rosen S, Thura S, Mohamed S, Xulu T, Naing AY, Barralon M, Cavenaugh C, Kyi KP, Sanne I. Treatment outcomes and costs of a simplified antiviral treatment strategy for hepatitis C among monoinfected and HIV and/or hepatitis B virus-co-infected patients in Myanmar. J Viral Hepat 2021; 28:147-158. [PMID: 32935438 PMCID: PMC7746582 DOI: 10.1111/jvh.13405] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 09/01/2020] [Indexed: 12/13/2022]
Abstract
Access to hepatitis C virus (HCV) testing and treatment is limited in Myanmar. We assessed an integrated HIV and viral hepatitis testing and HCV treatment strategy. Sofosbuvir/velpatasvir (SOF/VEL) ± weight-based ribavirin for 12 weeks was provided at three treatment sites in Myanmar and sustained virologic response (SVR) assessed at 12 weeks after treatment. Participants co-infected with HBV were treated concurrently with tenofovir. Cost estimates in 2018 USD were made at Yangon and Mandalay using standard micro-costing methods. 803 participants initiated SOF/VEL; 4.8% were lost to follow-up. SVR was achieved in 680/803 (84.6%) by intention-to-treat analysis. SVR amongst people who inject drugs (PWID) was 79.7% (381/497), but 92.5% among PWID on opioid substitution therapy (OST) (74/80), and 97.4% among non-PWID (298/306). Utilizing data from 492 participants, of whom 93% achieved SVR, the estimated average cost of treatment per patient initiated was $1030 (of which 54% were medication costs), with a production cost per successful outcome (SVR) of $1109 and real-world estimate of $1250. High SVR rates were achieved for non-PWID and PWID on OST. However, the estimated average cost of the intervention (under the assumption of no genotype testing and reduced real-world effectiveness) of $1250/patient is unaffordable for a national elimination strategy. Reductions in the cost of antivirals and linkage to social and behavioural health services including substance use disorder treatment to increase retention and adherence to treatment are critical to HCV elimination in this population.
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Affiliation(s)
| | - Charles S. Chasela
- Right to Care/EQUIP HealthPretoriaSouth Africa,Department of Epidemiology and BiostatisticsSchool of Public HealthFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Kara W. Chew
- David Geffen School of Medicine at UCLALos AngelesCAUSA
| | - Thomas Minior
- U.S. Agency for International DevelopmentWashingtonDCUSA
| | - Aye A. Lwin
- Advanced Biological Laboratories (ABL) SARue des jardiniersLuxembourg
| | | | - Ndeye Drame
- School of Public HealthBoston UniversityBostonMAUSA
| | | | | | | | | | | | - Murdo Bijl
- Asian Harm Reduction NetworkKachinMyanmar
| | - Constance Wose Kinge
- Division of Epidemiology and SurveillanceNational Institute for Occupational HealthJohannesburgSouth Africa,Hepatitis Virus Diversity Research UnitDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Sydney Rosen
- School of Public HealthBoston UniversityBostonMAUSA,Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Si Thura
- Community Partners InternationalYangonMyanmar
| | - Sofiane Mohamed
- Advanced Biological Laboratories (ABL) SARue des jardiniersLuxembourg
| | | | | | - Matthiue Barralon
- Advanced Biological Laboratories (ABL) SARue des jardiniersLuxembourg
| | | | | | - Ian Sanne
- Right to Care/EQUIP HealthPretoriaSouth Africa,School of Public HealthBoston UniversityBostonMAUSA,Department of MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburg,Immunology Research Division, Department of Medical ResearchMinistry of Health and SportsYangonMyanmar
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Larson BA, Pascoe SJ, Huber A, Long LC, Murphy J, Miot J, Fox MP, Fraser-Hurt N, Rosen S. Will differentiated care for stable HIV patients reduce healthcare systems costs? J Int AIDS Soc 2020; 23:e25541. [PMID: 32686911 PMCID: PMC7370539 DOI: 10.1002/jia2.25541] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/17/2020] [Accepted: 05/07/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION South Africa's National Department of Health launched the National Adherence Guidelines for Chronic Diseases in 2015. These guidelines include adherence clubs (AC) and decentralized medication delivery (DMD) as two differentiated models of care for stable HIV patients on antiretroviral therapy. While the adherence guidelines do not suggest that provider costs (costs to the healthcare system for medications, laboratory tests and visits to clinics or alternative locations) for stable patients in these differentiated models of care will be lower than conventional, clinic-based care, recent modelling exercises suggest that such differentiated models could substantially reduce provider costs. In the context of continued implementation of the guidelines, we discuss the conditions under which provider costs of care for stable HIV patients could fall, or rise, with AC and DMD models of care in South Africa. DISCUSSION In prior studies of HIV care and treatment costs, three main cost categories are antiretroviral medications, laboratory tests and general interaction costs based on encounters with health workers. Stable patients are likely to be on the national first-line regimen (Tenofovir/Entricitabine/Efavarinz (TDF/FTC/EFV)), so no difference in the costs of medications is expected. Laboratory testing guidelines for stable patients are the same regardless of the model of care, so no difference in laboratory costs is expected as well. Based on existing information regarding the costs of clinic visits, AC visits and DMD drug pickups, we expect that for some clinics, visit costs for DMD or AC models of care could be less, but modestly so, than for conventional, clinic-based care. For other clinics, however, DMD or AC models could have higher visit costs (see Table 2). CONCLUSIONS The standard of care for stable patients has already been "differentiated" for years in South Africa, prior to the roll out of the new adherence guidelines. AC and DMD models of care, when implemented as envisioned in the guidelines, are unlikely to generate substantive reductions or increases in provider costs of care.
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Affiliation(s)
- Bruce A Larson
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Sophie Js Pascoe
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Amy Huber
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence C Long
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joshua Murphy
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jacqui Miot
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P Fox
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | | | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Cerecero-García D, Pineda-Antunez C, Alexander L, Cameron D, Martinez-Silva G, Obure CD, Marseille E, Vu L, Kahn JG, Vassall A, Gomez G, Bollinger L, Levin C, Bautista-Arredondo S. A meta-analysis approach for estimating average unit costs for ART using pooled facility-level primary data from African countries. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2020; 18:297-305. [PMID: 31779577 DOI: 10.2989/16085906.2019.1688362] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective: To estimate facility-level average cost for ART services and explore unit cost variations using pooled facility-level cost estimates from four HIV empirical cost studies conducted in five African countries .Methods: Through a literature search we identified studies reporting facility-level costs for ART programmes. We requested the underlying data and standardised the disparate data sources to make them comparable. Subsequently, we estimated the annual cost per patient served and assessed the cost variation among facilities and other service delivery characteristics using descriptive statistics and meta-analysis. All costs were converted to 2017 US dollars ($). Results: We obtained and standardised data from four studies across five African countries and 139 facilities. The weighted average cost per patient on ART was $251 (95% CI: 193-308). On average, 46% of the mean unit cost correspond to antiretroviral (ARVs) costs, 31% to personnel costs, 20% other recurrent costs, and 2% to capital costs. We observed a lot of variation in unit cost and scale levels between countries. We also observed a negative relationship between ART unit cost and the number of patients served in a year.Conclusion: Our approach allowed us to explore unit cost variation across contexts by pooling ART costs from multiple sources. Our research provides an example of how to estimate costs based on heterogeneous sources reconciling methodological differences across studies and contributes by giving an example on how to estimate costs based on heterogeneous sources of data. Also, our study provides additional information on costs for funders, policy-makers, and decision-makers in the process of designing or scaling-up HIV interventions.
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Affiliation(s)
| | | | - Lily Alexander
- HIV AIDS TB Research Consortium CISIDAT, Cuernavaca, Mexico
| | - Drew Cameron
- Health Policy, University of California Berkeley, Berkeley, USA
| | | | | | - Elliot Marseille
- Center for Global Surgical Studies, University of California San Francisco, San Francisco, USA
| | - Lung Vu
- Population Council, Washington, USA
| | - James G Kahn
- Institute for Health Policy Studies, University of California San Francisco, San Francisco, USA
| | - Anna Vassall
- London School of Hygiene and Tropical Medicine, London, UK
| | - Gabriela Gomez
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Carol Levin
- Department of Global Health, University of Washington, Seattle, USA
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Larson BA, Halim N, Tsikhutsu I, Bii M, Coakley P, Rockers PC. A tool for estimating antiretroviral medication coverage for HIV-infected women during pregnancy (PMTCT-ACT). Glob Health Res Policy 2019; 4:29. [PMID: 31637308 PMCID: PMC6794749 DOI: 10.1186/s41256-019-0121-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 09/23/2019] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND In the typical prevention of mother to child transmission (PMTCT) of HIV cascade of care discussion or analysis, the period of analysis begins at the first visit for antenatal care (ANC) for that pregnancy. This starting point is problematic for two reasons: (1) a large number of HIV-infected women are already on life-long antiretroviral therapy (ART) when presenting for ANC; and (2) women present to ANC at different gestational ages. The PMTCT ART Coverage Tool (PMTCT-ACT), which estimates the proportion of days covered (PDC) with ART, was developed to address each of these problems. METHODS PDC is a preferred method to measure adherence to chronic medications, such as ART. For evaluating the PMTCT cascade of care, as indicated by PDC with ART over various time periods, a "starting point" based on a specific day before delivery must be defined that applies to all women (treatment experienced or naïve at the first ANC visit at any gestational age). Using the example of 168 days prior to delivery (24 weeks), PMTCT-ACT measures PDC with ART during that period. PMTCT-ACT is provided as a STATA do-file. Using an example dataset for two women (ID1 is treatment experienced; ID2 is treatment naïve), the details of each major portion of the tool (Parts 1-5) are presented. PMTCT-ACT along with the intermediate datasets created during the analysis are provided as supplemental files. CONCLUSIONS Evaluating the PMTCT cascade of care requires a standard definition of the follow-up period during pregnancy that applies to all HIV-infected pregnant women and a standard measure of adherence. PMTCT-ACT is a new tool that fits this purpose. PMTCT-ACT can also be easily adjusted to evaluate other ante- and post-natal periods (e.g., final 4 weeks, final 8 weeks, complete pregnancy period, initial 24 weeks postpartum, time periods consistent with infant HIV testing guidelines).
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Affiliation(s)
- Bruce A. Larson
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118 USA
| | - Nafisa Halim
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118 USA
| | - Isaac Tsikhutsu
- Kenya Medical Research Institute, U.S. Army Medical Research Directorate, Africa, Kenya
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD USA
- Henry Jackson Foundation MRI, Kericho, Kenya
| | - Margaret Bii
- Kenya Medical Research Institute, U.S. Army Medical Research Directorate, Africa, Kenya
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD USA
- Henry Jackson Foundation MRI, Kericho, Kenya
| | - Peter Coakley
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD USA
| | - Peter C. Rockers
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118 USA
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Kumar GA, Dandona R, Rewari BB, Kumar SGP, Tanwar S, Gagnier MC, Vishnumolakala VS, Dandona L. Decreasing cost of public sector first-line ART services in India from 2007-2008 to 2015-2016. PLoS One 2018; 13:e0206988. [PMID: 30419042 PMCID: PMC6231637 DOI: 10.1371/journal.pone.0206988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 10/23/2018] [Indexed: 12/02/2022] Open
Abstract
Introduction India has scaled-up antiretroviral treatment (ART) in public sector facilities, but data to understand time trends of average cost of ART are limited. Materials and methods Cost and output data were collected at all public sector ART centres in undivided Andhra Pradesh (high-HIV burden state) and Rajasthan (low-HIV burden state) in India from fiscal year 2007–2008 to 2012–2013. Average cost per patient for first-line ART, and its relation with scale of services, were assessed. Using data on scale of services, the average cost was estimated up to 2015–2016. Break-even point was estimated from average and marginal cost functions. Costs were adjusted to 2015 constant price. Results The average cost per patient alive and on ART in 2015–2016 was US$162 in undivided Andhra Pradesh and US$186 in Rajasthan, which was 51.4% and 35.8% lower than in 2007–2008, respectively. Average ART drug cost declined by 27.2% during this period, and was 70.9% and 61.5% of the total ART cost in the two states in 2015–2016. The average cost other than ART drugs declined by 73.1% and 45.7%, with the number of patients served increasing 7 and 14.2 times, respectively. Average cost other than ART drugs had a significant negative relation with scale (R2 = 86.4%-82.8%, p<0.001). Break-even analysis suggested that 47.5% and 58.8% of the ART centres in undivided Andhra Pradesh and Rajasthan, respectively, were functioning below optimal scale in 2015–2016. The estimated total economic cost of first-line ART services provided in the public sector in India in fiscal year 2015–2016 was US$ 151 million; it would be US$ 216.1 million to provide this to all eligible persons in India. Conclusion The average cost of providing first-line ART has declined in India, and further reduction is possible if the optimal scale of services is achieved. These findings can inform resource requirement for the ART programme in India.
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Affiliation(s)
| | - Rakhi Dandona
- Public Health Foundation of India, New Delhi, India
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, United States of America
| | - Bharat B. Rewari
- National AIDS Control Organisation, Ministry of Health and Family Welfare, Government of India, New Delhi, India
- World Health Organization Country Office for India, New Delhi, India
| | | | - Sukarma Tanwar
- Public Health Foundation of India, New Delhi, India
- National AIDS Control Organisation, Ministry of Health and Family Welfare, Government of India, New Delhi, India
- World Health Organization Country Office for India, New Delhi, India
| | - Marielle C. Gagnier
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, United States of America
| | | | - Lalit Dandona
- Public Health Foundation of India, New Delhi, India
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, United States of America
- * E-mail:
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Bautista-Arredondo S, Sosa-Rubi SG, Opuni M, Contreras-Loya D, La Hera-Fuentes G, Kwan A, Chaumont C, Chompolola A, Condo J, Dzekedzeke K, Galarraga O, Martinson N, Masiye F, Nsanzimana S, Wamai R, Wang’ombe J. Influence of supply-side factors on voluntary medical male circumcision costs in Kenya, Rwanda, South Africa, and Zambia. PLoS One 2018; 13:e0203121. [PMID: 30212497 PMCID: PMC6136711 DOI: 10.1371/journal.pone.0203121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 07/30/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND In this study, we described facility-level voluntary medical male circumcision (VMMC) unit cost, examined unit cost variation across facilities, and investigated key facility characteristics associated with unit cost variation. METHODS We used data from 107 facilities in Kenya, Rwanda, South Africa, and Zambia covering 2011 or 2012. We used micro-costing to estimate economic costs from the service provider's perspective. Average annual costs per client were estimated in 2013 United States dollars (US$). Econometric analysis was used to explore the relationship between VMMC total and unit cost and facility characteristics. RESULTS Average VMMC unit cost ranged from US$66 (SD US$79) in Kenya to US$160 (SD US$144) in South Africa. Total cost function estimates were consistent with economies of scale and scope. We found a negative association between the number of VMMC clients and VMMC unit cost with a 3% decrease in unit cost for every 10% increase in number of clients and we found a negative association between the provision of other HIV services and VMMC unit cost. Also, VMMC unit cost was lower in primary health care facilities than in hospitals, and lower in facilities implementing task shifting. CONCLUSIONS Substantial efficiency gains could be made in VMMC service delivery in all countries. Options to increase efficiency of VMMC programs in the short term include focusing service provision in high yield sites when demand is high, focusing on task shifting, and taking advantage of efficiencies created by integrating HIV services. In the longer term, reductions in VMMC unit cost are likely by increasing the volume of clients at facilities by implementing effective demand generation activities.
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Affiliation(s)
- Sergio Bautista-Arredondo
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico
- School of Public Health, University of California, Berkeley, United States of America
| | - Sandra G. Sosa-Rubi
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico
- * E-mail:
| | | | - David Contreras-Loya
- School of Public Health, University of California, Berkeley, United States of America
| | - Gina La Hera-Fuentes
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico
| | - Ada Kwan
- School of Public Health, University of California, Berkeley, United States of America
| | - Claire Chaumont
- T.H. Chan School of Public Health, Harvard University, Boston, United States of America
| | | | - Jeanine Condo
- School of Public Health, National University of Rwanda, Kigali, Rwanda
| | | | - Omar Galarraga
- School of Public Health, Brown University, Providence, United States of America
| | - Neil Martinson
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Felix Masiye
- Division of Economics, University of Zambia, Lusaka, Zambia
| | | | - Richard Wamai
- College of Social Science and Humanities, Northeastern University, Boston, United States of America
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12
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Larson BA, Bii M, Halim N, Rohr JK, Sugut W, Sawe F. Incremental treatment costs for HIV-infected women initiating antiretroviral therapy during pregnancy: A 24-month micro-costing cohort study for a maternal and child health clinic in Kenya. PLoS One 2018; 13:e0200199. [PMID: 30096177 PMCID: PMC6086393 DOI: 10.1371/journal.pone.0200199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 06/21/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND To date, little information exists on the costs of providing antiretroviral therapy (ART) within maternal and child health (MCH) clinics in Kenya. The main objective of this analysis was to estimate the annual incremental cost of providing ART within a MCH clinic for adult women initiated on ART during pregnancy over the first one and two years on treatment. The study site was the District Hospital in Kericho, Kenya. METHODS A micro-costing approach from the provider's perspective, based on a retrospective review of patient medical records, was used to evaluate incremental costs of care (2012 USD). Cost per patient in two cohorts were evaluated: the MCH clinic group comprised of adult women who initiated ART at the site's MCH clinic during pregnancy between 2008-2011; and for comparison, the ART clinic group comprised of adult, non-pregnant women who initiated ART at the site's ART clinic during 2008-2011. The two groups were matched on age and baseline CD4 count at initiation. Retention at year one/two on ART was defined as having completed a clinic visit at 365/730 days on ART +/- 90 days. RESULTS For patients defined as retained in care at year one, average incremental costs per patient were $234 for the MCH clinic group (median: 215; IQR: 186, 282) and $292 in the ART clinic group (median: 227; IQR: 178, 357). ARV and laboratory costs were less on average for the MCH clinic group compared to the ART clinic group (due to lower cost regimens and fewer tests), while personnel costs were higher for the MCH clinic group. CONCLUSIONS The annual incremental cost per patient of providing ART were similar in the two clinic settings in 2012. With shifts in recommended ARV regimens and lab monitoring over time, annual costs of care (using 2016 USD unit costs) have remained relatively constant in nominal terms for the MCH clinic group but have fallen substantially for the ART clinic group (from nominal $292 in 2012 to nominal $227 in 2016).
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Affiliation(s)
- Bruce A. Larson
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- * E-mail:
| | - Margaret Bii
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya
- HJF Medical Research International, Inc., Nairobi, Kenya
| | - Nafisa Halim
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
| | - Julia K. Rohr
- Harvard Center for Population and Development Studies, Cambridge, MA, United States of America
| | - William Sugut
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya
- HJF Medical Research International, Inc., Nairobi, Kenya
| | - Fredrick Sawe
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya
- HJF Medical Research International, Inc., Nairobi, Kenya
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13
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Meyer-Rath G, Johnson LF, Pillay Y, Blecher M, Brennan AT, Long L, Moultrie H, Sanne I, Fox MP, Rosen S. Changing the South African national antiretroviral therapy guidelines: The role of cost modelling. PLoS One 2017; 12:e0186557. [PMID: 29084275 PMCID: PMC5662079 DOI: 10.1371/journal.pone.0186557] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 10/02/2017] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND We were tasked by the South African Department of Health to assess the cost implications to the largest ART programme in the world of adopting sets of ART guidelines issued by the World Health Organization between 2010 and 2016. METHODS Using data from large South African ART clinics (n = 24,244 patients), projections of patients in need of ART, and cost data from bottom-up cost analyses, we constructed a population-level health-state transition model with 6-monthly transitions between health states depending on patients' age, CD4 cell count/ percentage, and, for adult first-line ART, time on treatment. FINDINGS For each set of guidelines, the modelled increase in patient numbers as a result of prevalence and uptake was substantially more than the increase resulting from additional eligibility. Under each set of guidelines, the number of people on ART was projected to increase by 31-133% over the next seven years, and cost by 84-175%, while increased eligibility led to 1-26% more patients, and 1-17% higher cost. The projected increases in treatment cost due to the 2010 and the 2015 WHO guidelines could be offset in their entirety by the introduction of cost-saving measures such as opening the drug tenders for international competition and task-shifting. Under universal treatment, annual costs of the treatment programme will decrease for the first time from 2024 onwards. CONCLUSIONS Annual budgetary requirements for ART will continue to increase in South Africa until universal treatment is taken to full scale. Model results were instrumental in changing South African ART guidelines, more than tripling the population on treatment between 2009 and 2017, and reducing the per-patient cost of treatment by 64%.
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Affiliation(s)
- Gesine Meyer-Rath
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- Health Economics and Epidemiology Research Office (HE2RO), Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Leigh F. Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Yogan Pillay
- National Department of Health, Pretoria, South Africa
| | | | - Alana T. Brennan
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- Health Economics and Epidemiology Research Office (HE2RO), Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office (HE2RO), Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Harry Moultrie
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ian Sanne
- Health Economics and Epidemiology Research Office (HE2RO), Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Clinical HIV Research Unit, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P. Fox
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- Health Economics and Epidemiology Research Office (HE2RO), Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States of America
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- Health Economics and Epidemiology Research Office (HE2RO), Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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14
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Hoffman R, Bardon A, Rosen S, Fox M, Kalua T, Xulu T, Taylor A, Sanne I. Varying intervals of antiretroviral medication dispensing to improve outcomes for HIV patients (The INTERVAL Study): study protocol for a randomized controlled trial. Trials 2017; 18:476. [PMID: 29029644 PMCID: PMC5640907 DOI: 10.1186/s13063-017-2177-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 09/07/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Requirements for frequent dispensing of antiretroviral therapy (ART) place demands on health systems and can lead to suboptimal adherence and disengagement in care for patients due to the time and cost of frequent clinic visits. Rigorous data are needed to define optimal ART dispensing strategies and to evaluate the impact of a longer medication supply on retention and virologic suppression and determine whether this strategy lowers costs for both the patient and the health system. To date, no randomized studies have tested the benefits of 6-month dispensing of ART compared to 3-month and standard of care approaches. METHODS This study will be an unblinded cluster-randomized, matched controlled trial conducted among 8200 stable, HIV-infected individuals age 18 years and older on ART in Malawi and Zambia, to compare three ART dispensing intervals on the outcomes of retention in care (primary outcome), virologic suppression, and cost-effectiveness. Thirty clusters will be matched according to country, facility type, and ART cohort size and randomized to one of three study arms: standard of care, 3-month dispensing, and 6-month dispensing. Study participants will be followed, and outcomes will be measured at 12, 24, and 36 months. A subset of participants (n = 240) and providers (n = 180) will also participate in qualitative interviews to evaluate feasibility and acceptability of different ART dispensing intervals. DISCUSSION This study will be the first to compare 6-month and 3-month ART dispensing intervals for stable, HIV-infected individuals in Malawi and Zambia. We focus on outcomes relevant to country programs, including retention, virologic suppression, and cost-effectiveness. Results from the study will help resource-limited health systems better understand the full scope of outcomes resulting from various ART dispensing intervals and help to inform health policy decisions. TRIAL REGISTRATION ClinicalTrials.gov, NCT03101592 . Registered on 18 March 2017. Pan African Clinical Trials, PACTR201706002336105 . Registered on 2 June 2017.
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Affiliation(s)
- Risa Hoffman
- Division of Infectious Diseases, Department of Medicine, UCLA, 10833 Le Conte Ave, 37-121 CHS, Los Angeles, CA, 90095, USA. .,EQUIP, 3rd Floor Outspan Building, 1006 Lenchen North Avenue, Centurion, South Africa.
| | - Ashley Bardon
- Division of Infectious Diseases, Department of Medicine, UCLA, 10833 Le Conte Ave, 37-121 CHS, Los Angeles, CA, 90095, USA.,EQUIP, 3rd Floor Outspan Building, 1006 Lenchen North Avenue, Centurion, South Africa
| | - Sydney Rosen
- EQUIP, 3rd Floor Outspan Building, 1006 Lenchen North Avenue, Centurion, South Africa.,Department of Global Health, Boston University School of Public Health, 801 Massachusetts Ave, Crosstown Center, Boston, MA, 02118, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew Fox
- EQUIP, 3rd Floor Outspan Building, 1006 Lenchen North Avenue, Centurion, South Africa.,Department of Epidemiology, Boston University School of Public Health, 801 Massachusetts Ave, Crosstown Center, Boston, MA, 02118, USA
| | - Thoko Kalua
- Malawi Ministry of Health, P.O. Box 30377, Capital City, Lilongwe, Malawi
| | - Thembi Xulu
- EQUIP, 3rd Floor Outspan Building, 1006 Lenchen North Avenue, Centurion, South Africa.,Right to Care, 3rd Floor Outspan Building, 1006 Lenchen North Avenue, Centurion, South Africa
| | - Angela Taylor
- Right to Care, 3rd Floor Outspan Building, 1006 Lenchen North Avenue, Centurion, South Africa.,EQUIP-Zambia, 11059 Off Brentwood Road, Mikwala House, Longacres, Lusaka, Zambia
| | - Ian Sanne
- EQUIP, 3rd Floor Outspan Building, 1006 Lenchen North Avenue, Centurion, South Africa.,Right to Care, 3rd Floor Outspan Building, 1006 Lenchen North Avenue, Centurion, South Africa.,Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, 1 York Ave, Parktown, 2193, South Africa
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15
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Hickey MD, Odeny TA, Petersen M, Neilands TB, Padian N, Ford N, Matthay Z, Hoos D, Doherty M, Beryer C, Baral S, Geng EH. Specification of implementation interventions to address the cascade of HIV care and treatment in resource-limited settings: a systematic review. Implement Sci 2017; 12:102. [PMID: 28784155 PMCID: PMC5547499 DOI: 10.1186/s13012-017-0630-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 07/17/2017] [Indexed: 01/23/2023] Open
Abstract
Background The global response to HIV has started over 18 million persons on life-saving antiretroviral therapy (ART)—the vast majority in low- and middle-income countries (LMIC)—yet substantial gaps remain: up to 40% of persons living with HIV (PLHIV) know their status, while another 30% of those who enter care are inadequately retained after starting treatment. Identifying strategies to enhance use of treatment is urgently needed, but the conceptualization and specification of implementation interventions is not always complete. We sought to assess the completeness of intervention reporting in research to advance uptake of treatment for HIV globally. Methods We carried out a systematic review to identify interventions targeting the adult HIV care cascade in LMIC dating from 1990 to 2017. We identified components of each intervention as “intervention types” to decompose interventions into common components. We grouped “intervention types” into a smaller number of more general “implementation approaches” to aid summarization. We assessed the reporting of six intervention characteristics adapted from the implementation science literature: the actor, action, action dose, action temporality, action target, and behavioral target in each study. Findings In 157 unique studies, we identified 34 intervention “types,” which were empirically grouped into six generally understandable “approaches.” Overall, 42% of interventions defined the actor, 64% reported the action, 41% specified the intervention “dose,” 43% reported action temporality, 61% defined the action target, and 69% reported a target behavior. Average completeness of reporting varied across approaches from a low of 50% to a high of 72%. Dimensions that involved conceptualization of the practices themselves (e.g., actor, dose, temporality) were in general less well specified than consequences (e.g., action target and behavioral target). Implications The conceptualization and Reporting of implementation interventions to advance treatment for HIV in LMIC is not always complete. Dissemination of standards for reporting intervention characteristics can potentially promote transparency, reproducibility, and scientific accumulation in the area of implementation science to address HIV in low- and middle-income countries. Electronic supplementary material The online version of this article (doi:10.1186/s13012-017-0630-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthew D Hickey
- Division of General Internal Medicine, San Francisco General Hospital, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | | | - Maya Petersen
- Department of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Torsten B Neilands
- Center for AIDS Prevention Studies, Department of Medicine, UCSF, San Francisco, CA, USA
| | - Nancy Padian
- Department of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Nathan Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | | | - David Hoos
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Meg Doherty
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Chris Beryer
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stefan Baral
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elvin H Geng
- Division of ID HIV and Global Medicine, San Francisco General Hospital, Department of Medicine, UCSF, Building 80, 6th Floor, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.
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Initiating antiretroviral therapy for HIV at a patient's first clinic visit: a cost-effectiveness analysis of the rapid initiation of treatment randomized controlled trial. AIDS 2017; 31:1611-1619. [PMID: 28463879 DOI: 10.1097/qad.0000000000001528] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Determine the cost and cost-effectiveness of single-visit (same-day) antiretroviral treatment (ART) initiation compared to standard of care initiation. DESIGN Cost-effectiveness analysis of individually randomized (1 : 1) pragmatic trial of single-visit initiation, which increased viral suppression at 10 months by 26% [relative risk (95% confidence interval) 1.26 (1.05-1.50)]. SETTING Primary health clinic in Johannesburg, South Africa. STUDY PARTICIPANTS HIV positive, adult, nonpregnant patients not yet on ART or known to be eligible who presented at the clinic 8 May 2013 to 29 August 2014. INTERVENTION Same-day ART initiation using point-of-care laboratory instruments and accelerated clinic procedures to allow treatment-eligible patients to receive antiretroviral medications at the same visit as testing HIV positive or having an eligible CD4 cell count. Comparison was to standard of care ART initiation, which typically required three to five additional clinic visits. MAIN OUTCOME MEASURE(S) Average cost per patient enrolled and per patient achieving the primary outcome of initiated 90 days or less and suppressed 10 months or less, and production cost per patient achieving primary outcome (all costs per primary outcome patients). RESULTS The average cost per patient enrolled, per patient achieving the primary outcome, and production cost were $319, $487, and $738 in the standard arm and $451, $505, and $707 in the rapid arm. CONCLUSION Same-day treatment initiation was more effective than standard initiation, more expensive per patient enrolled, and less expensive to produce a patient achieving the primary outcome. Omitting point-of-care laboratory tests at initiation and focusing on high-volume clinics have the potential to reduce costs substantially and should be evaluated in routine settings.
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17
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Kimaro GD, Mfinanga S, Simms V, Kivuyo S, Bottomley C, Hawkins N, Harrison TS, Jaffar S, Guinness L. The costs of providing antiretroviral therapy services to HIV-infected individuals presenting with advanced HIV disease at public health centres in Dar es Salaam, Tanzania: Findings from a randomised trial evaluating different health care strategies. PLoS One 2017; 12:e0171917. [PMID: 28234969 PMCID: PMC5325220 DOI: 10.1371/journal.pone.0171917] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 01/28/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Understanding the costs associated with health care delivery strategies is essential for planning. There are few data on health service resources used by patients and their associated costs within antiretroviral (ART) programmes in Africa. MATERIAL AND METHODS The study was nested within a large trial, which evaluated screening for cryptococcal meningitis and tuberculosis and a short initial period of home-based adherence support for patients initiating ART with advanced HIV disease in Tanzania and Zambia. The economic evaluation was done in Tanzania alone. We estimated costs of providing routine ART services from the health service provider's perspective using a micro-costing approach. Incremental costs for the different novel components of service delivery were also estimated. All costs were converted into US dollars (US$) and based on 2012 prices. RESULTS Of 870 individuals enrolled in Tanzania, 434 were enrolled in the intervention arm and 436 in the standard care/control arm. Overall, the median (IQR) age and CD4 cell count at enrolment were 38 [31, 44] years and 52 [20, 89] cells/mm3, respectively. The mean per patient costs over the first three months and over a one year period of follow up following ART initiation in the standard care arm were US$ 107 (95%CI 101-112) and US$ 265 (95%CI 254-275) respectively. ART drugs, clinic visits and hospital admission constituted 50%, 19%, and 19% of the total cost per patient year, while diagnostic tests and non-ART drugs (co-trimoxazole) accounted for 10% and 2% of total per patient year costs. The incremental costs of the intervention to the health service over the first three months was US$ 59 (p<0.001; 95%CI 52-67) and over a one year period was US$ 67(p<0.001; 95%CI 50-83). This is equivalent to an increase of 55% (95%CI 51%-59%) in the mean cost of care over the first three months, and 25% (95%CI 20%-30%) increase over one year of follow up.
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MESH Headings
- Adult
- Anti-HIV Agents/economics
- Anti-HIV Agents/therapeutic use
- Antiretroviral Therapy, Highly Active/economics
- CD4 Lymphocyte Count
- Delivery of Health Care/economics
- Delivery of Health Care/statistics & numerical data
- Disease Progression
- Female
- HIV Infections/diagnosis
- HIV Infections/drug therapy
- HIV Infections/economics
- HIV Infections/virology
- Health Care Costs/statistics & numerical data
- Health Resources
- Humans
- Male
- Meningitis, Cryptococcal/diagnosis
- Meningitis, Cryptococcal/drug therapy
- Meningitis, Cryptococcal/economics
- Meningitis, Cryptococcal/microbiology
- Public Health Systems Research
- Tanzania
- Trimethoprim, Sulfamethoxazole Drug Combination/economics
- Trimethoprim, Sulfamethoxazole Drug Combination/therapeutic use
- Tuberculosis, Pulmonary/diagnosis
- Tuberculosis, Pulmonary/drug therapy
- Tuberculosis, Pulmonary/economics
- Tuberculosis, Pulmonary/microbiology
- Zambia
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Affiliation(s)
- Godfather Dickson Kimaro
- Muhimbili Medical Research Centre, National Institute for Medical Research, Dar es Salaam, Tanzania
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sayoki Mfinanga
- Muhimbili Medical Research Centre, National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Victoria Simms
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sokoine Kivuyo
- Muhimbili Medical Research Centre, National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Christian Bottomley
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Neil Hawkins
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Thomas S. Harrison
- Institute for Infection and Immunity, St Georges University of London, London, United Kingdom
| | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Lorna Guinness
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
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18
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Long LC, Rosen SB, Brennan A, Moyo F, Sauls C, Evans D, Modi SL, Sanne I, Fox MP. Treatment Outcomes and Costs of Providing Antiretroviral Therapy at a Primary Health Clinic versus a Hospital-Based HIV Clinic in South Africa. PLoS One 2016; 11:e0168118. [PMID: 27942005 PMCID: PMC5152901 DOI: 10.1371/journal.pone.0168118] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 11/27/2016] [Indexed: 12/02/2022] Open
Abstract
Background In 2010 South Africa revised its HIV treatment guidelines to allow the initiation and management of patients on antiretroviral therapy (ART) by nurses, rather than solely doctors, under a program called NIMART (Nurse Initiated and Managed Antiretroviral Therapy). We compared the outcomes and costs of NIMART between the two major public sector HIV treatment delivery models in use in South Africa today, primary health clinics and hospital-based HIV clinics. Methods and findings The study was conducted at one hospital-based outpatient HIV clinic and one primary health clinic (PHC) in Gauteng Province. A retrospective cohort of adult patients initiated on ART at the PHC was propensity-score matched to patients initiated at the hospital outpatient clinic. Each patient was assigned a 12-month outcome of alive and in care or died/lost to follow up. Costs were estimated from the provider perspective for the 12 months after ART initiation. The proportion of patients alive and in care at 12 months did not differ between the PHC (76.5%) and the hospital-based site (74.2%). The average annual cost per patient alive and in care at 12 months after ART initiation was significantly lower at the PHC (US$238) than at the hospital outpatient clinic (US$428). Conclusions Initiating and managing ART patients at PHCs under NIMART is producing equally good outcomes as hospital-based HIV clinic care at much lower cost. Evolution of hospital-based clinics into referral facilities that serve complicated patients, while investing most program expansion resources into PHCs, may be a preferred strategy for achieving treatment coverage targets.
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Affiliation(s)
- Lawrence C. Long
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
- * E-mail:
| | - Sydney B. Rosen
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
- Center for Global Health & Development, Boston University, Boston, Massachusetts, United States of America
| | - Alana Brennan
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Center for Global Health & Development, Boston University, Boston, Massachusetts, United States of America
| | - Faith Moyo
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
| | - Celeste Sauls
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
| | - Denise Evans
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
| | | | - Ian Sanne
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
- Center for Global Health & Development, Boston University, Boston, Massachusetts, United States of America
- Right to Care, Johannesburg, South Africa
| | - Matthew P. Fox
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
- Center for Global Health & Development, Boston University, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
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19
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Gomez GB, Dowdy DW, Bastos ML, Zwerling A, Sweeney S, Foster N, Trajman A, Islam MA, Kapiga S, Sinanovic E, Knight GM, White RG, Wells WA, Cobelens FG, Vassall A. Cost and cost-effectiveness of tuberculosis treatment shortening: a model-based analysis. BMC Infect Dis 2016; 16:726. [PMID: 27905897 PMCID: PMC5131398 DOI: 10.1186/s12879-016-2064-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 11/08/2016] [Indexed: 12/05/2022] Open
Abstract
Background Despite improvements in treatment success rates for tuberculosis (TB), current six-month regimen duration remains a challenge for many National TB Programmes, health systems, and patients. There is increasing investment in the development of shortened regimens with a number of candidates in phase 3 trials. Methods We developed an individual-based decision analytic model to assess the cost-effectiveness of a hypothetical four-month regimen for first-line treatment of TB, assuming non-inferiority to current regimens of six-month duration. The model was populated using extensive, empirically-collected data to estimate the economic impact on both health systems and patients of regimen shortening for first-line TB treatment in South Africa, Brazil, Bangladesh, and Tanzania. We explicitly considered ‘real world’ constraints such as sub-optimal guideline adherence. Results From a societal perspective, a shortened regimen, priced at USD1 per day, could be a cost-saving option in South Africa, Brazil, and Tanzania, but would not be cost-effective in Bangladesh when compared to one gross domestic product (GDP) per capita. Incorporating ‘real world’ constraints reduces cost-effectiveness. Patient-incurred costs could be reduced in all settings. From a health service perspective, increased drug costs need to be balanced against decreased delivery costs. The new regimen would remain a cost-effective option, when compared to each countries’ GDP per capita, even if new drugs cost up to USD7.5 and USD53.8 per day in South Africa and Brazil; this threshold was above USD1 in Tanzania and under USD1 in Bangladesh. Conclusion Reducing the duration of first-line TB treatment has the potential for substantial economic gains from a patient perspective. The potential economic gains for health services may also be important, but will be context-specific and dependent on the appropriate pricing of any new regimen. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-2064-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- G B Gomez
- Amsterdam Institute for Global Health and Development and Department of Global Health, Academic Medical Center, University of Amsterdam, Trinity Building C, Pietersbergweg 17, Amsterdam, 1105 BM, The Netherlands. .,Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | - D W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - M L Bastos
- Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,Tuberculosis Scientific League, Rio de Janeiro, Brazil
| | - A Zwerling
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - S Sweeney
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - N Foster
- Health Economics Unit, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - A Trajman
- Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,Tuberculosis Scientific League, Rio de Janeiro, Brazil.,McGill University, Montreal, Canada
| | - M A Islam
- BRAC Health Nutrition and Population Programme, BRAC Centre, Dhaka, Bangladesh
| | - S Kapiga
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
| | - E Sinanovic
- Health Economics Unit, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - G M Knight
- TB Modelling Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - R G White
- TB Modelling Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - W A Wells
- Global Alliance for TB Drug Development, New York, USA.,Present address: United States Agency for International Development, Washington, DC, USA
| | - F G Cobelens
- Amsterdam Institute for Global Health and Development and Department of Global Health, Academic Medical Center, University of Amsterdam, Trinity Building C, Pietersbergweg 17, Amsterdam, 1105 BM, The Netherlands.,KNCV Tuberculosis Foundation, The Hague, Netherlands
| | - A Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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20
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Annual cost of antiretroviral therapy among three service delivery models in Uganda. J Int AIDS Soc 2016; 19:20840. [PMID: 27443270 PMCID: PMC4956730 DOI: 10.7448/ias.19.5.20840] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 05/03/2016] [Accepted: 05/04/2016] [Indexed: 11/30/2022] Open
Abstract
Introduction In response to the increasing burden of HIV, the Ugandan government has employed different service delivery models since 2004 that aim to reduce costs and remove barriers to accessing HIV care. These models include community-based approaches to delivering antiretroviral therapy (ART) and delegating tasks to lower-level health workers. This study aimed to provide data on annual ART cost per client among three different service delivery models in Uganda. Methods Costing data for the entire year 2012 were retrospectively collected as part of a larger task-shifting study conducted in three organizations in Uganda: Kitovu Mobile (KM), the AIDS Support Organisation (TASO) and Uganda Cares (UC). A standard cost data capture tool was developed and used to retrospectively collect cost information regarding antiretroviral (ARV) drugs and non-ARV drugs, ART-related lab tests, personnel and administrative costs. A random sample of four TASO centres (out of 11), four UC clinics (out of 29) and all KM outreach units were selected for the study. Results Cost varied across sites within each organization as well as across the three organizations. In addition, the number of annual ART visits was more frequent in rural areas and through KM (the community distribution model), which played a major part in the overall annual ART cost. The annual cost per client (in USD) was $404 for KM, $332 for TASO and $257 for UC. These estimates were lower than previous analyses in Uganda or the region compared to data from 2001 to 2009, but comparable with recent estimates using data from 2010 to 2013. ARVs accounted for the majority of the total cost, followed by personnel and operational costs. Conclusions The study provides updated data on annual cost per ART visit for three service delivery models in Uganda. These data will be vital for in-country budgetary efforts to ensure that universal access to ART, as called for in the 2015 World Health Organization (WHO) guidelines, is achievable. The lower annual ART cost found in this study indicates that we may be able to treat all people with HIV as laid out in the 2015 WHO guidelines. The variation of costs across sites and the three models indicates the potential for efficiency gains.
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21
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Lessons learned and study results from HIVCore, an HIV implementation science initiative. J Int AIDS Soc 2016. [DOI: 10.7448/ias.19.5.21261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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22
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Long LC, Fox MP, Sauls C, Evans D, Sanne I, Rosen SB. The High Cost of HIV-Positive Inpatient Care at an Urban Hospital in Johannesburg, South Africa. PLoS One 2016; 11:e0148546. [PMID: 26885977 PMCID: PMC4757549 DOI: 10.1371/journal.pone.0148546] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 01/19/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND While most HIV care is provided on an outpatient basis, hospitals continue to treat serious HIV-related admissions, which is relatively resource-intensive and expensive. This study reports the primary reasons for HIV-related admission at a regional, urban hospital in Johannesburg, South Africa and estimates the associated lengths of stay and costs. METHODS AND FINDINGS A retrospective cohort study of adult, medical admissions was conducted. Each admission was assigned a reason for admission and an outcome. The length of stay was calculated for all patients (N = 1,041) and for HIV-positive patients (n = 469), actual utilization and associated costs were also estimated. Just under half were known to be HIV-positive admissions. Deaths and transfers were proportionately higher amongst HIV-positive admissions compared to HIV-negative and unknown. The three most common reasons for admission were tuberculosis and other mycobacterial infections (18%, n = 187), cardiovascular disorders (12%, n = 127) and bacterial infections (12%, n = 121). The study sample utilized a total of 7,733 bed days of those, 55% (4,259/7,733) were for HIV-positive patients. The average cost per admission amongst confirmed HIV-positive patients, which was an average of 9.3 days in length, was $1,783 (United States Dollars). CONCLUSIONS Even in the era of large-scale antiretroviral treatment, inpatient facilities in South Africa shoulder a significant HIV burden. The majority of this burden is related to patients not on ART (298/469, 64%), and accounts for more than half of all inpatient resources. Reducing the costs of inpatient care is thus another important benefit of expanding access to ART, promoting earlier ART initiation, and achieving rates of ART retention and adherence.
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Affiliation(s)
- Lawrence C. Long
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
| | - Matthew P. Fox
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
- Center for Global Health & Development, Boston University, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Celeste Sauls
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
| | - Denise Evans
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
| | - Ian Sanne
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
- Center for Global Health & Development, Boston University, Boston, Massachusetts, United States of America
| | - Sydney B. Rosen
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
- Center for Global Health & Development, Boston University, Boston, Massachusetts, United States of America
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23
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Lépine A, Chandrashekar S, Shetty G, Vickerman P, Bradley J, Alary M, Moses S, Vassall A. What Determines HIV Prevention Costs at Scale? Evidence from the Avahan Programme in India. HEALTH ECONOMICS 2016; 25 Suppl 1:67-82. [PMID: 26763652 PMCID: PMC5019264 DOI: 10.1002/hec.3296] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 09/02/2015] [Accepted: 09/24/2015] [Indexed: 05/24/2023]
Abstract
Expanding essential health services through non-government organisations (NGOs) is a central strategy for achieving universal health coverage in many low-income and middle-income countries. Human immunodeficiency virus (HIV) prevention services for key populations are commonly delivered through NGOs and have been demonstrated to be cost-effective and of substantial global public health importance. However, funding for HIV prevention remains scarce, and there are growing calls internationally to improve the efficiency of HIV prevention programmes as a key strategy to reach global HIV targets. To date, there is limited evidence on the determinants of costs of HIV prevention delivered through NGOs; and thus, policymakers have little guidance in how best to design programmes that are both effective and efficient. We collected economic costs from the Indian Avahan initiative, the largest HIV prevention project conducted globally, during the first 4 years of its implementation. We use a fixed-effect panel estimator and a random-intercept model to investigate the determinants of average cost. We find that programme design choices such as NGO scale, the extent of community involvement, the way in which support is offered to NGOs and how clinical services are organised substantially impact average cost in a grant-based payment setting.
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Affiliation(s)
- Aurélia Lépine
- London School of Hygiene and Tropical Medicine, London, UK
| | - Sudhashree Chandrashekar
- London School of Hygiene and Tropical Medicine, London, UK
- St John's Research Institute, Bangalore, India
| | | | | | - Janet Bradley
- URESP, Centre de recherche du CHU de Québec, Québec, Canada
| | - Michel Alary
- URESP, Centre de recherche du CHU de Québec, Québec, Canada
- Département de médecine sociale et préventive, Université Laval, Québec, Canada
| | - Stephen Moses
- Karnataka Health Promotion Trust, Bangalore, India
- University of Manitoba, Winnipeg, Canada
| | - Anna Vassall
- London School of Hygiene and Tropical Medicine, London, UK
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24
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The Impact and Cost-Effectiveness of a Four-Month Regimen for First-Line Treatment of Active Tuberculosis in South Africa. PLoS One 2015; 10:e0145796. [PMID: 26717007 PMCID: PMC4696677 DOI: 10.1371/journal.pone.0145796] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 12/08/2015] [Indexed: 01/26/2023] Open
Abstract
Background A 4-month first-line treatment regimen for tuberculosis disease (TB) is expected to have a direct impact on patient outcomes and societal costs, as well as an indirect impact on Mycobacterium tuberculosis transmission. We aimed to estimate this combined impact in a high TB-burden country: South Africa. Method An individual based M. tb transmission model was fitted to the TB burden of South Africa using a standard TB natural history framework. We measured the impact on TB burden from 2015–2035 of introduction of a non-inferior 4-month regimen replacing the standard 6-month regimen as first-line therapy. Impact was measured with respect to three separate baselines (Guidelines, Policy and Current), reflecting differences in adherence to TB and HIV treatment guidelines. Further scenario analyses considered the variation in treatment-related parameters and resistance levels. Impact was measured in terms of differences in TB burden and Disability Adjusted Life Years (DALYs) averted. We also examined the highest cost at which the new regimen would be cost-effective for several willingness-to-pay thresholds. Results It was estimated that a 4-month regimen would avert less than 1% of the predicted 6 million person years with TB disease in South Africa between 2015 and 2035. A similarly small impact was seen on deaths and DALYs averted. Despite this small impact, with the health systems and patient cost savings from regimen shortening, the 4-month regimen could be cost-effective at $436 [NA, 5983] (mean [range]) per month at a willingness-to-pay threshold of one GDP per capita ($6,618). Conclusion The introduction of a non-inferior 4-month first-line TB regimen into South Africa would have little impact on the TB burden. However, under several scenarios, it is likely that the averted societal costs would make such a regimen cost-effective in South Africa.
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25
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Meyer-Rath G, Pienaar J, Brink B, van Zyl A, Muirhead D, Grant A, Churchyard G, Watts C, Vickerman P. The Impact of Company-Level ART Provision to a Mining Workforce in South Africa: A Cost-Benefit Analysis. PLoS Med 2015; 12:e1001869. [PMID: 26327271 PMCID: PMC4556678 DOI: 10.1371/journal.pmed.1001869] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 07/17/2015] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND HIV impacts heavily on the operating costs of companies in sub-Saharan Africa, with many companies now providing antiretroviral therapy (ART) programmes in the workplace. A full cost-benefit analysis of workplace ART provision has not been conducted using primary data. We developed a dynamic health-state transition model to estimate the economic impact of HIV and the cost-benefit of ART provision in a mining company in South Africa between 2003 and 2022. METHODS AND FINDINGS A dynamic health-state transition model, called the Workplace Impact Model (WIM), was parameterised with workplace data on workforce size, composition, turnover, HIV incidence, and CD4 cell count development. Bottom-up cost analyses from the employer perspective supplied data on inpatient and outpatient resource utilisation and the costs of absenteeism and replacement of sick workers. The model was fitted to workforce HIV prevalence and separation data while incorporating parameter uncertainty; univariate sensitivity analyses were used to assess the robustness of the model findings. As ART coverage increases from 10% to 97% of eligible employees, increases in survival and retention of HIV-positive employees and associated reductions in absenteeism and benefit payments lead to cost savings compared to a scenario of no treatment provision, with the annual cost of HIV to the company decreasing by 5% (90% credibility interval [CrI] 2%-8%) and the mean cost per HIV-positive employee decreasing by 14% (90% CrI 7%-19%) by 2022. This translates into an average saving of US$950,215 (90% CrI US$220,879-US$1.6 million) per year; 80% of these cost savings are due to reductions in benefit payments and inpatient care costs. Although findings are sensitive to assumptions regarding incidence and absenteeism, ART is cost-saving under considerable parameter uncertainty and in all tested scenarios, including when prevalence is reduced to 1%-except when no benefits were paid out to employees leaving the workforce and when absenteeism rates were half of what data suggested. Scaling up ART further through a universal test and treat strategy doubles savings; incorporating ART for family members reduces savings but is still marginally cost-saving compared to no treatment. Our analysis was limited to the direct cost of HIV to companies and did not examine the impact of HIV prevention policies on the miners or their families, and a few model inputs were based on limited data, though in sensitivity analysis our results were found to be robust to changes to these inputs along plausible ranges. CONCLUSIONS Workplace ART provision can be cost-saving for companies in high HIV prevalence settings due to reductions in healthcare costs, absenteeism, and staff turnover. Company-sponsored HIV counselling and voluntary testing with ensuing treatment of all HIV-positive employees and family members should be implemented universally at workplaces in countries with high HIV prevalence.
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Affiliation(s)
- Gesine Meyer-Rath
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Center for Global Health and Development, Boston University, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jan Pienaar
- Highveld Hospital, Anglo American Coal, Emalahleni, South Africa
| | | | | | | | - Alison Grant
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Gavin Churchyard
- The Aurum Institute, Johannesburg, South Africa
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Charlotte Watts
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Peter Vickerman
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
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26
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Obure CD, Sweeney S, Darsamo V, Michaels-Igbokwe C, Guinness L, Terris-Prestholt F, Muketo E, Nhlabatsi Z, Warren CE, Mayhew S, Watts C, Vassall A. The Costs of Delivering Integrated HIV and Sexual Reproductive Health Services in Limited Resource Settings. PLoS One 2015; 10:e0124476. [PMID: 25933414 PMCID: PMC4416893 DOI: 10.1371/journal.pone.0124476] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 03/14/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To present evidence on the total costs and unit costs of delivering six integrated sexual reproductive health and HIV services in a high and medium HIV prevalence setting, in order to support policy makers and planners scaling up these essential services. DESIGN A retrospective facility based costing study conducted in 40 non-government organization and public health facilities in Kenya and Swaziland. METHODS Economic and financial costs were collected retrospectively for the year 2010/11, from each study site with an aim to estimate the cost per visit of six integrated HIV and SRH services. A full cost analysis using a combination of bottom-up and step-down costing methods was conducted from the health provider's perspective. The main unit of analysis is the economic unit cost per visit for each service. Costs are converted to 2013 International dollars. RESULTS The mean cost per visit for the HIV/SRH services ranged from $Int 14.23 (PNC visit) to $Int 74.21 (HIV treatment visit). We found considerable variation in the unit costs per visit across settings with family planning services exhibiting the least variation ($Int 6.71-52.24) and STI treatment and HIV treatment visits exhibiting the highest variation in unit cost ranging from ($Int 5.44-281.85) and ($Int 0.83-314.95), respectively. Unit costs of visits were driven by fixed costs while variability in visit costs across facilities was explained mainly by technology used and service maturity. CONCLUSION For all services, variability in unit costs and cost components suggest that potential exists to reduce costs through better use of both human and capital resources, despite the high proportion of expenditure on drugs and medical supplies. Further work is required to explore the key drivers of efficiency and interventions that may facilitate efficiency improvements.
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Affiliation(s)
- Carol Dayo Obure
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Sedona Sweeney
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Vanessa Darsamo
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Christine Michaels-Igbokwe
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lorna Guinness
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Fern Terris-Prestholt
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | | | | | - Susannah Mayhew
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Charlotte Watts
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Lépine A, Vassall A, Chandrashekar S, Blanc E, Le Nestour A. Estimating unbiased economies of scale of HIV prevention projects: a case study of Avahan. Soc Sci Med 2015; 131:164-72. [PMID: 25779621 DOI: 10.1016/j.socscimed.2015.03.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Governments and donors are investing considerable resources on HIV prevention in order to scale up these services rapidly. Given the current economic climate, providers of HIV prevention services increasingly need to demonstrate that these investments offer good 'value for money'. One of the primary routes to achieve efficiency is to take advantage of economies of scale (a reduction in the average cost of a health service as provision scales-up), yet empirical evidence on economies of scale is scarce. Methodologically, the estimation of economies of scale is hampered by several statistical issues preventing causal inference and thus making the estimation of economies of scale complex. In order to estimate unbiased economies of scale when scaling up HIV prevention services, we apply our analysis to one of the few HIV prevention programmes globally delivered at a large scale: the Indian Avahan initiative. We costed the project by collecting data from the 138 Avahan NGOs and the supporting partners in the first four years of its scale-up, between 2004 and 2007. We develop a parsimonious empirical model and apply a system Generalized Method of Moments (GMM) and fixed-effects Instrumental Variable (IV) estimators to estimate unbiased economies of scale. At the programme level, we find that, after controlling for the endogeneity of scale, the scale-up of Avahan has generated high economies of scale. Our findings suggest that average cost reductions per person reached are achievable when scaling-up HIV prevention in low and middle income countries.
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Affiliation(s)
- Aurélia Lépine
- Social and Mathematical Epidemiology Group, Global Health and Development Department, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH London, United Kingdom.
| | - Anna Vassall
- Social and Mathematical Epidemiology Group, Global Health and Development Department, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH London, United Kingdom
| | - Sudha Chandrashekar
- Social and Mathematical Epidemiology Group, Global Health and Development Department, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH London, United Kingdom; St. John's Research Institute, Department of Epidemiology and Biostatistics, St. John Nagar, Bangalore 560034, India
| | - Elodie Blanc
- Joint Program on the Science and Policy of Global Change, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, MA 02139, USA
| | - Alexis Le Nestour
- University of Otago, Department of Economics, PO Box 56, Dunedin 9054, New Zealand
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Superior outcomes and lower outpatient costs with scale-up of antiretroviral therapy at the GHESKIO clinic in Port-au-Prince, Haiti. J Acquir Immune Defic Syndr 2014; 66:e72-9. [PMID: 24984189 DOI: 10.1097/qai.0000000000000200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Treatment protocols and prices of antiretroviral therapy (ART) have changed over time. Yet, limited data exist to evaluate the impact of these changes on patient outcomes and treatment costs in resource-poor settings. METHODS We compared patient-level data on outcomes, utilization, and cost for the first 2 years of ART for a cohort of adult patients initiating ART in 2003-2004 and a cohort initiating ART in 2006-2008 at the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections clinic (GHESKIO) in Port-au-Prince, Haiti. Costs were measured from the health center perspective. Multivariate analyses were conducted to account for the potential impact of differences in disease severity at baseline. RESULTS With the exclusion of patients who transferred care, 92% (167/181) of patients in the 2006-2008 cohort and 75% (150/200) in the 2003-2004 cohort were alive and in care at the end of the study period. The mean cost per patient for the 2-year study period was US$723 for the 2006-2008 cohort vs. US$1191 for the 2003-2004 cohort, a cost difference of US$468 (P < 0.0001). The mean cost per patient alive and in care at the end of the 2-year study period was US$744 for the 2006-2008 cohort vs. US$1489 for the 2003-2004 cohort (P < 0.0001). CONCLUSIONS HIV treatment outcomes in Haiti have improved over time while treatment costs declined by over 50% per patient alive and in care at the end of the 2-year study period. The major drivers in the reduction of treatment costs were the lower price of ART, lower costs for laboratory testing, and lower overhead costs.
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Marseille E, Jiwani A, Raut A, Verguet S, Walson J, Kahn JG. Scaling up integrated prevention campaigns for global health: costs and cost-effectiveness in 70 countries. BMJ Open 2014; 4:e003987. [PMID: 24969782 PMCID: PMC4078786 DOI: 10.1136/bmjopen-2013-003987] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE This study estimated the health impact, cost and cost-effectiveness of an integrated prevention campaign (IPC) focused on diarrhoea, malaria and HIV in 70 countries ranked by per capita disability-adjusted life-year (DALY) burden for the three diseases. METHODS We constructed a deterministic cost-effectiveness model portraying an IPC combining counselling and testing, cotrimoxazole prophylaxis, referral to treatment and condom distribution for HIV prevention; bed nets for malaria prevention; and provision of household water filters for diarrhoea prevention. We developed a mix of empirical and modelled cost and health impact estimates applied to all 70 countries. One-way, multiway and scenario sensitivity analyses were conducted to document the strength of our findings. We used a healthcare payer's perspective, discounted costs and DALYs at 3% per year and denominated cost in 2012 US dollars. PRIMARY AND SECONDARY OUTCOMES The primary outcome was cost-effectiveness expressed as net cost per DALY averted. Other outcomes included cost of the IPC; net IPC costs adjusted for averted and additional medical costs and DALYs averted. RESULTS Implementation of the IPC in the 10 most cost-effective countries at 15% population coverage would cost US$583 million over 3 years (adjusted costs of US$398 million), averting 8.0 million DALYs. Extending IPC programmes to all 70 of the identified high-burden countries at 15% coverage would cost an adjusted US$51.3 billion and avert 78.7 million DALYs. Incremental cost-effectiveness ranged from US$49 per DALY averted for the 10 countries with the most favourable cost-effectiveness to US$119, US$181, US$335, US$1692 and US$8340 per DALY averted as each successive group of 10 countries is added ordered by decreasing cost-effectiveness. CONCLUSIONS IPC appears cost-effective in many settings, and has the potential to substantially reduce the burden of disease in resource-poor countries. This study increases confidence that IPC can be an important new approach for enhancing global health.
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Affiliation(s)
| | - Aliya Jiwani
- Health Strategies International, Arlington, Virginia, USA
| | - Abhishek Raut
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Stéphane Verguet
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Judd Walson
- Departments of Global Health, Medicine, Pediatrics, and Epidemiology, University of Washington, Seattle, Washington, USA
| | - James G Kahn
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
- Global Health Sciences, University of California, San Francisco, California, USA
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Cianci F, Sweeney S, Konate I, Nagot N, Low A, Mayaud P, Vickerman P. The cost of providing combined prevention and treatment services, including ART, to female sex workers in Burkina Faso. PLoS One 2014; 9:e100107. [PMID: 24950185 PMCID: PMC4064981 DOI: 10.1371/journal.pone.0100107] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 05/21/2014] [Indexed: 11/18/2022] Open
Abstract
Background Female Sex workers (FSW) are important in driving HIV transmission in West Africa. The Yerelon clinic in Burkina Faso has provided combined preventative and therapeutic services, including anti-retroviral therapy (ART), for FSWs since 1998, with evidence suggesting it has decreased HIV prevalence and incidence in this group. No data exists on the costs of such a combined prevention and treatment intervention for FSW. This study aims to determine the mean cost of service provision per patient year for FSWs attending the Yerelon clinic, and identifies differences in costs between patient groups. Methods Field-based retrospective cost analyses were undertaken using top-down and bottom-up costing approaches for 2010. Expenditure and service utilisation data was collated from primary sources. Patients were divided into groups according to full-time or occasional sex-work, HIV status and ART duration. Patient specific service use data was extracted. Costs were converted to 2012 US$. Sensitivity analyses considered removal of all research costs, different discount rates and use of different ART treatment regimens and follow-up schedules. Results Using the top-down costing approach, the mean annual cost of service provision for FSWs on or off ART was US$1098 and US$882, respectively. The cost for FSWs on ART reduced by 29%, to US$781, if all research-related costs were removed and national ART monitoring guidelines were followed. The bottom-up patient-level costing showed the cost of the service varied greatly across patient groups (US$505–US$1117), primarily due to large differences in the costs of different ART regimens. HIV-negative women had the lowest annual cost at US$505. Conclusion Whilst FSWs may require specialised services to optimise their care and hence, the public health benefits, our study shows that the cost of ART provision within a combined prevention and treatment intervention setting is comparable to providing ART to other population groups in Africa.
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Affiliation(s)
- Fiona Cianci
- Social and Mathematical Epidemiology Group, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Sedona Sweeney
- Social and Mathematical Epidemiology Group, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Issouf Konate
- UR-VIH/MA, Centre Muraz, Bobo-Dioulasso, Burkina Faso
| | - Nicolas Nagot
- INSERM U1058 & University of Montpellier 1, Montpellier, France
| | - Andrea Low
- INSERM U1058 & University of Montpellier 1, Montpellier, France
| | - Philippe Mayaud
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Peter Vickerman
- Social and Mathematical Epidemiology Group, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
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Siapka M, Remme M, Obure CD, Maier CB, Dehne KL, Vassall A. Is there scope for cost savings and efficiency gains in HIV services? A systematic review of the evidence from low- and middle-income countries. Bull World Health Organ 2014; 92:499-511AD. [PMID: 25110375 DOI: 10.2471/blt.13.127639] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Revised: 12/26/2013] [Accepted: 12/31/2013] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To synthesize the data available--on costs, efficiency and economies of scale and scope--for the six basic programmes of the UNAIDS Strategic Investment Framework, to inform those planning the scale-up of human immunodeficiency virus (HIV) services in low- and middle-income countries. METHODS The relevant peer-reviewed and "grey" literature from low- and middle-income countries was systematically reviewed. Search and analysis followed Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. FINDINGS Of the 82 empirical costing and efficiency studies identified, nine provided data on economies of scale. Scale explained much of the variation in the costs of several HIV services, particularly those of targeted HIV prevention for key populations and HIV testing and treatment. There is some evidence of economies of scope from integrating HIV counselling and testing services with several other services. Cost efficiency may also be improved by reducing input prices, task shifting and improving client adherence. CONCLUSION HIV programmes need to optimize the scale of service provision to achieve efficiency. Interventions that may enhance the potential for economies of scale include intensifying demand-creation activities, reducing the costs for service users, expanding existing programmes rather than creating new structures, and reducing attrition of existing service users. Models for integrated service delivery--which is, potentially, more efficient than the implementation of stand-alone services--should be investigated further. Further experimental evidence is required to understand how to best achieve efficiency gains in HIV programmes and assess the cost-effectiveness of each service-delivery model.
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Affiliation(s)
- Mariana Siapka
- SaME Modelling and Economics, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, England
| | - Michelle Remme
- SaME Modelling and Economics, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, England
| | - Carol Dayo Obure
- SaME Modelling and Economics, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, England
| | - Claudia B Maier
- Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
| | - Karl L Dehne
- Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
| | - Anna Vassall
- SaME Modelling and Economics, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, England
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Zeng W, Rwiyereka AK, Amico PR, Ávila-Figueroa C, Shepard DS. Efficiency of HIV/AIDS health centers and effect of community-based health insurance and performance-based financing on HIV/AIDS service delivery in Rwanda. Am J Trop Med Hyg 2014; 90:740-746. [PMID: 24515939 PMCID: PMC3973523 DOI: 10.4269/ajtmh.12-0697] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
This study evaluates the efficiency of rural health centers in Rwanda in delivering the three key human immunodeficiency virus/acquired immunodeficiency syndrome services: antiretroviral treatment, prevention of mother-to-child transmission, and voluntary counseling and testing using data envelopment analysis, and assesses the impact of community-based health insurance (CBHI) and performance-based financing on improving the delivery of the three services. Results show that health centers average efficiency of 78%, and despite the observed variation, the performance increased by 15.6% from 2006 through 2007. When the services are examined separately, each 1% growth of CBHI use was associated with 3.7% more prevention of mother-to-child transmission and 2.5% more voluntary counseling and testing services. Although more health centers would have been needed to evaluate performance-based financing, we found that high use of CBHI in Rwanda was an important contributor to improving human immunodeficiency virus/acquired immunodeficiency syndrome services in rural health centers in Rwanda.
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Affiliation(s)
- Wu Zeng
- *Address correspondence to Wu Zeng, Schneider Institutes for Health Policy, Heller School MS035, Brandeis University, Waltham, MA 02454-9110. E-mail:
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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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Harding R, Simms V, Penfold S, Downing J, Powell RA, Mwangi-Powell F, Namisango E, Moreland S, Gikaara N, Atieno M, Kataike J, Nsubuga C, Munene G, Banga G, Higginson IJ. The presence of CD4 counts for the management of HIV patients in East Africa: a multicentred study. AIDS Care 2013; 26:613-8. [PMID: 24099416 DOI: 10.1080/09540121.2013.844765] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
New WHO guidance stipulates six-monthly CD4 testing and treatment initiation at CD4 less than 350. This study aimed to determine the presence of CD4 results in patient records across five care facilities in Kenya, and to identify factors associated with the presence of CD4 count. This is a cross-sectional study of consecutive outpatients. Participants completed self-reported outcomes of demographics, and both physical and mental health dimensions of quality of life and function; charts were reviewed for a CD4 count in the previous 13 months; 548 patients participated. For those diagnosed during the 13-month study period, 7.1% of the sample had no CD4 result on record. For those diagnosed prior to the study, 8.7% had no result. Multivariate logistic regression revealed that 30 days post-HIV diagnosis, facility and antiretroviral therapy use were associated with the odds of having a CD4 result on file. At six months, poverty and prevalence of multidimensional problems were associated with lack of CD4 result. For those diagnosed prior to the observation period, education level was associated with more infrequent CD4 counts, and facility and number of dependants were associated with odds of a CD4 result within six months. Our data suggest inconsistencies in CD4 results availability within and between facilities. Implementation of new guidance will require a shift in practice.
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Affiliation(s)
- Richard Harding
- a Department of Palliative Care, Policy & Rehabilitation, King's College London , Cicely Saunders Institute , London , UK
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Shepherd BE, Blevins M, Vaz LME, Moon TD, Kipp AM, José E, Ferreira FG, Vermund SH. Impact of definitions of loss to follow-up on estimates of retention, disease progression, and mortality: application to an HIV program in Mozambique. Am J Epidemiol 2013; 178:819-28. [PMID: 23785113 PMCID: PMC3755641 DOI: 10.1093/aje/kwt030] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 02/07/2013] [Indexed: 11/14/2022] Open
Abstract
Patient retention is critical to the management of chronic diseases such as human immunodeficiency virus (HIV); hence, accurate measures of loss to follow-up (LTF) are important. Many different LTF definitions have been proposed. In a cohort of 9,692 HIV-infected patients initiating antiretroviral therapy in Mozambique from 2006 to 2011, we investigated the impact of the definition of LTF on estimated rates of LTF, acquired immunodeficiency syndrome (AIDS)-defining events, and death by applying 17 different definitions of LTF gleaned from HIV literature. We further investigated the impact of 4 specific components of the LTF definitions. Cumulative incidences of LTF and AIDS-defining events were estimated by treating death as a competing risk; Kaplan-Meier techniques and variations to account for informative censoring were used to estimate rates of mortality. Estimates of LTF 2 years after treatment initiation were high and varied substantially, from 22% to 84% depending on the LTF definition used. Estimates of 2-year mortality varied from 11% to 16%, and estimates of 2-year AIDS-defining events varied from 6% to 8%. As seen here, the choice of LTF definition can greatly affect study conclusions and program evaluations. Selection of LTF definitions should be based on the study outcome, available data on clinical encounters, and the patients' visit schedules; we suggest some general guidelines.
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Affiliation(s)
- Bryan E Shepherd
- Vanderbilt University School of Medicine, 1161 21st Avenue South, Nashville,TN 37232-2158, USA.
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Rates and cost of hospitalization before and after initiation of antiretroviral therapy in urban and rural settings in South Africa. J Acquir Immune Defic Syndr 2013. [PMID: 23187948 DOI: 10.1097/qai.0b013e31827e8785] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Few studies have compared hospitalizations before and after antiretroviral therapy (ART) initiation in the same patients. We analyzed the cost of hospitalizations among 3906 adult patients in 2 South African hospitals, 30% of whom initiated ART. Hospitalizations were 50% and 40% more frequent and 1.5 and 2.6 times more costly at a CD4 cell count, 100 cells/mm(3) when compared with 200–350 cells/mm(3) in the pre-ART and ART period, respectively. Mean inpatient cost per patient year was USD 117 (95%confidence interval, 85 to 158) for patients on ART and USD 72(95% confidence interval, 56 to 89) for pre-ART patients. Raising ART eligibility thresholds could avoid the high cost of hospitalization before and immediately after ART initiation.
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Scott CA, Iyer H, Bwalya DL, McCoy K, Meyer-Rath G, Moyo C, Bolton-Moore C, Larson B, Rosen S. Retention in care and outpatient costs for children receiving antiretroviral therapy in Zambia: a retrospective cohort analysis. PLoS One 2013; 8:e67910. [PMID: 23840788 PMCID: PMC3695874 DOI: 10.1371/journal.pone.0067910] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 05/22/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There are few published estimates of the cost of pediatric antiretroviral therapy (ART) in Africa. Our objective was to estimate the outpatient cost of providing ART to children remaining in care at six public sector clinics in Zambia during the first three years after ART initiation, stratified by service delivery site and time on treatment. METHODS Data on resource utilization (drugs, diagnostics, outpatient visits, fixed costs) and treatment outcomes (in care, died, lost to follow up) were extracted from medical records for 1,334 children at six sites who initiated ART at <15 years of age between 2006 and 2011. Fixed and variable unit costs (reported in 2011 USD) were estimated from the provider's perspective using site level data. RESULTS Median age at ART initiation was 4.0 years; median CD4 percentage was 14%. One year after ART initiation, 73% of patients remained in care, ranging from 60% to 91% depending on site. The average annual outpatient cost per patient remaining in care was $209 (95% CI, $199-$219), ranging from $116 (95% CI, $107-$126) to $516 (95% CI, $499-$533) depending on site. Average annual costs decreased as time on treatment increased. Antiretroviral drugs were the largest component of all outpatient costs (>50%) at four sites. At the two remaining sites, outpatient visits and fixed costs together accounted for >50% of outpatient costs. The distribution of costs is slightly skewed, with median costs 3% to 13% lower than average costs during the first year after ART initiation depending on site. CONCLUSIONS Outpatient costs for children initiating ART in Zambia are low and comparable to reported outpatient costs for adults. Outpatient costs and retention in care vary widely by site, suggesting opportunities for efficiency gains. Taking advantage of such opportunities will help ensure that targets for pediatric treatment coverage can be met.
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Affiliation(s)
- Callie A. Scott
- Center for Global Health and Development, Boston University, Boston, Massachusetts, United States of America
- Zambia Center for Applied Health Research and Development, Lusaka, Zambia
- * E-mail:
| | - Hari Iyer
- Zambia Center for Applied Health Research and Development, Lusaka, Zambia
| | | | - Kelly McCoy
- Center for Global Health and Development, Boston University, Boston, Massachusetts, United States of America
| | - Gesine Meyer-Rath
- Center for Global Health and Development, Boston University, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Carolyn Bolton-Moore
- Department of Obstetrics & Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Bruce Larson
- Center for Global Health and Development, Boston University, Boston, Massachusetts, United States of America
- Department of International Health, School of Public Health, Boston University, Boston, Massachusetts, United States of America
| | - Sydney Rosen
- Center for Global Health and Development, Boston University, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Peltzer K, Ramlagan S, Khan MS, Gaede B. The social and clinical characteristics of patients on antiretroviral therapy who are 'lost to follow-up' in KwaZulu-Natal, South Africa: a prospective study. SAHARA J 2013; 8:179-86. [PMID: 23236959 DOI: 10.1080/17290376.2011.9725002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
A significant proportion of those initiating antiretroviral treatment (ART) for HIV infection are lost to follow-up. Causes (including HIV symptoms, quality of life, depression, herbal treatment and alcohol use) for discontinuing ART follow-up in predominantly rural resource-limited settings are not well understood. This is a prospective study of the treatment-naïve patients recruited from three (one urban, one-semi-urban and one rural) public hospitals in Uthukela health district in KwaZulu-Natal from October 2007 to February 2008. The aim of this study was to investigate predictors of loss to follow-up or all caused attrition from an ART programme within a cohort followed up for over 12 months. A total of 735 patients (217 men and 518 women) prior to initiating ART completed a baseline questionnaire and 6- and 12-months' follow-up. At 12-months follow-up 557 (75.9%) individuals continued active ART, 177 (24.1%) were all cause attrition, there were 82 deaths (13.8%), 58 (7.9%) transfers, 7 (1.0%) refused participation, 8 (1.1%) were not yet on ART and 22 (3.0%) could not be traced. Death by 12-months of follow-up was associated with lower CD4 cell counts (risk ratio, RR=2.05, confidence intervals, CI=1.20-3.49) and higher depression levels (RR=1.05, CI=1.01-1.09) at baseline assessment. The high early mortality rates indicate that patients are enrolling into ART programmes with far too advanced immunodeficiency; median CD4 cell counts 119 (IQR=59-163). Causes of late access to the ART programme, such as delays in health care access (delayed health care seeking), health system delays, or inappropriate treatment criteria, need to be addressed. Differences in health status (lower CD4 cell counts and higher depression scores) should be taken into account when initiating patients on ART. Treating depression at ART initiation is recommended to improve treatment outcome.
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Affiliation(s)
- Karl Peltzer
- Research Programme HIV/AIDS, STI and TB-HAST, Human Sciences Research Council, South Africa.
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Pinto AD, van Lettow M, Rachlis B, Chan AK, Sodhi SK. Patient costs associated with accessing HIV/AIDS care in Malawi. J Int AIDS Soc 2013; 16:18055. [PMID: 23517716 PMCID: PMC3604364 DOI: 10.7448/ias.16.1.18055] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 01/18/2013] [Accepted: 01/29/2013] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION The decentralization of HIV services has been shown to improve equity in access to care for the rural poor of sub-Saharan Africa. This study aims to contribute to our understanding of the impact of decentralization on costs borne by patients. Such information is valuable for economic evaluations of anti-retroviral therapy programmes that take a societal perspective. We compared costs reported by patients who received care in an urban centralized programme to those in the same district who received care through rural decentralized care (DC). METHODS A cross-sectional survey on patient characteristics and costs associated with accessing HIV care was conducted, in May 2010, on 120 patients in centralized care (CC) at a tertiary referral hospital and 120 patients in DC at five rural health centres in Zomba District, Malawi. Differences in costs borne by each group were compared using χ2 and t-tests, and a regression model was developed to adjust for confounders, using bootstrapping to address skewed cost data. RESULTS There was no significant difference between the groups with respect to sex and age. However, there were significant differences in socio-economic status, with higher educational attainment (p<0.001), personal income (p=0.007) and household income per person (p=0.005) in CC. Travel times were similar (p=0.65), as was time waiting at the clinic (p=0.63) and total time spent seeking care (p=0.65). There was a significant difference in travel-related expenses (p<0.001) related to the type of travel participants noted that they used. In CC, 60% of participants reported using a mini-bus to reach the clinic; in DC only 4% reported using a mini-bus, and the remainder reported travelling on foot or by bicycle. There were no significant differences between the groups in the amount of lost income reported or other out-of-pocket costs. Approximately 91 Malawi Kwacha (95% confidence intervals: 1-182 MKW) or US$0.59 represents the adjusted difference in total costs per visit between CC and DC. CONCLUSIONS Even within a system of HIV/AIDS care where patients do not pay to see clinicians or for most medications, they still incur costs. We found that most costs are travel related. This has important implications for poorer patients who live at a distance from health facilities for whom these costs may be significant.
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Affiliation(s)
- Andrew D Pinto
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Canada.
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Bor J, Herbst AJ, Newell ML, Bärnighausen T. Increases in adult life expectancy in rural South Africa: valuing the scale-up of HIV treatment. Science 2013; 339:961-5. [PMID: 23430655 PMCID: PMC3860268 DOI: 10.1126/science.1230413] [Citation(s) in RCA: 430] [Impact Index Per Article: 39.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The scale-up of antiretroviral therapy (ART) is expected to raise adult life expectancy in populations with high HIV prevalence. Using data from a population cohort of over 101,000 individuals in rural KwaZulu-Natal, South Africa, we measured changes in adult life expectancy for 2000-2011. In 2003, the year before ART became available in the public-sector health system, adult life expectancy was 49.2 years; by 2011, adult life expectancy had increased to 60.5 years--an 11.3-year gain. Based on standard monetary valuation of life, the survival benefits of ART far outweigh the costs of providing treatment in this community. These gains in adult life expectancy signify the social value of ART and have implications for the investment decisions of individuals, governments, and donors.
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Affiliation(s)
- Jacob Bor
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Post Office Box 198, Mtubatuba, KwaZulu-Natal 3935, South Africa.
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A novel Markov model projecting costs and outcomes of providing antiretroviral therapy to public patients in private practices versus public clinics in South Africa. PLoS One 2013; 8:e53570. [PMID: 23405073 PMCID: PMC3566152 DOI: 10.1371/journal.pone.0053570] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Accepted: 12/03/2012] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Providing private antiretroviral therapy (ART) care for public sector patients could increase access to ART in low- and middle-income countries. We compared the costs and outcomes of a private-care and a public-care ART program in South Africa. METHODS A novel Markov model was developed from the public-care program. Patients were first tunneled for 6 months in their baseline CD4 category before being distributed into a dynamic CD4 and viral load model. Patients were allowed to return to ART care from loss to follow up (LTFU). We then populated this modeling framework with estimates derived from the private-care program to externally validate the model. RESULTS Baseline characteristics were similar in the two programs. Clinic visit utilization was higher and death rates were lower in the first few years on ART in the public-care program. After 10 years on ART we estimated the following outcomes in the public-care and private-care programs respectively: viral load <1000 copies/ml 89% and 84%, CD4 >500 cells/μl 33% and 37%, LTFU 14% and 14%, and death 27% and 32%. Lifetime undiscounted survival estimates were 14.1 (95%CI 13.2-14.9) and (95%CI 12.7-14.5) years with costs of 18,734 (95%CI 12,588-14,022) and 13,062 (95%CI 12,077-14,047) USD in the private-care and public-care programs respectively. When clinic visit utilization in the public-care program was reduced by two thirds after the initial 6 months on ART, which is similar to their current practice, the costs were comparable between the programs. CONCLUSIONS Using a novel Markov model, we determined that the private-care program had similar outcomes but lower costs than the public-care program, largely due to lower visit frequencies. These findings have important implications for increasing and sustaining coverage of patients in need of ART care in resource-limited settings.
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Abstract
OBJECTIVE Little is known about the cost of paediatric antiretroviral treatment (ART) in low-income and middle-income countries. We analysed the average cost of providing paediatric ART in South Africa during the first 2 years after ART initiation, stratified by patient outcomes. METHODS We collected data on outpatient resource use and treatment outcomes of 288 children in two Johannesburg public clinics, Empilweni Services and Research Unit (ESRU) and Harriet Shezi Children's Clinic (HSCC) from 2005 to 2009. Patient-level resource use was estimated from patient records. Unit cost data came from site accounts and public-sector sources. Patient outcomes at month 12 and 24 after initiation were defined based on patients' weight CD4 cell counts/percentages, viral loads, and the presence of new WHO stage 3/4 conditions. RESULTS Median age/CD4 percentage at initiation was 4.03 years/12.40% in ESRU and 5.84 years/14.05% in HSCC, respectively. Sixty-two and 91% of patients remained in care and responding to treatment at month 12 in ESRU and HSCC, respectively, and 68 and 80% at month 24. The average cost per patient in care and responding was US$ 830 in year 1 and US$ 717 in year 2 in ESRU and US$ 678 and US$ 782 in HSCC. Antiretroviral drugs comprised 33-52% of total cost, clinic visits 23-31%, lab tests 12-16%, and fixed costs 8-18%. CONCLUSIONS Costs varied between the two clinics but were comparable with those of adult ART. Few very young children accessed ART in either clinic and those who did were already very ill, emphasizing the importance of early infant treatment.
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Cost and resource use of patients on antiretroviral therapy in the urban and semiurban public sectors of South Africa. J Acquir Immune Defic Syndr 2013; 61:e25-32. [PMID: 22895437 DOI: 10.1097/qai.0b013e31826cc575] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND South Africa has the world's largest number of patients on antiretroviral treatment (ART). As coverage expands beyond urban environments, the cost of care is becoming increasingly important. METHODS Health care cost data for the first year after initiation were analyzed for cohorts of patients in a semiurban and an urban public sector ART clinic in South Africa. We compared mean cost by CD4 cell count and time on ART between clinics. RESULTS Patients in both clinics had comparable CD4 cell counts at initiation and under treatment. In the urban clinic, mean cost per patient-year on ART in 2011 USD was $1040 [95% confidence interval (CI): $800 to $1280], of which outpatient cost was $692 (67%) and inpatient cost was $348 (33%). Fourteen percent of urban patients required inpatient care at a mean length of stay of 9 days and mean cost per hospitalized patient of $1663 (95% CI: $1103 to $2041). In the semiurban clinic, mean cost per patient-year on ART was $1115 (95% CI: $776 to $1453), of which outpatient cost was $697 (63%) and inpatient cost $418 (37%). Seven percent of semiurban patients required inpatient care at a mean length of stay of 28 days and mean cost per hospitalized patient of $3824 (95% CI: $1143 to $6505). CONCLUSIONS Outpatient ART provision in the semiurban setting cost the same as in the urban setting, but inpatient costs are higher in the semiurban clinic because of longer hospitalizations. Cost in both clinics was highest in the first 3 months on ART and at CD4 cell counts <50 cells/μL.
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Larson BA, Bii M, Henly-Thomas S, McCoy K, Sawe F, Shaffer D, Rosen S. ART treatment costs and retention in care in Kenya: a cohort study in three rural outpatient clinics. J Int AIDS Soc 2013; 16:18026. [PMID: 23305696 PMCID: PMC3536940 DOI: 10.7448/ias.16.1.18026] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 12/05/2012] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION After almost 10 years of PEPFAR funding for antiretroviral therapy (ART) treatment programmes in Kenya, little is known about the cost of care provided to HIV-positive patients receiving ART. With some 430,000 ART patients, understanding and managing costs is essential to treatment programme sustainability. METHODS Using patient-level data from medical records (n=120/site), we estimated the cost of providing ART at three treatment sites in the Rift Valley Province of Kenya (a clinic at a government hospital, a hospital run by a large agricultural company and a mission hospital). Costs included ARV and non-ARV drugs, laboratory tests, salaries to personnel providing patient care, and infrastructure and other fixed costs. We report the average cost per patient during the first 12 months after ART initiation, stratified by site, and the average cost per patient achieving the primary outcome, retention in care 12 months after treatment initiation. RESULTS The cost per patient initiated on ART was $206, $252 and $213 at Sites 1, 2 and 3, respectively. The proportion of patients remaining in care at 12 months was similar across all sites (0.82, 0.80 and 0.84). Average costs for the subset of patients who remained in care at 12 months was also similar (Site 1, $229; Site 2, $287; Site 3, $237). Patients not retained in care cost substantially less (Site 1, $104; Site 2, $113; Site 3, $88). For the subset of patients who remained in care at 12 months, ART medications accounted for 51%, 44% and 50% of the costs, with the remaining costs split between non-ART medications (15%, 11%, 10%), laboratory tests (14%, 15%, 15%), salaries to personnel providing patient care (9%, 11%, 12%) and fixed costs (11%, 18%, 13%). CONCLUSIONS At all three sites, 12-month retention in care compared favourably to retention rates reported in the literature from other low-income African countries. The cost of providing treatment was very low, averaging $224 in the first year, less than $20/month. The cost of antiretroviral medications, roughly $120 per year, accounted for approximately half of the total costs per patient retained in care after 12 months.
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Affiliation(s)
- Bruce A Larson
- Center for Global Health and Development, Boston University, Boston, MA, USA.
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Menzies NA, Cohen T, Lin HH, Murray M, Salomon JA. Population health impact and cost-effectiveness of tuberculosis diagnosis with Xpert MTB/RIF: a dynamic simulation and economic evaluation. PLoS Med 2012; 9:e1001347. [PMID: 23185139 PMCID: PMC3502465 DOI: 10.1371/journal.pmed.1001347] [Citation(s) in RCA: 153] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Accepted: 10/12/2012] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The Xpert MTB/RIF test enables rapid detection of tuberculosis (TB) and rifampicin resistance. The World Health Organization recommends Xpert for initial diagnosis in individuals suspected of having multidrug-resistant TB (MDR-TB) or HIV-associated TB, and many countries are moving quickly toward adopting Xpert. As roll-out proceeds, it is essential to understand the potential health impact and cost-effectiveness of diagnostic strategies based on Xpert. METHODS AND FINDINGS We evaluated potential health and economic consequences of implementing Xpert in five southern African countries--Botswana, Lesotho, Namibia, South Africa, and Swaziland--where drug resistance and TB-HIV coinfection are prevalent. Using a calibrated, dynamic mathematical model, we compared the status quo diagnostic algorithm, emphasizing sputum smear, against an algorithm incorporating Xpert for initial diagnosis. Results were projected over 10- and 20-y time periods starting from 2012. Compared to status quo, implementation of Xpert would avert 132,000 (95% CI: 55,000-284,000) TB cases and 182,000 (97,000-302,000) TB deaths in southern Africa over the 10 y following introduction, and would reduce prevalence by 28% (14%-40%) by 2022, with more modest reductions in incidence. Health system costs are projected to increase substantially with Xpert, by US$460 million (294-699 million) over 10 y. Antiretroviral therapy for HIV represents a substantial fraction of these additional costs, because of improved survival in TB/HIV-infected populations through better TB case-finding and treatment. Costs for treating MDR-TB are also expected to rise significantly with Xpert scale-up. Relative to status quo, Xpert has an estimated cost-effectiveness of US$959 (633-1,485) per disability-adjusted life-year averted over 10 y. Across countries, cost-effectiveness ratios ranged from US$792 (482-1,785) in Swaziland to US$1,257 (767-2,276) in Botswana. Assessing outcomes over a 10-y period focuses on the near-term consequences of Xpert adoption, but the cost-effectiveness results are conservative, with cost-effectiveness ratios assessed over a 20-y time horizon approximately 20% lower than the 10-y values. CONCLUSIONS Introduction of Xpert could substantially change TB morbidity and mortality through improved case-finding and treatment, with more limited impact on long-term transmission dynamics. Despite extant uncertainty about TB natural history and intervention impact in southern Africa, adoption of Xpert evidently offers reasonable value for its cost, based on conventional benchmarks for cost-effectiveness. However, the additional financial burden would be substantial, including significant increases in costs for treating HIV and MDR-TB. Given the fundamental influence of HIV on TB dynamics and intervention costs, care should be taken when interpreting the results of this analysis outside of settings with high HIV prevalence.
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Affiliation(s)
- Nicolas A Menzies
- Center for Health Decision Sciences, Harvard School of Public Health, Boston, Massachusetts, United States of America.
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Menzies NA, Berruti AA, Blandford JM. The determinants of HIV treatment costs in resource limited settings. PLoS One 2012; 7:e48726. [PMID: 23144946 PMCID: PMC3492412 DOI: 10.1371/journal.pone.0048726] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 09/28/2012] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Governments and international donors have partnered to provide free HIV treatment to over 6 million individuals in low and middle-income countries. Understanding the determinants of HIV treatment costs will help improve efficiency and provide greater certainty about future resource needs. METHODS AND FINDINGS We collected data on HIV treatment costs from 54 clinical sites in Botswana, Ethiopia, Mozambique, Nigeria, Uganda, and Vietnam. Sites provided free HIV treatment funded by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), national governments, and other partners. Service delivery costs were categorized into successive six-month periods from the date when each site began HIV treatment scale-up. A generalized linear mixed model was used to investigate relationships between site characteristics and per-patient costs, excluding ARV expenses. With predictors at their mean values, average annual per-patient costs were $177 (95% CI: 127-235) for pre-ART patients, $353 (255-468) for adult patients in the first 6 months of ART, and $222 (161-296) for adult patients on ART for >6 months (excludes ARV costs). Patient volume (no. patients receiving treatment) and site maturity (months since clinic began providing treatment services) were both strong independent predictors of per-patient costs. Controlling for other factors, costs declined by 43% (18-63) as patient volume increased from 500 to 5,000 patients, and by 28% (6-47) from 5,000 to 10,000 patients. For site maturity, costs dropped 41% (28-52) between months 0-12 and 25% (15-35) between months 12-24. Price levels (proxied by per-capita GDP) were also influential, with costs increasing by 22% (4-41) for each doubling in per-capita GDP. Additionally, the frequency of clinical follow-up, frequency of laboratory monitoring, and clinician-patient ratio were significant independent predictors of per-patient costs. CONCLUSIONS Substantial reductions in per-patient service delivery costs occur as sites mature and patient cohorts increase in size. Other predictors suggest possible strategies to reduce per-patient costs.
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Affiliation(s)
- Nicolas A Menzies
- U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
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Verguet S, Lim SS, Murray CJL, Gakidou E, Salomon JA. Incorporating loss to follow-up in estimates of survival among HIV-infected individuals in sub-Saharan Africa enrolled in antiretroviral therapy programs. J Infect Dis 2012; 207:72-9. [PMID: 23100567 DOI: 10.1093/infdis/jis635] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Measuring the survival of human immunodeficiency virus-infected adult patients enrolled in antiretroviral therapy (ART) programs is complicated by short observation periods and loss to follow-up. We synthesized data from treatment cohorts in sub-Saharan Africa to estimate survival over 5 years after initiation of ART. METHODS We used data on retention, mortality, and loss to follow-up from 34 cohorts, including a total of 102,306 adult patients from 18 sub-Saharan African countries. These data were augmented by data from 13 sub-Saharan African studies tracking death rates among adult patients who were lost to follow-up (LTFU). We used a Poisson regression model to estimate survival over time, incorporating predicted mortality among LTFU patients. RESULTS Across studies, the median CD4(+) cell count at ART initiation was 104 cells/mm(3), 65% of patients were female, and the median age was 37 years. Survival at 1 year and 5 years were estimated to be 0.87 (95% confidence interval [CI], 0.72-0.94) and 0.70 (95% CI, 0.36-0.86), respectively, after adjustment for loss to follow-up. The life-years gained by a patient during the 5-year period after starting ART were estimated at 2.1 (95% CI, 1.6-2.3) in the adjusted model, compared with 1.7 (95% CI, 1.1-2.0) if there was 100% mortality among LTFU patients and with 2.4 (1.7-2.7) if there was 0% mortality among LTFU patients. CONCLUSIONS Accounting for loss to follow-up produces substantial changes in the estimated life-years gained during the first 5 years of ART receipt.
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Affiliation(s)
- Stéphane Verguet
- Department of Global Health, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA 98104, USA.
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Gavaza P, Rascati KL, Oladapo AO, Khoza S. The state of health economic research in South Africa: a systematic review. PHARMACOECONOMICS 2012; 30:925-40. [PMID: 22809450 DOI: 10.2165/11589450-000000000-00000] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
BACKGROUND Economic factors are a limiting factor toward the implementation of many health programmes and interventions. Economic evaluation has a great potential to contribute toward cost-effective healthcare delivery in South Africa. Little is known about the characteristics and quality of health economic (including pharmacoeconomic) research in South Africa. OBJECTIVE AND METHODS This study assessed the state of health economic (including pharmacoeconomic) research in South Africa. PUBMED, MEDLINE, HealthSTAR, EconLit and PsycINFO databases were searched to identify health economic articles pertaining to South Africa published between 1 January 1977 and 30 April 2010. The searches used the following Medical Subject Headings (MeSH) terms and text words alone and in combination: 'costs', 'health' and 'South Africa'. Our study included only original economic studies/analyses that pertained to South Africa, addressed a health-related topic, and had a statement or word in the title, abstract or keywords that indicated that an economic (including cost) analysis had been conducted. The study only included complete peer-reviewed publications (e.g. abstracts were excluded) that were reported in the English language. Two reviewers independently scored each article in the final sample using the data collection form designed for the study. RESULTS In total, 108 studies investigating a wide variety of diseases were included in the study. These articles were published in 39 different journals mostly based outside of South Africa between 1977 and 2010. On average, each article was written by three authors. Most first authors had medical/clinical training and resided in South Africa at the time of publication of their study. Based on a 1-10 scale, with 10 indicating the highest quality, the mean quality score for all studies was 7.59 (SD 1.42) and half of the articles were of good quality (score 8-10) The quality of studies was related to the country in which the journal publishing the article was based (outside South Africa = higher); current residence of the primary author (outside South Africa = higher); method of economic analysis (economic evaluations higher than cost studies); type of data used (secondary higher than primary); primary training of the first author (health economics/pharmacoeconomics = higher); type of medical function (diagnosis = higher); study perspective (societal = higher); primary health intervention (pharmaceuticals = higher); study design (modelling = higher); number of authors (more = higher); and year of publication (more recent = higher) [p ≤ 0.05]. CONCLUSION Half of the articles were of poor or fair quality. Measures are needed to promote the commissioning of more and better quality health economic and pharmacoeconomic studies in South Africa.
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Affiliation(s)
- Paul Gavaza
- Appalachian College of Pharmacy, Oakwood, VA 24631, USA.
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Sarti FM, Nishijima M, Coelho Campino AC, Cyrillo DC. A comparative analysis of outpatient costs in HIV treatment programs. Rev Assoc Med Bras (1992) 2012. [DOI: 10.1590/s0104-42302012000500013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Sarti FM, Nishijima M, Coelho Campino AC, Cyrillo DC. A comparative analysis of outpatient costs in HIV treatment programs. Rev Assoc Med Bras (1992) 2012. [DOI: 10.1016/s0104-4230(12)70250-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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