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Corlis J, Zhu J, Macul H, Tiberi O, Boothe MAS, Resch SC. Framework for determining the optimal course of action when efficiency and affordability measures differ by perspective in cost-effectiveness analysis-with an illustrative case of HIV treatment in Mozambique. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2023; 21:62. [PMID: 37705101 PMCID: PMC10498553 DOI: 10.1186/s12962-023-00474-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 09/03/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Cost-effectiveness analysis (CEA) is a standard tool for evaluating health programs and informing decisions about resource allocation and prioritization. Most CEAs evaluating health interventions in low- and middle-income countries adopt a health sector perspective, accounting for resources funded by international donors and country governments, while often excluding out-of-pocket expenditures and time costs borne by program beneficiaries. Even when patients' costs are included, a companion analysis focused on the patient perspective is rarely performed. We view this as a missed opportunity. METHODS We developed methods for assessing intervention affordability and evaluating whether optimal interventions from the health sector perspective also represent efficient and affordable options for patients. We mapped the five different patterns that a comparison of the perspective results can yield into a practical framework, and we provided guidance for researchers and decision-makers on how to use results from multiple perspectives. To illustrate the methodology, we conducted a CEA of six HIV treatment delivery models in Mozambique. We conducted a Monte Carlo microsimulation with probabilistic sensitivity analysis from both patient and health sector perspectives, generating incremental cost-effectiveness ratios for the treatment approaches. We also calculated annualized patient costs for the treatment approaches, comparing the costs with an affordability threshold. We then compared the cost-effectiveness and affordability results from the two perspectives using the framework we developed. RESULTS In this case, the two perspectives did not produce a shared optimal approach for HIV treatment at the willingness-to-pay threshold of 0.3 × Mozambique's annual GDP per capita per DALY averted. However, the clinical 6-month antiretroviral drug distribution strategy, which is optimal from the health sector perspective, is efficient and affordable from the patient perspective. All treatment approaches, except clinical 1-month distributions of antiretroviral drugs which were standard before Covid-19, had an annual cost to patients less than the country's annual average for out-of-pocket health expenditures. CONCLUSION Including a patient perspective in CEAs and explicitly considering affordability offers decision-makers additional insights either by confirming that the optimal strategy from the health sector perspective is also efficient and affordable from the patient perspective or by identifying incongruencies in value or affordability that could affect patient participation.
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Affiliation(s)
| | - Jinyi Zhu
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN USA
| | - Hélder Macul
- Programa Nacional de Controle de ITS-HIV/SIDA, Ministério da Saúde, Maputo, Mozambique
| | - Orrin Tiberi
- Programa Nacional de Controle de ITS-HIV/SIDA, Ministério da Saúde, Maputo, Mozambique
| | | | - Stephen C. Resch
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA USA
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Sakita FM, Prattipati S, Chick J, Samu LP, Maro AV, Coaxum L, Galson SW, Samuel D, Limkakeng AT, O'Leary PR, Kilonzo KG, Thielman NM, Temu G, Hertz JT. Six-month blood pressure and glucose control among HIV-infected adults with elevated blood pressure and hyperglycemia in northern Tanzania: A prospective observational study. PLoS One 2023; 18:e0285472. [PMID: 37155672 PMCID: PMC10166506 DOI: 10.1371/journal.pone.0285472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 04/25/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND People with HIV in sub-Saharan Africa are increasingly developing age-related comorbidities. The purpose of this prospective observational study was to describe 6-month outcomes among Tanzanians with HIV and elevated blood pressure or hyperglycemia under current care pathways. METHODS Adults presenting for routine HIV care were enrolled and underwent blood pressure and blood glucose measurements. Participants with abnormal blood pressure or glucose were referred for further care, as per current guidelines. Participants' blood pressure and point-of-care glucose were re-evaluated during their 6-month follow-up visit. Elevated blood pressure was defined as systolic ≥140 mmHg or diastolic ≥90 mmHg. Hyperglycemia was defined as fasting glucose ≥126 mg/dl or random glucose ≥200 mg/dl. An electrocardiogram was obtained at enrollment and at follow-up. Interim myocardial infarction and interim myocardial ischemia were defined as new pathologic Q waves and new T-wave inversions, respectively. RESULTS Of 500 participants, 155 had elevated blood pressure and 17 had hyperglycemia at enrolment. At 6-month follow-up, 7 (4.6%) of 155 participants with elevated blood pressure reported current use of an anti-hypertensive medication, 100 (66.2%) had persistent elevated blood pressure, 12 (7.9%) developed interim myocardial infarction, and 13 (8.6%) developed interim myocardial ischemia. Among 17 participants with hyperglycemia, 9 (56%) had persistent hyperglycemia at 6 months and 2 (12.5%) reported current use of an anti-hyperglycemic medication. CONCLUSIONS Interventions are needed to improve non-communicable disease care pathways among Tanzanians with HIV.
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Affiliation(s)
- Francis M Sakita
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Sainikitha Prattipati
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Jordan Chick
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Linda P Samu
- Health Department, Moshi Municipal Council, Moshi, Tanzania
| | | | - Lauren Coaxum
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Sophie W Galson
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | | | - Alexander T Limkakeng
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Paige R O'Leary
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Kajiru G Kilonzo
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Nathan M Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Gloria Temu
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
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Costs incurred by patients with tuberculosis co-infected with human immunodeficiency virus in Bhavnagar, western India: a sequential explanatory mixed-methods research. BMC Health Serv Res 2022; 22:1268. [PMID: 36261837 PMCID: PMC9581761 DOI: 10.1186/s12913-022-08647-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 10/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND India reports the highest number of tuberculosis (TB) and second-highest number of the human immunodeficiency virus (HIV) globally. We hypothesize that HIV might increase the existing financial burden of care among patients with TB. We conducted this study to estimate the costs incurred by patients with TB co-infected with HIV and to explore the perspectives of patients as well as program functionaries for reducing the costs. METHODS We conducted a descriptive cross-sectional study among 234 co-infected TB-HIV patients notified in the Bhavnagar region of western India from 2017 to 2020 to estimate the costs incurred, followed by in-depth interviews among program functionaries and patients to explore the solutions for reducing the costs. Costs were estimated in Indian rupees (INR) and expressed as median (interquartile range IQR). The World Health Organization defines catastrophic costs as when the total costs incurred by patients exceed 20% of annual household income. The in-depth interviews were audio-recorded, transcribed, and analyzed as codes grouped into categories. RESULTS Among the 234 TB-HIV co-infected patients, 78% were male, 18% were sole earners in the family, and their median (IQR) monthly family income was INR 9000 (7500-11,000) [~US$ 132 (110-162)]. The total median (IQR) costs incurred for TB were INR 4613 (2541-7429) [~US$ 69 (37-109)], which increased to INR 7355 (4337-11,657) [~US$ 108 (64-171)] on adding the costs due to HIV. The catastrophic costs at a 20% cut-off of annual household income for TB were 4% (95% CI 2-8%), which increased to 12% (95% CI 8-16%) on adding the costs due to HIV. Strengthening health systems, cash benefits, reducing costs through timely referral, awareness generation, and improvements in caregiving were some of the solutions provided by program functionaries and the patients. CONCLUSION We conclude that catastrophic costs due to TB-HIV co-infection were higher than that due to TB alone in our study setting. Bringing care closer to the patients would reduce their costs. Strengthening town-level healthcare facilities for diagnostics as well as treatment might shift the healthcare-seeking of patients from the private sector towards the government and thereby reduce the costs incurred.
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Ruhago G, Forsythe S, Van de Ven R, Apicella L. Estimating the cost and efficiency gain of rolling out a multi-month dispensing programme for antiretroviral treatment in Tanzania. AFRICAN JOURNAL OF AIDS RESEARCH 2022; 21:385-390. [DOI: 10.2989/16085906.2022.2133619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- George Ruhago
- Development Studies, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Okere NE, Sambu V, Ndungile Y, van Praag E, Hermans S, Naniche D, de Wit TFR, Maokola W, Gomez GB. The Shinyanga Patient: A Patient's Journey through HIV Treatment Cascade in Rural Tanzania. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:8418. [PMID: 34444166 PMCID: PMC8393654 DOI: 10.3390/ijerph18168418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/23/2021] [Accepted: 08/04/2021] [Indexed: 12/30/2022]
Abstract
The 2016-2017 Tanzania HIV Impact Survey (THIS) reported the accomplishments towards the 90-90-90 global HIV targets at 61-94-87, affirming the need to focus on the first 90 (i.e., getting 90% of people living with HIV (PLHIV) tested). We conducted a patient-pathway analysis to understand the gap observed, by assessing the alignment between where PLHIV seek healthcare and where HIV services are available in the Shinyanga region, Tanzania. We used existing and publicly available data from the National AIDS Control program, national surveys, registries, and relevant national reports. Region-wide, the majority (n = 458/722, 64%) of THIS respondents accessed their last HIV test at public sector facilities. There were 65.9%, 45.1%, and 74.1% who could also access antiretroviral therapy (ART), CD4 testing, and HIV viral load testing at the location of their last HIV test, respectively. In 2019, the viral suppression rate estimated among PLHIV on ART in the Shinyanga region was 91.5%. PLHIV access HIV testing mostly in public health facilities; our research shows that synergies can be achieved to improve access to services further down the cascade in this sector. Furthermore, effective engagement with the private sector (not-for-profit and for-profit) will help to achieve the last mile toward ending the HIV epidemic.
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Affiliation(s)
- Nwanneka E Okere
- Department of Global Health, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (S.H.); (T.F.R.d.W.)
- Amsterdam Institute for Global Health and Development, 1105 BP Amsterdam, The Netherlands;
| | - Veryeh Sambu
- National AIDS Control Programme, Dodoma 41110, Tanzania; (V.S.); (W.M.)
| | - Yudas Ndungile
- Regional Health Management Team, Shinyanga 37103, Tanzania;
| | - Eric van Praag
- Amsterdam Institute for Global Health and Development, 1105 BP Amsterdam, The Netherlands;
| | - Sabine Hermans
- Department of Global Health, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (S.H.); (T.F.R.d.W.)
- Amsterdam Institute for Global Health and Development, 1105 BP Amsterdam, The Netherlands;
| | - Denise Naniche
- ISGlobal-Barcelona Institute for Global Health, Hospital Clinic, University of Barcelona, 08036 Barcelona, Spain;
| | - Tobias F Rinke de Wit
- Department of Global Health, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (S.H.); (T.F.R.d.W.)
- Amsterdam Institute for Global Health and Development, 1105 BP Amsterdam, The Netherlands;
| | - Werner Maokola
- National AIDS Control Programme, Dodoma 41110, Tanzania; (V.S.); (W.M.)
| | - Gabriela B Gomez
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK;
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Stelmach RD, Rabkin M, Abo K, Ahoba I, Gildas Anago M, Boccanera R, Brou H, Flueckiger R, Hartsough K, Msukwa M, Zech J, Young F, Nugent R. Financial burdens of HIV and chronic disease on people living with HIV in Côte d'Ivoire: A cross-sectional out-of-pocket expenditure study. PLoS One 2021; 16:e0255074. [PMID: 34324545 PMCID: PMC8320983 DOI: 10.1371/journal.pone.0255074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 07/11/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Although people living with HIV in Côte d'Ivoire receive antiretroviral therapy (ART) at no cost, other out-of-pocket (OOP) spending related to health can still create a barrier to care. METHODS A convenience sample of 400 adults living with HIV for at least 1 year in Côte d'Ivoire completed a survey on their health spending for HIV and chronic non-communicable diseases (NCDs). In addition to descriptive statistics, we performed simple linear regression analyses with bootstrapped 95% confidence intervals. FINDINGS 365 participants (91%) reported OOP spending for HIV care, with a median of $16/year (IQR 5-48). 34% of participants reported direct costs with a median of $2/year (IQR 1-41). No participants reported user fees for HIV services. 87% of participants reported indirect costs, with a median of $17/year (IQR 7-41). 102 participants (26%) reported at least 1 NCD. Of these, 80 (78%) reported OOP spending for NCD care, with a median of $50/year (IQR 6-107). 76 participants (95%) with both HIV and NCDs reported direct costs, and 48% reported paying user fees for NCD services. Participants had missed a median of 2 HIV appointments in the past year (IQR 2-3). Higher OOP costs were not associated with the number of HIV appointments missed. 21% of participants reported spending over 10% of household income on HIV and/or NCD care. DISCUSSION AND CONCLUSIONS Despite the availability of free ART, most participants reported OOP spending. OOP costs were much higher for participants with co-morbid NCDs.
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Affiliation(s)
| | - Miriam Rabkin
- ICAP at Columbia University, New York, NY, United States of America
| | - Kouame Abo
- Programme National de Lutte Contre le SIDA (PNLS), Abidjan, Côte d'Ivoire
| | - Irma Ahoba
- Programme National de Lutte Contre le SIDA (PNLS), Abidjan, Côte d'Ivoire
| | | | - Rodrigo Boccanera
- Health Resources and Services Administration, Rockville, MD, United States of America
| | - Hermann Brou
- ICAP at Columbia University, New York, NY, United States of America
| | | | - Kieran Hartsough
- ICAP at Columbia University, New York, NY, United States of America
| | - Martin Msukwa
- ICAP at Columbia University, New York, NY, United States of America
| | - Jennifer Zech
- ICAP at Columbia University, New York, NY, United States of America
| | | | - Rachel Nugent
- RTI International, Seattle, WA, United States of America
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Taverne B, Laborde-Balen G, Diaw K, Gueye M, Have NN, Etard JF, Sow K. Does universal health coverage reduce out-of-pocket expenditures for medical consultations for people living with HIV in Senegal? An exploratory cross-sectional study. BMJ Open 2021; 11:e046579. [PMID: 34233979 PMCID: PMC8264868 DOI: 10.1136/bmjopen-2020-046579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 06/22/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES In Senegal, a national health coverage system named Couverture Medicale Universelle (CMU) has been under development since 2013; its impact on out-of-pocket (OOP) expenses for people living with HIV (PLHIV) remains unknown. Our objective was to assess the impact of the national health coverage system on health expenses for PLHIV by measuring the OOP amount for a routine consultation for various categories of PLHIV, in Dakar and different regions in Senegal, viewed from the patients' perspective. DESIGN, SETTING AND PARTICIPANTS Cross-sectional survey in 2018 and 2019 using a face-to-face questionnaire with PLHIV: 344 adults followed up at Fann Regional Centre for research and training in clinical treatment in Dakar; 60 adult men who have sex with men (MSM) in 2 hospitals in Dakar and 7 facilities in the regions; and 130 children and adolescents (0-19 years) in 16 care facilities in the southern regions. We have calculated the total price of the consultation and associated prescriptions along with the patient's OOP medical and transportation contributions. The average amounts were compared using the Student's t-test. RESULTS All patients are on antiretroviral treatment with a median duration of 6 years, 5 years and 3 years for adults, MSM and children/adolescents, respectively. The percentage of people who have health coverage is 26%, 18% and 44% for adults, MSM and children. In practice, these systems are rarely used. The OOP amount (health expenses+transportation costs) for a routine consultation is €11 for adults and children, and €32.5 for MSM. CONCLUSION The number of PLHIV with coverage is low, and the system's effectiveness remains limited. Currently, this system has proved ineffective in implementing free healthcare, recommended by WHO since 2005.
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Affiliation(s)
- Bernard Taverne
- TransVIHMI, University of Montpellier, INSERM, Institut de Recherche pour le Développement, Montpellier, France
- Centre Régional de Recherche et de Formation à la prise en charge Clinique de Fann, Dakar, Senegal
| | - Gabrièle Laborde-Balen
- TransVIHMI, University of Montpellier, INSERM, Institut de Recherche pour le Développement, Montpellier, France
- Centre Régional de Recherche et de Formation à la prise en charge Clinique de Fann, Dakar, Senegal
| | | | - Madjiguene Gueye
- Centre Régional de Recherche et de Formation à la prise en charge Clinique de Fann, Dakar, Senegal
| | - Ndeye-Ngone Have
- Réseau National des Associations de Personnes Vivant Avec le VIH (RNP+), Dakar, Senegal
| | - Jean-Francois Etard
- TransVIHMI, University of Montpellier, INSERM, Institut de Recherche pour le Développement, Montpellier, France
| | - Khoudia Sow
- Centre Régional de Recherche et de Formation à la prise en charge Clinique de Fann, Dakar, Senegal
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Mhina C, Bosworth H, Bartlett JA, Vilme H, Mosha JH, Shoo DF, Kakumbi TJ, Jacob G, Muiruri C. The impact of out-of-pocket expenditures on missed appointments at HIV care and treatment centers in Northern Tanzania. GLOBAL HEALTH JOURNAL 2021. [DOI: 10.1016/j.glohj.2021.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Okere NE, Corball L, Kereto D, Hermans S, Naniche D, Rinke de Wit TF, Gomez GB. Patient-incurred costs in a differentiated service delivery club intervention compared to standard clinical care in Northwest Tanzania. J Int AIDS Soc 2021; 24:e25760. [PMID: 34164916 PMCID: PMC8222647 DOI: 10.1002/jia2.25760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 05/04/2021] [Accepted: 05/25/2021] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Placing all clients with a positive diagnosis for HIV on antiretroviral therapy (ART) has cost implications both for patients and health systems, which could, in turn, affect feasibility, sustainability and uptake of new services. Patient-incurred costs are recognized barriers to healthcare access. Differentiated service delivery (DSD) models in general and community-based care in particular, could reduce these costs. We aimed to assess patient-incurred costs of a community-based DSD intervention (clubs) compared to clinic-based care in the Shinyanga region, Tanzania. METHODS Cross-sectional survey among stable ART patients (n = 390, clinic-based; n = 251, club-based). For each group, we collected socio-demographic, income and expenditure data between May and August 2019. We estimated direct and indirect patient-incurred costs. Direct costs included out-of-pocket expenditures. Indirect costs included income loss due to time spent during transport, accessing services and off work during illness. Cost drivers were assessed in multivariate regression models. RESULTS Overall, costs were significantly higher among clinic participants. Costs (USD) per year for clinic versus club were as follows: 11.7 versus 4.17 (p < 0.001) for direct costs, 20.9 versus 8.23 (p < 0.001) for indirect costs and 32.2 versus 12.4 (p < 0.001) for total costs. Time spent accessing care and time spent in illness (hours/year) were 38.3 versus 13.8 (p < 0.001) and 16.0 versus 6.69 (p < 0.001) respectively. The main cost drivers included transportation (clinic vs. club: 67.7% vs. 44.1%) for direct costs and income loss due to time spent accessing care (clinic vs. club: 60.4% vs. 56.7%) for indirect costs. Factors associated with higher total costs among patients attending clinic services were higher education level (coefficient [95% confidence interval]) 20.9 [5.47 to 36.3]) and formal employment (44.2 [20.0 to 68.5). Differences in mean total costs remained significantly higher with formal employment, rural residence, in addition to more frequent visits among clinic participants. The percentage of households classified as having had catastrophic expenditures in the last year was low but significantly higher among clinic participants (10.8% vs. 5.18%, p = 0.014). CONCLUSIONS Costs incurred by patients accessing DSD in the community are significantly lower compared to those accessing standard clinic-based care. DSD models could improve access, especially in resource-limited settings.
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Affiliation(s)
- Nwanneka E Okere
- Amsterdam Institute for Global Health and DevelopmentDepartment of Global HealthAmsterdam UMCUniversity of AmsterdamAmsterdamNetherlands
| | - Lucia Corball
- Amsterdam Institute for Global Health and DevelopmentDepartment of Global HealthAmsterdam UMCUniversity of AmsterdamAmsterdamNetherlands
| | | | - Sabine Hermans
- Amsterdam Institute for Global Health and DevelopmentDepartment of Global HealthAmsterdam UMCUniversity of AmsterdamAmsterdamNetherlands
| | - Denise Naniche
- ISGLOBAL‐Barcelona Institute for Global HealthHospital ClinicUniversity of BarcelonaBarcelonaSpain
| | - Tobias F Rinke de Wit
- Amsterdam Institute for Global Health and DevelopmentDepartment of Global HealthAmsterdam UMCUniversity of AmsterdamAmsterdamNetherlands
| | - Gabriela B Gomez
- Department of Global Health and DevelopmentLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
- Present address:
Vaccine epidemiology and modelling DepartmentSanofi PasteurLyonFrance
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Nichols BE, Cele R, Lekodeba N, Tukei B, Ngorima-Mabhena N, Tiam A, Maotoe T, Sejana MV, Faturiyele IO, Chasela C, Rosen S, Fatti G. Economic evaluation of differentiated service delivery models for HIV treatment in Lesotho: costs to providers and patients. J Int AIDS Soc 2021; 24:e25692. [PMID: 33838012 PMCID: PMC8035675 DOI: 10.1002/jia2.25692] [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] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 01/25/2021] [Accepted: 02/23/2021] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Lesotho, the country with the second-highest HIV/AIDS prevalence (23.6%) in the world, has made considerable progress towards achieving the "95-95-95" UNAIDS targets, but recent success in improving treatment access to all known HIV positive individuals has severely strained existing healthcare infrastructure, financial and human resources. Lesotho also faces the challenge of a largely rural population who incur a significant time and financial burden to visit healthcare facilities. Using data from a cluster-randomized non-inferiority trial conducted between August 2017 and July 2019, we evaluated costs to providers and costs to patients of community-based differentiated models of multi-month delivery of antiretroviral therapy (ART) in Lesotho. METHODS The trial of multi-month dispensing compared 12-month retention in care among three arms: conventional care, which required quarterly facility visits and ART dispensation (3MF); three-month community adherence groups (CAGs) (3MC) and six-month community ART distribution (6MCD). We first estimated the average total annual cost of providing HIV care and treatment followed by the total cost per patient retained 12 months after entry for each arm, using resource utilization data from the trial and local unit costs. We then estimated the average annual cost to patients in each arm with self-reported questionnaire data. RESULTS The average total annual cost of providing HIV care and treatment per patient was the highest in the 3MF arm ($122.28, standard deviation [SD] $23.91), followed by 3MC ($114.20, SD $23.03) and the 6MCD arm ($112.58, SD $21.44). Per patient retained in care, the average provider cost was $125.99 (SD $24.64) in the 3MF arm and 6% to 8% less for the other two arms ($118.38, SD $23.87 and $118.83, SD $22.63 for the 3MC and 6MCD respectively). There was a large reduction in patient costs for both differentiated service delivery arms: from $44.42 (SD $12.06) annually in the 3MF arm to $16.34 (SD $5.11) annually in the 3MC (63% reduction) and $18.77 (SD $8.31) annually in 6MCD arm (58% reduction). CONCLUSIONS Community-based, multi-month models of ART in Lesotho are likely to produce small cost savings to treatment providers and large savings to patients in Lesotho. Patient cost savings may support long-term adherence and retention in care.
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Affiliation(s)
- Brooke E Nichols
- Department of Global Health, School of Public Health, Boston University, 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
| | - Refiloe Cele
- 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
| | - Nkgomeleng Lekodeba
- 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
| | - Betty Tukei
- Right to Care, Centurion, South Africa.,EQUIP Lesotho, Maseru, Lesotho
| | | | | | | | | | - Iyiola O Faturiyele
- Department of Epidemiology & Biostatistics, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Charles Chasela
- Right to Care, Centurion, South Africa.,USAID, Washington DC, USA
| | - Sydney Rosen
- Department of Global Health, School of Public Health, Boston University, 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
| | - Geoffrey Fatti
- Kheth'Impilo AIDS Free Living, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Assebe LF, Negussie EK, Jbaily A, Tolla MTT, Johansson KA. Financial burden of HIV and TB among patients in Ethiopia: a cross-sectional survey. BMJ Open 2020; 10:e036892. [PMID: 32487582 PMCID: PMC7265036 DOI: 10.1136/bmjopen-2020-036892] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES HIV and tuberculosis (TB) are major global health threats and can result in household financial hardships. Here, we aim to estimate the household economic burden and the incidence of catastrophic health expenditures (CHE) incurred by HIV and TB care across income quintiles in Ethiopia. DESIGN A cross-sectional survey. SETTING 27 health facilities in Afar and Oromia regions for TB, and nationwide household survey for HIV. PARTICIPANTS A total of 1006 and 787 individuals seeking HIV and TB care were enrolled, respectively. OUTCOME MEASURES The economic burden (ie, direct and indirect cost) of HIV and TB care was estimated. In addition, the CHE incidence and intensity were determined using direct costs exceeding 10% of the household income threshold. RESULTS The mean (SD) age of HIV and TB patient was 40 (10), and 30 (14) years, respectively. The mean (SD) patient cost of HIV was $78 ($170) per year and $115 ($118) per TB episode. Out of the total cost, the direct cost of HIV and TB constituted 69% and 46%, respectively. The mean (SD) indirect cost was $24 ($66) per year for HIV and $63 ($83) per TB episode. The incidence of CHE for HIV was 20%; ranges from 43% in the poorest to 4% in the richest income quintile (p<0.001). Similarly, for TB, the CHE incidence was 40% and ranged between 58% and 20% among the poorest and richest income quintiles, respectively (p<0.001). This figure was higher for drug-resistant TB (62%). CONCLUSIONS HIV and TB are causes of substantial economic burden and CHE, inequitably, affecting those in the poorest income quintile. Broadening the health policies to encompass interventions that reduce the high cost of HIV and TB care, particularly for the poor, is urgently needed.
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Affiliation(s)
- Lelisa Fekadu Assebe
- Department Of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
- Disease Prevention and Control, Ministry of Health, Addis Ababa, Ethiopia
| | | | - Abdulrahman Jbaily
- Department Of Global Health and Population, Harvard T.H.Chan School of Public Health,Harvard University, Boston, Massachusetts, USA
| | - Mieraf Taddesse Taddesse Tolla
- Department Of Global Health and Population, Harvard T.H.Chan School of Public Health,Harvard University, Boston, Massachusetts, USA
| | - Kjell Arne Johansson
- Department Of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
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