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Medina-Marino A, Bezuidenhout D, Bezuidenhout C, Facente SN, Fourie B, Shin SS, Penn-Nicholson A, Theron G. In-home TB Testing Using GeneXpert Edge is Acceptable, Feasible, and Improves the Proportion of Symptomatic Household Contacts Tested for TB: A Proof-of-Concept Study. Open Forum Infect Dis 2024; 11:ofae279. [PMID: 38868309 PMCID: PMC11167660 DOI: 10.1093/ofid/ofae279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Accepted: 05/13/2024] [Indexed: 06/14/2024] Open
Abstract
Background Household contact investigations are effective for finding tuberculosis (TB) cases but are hindered by low referral uptake for clinic-based evaluation and testing. We assessed the acceptability and feasibility of in-home testing of household contacts (HHC) using the GeneXpert Edge platform. Methods We conducted a 2-arm, randomized study in Eastern Cape, South Africa. HHCs were verbally assessed using the World Health Organization-recommended 4-symptom screen. Households with ≥1 eligible symptomatic contact were randomized. Intervention households received in-home GeneXpert MTB/RIF molecular testing. GeneXpert-positive HHCs were referred for clinic-based treatment. Standard-of-care households were referred for clinic-based sputum collection and testing. We defined acceptability as agreeing to in-home testing and feasibility as generation of valid Xpert MTB/RIF results. The proportion and timeliness of test results received was compared between groups. Results Eighty-four households were randomized (n = 42 per arm). Of 100 eligible HHCs identified, 98/100 (98%) provided consent. Of 51 HHCs allocated to the intervention arm, all accepted in-home testing; of those, 24/51 (47%) were sputum productive and 23/24 (96%) received their test results. Of 47 HCCs allocated to standard-of-care, 7 (15%) presented for clinic-based TB evaluation, 6/47 (13%) were tested, and 4/6 (67%) returned for their results. The median (interquartile range) number of days from screening to receiving test results was 0 (0) and 16.5 (11-15) in the intervention and standard-of-care arms, respectively. Conclusions In-home testing for TB was acceptable, feasible, and increased HHCs with a molecular test result. In-home testing mitigates a major limitation of household contact investigations (dependency on clinic-based referral), revealing new strategies for enhancing early case detection.
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Affiliation(s)
- Andrew Medina-Marino
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dana Bezuidenhout
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York City, New York, USA
| | | | - Shelley N Facente
- School of Public Health, University of California Berkeley, Berkeley, California, USA
| | - Bernard Fourie
- Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Sanghyuk S Shin
- Sue & Bill Gross School of Nursing, University of California Irvine, Irvine, California, USA
| | | | - Grant Theron
- NRF-DSI Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Cape Town, South Africa
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Borgstede SJ, Elly A, Helova A, Kwena Z, Darbes LA, Hatcher A, Thirumurthy H, Owino G, Pisu M, Owuor K, Braun T, Turan JM, Bukusi EA, Nghiem VT. Cost of Home-Based Couples Human Immunodeficiency Virus Counseling and Testing and Human Immunodeficiency Virus Self-Testing During Pregnancy and Postpartum in Southwestern Kenya. Value Health Reg Issues 2023; 34:125-132. [PMID: 36709657 PMCID: PMC9992305 DOI: 10.1016/j.vhri.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 11/05/2022] [Accepted: 11/30/2022] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Home-based couples HIV testing and counseling and HIV self-testing (HIVST) for pregnant women can promote HIV status disclosure and male partner testing; however, cost data are lacking. We examined a home-based couples intervention (HBCI) and HIVST intervention costs per couple (unit cost) during pregnancy and postpartum in Kenya. METHODS This randomized controlled trial is comparing HBCI and HIVST for couples among pregnant women attending antenatal care clinics in two counties in southwestern Kenya. We used micro-costing to estimate the unit cost per couple receiving the intervention as the total of direct and indirect costs for each study arm in 2019 US$. We used a one-month window to conduct a time and motion study to determine personnel effort and resources. We then compared the unit cost by arm, identified key cost drivers, and conducted sensitivity analyses for cost uncertainties. RESULTS At base-case, the unit cost was $129.01 and $41.99, respectively, for HBCI and HIVST. Personnel comprised half of the unit cost for both arms. Staff spent more time on activities related to participant engagement in HBCI (accounting for 6.4% of the unit cost) than in HIVST (2.3%). Staff training was another key cost driver in HBCI (20.1% of the unit cost compared to 12.5% in HIVST). Sensitivity analyses revealed that the unit cost ranges were $104.64-$154.54 for HBCI and $30.49-$56.59 for HIVST. CONCLUSIONS Our findings may guide spending decisions for future HIV prevention and treatment programs for pregnant couples in resource-limited settings such as Kenya.
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Affiliation(s)
- Seth J Borgstede
- Department of Health Policy and Organization, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Assurah Elly
- Research, Care and Treatment Programme, Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Anna Helova
- Department of Health Policy and Organization, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA; Sparkman Center for Global Health, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Zachary Kwena
- Research, Care and Treatment Programme, Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Lynae A Darbes
- Center for Sexuality and Health Disparities, and Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Abigail Hatcher
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Harsha Thirumurthy
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - George Owino
- Research, Care and Treatment Programme, Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Maria Pisu
- Department of Preventive Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kevin Owuor
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Thomas Braun
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Janet M Turan
- Department of Health Policy and Organization, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA; Sparkman Center for Global Health, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Elizabeth A Bukusi
- Research, Care and Treatment Programme, Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Van T Nghiem
- Department of Health Policy and Organization, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA.
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Costs and cost-effectiveness of HIV counselling and testing modalities in Southern Mozambique. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2022; 20:49. [PMID: 36068574 PMCID: PMC9447341 DOI: 10.1186/s12962-022-00378-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 08/08/2022] [Indexed: 11/10/2022] Open
Abstract
Objective Despite the high HIV associated burden, Mozambique lacks data on HIV counselling and testing (HCT) costs. To help guide national HIV/AIDS programs, we estimated the cost per test for voluntary counselling and testing (VCT) from the patient’s perspective and the costs per person tested and per HIV-positive individual linked to care to the healthcare provider for VCT, provider-initiated counselling and testing (PICT) and home-based testing (HBT). We also assessed the cost-effectiveness of these strategies for linking patients to care. Methods Data from a cohort study conducted in the Manhiça District were used to derive costs and linkage-to-care outcomes of the three HCT strategies. A decision tree was used to model HCT costs according to the likelihood of HCT linking individuals to care and to obtain the incremental cost-effectiveness ratios (ICERs) of PICT and HBT with VCT as the comparator. Sensitivity analyses were performed to assess robustness of base-case findings. Findings Based on costs and valuations in 2015, average and median VCT costs to the patient per individual tested were US$1.34 and US$1.08, respectively. Costs per individual tested were greatest for HBT (US$11.07), followed by VCT (US$7.79), and PICT (US$7.14). The costs per HIV-positive individual linked to care followed a similar trend. PICT was not cost-effective in comparison with VCT at a willingness-to-accept threshold of US$4.53, but only marginally given a corresponding base-case ICER of US$4.15, while HBT was dominated, with higher costs and lower impact than VCT. Base-case results for the comparison between PICT and VCT presented great uncertainty, whereas findings for HBT were robust. Conclusion PICT and VCT are likely equally cost-effective in Manhiça. We recommend that VCT be offered as the predominant HCT strategy in Mozambique, but expansion of PICT could be considered in limited-resource areas. HBT without facilitated linkage or reduced costs is unlikely to be cost-effective.
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Mukora R, Smith HJ, Herce ME, Chimoyi L, Hausler H, Fielding KL, Charalambous S, Hoffmann CJ. Costs of implementing universal test and treat in three correctional facilities in South Africa and Zambia. PLoS One 2022; 17:e0272595. [PMID: 36006967 PMCID: PMC9409581 DOI: 10.1371/journal.pone.0272595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 07/21/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction
Universal test and treat (UTT) is a population-based strategy that aims to ensure widespread HIV testing and rapid antiretroviral therapy (ART) for all who have tested positive regardless of CD4 count to decrease HIV incidence and improve health outcomes. Little is known about the specific resources required to implement UTT in correctional facilities for incarcerated people. The primary aim of this study was to describe the resources used to implement UTT and to provide detailed costing to inform UTT scale-up in similar settings.
Methods
The costing study was a cross-sectional descriptive study conducted in three correctional complexes, Johannesburg Correctional Facility in Johannesburg (>4000 inmates) South Africa, and Brandvlei (~3000 inmates), South Africa and Lusaka Central (~1400 inmates), Zambia. Costing was determined through a survey conducted between September and December 2017 that identified materials and labour used for three separate components of UTT: HIV testing services (HTS), ART initiation, and ART maintenance. Our study participants were staff working in the correctional facilities involved in any activity related to UTT implementation. Unit costs were reported as cost per client served while total costs were reported for all clients seen over a 12-month period.
Results
The cost of HIV testing services (HTS) per client was $ 92.12 at Brandvlei, $ 73.82 at Johannesburg, and $ 65.15 at Lusaka. The largest cost driver for HIV testing at Brandvlei were staff costs at 55.6% of the total cost, while at Johannesburg (56.5%) and Lusaka (86.6%) supplies were the largest contributor. The cost per client initiated on ART was $917 for Brandvlei, $421.8 for Johannesburg, and $252.1 for Lusaka. The activity cost drivers were adherence counselling at Brandvlei (59%), and at Johannesburg and Lusaka it was the actual ART initiation at 75.6% and 75.8%, respectively. The annual unit cost for ART maintenance was $2,640.6 for Brandvlei, $710 for Johannesburg, and $385.5 for Lusaka. The activity cost drivers for all three facilities were side effect monitoring, and initiation of isoniazid preventive treatment (IPT), cotrimoxazole, and fluconazole, with this comprising 44.7% of the total cost at Brandvlei, 88.9% at Johannesburg, and 50.5% at Lusaka.
Conclusion
Given the needs of this population, the opportunity to reach inmates at high risk for HIV, and overall national and global 95-95-95 goals, the UTT policies for incarcerated individuals are of vital importance. Our findings provide comparator costing data and highlight key drivers of UTT cost by facility.
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Affiliation(s)
- Rachel Mukora
- The Aurum Institute, Aurum House, The Ridge, Johannesburg, South Africa
- * E-mail:
| | - Helene J. Smith
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
- School of Public Health & Community Medicine, University of New South Wales, Sydney, Australia
| | - Michael E. Herce
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Lucy Chimoyi
- The Aurum Institute, Aurum House, The Ridge, Johannesburg, South Africa
| | | | - Katherine L. Fielding
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Salome Charalambous
- The Aurum Institute, Aurum House, The Ridge, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Christopher J. Hoffmann
- The Aurum Institute, Aurum House, The Ridge, Johannesburg, South Africa
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
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Goense CJD, Evers YJ, Hoebe CJPA, Crutzen R, Dukers-Muijrers NHTM. Intention to use and acceptability of home-based sexual health care among men who have sex with men who previously attended clinic-based sexual health care. FRONTIERS IN REPRODUCTIVE HEALTH 2022; 4:967770. [PMID: 36303612 PMCID: PMC9580753 DOI: 10.3389/frph.2022.967770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/28/2022] [Indexed: 12/03/2022] Open
Abstract
The COVID-19 pandemic has temporarily disrupted access to clinic-based sexual health care for men who have sex with men (MSM) in the Netherlands. The importance of home-based sexual health care has been underpinned as an extension of clinic-based care. This paper aims to assess intention to use, and acceptability of home-based sexual health care among MSM who previously attended clinic-based sexual health care. In November 2020, 424 MSM who had attended an STI clinic pre-pandemic were invited to participate in an online survey; 154 MSM completed the survey (response 36%). Intention to use self-sampling STI/HIV tests was assessed (median; scale 0–100) and compared across sociodemographic and sexual behavior characteristics by Kruskal-Wallis H tests. Descriptive analyses provided insights in acceptability of home-based sexual health care. Of participants (median age 47), 60.4% (93/154) tested for STI/HIV in the past 6 months, most of them attended a clinic. The median score on intention to use self-sampling tests was 86.5 (SD = 33.4) and did not differ by sociodemographic or sexual behavioral characteristics (all p-values > 0.1). Participants were positive toward online sexual health counseling (median attitude = 75.0, SD = 29.6) and their main preferred topics were PrEP use and STI/HIV testing. MSM who attended clinic-based care expressed intention to use self-sampling tests and a positive attitude toward online sexual health counseling. Home-based sexual health care elements are not currently integrated within Dutch clinic-based sexual health care and should be considered an addition for continued provision of care and extended reach of MSM.
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Affiliation(s)
- Cornelia J. D. Goense
- Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, Heerlen, Netherlands
- Department of Social Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands
- *Correspondence: Cornelia J. D. Goense
| | - Ymke J. Evers
- Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, Heerlen, Netherlands
- Department of Social Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands
| | - Christian J. P. A. Hoebe
- Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, Heerlen, Netherlands
- Department of Social Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands
- Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands
| | - Rik Crutzen
- Department of Health Promotion, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands
| | - Nicole H. T. M. Dukers-Muijrers
- Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, Heerlen, Netherlands
- Department of Health Promotion, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands
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Myburgh H, Reynolds L, Hoddinott G, van Aswegen D, Grobbelaar N, Gunst C, Jennings K, Kruger J, Louis F, Mubekapi-Musadaidzwa C, Viljoen L, Wademan D, Bock P. Implementing 'universal' access to antiretroviral treatment in South Africa: a scoping review on research priorities. Health Policy Plan 2021; 36:923-938. [PMID: 33963393 PMCID: PMC8227479 DOI: 10.1093/heapol/czaa094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2020] [Indexed: 01/15/2023] Open
Abstract
‘Universal’ access to antiretroviral treatment (ART) has become the global standard for treating people living with HIV and achieving epidemic control; yet, findings from numerous ‘test and treat’ trials and implementation studies in sub-Saharan Africa suggest that bringing ‘universal' access to ART to scale is more complex than anticipated. Using South Africa as a case example, we describe the research priorities and foci in the literature on expanded ART access. To do so, we adapted Arksey and O’Malley’s six-stage scoping review framework to describe the peer-reviewed literature and opinion pieces on expanding access to ART in South Africa between 2000 and 2017. Data collection included systematic searches of two databases and hand-searching of a sub-sample of reference lists. We used an adapted socio-ecological thematic framework to categorize data according to where it located the challenges and opportunities of expanded ART eligibility: individual/client, health worker–client relationship, clinic/community context, health systems infrastructure and/or policy context. We included 194 research articles and 23 opinion pieces, of 1512 identified, addressing expanded ART access in South Africa. The peer-reviewed literature focused on the individual and health systems infrastructure; opinion pieces focused on changing roles of individuals, communities and health services implementers. We contextualized our findings through a consultative process with a group of researchers, HIV clinicians and programme managers to consider critical knowledge gaps. Unlike the published literature, the consultative process offered particular insights into the importance of researching and intervening in the relational aspects of HIV service delivery as South Africa’s HIV programme expands. An overwhelming focus on individual and health systems infrastructure factors in the published literature on expanded ART access in South Africa may skew understanding of HIV programme shortfalls away from the relational aspects of HIV services delivery and delay progress with finding ways to leverage non-medical modalities for achieving HIV epidemic control.
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Affiliation(s)
- Hanlie Myburgh
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa.,Amsterdam Institute for Social Science Research (AISSR), University of Amsterdam, Nieuwe Achtergracht 166, WV, Amsterdam, the Netherlands
| | - Lindsey Reynolds
- Department of Sociology and Social Anthropology, Faculty of Arts and Social Sciences, Stellenbosch University, c/o Merriman and Ryneveld Avenue, Stellenbosch, 7600, South Africa
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
| | - Dianne van Aswegen
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
| | - Nelis Grobbelaar
- The Anova Health Institute, Willie Van Schoor Avenue, Bellville, Cape Town, 7530, South Africa
| | - Colette Gunst
- Division of Family Medicine and Primary Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa.,Western Cape Department of Health, Cape Winelands District, 7 Haarlem Street, Worcester, 6850, South Africa
| | - Karen Jennings
- City of Cape Town Health Department, Cape Town Municipality, 12 Hertzog Boulevard, Cape Town, 8001, South Africa
| | - James Kruger
- Western Cape Department of Health, HIV Treatment and PMTCT Programme, 4 Dorp Street, Cape Town, 8000, South Africa
| | - Francoise Louis
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
| | - Constance Mubekapi-Musadaidzwa
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
| | - Lario Viljoen
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
| | - Dillon Wademan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
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Uzoaru F, Nwaozuru U, Ong JJ, Obi F, Obiezu-Umeh C, Tucker JD, Shato T, Mason SL, Carter V, Manu S, BeLue R, Ezechi O, Iwelunmor J. Costs of implementing community-based intervention for HIV testing in sub-Saharan Africa: a systematic review. Implement Sci Commun 2021; 2:73. [PMID: 34225820 PMCID: PMC8259076 DOI: 10.1186/s43058-021-00177-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 06/22/2021] [Indexed: 12/20/2022] Open
Abstract
Background Community-based interventions (CBIs) are interventions aimed at improving the well-being of people in a community. CBIs for HIV testing seek to increase the availability of testing services to populations that have been identified as at high risk by reaching them in homes, schools, or community centers. However, evidence for a detailed cost analysis of these community-based interventions in sub-Saharan Africa (SSA) is limited. We conducted a systematic review of the cost analysis of HIV testing interventions in SSA. Methods Keyword search was conducted on SCOPUS, CINAHL, MEDLINE, PsycINFO, Web of Science, and Global Health databases. Three categories of key terms used were cost (implementation cost OR cost-effectiveness OR cost analysis OR cost-benefit OR marginal cost), intervention (HIV testing), and region (sub-Saharan Africa OR sub-Saharan Africa OR SSA). CBI studies were included if they primarily focused on HIV testing, was implemented in SSA, and used micro-costing or ingredients approach. Results We identified 1533 citations. After screening, ten studies were included in the review: five from East Africa and five from Southern Africa. Two studies conducted cost-effectiveness analysis, and one study was a cost-utility analysis. The remainder seven studies were cost analyses. Four intervention types were identified: HIV self-testing (HIVST), home-based, mobile, and Provider Initiated Testing and Counseling. Commonly costed resources included personnel (n = 9), materials and equipment (n = 6), and training (n = 5). Cost outcomes reported included total intervention cost (n = 9), cost per HIV test (n = 9), cost per diagnosis (n = 5), and cost per linkage to care (n = 3). Overall, interventions were implemented at a higher cost than controls, with the largest cost difference with HIVST compared to facility-based testing. Conclusion To better inform policy, there is an urgent need to evaluate the costs associated with implementing CBIs in SSA. It is important for cost reports to be detailed, uniform, and informed by economic evaluation guidelines. This approach minimizes biases that may lead decision-makers to underestimate the resources required to scale up, sustain, or reproduce successful interventions in other settings. In an evolving field of implementation research, this review contributes to current resources on implementation cost studies. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-021-00177-y.
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Affiliation(s)
- Florida Uzoaru
- College of Public Health and Social Justice, Saint Louis University, St Louis, MO, USA.
| | - Ucheoma Nwaozuru
- College of Public Health and Social Justice, Saint Louis University, St Louis, MO, USA
| | - Jason J Ong
- Department of Clinical Research and Development, London School of Hygiene and Tropical Medicine, United Kingdom Central Clinical School, Monash University, Melbourne, Australia
| | - Felix Obi
- Health Policy Research Group, University of Nigeria, Nsukka, Nigeria
| | - Chisom Obiezu-Umeh
- College of Public Health and Social Justice, Saint Louis University, St Louis, MO, USA
| | - Joseph D Tucker
- Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Thembekile Shato
- College of Public Health and Social Justice, Saint Louis University, St Louis, MO, USA
| | - Stacey L Mason
- College of Public Health and Social Justice, Saint Louis University, St Louis, MO, USA
| | - Victoria Carter
- College of Public Health and Social Justice, Saint Louis University, St Louis, MO, USA
| | - Sunita Manu
- College of Public Health and Social Justice, Saint Louis University, St Louis, MO, USA
| | - Rhonda BeLue
- College of Public Health and Social Justice, Saint Louis University, St Louis, MO, USA
| | - Oliver Ezechi
- Clinical Sciences Department, Nigerian Institute of Medical Research, Lagos, Nigeria
| | - Juliet Iwelunmor
- College of Public Health and Social Justice, Saint Louis University, St Louis, MO, USA
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8
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Madut DB, Manavalan P, Mtalo A, Peter TA, Ostermann J, Njau B, Thielman NM. Increasing the Uptake of HIV Testing among Men in Tanzania: A Novel Intervention for Bar Patrons. AIDS Behav 2021; 25:2014-2022. [PMID: 33389376 DOI: 10.1007/s10461-020-03131-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2020] [Indexed: 11/29/2022]
Abstract
We investigated a novel community-based HIV testing and counseling (HTC) strategy by recruiting men from bars in northern Tanzania in order to identify new HIV infections. All bars in the town of Boma Ng'ombe were identified and male patrons were systematically invited to participate in a health study. HIV testing was offered to all enrolled participants. Outputs included HIV test yield, cost per diagnosis, and comparison of our observed test yield to that among male patients contemporaneously tested at five local facility-based HTC. We enrolled 366 participants and identified 17 new infections - providing a test yield of 5.3% (95% Confidence interval [CI] 3.3-8.4). The test yield among men contemporaneously tested at five local HTC centers was 2.1% (95% CI 1.6-2.8). The cost-per-diagnosis was $634. Our results suggest that recruiting male bar patrons for HIV testing is efficient for identifying new HIV infections. The scalability of this intervention warrants further evaluation.
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Affiliation(s)
- Deng B Madut
- Department of Medicine, Duke University, 315 Trent Drive, Durham, NC, 27710, USA.
- Duke Global Health Institute, Durham, NC, USA.
| | - Preeti Manavalan
- Department of Medicine, Duke University, 315 Trent Drive, Durham, NC, 27710, USA
- Duke Global Health Institute, Durham, NC, USA
| | - Antipas Mtalo
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | | | - Jan Ostermann
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Bernard Njau
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Nathan M Thielman
- Department of Medicine, Duke University, 315 Trent Drive, Durham, NC, 27710, USA
- Duke Global Health Institute, Durham, NC, USA
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MacKellar D, Thompson R, Nelson R, Casavant I, Pals S, Bonzela J, Jaramillo A, Cardoso J, Ujamaa D, Tamele S, Chivurre V, Malimane I, Pathmanathan I, Heitzinger K, Wei S, Couto A, Vergara A. Annual home-based HIV testing in the Chókwè Health Demographic Surveillance System, Mozambique, 2014 to 2019: serial population-based survey evaluation. J Int AIDS Soc 2021; 24:e25762. [PMID: 34259391 PMCID: PMC8278856 DOI: 10.1002/jia2.25762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 05/17/2021] [Accepted: 05/25/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION WHO recommends implementing a mix of community and facility testing strategies to diagnose 95% of persons living with HIV (PLHIV). In Mozambique, a country with an estimated 506,000 undiagnosed PLHIV, use of home-based HIV testing services (HBHTS) to help achieve the 95% target has not been evaluated. METHODS HBHTS was provided at 20,000 households in the Chókwè Health Demographic Surveillance System (CHDSS), Mozambique, in annual rounds (R) during 2014 to 2019. Trends in prevalence of HIV infection, prior HIV diagnosis among PLHIV (diagnostic coverage), and undiagnosed HIV infection were assessed with three population-based surveys conducted in R1 (04/2014 to 04/2015), R3 (03/2016 to 12/2016), and R5 (04/2018 to 03/2019) of residents aged 15 to 59 years. Counts of patients aged ≥15 years tested for HIV in CHDSS healthcare facilities were obtained from routine reports. RESULTS During 2014 to 2019, counsellors conducted 92,512 home-based HIV tests and newly diagnosed 3711 residents aged 15 to 59 years. Prevalence of HIV infection was stable (R1, 25.1%; R3 23.6%; R5 22.9%; p-value, 0.19). After the first two rounds (44,825 home-based tests; 31,717 facility-based tests), diagnostic coverage increased from 73.8% (95% CI 70.3 to 77.2) in R1 to 93.0% (95% CI 91.3 to 94.7) in R3, and prevalence of undiagnosed HIV infection decreased from 6.6% (95% CI 5.6 to 7.5) in R1 to 1.7% (95% CI 1.2 to 2.1) in R3. After two more rounds (32,226 home-based tests; 46,003 facility-based tests), diagnostic coverage was 95.4% (95% CI 93.7 to 97.1) and prevalence of undiagnosed HIV infection was 1.1% (95% CI 0.7 to 1.5) in R5. Prevalence of having last tested at home was 12.7% (95% CI 11.3 to 14.0) in R1, 45.2% (95% CI 43.4 to 47.0) in R3, and 41.4% (95% CI 39.5 to 43.2) in R5, and prevalence of having last tested at a healthcare facility was 45.3% (95% CI 43.3 to 47.3) in R1, 40.1% (95% CI 38.4 to 41.8) in R3, and 45.2% (95% CI 43.3 to 47.0) in R5. CONCLUSIONS HBHTS successfully augmented facility-based testing to achieve HIV diagnostic coverage in a high-burden community of Mozambique. HBHTS should be considered in sub-Saharan Africa communities striving to diagnose 95% of persons living with HIV.
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Affiliation(s)
- Duncan MacKellar
- Division of Global HIV and TBNational Center for Global HealthUS Centers for Disease Control and PreventionAtlantaGAUSA
| | - Ricardo Thompson
- Chókwè Health Research and Training CenterNational Institute of HealthChókwèMozambique
| | - Robert Nelson
- Division of Global HIV and TBNational Center for Global HealthUS Centers for Disease Control and PreventionAtlantaGAUSA
| | | | - Sherri Pals
- Division of Global HIV and TBNational Center for Global HealthUS Centers for Disease Control and PreventionAtlantaGAUSA
| | - Juvencio Bonzela
- Chókwè Health Research and Training CenterNational Institute of HealthChókwèMozambique
| | | | | | | | - Stelio Tamele
- District Directorate of Public HealthChókwèMozambique
| | | | - Inacio Malimane
- US Centers for Disease Control and PreventionMaputoMozambique
| | - Ishani Pathmanathan
- Division of Global HIV and TBNational Center for Global HealthUS Centers for Disease Control and PreventionAtlantaGAUSA
| | | | - Stanley Wei
- US Centers for Disease Control and PreventionMaputoMozambique
| | - Aleny Couto
- Mozambique Ministry of HealthMaputoMozambique
| | - Alfredo Vergara
- US Centers for Disease Control and PreventionMaputoMozambique
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Dziva Chikwari C, Simms V, Kranzer K, Dringus S, Chikodzore R, Sibanda E, Webb K, Engelsmann B, Redzo N, Bandason T, Mujuru H, Apollo T, Ncube G, Hatzold K, Weiss HA, Ferrand RA. Comparison of index-linked HIV testing for children and adolescents in health facility and community settings in Zimbabwe: findings from the interventional B-GAP study. Lancet HIV 2021; 8:e138-e148. [PMID: 33197393 PMCID: PMC8011056 DOI: 10.1016/s2352-3018(20)30267-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 09/01/2020] [Accepted: 09/10/2020] [Indexed: 04/15/2023]
Abstract
BACKGROUND Index-linked HIV testing, whereby children of individuals with HIV are targeted for testing, increases HIV yield but relies on uptake. Community-based testing might address barriers to testing access. In the Bridging the Gap in HIV testing and care for children in Zimbabwe (B-GAP) study, we investigated the uptake and yield of index-linked testing in children and the uptake of community-based vs facility-based HIV testing in Zimbabwe. METHODS B-GAP was an interventional study done in the city of Bulawayo and the province of Matabeleland South between Jan 29 and Dec 12, 2018. All HIV-positive attendees (index patients) at six urban and three rural primary health-care clinics were offered facility-based or community-based HIV testing for children (age 2-18 years) living in their households who had never been tested or had tested as HIV-negative more than 6 months ago. Community-based options involved testing in the home by either a trained lay worker with a blood-based rapid diagnostic test (used in facility-based testing), or by the child's caregiver with an oral HIV test. Among consenting individuals, the primary outcome was testing uptake in terms of the proportion of eligible children tested. Secondary outcomes were uptake of the different HIV testing methods, HIV yield (proportion of eligible children who tested positive), and HIV prevalence (proportion of HIV-positive children among those tested). Logistic regression adjusting for within-index clustering was used to investigate index patient and child characteristics associated with testing uptake, and the uptake of community-based versus facility-based testing. FINDINGS Overall, 2870 index patients were linked with 6062 eligible children (3115 [51·4%] girls [sex unknown in seven], median age 8 years [IQR 5-13]). Testing was accepted by index patients for 5326 (87·9%) children, and 3638 were tested with a known test outcome, giving an overall testing uptake among 6062 eligible children of 60·0%. 39 children tested positive for HIV, giving an HIV prevalence among the 3638 children of 1·1% and an HIV yield among 6062 eligible children of 0·6%. Uptake was positively associated with female sex in the index patient (adjusted odds ratio [aOR] 1·56 [95% CI 1·38-1·77], p<0·0001) and child (aOR 1·10 [1·03-1·19], p=0·0080), and negatively associated with any financial cost of travel to a clinic (aOR 0·86 [0·83-0·88], p<0·0001), increased child age (6-9 years: aOR 0·99 (0·89-1·09); 10-15 years: aOR 0·91 [0·83-1·00]; and 16-18 years: aOR 0·75 [0·66-0·85]; p=0·0001 vs 2-5 years), and unknown HIV status of the mother (aOR 0·81 [0·68-0·98], p=0·027 vs HIV-positive status). Additionally, children had increased odds of being tested if community-based testing was chosen over facility-based testing at screening (1320 [73·9%] children tested of 1787 vs 2318 [65·5%] of 3539; aOR 1·49 [1·22-1·81], p=0·0001). INTERPRETATION The HIV yield of index-linked testing was low compared with blanket testing approaches in similar settings. Index-linked HIV testing can improve testing uptake among children, although strategies that improve testing uptake in older children are needed. Community based testing by lay workers is a feasible strategy that can be used to improve uptake of HTS among children and adolescents. FUNDING UK Medical Research Council, UK Department for International Development, Wellcome Trust.
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Affiliation(s)
- Chido Dziva Chikwari
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK; Biomedical Research and Training Institute, Harare, Zimbabwe.
| | - Victoria Simms
- Medical Research Council Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK; Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Katharina Kranzer
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK; Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Stefanie Dringus
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Karen Webb
- Organization for Public Health Interventions and Development, Harare, Zimbabwe
| | - Barbara Engelsmann
- Organization for Public Health Interventions and Development, Harare, Zimbabwe
| | - Nicol Redzo
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Tsitsi Bandason
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Hilda Mujuru
- Department of Paediatrics, University of Zimbabwe, Harare, Zimbabwe
| | - Tsitsi Apollo
- AIDS and Tuberculosis Unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Getrude Ncube
- AIDS and Tuberculosis Unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | | | - Helen A Weiss
- Medical Research Council Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Rashida A Ferrand
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK; Biomedical Research and Training Institute, Harare, Zimbabwe
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11
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Using repeated home-based HIV testing services to reach and diagnose HIV infection among persons who have never tested for HIV, Chókwè health demographic surveillance system, Chókwè district, Mozambique, 2014-2017. PLoS One 2020; 15:e0242281. [PMID: 33216773 PMCID: PMC7678994 DOI: 10.1371/journal.pone.0242281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/29/2020] [Indexed: 11/19/2022] Open
Abstract
Background HIV prevalence in Mozambique (12.6%) is one of the highest in the world, yet ~40% of people living with HIV (PLHIV) do not know their HIV status. Strategies to increase HIV testing uptake and diagnosis among PLHIV are urgently needed. Home-based HIV testing services (HBHTS) have been evaluated primarily as a 1-time campaign strategy. Little is known about the potential of repeating HBHTS to diagnose HIV infection among persons who have never been tested (NTs), nor about factors/reasons associated with never testing in a generalized epidemic setting. Methods During 2014–2017, counselors visited all households annually in the Chókwè Health and Demographic Surveillance System (CHDSS) and offered HBHTS. Cross-sectional surveys were administered to randomly selected 10% or 20% samples of CHDSS households with participants aged 15–59 years before HBHTS were conducted during the visit. Descriptive statistics and logistic regression were used to assess the proportion of NTs, factors/reasons associated with never having been tested, HBHTS acceptance, and HIV-positive diagnosis among NTs. Results The proportion of NTs decreased from 25% (95% confidence interval [CI]:23%–26%) during 2014 to 12% (95% CI:11% –13%), 7% (95% CI:6%–8%), and 7% (95% CI:6%–8%) during 2015, 2016, and 2017, respectively. Adolescent boys and girls and adult men were more likely than adult women to be NTs. In each of the four years, the majority of NTs (87%–90%) accepted HBHTS. HIV-positive yield among NTs subsequently accepting HBHTS was highest (13%, 95% CI:10%–15%) during 2014 and gradually reduced to 11% (95% CI:8%–15%), 9% (95% CI:6%–12%), and 2% (95% CI:0%–4%) during 2015, 2016, and 2017, respectively. Conclusions Repeated HBHTS was helpful in increasing HIV testing coverage and identifying PLHIV in Chókwè. In high HIV-prevalence settings with low testing coverage, repeated HBHTS can be considered to increase HIV testing uptake and diagnosis among NTs.
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Abstract
OBJECTIVES This study estimates the costs of community-based HIV testing services (HTS) in Lesotho and assesses the potential efficiency gains achieved by adding HIV self-testing (HIVST) and then self-testing booths. DESIGN Micro-costing analysis using longitudinal data from a real-world intervention. METHODS We collected data prospectively on provider's costs and programmatic outcomes over three time periods of approximately 8 months each, between May 2017 and April 2019. The scope of services was extended during each period as follows: HTS only, HTS and HIVST, HTS and HIVST with individual HIVST booths wherein clients were encouraged to self-test on-site followed by on-site confirmative testing for those with reactive self-test. For each implementation period, we estimated the full financial and economic implementation costs, the incremental costs of adding HIVST onto conventional HTS and the cost per HIV positive case identified. RESULTS Costs per HIV-positive case identified increased between period 1 (US$956) and period 2 (US$1249) then dropped in period 3 (US$813). Full versus incremental cost analyses resulted in large differences in the magnitude of costs, attributable to methods rather than resource use: for example, in period 3, the average full and incremental cost estimates for HTS were US$34.3 and US$23.5 per person tested, and for HIVST were US$37.7 and US$14.0 per kit provided, respectively. CONCLUSION In Lesotho, adding HIVST to community-based HTS improves its overall affordability for HIV-positive case finding. The reporting of both full and incremental cost estimates increase transparency for use in priority setting, budgeting and financial planning for scale-up.
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13
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Olwanda EE, Kahn JG, Choi Y, Islam JY, Huchko M. Comparison of the costs of HPV testing through community health campaigns versus home-based testing in rural Western Kenya: a microcosting study. BMJ Open 2020; 10:e033979. [PMID: 33109637 PMCID: PMC7592277 DOI: 10.1136/bmjopen-2019-033979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 07/29/2020] [Accepted: 09/21/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To estimate the cost of human papillomavirus (HPV)-based screening through community health campaigns (CHCs) and home-based testing. SETTING CHCs and home-based testing in six communities in rural Western Kenya. PARTICIPANTS CHCs and home-based screening reached 2297 and 1002 women aged 25-65 years, respectively. OUTCOME MEASURES Outcome measures were overall cost per woman screened achieved through the CHCs and home-based testing and the cost per woman for each activity comprising the screening intervention. RESULTS The mean cost per woman screened through CHCs and home-based testing were similar, at $37.7 (range $26.4-$52.0) and $37.1 (range $27.6-$54.0), respectively. For CHCs, personnel represented 49% of overall cost, supplies 25%, services 5% and capital goods 23%. For home-based testing, these were: personnel 73%, supplies 25%, services 1% and capital goods 2%. A greater number of participants was associated with a lower cost per participant. CONCLUSIONS The mean cost per woman screened is comparable for CHC and home-based testing, with differences in type of input. The CHCs generally reached more eligible women in the six communities, whereas home-based strategies more efficiently reached populations with low screening rates. TRIAL REGISTRATION NUMBER NCT02124252.
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Affiliation(s)
| | - James G Kahn
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA
| | - Yujung Choi
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Duke University, Department of Obstetrics and Gynecology, Durham, NC, USA
| | - Jessica Yasmine Islam
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Megan Huchko
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Duke University, Department of Obstetrics and Gynecology, Durham, NC, USA
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Maher AD, Nakanyala T, Mutenda N, Banda KM, Prybylski D, Wolkon A, Jonas A, Sawadogo S, Ntema C, Chipadze MR, Sinvula G, Tizora A, Mwandemele A, Chaturvedi S, Agovi AMA, Agolory S, Hamunime N, Lowrance DW, Mcfarland W, Patel SV. Rates and Correlates of HIV Incidence in Namibia's Zambezi Region From 2014 to 2016: Sentinel, Community-Based Cohort Study. JMIR Public Health Surveill 2020; 6:e17107. [PMID: 32348290 PMCID: PMC7381049 DOI: 10.2196/17107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 03/06/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Direct measures of HIV incidence are needed to assess the population-level impact of prevention programs but are scarcely available in the subnational epidemic hotspots of sub-Saharan Africa. We created a sentinel HIV incidence cohort within a community-based program that provided home-based HIV testing to all residents of Namibia's Zambezi region, where approximately 24% of the adult population was estimated to be living with HIV. OBJECTIVE The aim of this study was to estimate HIV incidence, detect correlates of HIV acquisition, and assess the feasibility of the sentinel, community-based approach to HIV incidence surveillance in a subnational epidemic hotspot. METHODS Following the program's initial home-based testing (December 2014-July 2015), we purposefully selected 10 clusters of 60 to 70 households each and invited residents who were HIV negative and aged ≥15 years to participate in the cohort. Consenting participants completed behavioral interviews and a second HIV test approximately 1 year later (March-September 2016). We used Poisson models to calculate HIV incidence rates between baseline and follow-up and multivariable Cox proportional hazard models to assess the correlates of seroconversion. RESULTS Among 1742 HIV-negative participants, 1624 (93.23%) completed follow-up. We observed 26 seroconversions in 1954 person-years (PY) of follow-up, equating to an overall incidence rate of 1.33 per 100 PY (95% CI 0.91-1.95). Among women, the incidence was 1.55 per 100 PY (95% CI 1.12-2.17) and significantly higher among those aged 15 to 24 years and residing in rural areas (adjusted hazard ratio [aHR] 4.26, 95% CI 1.39-13.13; P=.01), residing in the Ngweze suburb of Katima Mulilo city (aHR 2.34, 95% CI 1.25-4.40; P=.01), who had no prior HIV testing in the year before cohort enrollment (aHR 3.38, 95% CI 1.04-10.95; P=.05), and who had engaged in transactional sex (aHR 17.64, 95% CI 2.88-108.14; P=.02). Among men, HIV incidence was 1.05 per 100 PY (95% CI 0.54-2.31) and significantly higher among those aged 40 to 44 years (aHR 13.04, 95% CI 5.98-28.41; P<.001) and had sought HIV testing outside the study between baseline and follow-up (aHR 8.28, 95% CI 1.39-49.38; P=.02). No seroconversions occurred among persons with HIV-positive partners on antiretroviral treatment. CONCLUSIONS Nearly three decades into Namibia's generalized HIV epidemic, these are the first estimates of HIV incidence for its highest prevalence region. By creating a sentinel incidence cohort from the infrastructure of an existing community-based testing program, we were able to characterize current transmission patterns, corroborate known risk factors for HIV acquisition, and provide insight into the efficacy of prevention interventions in a subnational epidemic hotspot. This study demonstrates an efficient and scalable framework for longitudinal HIV incidence surveillance that can be implemented in diverse sentinel sites and populations.
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Affiliation(s)
- Andrew D Maher
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, United States
- South African Centre for Epidemiological Modelling and Analysis, Stellenbosch University, Stellenbosch, South Africa
| | - Tuli Nakanyala
- Directorate for Special Programs, Ministry of Health and Social Services, Windhoek, Namibia
| | - Nicholus Mutenda
- Directorate for Special Programs, Ministry of Health and Social Services, Windhoek, Namibia
| | - Karen M Banda
- Directorate for Special Programs, Ministry of Health and Social Services, Windhoek, Namibia
| | - Dimitri Prybylski
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Adam Wolkon
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Anna Jonas
- Directorate for Special Programs, Ministry of Health and Social Services, Windhoek, Namibia
| | - Souleymane Sawadogo
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Charity Ntema
- Total Control of the Epidemic, Development Aid from People to People, Windhoek, Namibia
| | | | - Grace Sinvula
- Total Control of the Epidemic, Development Aid from People to People, Windhoek, Namibia
| | - Annastasia Tizora
- Total Control of the Epidemic, Development Aid from People to People, Windhoek, Namibia
| | - Asen Mwandemele
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Shaan Chaturvedi
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Afiba Manza-A Agovi
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Simon Agolory
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Ndapewa Hamunime
- Directorate for Special Programs, Ministry of Health and Social Services, Windhoek, Namibia
| | - David W Lowrance
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Willi Mcfarland
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Sadhna V Patel
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Atlanta, GA, United States
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15
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Williams LD, Korobchuk A, Smyrnov P, Sazonova Y, Nikolopoulos GK, Skaathun B, Morgan E, Schneider J, Vasylyeva TI, Duong YT, Chernyavska S, Goncharov V, Kotlik L, Friedman SR. Social network approaches to locating people recently infected with HIV in Odessa, Ukraine. J Int AIDS Soc 2020; 22:e25330. [PMID: 31245917 PMCID: PMC6595706 DOI: 10.1002/jia2.25330] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 05/28/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction This paper examines the extent to which an intervention succeeded in locating people who had recently become infected with HIV in the context of the large‐scale Ukrainian epidemic. Locating and intervening with people who recently became infected with HIV (people with recent infection, or PwRI) can reduce forward HIV transmission and help PwRI remain healthy. Methods The Transmission Reduction Intervention Project (TRIP) recruited recently‐infected and longer‐term infected seeds in Odessa, Ukraine, in 2013 to 2016, and asked them to help recruit their extended risk network members. The proportions of network members who were PwRI were compared between TRIP arms (i.e. networks of recently‐infected seeds vs. networks of longer‐term infected seeds) and to the proportion of participants who were PwRI in an RDS‐based Integrated Biobehavioral Surveillance of people who inject drugs in 2013. Results The networks of PwRI seeds and those of longer‐term infected seeds had similar (2%) proportions who were themselves PwRI. This was higher than the 0.25% proportion in IBBS (OR = 7.80; p = 0.016). The odds ratio among the subset of participants who injected drugs was 11.17 (p = 0.003). Cost comparison analyses using simplified ingredients‐based methods found that TRIP spent no more than US $4513 per PwRI located whereas IBBS spent $11,924. Conclusions Further research is needed to confirm these results and improve TRIP further, but our findings suggest that interventions that trace the networks of people who test HIV‐positive are a cost‐effective way to locate PwRI and reduce HIV transmission and should therefore be implemented.
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Affiliation(s)
| | | | | | | | | | - Britt Skaathun
- Division of Global Public Health, University of California San Diego, San Diego, CA, USA.,University of Chicago, Chicago, IL, USA
| | - Ethan Morgan
- Department of Medicine and Center for HIV Elimination, University of Chicago, Chicago, IL, USA
| | - John Schneider
- Department of Medicine and Center for HIV Elimination, University of Chicago, Chicago, IL, USA
| | | | - Yen T Duong
- ICAP-NY, Columbia University, New York, NY, USA
| | - Svitlana Chernyavska
- Odessa Regional Laboratory Center of the Ministry of Health of Ukraine, Odessa, Ukraine
| | - Vitaliy Goncharov
- Odessa Regional Laboratory Center of the Ministry of Health of Ukraine, Odessa, Ukraine
| | - Ludmila Kotlik
- Odessa Regional Laboratory Center of the Ministry of Health of Ukraine, Odessa, Ukraine
| | - Samuel R Friedman
- National Development and Research Institutes, New York, NY, USA.,Center for Drug Use and HIV Research, New York, NY, USA.,Department of Population Health, New York University Medical School, New York, NY, USA
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Hauck K. The costs of home-based HIV testing and counselling in sub-Saharan Africa and its association with testing yield: a literature review. AFRICAN JOURNAL OF AIDS RESEARCH : AJAR 2019; 18:324-331. [PMID: 31779570 DOI: 10.2989/16085906.2019.1680399] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
More than 14.5 of the 36.7 million people living with HIV globally do not know their HIV status, making comprehensive testing interventions a critical step in ending the HIV/AIDS epidemic. Home-based testing and counselling (HBTC) involves small teams of community health workers with basic training going from door-to-door and offering services in people's homes. HBTC is effective in reaching individuals that are unlikely to test otherwise, but there is conflicting evidence on its costs and little insight into why estimates are different. We undertook a comparative review of existing costing studies of HBTC in sub-Saharan Africa. Yield or positivity rate, the number of persons tested positive among all tested, is an important metric to judge the efficacy of a testing campaign. We conducted descriptive analyses to test whether unit costs are associated with yield. Studies varied in size with a maximum of 264 953 and a minimum of 494 persons tested. The average "cost per person tested" across 14 studies was $22.8 (SD $14.5) with a minimum of $6 and a maximum of $55.4, and the average "cost per person tested HIV-positive' across 12 studies was $439.4 (SD $399.7) with a minimum of $66.2 and a maximum of $800.9. Correlations between unit cost estimates and yield were not statistically significant. Existant estimates of the costs of HBTC are conflicting, and it is likely that differences in the setting, design and implementation of the studies are responsible for the discrepancies. This makes it difficult to reliably estimate the costs and cost-effectiveness of HBTC.
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Affiliation(s)
- Katharina Hauck
- Abdul Latif Jameel Institute for Disease and Emergency Analytics, MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
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Zang X, Krebs E, Wang L, Marshall BDL, Granich R, Schackman BR, Montaner JSG, Nosyk B. Structural Design and Data Requirements for Simulation Modelling in HIV/AIDS: A Narrative Review. PHARMACOECONOMICS 2019; 37:1219-1239. [PMID: 31222521 PMCID: PMC6711792 DOI: 10.1007/s40273-019-00817-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Born out of a necessity for fiscal sustainability, simulation modeling is playing an increasingly prominent role in setting priorities for combination implementation strategies for HIV treatment and prevention globally. The design of a model and the data inputted into it are central factors in ensuring credible inferences. We executed a narrative review of a set of dynamic HIV transmission models to comprehensively synthesize and compare the structural design and the quality of evidence used to support each model. We included 19 models representing both generalized and concentrated epidemics, classified as compartmental, agent-based, individual-based microsimulation or hybrid in our review. We focused on four structural components (population construction; model entry, exit and HIV care engagement; HIV disease progression; and the force of HIV infection), and two analytical components (model calibration/validation; and health economic evaluation, including uncertainty analysis). While the models we reviewed focused on a variety of individual interventions and their combinations, their structural designs were relatively homogenous across three of the four focal components, with key structural elements influenced by model type and epidemiological context. In contrast, model entry, exit and HIV care engagement tended to differ most across models, with some health system interactions-particularly HIV testing-not modeled explicitly in many contexts. The quality of data used in the models and the transparency with which the data was presented differed substantially across model components. Representative and high-quality data on health service delivery were most commonly not accessed or were unavailable. The structure of an HIV model should ideally fit its epidemiological context and be able to capture all efficacious treatment and prevention services relevant to a robust combination implementation strategy. Developing standardized guidelines on evidence syntheses for health economic evaluation would improve transparency and help prioritize data collection to reduce decision uncertainty.
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Affiliation(s)
- Xiao Zang
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Emanuel Krebs
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
| | - Linwei Wang
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
| | | | - Reuben Granich
- Independent Public Health Consultant, Washington, DC, USA
| | | | - Julio S G Montaner
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Bohdan Nosyk
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada.
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.
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Cost implications of HIV retesting for verification in Africa. PLoS One 2019; 14:e0218936. [PMID: 31260467 PMCID: PMC6602186 DOI: 10.1371/journal.pone.0218936] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 06/12/2019] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION HIV misdiagnosis leads to severe individual and public health consequences. Retesting for verification of all HIV-positive cases prior to antiretroviral therapy initiation can reduce HIV misdiagnosis, yet this practice has not been not widely implemented. METHODS We evaluated and compared the cost of retesting for verification of HIV seropositivity (retesting) to the cost of antiretroviral treatment (ART) for misdiagnosed cases in the absence of retesting (no retesting), from the perspective of the health care system. We estimated the number of misdiagnosed cases based on a review of misdiagnosis rates, and the number of positives persons needing ART initiation by 2020. We presented the total and per person costs of retesting as compared to no retesting, over a ten-year horizon, across 50 countries in Africa grouped by income level. We conducted univariate sensitivity analysis on all model input parameters, and threshold analysis to evaluate the parameter values where the total costs of retesting and the costs no retesting are equivalent. Cost data were adjusted to 2017 United States Dollars. RESULTS AND DISCUSSION The estimated number of misdiagnoses, in the absence of retesting was 156,117, 52,720 and 29,884 for lower-income countries (LICs), lower-middle income countries (LMICs), and upper middle-income countries (UMICs), respectively, totaling 240,463 for Africa. Under the retesting scenario, costs per person initially diagnosed were: $40, $21, and $42, for LICs, LMICs, and UMICs, respectively. When retesting for verification is implemented, the savings in unnecessary ART were $125, $43, and $75 per person initially diagnosed, for LICs, LMICs, and UMICs, respectively. Over the ten-year horizon, the total costs under the retesting scenario, over all country income levels, was $475 million, and was $1.192 billion under the no retesting scenario, representing total estimated savings of $717 million in HIV treatment costs averted. CONCLUSIONS Results show that to reduce HIV misdiagnosis, countries in Africa should implement the WHO's recommendation of retesting for verification prior to ART initiation, as part of a comprehensive quality assurance program for HIV testing services.
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Detels R, Wu J, Wu Z. Control of HIV/AIDS can be achieved with multi-strategies. GLOBAL HEALTH JOURNAL 2019. [DOI: 10.1016/j.glohj.2019.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Smyrnov P, Williams LD, Korobchuk A, Sazonova Y, Nikolopoulos GK, Skaathun B, Morgan E, Schneider J, Vasylyeva TI, Friedman SR. Risk network approaches to locating undiagnosed HIV cases in Odessa, Ukraine. J Int AIDS Soc 2019; 21. [PMID: 29356365 PMCID: PMC5810318 DOI: 10.1002/jia2.25040] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 12/08/2017] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Providing HIV healthcare and Treatment as Prevention both depend on diagnosing HIV cases, preferably soon after initial infection. We hypothesized that tracing risk networks recruits higher proportions of undiagnosed positives than outreach-based testing or respondent-driven sampling (RDS) in Odessa, Ukraine. METHODS The Transmission Reduction Intervention Project (TRIP) used risk network tracing to recruit sexual and injection networks of recently-infected and longer-term infected (LTs) seeds (2013 to 2016). Integrated Biobehavioural Surveillance (IBBS) (2013) used RDS to recruit people who inject drugs (PWID). Outreach Testing tested PWID for HIV at community outreach sites (2013 to 2016). Proportions of undiagnosed positives among those tested were compared TRIP versus IBBS; TRIP versus Outreach Testing and between TRIP arms. Costs were compared across the projects. RESULTS TRIP tested 1252 people (21% women) in seeds' risk networks; IBBS tested 400 (18% women); Outreach Testing 13,936 (31% women). TRIP networks included a higher proportion of undiagnosed positives (14.6%) than IBBS (5.0%) or Outreach Testing (2.4%); odds ratio (OR) 3.25 (95% CI 2.07, 5.12) versus IBBS and 7.03 (CI 5.95, 8.31) versus Outreach Testing respectively. Findings remained significant in analyses stratified by sex and when PWID in TRIP networks were compared with Outreach Testing and IBBS. Within TRIP, recently-infected participants' networks contained higher proportions of undiagnosed positives (16.3%) than LTs' networks (12.2%); OR 1.41 (CI 1.01, 1.95). TRIP located undiagnosed positives less expensively than did RDS or Outreach Testing. CONCLUSIONS TRIP's recruiting techniques, including prioritizing networks of the recently infected, find undiagnosed HIV-positive people efficiently. They should be integrated with standard practice to improve case-finding. Research should test these techniques in other socio-epidemiologic contexts. CLINICAL TRIAL REGISTRY Registered ClinicalTrials.gov: NCT01827228.
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Affiliation(s)
| | | | | | | | | | - Britt Skaathun
- University of Chicago, Chicago, IL, USA.,Division of Global Public Health, University of California, San Diego, CA, USA
| | | | - John Schneider
- Department of Medicine and Center for HIV Elimination, University of Chicago, Chicago, IL, USA
| | | | - Samuel R Friedman
- National Development and Research Institutes, New York, NY, USA.,Center for Drug Use and HIV Research, New York, NY, USA
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Cham HJ, MacKellar D, Maruyama H, Rwabiyago OE, Msumi O, Steiner C, Kundi G, Weber R, Byrd J, Suraratdecha C, Mengistu T, Churi E, Pals S, Madevu-Matson C, Alexander G, Porter S, Kazaura K, Mbilinyi D, Morales F, Rutachunzibwa T, Justman J, Rwebembera A. Methods, outcomes, and costs of a 2.5 year comprehensive facility-and community-based HIV testing intervention in Bukoba Municipal Council, Tanzania, 2014-2017. PLoS One 2019; 14:e0215654. [PMID: 31048912 PMCID: PMC6497243 DOI: 10.1371/journal.pone.0215654] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 04/07/2019] [Indexed: 11/18/2022] Open
Abstract
To diagnose ≥90% HIV-infected residents (diagnostic coverage), the Bukoba Combination Prevention Evaluation (BCPE) implemented provider-initiated (PITC), home- (HBHTC), and venue-based (VBHTC) HIV testing and counseling (HTC) intervention in Bukoba Municipal Council, a mixed urban and rural lake zone community of 150,000 residents in Tanzania. This paper describes the methods, outcomes, and incremental costs of these HTC interventions. PITC was implemented in outpatient department clinics in all eight public and three faith-based health facilities. In clinics, lay counselors routinely screened and referred eligible patients for HIV testing conducted by HTC-dedicated healthcare workers. In all 14 wards, community teams offered HTC to eligible persons encountered at 31,293 home visits and at 79 male- and youth-frequented venues. HTC was recommended for persons who were not in HIV care or had not tested in the prior 90 days. BCPE conducted 133,695 HIV tests during the 2.5 year intervention (PITC: 88,813, 66%; HBHTC: 27,407, 21%; VBHTC: 17,475, 13%). Compared with other strategies, PITC conducted proportionally more tests among females (65%), and VBHTC conducted proportionally more tests among males (69%) and young-adults aged 15-24 years (42%). Of 5,550 (4.2% of all tests) HIV-positive tests, 4,143 (75%) clients were newly HIV diagnosed, including 1,583 males and 881 young adults aged 15-24 years. Of HIV tests conducted 3.7%, 1.8%, and 2.1% of PITC, HBHTC, and VBHTC clients, respectively, were newly HIV diagnosed; PITC accounted for 79% of all new diagnoses. Cost per test (per new diagnosis) was $4.55 ($123.66), $6.45 ($354.44), and $7.98 ($372.67) for PITC, HBHTC, and VBHTC, respectively. In a task-shifting analysis in which lay counselors replaced healthcare workers, estimated costs per test (per new diagnosis) would have been $3.06 ($83.15), $ 4.81 ($264.04), and $5.45 ($254.52), for PITC, HBHTC, and VBHTC, respectively. BCPE models reached different target groups, including men and young adults, two groups with consistently low coverage. Implementation of multiple models is likely necessary to achieve ≥90% diagnostic coverage.
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Affiliation(s)
- Haddi Jatou Cham
- Division of Global HIV and TB, National Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- * E-mail:
| | - Duncan MacKellar
- Division of Global HIV and TB, National Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | | | | | - Omari Msumi
- ICAP at Columbia University, Dar es Salaam, Tanzania
| | | | - Gerald Kundi
- ICAP at Columbia University, Dar es Salaam, Tanzania
| | - Rachel Weber
- U.S. Centers for Disease Control and Prevention, Yaounde, Cameroon
| | - Johnita Byrd
- ICF International, Atlanta, Georgia, United States of America
| | - Chutima Suraratdecha
- Division of Global HIV and TB, National Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Tewodaj Mengistu
- Division of Global HIV and TB, National Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Eliufoo Churi
- Henry Jackson Foundation Medical Research International, Mbeya, Tanzania
| | - Sherri Pals
- Division of Global HIV and TB, National Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | | | | | - Sarah Porter
- Division of Global HIV and TB, National Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Kokuhumbya Kazaura
- U.S. Centers for Disease Control and Prevention, Dar es Salaam, Tanzania
| | | | | | - Thomas Rutachunzibwa
- Ministry of Health, Community Development, Gender, Elderly and Children, Bukoba, Tanzania
| | | | - Anath Rwebembera
- National AIDS Control Program, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
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Lasry A, Bachanas P, Suraratdecha C, Alwano MG, Behel S, Pals S, Block L, Moore J. Cost of Community-Based HIV Testing Activities to Reach Saturation in Botswana. AIDS Behav 2019; 23:875-882. [PMID: 30673897 DOI: 10.1007/s10461-019-02408-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In Botswana, 85% of persons living with HIV are aware of their status. We performed an economic analysis of HIV testing activities implemented during intensive campaigns, in 11 communities, between April 2015 and March 2016, through the Botswana Combination Prevention Project. The total cost was $1,098,312, or $99,847 per community, with 60% attributable to home-based testing and 40% attributable to mobile testing. The cost per person tested was $44, and $671 per person testing positive (2017 USD). Labor costs comprised 64% of total costs. In areas of high HIV prevalence and treatment coverage, the cost of untargeted home-based testing may be inflated by the efforts required to assess the testing eligibility of clients who are HIV-positive and on ART. Home-based and mobile testing delivered though an intensive community-based campaign allowed the identification of HIV positive persons, who may not access health facilities, at a cost comparable to other studies.
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Affiliation(s)
- Arielle Lasry
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop E-04, Atlanta, GA, 30329-4018, USA.
| | - Pamela Bachanas
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop E-04, Atlanta, GA, 30329-4018, USA
| | - Chutima Suraratdecha
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop E-04, Atlanta, GA, 30329-4018, USA
| | - Mary Grace Alwano
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop E-04, Atlanta, GA, 30329-4018, USA
| | - Stephanie Behel
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop E-04, Atlanta, GA, 30329-4018, USA
| | - Sherri Pals
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop E-04, Atlanta, GA, 30329-4018, USA
| | - Lisa Block
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop E-04, Atlanta, GA, 30329-4018, USA
| | - Janet Moore
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop E-04, Atlanta, GA, 30329-4018, USA
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Mangenah C, Mwenge L, Sande L, Ahmed N, d'Elbée M, Chiwawa P, Chigwenah T, Kanema S, Mutseta MN, Nalubamba M, Chilongosi R, Indravudh P, Sibanda EL, Neuman M, Ncube G, Ong JJ, Mugurungi O, Hatzold K, Johnson CC, Ayles H, Corbett EL, Cowan FM, Maheswaran H, Terris‐Prestholt F. Economic cost analysis of door-to-door community-based distribution of HIV self-test kits in Malawi, Zambia and Zimbabwe. J Int AIDS Soc 2019; 22 Suppl 1:e25255. [PMID: 30907499 PMCID: PMC6432106 DOI: 10.1002/jia2.25255] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 01/18/2019] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION HIV self-testing (HIVST) is recommended by the World Health Organization in addition to other testing modalities to increase uptake of HIV testing, particularly among harder-to-reach populations. This study provides the first empirical evidence of the costs of door-to-door community-based HIVST distribution in Malawi, Zambia and Zimbabwe. METHODS HIVST kits were distributed door-to-door in 71 sites across Malawi, Zambia and Zimbabwe from June 2016 to May 2017. Programme expenditures, supplemented by on-site observation and monitoring and evaluation data were used to estimate total economic and unit costs of HIVST distribution, by input and site. Inputs were categorized into start-up, capital and recurrent costs. Sensitivity and scenario analyses were performed to assess the impact of key parameters on unit costs. RESULTS In total, 152,671, 103,589 and 93,459 HIVST kits were distributed in Malawi, Zambia and Zimbabwe over 12, 11 and 10 months respectively. Across these countries, 43% to 51% of HIVST kits were distributed to men. The average cost per HIVST kit distributed was US$8.15, US$16.42 and US$13.84 in Malawi, Zambia and Zimbabwe, respectively, with pronounced intersite variation within countries driven largely by site-level fixed costs. Site-level recurrent costs were 70% to 92% of full costs and 20% to 62% higher than routine HIV testing services (HTS) costs. Personnel costs contributed from 26% to 52% of total costs across countries reflecting differences in remuneration approaches and country GDP. CONCLUSIONS These early door-to-door community HIVST distribution programmes show large potential, both for reaching untested populations and for substantial economies of scale as HIVST programmes scale-up and mature. From a societal perspective, the costs of HIVST appear similar to conventional HTS, with the higher providers' costs substantially offsetting user costs. Future approaches to minimizing cost and/or maximize testing coverage could include unpaid door-to-door community-led distribution to reach end-users and integrating HIVST into routine clinical services via direct or secondary distribution strategies with lower fixed costs.
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Affiliation(s)
| | | | - Linda Sande
- Malawi‐Liverpool‐Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
- Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Nurilign Ahmed
- Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Marc d'Elbée
- Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | | | | | | | | | | | | | - Pitchaya Indravudh
- Malawi‐Liverpool‐Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
- Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Euphemia L Sibanda
- Centre for Sexual HealthHIV and AIDS ResearchHarareZimbabwe
- Liverpool School of Tropical MedicineLiverpoolUK
| | | | | | - Jason J Ong
- Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
| | | | | | - Cheryl C Johnson
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
- Department of HIV/AIDSWorld Health OrganizationGenevaSwitzerland
| | - Helen Ayles
- ZambartLusakaZambia
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
| | - Elizabeth L Corbett
- Malawi‐Liverpool‐Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
| | - Frances M Cowan
- Centre for Sexual HealthHIV and AIDS ResearchHarareZimbabwe
- Liverpool School of Tropical MedicineLiverpoolUK
| | | | - Fern Terris‐Prestholt
- Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
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Meyer-Rath G, van Rensburg C, Chiu C, Leuner R, Jamieson L, Cohen S. The per-patient costs of HIV services in South Africa: Systematic review and application in the South African HIV Investment Case. PLoS One 2019; 14:e0210497. [PMID: 30807573 PMCID: PMC6391029 DOI: 10.1371/journal.pone.0210497] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 12/23/2018] [Indexed: 12/29/2022] Open
Abstract
Background In economic analyses of HIV interventions, South Africa is often used as a case in point, due to the availability of good epidemiological and programme data and the global relevance of its epidemic. Few analyses however use locally relevant cost data. We reviewed available cost data as part of the South African HIV Investment Case, a modelling exercise to inform the optimal use of financial resources for the country’s HIV programme. Methods We systematically reviewed publication databases for published cost data covering a large range of HIV interventions and summarised relevant unit costs (cost per person receiving a service) for each. Where no data was found in the literature, we constructed unit costs either based on available information regarding ingredients and relevant public-sector prices, or based on expenditure records. Results Only 42 (5%) of 1,047 records included in our full-text review reported primary cost data on HIV interventions in South Africa, with 71% of included papers covering ART. Other papers detailed the costs of HCT, MMC, palliative and inpatient care; no papers were found on the costs of PrEP, social and behaviour change communication, and PMTCT. The results informed unit costs for 5 of 11 intervention categories included in the Investment Case, with the remainder costed based on ingredients (35%) and expenditure data (10%). Conclusions A large number of modelled economic analyses of HIV interventions in South Africa use as inputs the same, often outdated, cost analyses, without reference to additional literature review. More primary cost analyses of non-ART interventions are needed.
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Affiliation(s)
- Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Center for Global Health and Development, Boston University, Boston, Massachusetts, United States of America
- * E-mail:
| | - Craig van Rensburg
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Calvin Chiu
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rahma Leuner
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lise Jamieson
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Steve Cohen
- Strategic Development Consultants, Pietermaritzburg, South Africa
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Lewis L, Maughan-Brown B, Grobler A, Cawood C, Khanyile D, Glenshaw M, Kharsany ABM. Impact of Home-Based HIV Testing Services on Progress Toward the UNAIDS 90-90-90 Targets in a Hyperendemic Area of South Africa. J Acquir Immune Defic Syndr 2019; 80:135-144. [PMID: 30422908 PMCID: PMC6331263 DOI: 10.1097/qai.0000000000001900] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In several subgroups of South Africa, the percentage of HIV-positive individuals aware of their status falls well below the UNAIDS 90% target. This study examined the impact that home-based HIV testing services (HBHTS) had on knowledge of status in a hyperendemic area of South Africa. METHODS We analysed data from the second cross-sectional HIV Incidence Provincial Surveillance System survey (2015/2016), a representative sample (n = 10,236) of individuals aged 15-49 years. Participants completed a questionnaire, provided blood samples for laboratory testing (used to estimate HIV prevalence), and were offered HBHTS. The proportion of people living with HIV (n = 3870) made aware of their status through HBHTS was measured, and factors associated with HBHTS uptake were identified. RESULTS Knowledge of HIV-positive status at the time of the survey was 62.9% among men and 73.4% among women. Through HBHTS, the percentage of HIV-positive men and women who knew their status rose to 74.2% and 80.5%, respectively. The largest impact was observed among youth (15-24 years). Knowledge of status increased from 36.6% to 59.3% and from 50.8% to 64.8% among young men and women, respectively. In addition, 51.4% of those who had previously never tested received their first test. Key reasons for declining HBHTS among undiagnosed HIV-positive individuals included fear and self-report of an HIV-negative status. CONCLUSIONS HBHTS was effective in increasing awareness of HIV-positive status, particularly among youth, men, and those who had never tested. HBHTS could have a marked impact on progress toward the UNAIDS 90-90-90 targets within these subgroups.
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Affiliation(s)
- Lara Lewis
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Brendan Maughan-Brown
- Southern Africa Labour and Development Research Unit, University of Cape Town, Cape Town, South Africa
| | - Anneke Grobler
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children’s Research Institute, Melbourne, Australia
| | - Cherie Cawood
- Epicentre AIDS Risk Management (Pty) Limited, P O Box 3484, Paarl 7620, Cape Town, South Africa
| | - David Khanyile
- Epicentre AIDS Risk Management (Pty) Limited, P O Box 3484, Paarl 7620, Cape Town, South Africa
| | - Mary Glenshaw
- Centres for Disease Control and Prevention (CDC), Pretoria, South Africa
| | - Ayesha BM Kharsany
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
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Acceptability of Home-Based Human Immunodeficiency Virus Testing and Counseling in Low- and Middle-Income Countries. POINT OF CARE 2018. [DOI: 10.1097/poc.0000000000000172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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"If you are here at the clinic, you do not know how many people need help in the community": Perspectives of home-based HIV services from health care workers in rural KwaZulu-Natal, South Africa in the era of universal test-and-treat. PLoS One 2018; 13:e0202473. [PMID: 30412926 PMCID: PMC6226311 DOI: 10.1371/journal.pone.0202473] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 08/03/2018] [Indexed: 12/21/2022] Open
Abstract
Background Limited engagement in clinic-based care is affecting the HIV response. We explored the field experiences and perceptions of local health care workers regarding home-based strategies as opportunities to improve the cascade of care of people living with HIV in rural South Africa as part of a Universal Test-and-Treat approach. Methods In Hlabisa sub-district, home-based HIV services, including rapid HIV testing and counselling, and support for linkage to and retention in clinic-based HIV care, were implemented by health care workers within the ANRS 12249 Treatment-as-Prevention (TasP) trial. From April to July 2016, we conducted a mixed-methods study among health care workers from the TasP trial and from local government clinics, using self-administrated questionnaires (n = 90 in the TasP trial, n = 56 in government clinics), semi-structured interviews (n = 13 in the TasP trial, n = 5 in government clinics) and three focus group discussions (n = 6–10 health care workers of the TasP trial per group). Descriptive statistics were used for quantitative data and qualitative data were analysed thematically. Results More than 90% of health care workers assessed home-based testing and support for linkage to care as feasible and acceptable by the population they serve. Many health care workers underlined how home visits could facilitate reaching people who had slipped through the cracks of the clinic-based health care system and encourage them to successfully access care. Health care workers however expressed concerns about the ability of home-based services to answer the HIV care needs of all community members, including people working outside their home during the day or those who fear HIV-related stigmatization. Overall, health care workers encouraged policy-makers to more formally integrate home-based services in the local health system. They promoted reshaping the disease-specific and care-oriented services towards more comprehensive goals. Conclusion Because home-based services allow identification of people early during their infection and encourage them to take actions leading to viral suppression, HCWs assessed them as valuable components within the panel of UTT interventions, aiming to reach the 90-90-90 UNAIDS targets, especially in the rural Southern African region. Trial registration The registration number of the ANRS 12249 TasP trial on ClinicalTrials.gov is NCT01509508.
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Feasibility and acceptability of home-based HIV testing among refugees: a pilot study in Nakivale refugee settlement in southwestern Uganda. BMC Infect Dis 2018; 18:332. [PMID: 30012110 PMCID: PMC6048800 DOI: 10.1186/s12879-018-3238-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 07/05/2018] [Indexed: 12/28/2022] Open
Abstract
Background Refugees in sub-Saharan Africa face both the risk of HIV infection and barriers to HIV testing. We conducted a pilot study to determine the feasibility and acceptability of home-based HIV testing in Nakivale Refugee Settlement in Uganda and to compare home-based and clinic-based testing participants in Nakivale. Methods From February–March 2014, we visited homes in 3 villages in Nakivale up to 3 times and offered HIV testing. We enrolled adults who spoke English, Kiswahili, Kinyarwanda, or Runyankore; some were refugees and some Ugandan nationals. We surveyed them about their socio-demographic characteristics. We evaluated the proportion of individuals encountered (feasibility) and assessed participation in HIV testing among those encountered (acceptability). We compared characteristics of home-based and clinic-based testers (from a prior study in Nakivale) using Wilcoxon rank sum and Pearson’s chi-square tests. We examined the relationship between a limited number of factors (time of visit, sex, and number of individuals at home) on willingness to test, using logistic regression models with the generalized estimating equations approach to account for clustering. Results Of 566 adults living in 319 homes, we encountered 507 (feasibility = 90%): 353 (62%) were present at visit one, 127 (22%) additional people at visit two, and 27 (5%) additional people at visit three. Home-based HIV testing participants totaled 378 (acceptability = 75%). Compared to clinic-based testers, home-based testers were older (median age 30 [IQR 24–40] vs 28 [IQR 22–37], p < 0.001), more likely refugee than Ugandan national (93% vs 79%, < 0.001), and more likely to live ≥1 h from clinic (74% vs 52%, < 0.001). The HIV prevalence was lower, but not significantly, in home-based compared to clinic-based testing participants (1.9 vs 3.4% respectively, p = 0.27). Testing was not associated with time of visit (p = 0.50) or sex (p = 0.66), but for each additional person at home, the odds of accepting HIV testing increased by over 50% (OR 1.52, 95%CI 1.12–2.06, p = 0.007). Conclusions Home-based HIV testing in Nakivale Refugee Settlement was feasible, with 90% of eligible individuals encountered within 3 visits, and acceptable with 75% willing to test for HIV, with a yield of nearly 2% individuals tested identified as HIV-positive.
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Cost-effectiveness of health care service delivery interventions in low and middle income countries: a systematic review. Glob Health Res Policy 2018; 3:17. [PMID: 29930989 PMCID: PMC5992822 DOI: 10.1186/s41256-018-0073-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 05/07/2018] [Indexed: 01/17/2023] Open
Abstract
Background Low and middle income countries (LMICs) face severe resource limitations but the highest burden of disease. There is a growing evidence base on effective and cost-effective interventions for these diseases. However, questions remain about the most cost-effective method of delivery for these interventions. We aimed to review the scope, quality, and findings of economic evaluations of service delivery interventions in LMICs. Methods We searched PUBMED, MEDLINE, EconLit, and NHS EED for studies published between 1st January 2000 and 30th October 2016 with no language restrictions. We included all economic evaluations that reported incremental costs and benefits or summary measures of the two such as an incremental cost effectiveness ratio. Studies were grouped by both disease area and outcome measure and permutation plots were completed for similar interventions. Quality was judged by the Drummond checklist. Results Overall, 3818 potentially relevant abstracts were identified of which 101 studies were selected for full text review. Thirty-seven studies were included in the final review. Twenty-three studies reported on interventions we classed as “changing by whom and where care was provided”, specifically interventions that entailed task-shifting from doctors to nurses or community health workers or from facilities into the community. Evidence suggests this type of intervention is likely to be cost-effective or cost-saving. Nine studies reported on quality improvement initiatives, which were generally found to be cost-effective. Quality and methods differed widely limiting comparability of the studies and findings. Conclusions There is significant heterogeneity in the literature, both methodologically and in quality. This renders further comparisons difficult and limits the utility of the available evidence to decision makers.
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Naik R, Zembe W, Adigun F, Jackson E, Tabana H, Jackson D, Feeley F, Doherty T. What Influences Linkage to Care After Home-Based HIV Counseling and Testing? AIDS Behav 2018. [PMID: 28643242 PMCID: PMC5847222 DOI: 10.1007/s10461-017-1830-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
To maximize the benefits of test and treat strategies that utilize community-based HIV testing, clients who test positive must link to care in a timely manner. However, linkage rates across the HIV treatment cascade are typically low and little is known about what might facilitate or hinder care-seeking behavior. This qualitative study was conducted within a home-based HIV counseling and testing (HBHCT) intervention in South Africa. In-depth interviews were conducted with 30 HBHCT clients who tested HIV positive to explore what influenced their care-seeking behavior. A set of field notes for 196 additional HBHCT clients who tested HIV positive at home were also reviewed and analyzed. Content analysis showed that linkage to care is influenced by a myriad of factors at the individual, relationship, community, and health system levels. These factors subtly interact and at times reinforce each other. While some factors such as belief in test results, coping ability, social support, and prior experiences with the health system affect clients’ desire and motivation to seek care, others such as limited time and resources affect their agency to do so. To ensure that the benefits of community-based testing models are realized through timely linkage to care, programs and interventions must take into account and address clients’ emotions, motivation levels, living situations, relationship dynamics, responsibilities, and personal resources.
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Affiliation(s)
- Reshma Naik
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa.
- Department of Global Health, School of Public Health, Boston University, Boston, MA, USA.
- Population Reference Bureau, 1875 Connecticut Avenue, NW, Suite 520, Washington, DC, USA.
| | - Wanga Zembe
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
| | - Fatima Adigun
- Department of Global Health, School of Public Health, Boston University, Boston, MA, USA
| | - Elizabeth Jackson
- Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York City, NY, USA
| | - Hanani Tabana
- Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden
| | - Debra Jackson
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Frank Feeley
- Department of Global Health, School of Public Health, Boston University, Boston, MA, USA
| | - Tanya Doherty
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
- School of Public Health, University of the Western Cape, Bellville, South Africa
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Maughan-Brown B, Smith P, Kuo C, Harrison A, Lurie MN, Bekker LG, Galárraga O. Readiness for Antiretroviral Therapy: Implications for Linking HIV-Infected Individuals to Care and Treatment. AIDS Behav 2018; 22:691-700. [PMID: 28752353 PMCID: PMC5785568 DOI: 10.1007/s10461-017-1834-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Using survey data collected immediately after referral for ART (N = 87), this study examined ART-readiness among individuals (18 years and older) attending a mobile health clinic in South Africa. Most participants reported being very ready (84%) and motivated (85%) to start ART, but only 72% were assessed as ready for ART on all measures. Treatment readiness was lower among individuals who did not think they would test HIV-positive (aOR 0.26, p < 0.05) and among individuals who reported being in good health (aOR 0.44, p < 0.1). In contrast, higher readiness was associated with better ART knowledge (aOR 4.31, p < 0.05) and knowing someone who had experienced positive health effects from ART (aOR 2.65, p < 0.05). Results indicate that post-test counselling will need to be designed to deal with surprise at HIV diagnosis, and that health messaging needs to be carefully crafted to support uptake of ART among HIV-positive but healthy individuals. Further research is needed on effective post-test counselling approaches and effective framing of health messaging to increase awareness of the multiple positive benefits of early ART initiation and corresponding readiness to engage in treatment.
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Affiliation(s)
- Brendan Maughan-Brown
- Southern Africa Labour and Development Research Unit, University of Cape Town, Private Bag Rondebosch, Cape Town, 7701, South Africa.
| | - Philip Smith
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Caroline Kuo
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Abigail Harrison
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Mark N Lurie
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Omar Galárraga
- Department of Health Services, Policy & Practice (HSPP), Brown University School of Public Health, Providence, RI, USA
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Maughan-Brown B, Smith P, Kuo C, Harrison A, Lurie MN, Bekker LG, Galárraga O. A Conditional Economic Incentive Fails to Improve Linkage to Care and Antiretroviral Therapy Initiation Among HIV-Positive Adults in Cape Town, South Africa. AIDS Patient Care STDS 2018; 32:70-78. [PMID: 29432045 PMCID: PMC5808383 DOI: 10.1089/apc.2017.0238] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Interventions to improve antiretroviral therapy (ART) access are urgently needed to maximize the multiple benefits from ART. This pilot study examined the effect of a conditional economic incentive on linkage to care and uptake of treatment following ART referral by a mobile health clinic. Between April 2015 and May 2016, 86 individuals (≥18 years old) referred for ART in a resource-limited setting were randomized (1:1) to a control group or to an incentive: R300 cash (∼$23, or 3.5 days minimum wage in the domestic worker sector), conditional upon starting ART within 3 months. Outcome data were obtained from clinic records. The incentive effects on linkage to care (first clinic visit within 3 months) and ART initiation (treatment uptake within 3 months) were assessed using logistic regression. Overall, 67% linked to care and 42% initiated ART within 3 months after referral. No significant differences were found between the incentive and non-incentive group in terms of linkage to care [adjusted odds ratio (aOR): 0.70, 95% confidence interval (CI): 0.26-1.91] and initiation of ART (aOR: 0.67, 95% CI: 0.26-1.78). Ordinary least-squares regression analysis showed that incentivized individuals linked to care in fewer days (-7.9, 95% CI: -18.09 to 2.26) and started treatment in fewer days (-7.3, 95% CI: -27.01 to 12.38), but neither result was statistically significant. Our findings demonstrate poor treatment uptake by both the intervention and control participants and further highlight the challenge in achieving universal early treatment access. Further research is required to understand how economic incentives, which have been shown to have many benefits, can be applied to improve linkage to HIV care and treatment.
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Affiliation(s)
- Brendan Maughan-Brown
- Southern Africa Labour and Development Research Unit (SALDRU), University of Cape Town, Cape Town, South Africa
| | - Philip Smith
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Caroline Kuo
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Abigail Harrison
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island
| | - Mark N. Lurie
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Omar Galárraga
- Department of Health Services, Policy and Practice (HSPP), Brown University School of Public Health, Providence, Rhode Island
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Nkonki LL, Chola LL, Tugendhaft AA, Hofman KK. Modelling the cost of community interventions to reduce child mortality in South Africa using the Lives Saved Tool (LiST). BMJ Open 2017; 7:e011425. [PMID: 28851766 PMCID: PMC5577872 DOI: 10.1136/bmjopen-2016-011425] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 01/18/2017] [Accepted: 03/17/2017] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE To estimate the costs and impact on reducing child mortality of scaling up interventions that can be delivered by community health workers at community level from a provider's perspective. SETTING In this study, we used the Lives Saved Tool (LiST), a module in the spectrum software. Within the spectrum software, LiST interacts with other modules, the AIDS Impact Module, Family Planning Module and Demography Projections Module (Dem Proj), to model the impact of more than 60 interventions that affect cause-specific mortality. PARTICIPANTS DemProj Based on National South African Data. INTERVENTIONS A total of nine interventions namely, breastfeeding promotion, complementary feeding, vitamin supplementation, hand washing with soap, hygienic disposal of children's stools, oral rehydration solution, oral antibiotics for the treatment of pneumonia, therapeutic feeding for wasting and treatment for moderate malnutrition. PRIMARY AND SECONDARY OUTCOME MEASURES Reducing child mortality. RESULTS A total of 9 interventions can prevent 8891 deaths by 2030. Hand washing with soap (21%) accounts for the highest number of deaths prevented, followed by therapeutic feeding (19%) and oral rehydration therapy (16%). The top 5 interventions account for 77% of all deaths prevented. At scale, an estimated cost of US$169.5 million (US$3 per capita) per year will be required in community health worker costs. CONCLUSION The use of community health workers offers enormous opportunities for saving lives. These programmes require appropriate financial investments. Findings from this study show what can be achieved if concerted effort is channelled towards the identified set of life-saving interventions.
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Affiliation(s)
- Lungiswa Ll Nkonki
- Division of Community Health, Centre for Health Systems and Services Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Lumbwe L Chola
- Population Health, Health Systems and Innovation, Human Science Research Council, Pretoria, South africa
| | - Aviva A Tugendhaft
- PRICELESS SA-MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South africa
| | - Karen K Hofman
- PRICELESS SA-MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South africa
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Ruzagira E, Baisley K, Kamali A, Biraro S, Grosskurth H. Linkage to HIV care after home-based HIV counselling and testing in sub-Saharan Africa: a systematic review. Trop Med Int Health 2017; 22:807-821. [PMID: 28449385 DOI: 10.1111/tmi.12888] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Home-based HIV counselling and testing (HBHCT) has the potential to increase HIV testing uptake in sub-Saharan Africa (SSA), but data on linkage to HIV care after HBHCT are scarce. We conducted a systematic review of linkage to care after HBHCT in SSA. METHODS Five databases were searched for studies published between 1st January 2000 and 19th August 2016 that reported on linkage to care among adults newly identified with HIV infection through HBHCT. Eligible studies were reviewed, assessed for risk of bias and findings summarised using the PRISMA guidelines. RESULTS A total of 14 studies from six countries met the eligibility criteria; nine used specific strategies (point-of-care CD4 count testing, follow-up counselling, provision of transport funds to clinic and counsellor facilitation of HIV clinic visit) in addition to routine referral to facilitate linkage to care. Time intervals for ascertaining linkage ranged from 1 week to 12 months post-HBHCT. Linkage ranged from 8.2% [95% confidence interval (CI), 6.8-9.8%] to 99.1% (95% CI, 96.9-99.9%). Linkage was generally lower (<33%) if HBHCT was followed by referral only, and higher (>80%) if additional strategies were used. Only one study assessed linkage by means of a randomised trial. Five studies had data on cotrimoxazole (CTX) prophylaxis and 12 on ART eligibility and initiation. CTX uptake among those eligible ranged from 0% to 100%. The proportion of persons eligible for ART ranged from 16.5% (95% CI, 12.1-21.8) to 77.8% (95% CI, 40.0-97.2). ART initiation among those eligible ranged from 14.3% (95% CI, 0.36-57.9%) to 94.9% (95% CI, 91.3-97.4%). Additional linkage strategies, whilst seeming to increase linkage, were not associated with higher uptake of CTX and/or ART. Most of the studies were susceptible to risk of outcome ascertainment bias. A pooled analysis was not performed because of heterogeneity across studies with regard to design, setting and the key variable definitions. CONCLUSION Only few studies from SSA investigated linkage to care among adults newly diagnosed with HIV through HBHCT. Linkage was often low after routine referral but higher if additional interventions were used to facilitate it. The effectiveness of linkage strategies should be confirmed through randomised controlled trials.
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Affiliation(s)
- Eugene Ruzagira
- London School of Hygiene and Tropical Medicine, London, UK.,MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
| | - Kathy Baisley
- London School of Hygiene and Tropical Medicine, London, UK
| | - Anatoli Kamali
- MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda.,International AIDS Vaccine Initiative, New York, NY, USA
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A Comparison of Home-Based Versus Outreach Event-Based Community HIV Testing in Ugandan Fisherfolk Communities. AIDS Behav 2017; 21:547-560. [PMID: 27900501 DOI: 10.1007/s10461-016-1629-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
We compared two community-based HIV testing models among fisherfolk in Lake Victoria, Uganda. From May to July 2015, 1364 fisherfolk residents of one island were offered (and 822 received) home-based testing, and 344 fisherfolk on another island were offered testing during eight community mobilization events (outreach event-based testing). Of 207 home-based testing clients identified as HIV-positive (15% of residents), 82 were newly diagnosed, of whom 31 (38%) linked to care within 3 months. Of 41 who screened positive during event-based testing (12% of those tested), 33 were newly diagnosed, of whom 24 (75%) linked to care within 3 months. Testing costs per capita were similar for home-based ($45.09) and event-based testing ($46.99). Compared to event-based testing, home-based testing uncovered a higher number of new HIV cases but was associated with lower linkage to care. Novel community-based test-and-treat programs are needed to ensure timely linkage to care for newly diagnosed fisherfolk.
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Gilbert JA, Shenoi SV, Moll AP, Friedland GH, Paltiel AD, Galvani AP. Cost-Effectiveness of Community-Based TB/HIV Screening and Linkage to Care in Rural South Africa. PLoS One 2016; 11:e0165614. [PMID: 27906986 PMCID: PMC5131994 DOI: 10.1371/journal.pone.0165614] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 10/15/2016] [Indexed: 01/08/2023] Open
Abstract
South Africa has one of the highest burdens of TB worldwide, driven by the country's widespread prevalence of HIV, and further complicated by drug resistance. Active case finding within the community, particularly in rural areas where healthcare access is limited, can significantly improve diagnosis and treatment coverage in high-incidence settings. We evaluated the potential health and economic consequences of implementing community-based TB/HIV screening and linkage to care. Using a dynamic model of TB and HIV transmission over a time horizon of 10 years, we compared status quo TB/HIV control to community-based TB/HIV screening at frequencies of once every two years, one year, and six months. We also considered the impact of extending IPT from 36 months for TST positive and 12 months for TST negative or unknown patients (36/12) to lifetime use for all HIV-infected patients. We conducted a probabilistic sensitivity analysis to assess the effect of parameter uncertainty on the cost-effectiveness results. We identified four strategies that saved the most life years for a given outlay: status quo TB/HIV control with 36/12 months of IPT and TB/HIV screening strategies at frequencies of once every two years, one year, and six months with lifetime IPT. All of these strategies were very cost-effective at a threshold of $6,618 per life year saved (the per capita GDP of South Africa). Community-based TB/HIV screening with linkage to care is therefore very cost-effective in rural South Africa.
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Affiliation(s)
- Jennifer A. Gilbert
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
- Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Sheela V. Shenoi
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Anthony P. Moll
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, Connecticut, United States of America
- Church of Scotland Hospital, Tugela Ferry, KwaZulu-Natal, South Africa
| | - Gerald H. Friedland
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - A. David Paltiel
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Alison P. Galvani
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
- Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut, United States of America
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Abstract
Among Ugandan fisherfolk, HIV prevalence (with estimates ranging from 15 to 40 %) is higher than in the general population (about 7 %), potentially due to high-risk behaviors and low access to HIV testing and healthcare. We conducted semi-structured interviews on barriers to linkage to care with 10 key stakeholders and 25 fisherfolk within 1-2 months of their testing HIV-positive at clinic outreach events in Ugandan Lake Victoria communities. Interviews were recorded, transcribed, translated, and coded using grounded theory methods. Participants cited low healthcare access and quality of care, mobility, competing needs for work during clinic hours, stigma, and low social support as barriers. Over 10 % of clients screened positive for HIV at outreach events, and only half accessed care. Linkage to care issues may begin with the failure to attract high-risk fisherfolk to testing. New models of HIV testing and treatment delivery are needed to reach fisherfolk.
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Access to HIV care in the context of universal test and treat: challenges within the ANRS 12249 TasP cluster-randomized trial in rural South Africa. J Int AIDS Soc 2016; 19:20913. [PMID: 27258430 PMCID: PMC4891946 DOI: 10.7448/ias.19.1.20913] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 04/09/2016] [Accepted: 04/26/2016] [Indexed: 01/09/2023] Open
Abstract
Introduction We aimed to quantify and identify associated factors of linkage to HIV care following home-based HIV counselling and testing (HBHCT) in the ongoing ANRS 12249 treatment-as-prevention (TasP) cluster-randomized trial in rural KwaZulu-Natal, South Africa. Methods Individuals ≥16 years were offered HBHCT; those who were identified HIV positive were referred to cluster-based TasP clinics and offered antiretroviral treatment (ART) immediately (five clusters) or according to national guidelines (five clusters). HIV care was also available in the local Department of Health (DoH) clinics. Linkage to HIV care was defined as TasP or DoH clinic attendance within three months of referral among adults not in HIV care at referral. Associated factors were identified using multivariable logistic regression adjusted for trial arm. Results Overall, 1323 HIV-positive adults (72.9% women) not in HIV care at referral were included, of whom 36.9% (n=488) linked to care <3 months of referral (similar by sex). In adjusted analyses (n=1222), individuals who had never been in HIV care before referral were significantly less likely to link to care than those who had previously been in care (<33% vs. >42%, p<0.001). Linkage to care was lower in students (adjusted odds-ratio [aOR]=0.47; 95% confidence interval [CI] 0.24–0.92) than in employed adults, in adults who completed secondary school (aOR=0.68; CI 0.49–0.96) or at least some secondary school (aOR=0.59; CI 0.41–0.84) versus ≤ primary school, in those who lived at 1 to 2 km (aOR=0.58; CI 0.44–0.78) or 2–5 km from the nearest TasP clinic (aOR=0.57; CI 0.41–0.77) versus <1 km, and in those who were referred to clinic after ≥2 contacts (aOR=0.75; CI 0.58–0.97) versus those referred at the first contact. Linkage to care was higher in adults who reported knowing an HIV-positive family member (aOR=1.45; CI 1.12–1.86) versus not, and in those who said that they would take ART as soon as possible if they were diagnosed HIV positive (aOR=2.16; CI 1.13–4.10) versus not. Conclusions Fewer than 40% of HIV-positive adults not in care at referral were linked to HIV care within three months of HBHCT in the TasP trial. Achieving universal test and treat coverage will require innovative interventions to support linkage to HIV care.
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Bajunirwe F, Tumwebaze F, Abongomera G, Akakimpa D, Kityo C, Mugyenyi PN. Identification of gaps for implementation science in the HIV prevention, care and treatment cascade; a qualitative study in 19 districts in Uganda. BMC Res Notes 2016; 9:217. [PMID: 27074947 PMCID: PMC4831085 DOI: 10.1186/s13104-016-2024-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 04/05/2016] [Indexed: 12/12/2022] Open
Abstract
Background Over the last 20 years, countries in sub Saharan Africa have made significant strides in the implementation of programs for HIV prevention, care and treatment. Despite, the significant progress made, many targets set by the United Nations have not been met. There remains a large gap between the ideal and what has been achieved. There are several operational issues that may be responsible for this gap, and these need to be addressed in order to achieve the targets. Therefore, the aim of this study was to identify gaps in the HIV prevention, care and treatment cascade, in a large district based HIV implementation program. We aimed to identify gaps that are amenable for evaluation using implementation science, in order to improve the delivery of HIV programs in rural Uganda. Methods We conducted key informant (KI) interviews with 60 district health officers and managers of HIV/AIDS clinics and organizations and 32 focus group discussions with exit clients seeking care and treatment for HIV in the 19 districts. The data analysis process was guided using a framework approach. The recordings were transcribed verbatim. Transcripts were read back and forth and codes generated based on the framework. Results Nine emerging themes that comprise the gaps were identified and these were referral mechanisms indicating several loop holes, low levels of integration of HIV/TB services, low uptake of services for PMTCT services by pregnant women, low coverage of services for most at risk populations (MARPs), poor HIV coordination structures in the districts, poor continuity in the delivery of pediatric HIV/AIDS services, limited community support for orphans and vulnerable (OVC’s), inadequate home based care services and HIV services and support for discordant couples. The themes indicate there are plenty of gaps that need to be covered and have been ignored by current programs. Conclusions Our study has identified several gaps and suggested several interventions that should be tested before large scale implementation. The implementation of these programs should be adequately evaluated in order to provide field evidence of effectiveness and replicability in similar areas.
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Affiliation(s)
- Francis Bajunirwe
- Department of Community Health, Mbarara University of Science and Technology, P.O.BOX 1410, Mbarara, Uganda.
| | - Flora Tumwebaze
- Joint Clinical Research Center, P.O.BOX 10005, Kampala, Uganda
| | | | - Denis Akakimpa
- Joint Clinical Research Center, P.O.BOX 10005, Kampala, Uganda
| | - Cissy Kityo
- Joint Clinical Research Center, P.O.BOX 10005, Kampala, Uganda
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