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Cerecero-García D, Terris-Prestholt F, Macías-González F, Bautista-Arredondo S. State of HIV costing in Latin America and the Caribbean: a systematic literature review. Rev Panam Salud Publica 2024; 48:e84. [PMID: 39286659 PMCID: PMC11404235 DOI: 10.26633/rpsp.2024.84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Accepted: 06/26/2024] [Indexed: 09/19/2024] Open
Abstract
Objectives To summarize available data on unit costs for human immunodeficiency virus (HIV) testing, prevention, and care interventions in Latin America and the Caribbean. Methods We conducted a systematic literature review of costing studies published between 2012 and 2024, and selected those reporting empirically measured costing data. The available data were categorized according to predefined intervention categories and compared by time and place. We also explored variations in unit costs by intervention type. Results Of 1 746 studies identified, 22 met the inclusion criteria, which provided 103 unique unit cost estimates from nine countries. About 50% of the included studies were published between 2019 and 2021. Antiretroviral therapy services had the most cost data available (39% of unit costs), followed by inpatient care (27%) and HIV testing (24%). Considerable cost variations were observed both within and between interventions. Conclusions Our analysis underscores the need for accurate and reliable cost data to support HIV budgeting and decision-making efforts. We identified several gaps in the availability of cost data and emphasize the importance of presenting results more effectively by incorporating key contextual variables. Given the challenges of shrinking budgets and sustainability risks, robust evidence is indispensable to inform priority setting and budget allocation for HIV services.
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Affiliation(s)
- Diego Cerecero-García
- Public Health Policy Evaluation Unit Imperial College London England Public Health Policy Evaluation Unit, Imperial College, London, England
| | - Fern Terris-Prestholt
- United Nations Joint Programme on HIV/AIDS Geneva Switzerland United Nations Joint Programme on HIV/AIDS, Geneva, Switzerland
| | - Fernando Macías-González
- Center for Evaluation Research and Surveys National Institute of Public Health Mexico City Mexico Center for Evaluation Research and Surveys, National Institute of Public Health, Mexico City, Mexico
| | - Sergio Bautista-Arredondo
- Center for Evaluation Research and Surveys National Institute of Public Health Mexico City Mexico Center for Evaluation Research and Surveys, National Institute of Public Health, Mexico City, Mexico
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d'Elbée M, Terris-Prestholt F, Briggs A, Griffiths UK, Larmarange J, Medley GF, Gomez GB. Estimating health care costs at scale in low- and middle-income countries: Mathematical notations and frameworks for the application of cost functions. HEALTH ECONOMICS 2023; 32:2216-2233. [PMID: 37332114 DOI: 10.1002/hec.4722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 04/13/2023] [Accepted: 05/12/2023] [Indexed: 06/20/2023]
Abstract
Appropriate costing and economic modeling are major factors for the successful scale-up of health interventions. Various cost functions are currently being used to estimate costs of health interventions at scale in low- and middle-income countries (LMICs) potentially resulting in disparate cost projections. The aim of this study is to gain understanding of current methods used and provide guidance to inform the use of cost functions that is fit for purpose. We reviewed seven databases covering the economic and global health literature to identify studies reporting a quantitative analysis of costs informing the projected scale-up of a health intervention in LMICs between 2003 and 2019. Of the 8725 articles identified, 40 met the inclusion criteria. We classified studies according to the type of cost functions applied-accounting or econometric-and described the intended use of cost projections. Based on these findings, we developed new mathematical notations and cost function frameworks for the analysis of healthcare costs at scale in LMICs setting. These notations estimate variable returns to scale in cost projection methods, which is currently ignored in most studies. The frameworks help to balance simplicity versus accuracy and increase the overall transparency in reporting of methods.
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Affiliation(s)
- Marc d'Elbée
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- University of Bordeaux, National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Centre, Bordeaux, France
- Ceped UMR 196, Université Paris Cité, Research Institute for Sustainable Development (IRD), Inserm, Paris, France
| | - Fern Terris-Prestholt
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Andrew Briggs
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Ulla Kou Griffiths
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- Health Section, Program Group, UNICEF, New York, New York, USA
| | - Joseph Larmarange
- Ceped UMR 196, Université Paris Cité, Research Institute for Sustainable Development (IRD), Inserm, Paris, France
| | - Graham Francis Medley
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Gabriella Beatriz Gomez
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- IAVI, New York, New York, USA
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3
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d'Elbée M, Gomez GB, Sande LA, Mwenge L, Mangenah C, Johnson C, Medley GF, Neuman M, Hatzold K, Corbett EL, Meyer-Rath G, Terris-Prestholt F. Modelling costs of community-based HIV self-testing programmes in Southern Africa at scale: an econometric cost function analysis across five countries. BMJ Glob Health 2021; 6:e005554. [PMID: 34275875 PMCID: PMC8287624 DOI: 10.1136/bmjgh-2021-005554] [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] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/25/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Following success demonstrated with the HIV Self-Testing AfRica Initiative, HIV self-testing (HIVST) is being added to national HIV testing strategies in Southern Africa. An analysis of the costs of scaling up HIVST is needed to inform national plans, but there is a dearth of evidence on methods for forecasting costs at scale from pilot projects. Econometric cost functions (ECFs) apply statistical inference to predict costs; however, we often do not have the luxury of collecting large amounts of location-specific data. We fit an ECF to identify key drivers of costs, then use a simpler model to guide cost projections at scale. METHODS We estimated the full economic costs of community-based HIVST distribution in 92 locales across Malawi, Zambia, Zimbabwe, South Africa and Lesotho between June 2016 and June 2019. We fitted a cost function with determinants related to scale, locales organisational and environmental characteristics, target populations, and per capita Growth Domestic Product (GDP). We used models differing in data intensity to predict costs at scale. We compared predicted estimates with scale-up costs in Lesotho observed over a 2-year period. RESULTS The scale of distribution, type of community-based intervention, percentage of kits distributed to men, distance from implementer's warehouse and per capita GDP predicted average costs per HIVST kit distributed. Our model simplification approach showed that a parsimonious model could predict costs without losing accuracy. Overall, ECF showed a good predictive capacity, that is, forecast costs were close to observed costs. However, at larger scale, variations of programme efficiency over time (number of kits distributed per agent monthly) could potentially influence cost predictions. DISCUSSION Our empirical cost function can inform community-based HIVST scale-up in Southern African countries. Our findings suggest that a parsimonious ECF can be used to forecast costs at scale in the context of financial planning and budgeting.
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Affiliation(s)
- Marc d'Elbée
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Gabriela B Gomez
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Linda Alinafe Sande
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
- Department of HIV/AIDS & TB, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Collin Mangenah
- Department of Health Economics, Centre for Sexual Health HIV/AIDS Research, Harare, Zimbabwe
| | - Cheryl Johnson
- Global HIV, Hepatitis and STI Programme, World Health Organisation, Geneva, Switzerland
| | - Graham F Medley
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Melissa Neuman
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Karin Hatzold
- Population Services International, Washington, DC, USA
| | - Elizabeth Lucy Corbett
- Department of HIV/AIDS & TB, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Gesine Meyer-Rath
- Department of Internal Medicine, Health Economics and Epidemiology Research Office (HE2RO) - University of the Witwatersrand, Johannesburg, South Africa
- Center for Global Health and Development, Boston University, Boston, Massachusetts, USA
| | - Fern Terris-Prestholt
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
- Department of Global Health & Development, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
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4
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Kimaro GD, Guinness L, Shiri T, Kivuyo S, Chanda D, Bottomley C, Chen T, Kahwa A, Hawkins N, Mwaba P, Mfinanga SG, Harrison TS, Jaffar S, Niessen LW. Cryptococcal Meningitis Screening and Community-based Early Adherence Support in People With Advanced Human Immunodeficiency Virus Infection Starting Antiretroviral Therapy in Tanzania and Zambia: A Cost-effectiveness Analysis. Clin Infect Dis 2021; 70:1652-1657. [PMID: 31149704 PMCID: PMC7146002 DOI: 10.1093/cid/ciz453] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 05/30/2019] [Indexed: 01/05/2023] Open
Abstract
Background A randomized trial demonstrated that among people living with late-stage human immunodeficiency virus (HIV) infection initiating antiretroviral therapy, screening serum for cryptococcal antigen (CrAg) combined with adherence support reduced all-cause mortality by 28%, compared with standard clinic-based care. Here, we present the cost-effectiveness. Methods HIV-infected adults with CD4 count <200 cells/μL were randomized to either CrAg screening plus 4 weekly home visits to provide adherence support or to standard clinic-based care in Dar es Salaam and Lusaka. The primary economic outcome was health service care cost per life-year saved as the incremental cost-effectiveness ratio (ICER), based on 2017 US dollars. We used nonparametric bootstrapping to assess uncertainties and univariate deterministic sensitivity analysis to examine the impact of individual parameters on the ICER. Results Among the intervention and standard arms, 1001 and 998 participants, respectively, were enrolled. The annual mean cost per participant in the intervention arm was US$339 (95% confidence interval [CI], $331–$347), resulting in an incremental cost of the intervention of US$77 (95% CI, $66–$88). The incremental cost was similar when analysis was restricted to persons with CD4 count <100 cells/μL. The ICER for the intervention vs standard care, per life-year saved, was US$70 (95% CI, $43–$211) for all participants with CD4 count up to 200 cells/μL and US$91 (95% CI, $49–$443) among those with CD4 counts <100 cells /μL. Cost-effectveness was most sensitive to mortality estimates. Conclusions Screening for cryptococcal antigen combined with a short period of adherence support, is cost-effective in resource-limited settings.
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Affiliation(s)
- Godfather Dickson Kimaro
- Muhimbili Medical Research Centre, National Institute of Medical Research, Dar es Salaam, United Republic of Tanzania.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Lorna Guinness
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Tinevimbo Shiri
- Department of International Public Health, Liverpool School of Tropical Medicine, United Kingdom
| | - Sokoine Kivuyo
- Muhimbili Medical Research Centre, National Institute of Medical Research, Dar es Salaam, United Republic of Tanzania
| | - Duncan Chanda
- University Teaching Hospital, Lusaka Apex Medical University, Zambia
| | - Christian Bottomley
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Tao Chen
- Department of International Public Health, Liverpool School of Tropical Medicine, United Kingdom
| | - Amos Kahwa
- Muhimbili Medical Research Centre, National Institute of Medical Research, Dar es Salaam, United Republic of Tanzania
| | - Neil Hawkins
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Peter Mwaba
- Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University, Zambia
| | - Sayoki Godfrey Mfinanga
- Muhimbili Medical Research Centre, National Institute of Medical Research, Dar es Salaam, United Republic of Tanzania.,Department of International Public Health, Liverpool School of Tropical Medicine, United Kingdom
| | - Thomas S Harrison
- Institute for Infection and Immunity, Centre for Global Health, St George's University of London, United Kingdom
| | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, United Kingdom
| | - Louis W Niessen
- Department of International Public Health, Liverpool School of Tropical Medicine, United Kingdom.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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5
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Hughes CS, Brown J, Murombedzi C, Chirenda T, Chareka G, Mhlanga F, Mateveke B, Gitome S, Makurumure T, Matubu A, Mgodi N, Chirenje Z, Kahn JG. Estimated costs for the delivery of safer conception strategies for HIV-discordant couples in Zimbabwe: a cost analysis. BMC Health Serv Res 2020; 20:940. [PMID: 33046066 PMCID: PMC7552466 DOI: 10.1186/s12913-020-05784-4] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In recent years, safer conception strategies have been developed to help HIV-serodiscordant couples conceive a child without transmitting HIV to the seronegative partner. The SAFER clinical trial assessed implementation of these strategies in Zimbabwe. METHODS As a part of the SAFER study, we estimated the costs (in 2017 $US) associated with individual and combination strategies, in the trial setting and real-world practice, from a healthcare system perspective. Safer conception strategies included: 1) ART with frequent viral load testing until achieving undetectable viral load (ART-VL); 2) daily oral pre-exposure prophylaxis (PrEP); 3) semen-washing with intrauterine insemination; and 4) manual self-insemination at home. For costs in the trial, we used a micro-costing approach, including a time and motion study to quantify personnel effort, and estimated the cost per couple for individual and combination strategies for a mean of 6 months of safer services. For real-world practice, we modeled costs for three implementation scenarios, representing differences from the trial in input prices (paid by the Ministry of Health and Child Care [MOHCC]), intervention intensity, and increments to current HIV prevention and treatment practices and guidelines. We used one-way sensitivity analyses to assess the impact of uncertainty in input variables. RESULTS Individual strategy costs were $769-$1615 per couple in the trial; $185-$563 if using MOHCC prices. Under the target intervention intensity and using MOHCC prices, individual strategy costs were $73-$360 per couple over and above the cost of current HIV clinical practices. The cost of delivering the most commonly selected combination, ART-VL plus PrEP, ranged from $166-$517 per couple under the three real-world scenarios. Highest costs were for personnel, lab tests, and strategy-specific consumables, in variable proportions by clinical strategy and analysis scenario. Total costs were most affected by uncertainty in the price of PrEP, number of semen-washing attempts, and scale-up of semen-washing capacity. CONCLUSIONS Safer conception methods have costs that may be affordable in many low-resource settings. These cost data will help implementers and policymakers add safer conception services. Cost-effectiveness analysis is needed to assess value for money for safer conception services overall and for safer strategy combinations. TRIAL REGISTRATION Registry Name: Clinicaltrials.gov. TRIAL REGISTRATION NUMBER NCT03049176 . Registration date: February 9, 2017.
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Affiliation(s)
- Carolyn Smith Hughes
- Institute for Global Health Sciences, University of California, 550 16th Street, 3rd Floor, San Francisco, 94158, USA.
| | - Joelle Brown
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, USA
| | - Caroline Murombedzi
- College of Health Sciences Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Thandiwe Chirenda
- College of Health Sciences Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Gift Chareka
- College of Health Sciences Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Felix Mhlanga
- College of Health Sciences Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | | | - Serah Gitome
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Allen Matubu
- College of Health Sciences Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Nyaradzo Mgodi
- College of Health Sciences Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Zvavahera Chirenje
- College of Health Sciences Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - James G Kahn
- Department of Epidemiology and Biostatistics, University of California, San Francisco, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, USA
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6
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Portnoy A, Vaughan K, Clarke-Deelder E, Suharlim C, Resch SC, Brenzel L, Menzies NA. Producing Standardized Country-Level Immunization Delivery Unit Cost Estimates. PHARMACOECONOMICS 2020; 38:995-1005. [PMID: 32596785 PMCID: PMC7437655 DOI: 10.1007/s40273-020-00930-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND To plan for the financial sustainability of immunization programs and make informed decisions to improve immunization coverage and equity, decision-makers need to know how much these programs cost beyond the cost of the vaccine. Non-vaccine delivery cost estimates can significantly influence the cost-effectiveness estimates used to allocate resources at the country level. However, many low- and middle-income countries (LMICs) do not have immunization delivery unit cost estimates available, or have estimates that are uncertain, unreliable, or old. We undertook a Bayesian evidence synthesis to generate country-level estimates of immunization delivery unit costs for LMICs. METHODS From a database of empirical immunization costing studies, we extracted estimates of the delivery cost per dose for routine childhood immunization services, excluding vaccine costs. A Bayesian meta-regression model was used to regress delivery cost per dose estimates, stratified by cost category, against a set of predictor variables including country-level [gross domestic product per capita, reported diphtheria-tetanus-pertussis third dose coverage (DTP3), population, and number of doses in the routine vaccination schedule] and study-level (study year, single antigen or programmatic cost per dose, and financial or economic cost) predictors. The fitted prediction model was used to generate standardized estimates of the routine immunization delivery cost per dose for each LMIC for 2009-2018. Alternative regression models were specified in sensitivity analyses. RESULTS We estimated the prediction model using the results from 29 individual studies, covering 24 countries. The predicted economic cost per dose for routine delivery of childhood vaccines (2018 US dollars), not including the price of the vaccine, was $1.87 (95% uncertainty interval $0.64-4.38) across all LMICs. By individual cost category, the programmatic economic cost per dose for routine delivery of childhood vaccines was $0.74 ($0.26-1.70) for labor, $0.26 ($0.08-0.67) for supply chain, $0.22 ($0.06-0.57) for capital, and $0.65 ($0.20-1.66) for other service delivery costs. CONCLUSIONS Accurate immunization delivery costs are necessary for assessing the cost-effectiveness and strategic planning needs of immunization programs. The cost estimates from this analysis provide a broad indication of immunization delivery costs that may be useful when accurate local data are unavailable.
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Affiliation(s)
- Allison Portnoy
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Avenue 2nd Floor, Boston, MA, 02115, USA.
| | | | - Emma Clarke-Deelder
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Christian Suharlim
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Avenue 2nd Floor, Boston, MA, 02115, USA
- Management Sciences for Health, Boston, MA, USA
| | - Stephen C Resch
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Avenue 2nd Floor, Boston, MA, 02115, USA
| | | | - Nicolas A Menzies
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Avenue 2nd Floor, Boston, MA, 02115, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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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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8
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Clarke-Deelder E, Vassall A, Menzies NA. Estimators Used in Multisite Healthcare Costing Studies in Low- and Middle-Income Countries: A Systematic Review and Simulation Study. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:1146-1153. [PMID: 31563257 PMCID: PMC6859917 DOI: 10.1016/j.jval.2019.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/24/2019] [Accepted: 05/28/2019] [Indexed: 05/08/2023]
Abstract
BACKGROUND In low- and middle-income countries, multisite costing studies are increasingly used to estimate healthcare program costs. These studies have employed a variety of estimators to summarize sample data and make inferences about overall program costs. OBJECTIVE We conducted a systematic review and simulation study to describe these estimation methods and quantify their performance in terms of expected bias and variance. METHODS We reviewed the published literature through January 2017 to identify multisite costing studies conducted in low- and middle-income countries and extracted data on analytic approaches. To assess estimator performance under realistic conditions, we conducted a simulation study based on 20 empirical cost data sets. RESULTS The most commonly used estimators were the volume-weighted mean and the simple mean, despite theoretical reasons to expect bias in the simple mean. When we tested various estimators in realistic study scenarios, the simple mean exhibited an upward bias ranging from 12% to 113% of the true cost across a range of study sample sizes and data sets. The volume-weighted mean exhibited minimal bias and substantially lower root mean squared error. Further gains were possible using estimators that incorporated auxiliary information on delivery volumes. CONCLUSIONS The choice of summary estimator in multisite costing studies can significantly influence study findings and, therefore, the economic analyses they inform. Use of the simple mean to summarize the results of multisite costing studies should be considered inappropriate. Our study demonstrates that several alternative better-performing methods are available.
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Affiliation(s)
- Emma Clarke-Deelder
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA.
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, England, UK
| | - Nicolas A Menzies
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
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9
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The economic returns of ending the AIDS epidemic as a public health threat. Health Policy 2018; 123:104-108. [PMID: 30497785 DOI: 10.1016/j.healthpol.2018.11.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 11/14/2018] [Accepted: 11/15/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND In 2016, countries agreed on a Fast-Track strategy to "end the AIDS epidemic by 2030". The treatment and prevention components of the Fast-Track strategy aim to markedly reduce new HIV infections, AIDS-related deaths and HIV-related discrimination. This study assesses the economic returns of this ambitious strategy. METHODS We estimated the incremental costs, benefits and economic returns of the Fast-Track scenario in low- and middle-income countries, compared to a counterfactual defined as maintaining coverage of HIV-related services at 2015 levels. The benefits are calculated using the full-income approach, which values both the changes in income and in mortality, and the productivity approach. FINDINGS The incremental costs of the Fast-Track scenario over the constant scenario for 2017-2030 represent US$86 billion or US$13.69 per capita. The full-income valuation of the incremental benefits of the decrease in mortality amounts to US$88.14 per capita, representing 6.44 times the resources invested for all countries. These returns on investment vary by region, with the largest return in the Asia-Pacific region, followed by Eastern and Southern Africa. Returns using the productivity approach are smaller but ranked similarly across regions. INTERPRETATION In all regions, the economic and social value of the additional life-years saved by the Fast-Track approach exceeds its incremental costs, implying that this strategy for ending the AIDS epidemic is a sound economic investment.
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10
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Maulsby C, Jain KM, Weir BW, Enobun B, Werner M, Riordan M, Holtgrave DR. Cost-Utility of Access to Care, a National HIV Linkage, Re-engagement and Retention in Care Program. AIDS Behav 2018; 22:3734-3741. [PMID: 29302844 DOI: 10.1007/s10461-017-2015-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Linkage to HIV medical care and on-going engagement in HIV medical care are vital for ending the HIV epidemic. However, little is known about the cost-utility of HIV linkage, re-engagement and retention (LRC) in care programs. This paper presents the cost-utility analysis of Access to Care, a national HIV LRC program. Using standard methods from the US Panel on Cost-Effectiveness in Health and Medicine, we calculated the cost-utility ratio. Seven Access to Care programs were cost-effective and two were cost-saving. This study adds to a small but growing body of evidence to support the cost-effectiveness of LRC programs.
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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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Zakumumpa H, Dube N, Damian RS, Rutebemberwa E. Understanding the dynamic interactions driving the sustainability of ART scale-up implementation in Uganda. Glob Health Res Policy 2018; 3:23. [PMID: 30123838 PMCID: PMC6091155 DOI: 10.1186/s41256-018-0079-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 07/16/2018] [Indexed: 01/01/2023] Open
Abstract
Background Despite increasing recognition that health-systems constraints are the fundamental barrier to attaining anti-retroviral therapy (ART) scale-up targets in Sub-Saharan Africa, current discourses are dominated by a focus on financial sustainability. Utilizing the health system dynamics framework, this study aimed to explore the interactions in health system components and their influence on the sustainability of ART scale-up implementation in Uganda. Methods This study entailed qualitative organizational case-studies within a two-phased mixed-methods sequential explanatory research design. In Phase One, a survey of 195 health facilities across Uganda which commenced ART services between 2004 and 2009 was conducted. In Phase Two, six health facilities were purposively selected for in-depth examination involving i) In-depth interviews (n = 44) ii) and semi-structured interviews (n = 35). Qualitative data was analyzed by coding and thematic analysis. Descriptive statistics were managed in STATA (v 13). Results Five dynamic interactions in ART program sustainability drivers were identified; i) Failure to update basic ART program records contributed to chronic ART medicines stock-outs ii) Health workforce shortages and escalating patient volumes prompted adaptations in ART service delivery models iii) Broader governance issues manifested in poor road networks undermined ART medicines supply chains iv) Sustained financing for ART programs was influenced by external donors v) The values associated with the ownership-type of a health facility affected ART service delivery and coverage. Conclusion The sustainability of ART programs at the facility-level in Uganda is a function of a complex interaction in elements of the health system and must be understood beyond sustaining international funding for ART scale-up.
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Affiliation(s)
- Henry Zakumumpa
- 1School of Public Health, Makerere University, Kampala, Uganda
| | - Nkosiyazi Dube
- 2School of Health and Community Development, University of the Witwatersrand, Johannesburg, South Africa
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Cunnama L, Abrams EJ, Myer L, Gachuhi A, Dlamini N, Hlophe T, Kikuvi J, Langwenya N, Mthethwa S, Mudonhi D, Nhlabatsi B, Nuwagaba-Biribonwoha H, Okello V, Sahabo R, Zerbe A, Sinanovic E. Cost and cost-effectiveness of transitioning to universal initiation of lifelong antiretroviral therapy for all HIV-positive pregnant and breastfeeding women in Swaziland. Trop Med Int Health 2018; 23:950-959. [PMID: 29956426 DOI: 10.1111/tmi.13121] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To assess the costs and cost-effectiveness of transitioning from antiretroviral therapy (ART) initiation based on CD4 cell count and WHO clinical staging ('Option A') to universal ART ('Option B+') for all HIV-infected pregnant and breastfeeding women in Swaziland. METHODS We measured the total costs of prevention of mother-to-child HIV transmission (PMTCT) service delivery at public sector facilities with empirical cost data collected at three points in time: once under Option A and again twice after transition to the Option B+ approach. The cost per woman treated per month includes recurrent costs (personnel, overheads, medication and diagnostic tests) and capital costs (buildings, furniture, start-up costs and training). Cost-effectiveness was estimated from the health services perspective as the cost per woman retained in care through 6 months postpartum. This analysis is nested within a larger stepped-wedge evaluation, which demonstrated a 26% increase in maternal retention after the transition to Option B+. RESULTS Across the five sites, the total cost for PMTCT during the study period (from August 2013 to October 2015, in 2015 US$) was $868,426 for Option B+ and $680 508 for Option A. The cost per woman treated per month was $183 for a woman on ART under Option B+, and $127 and $118 for a woman on ART and zidovudine (AZT), respectively, under Option A. The weighted average cost per woman treated on Option B+ was $826 compared to $525 under Option A. The main cost drivers were the start-up costs, additional training provided and staff time spent on PMTCT tasks for Option B+. The incremental cost-effectiveness ratio was estimated at $912 for every additional mother retained in care through six months postpartum. CONCLUSIONS The cost and cost-effectiveness outcomes from this study indicate that there is a robust economic case for pursuing the Option B+ approach in Swaziland and similar settings such as South Africa. Furthermore, these costs can be used to aid decision making and budgeting, for similar settings transitioning to test and treat strategy.
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Affiliation(s)
- L Cunnama
- Health Economics Unit, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - E J Abrams
- Mailman School of Public Health, ICAP at Columbia University, New York, NY, USA.,College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - L Myer
- Division of Epidemiology & Biostatistics, University of Cape Town, Cape Town, South Africa
| | - A Gachuhi
- Mailman School of Public Health, ICAP at Columbia University, New York, NY, USA
| | - N Dlamini
- ICAP at Columbia University, Mbabane, Swaziland
| | - T Hlophe
- Monitoring & Evaluation, Deputy Prime Minister's Office, Mbabane, Swaziland
| | - J Kikuvi
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
| | - N Langwenya
- Division of Epidemiology & Biostatistics, University of Cape Town, Cape Town, South Africa
| | - S Mthethwa
- Swaziland Ministry of Health, Mbabane, Swaziland
| | - D Mudonhi
- ICAP at Columbia University, Mbabane, Swaziland
| | - B Nhlabatsi
- Swaziland Ministry of Health, Mbabane, Swaziland
| | - H Nuwagaba-Biribonwoha
- Mailman School of Public Health, ICAP at Columbia University, New York, NY, USA.,ICAP at Columbia University, Mbabane, Swaziland
| | - V Okello
- Swaziland Ministry of Health, Mbabane, Swaziland
| | - R Sahabo
- Mailman School of Public Health, ICAP at Columbia University, New York, NY, USA.,ICAP at Columbia University, Mbabane, Swaziland
| | - A Zerbe
- Mailman School of Public Health, ICAP at Columbia University, New York, NY, USA
| | - E Sinanovic
- Health Economics Unit, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
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14
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Bautista-Arredondo S, Colchero MA, Amanze OO, La Hera-Fuentes G, Silverman-Retana O, Contreras-Loya D, Ashefor GA, Ogungbemi KM. Explaining the heterogeneity in average costs per HIV/AIDS patient in Nigeria: The role of supply-side and service delivery characteristics. PLoS One 2018; 13:e0194305. [PMID: 29718906 PMCID: PMC5931468 DOI: 10.1371/journal.pone.0194305] [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: 05/20/2017] [Accepted: 02/24/2018] [Indexed: 11/19/2022] Open
Abstract
Objective We estimated the average annual cost per patient of ART per facility (unit cost) in Nigeria, described the variation in costs across facilities, and identified factors associated with this variation. Methods We used facility-level data of 80 facilities in Nigeria, collected between December 2014 and May 2015. We estimated unit costs at each facility as the ratio of total costs (the sum of costs of staff, recurrent inputs and services, capital, training, laboratory tests, and antiretroviral and TB treatment drugs) divided by the annual number of patients. We applied linear regressions to estimate factors associated with ART cost per patient. Results The unit ART cost in Nigeria was $157 USD nationally and the facility-level mean was $231 USD. The study found a wide variability in unit costs across facilities. Variations in costs were explained by number of patients, level of care, task shifting (shifting tasks from doctors to less specialized staff, mainly nurses, to provide ART) and provider´s competence. The study illuminated the potentially important role that management practices can play in improving the efficiency of ART services. Conclusions Our study identifies characteristics of services associated with the most efficient implementation of ART services in Nigeria. These results will help design efficient program scale-up to deliver comprehensive HIV services in Nigeria by distinguishing features linked to lower unit costs.
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Affiliation(s)
- Sergio Bautista-Arredondo
- Center for Health Systems Research, Instituto Nacional de Salud Pública, Cuernavaca, Mexico
- UC, Berkeley. School of Public Health, Berkeley, California, United States of America
| | - M. Arantxa Colchero
- Center for Health Systems Research, Instituto Nacional de Salud Pública, Cuernavaca, Mexico
- * E-mail:
| | | | - Gina La Hera-Fuentes
- Center for Health Systems Research, Instituto Nacional de Salud Pública, Cuernavaca, Mexico
| | - Omar Silverman-Retana
- Center for Health Systems Research, Instituto Nacional de Salud Pública, Cuernavaca, Mexico
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - David Contreras-Loya
- Center for Health Systems Research, Instituto Nacional de Salud Pública, Cuernavaca, Mexico
- UC, Berkeley. School of Public Health, Berkeley, California, United States of America
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15
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Galárraga O, Wamai RG, Sosa-Rubí SG, Mugo MG, Contreras-Loya D, Bautista-Arredondo S, Nyakundi H, Wang’ombe JK. HIV prevention costs and their predictors: evidence from the ORPHEA Project in Kenya. Health Policy Plan 2017; 32:1407-1416. [PMID: 29029086 PMCID: PMC5886164 DOI: 10.1093/heapol/czx121] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2017] [Indexed: 01/14/2023] Open
Abstract
We estimate costs and their predictors for three HIV prevention interventions in Kenya: HIV testing and counselling (HTC), prevention of mother-to-child transmission (PMTCT) and voluntary medical male circumcision (VMMC). As part of the 'Optimizing the Response of Prevention: HIV Efficiency in Africa' (ORPHEA) project, we collected retrospective data from government and non-governmental health facilities for 2011-12. We used multi-stage sampling to determine a sample of health facilities by type, ownership, size and interventions offered totalling 144 sites in 78 health facilities in 33 districts across Kenya. Data sources included key informants, registers and time-motion observation methods. Total costs of production were computed using both quantity and unit price of each input. Average cost was estimated by dividing total cost per intervention by number of clients accessing the intervention. Multivariate regression methods were used to analyse predictors of log-transformed average costs. Average costs were $7 and $79 per HTC and PMTCT client tested, respectively; and $66 per VMMC procedure. Results show evidence of economies of scale for PMTCT and VMMC: increasing the number of clients per year by 100% was associated with cost reductions of 50% for PMTCT, and 45% for VMMC. Task shifting was associated with reduced costs for both PMTCT (59%) and VMMC (54%). Costs in hospitals were higher for PMTCT (56%) in comparison to non-hospitals. Facilities that performed testing based on risk factors as opposed to universal screening had higher HTC average costs (79%). Lower VMMC costs were associated with availability of male reproductive health services (59%) and presence of community advisory board (52%). Aside from increasing production scale, HIV prevention costs may be contained by using task shifting, non-hospital sites, service integration and community supervision.
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Affiliation(s)
- Omar Galárraga
- School of Public Health, Brown University, Providence, RI, USA
| | - Richard G Wamai
- Global Health Initiative, Northeastern University, Boston, MA, USA
| | - Sandra G Sosa-Rubí
- Health Economics Unit, Mexican Institute of Public Health, Cuernavaca, Mexico
| | - Mercy G Mugo
- Department of Economics, University of Nairobi, Nairobi, Kenya
| | - David Contreras-Loya
- School of Public Health, University of California at Berkeley, Berkeley, CA, USA and
| | | | - Helen Nyakundi
- School of Public Health, University of Nairobi, Nairobi, Kenya
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16
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Martin T, Mweene M. Late stage presentation of HIV-positive patients to antiretroviral outpatient clinic in Zambia. South Afr J HIV Med 2017; 18:717. [PMID: 29568637 PMCID: PMC5843034 DOI: 10.4102/sajhivmed.v18i1.717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 08/18/2017] [Indexed: 11/01/2022] Open
Abstract
Background The World Health Organization (WHO) and the Zambian Ministry of Health set out new guidelines on combination antiretroviral therapy (cART) in 2013 expanding the eligibility criteria for patients with HIV. Objectives The primary objective were to determine when cART was initiated in HIV-positive outpatients according to clinical and immunological criteria, and to identify what proportion of patients who were eligible for cART according to 2013 WHO and 2013 Zambian cART guidelines were currently on cART. Methodology This was a clinical audit of HIV-positive outpatients attending the cART clinic at Ndola Central Hospital in Ndola, Zambia, with retrospective cross-sectional chart review and survey design. Data were collected from clinical records and interviews with patients. Results A total of 99% of patients eligible for cART according to 2013 guidelines were on treatment. Clinical staging of patients at initiated on cART (n = 206) was as follows: 28% clinical stage I, 21% clinical stage II, 36% clinical stage III and 15% clinical stage IV. The median CD4 count when patients were started on cART was 147 cells/mm3. Conclusion The results show that a majority of patients were initiated on cART late in their disease course according to immunological (CD4 < 200 cell/mm3) and clinical criteria (stage III or IV). However, the vast majority of patients eligible for cART were currently on treatment. The late initiation of cART appears to be a result of late diagnosis of HIV.
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Affiliation(s)
- Timothy Martin
- The School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, United Kingdom
| | - Morgan Mweene
- Zambia Medical Association, Lusaka, Zambia.,Zambia College of Physicians, Zambia.,East Central and Southern Africa College of Physicians, Zambia.,International Society of Nephrology, Brussels, Belgium
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17
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Miyano S, Syakantu G, Komada K, Endo H, Sugishita T. Cost-effectiveness analysis of the national decentralization policy of antiretroviral treatment programme in Zambia. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2017; 15:4. [PMID: 28413361 PMCID: PMC5388995 DOI: 10.1186/s12962-017-0065-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 03/24/2017] [Indexed: 11/23/2022] Open
Abstract
Background In resource-limited settings with a high prevalence of human immunodeficiency virus (HIV) infection such as Zambia, decentralization of HIV/acquired immunodeficiency syndrome (HIV/AIDS) treatment and care with effective use of resources is a cornerstone of universal treatment and care. Objectives This research aims to analyse the cost effectiveness of the National Mobile Antiretroviral Therapy (ART) Services Programme in Zambia as a means of decentralizing ART services. Methods Cost-effectiveness analyses were performed using a decision analytic model and Markov model to compare the original ART programme, ‘Hospital-based ART’, with the intervention programme, Hospital-based plus ‘Mobile ART’, from the perspective of the district government health office in Zambia. The total cost of ART services, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) were examined. Results The mean annual per-patient costs were 1259.16 USD for the original programme and 2601.02 USD for the intervention programme, while the mean number of QALYs was 6.81 for the original and 7.27 for the intervention programme. The ICER of the intervention programme relative to the original programme was 2965.17 USD/QALY, which was much below the willingness-to-pay (WTP), or three times the GDP per capita (4224 USD), but still over the GDP per capita (1408 USD). In the sensitivity analysis, the ICER of the intervention programme did not substantially change. Conclusion The National Mobile ART Services Programme in Zambia could be a cost-effective approach to decentralizing ART services into rural areas in Zambia. This programme could be expanded to more districts where it has not yet been introduced to improve access to ART services and the health of people living with HIV (PLHIV) in rural areas. Electronic supplementary material The online version of this article (doi:10.1186/s12962-017-0065-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Shinsuke Miyano
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655 Japan
| | - Gardner Syakantu
- Department of Clinical Care and Diagnostic Services, Ministry of Health Zambia, Lusaka, Zambia
| | - Kenichi Komada
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655 Japan
| | - Hiroyoshi Endo
- Graduate School of Public Health, St. Luke's International University, Tokyo, Japan
| | - Tomohiko Sugishita
- Department of International Affairs and Tropical Medicine, Tokyo Women's University, Tokyo, Japan
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18
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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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Price JT, Wheeler SB, Stranix-Chibanda L, Hosek SG, Watts DH, Siberry GK, Spiegel HML, Stringer JS, Chi BH. Cost-Effectiveness of Pre-exposure HIV Prophylaxis During Pregnancy and Breastfeeding in Sub-Saharan Africa. J Acquir Immune Defic Syndr 2016; 72 Suppl 2:S145-53. [PMID: 27355502 PMCID: PMC5043081 DOI: 10.1097/qai.0000000000001063] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Antiretroviral pre-exposure prophylaxis (PrEP) for the prevention of HIV acquisition is cost-effective when delivered to those at substantial risk. Despite a high incidence of HIV infection among pregnant and breastfeeding women in sub-Saharan Africa (SSA), a theoretical increased risk of preterm birth on PrEP could outweigh the HIV prevention benefit. METHODS We developed a decision analytic model to evaluate a strategy of daily oral PrEP during pregnancy and breastfeeding in SSA. We approached the analysis from a health care system perspective across a lifetime time horizon. Model inputs were derived from existing literature and local sources. The incremental cost-effectiveness ratio (ICER) of PrEP versus no PrEP was calculated in 2015 U.S. dollars per disability-adjusted life year (DALY) averted. We evaluated the effect of uncertainty in baseline estimates through one-way and probabilistic sensitivity analyses. RESULTS PrEP administered to pregnant and breastfeeding women in SSA was cost-effective. In a base case of 10,000 women, the administration of PrEP averted 381 HIV infections but resulted in 779 more preterm births. PrEP was more costly per person ($450 versus $117), but resulted in fewer disability-adjusted life years (DALYs) (3.15 versus 3.49). The incremental cost-effectiveness ratio of $965/DALY averted was below the recommended regional threshold for cost-effectiveness of $6462/DALY. Probabilistic sensitivity analyses demonstrated robustness of the model. CONCLUSIONS Providing PrEP to pregnant and breastfeeding women in SSA is likely cost-effective, although more data are needed about adherence and safety. For populations at high risk of HIV acquisition, PrEP may be considered as part of a broader combination HIV prevention strategy.
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Affiliation(s)
- Joan T. Price
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, Chapel Hill, NC
| | - Stephanie B. Wheeler
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lynda Stranix-Chibanda
- Department of Pediatrics and Child Health, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Sybil G. Hosek
- Department of Psychiatry, John Stroger Hospital of Cook County, Chicago, IL
| | - D. Heather Watts
- Office of the Global AIDS Coordinator and Health Diplomacy, U.S. Department of State, Washington, DC
| | - George K. Siberry
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD; and
| | - Hans M. L. Spiegel
- Kelly Government Services, Contractor to Prevention Sciences Program, Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Jeffrey S. Stringer
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, Chapel Hill, NC
| | - Benjamin H. Chi
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, Chapel Hill, NC
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Orlando S, Diamond S, Palombi L, Sundaram M, Shear Zimmer L, Marazzi MC, Mancinelli S, Liotta G. Cost-Effectiveness and Quality of Care of a Comprehensive ART Program in Malawi. Medicine (Baltimore) 2016; 95:e3610. [PMID: 27227921 PMCID: PMC4902345 DOI: 10.1097/md.0000000000003610] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of this study is to assess the cost-effectiveness of a holistic, comprehensive human immunodeficiency virus (HIV) treatment Program in Malawi.Comprehensive cost data for the year 2010 have been collected at 30 facilities from the public network of health centers providing antiretroviral treatment (ART) throughout the country; two of these facilities were operated by the Disease Relief through Excellent and Advanced Means (DREAM) program.The outcomes analysis was carried out over five years comparing two cohorts of patients on treatment: 1) 2387 patients who started ART in the two DREAM centers during 2008, 2) patients who started ART in Malawi in the same year under the Ministry of Health program.Assuming the 2010 cost as constant over the five years the cost-effective analysis was undertaken from a health sector and national perspective; a sensitivity analysis included two hypothesis of ART impact on patients' income.The total cost per patient per year (PPPY) was $314.5 for the DREAM protocol and $188.8 for the other Malawi ART sites, with 737 disability adjusted life years (DALY) saved among the DREAM program patients compared with the others. The Incremental Cost-Effectiveness Ratio was $1640 per DALY saved; it ranged between $896-1268 for national and health sector perspective respectively. The cost per DALY saved remained under $2154 that is the AFR-E-WHO regional gross domestic product per capita threshold for a program to be considered very cost-effective.HIV/acquired immune deficiency syndrome comprehensive treatment program that joins ART with laboratory monitoring, treatment adherence reinforcing and Malnutrition control can be very cost-effective in the sub-Saharan African setting.
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Affiliation(s)
- Stefano Orlando
- From the Dream programme - Community of Sant'Egidio (SO), Clinton Health Access Initiative (SD, LSZ), Department of Public Health, University of Tor Vergata, Rome, Italy (LP, SM, GL), Bill and Melinda Gates Foundation (MS), and LUMSA University, Rome, Italy (MCM)
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Jain KM, Maulsby C, Brantley M, Kim JJ, Zulliger R, Riordan M, Charles V, Holtgrave DR. Cost and cost threshold analyses for 12 innovative US HIV linkage and retention in care programs. AIDS Care 2016; 28:1199-204. [PMID: 27017972 DOI: 10.1080/09540121.2016.1164294] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Out of >1,000,000 people living with HIV in the USA, an estimated 60% were not adequately engaged in medical care in 2011. In response, AIDS United spearheaded 12 HIV linkage and retention in care programs. These programs were supported by the Social Innovation Fund, a White House initiative. Each program reflected the needs of its local population living with HIV. Economic analyses of such programs, such as cost and cost threshold analyses, provide important information for policy-makers and others allocating resources or planning programs. Implementation costs were examined from societal and payer perspectives. This paper presents the results of cost threshold analyses, which provide an estimated number of HIV transmissions that would have to be averted for each program to be considered cost-saving and cost-effective. The methods were adapted from the US Panel on Cost-effectiveness in Health and Medicine. Per client program costs ranged from $1109.45 to $7602.54 from a societal perspective. The cost-saving thresholds ranged from 0.32 to 1.19 infections averted, and the cost-effectiveness thresholds ranged from 0.11 to 0.43 infections averted by the programs. These results suggest that such programs are a sound and efficient investment towards supporting goals set by US HIV policy-makers. Cost-utility data are pending.
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Affiliation(s)
- Kriti M Jain
- a Department of Health, Behavior, and Society , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Catherine Maulsby
- a Department of Health, Behavior, and Society , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Meredith Brantley
- a Department of Health, Behavior, and Society , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | | | - Jeeyon Janet Kim
- a Department of Health, Behavior, and Society , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Rose Zulliger
- a Department of Health, Behavior, and Society , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | | | | | - David R Holtgrave
- a Department of Health, Behavior, and Society , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
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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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The HIV Treatment Gap: Estimates of the Financial Resources Needed versus Available for Scale-Up of Antiretroviral Therapy in 97 Countries from 2015 to 2020. PLoS Med 2015; 12:e1001907; discussion e1001907. [PMID: 26599990 PMCID: PMC4658189 DOI: 10.1371/journal.pmed.1001907] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 10/16/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) released revised guidelines in 2015 recommending that all people living with HIV, regardless of CD4 count, initiate antiretroviral therapy (ART) upon diagnosis. However, few studies have projected the global resources needed for rapid scale-up of ART. Under the Health Policy Project, we conducted modeling analyses for 97 countries to estimate eligibility for and numbers on ART from 2015 to 2020, along with the facility-level financial resources required. We compared the estimated financial requirements to estimated funding available. METHODS AND FINDINGS Current coverage levels and future need for treatment were based on country-specific epidemiological and demographic data. Simulated annual numbers of individuals on treatment were derived from three scenarios: (1) continuation of countries' current policies of eligibility for ART, (2) universal adoption of aspects of the WHO 2013 eligibility guidelines, and (3) expanded eligibility as per the WHO 2015 guidelines and meeting the Joint United Nations Programme on HIV/AIDS "90-90-90" ART targets. We modeled uncertainty in the annual resource requirements for antiretroviral drugs, laboratory tests, and facility-level personnel and overhead. We estimate that 25.7 (95% CI 25.5, 26.0) million adults and 1.57 (95% CI 1.55, 1.60) million children could receive ART by 2020 if countries maintain current eligibility plans and increase coverage based on historical rates, which may be ambitious. If countries uniformly adopt aspects of the WHO 2013 guidelines, 26.5 (95% CI 26.0 27.0) million adults and 1.53 (95% CI 1.52, 1.55) million children could be on ART by 2020. Under the 90-90-90 scenario, 30.4 (95% CI 30.1, 30.7) million adults and 1.68 (95% CI 1.63, 1.73) million children could receive treatment by 2020. The facility-level financial resources needed for scaling up ART in these countries from 2015 to 2020 are estimated to be US$45.8 (95% CI 45.4, 46.2) billion under the current scenario, US$48.7 (95% CI 47.8, 49.6) billion under the WHO 2013 scenario, and US$52.5 (95% CI 51.4, 53.6) billion under the 90-90-90 scenario. After projecting recent external and domestic funding trends, the estimated 6-y financing gap ranges from US$19.8 billion to US$25.0 billion, depending on the costing scenario and the U.S. President's Emergency Plan for AIDS Relief contribution level, with the gap for ART commodities alone ranging from US$14.0 to US$16.8 billion. The study is limited by excluding above-facility and other costs essential to ART service delivery and by the availability and quality of country- and region-specific data. CONCLUSIONS The projected number of people receiving ART across three scenarios suggests that countries are unlikely to meet the 90-90-90 treatment target (81% of people living with HIV on ART by 2020) unless they adopt a test-and-offer approach and increase ART coverage. Our results suggest that future resource needs for ART scale-up are smaller than stated elsewhere but still significantly threaten the sustainability of the global HIV response without additional resource mobilization from domestic or innovative financing sources or efficiency gains. As the world moves towards adopting the WHO 2015 guidelines, advances in technology, including the introduction of lower-cost, highly effective antiretroviral regimens, whose value are assessed here, may prove to be "game changers" that allow more people to be on ART with the resources available.
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The HIV cure research agenda: the role of mathematical modelling and cost-effectiveness analysis. J Virus Erad 2015. [DOI: 10.1016/s2055-6640(20)30929-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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Freedberg KA, Possas C, Deeks S, Ross AL, Rosettie KL, Di Mascio M, Collins C, Walensky RP, Yazdanpanah Y. The HIV Cure Research Agenda: The Role of Mathematical Modelling and Cost-Effectiveness Analysis. J Virus Erad 2015; 1:245-249. [PMID: 26878073 PMCID: PMC4748959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The research agenda towards an HIV cure is building rapidly. In this article, we discuss the reasons for and methodological approach to using mathematical modeling and cost-effectiveness analysis in this agenda. We provide a brief description of the proof of concept for cure and the current directions of cure research. We then review the types of clinical economic evaluations, including cost analysis, cost-benefit analysis, and cost-effectiveness analysis. We describe the use of mathematical modeling and cost-effectiveness analysis early in the HIV epidemic as well as in the era of combination antiretroviral therapy. We then highlight the novel methodology of Value of Information analysis and its potential role in the planning of clinical trials. We close with recommendations for modeling and cost-effectiveness analysis in the HIV cure agenda.
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Affiliation(s)
- Kenneth A Freedberg
- Corresponding author: Kenneth A Freedberg,
Medical Practice Evaluation Center,
Massachusetts General Hospital,
50 Staniford Street, Suite 901,
Boston,
MA02114,
USA
| | - Cristina Possas
- Oswaldo Cruz Foundation, Evandro Chagas National Institute of Infectious Diseases and Bio-Manguinhos,
Rio de Janeiro,
Brazil
| | | | - Anna Laura Ross
- International and Scientific Relations Office, ANRS,
Paris,
France
- International AIDS Society,
Geneva,
Switzerland
| | - Katherine L Rosettie
- Divisions of General Internal Medicine and Infectious Disease,
Massachusetts General Hospital
- Medical Practice Evaluation Center, Department of Medicine,
Massachusetts General Hospital
| | - Michele Di Mascio
- Division of Clinical Research,
National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services,
Bethesda,
MD,
USA
| | - Chris Collins
- Community Mobilization Division,
Joint United Nations Programme on HIV/AIDS (UNAIDS),
Geneva,
Switzerland
| | - Rochelle P Walensky
- Division of Infectious Disease,
Brigham and Women's Hospital,
Boston,
MA,
USA
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Cost-effectiveness analysis along the continuum of HIV care: how can we optimize the effect of HIV treatment as prevention programs? Curr HIV/AIDS Rep 2015; 11:468-78. [PMID: 25173799 DOI: 10.1007/s11904-014-0227-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The cascade of HIV care has been proposed as a useful tool to monitor health system performance across the key stages of HIV care delivery to reduce morbidity, mortality, and HIV transmission, the focal points of HIV Treatment as Prevention campaigns. Interventions to improve the cascade at its various stages may vary substantially in their ability to deliver health value per amount expended. In order to meet global antiretroviral treatment access targets, there is an urgent need to maximize the value of health spending by prioritizing cost-effective interventions. We executed a literature review on economic evaluations of interventions to improve specific stages of the cascade of HIV care. In total, 33 articles met the criteria for inclusion in the review, 22 (67 %) of which were published within the last 5 years. Nonetheless, substantial gaps in our knowledge remain, particularly for interventions to improve linkage and retention in HIV care in developed and developing-world settings and generalized and concentrated epidemics. We make the case here that the attention of scientists and policymakers needs to turn to the development, implementation, and rigorous evaluation of interventions to improve the various stages of the cascade of HIV care.
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Verguet S, Kahn JG, Marseille E, Jiwani A, Kern E, Walson JL. Are long-lasting insecticide-treated bednets and water filters cost-effective tools for delaying HIV disease progression in Kenya? Glob Health Action 2015; 8:27695. [PMID: 26065636 PMCID: PMC4463495 DOI: 10.3402/gha.v8.27695] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 05/06/2015] [Accepted: 05/07/2015] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Co-infection with malaria and other infectious diseases has been shown to increase viral load and accelerate HIV disease progression. A recent study in Kenya demonstrated that providing long-lasting insecticide-treated bednets (LLIN) and water filters (WF) to HIV-positive adults with CD4 >350 cells/mm(3) significantly reduced HIV progression. DESIGN We conducted a cost analysis to estimate the potential net financial savings gained by delaying HIV progression and increasing the time to antiretroviral therapy (ART) eligibility through delivering LLIN and WF to 10% of HIV-positive adults with CD4 >350 cells/mm(3) in Kenya. RESULTS Given a 3-year duration of intervention benefit, intervention unit cost of US$32 and patient-year ART cost of US$757 (2011 US$), over the lifetime of ART patients, in Kenya, we estimated the intervention could yield a return on investment (ROI) of 11 (95% uncertainty range [UR]: 5-23), based on a cost of about US$2 million and savings in ART costs of about US$26 million (95% UR: 8-50) (discounted at 3%). Our findings were subjected to a number of sensitivity analyses. Of note, deferral of time to ART eligibility could potentially result in 3,000 new HIV infections not averted by ART and thus decrease ART cost savings to US$14 million, decreasing the ROI to 6. CONCLUSIONS Provision of LLIN and WF could be a cost-saving and practical method to defer time to ART eligibility in the context of highly resource-constrained environments experiencing donor fatigue for HIV/AIDS programs.
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Affiliation(s)
- Stéphane Verguet
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA;
| | - James G Kahn
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
- Global Health Sciences, University of California, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | | | - Aliya Jiwani
- Health Strategies International, Arlington, VA, USA
| | - Eli Kern
- Assessment, Policy Development & Evaluation, Public Health-Seattle & King County, WA, USA
| | - Judd L Walson
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
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Mfinanga S, Chanda D, Kivuyo SL, Guinness L, Bottomley C, Simms V, Chijoka C, Masasi A, Kimaro G, Ngowi B, Kahwa A, Mwaba P, Harrison TS, Egwaga S, Jaffar S. Cryptococcal meningitis screening and community-based early adherence support in people with advanced HIV infection starting antiretroviral therapy in Tanzania and Zambia: an open-label, randomised controlled trial. Lancet 2015; 385:2173-82. [PMID: 25765698 DOI: 10.1016/s0140-6736(15)60164-7] [Citation(s) in RCA: 179] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Mortality in people in Africa with HIV infection starting antiretroviral therapy (ART) is high, particularly in those with advanced disease. We assessed the effect of a short period of community support to supplement clinic-based services combined with serum cryptococcal antigen screening. METHODS We did an open-label, randomised controlled trial in six urban clinics in Dar es Salaam, Tanzania, and Lusaka, Zambia. From February, 2012, we enrolled eligible individuals with HIV infection (age ≥18 years, CD4 count of <200 cells per μL, ART naive) and randomly assigned them to either the standard clinic-based care supplemented with community support or standard clinic-based care alone, stratified by country and clinic, in permuted block sizes of ten. Clinic plus community support consisted of screening for serum cryptococcal antigen combined with antifungal therapy for patients testing antigen positive, weekly home visits for the first 4 weeks on ART by lay workers to provide support, and in Tanzania alone, re-screening for tuberculosis at 6-8 weeks after ART initiation. The primary endpoint was all-cause mortality at 12 months, analysed by intention to treat. This trial is registered with the International Standard Randomised Controlled Trial Number registry, number ISCRTN 20410413. FINDINGS Between Feb 9, 2012, and Sept 30, 2013, 1001 patients were randomly assigned to clinic plus community support and 998 to standard care. 89 (9%) of 1001 participants in the clinic plus community support group did not receive their assigned intervention, and 11 (1%) of 998 participants in the standard care group received a home visit or a cryptococcal antigen screen rather than only standard care. At 12 months, 25 (2%) of 1001 participants in the clinic plus community support group and 24 (2%) of 998 participants in the standard care group had been lost to follow-up, and were censored at their last visit for the primary analysis. At 12 months, 134 (13%) of 1001 participants in the clinic plus community support group had died compared with 180 (18%) of 998 in the standard care group. Mortality was 28% (95% CI 10-43) lower in the clinic plus community support group than in standard care group (p=0·004). INTERPRETATION Screening and pre-emptive treatment for cryptococcal infection combined with a short initial period of adherence support after initiation of ART could substantially reduce mortality in HIV programmes in Africa. FUNDING European and Developing Countries Clinical Trials Partnership.
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Affiliation(s)
- Sayoki Mfinanga
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - Duncan Chanda
- Institute for Medical Research and Training, University Teaching Hospital, Lusaka, Zambia
| | - Sokoine L Kivuyo
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - Lorna Guinness
- Faculty of Public Health Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Christian Bottomley
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Victoria Simms
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Carol Chijoka
- Institute for Medical Research and Training, University Teaching Hospital, Lusaka, Zambia
| | - Ayubu Masasi
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - Godfather Kimaro
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - Bernard Ngowi
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - Amos Kahwa
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - Peter Mwaba
- Institute for Medical Research and Training, University Teaching Hospital, Lusaka, Zambia
| | - Thomas S Harrison
- Institute for Infection and Immunity, St Georges University of London, London, UK
| | - Saidi Egwaga
- National Tuberculosis and Leprosy Control Program, Ministry of Health and Socio-Welfare, Dar es Salaam, Tanzania
| | - Shabbar Jaffar
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.
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Zhang L, Phanuphak N, Henderson K, Nonenoy S, Srikaew S, Shattock AJ, Kerr CC, Omune B, van Griensven F, Osornprasop S, Oelrichs R, Ananworanich J, Wilson DP. Scaling up of HIV treatment for men who have sex with men in Bangkok: a modelling and costing study. Lancet HIV 2015; 2:e200-7. [PMID: 26423002 DOI: 10.1016/s2352-3018(15)00020-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 02/03/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite the high prevalence of HIV in men who have sex with men (MSM) in Bangkok, little investment in HIV prevention for MSM has been made. HIV testing and treatment coverage remains low. Through a pragmatic programme-planning approach, we assess possible service linkage and provision of HIV testing and antiretroviral treatment (ART) to MSM in Bangkok, and the most cost-effective scale-up strategy. METHODS We obtained epidemiological and service capacity data from the Thai National Health Security Office database for 2011. We surveyed 13 representative medical facilities for detailed operational costs of HIV-related services for sexually active MSM (defined as having sex with men in the past 12 months) in metropolitan Bangkok. We estimated the costs of various ART scale-up scenarios, accounting for geographical accessibility across Bangkok. We used an HIV transmission population-based model to assess the cost-effectiveness of the scenarios. FINDINGS For present HIV testing (23% [95% CI 17-36] of MSM at high risk in 2011) and ART provision (20% of treatment-eligible MSM at high risk on ART in 2011) to be sustained, a US$73·8 million ($51·0 million to $97·0 million) investment during the next decade would be needed, which would link an extra 43,000 (27,900-58,000) MSM at high risk to HIV testing and 5100 (3500-6700) to ART, achieving an ART coverage of 44% for MSM at high risk in 2022. An additional $55·3 million investment would link an extra 46,700 (30,300-63,200) MSM to HIV testing and 12,600 (8800-16,600) to ART, achieving universal ART coverage of this population by 2022. This increased investment is achievable within present infrastructure capacity. Consequently, an estimated 5100 (3600-6700) HIV-related deaths and 3700 (2600-4900) new infections could be averted in MSM by 2022, corresponding to a 53% reduction in deaths and a 35% reduction in infections from 2012 levels. The expansion would cost an estimated $10,809 (9071-13,274) for each HIV-related death, $14,783 (12,389-17,960) per new infection averted, and $351 (290-424) per disability-adjusted life-year averted. INTERPRETATION Spare capacity in Bangkok's medical facilities can be used to expand ART access for MSM with large epidemiological benefits. The expansion needs increased funding directed to MSM services, but given the epidemiological trends, is probably cost effective. Our modelling approach and outcomes are likely to be applicable to other settings. FUNDING World Bank Group and Australian National Health and Medical Research Council.
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Affiliation(s)
- Lei Zhang
- The Kirby Institute, University of New South Wales, Kensington, NSW, Australia
| | | | - Klara Henderson
- The Kirby Institute, University of New South Wales, Kensington, NSW, Australia
| | | | - Sasiwan Srikaew
- Thai Red Cross Society AIDS Research Centre, Bangkok, Thailand
| | - Andrew J Shattock
- The Kirby Institute, University of New South Wales, Kensington, NSW, Australia
| | - Cliff C Kerr
- The Kirby Institute, University of New South Wales, Kensington, NSW, Australia
| | - Brenda Omune
- Thai Red Cross Society AIDS Research Centre, Bangkok, Thailand
| | | | | | | | - Jintanat Ananworanich
- Thai Red Cross Society AIDS Research Centre, Bangkok, Thailand; US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA; Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - David P Wilson
- The Kirby Institute, University of New South Wales, Kensington, NSW, Australia.
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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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Wilson D, Taaffe J, Fraser-Hurt N, Gorgens M. The economics, financing and implementation of HIV treatment as prevention: what will it take to get there? AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2015; 13:109-19. [PMID: 25174628 DOI: 10.2989/16085906.2014.943254] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The 2013 Lancet Commission Report, Global Health 2035, rightly pointed out that we are at a unique place in history where a "grand convergence" of health initiatives to reduce both infectious diseases, and child and maternal mortality--diseases that still plague low income countries--would yield good returns in terms of development and health outcomes. This would also be a good economic investment. Such investments would support achieving health goals of reducing under-five (U5) mortality to 16 per 1000 live births, reducing deaths due to HIV/AIDS to 8 per 100,000 population, and reducing annual TB deaths to 4 per 100,000 population. Treatment as prevention (TasP) holds enormous potential in reducing HIV transmission, and morbidity and mortality associated with HIV/AIDS--and therefore contributing to Global Health 2035 goals. However, TasP requires large financial investments and poses significant implementation challenges. In this review, we discuss the potential effectiveness, financing and implementation of TasP. Overall, we conclude that TasP shows great promise as a cost-effective intervention to address the dual aims of reducing new HIV infections and reducing the global burden of HIV-related disease. Successful implementation will be no easy feat, though. The dramatic increases in the numbers of persons who need antiretroviral therapy (ART) under a TasP approach will pose enormous challenges at all stages of the HIV treatment cascade: HIV diagnosis, antiretroviral (ARV) initiation, ARV adherence and retention, and increased drug resistance with long-term enrolment on ART. Overcoming these implementation challenges will require targeted implementation, not focusing exclusively on TasP, most-at-risk population (MARP)-friendly services for key populations, integrating services, task shifting, more efficient programme management, balancing supply and demand, integration into universal health coverage efforts, demand creation, improved ART retention and adherence strategies, the use of incentives to improve HIV treatment outcomes and reduce unit costs, continued operational research and tapping into technological innovations.
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Marseille E, Larson B, Kazi DS, Kahn JG, Rosen S. Thresholds for the cost-effectiveness of interventions: alternative approaches. Bull World Health Organ 2014; 93:118-24. [PMID: 25883405 PMCID: PMC4339959 DOI: 10.2471/blt.14.138206] [Citation(s) in RCA: 560] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 10/27/2014] [Accepted: 11/26/2014] [Indexed: 12/22/2022] Open
Abstract
Many countries use the cost-effectiveness thresholds recommended by the World Health Organization's Choosing Interventions that are Cost-Effective project (WHO-CHOICE) when evaluating health interventions. This project sets the threshold for cost-effectiveness as the cost of the intervention per disability-adjusted life-year (DALY) averted less than three times the country's annual gross domestic product (GDP) per capita. Highly cost-effective interventions are defined as meeting a threshold per DALY averted of once the annual GDP per capita. We argue that reliance on these thresholds reduces the value of cost-effectiveness analyses and makes such analyses too blunt to be useful for most decision-making in the field of public health. Use of these thresholds has little theoretical justification, skirts the difficult but necessary ranking of the relative values of locally-applicable interventions and omits any consideration of what is truly affordable. The WHO-CHOICE thresholds set such a low bar for cost-effectiveness that very few interventions with evidence of efficacy can be ruled out. The thresholds have little value in assessing the trade-offs that decision-makers must confront. We present alternative approaches for applying cost-effectiveness criteria to choices in the allocation of health-care resources.
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Affiliation(s)
- Elliot Marseille
- Health Strategies International, 555 Fifty-ninth Street, Oakland, California, 94609, United States of America (USA)
| | - Bruce Larson
- Center for Global Health and Development, Boston University, Boston, USA
| | - Dhruv S Kazi
- Division of Cardiology, San Francisco General Hospital, San Francisco, USA
| | - James G Kahn
- Institute for Health Policy Studies, University of California - San Francisco, San Francisco, USA
| | - Sydney Rosen
- Center for Global Health and Development, Boston University, Boston, USA
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Tagar E, Sundaram M, Condliffe K, Matatiyo B, Chimbwandira F, Chilima B, Mwanamanga R, Moyo C, Chitah BM, Nyemazi JP, Assefa Y, Pillay Y, Mayer S, Shear L, Dain M, Hurley R, Kumar R, McCarthy T, Batra P, Gwinnell D, Diamond S, Over M. Multi-country analysis of treatment costs for HIV/AIDS (MATCH): facility-level ART unit cost analysis in Ethiopia, Malawi, Rwanda, South Africa and Zambia. PLoS One 2014; 9:e108304. [PMID: 25389777 PMCID: PMC4229087 DOI: 10.1371/journal.pone.0108304] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 08/27/2014] [Indexed: 11/30/2022] Open
Abstract
Background Today's uncertain HIV funding landscape threatens to slow progress towards treatment goals. Understanding the costs of antiretroviral therapy (ART) will be essential for governments to make informed policy decisions about the pace of scale-up under the 2013 WHO HIV Treatment Guidelines, which increase the number of people eligible for treatment from 17.6 million to 28.6 million. The study presented here is one of the largest of its kind and the first to describe the facility-level cost of ART in a random sample of facilities in Ethiopia, Malawi, Rwanda, South Africa and Zambia. Methods & Findings In 2010–2011, comprehensive data on one year of facility-level ART costs and patient outcomes were collected from 161 facilities, selected using stratified random sampling. Overall, facility-level ART costs were significantly lower than expected in four of the five countries, with a simple average of $208 per patient-year (ppy) across Ethiopia, Malawi, Rwanda and Zambia. Costs were higher in South Africa, at $682 ppy. This included medications, laboratory services, direct and indirect personnel, patient support, equipment and administrative services. Facilities demonstrated the ability to retain patients alive and on treatment at these costs, although outcomes for established patients (2–8% annual loss to follow-up or death) were better than outcomes for new patients in their first year of ART (77–95% alive and on treatment). Conclusions This study illustrated that the facility-level costs of ART are lower than previously understood in these five countries. While limitations must be considered, and costs will vary across countries, this suggests that expanded treatment coverage may be affordable. Further research is needed to understand investment costs of treatment scale-up, non-facility costs and opportunities for more efficient resource allocation.
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Affiliation(s)
- Elya Tagar
- HIV, TB and Health Financing, Clinton Health Access Initiative, Boston, Massachusetts, United States of America
- * E-mail:
| | - Maaya Sundaram
- HIV, TB and Health Financing, Clinton Health Access Initiative, Boston, Massachusetts, United States of America
| | - Kate Condliffe
- HIV, TB and Health Financing, Clinton Health Access Initiative, Boston, Massachusetts, United States of America
| | - Blackson Matatiyo
- Planning, Monitoring, Evaluation and Research, National AIDS Commission, Lilongwe, Malawi
| | | | - Ben Chilima
- Community Health Sciences Unit, Ministry of Health, Lilongwe, Malawi
| | - Robert Mwanamanga
- Department of Planning and Policy Development, Ministry of Health, Lilongwe, Malawi
| | - Crispin Moyo
- National ART Program, Ministry of Health, Lusaka, Zambia
| | | | - Jean Pierre Nyemazi
- Planning, Monitoring and Evaluation Division, Ministry of Health, Kigali, Rwanda
| | - Yibeltal Assefa
- Planning, Monitoring and Evaluation Directorate, Federal HIV/AIDS Prevention and Control Office, Addis Ababa, Ethiopia
| | - Yogan Pillay
- HIV/AIDS, TB and MCWH, National Department of Health, Pretoria, South Africa
| | - Sam Mayer
- HIV, TB and Health Financing, Clinton Health Access Initiative, Boston, Massachusetts, United States of America
| | - Lauren Shear
- HIV, TB and Health Financing, Clinton Health Access Initiative, Lilongwe, Malawi
| | - Mary Dain
- HIV, TB and Health Financing, Clinton Health Access Initiative, Kigali, Rwanda
| | - Raphael Hurley
- HIV, TB and Health Financing, Clinton Health Access Initiative, Addis Ababa, Ethiopia
| | - Ritu Kumar
- HIV, TB and Health Financing, Clinton Health Access Initiative, Lusaka, Zambia
| | - Thomas McCarthy
- HIV, TB and Health Financing, Clinton Health Access Initiative, Pretoria, South Africa
| | - Parul Batra
- HIV, TB and Health Financing, Clinton Health Access Initiative, Boston, Massachusetts, United States of America
| | - Dan Gwinnell
- HIV, TB and Health Financing, Clinton Health Access Initiative, Boston, Massachusetts, United States of America
| | - Samantha Diamond
- HIV, TB and Health Financing, Clinton Health Access Initiative, Boston, Massachusetts, United States of America
| | - Mead Over
- Center for Global Development, Washington, District of Columbia, United States of America
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Marseille E, Kahn JG. Avahan and the cost-effectiveness of "prevention as prevention". LANCET GLOBAL HEALTH 2014; 2:e493-e494. [PMID: 25304404 DOI: 10.1016/s2214-109x(14)70295-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | - James G Kahn
- Institute for Health Policy Studies and Global Health Sciences, University of California San Francisco, San Francisco, CA 94143, USA.
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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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Koethe JR, Marseille E, Giganti MJ, Chi BH, Heimburger D, Stringer JS. Estimating the cost-effectiveness of nutrition supplementation for malnourished, HIV-infected adults starting antiretroviral therapy in a resource-constrained setting. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2014; 12:10. [PMID: 24839400 PMCID: PMC4024113 DOI: 10.1186/1478-7547-12-10] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 04/17/2014] [Indexed: 11/18/2022] Open
Abstract
Background Low body mass index (BMI) individuals starting antiretroviral therapy (ART) for HIV infection in sub-Saharan Africa have high rates of death and loss to follow-up in the first 6 months of treatment. Nutritional supplementation may improve health outcomes in this population, but the anticipated benefit of any intervention should be commensurate with the cost given resource limitations and the need to expand access to ART in the region. Methods We used Markov models incorporating historical data and program-wide estimates of treatment costs and health benefits from the Zambian national ART program to estimate the improvements in 6-month survival and program retention among malnourished adults necessary for a combined nutrition support and ART treatment program to maintain cost-effectiveness parity with ART treatment alone. Patients were stratified according to World Health Organization criteria for severe (BMI <16.0 kg/m2), moderate (16.00-16.99 kg/m2), and mild (17.00-18.49 kg/m2) malnutrition categories. Results 19,247 patients contributed data between May 2004 and October 2010. Quarterly survival and retention were lowest in the BMI <16.0 kg/m2 category compared to higher BMI levels, and there was less variation in both measures across BMI strata after 180 days. ART treatment was estimated to cost $556 per year and averted 7.3 disability-adjusted life years. To maintain cost-effectiveness parity with ART alone, a supplement needed to cost $10.99 per quarter and confer a 20% reduction in both 6-month mortality and loss to follow-up among BMI <16.0 kg/m2 patients. Among BMI 17.00-18.49 kg/m2 patients, supplement costs accompanying a 20% reduction in mortality and loss to follow-up could not exceed $5.18 per quarter. In sensitivity analyses, the maximum permitted supplement cost increased if the ART program cost rose, and fell if patients classified as lost to follow-up at 6 months subsequently returned to care. Conclusions Low BMI adults starting ART in sub-Saharan Africa are at high risk of early mortality and loss to follow-up. The expense of providing nutrition supplementation would require only modest improvements in survival and program retention to be cost-effective for the most severely malnourished individuals starting ART, but interventions are unlikely to be cost-effective among those in higher BMI strata.
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Affiliation(s)
- John R Koethe
- Centre for Infectious Diseases Research in Zambia, Plot 5032 Great North Road, Lusaka, Zambia ; Division of Infectious Diseases, Vanderbilt University School of Medicine, 215 Light Hall, Nashville, TN 37232, USA
| | - Elliot Marseille
- Health Strategies International, 555 59th Street, Oakland, CA 94609, USA
| | - Mark J Giganti
- Centre for Infectious Diseases Research in Zambia, Plot 5032 Great North Road, Lusaka, Zambia ; Department of Biostatistics, Vanderbilt University School of Medicine, 215 Light Hall, Nashville, TN 37232, USA
| | - Benjamin H Chi
- Centre for Infectious Diseases Research in Zambia, Plot 5032 Great North Road, Lusaka, Zambia ; Department of Obstetrics and Gynecology, UNC Global Women's Health, University of North Carolina at Chapel Hill School of Medicine, 3009 Old Clinic Building CB #7570, Chapel Hill, NC 27599-7570, USA
| | - Douglas Heimburger
- Centre for Infectious Diseases Research in Zambia, Plot 5032 Great North Road, Lusaka, Zambia ; Vanderbilt Institute for Global Health, 2525 West End Ave., Nashville, TN 37203, USA
| | - Jeffrey S Stringer
- Centre for Infectious Diseases Research in Zambia, Plot 5032 Great North Road, Lusaka, Zambia ; Department of Obstetrics and Gynecology, UNC Global Women's Health, University of North Carolina at Chapel Hill School of Medicine, 3009 Old Clinic Building CB #7570, Chapel Hill, NC 27599-7570, USA
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Scott CA, Iyer HS, McCoy K, Moyo C, Long L, Larson BA, Rosen S. Retention in care, resource utilization, and costs for adults receiving antiretroviral therapy in Zambia: a retrospective cohort study. BMC Public Health 2014; 14:296. [PMID: 24684772 PMCID: PMC3995515 DOI: 10.1186/1471-2458-14-296] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 03/14/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Of the estimated 800,000 adults living with HIV in Zambia in 2011, roughly half were receiving antiretroviral therapy (ART). As treatment scale up continues, information on the care provided to patients after initiating ART can help guide decision-making. We estimated retention in care, the quantity of resources utilized, and costs for a retrospective cohort of adults initiating ART under routine clinical conditions in Zambia. METHODS Data on resource utilization (antiretroviral [ARV] and non-ARV drugs, laboratory tests, outpatient clinic visits, and fixed resources) and retention in care were extracted from medical records for 846 patients who initiated ART at ≥15 years of age at six treatment sites between July 2007 and October 2008. Unit costs were estimated from the provider's perspective using site- and country-level data and are reported in 2011 USD. RESULTS Patients initiated ART at a median CD4 cell count of 145 cells/μL. Fifty-nine percent of patients initiated on a tenofovir-containing regimen, ranging from 15% to 86% depending on site. One year after ART initiation, 75% of patients were retained in care. The average cost per patient retained in care one year after ART initiation was $243 (95% CI, $194-$293), ranging from $184 (95% CI, $172-$195) to $304 (95% CI, $290-$319) depending on site. Patients retained in care one year after ART initiation received, on average, 11.4 months' worth of ARV drugs, 1.5 CD4 tests, 1.3 blood chemistry tests, 1.4 full blood count tests, and 6.5 clinic visits with a doctor or clinical officer. At all sites, ARV drugs were the largest cost component, ranging from 38% to 84% of total costs, depending on site. CONCLUSIONS Patients initiate ART late in the course of disease progression and a large proportion drop out of care after initiation. The quantity of resources utilized and costs vary widely by site, and patients utilize a different mix of resources under routine clinical conditions than if they were receiving fully guideline-concordant care. Improving retention in care and guideline concordance, including increasing the use of tenofovir in first-line ART regimens, may lead to increases in overall treatment costs.
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Affiliation(s)
| | | | | | | | | | - Bruce A Larson
- Center for Global Health and Development, Boston University, Crosstown Center, 3rd Floor, 801 Massachusetts Avenue, Boston, MA 02118, USA.
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Jiwani A, Matheson A, Kahn JG, Raut A, Verguet S, Marseille E, Walson J. Integrated disease prevention campaigns: assessing country opportunity for implementation via an index approach. BMJ Open 2014; 4:e004308. [PMID: 24647447 PMCID: PMC3963065 DOI: 10.1136/bmjopen-2013-004308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVES To help stakeholders identify and prioritise countries with the best opportunities for implementation of an integrated prevention campaign (IPC) focused on diarrhoea, malaria and HIV prevention. DESIGN Cross-sectional analysis of country-specific epidemiological data using an index tool developed for this purpose. SETTING We calculated the total disability-adjusted life years (DALYs) attributed to diarrhoea, malaria and HIV for 214 World Bank economies. Criteria for inclusion were: low-income and middle-income countries, and total annual DALY burden in the top tertile (≥87 000 DALYs). 70 countries met inclusion criteria and were included in our opportunity analysis. OUTCOME MEASURES We synthesised data on 10 indicators related to the potential reduction in burden and new coverage achievable by an IPC. We scored and ranked countries based on three summary opportunity metrics: DALYs per capita across the diseases, a composite score of tertile rankings of burden for each disease, and a score combining burden and intervention opportunity. RESULTS We estimated the total annual global burden attributable to diarrhoea, malaria and HIV at 135 million DALYs. All of the countries with the highest opportunity for implementation of a diarrhoea, malaria and HIV IPC are in sub-Saharan Africa, regardless of opportunity metric used. Although the overall rank order changes, 16 countries rank among the top 23 highest opportunity countries for all three metrics. CONCLUSIONS Stakeholders can use this objective metric-based approach to prioritise countries for IPC scale-up. Priority countries are largely robust to the opportunity metric chosen.
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Affiliation(s)
- Aliya Jiwani
- Health Strategies International, Arlington, Virginia, USA
| | - Alastair Matheson
- Department of 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
| | - 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
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Marseille E, Kahn JG, Beatty S, Jared M, Perchal P. Adult male circumcision in Nyanza, Kenya at scale: the cost and efficiency of alternative service delivery modes. BMC Health Serv Res 2014; 14:31. [PMID: 24450374 PMCID: PMC3902184 DOI: 10.1186/1472-6963-14-31] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 01/15/2014] [Indexed: 11/14/2022] Open
Abstract
Background Adult male circumcision (MC) services in Kenya are provided through both horizontal and vertical programs, and via facility-based, mobile and outreach service delivery. This study assesses the costs and composition of unit costs for each program approach and service delivery mode and assess the cost-effectiveness of each. Methods This study was conducted on the unit costs of adult MC delivery in 222 purposively-selected MC delivery sites in Nyanza Province, Kenya from November 2008 through April 2010 using program data from the AIDS, Population, and Health Integrated Assistance Project II (APHIA II) and from the Nyanza Reproductive Health Society (NRHS). The former program can be characterized as horizontal or integrated; the latter as ‘diagonal’; containing both horizontal and vertical elements. Expenditure and services data were collected from project financial and monitoring documents and via discussions with program officials. In addition, per-case, direct service delivery costs were calculated using time and motion observations of 246 adult MC procedures performed during May and June, 2010. We calculated the cost per HIV infections averted for each of the service delivery modalities. Results Unit cost per adult MC was $38.62 and $44.24 for APHIA II and NRHS respectively, ranging from $29.32 (APHIA II mobile) to $46.20 (NRHS outreach/mobile). Unit costs at base facilities was similar for the two approaches. Time and motion data revealed that the opportunity cost of the elapsed time between the arrival of the surgical team and the time the first MC procedure begins varies between $2.08 and $6.27 per case. The cost per HIV infection (HIA) averted ranged from $117.29 for mobile service via the horizontal APHIA-II program to $184.84 per HIA for the diagonal NRHS program. Conclusions This study provides evidence for the similar efficiency of a horizontal approach (APHIA II) and a combination of horizontal and vertical approaches (NRHS) to support scale-up of adult MC services in Nyanza. Differences in unit cost are modest, not consistently in the same direction, and largely explained by differences in compensation levels.
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Affiliation(s)
- Elliot Marseille
- Health Strategies International, 555 59th St,, Oakland, CA, 94609, USA.
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Eaton JW, Menzies NA, Stover J, Cambiano V, Chindelevitch L, Cori A, Hontelez JAC, Humair S, Kerr CC, Klein DJ, Mishra S, Mitchell KM, Nichols BE, Vickerman P, Bakker R, Bärnighausen T, Bershteyn A, Bloom DE, Boily MC, Chang ST, Cohen T, Dodd PJ, Fraser C, Gopalappa C, Lundgren J, Martin NK, Mikkelsen E, Mountain E, Pham QD, Pickles M, Phillips A, Platt L, Pretorius C, Prudden HJ, Salomon JA, van de Vijver DAMC, de Vlas SJ, Wagner BG, White RG, Wilson DP, Zhang L, Blandford J, Meyer-Rath G, Remme M, Revill P, Sangrujee N, Terris-Prestholt F, Doherty M, Shaffer N, Easterbrook PJ, Hirnschall G, Hallett TB. Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models. Lancet Glob Health 2013; 2:23-34. [PMID: 25083415 PMCID: PMC4114402 DOI: 10.1016/s2214-109x(13)70172-4] [Citation(s) in RCA: 153] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND New WHO guidelines recommend ART initiation for HIV-positive persons with CD4 cell counts ≤500 cells/µL, a higher threshold than was previously recommended. Country decision makers must consider whether to further expand ART eligibility accordingly. METHODS We used multiple independent mathematical models in four settings-South Africa, Zambia, India, and Vietnam-to evaluate the potential health impact, costs, and cost-effectiveness of different adult ART eligibility criteria under scenarios of current and expanded treatment coverage, with results projected over 20 years. Analyses considered extending eligibility to include individuals with CD4 ≤500 cells/µL or all HIV-positive adults, compared to the previous recommendation of initiation with CD4 ≤350 cells/µL. We assessed costs from a health system perspective, and calculated the incremental cost per DALY averted ($/DALY) to compare competing strategies. Strategies were considered 'very cost-effective' if the $/DALY was less than the country's per capita gross domestic product (GDP; South Africa: $8040, Zambia: $1425, India: $1489, Vietnam: $1407) and 'cost-effective' if $/DALY was less than three times per capita GDP. FINDINGS In South Africa, the cost per DALY averted of extending ART eligibility to CD4 ≤500 cells/µL ranged from $237 to $1691/DALY compared to 2010 guidelines; in Zambia, expanded eligibility ranged from improving health outcomes while reducing costs (i.e. dominating current guidelines) to $749/DALY. Results were similar in scenarios with substantially expanded treatment access and for expanding eligibility to all HIV-positive adults. Expanding treatment coverage in the general population was therefore found to be cost-effective. In India, eligibility for all HIV-positive persons ranged from $131 to $241/DALY and in Vietnam eligibility for CD4 ≤500 cells/µL cost $290/DALY. In concentrated epidemics, expanded access among key populations was also cost-effective. INTERPRETATION Earlier ART eligibility is estimated to be very cost-effective in low- and middle-income settings, although these questions should be revisited as further information becomes available. Scaling-up ART should be considered among other high-priority health interventions competing for health budgets. FUNDING The Bill and Melinda Gates Foundation and World Health Organization.
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Affiliation(s)
- Jeffrey W Eaton
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Nicolas A Menzies
- Center for Health Decision Science, Harvard School of Public Health, Boston, MA, USA
| | | | - Valentina Cambiano
- Research Department of Infection and Population Health, University College London, London, UK
| | - Leonid Chindelevitch
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA
| | - Anne Cori
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Jan A C Hontelez
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa
- Nijmegen International Center for Health System Analysis and Education (NICHE), Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Salal Humair
- Harvard School of Public Health, Boston, MA, USA
| | - Cliff C Kerr
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Daniel J Klein
- Epidemiological Modeling Group, Intellectual Ventures Laboratory, Bellevue, WA, USA
| | - Sharmistha Mishra
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
- Division of Infectious Diseases, St. Michael’s Hospital, University of Toronto, Canada
| | - Kate M Mitchell
- Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Brooke E Nichols
- Department of Virology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Peter Vickerman
- Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Roel Bakker
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Till Bärnighausen
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa
- Harvard School of Public Health, Boston, MA, USA
| | - Anna Bershteyn
- Epidemiological Modeling Group, Intellectual Ventures Laboratory, Bellevue, WA, USA
| | | | - Marie-Claude Boily
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Stewart T Chang
- Epidemiological Modeling Group, Intellectual Ventures Laboratory, Bellevue, WA, USA
| | - Ted Cohen
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
| | - Peter J Dodd
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Christophe Fraser
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | | | - Jens Lundgren
- Copenhagen University Hospital/Rigshospitalet, Copenhagen, Denmark
- University of Copenhagen, Copenhagen, Denmark
| | - Natasha K Martin
- Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Evelinn Mikkelsen
- Nijmegen International Center for Health System Analysis and Education (NICHE), Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Elisa Mountain
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Quang D Pham
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Michael Pickles
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Andrew Phillips
- Research Department of Infection and Population Health, University College London, London, UK
| | - Lucy Platt
- Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Holly J Prudden
- Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Joshua A Salomon
- Center for Health Decision Science, Harvard School of Public Health, Boston, MA, USA
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA
| | | | - Sake J de Vlas
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Bradley G Wagner
- Epidemiological Modeling Group, Intellectual Ventures Laboratory, Bellevue, WA, USA
| | - Richard G White
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - David P Wilson
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Lei Zhang
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - John Blandford
- U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Gesine Meyer-Rath
- Center for Global Health and Development, Boston University, Boston, MA, USA
- Health Economics and Epidemiology Research Office, Department of Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Michelle Remme
- Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | | | - Fern Terris-Prestholt
- Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Meg Doherty
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Nathan Shaffer
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | | | | | - Timothy B Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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41
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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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