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Meyer-Rath G, van Rensburg C, Chiu C, Leuner R, Jamieson L, Cohen S. The per-patient costs of HIV services in South Africa: Systematic review and application in the South African HIV Investment Case. PLoS One 2019; 14:e0210497. [PMID: 30807573 PMCID: PMC6391029 DOI: 10.1371/journal.pone.0210497] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 12/23/2018] [Indexed: 12/29/2022] Open
Abstract
Background In economic analyses of HIV interventions, South Africa is often used as a case in point, due to the availability of good epidemiological and programme data and the global relevance of its epidemic. Few analyses however use locally relevant cost data. We reviewed available cost data as part of the South African HIV Investment Case, a modelling exercise to inform the optimal use of financial resources for the country’s HIV programme. Methods We systematically reviewed publication databases for published cost data covering a large range of HIV interventions and summarised relevant unit costs (cost per person receiving a service) for each. Where no data was found in the literature, we constructed unit costs either based on available information regarding ingredients and relevant public-sector prices, or based on expenditure records. Results Only 42 (5%) of 1,047 records included in our full-text review reported primary cost data on HIV interventions in South Africa, with 71% of included papers covering ART. Other papers detailed the costs of HCT, MMC, palliative and inpatient care; no papers were found on the costs of PrEP, social and behaviour change communication, and PMTCT. The results informed unit costs for 5 of 11 intervention categories included in the Investment Case, with the remainder costed based on ingredients (35%) and expenditure data (10%). Conclusions A large number of modelled economic analyses of HIV interventions in South Africa use as inputs the same, often outdated, cost analyses, without reference to additional literature review. More primary cost analyses of non-ART interventions are needed.
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Affiliation(s)
- Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Center for Global Health and Development, Boston University, Boston, Massachusetts, United States of America
- * E-mail:
| | - Craig van Rensburg
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Calvin Chiu
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rahma Leuner
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lise Jamieson
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Steve Cohen
- Strategic Development Consultants, Pietermaritzburg, South Africa
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Maheswaran H, Petrou S, Cohen D, MacPherson P, Kumwenda F, Lalloo DG, Corbett EL, Clarke A. Economic costs and health-related quality of life outcomes of hospitalised patients with high HIV prevalence: A prospective hospital cohort study in Malawi. PLoS One 2018; 13:e0192991. [PMID: 29543818 PMCID: PMC5854246 DOI: 10.1371/journal.pone.0192991] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 02/03/2018] [Indexed: 11/26/2022] Open
Abstract
Introduction Although HIV infection and its associated co-morbidities remain the commonest reason for hospitalisation in Africa, their impact on economic costs and health-related quality of life (HRQoL) are not well understood. This information is essential for decision-makers to make informed choices about how to best scale-up anti-retroviral treatment (ART) programmes. This study aimed to quantify the impact of HIV infection and ART on economic outcomes in a prospective cohort of hospitalised patients with high HIV prevalence. Methods Sequential medical admissions to Queen Elizabeth Central Hospital, Malawi, between June-December 2014 were followed until discharge, with standardised classification of medical diagnosis and estimation of healthcare resources used. Primary costing studies estimated total health provider cost by medical diagnosis. Participants were interviewed to establish direct non-medical and indirect costs. Costs were adjusted to 2014 US$ and INT$. HRQoL was measured using the EuroQol EQ-5D. Multivariable analyses estimated predictors of economic outcomes. Results Of 892 eligible participants, 80.4% (647/892) were recruited and medical notes found. In total, 447/647 (69.1%) participants were HIV-positive, 339/447 (75.8%) were on ART prior to admission, and 134/647 (20.7%) died in hospital. Mean duration of admission for HIV-positive participants not on ART and HIV-positive participants on ART was 15.0 days (95%CI: 12.0–18.0) and 12.2 days (95%CI: 10.8–13.7) respectively, compared to 10.8 days (95%CI: 8.8–12.8) for HIV-negative participants. Mean total provider cost per hospital admission was US$74.78 (bootstrap 95%CI: US$25.41-US$124.15) higher for HIV-positive than HIV-negative participants. Amongst HIV-positive participants, the mean total provider cost was US$106.87 (bootstrap 95%CI: US$25.09-US$106.87) lower for those on ART than for those not on ART. The mean total direct non-medical and indirect cost per hospital admission was US$87.84. EQ-5D utility scores were lower amongst HIV-positive participants, but not significantly different between those on and not on ART. Conclusions HIV-related hospital care poses substantial financial burdens on health systems and patients; however, per-admission costs are substantially lower for those already initiated onto ART prior to admission. These potential cost savings could offset some of the additional resources needed to provide universal access to ART.
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Affiliation(s)
- Hendramoorthy Maheswaran
- Division of Health Sciences, University of Warwick Medical School, Coventry, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Public Health and Policy, University of Liverpool, Liverpool, United Kingdom
- * E-mail:
| | - Stavros Petrou
- Division of Health Sciences, University of Warwick Medical School, Coventry, United Kingdom
| | - Danielle Cohen
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Peter MacPherson
- Department of Public Health and Policy, University of Liverpool, Liverpool, United Kingdom
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Felistas Kumwenda
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - David G. Lalloo
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Elizabeth L. Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Aileen Clarke
- Division of Health Sciences, University of Warwick Medical School, Coventry, United Kingdom
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Tomich LGMDM, Núñez M, Mendes-Correa MC. Drug-induced liver injury in hospitalized HIV patients: high incidence and association with drugs for tuberculosis. Ann Hepatol 2016; 14:888-94. [PMID: 26436361 DOI: 10.5604/16652681.1171778] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The evaluation of liver disease in HIV patients is cumbersome because may result from a number of different causes. The aim of this retrospective study was to estimate the incidence of severe drug induced liver injury (DILI) in a group of HIV inpatients and investigate potential risk factors. MATERIAL AND METHODS We performed a retrospective analysis of data from HIV-infected patients hospitalized between August 2010 and August 2011 in a tertiary hospital in São Paulo, Brazil. Severe hepatotoxicity was defined as grade 3 (5.1 to 10 x ULN) or 4 (> 10 x ULN) of ALT and AST levels. Factors analyzed included demographics, infection with hepatitis viruses, alcohol history and use of hepatotoxic drugs prior to or during hospital admission. RESULTS A total of 149 patients with HIV were hospitalized during the study period. The majority were male over 42 years of age and 82 (55%) were taking HAART initiated prior to admission. Mean CD4 counts were 164 cells/mm3. Thirty three patients (22.1%) developed severe DILI during hospital stay, which had a mean duration of 26 days. Factors associated with severe DILI in the multivariate analysis were abnormal baseline ALT levels [OR 2.02 (95%CI 1.13-3.59); p = 0.017] and tuberculosis therapy [OR 2.31 (95% CI 1.27-4.19); p = 0.006]. In conclusion, in this group of HIV patients admitted to a tertiary hospital in Brazil, we found a high incidence (22.1%) of severe DILI. The use of anti-tuberculosis drugs and baseline liver injury were independent factors associated with severe DILI during hospital stay.
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Affiliation(s)
| | - Marina Núñez
- Infectious Diseases, Wake Forest University Health Sciences Winston Salem, USA
| | - Maria Cassia Mendes-Correa
- Division of Infectious Diseases, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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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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Abo Y, Zannou Djimon M, Messou E, Balestre E, Kouakou M, Akakpo J, Ahouada C, de Rekeneire N, Dabis F, Lewden C, Minga A. Severe morbidity after antiretroviral (ART) initiation: active surveillance in HIV care programs, the IeDEA West Africa collaboration. BMC Infect Dis 2015; 15:176. [PMID: 25885859 PMCID: PMC4396560 DOI: 10.1186/s12879-015-0910-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 03/18/2015] [Indexed: 11/25/2022] Open
Abstract
Background The causes of severe morbidity in health facilities implementing Antiretroviral Treatment (ART) programmes are poorly documented in sub-Saharan Africa. We aimed to describe severe morbidity among HIV-infected patients after ART initiation, based on data from an active surveillance system established within a network of specialized care facilities in West African cities. Methods Within the International epidemiological Database to Evaluate AIDS (IeDEA) - West Africa collaboration, we conducted a prospective, multicenter data collection that involved two facilities in Abidjan, Côte d’Ivoire and one in Cotonou, Benin. Among HIV-infected adults receiving ART, events were recorded using a standardized form. A simple case-definition of severe morbidity (death, hospitalization, fever > 38°5C, Karnofsky index < 70%) was used at any patient contact point. Then a physician confirmed and classified the event as WHO stage 3 or 4 according to the WHO clinical classification or as degree 3 or 4 of the ANRS scale. Results From December 2009 to December 2011, 978 adults (71% women, median age 39 years) presented with 1449 severe events. The main diagnoses were: non-AIDS-defining infections (33%), AIDS-defining illnesses (33%), suspected adverse drug reactions (7%), other illnesses (4%) and syndromic diagnoses (16%). The most common specific diagnoses were: malaria (25%), pneumonia (13%) and tuberculosis (8%). The diagnoses were reported as syndromic in one out of five events recorded during this study. Conclusions This study highlights the ongoing importance of conventional infectious diseases among severe morbid events occurring in patients on ART in ambulatory HIV care facilities in West Africa. Meanwhile, additional studies are needed due to the undiagnosed aspect of severe morbidity in substantial proportion. Electronic supplementary material The online version of this article (doi:10.1186/s12879-015-0910-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yao Abo
- Programme PAC-CI, Centre Hospitalier Universitaire (CHU) de Treichville, 18 BP 1954, Abidjan 18, Côte d'Ivoire. .,Centre Médical de Suivi des Donneurs de Sang (CMSDS), Centre National de Transfusion Sanguine, Abidjan, Côte d'Ivoire.
| | - Marcel Zannou Djimon
- Centre de Traitement Ambulatoire (CTA), Centre National Hospitalier Universitaire (CNHU), Cotonou, Benin. .,Université d'Abomey-Calavi, Cotonou, Bénin.
| | - Eugène Messou
- University Bordeaux, ISPED, Bordeaux, France. .,Centre de Prise en charge de Recherche et de Formation (Aconda-CePReF), Abidjan, Côte d'Ivoire.
| | - Eric Balestre
- INSERM, Centre INSERM U897-Epidémiologie-Biostatistique, Bordeaux, France. .,University Bordeaux, ISPED, Bordeaux, France.
| | - Martial Kouakou
- Centre de Prise en charge de Recherche et de Formation (Aconda-CePReF), Abidjan, Côte d'Ivoire.
| | - Jocelyn Akakpo
- Centre de Traitement Ambulatoire (CTA), Centre National Hospitalier Universitaire (CNHU), Cotonou, Benin.
| | - Carin Ahouada
- Centre de Traitement Ambulatoire (CTA), Centre National Hospitalier Universitaire (CNHU), Cotonou, Benin.
| | - Nathalie de Rekeneire
- INSERM, Centre INSERM U897-Epidémiologie-Biostatistique, Bordeaux, France. .,University Bordeaux, ISPED, Bordeaux, France.
| | - François Dabis
- INSERM, Centre INSERM U897-Epidémiologie-Biostatistique, Bordeaux, France. .,University Bordeaux, ISPED, Bordeaux, France.
| | - Charlotte Lewden
- INSERM, Centre INSERM U897-Epidémiologie-Biostatistique, Bordeaux, France. .,University Bordeaux, ISPED, Bordeaux, France.
| | - Albert Minga
- Programme PAC-CI, Centre Hospitalier Universitaire (CHU) de Treichville, 18 BP 1954, Abidjan 18, Côte d'Ivoire. .,Centre Médical de Suivi des Donneurs de Sang (CMSDS), Centre National de Transfusion Sanguine, Abidjan, Côte d'Ivoire.
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Disease patterns and causes of death of hospitalized HIV-positive adults in West Africa: a multicountry survey in the antiretroviral treatment era. J Int AIDS Soc 2014; 17:18797. [PMID: 24713375 PMCID: PMC3980465 DOI: 10.7448/ias.17.1.18797] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 01/06/2014] [Accepted: 01/20/2014] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE We aimed to describe the morbidity and mortality patterns in HIV-positive adults hospitalized in West Africa. METHOD We conducted a six-month prospective multicentre survey within the IeDEA West Africa collaboration in six adult medical wards of teaching hospitals in Abidjan, Ouagadougou, Cotonou, Dakar and Bamako. From April to October 2010, all newly hospitalized HIV-positive patients were eligible. Baseline and follow-up information until hospital discharge was recorded using standardized forms. Diagnoses were reviewed by a local event validation committee using reference definitions. Factors associated with in-hospital mortality were studied with a logistic regression model. RESULTS Among 823 hospitalized HIV-positive adults (median age 40 years, 58% women), 24% discovered their HIV infection during the hospitalization, median CD4 count was 75/mm(3) (IQR: 25-177) and 48% had previously received antiretroviral treatment (ART). The underlying causes of hospitalization were AIDS-defining conditions (54%), other infections (32%), other diseases (8%) and non-specific illness (6%). The most frequent diseases diagnosed were: tuberculosis (29%), pneumonia (15%), malaria (10%) and cerebral toxoplasmosis (10%). Overall, 315 (38%) patients died during hospitalization and the underlying cause of death was AIDS (63%), non-AIDS-defining infections (26%), other diseases (7%) and non-specific illness or unknown cause (4%). Among them, the most frequent fatal diseases were: tuberculosis (36%), cerebral toxoplasmosis (10%), cryptococcosis (9%) and sepsis (7%). Older age, clinical WHO stage 3 and 4, low CD4 count, and AIDS-defining infectious diagnoses were associated with hospital fatality. CONCLUSIONS AIDS-defining conditions, primarily tuberculosis, and bacterial infections were the most frequent causes of hospitalization in HIV-positive adults in West Africa and resulted in high in-hospital fatality. Sustained efforts are needed to integrate care of these disease conditions and optimize earlier diagnosis of HIV infection and initiation of ART.
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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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Health care resource utilization in untreated HIV-infected children in a pediatric programme, Abidjan, Côte d'Ivoire, 2004-2009. J Acquir Immune Defic Syndr 2013; 62:e14-21. [PMID: 23262977 DOI: 10.1097/qai.0b013e3182739c95] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We describe health care resource utilization among HIV-1-infected children who have not yet undergone antiretroviral treatment (ART) in Abidjan, Côte d'Ivoire. METHODS HIV-infected children enrolled prospectively in an HIV care programme in 2 health facilities in Abidjan (2004-2009) were followed up from date of inclusion until database closeout, death, ART initiation, or loss to follow-up (no clinical contact for more than 6 months). Incidences of health care resource utilization (outpatient care, inpatient day care, and hospitalization) were described according to severe morbidity and mixed effect log linear models were computed to identify associated factors. RESULTS Overall, 405 children were included, entering care at a median age of 4.5 years, 66.9% were receiving cotrimoxazole prophylaxis, and 27.7% met 2006 WHO criteria for immunodeficiency by age. The median follow-up time was 11.6 months (interquartile range: 1.4; 30.7). Overall, 371 clinical events occurred in 162 children yielding to an incidence rate (IR) of 60.9/100 child-years (CY) [95% confidence interval (CI): 55.1 to 67.2]: 57% of clinical events led to outpatient care (IR: 33/100 CY), 38% to inpatient day care (IR: 22/100 CY), and 10% to hospitalization (IR: 5.9/100 CY). Further medical examinations were made allowing confirmed diagnoses in 40% of those (IR: 22.4/100 CY). Outpatient care was less common among immunodeficient children than those not (relative risk [RR] = 0.32, 95% CI: 0.18 to 0.56), in those whose main caregivers are both parents compared with those who are primarily cared for by their mother only (RR = 0.34, 95% CI: 0.15 to 0.77). CONCLUSION Untreated HIV-infected children require substantial inpatient and outpatient care in a context where ART is scaling up but still not available to all.
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Wong EB, Omar T, Setlhako GJ, Osih R, Feldman C, Murdoch DM, Martinson NA, Bangsberg DR, Venter WDF. Causes of death on antiretroviral therapy: a post-mortem study from South Africa. PLoS One 2012; 7:e47542. [PMID: 23094059 PMCID: PMC3472995 DOI: 10.1371/journal.pone.0047542] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 09/12/2012] [Indexed: 11/24/2022] Open
Abstract
Background Mortality in the first months of antiretroviral therapy (ART) is a significant clinical problem in sub-Saharan Africa. To date, no post-mortem study has investigated the causes of mortality in these patients. Methods HIV-positive adults who died as in-patients at a Johannesburg academic hospital underwent chart-review and ultrasound-guided needle autopsy for histological and microbiological examination of lung, liver, spleen, kidney, bone marrow, lymph node, skin and cerebrospinal fluid. A clinico-pathologic committee considered all available data and adjudicated immediate and contributing causes of death. Results Thirty-nine adults were enrolled: 14 pre-ART, 15 early-ART (7–90 days), and 10 late-ART (>90 days). Needle sampling yielded adequate specimen in 100% of kidney, skin, heart and cerebrospinal fluid samples, 97% of livers and lungs, 92% of bone marrows, 87% of spleens and 68% of lymph nodes. Mycobacterial infections were implicated in 69% of deaths (26 of 27 of these due to M. tuberculosis), bacterial infections in 33%, fungal infections in 21%, neoplasm in 26%, and non-infectious organ failure in 26%. Immune reconstitution inflammatory syndrome (IRIS) was implicated in 73% of early-ART deaths. Post-mortem investigations revealed previously undiagnosed causes of death in 49% of cases. Multiple pathologies were common with 62% of subjects with mycobacterial infection also having at least one other infectious or neoplastic cause of death. Conclusions Needle biopsy was efficient and yielded excellent pathology. The large majority of deaths in all three groups were caused by M. tuberculosis suggesting an urgent need for improved diagnosis and expedited treatment prior to and throughout the course of antiretroviral therapy. Complex, unrecognized co-morbidities pose an additional challenge.
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Affiliation(s)
- Emily B Wong
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa.
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Hospitalization trends, costs, and risk factors in HIV-infected children on antiretroviral therapy. AIDS 2012; 26:1943-52. [PMID: 22824633 DOI: 10.1097/qad.0b013e328357f7b9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To assess hospitalization trends in HIV-infected children on antiretroviral therapy (ART) in Thailand, an important indicator of morbidity, ART effectiveness, and health service utilization. DESIGN Prospective observational cohort METHOD Children initiating ART in 1999-2009 were followed in 40 public hospitals. Hospitalization rate per 100 person-years were calculated from ART initiation to last follow-up/death. Costs to the healthcare provider were calculated using WHO inpatient estimates for Thailand. Zero-inflated Poisson models were used to examine risk factors for early (<12 months of ART) and late hospitalization (≥12 months) and frequency of admissions. RESULTS A total of 578 children initiated ART, median follow-up being 64 months [interquartile range (IQR) 43-82]; 211 (37%) children were hospitalized with 451 admissions. Hospitalization rates declined from 63 per 100 person-years at less than 6 months to approximately 10 per 100 person-years after 2 years of ART, and costs fell from $35 per patient-month to under $5, respectively. Age less than 2 years, US Centers of Disease Control and Prevention stage B/C, and stunting at ART initiation were associated with early hospitalization. Among those hospitalized, baseline CD4 cell percentage less than 5%, wasting, initiation on dual therapy, late calendar year, and female sex were associated with higher incidence of early admissions (P <0.02). There were no predictors of late hospitalization, although previous hospitalization in less than 12 months of ART was associated with three times higher incidence of late admissions (P < 0.0001). CONCLUSION One in three children required hospitalization after ART. Admissions were highest in the first year of therapy and rapidly declined thereafter. Young age, advanced disease stage, and stunting at baseline were predictive of early hospitalization. Treatment initiation before disease progression would likely reduce hospitalization and alleviate demands on healthcare services.
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Cleary S, McIntyre D. Financing equitable access to antiretroviral treatment in South Africa. BMC Health Serv Res 2010; 10 Suppl 1:S2. [PMID: 20594368 PMCID: PMC2895746 DOI: 10.1186/1472-6963-10-s1-s2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background While South Africa spends approximately 7.4% of GDP on healthcare, only 43% of these funds are spent in the public system, which is tasked with the provision of care to the majority of the population including a large proportion of those in need of antiretroviral treatment (ART). South Africa is currently debating the introduction of a National Health Insurance (NHI) system. Because such a universal health system could mean increased public healthcare funding and improved access to human resources, it could improve the sustainability of ART provision. This paper considers the minimum resources that would be required to achieve the proposed universal health system and contrasts these with the costs of scaled up access to ART between 2010 and 2020. Methods The costs of ART and universal coverage (UC) are assessed through multiplying unit costs, utilization and estimates of the population in need during each year of the planning cycle. Costs are from the provider’s perspective reflected in real 2007 prices. Results The annual costs of providing ART increase from US$1 billion in 2010 to US$3.6 billion in 2020. If increases in funding to public healthcare only keep pace with projected real GDP growth, then close to 30% of these resources would be required for ART by 2020. However, an increase in the public healthcare resource envelope from 3.2% to 5%-6% of GDP would be sufficient to finance both ART and other services under a universal system (if based on a largely public sector model) and the annual costs of ART would not exceed 15% of the universal health system budget. Conclusions Responding to the HIV-epidemic is one of the many challenges currently facing South Africa. Whether this response becomes a “resource for democracy” or whether it undermines social cohesiveness within poor communities and between rich and poor communities will be partially determined by the steps that are taken during the next ten years. While the introduction of a universal system will be complex, it could generate a health system responsive to the needs of all South Africans.
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Affiliation(s)
- Susan Cleary
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
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