Cost and cost-effectiveness of transitioning to universal initiation of lifelong antiretroviral therapy for all HIV-positive pregnant and breastfeeding women in Swaziland

HIV Rapid Testing in the General Population and the Usefulness of PrEP in Ecuador: A Cost–Utility Analysis

Introduction

HIV is considered one of the most important chronic transmitted diseases worldwide. The Joint United Nations Program on HIV/AIDS in 2020 proposed the strategy “95–95–95” which goals to achieve a 95% of cases identified, receives ART, and will have achieved suppression of the virus. In Ecuador by 2020, according to the Ministry of Public Health, 45,056 persons are living with HIV, principally men between 15 and 49 years, and a mortality rate of 4.8/100,000 habitats. This study aims to determine the cost–utility of applying an early screening to a sexually active population vs. only a high-risk population and if the use of PrEP is justified depending on different contexts.

Methods

For the cost–utility evaluation, it was compared: (a) HIV screening performed only in the high-risk population vs. HIV screening in all population sexually active; and (b) the use of ART only for HIV treatment vs. ART as a treatment in diagnosed cases and the use of PrEP (only at a high-risk population of acquiring HIV). Calculation and weight of DALYs for HIV/SIDA were obtained through WHO guidelines. To generate the Markov model for HIV/AIDS, subjects were classified as symptomatic or asymptomatic, as well as the HIV deaths.

Results

Cost–benefit analysis (CUA) showed that ICER for early diagnosis had a negative value which means a saving if the strategy will be implemented as a regular test (–$591, –$4,360) and −108 and −934 DALYs, in the case of ART and PrEP, ICER the $30,541–$59,410, which resulted in more than the GDP's threshold and health years between 2,511 and 10,635 in the general population. With a reduction of 70% in the assigned budget for the early diagnosis, Ecuadorian people could lose between 4 and 6 DALYs, while if the budget reduces more than 50% to ART, it will generate a loss of 10–12 years of healthy life.

Conclusion

CUA demonstrates that an early diagnosis in a sexually active population is cost-beneficial. This, combined with ART or PrEP, is ideal to add years of healthy life.

Health Economic Evaluation Alongside Stepped Wedge Trials: A Methodological Systematic Review

BACKGROUND

Recently, there has been an increase in use of the stepped wedge trial (SWT) design in the context of health services research, due to its pragmatic and methodological advantages over the parallel group design.

OBJECTIVE

Our objective was to summarise the statistical methods used when conducting economic evaluations alongside SWTs.

METHODS

A systematic literature search extending to February 2020 was conducted in the PubMed, Scopus, Cochrane and National Health Service Economic Evaluation Database (NHS-EED) databases to find and evaluate studies where there was an intention to conduct an economic evaluation alongside an SWT. Studies were assessed for their eligibility, findings, reporting of statistical methods and quality of reporting.

RESULTS

Of the 586 studies retrieved from the literature search, 69 studies were identified and included in this systematic review. A total of 54 studies were published protocols, with eight economic evaluations and seven studies reporting full trial results. Included studies varied in terms of their reporting of statistical methods, in both detail and methodology. There were 34 studies that did not report any statistical methods for the economic evaluation, and only 16 studies reported appropriate methods, mainly using some form of mixed/multilevel model, and two used seemingly unrelated regression. Twelve studies reported the use of generic bootstrap methods and other modelling techniques, whilst the remaining studies failed to appropriately account for clustering, correlation or adjustment for time.

CONCLUSIONS

The use of appropriate statistical methods that account for time, clustering and correlation between costs and outcomes is an important part of SWT health economics analysis, one that will benefit from an effort to communicate the methods available and their performance.

How is becoming pregnant whilst HIV-positive? Voices of women at a selected rural clinic in Mpumalanga Province of South Africa

Background

Pregnancy decision-making is complicated for HIV-positive women because they have to contend with unpredictable symptoms, potential vertical transmission, and often a problematic life context including poverty, abuse, and stigma.

Purpose

The purpose of the study was to explore the views of HIV-positive women attending a support group at a clinic in the Mpumalanga Province, on becoming pregnant.

Methods

A qualitative, descriptive, and phenomenological research design was adopted to conduct one-on-one interviews using a semi-structured interview guide. Purposive sampling aided the selection of fifteen HIV-positive women who were members of the HIV/AIDS support group at the clinic. Data saturation was reached at participant number 15. Lincoln and Guba's four criteria for ensuring the trustworthiness of data were applied. Data were analysed using the open coding technique.

Results

The following categories emerged: Mitigating fears of becoming pregnant through the prevention of mother-to-child transmission (PMTCT) programme; relationship between becoming pregnant and stigma attached to HIV/AIDS; cultural and social norms about becoming pregnant and the relationship between support groups and becoming pregnant.

Conclusion

The study concluded that the desire to become pregnant amongst HIV-positive women is influenced by several aspects such as knowledge about the prevention of mother to child transmission, cultural values and social norms, and belonging to support groups where they were able to share experiences. Furthermore, becoming pregnant was viewed as an obligation to satisfy their partners/husbands and security to maintain marriages.

Effects of in-hospital breast feeding on brain function development in preterm infants in China: study protocol for a prospective longitudinal cohort study

INTRODUCTION

Due to immature brain development, preterm infants are more likely to develop neurological developmental defects compared with full-term infants. Most preterm infants without neurodevelopmental damage can eventually reach the same scholastic level as their same-age peers; however, some show persistent impairment. Breast feeding (BF), which is an important public health measure, is of great significance for preterm infants. Various active substances in breast milk promote the development of the brain and central nervous system in premature infants. We present a protocol for a prospective longitudinal cohort study to explore the effect of in-hospital BF on brain development in preterm infants and possible influencing factors.

METHODS AND ANALYSIS

This study will enrol 247 Chinese preterm infants (gestational age: 30-34 weeks) delivered in Women's Hospital School of Medicine, Zhejiang University, and transferred to the neonatal intensive care unit. Demographic, clinical and in-hospital BF data will be collected through electronic medical records. Moreover, follow-up data will be obtained by telephone, interview or online. Measurements will be obtained using the Breastfeeding Self-Efficacy Scale-Short Form, neuroimaging with functional near-infrared spectroscopy, extrauterine growth restriction and the Ages and Stages Questionnaire. Follow-up will be performed at 3, 6 and 12 months after birth.

ETHICS AND DISSEMINATION

This study has been approved by the Women's Hospital School of Medicine Zhejiang University Medical Ethics Committee (2019-058). The study results are expected to be published in peer-reviewed journals and reported at relevant national and international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR1900027648; Pre-results.

Cost variations in prevention of mother-to-child HIV transmission services integrated within maternal and child health services in rural Tanzania

We estimated the costs of Option B+ for HIV-infected pregnant women in 12 facilities in Morogoro Region, Tanzania, from a provider perspective. Costs of prevention of mother-to-child (PMTCT) HIV services were measured over 12 months to September 2017 to estimate the average costs per HIV testing episode, per HIV-positive case diagnosed, per patient-year on antiretroviral therapy (ART), and per neonatal HIV care. A one-way sensitivity analysis was undertaken to understand how staffing levels and other core resource inputs affected costs. The total number of HIV testing episodes was 25,593 with 279 HIV cases identified yielding a 1.1% positivity rate. The average cost per testing episode was US$5.49 (range US$2.13 to US$13.93), and the average cost per HIV case detected was US$503.29 (range US$230.61 to US$3330.38). The number of pregnant women initiated on ART was 278. The mean cost per patient-year on ART was US$159.89 (range US$100.91 to US$812.23). The average cost of neonatal HIV care was US$90.09 (range US$41.53 to US$180.26). PMTCT service costs varied widely across facilities due to variations in resource use, number of women testing, and HIV prevalence. The study provides further evidence against generalising cost estimates, and that budgeting and planning requires context specific cost information.

Standardized framework for evaluating costs of active case-finding programs: An analysis of two programs in Cambodia and Tajikistan

INTRODUCTION

Over the years, technological and process innovations enabled active case finding (ACF) programs to expand their capacities and scope to have evolved to close gaps in missing TB patients globally. However, with increased ACF program's operational complexity and a need for significant resource commitments, a comprehensive, transparent, and standardized approach in evaluating costs of ACF programs is needed to properly determine costs and value of ACF programs.

METHODS

Based on reviews of program activity and financial reports, multiple interviews with program managers of two TB REACH funded ACF programs deployed in Cambodia and Tajikistan, we first identified common program components, which formed the basis of the cost data collection, analysis, reporting framework. Within each program component and sub-activity group, cost data were collected and organized by relevant resource types (human resource, capital, recurrent, and overhead costs). Total shared, indirect and overhead costs were apportioned into each activity category based on direct human resource contribution (e.g. a number of staff and their relative level of effort dedicated to each program component). Capital assets were assessed specific to program components and were annualized based on their expected useful life and a 3% discount rate. All costs were assessed based on the service provider perspective and expressed in 2015 USD.

RESULTS

Over the two program years (April 2013 to December 2015), the Cambodia and Tajikistan ACF programs cumulated a total cost of $336,951 and $771,429 to screen 68,846 and 1,980,516 target population, bacteriologically test 4,589 and 19,764 presumptive TB, diagnose 731 and 2,246 TB patients in the respective programs. Recurrent costs were the largest cost components (54% and 34%) of the total costs for the respective programs and Xpert MTB/RIF (Xpert) testing incurred largest program component/activity cost for both programs. Cost per screening was $0.63 and $0.10 and cost per Xpert test was $25 and $18; Cost per TB case detected (Xpert) was $373 and $343 in Cambodia and Tajikistan.

CONCLUSIONS

Results from two contextually and programmatically different multi-component ACF programs demonstrate that our tool is fully capable of comprehensively and transparently evaluating and comparing costs of various ACF programs.