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Shepard DS, Halasa-Rappel YA, Rowlands KR, Kulchyckyj M, Basaza RK, Otieno ED, Mutatina B, Kariuki S, Musange SF. Economic analysis of a new four-panel rapid screening test in antenatal care in Kenya, Rwanda, and Uganda. BMC Health Serv Res 2023; 23:815. [PMID: 37525192 PMCID: PMC10391856 DOI: 10.1186/s12913-023-09775-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 07/03/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND We performed an economic analysis of a new technology used in antenatal care (ANC) clinics, the ANC panel. Introduced in 2019-2020 in five Rwandan districts, the ANC panel screens for four infections [hepatitis B virus (HBV), human immunodeficiency virus (HIV), malaria, and syphilis] using blood from a single fingerstick. It increases the scope and sensitivity of screening over conventional testing. METHODS We developed and applied an Excel-based economic and epidemiologic model to perform cost-effectiveness and cost-benefit analyses of this technology in Kenya, Rwanda, and Uganda. Costs include the ANC panel itself, its administration, and follow-up treatment. Effectiveness models predicted impacts on maternal and infant mortality and other outcomes. Key parameters are the baseline prevalence of each infection and the effectiveness of early treatment using observations from the Rwanda pilot, national and international literature, and expert opinion. For each parameter, we found the best estimate (with 95% confidence bound). RESULTS The ANC panel averted 92 (69-115) disability-adjusted life years (DALYs) per 1,000 pregnant women in ANC in Kenya, 54 (52-57) in Rwanda, and 258 (156-360) in Uganda. Net healthcare costs per woman ranged from $0.53 ($0.02-$4.21) in Kenya, $1.77 ($1.23-$5.60) in Rwanda, and negative $5.01 (-$6.45 to $0.48) in Uganda. Incremental cost-effectiveness ratios (ICERs) in dollars per DALY averted were $5.76 (-$3.50-$11.13) in Kenya, $32.62 ($17.54-$46.70) in Rwanda, and negative $19.40 (-$24.18 to -$15.42) in Uganda. Benefit-cost ratios were $17.48 ($15.90-$23.71) in Kenya, $6.20 ($5.91-$6.45) in Rwanda, and $25.36 ($16.88-$33.14) in Uganda. All results appear very favorable and cost-saving in Uganda. CONCLUSION Though subject to uncertainty, even our lowest estimates were still favorable. By combining field data and literature, the ANC model could be applied to other countries.
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Affiliation(s)
- Donald S Shepard
- The Heller School for Social Policy & Management, Brandeis University, Waltham, MA, 02454-9110, USA.
| | - Yara A Halasa-Rappel
- The Heller School for Social Policy & Management, Brandeis University, Waltham, MA, 02454-9110, USA
- Commonwealth Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Katharine R Rowlands
- The Heller School for Social Policy & Management, Brandeis University, Waltham, MA, 02454-9110, USA
| | - Maria Kulchyckyj
- The Heller School for Social Policy & Management, Brandeis University, Waltham, MA, 02454-9110, USA
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Nichols BE, Cele R, Jamieson L, Long LC, Siwale Z, Banda P, Moyo C, Rosen S. Community-based delivery of HIV treatment in Zambia: costs and outcomes. AIDS 2021; 35:299-306. [PMID: 33170578 PMCID: PMC7810408 DOI: 10.1097/qad.0000000000002737] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/21/2020] [Accepted: 09/02/2020] [Indexed: 01/29/2023]
Abstract
OBJECTIVE The aim is to determine the total annual cost per patient treated and total cost per patient retained on antiretroviral therapy in Zambia in conventional care in facilities and across community-based differentiated service delivery (DSD) models. DESIGN Economic evaluation was conducted using retrospective electronic record review.Twenty healthcare facilities (13 with DSD models and 7 as comparison sites) in six of Zambia's 10 provinces were considered. METHODS All individuals on antiretroviral therapy (ART) >18 years old at the study sites were enrolled in a DSD model or conventional care by site type, respectively, with at least 12 months of follow-up data. Accessing care through DSD models [community adherence groups (CAGs), urban adherence groups (UAGs), home ART delivery and care, and mobile ART services] or facility-based conventional care with 3-monthly visits. Total annual cost per patient treated and the annual cost per patient retained in care 12 months after model enrolment. Retention in care was defined as attending a clinic visit at 12 months ± 3 months. RESULTS The DSD models assessed cost more per patient/year than conventional care. Costs ranged from an annual $116 to $199 for the DSD models, compared with $100 for conventional care. CAGs and UAGs increased retention by 2 and 14%, respectively. All DSD models cost more per patient retained at 12 months than conventional care. The CAG had the lowest cost/patient retained for DSD models ($140-157). CONCLUSIONS Although they achieve equal or improved retention in care, out-of-facility models of ART were more expensive than conventional care.
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Affiliation(s)
- Brooke E. Nichols
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Refiloe Cele
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lise Jamieson
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence C. Long
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | - Sydney Rosen
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Kimaro GD, Guinness L, Shiri T, Kivuyo S, Chanda D, Bottomley C, Chen T, Kahwa A, Hawkins N, Mwaba P, Mfinanga SG, Harrison TS, Jaffar S, Niessen LW. Cryptococcal Meningitis Screening and Community-based Early Adherence Support in People With Advanced Human Immunodeficiency Virus Infection Starting Antiretroviral Therapy in Tanzania and Zambia: A Cost-effectiveness Analysis. Clin Infect Dis 2021; 70:1652-1657. [PMID: 31149704 PMCID: PMC7146002 DOI: 10.1093/cid/ciz453] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 05/30/2019] [Indexed: 01/05/2023] Open
Abstract
Background A randomized trial demonstrated that among people living with late-stage human immunodeficiency virus (HIV) infection initiating antiretroviral therapy, screening serum for cryptococcal antigen (CrAg) combined with adherence support reduced all-cause mortality by 28%, compared with standard clinic-based care. Here, we present the cost-effectiveness. Methods HIV-infected adults with CD4 count <200 cells/μL were randomized to either CrAg screening plus 4 weekly home visits to provide adherence support or to standard clinic-based care in Dar es Salaam and Lusaka. The primary economic outcome was health service care cost per life-year saved as the incremental cost-effectiveness ratio (ICER), based on 2017 US dollars. We used nonparametric bootstrapping to assess uncertainties and univariate deterministic sensitivity analysis to examine the impact of individual parameters on the ICER. Results Among the intervention and standard arms, 1001 and 998 participants, respectively, were enrolled. The annual mean cost per participant in the intervention arm was US$339 (95% confidence interval [CI], $331–$347), resulting in an incremental cost of the intervention of US$77 (95% CI, $66–$88). The incremental cost was similar when analysis was restricted to persons with CD4 count <100 cells/μL. The ICER for the intervention vs standard care, per life-year saved, was US$70 (95% CI, $43–$211) for all participants with CD4 count up to 200 cells/μL and US$91 (95% CI, $49–$443) among those with CD4 counts <100 cells /μL. Cost-effectveness was most sensitive to mortality estimates. Conclusions Screening for cryptococcal antigen combined with a short period of adherence support, is cost-effective in resource-limited settings.
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Affiliation(s)
- Godfather Dickson Kimaro
- Muhimbili Medical Research Centre, National Institute of Medical Research, Dar es Salaam, United Republic of Tanzania.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Lorna Guinness
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Tinevimbo Shiri
- Department of International Public Health, Liverpool School of Tropical Medicine, United Kingdom
| | - Sokoine Kivuyo
- Muhimbili Medical Research Centre, National Institute of Medical Research, Dar es Salaam, United Republic of Tanzania
| | - Duncan Chanda
- University Teaching Hospital, Lusaka Apex Medical University, Zambia
| | - Christian Bottomley
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Tao Chen
- Department of International Public Health, Liverpool School of Tropical Medicine, United Kingdom
| | - Amos Kahwa
- Muhimbili Medical Research Centre, National Institute of Medical Research, Dar es Salaam, United Republic of Tanzania
| | - Neil Hawkins
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Peter Mwaba
- Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University, Zambia
| | - Sayoki Godfrey Mfinanga
- Muhimbili Medical Research Centre, National Institute of Medical Research, Dar es Salaam, United Republic of Tanzania.,Department of International Public Health, Liverpool School of Tropical Medicine, United Kingdom
| | - Thomas S Harrison
- Institute for Infection and Immunity, Centre for Global Health, St George's University of London, United Kingdom
| | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, United Kingdom
| | - Louis W Niessen
- Department of International Public Health, Liverpool School of Tropical Medicine, United Kingdom.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Larson BA, Pascoe SJ, Huber A, Long LC, Murphy J, Miot J, Fox MP, Fraser-Hurt N, Rosen S. Will differentiated care for stable HIV patients reduce healthcare systems costs? J Int AIDS Soc 2020; 23:e25541. [PMID: 32686911 PMCID: PMC7370539 DOI: 10.1002/jia2.25541] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/17/2020] [Accepted: 05/07/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION South Africa's National Department of Health launched the National Adherence Guidelines for Chronic Diseases in 2015. These guidelines include adherence clubs (AC) and decentralized medication delivery (DMD) as two differentiated models of care for stable HIV patients on antiretroviral therapy. While the adherence guidelines do not suggest that provider costs (costs to the healthcare system for medications, laboratory tests and visits to clinics or alternative locations) for stable patients in these differentiated models of care will be lower than conventional, clinic-based care, recent modelling exercises suggest that such differentiated models could substantially reduce provider costs. In the context of continued implementation of the guidelines, we discuss the conditions under which provider costs of care for stable HIV patients could fall, or rise, with AC and DMD models of care in South Africa. DISCUSSION In prior studies of HIV care and treatment costs, three main cost categories are antiretroviral medications, laboratory tests and general interaction costs based on encounters with health workers. Stable patients are likely to be on the national first-line regimen (Tenofovir/Entricitabine/Efavarinz (TDF/FTC/EFV)), so no difference in the costs of medications is expected. Laboratory testing guidelines for stable patients are the same regardless of the model of care, so no difference in laboratory costs is expected as well. Based on existing information regarding the costs of clinic visits, AC visits and DMD drug pickups, we expect that for some clinics, visit costs for DMD or AC models of care could be less, but modestly so, than for conventional, clinic-based care. For other clinics, however, DMD or AC models could have higher visit costs (see Table 2). CONCLUSIONS The standard of care for stable patients has already been "differentiated" for years in South Africa, prior to the roll out of the new adherence guidelines. AC and DMD models of care, when implemented as envisioned in the guidelines, are unlikely to generate substantive reductions or increases in provider costs of care.
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Affiliation(s)
- Bruce A Larson
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Sophie Js Pascoe
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Amy Huber
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence C Long
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joshua Murphy
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jacqui Miot
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P Fox
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | | | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Tucker A, Tembo T, Tampi RP, Mutale J, Mukumba‐Mwenechanya M, Sharma A, Dowdy DW, Moore CB, Geng E, Holmes CB, Sikazwe I, Sohn H. Redefining and revisiting cost estimates of routine ART care in Zambia: an analysis of ten clinics. J Int AIDS Soc 2020; 23:e25431. [PMID: 32064766 PMCID: PMC7025092 DOI: 10.1002/jia2.25431] [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] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 10/11/2019] [Accepted: 11/20/2019] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Accurate costing is key for programme planning and policy implementation. Since 2011, there have been major changes in eligibility criteria and treatment regimens with price reductions in ART drugs, programmatic changes resulting in clinical task-shifting and decentralization of ART delivery to peripheral health centres making existing evidence on ART care costs in Zambia out-of-date. As decision makers consider further changes in ART service delivery, it is important to understand the current drivers of costs for ART care. This study provides updates on costs of ART services for HIV-positive patients in Zambia. METHODS We evaluated costs, assessed from the health systems perspective and expressed in 2016 USD, based on an activity-based costing framework using both top-down and bottom-up methods with an assessment of process and capacity. We collected primary site-level costs and resource utilization data from government documents, patient chart reviews and time-and-motion studies conducted in 10 purposively selected ART clinics. RESULTS The cost of providing ART varied considerably among the ten clinics. The average per-patient annual cost of ART service was $116.69 (range: $59.38 to $145.62) using a bottom-up method and $130.32 (range: $94.02 to $162.64) using a top-down method. ART drug costs were the main cost driver (67% to 7% of all costs) and are highly sensitive to the types of patient included in the analysis (long-term vs. all ART patients, including those recently initiated) and the data sources used (facility vs. patient level). Missing capacity costs made up 57% of the total difference between the top-down and bottom-up estimates. Variability in cost across the ten clinics was associated with operational characteristics. CONCLUSIONS Real-world costs of current routine ART services in Zambia are considerably lower than previously reported estimates and sensitive to operational factors and methods used. We recommend collection and monitoring of resource use and capacity data to periodically update cost estimates.
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Affiliation(s)
- Austin Tucker
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Tannia Tembo
- Center for Infectious Disease Research (CIDRZ)LusakaZambia
| | - Radhika P Tampi
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Jacob Mutale
- Center for Infectious Disease Research (CIDRZ)LusakaZambia
| | | | - Anjali Sharma
- Center for Infectious Disease Research (CIDRZ)LusakaZambia
| | - David W Dowdy
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Carolyn B Moore
- Center for Infectious Disease Research (CIDRZ)LusakaZambia
- University of AlabamaBirminghamALUSA
| | - Elvin Geng
- Department of Internal MedicineWashington University School of Medicine in St. LouisSt. LouisMOUSA
- Center for Dissemination and ImplementationInstitute for Public Health at Washington University in St. LouisSt. LouisMOUSA
| | - Charles B Holmes
- Center for Infectious Disease Research (CIDRZ)LusakaZambia
- Johns Hopkins University School of MedicineBaltimoreMDUSA
- Georgetown University School of MedicineWashingtonDCUSA
| | | | - Hojoon Sohn
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
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Larson BA, Halim N, Tsikhutsu I, Bii M, Coakley P, Rockers PC. A tool for estimating antiretroviral medication coverage for HIV-infected women during pregnancy (PMTCT-ACT). Glob Health Res Policy 2019; 4:29. [PMID: 31637308 PMCID: PMC6794749 DOI: 10.1186/s41256-019-0121-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 09/23/2019] [Indexed: 12/04/2022] Open
Abstract
Background In the typical prevention of mother to child transmission (PMTCT) of HIV cascade of care discussion or analysis, the period of analysis begins at the first visit for antenatal care (ANC) for that pregnancy. This starting point is problematic for two reasons: (1) a large number of HIV-infected women are already on life-long antiretroviral therapy (ART) when presenting for ANC; and (2) women present to ANC at different gestational ages. The PMTCT ART Coverage Tool (PMTCT-ACT), which estimates the proportion of days covered (PDC) with ART, was developed to address each of these problems. Methods PDC is a preferred method to measure adherence to chronic medications, such as ART. For evaluating the PMTCT cascade of care, as indicated by PDC with ART over various time periods, a “starting point” based on a specific day before delivery must be defined that applies to all women (treatment experienced or naïve at the first ANC visit at any gestational age). Using the example of 168 days prior to delivery (24 weeks), PMTCT-ACT measures PDC with ART during that period. PMTCT-ACT is provided as a STATA do-file. Using an example dataset for two women (ID1 is treatment experienced; ID2 is treatment naïve), the details of each major portion of the tool (Parts 1–5) are presented. PMTCT-ACT along with the intermediate datasets created during the analysis are provided as supplemental files. Conclusions Evaluating the PMTCT cascade of care requires a standard definition of the follow-up period during pregnancy that applies to all HIV-infected pregnant women and a standard measure of adherence. PMTCT-ACT is a new tool that fits this purpose. PMTCT-ACT can also be easily adjusted to evaluate other ante- and post-natal periods (e.g., final 4 weeks, final 8 weeks, complete pregnancy period, initial 24 weeks postpartum, time periods consistent with infant HIV testing guidelines).
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Affiliation(s)
- Bruce A Larson
- 1Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118 USA
| | - Nafisa Halim
- 1Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118 USA
| | - Isaac Tsikhutsu
- Kenya Medical Research Institute, U.S. Army Medical Research Directorate, Africa, Kenya.,3U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD USA.,Henry Jackson Foundation MRI, Kericho, Kenya
| | - Margaret Bii
- Kenya Medical Research Institute, U.S. Army Medical Research Directorate, Africa, Kenya.,3U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD USA.,Henry Jackson Foundation MRI, Kericho, Kenya
| | - Peter Coakley
- 3U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD USA
| | - Peter C Rockers
- 1Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118 USA
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Moucheraud C, Lenz C, Latkovic M, Wirtz VJ. The costs of diabetes treatment in low- and middle-income countries: a systematic review. BMJ Glob Health 2019; 4:e001258. [PMID: 30899566 PMCID: PMC6407562 DOI: 10.1136/bmjgh-2018-001258] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/04/2019] [Accepted: 01/12/2019] [Indexed: 01/24/2023] Open
Abstract
Introduction The rising burden of diabetes in low- and middle-income countries may cause financial strain on individuals and health systems. This paper presents a systematic review of direct medical costs for diabetes (types 1 and 2) in low- and middle-income countries. Methods Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, databases (PubMed, International Bibliography of Social Science, EconLit) were searched for publications reporting direct medical costs of type 1 and 2 diabetes. Data were extracted from all peer-reviewed papers meeting inclusion criteria, and were standardised into per-patient-visit, per-patient-year and/or per-complication-case costs (2016 US$). Results The search yielded 584 abstracts, and 52 publications were included in the analysis. Most articles were from Asia and Latin America, and most focused on type 2 diabetes. Per-visit outpatient costs ranged from under $5 to over $40 (median: $7); annual inpatient costs ranged from approximately $10 to over $1000 (median: $290); annual laboratory costs ranged from under $5 to over $100 (median: $25); and annual medication costs ranged from $15 to over $500 (median: $177), with particularly wide variation found for insulin. Care for complications was generally high-cost, but varied widely across countries and complication types. Conclusion This review identified substantial variation in diabetes treatment costs; some heterogeneity could be mitigated through improved methods for collecting, analysing and reporting data. Diabetes is a costly disease to manage in low- and middle-income countriesand should be a priority for the global health community seeking to achieve Universal Health Coverage.
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Affiliation(s)
- Corrina Moucheraud
- Health Policy and Management, University of California Fielding School of Public Health, Los Angeles, California, USA
| | - Cosima Lenz
- Health Policy and Management, University of California Fielding School of Public Health, Los Angeles, California, USA
| | - Michaella Latkovic
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Veronika J Wirtz
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
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Abstract
Objectives/design: As antiretroviral therapy (ART) rapidly expands in sub-Saharan Africa using new efficient care models, data on costs of these approaches are lacking. We examined costs of a streamlined HIV care delivery model within a large HIV test-and-treat study in Uganda and Kenya. Methods: We calculated observed per-person-per-year (ppy) costs of streamlined care in 17 health facilities in SEARCH Study intervention communities (NCT: 01864603) via micro-costing techniques, time-and-motion studies, staff interviews, and administrative records. Cost categories included salaries, ART, viral load testing, recurring goods/services, and fixed capital/facility costs. We then modeled costs under three increasingly efficient scale-up scenarios: lowest-cost ART, centralized viral load testing, and governmental healthcare worker salaries. We assessed the relationship between community-specific ART delivery costs, retention in care, and viral suppression. Results: Estimated streamlined HIV care delivery costs were $291/ppy. ART ($117/ppy for TDF/3TC/EFV [40%]) and viral load testing ($110/ppy for 2 tests/year [39%]) dominated costs versus salaries ($51/ppy), recurring costs ($5/ppy), and fixed costs ($7/ppy). Optimized ART scale-up with lowest-cost ART ($100/ppy), annual viral load testing ($24/ppy), and governmental healthcare salaries ($27/ppy), lowered streamlined care cost to $163/ppy. We found clinic-to-clinic heterogeneity in retention and viral suppression levels versus streamlined care delivery costs, but no correlation between cost and either retention or viral suppression. Conclusions: In the SEARCH Study, streamlined HIV care delivery costs were similar to or lower than prior estimates despite including viral load testing; further optimizations could substantially reduce costs further. These data can inform global strategies for financing ART expansion to achieve UNAIDS 90–90–90 targets.
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9
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Larson BA, Bii M, Halim N, Rohr JK, Sugut W, Sawe F. Incremental treatment costs for HIV-infected women initiating antiretroviral therapy during pregnancy: A 24-month micro-costing cohort study for a maternal and child health clinic in Kenya. PLoS One 2018; 13:e0200199. [PMID: 30096177 PMCID: PMC6086393 DOI: 10.1371/journal.pone.0200199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 06/21/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND To date, little information exists on the costs of providing antiretroviral therapy (ART) within maternal and child health (MCH) clinics in Kenya. The main objective of this analysis was to estimate the annual incremental cost of providing ART within a MCH clinic for adult women initiated on ART during pregnancy over the first one and two years on treatment. The study site was the District Hospital in Kericho, Kenya. METHODS A micro-costing approach from the provider's perspective, based on a retrospective review of patient medical records, was used to evaluate incremental costs of care (2012 USD). Cost per patient in two cohorts were evaluated: the MCH clinic group comprised of adult women who initiated ART at the site's MCH clinic during pregnancy between 2008-2011; and for comparison, the ART clinic group comprised of adult, non-pregnant women who initiated ART at the site's ART clinic during 2008-2011. The two groups were matched on age and baseline CD4 count at initiation. Retention at year one/two on ART was defined as having completed a clinic visit at 365/730 days on ART +/- 90 days. RESULTS For patients defined as retained in care at year one, average incremental costs per patient were $234 for the MCH clinic group (median: 215; IQR: 186, 282) and $292 in the ART clinic group (median: 227; IQR: 178, 357). ARV and laboratory costs were less on average for the MCH clinic group compared to the ART clinic group (due to lower cost regimens and fewer tests), while personnel costs were higher for the MCH clinic group. CONCLUSIONS The annual incremental cost per patient of providing ART were similar in the two clinic settings in 2012. With shifts in recommended ARV regimens and lab monitoring over time, annual costs of care (using 2016 USD unit costs) have remained relatively constant in nominal terms for the MCH clinic group but have fallen substantially for the ART clinic group (from nominal $292 in 2012 to nominal $227 in 2016).
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Affiliation(s)
- Bruce A. Larson
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- * E-mail:
| | - Margaret Bii
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya
- HJF Medical Research International, Inc., Nairobi, Kenya
| | - Nafisa Halim
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
| | - Julia K. Rohr
- Harvard Center for Population and Development Studies, Cambridge, MA, United States of America
| | - William Sugut
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya
- HJF Medical Research International, Inc., Nairobi, Kenya
| | - Fredrick Sawe
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya
- HJF Medical Research International, Inc., Nairobi, Kenya
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10
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Can differentiated care models solve the crisis in HIV treatment financing? Analysis of prospects for 38 countries in sub-Saharan Africa. J Int AIDS Soc 2017; 20:21648. [PMID: 28770597 PMCID: PMC5577732 DOI: 10.7448/ias.20.5.21648] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Introduction: Rapid scale-up of antiretroviral therapy (ART) in the context of financial and health system constraints has resulted in calls to maximize efficiency in ART service delivery. Adopting differentiated care models (DCMs) for ART could potentially be more cost-efficient and improve outcomes. However, no study comprehensively projects the cost savings across countries. We model the potential reduction in facility-level costs and number of health workers needed when implementing two types of DCMs while attempting to reach 90-90-90 targets in 38 sub-Saharan African countries from 2016 to 2020. Methods: We estimated the costs of three service delivery models: (1) undifferentiated care, (2) differentiated care by patient age and stability, and (3) differentiated care by patient age, stability, key vs. general population status, and urban vs. rural location. Frequency of facility visits, type and frequency of laboratory testing, and coverage of community ART support vary by patient subgroup. For each model, we estimated the total costs of antiretroviral drugs, laboratory commodities, and facility-level personnel and overhead. Certain groups under four-criteria differentiation require more intensive inputs. Community-based ART costs were included in the DCMs. We take into account underlying uncertainty in the projected numbers on ART and unit costs. Results: Total five-year facility-based ART costs for undifferentiated care are estimated to be US$23.33 billion (95% confidence interval [CI]: $23.3–$23.5 billion). An estimated 17.5% (95% CI: 17.4%–17.7%) and 16.8% (95% CI: 16.7%–17.0%) could be saved from 2016 to 2020 from implementing the age and stability DCM and four-criteria DCM, respectively, with annual cost savings increasing over time. DCMs decrease the full-time equivalent (FTE) health workforce requirements for ART. An estimated 46.4% (95% CI: 46.1%–46.7%) fewer FTE health workers are needed in 2020 for the age and stability DCM compared with undifferentiated care. Conclusions: Adopting DCMs can result in significant efficiency gains in terms of reduced costs and health workforce needs, even with the costs of scaling up community-based ART support under DCMs. Efficiency gains remained flat with increased differentiation. More evidence is needed on how to translate analyzed efficiency gains into implemented cost reductions at the facility level.
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Wall KM, Kilembe W, Vwalika B, Haddad LB, Khu NH, Brill I, Onwubiko U, Chomba E, Tichacek A, Allen S. Optimizing Prevention of HIV and Unplanned Pregnancy in Discordant African Couples. J Womens Health (Larchmt) 2017; 26:900-910. [PMID: 28829720 PMCID: PMC5576260 DOI: 10.1089/jwh.2016.6169] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Dual method use, which combines condoms with a more effective modern contraceptive to optimize prevention of HIV and unplanned pregnancy, is underutilized in high-risk heterosexual couples. MATERIALS AND METHODS Heterosexual HIV-discordant Zambian couples were enrolled from couples' voluntary HIV counseling and testing services into an open cohort with 3-monthly follow-up (1994-2012). Relative to dual method use, defined as consistent condom use plus modern contraception, we examine predictors of (1) condom-only use (suboptimal pregnancy prevention) or (2) modern contraceptive use with inconsistent condom use (effective pregnancy prevention and suboptimal HIV prevention). RESULTS Among 3,049 couples, dual method use occurred in 28% of intervals in M+F- and 23% in M-F+, p < 0.01; condom-only use in 56% in M+F- and 61% in M-F+, p < 0.01; and modern contraceptive use with inconsistent condom use in 16% regardless of serostatus. Predictors (p < 0.05) of condom-only use included the man being HIV+ (adjusted hazard ratio, aHR = 1.15); baseline oral contraceptive pill (aHR = 0.76), injectable (aHR = 0.48), or implant (aHR = 0.60) use; woman's age (aHR = 1.04 per 5 years) and lifetime number of sex partners (aHR = 1.01); postpartum periods (aHR = 1.25); and HIV stage of the index partner III/IV versus I (aHR = 1.10). Predictors (p < 0.05) of modern contraceptive use with inconsistent condom use included woman's age (aHR = 0.94 per 5 years) and HIV+ male circumcision (aHR = 1.51), while time-varying implant use was associated with more consistent condom use (aHR = 0.80). CONCLUSIONS Three-quarters of follow-up intervals did not include dual method use. This highlights the need for counseling to reduce unintended pregnancy and HIV transmission and enable safer conception.
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Affiliation(s)
- Kristin M. Wall
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Department of Epidemiology, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, Georgia
| | - William Kilembe
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Bellington Vwalika
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Departments of Gynecology and Obstetrics (BV), Internal Medicine (SL) and Surgery (RC), School of Medicine, University of Zambia, Lusaka, Zambia
| | - Lisa B. Haddad
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Department of Gynecology and Obstetrics, Emory University, School of Medicine, Atlanta, Georgia
| | - Naw Htee Khu
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Ilene Brill
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Department of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Udodirim Onwubiko
- Department of Epidemiology, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, Georgia
| | - Elwyn Chomba
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Ministry of Home Affairs and University of Zambia School of Medicine Lusaka, Lusaka, Zambia
| | - Amanda Tichacek
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Susan Allen
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Miyano S, Syakantu G, Komada K, Endo H, Sugishita T. Cost-effectiveness analysis of the national decentralization policy of antiretroviral treatment programme in Zambia. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2017; 15:4. [PMID: 28413361 PMCID: PMC5388995 DOI: 10.1186/s12962-017-0065-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 03/24/2017] [Indexed: 11/23/2022] Open
Abstract
Background In resource-limited settings with a high prevalence of human immunodeficiency virus (HIV) infection such as Zambia, decentralization of HIV/acquired immunodeficiency syndrome (HIV/AIDS) treatment and care with effective use of resources is a cornerstone of universal treatment and care. Objectives This research aims to analyse the cost effectiveness of the National Mobile Antiretroviral Therapy (ART) Services Programme in Zambia as a means of decentralizing ART services. Methods Cost-effectiveness analyses were performed using a decision analytic model and Markov model to compare the original ART programme, ‘Hospital-based ART’, with the intervention programme, Hospital-based plus ‘Mobile ART’, from the perspective of the district government health office in Zambia. The total cost of ART services, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) were examined. Results The mean annual per-patient costs were 1259.16 USD for the original programme and 2601.02 USD for the intervention programme, while the mean number of QALYs was 6.81 for the original and 7.27 for the intervention programme. The ICER of the intervention programme relative to the original programme was 2965.17 USD/QALY, which was much below the willingness-to-pay (WTP), or three times the GDP per capita (4224 USD), but still over the GDP per capita (1408 USD). In the sensitivity analysis, the ICER of the intervention programme did not substantially change. Conclusion The National Mobile ART Services Programme in Zambia could be a cost-effective approach to decentralizing ART services into rural areas in Zambia. This programme could be expanded to more districts where it has not yet been introduced to improve access to ART services and the health of people living with HIV (PLHIV) in rural areas. Electronic supplementary material The online version of this article (doi:10.1186/s12962-017-0065-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Shinsuke Miyano
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655 Japan
| | - Gardner Syakantu
- Department of Clinical Care and Diagnostic Services, Ministry of Health Zambia, Lusaka, Zambia
| | - Kenichi Komada
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655 Japan
| | - Hiroyoshi Endo
- Graduate School of Public Health, St. Luke's International University, Tokyo, Japan
| | - Tomohiko Sugishita
- Department of International Affairs and Tropical Medicine, Tokyo Women's University, Tokyo, Japan
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Kimaro GD, Mfinanga S, Simms V, Kivuyo S, Bottomley C, Hawkins N, Harrison TS, Jaffar S, Guinness L. The costs of providing antiretroviral therapy services to HIV-infected individuals presenting with advanced HIV disease at public health centres in Dar es Salaam, Tanzania: Findings from a randomised trial evaluating different health care strategies. PLoS One 2017; 12:e0171917. [PMID: 28234969 PMCID: PMC5325220 DOI: 10.1371/journal.pone.0171917] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 01/28/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Understanding the costs associated with health care delivery strategies is essential for planning. There are few data on health service resources used by patients and their associated costs within antiretroviral (ART) programmes in Africa. MATERIAL AND METHODS The study was nested within a large trial, which evaluated screening for cryptococcal meningitis and tuberculosis and a short initial period of home-based adherence support for patients initiating ART with advanced HIV disease in Tanzania and Zambia. The economic evaluation was done in Tanzania alone. We estimated costs of providing routine ART services from the health service provider's perspective using a micro-costing approach. Incremental costs for the different novel components of service delivery were also estimated. All costs were converted into US dollars (US$) and based on 2012 prices. RESULTS Of 870 individuals enrolled in Tanzania, 434 were enrolled in the intervention arm and 436 in the standard care/control arm. Overall, the median (IQR) age and CD4 cell count at enrolment were 38 [31, 44] years and 52 [20, 89] cells/mm3, respectively. The mean per patient costs over the first three months and over a one year period of follow up following ART initiation in the standard care arm were US$ 107 (95%CI 101-112) and US$ 265 (95%CI 254-275) respectively. ART drugs, clinic visits and hospital admission constituted 50%, 19%, and 19% of the total cost per patient year, while diagnostic tests and non-ART drugs (co-trimoxazole) accounted for 10% and 2% of total per patient year costs. The incremental costs of the intervention to the health service over the first three months was US$ 59 (p<0.001; 95%CI 52-67) and over a one year period was US$ 67(p<0.001; 95%CI 50-83). This is equivalent to an increase of 55% (95%CI 51%-59%) in the mean cost of care over the first three months, and 25% (95%CI 20%-30%) increase over one year of follow up.
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MESH Headings
- Adult
- Anti-HIV Agents/economics
- Anti-HIV Agents/therapeutic use
- Antiretroviral Therapy, Highly Active/economics
- CD4 Lymphocyte Count
- Delivery of Health Care/economics
- Delivery of Health Care/statistics & numerical data
- Disease Progression
- Female
- HIV Infections/diagnosis
- HIV Infections/drug therapy
- HIV Infections/economics
- HIV Infections/virology
- Health Care Costs/statistics & numerical data
- Health Resources
- Humans
- Male
- Meningitis, Cryptococcal/diagnosis
- Meningitis, Cryptococcal/drug therapy
- Meningitis, Cryptococcal/economics
- Meningitis, Cryptococcal/microbiology
- Public Health Systems Research
- Tanzania
- Trimethoprim, Sulfamethoxazole Drug Combination/economics
- Trimethoprim, Sulfamethoxazole Drug Combination/therapeutic use
- Tuberculosis, Pulmonary/diagnosis
- Tuberculosis, Pulmonary/drug therapy
- Tuberculosis, Pulmonary/economics
- Tuberculosis, Pulmonary/microbiology
- Zambia
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Affiliation(s)
- Godfather Dickson Kimaro
- Muhimbili Medical Research Centre, National Institute for Medical Research, Dar es Salaam, Tanzania
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sayoki Mfinanga
- Muhimbili Medical Research Centre, National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Victoria Simms
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sokoine Kivuyo
- Muhimbili Medical Research Centre, National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Christian Bottomley
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Neil Hawkins
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Thomas S. Harrison
- Institute for Infection and Immunity, St Georges University of London, London, United Kingdom
| | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Lorna Guinness
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Guillermo-Ladera D, Ventocilla-Gonzales I. Sobre «Determinantes de la asistencia irregular a consulta médica en pacientes con infección por el virus de la inmunodeficiencia humana: resultados de la encuesta hospitalaria de pacientes con el virus de la inmunodeficiencia humana, 2002-2012». Enferm Infecc Microbiol Clin 2016; 34:270-2. [DOI: 10.1016/j.eimc.2015.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 07/02/2015] [Indexed: 10/23/2022]
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Jain V, Chang W, Byonanebye DM, Owaraganise A, Twinomuhwezi E, Amanyire G, Black D, Marseille E, Kamya MR, Havlir DV, Kahn JG. Estimated Costs for Delivery of HIV Antiretroviral Therapy to Individuals with CD4+ T-Cell Counts >350 cells/uL in Rural Uganda. PLoS One 2015; 10:e0143433. [PMID: 26632823 PMCID: PMC4669141 DOI: 10.1371/journal.pone.0143433] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 11/04/2015] [Indexed: 12/22/2022] Open
Abstract
Background Evidence favoring earlier HIV ART initiation at high CD4+ T-cell counts (CD4>350/uL) has grown, and guidelines now recommend earlier HIV treatment. However, the cost of providing ART to individuals with CD4>350 in Sub-Saharan Africa has not been well estimated. This remains a major barrier to optimal global cost projections for accelerating the scale-up of ART. Our objective was to compute costs of ART delivery to high CD4+count individuals in a typical rural Ugandan health center-based HIV clinic, and use these data to construct scenarios of efficient ART scale-up. Methods Within a clinical study evaluating streamlined ART delivery to 197 individuals with CD4+ cell counts >350 cells/uL (EARLI Study: NCT01479634) in Mbarara, Uganda, we performed a micro-costing analysis of administrative records, ART prices, and time-and-motion analysis of staff work patterns. We computed observed per-person-per-year (ppy) costs, and constructed models estimating costs under several increasingly efficient ART scale-up scenarios using local salaries, lowest drug prices, optimized patient loads, and inclusion of viral load (VL) testing. Findings Among 197 individuals enrolled in the EARLI Study, median pre-ART CD4+ cell count was 569/uL (IQR 451–716). Observed ART delivery cost was $628 ppy at steady state. Models using local salaries and only core laboratory tests estimated costs of $529/$445 ppy (+/-VL testing, respectively). Models with lower salaries, lowest ART prices, and optimized healthcare worker schedules reduced costs by $100–200 ppy. Costs in a maximally efficient scale-up model were $320/$236 ppy (+/- VL testing). This included $39 for personnel, $106 for ART, $130/$46 for laboratory tests, and $46 for administrative/other costs. A key limitation of this study is its derivation and extrapolation of costs from one large rural treatment program of high CD4+ count individuals. Conclusions In a Ugandan HIV clinic, ART delivery costs—including VL testing—for individuals with CD4>350 were similar to estimates from high-efficiency programs. In higher efficiency scale-up models, costs were substantially lower. These favorable costs may be achieved because high CD4+ count patients are often asymptomatic, facilitating more efficient streamlined ART delivery. Our work provides a framework for calculating costs of efficient ART scale-up models using accessible data from specific programs and regions.
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Affiliation(s)
- Vivek Jain
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco (UCSF), San Francisco, CA, United States of America
- Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda
- * E-mail:
| | - Wei Chang
- Philip R. Lee Institute for Health Policy Studies, UCSF, San Francisco, CA, United States of America
| | | | | | - Ellon Twinomuhwezi
- Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda
| | - Gideon Amanyire
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| | - Douglas Black
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco (UCSF), San Francisco, CA, United States of America
- Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda
| | - Elliot Marseille
- Health Strategies International, Oakland, CA, United States of America
| | - Moses R. Kamya
- Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane V. Havlir
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco (UCSF), San Francisco, CA, United States of America
- Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda
| | - James G. Kahn
- Philip R. Lee Institute for Health Policy Studies, UCSF, San Francisco, CA, United States of America
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The HIV Treatment Gap: Estimates of the Financial Resources Needed versus Available for Scale-Up of Antiretroviral Therapy in 97 Countries from 2015 to 2020. PLoS Med 2015; 12:e1001907; discussion e1001907. [PMID: 26599990 PMCID: PMC4658189 DOI: 10.1371/journal.pmed.1001907] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 10/16/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) released revised guidelines in 2015 recommending that all people living with HIV, regardless of CD4 count, initiate antiretroviral therapy (ART) upon diagnosis. However, few studies have projected the global resources needed for rapid scale-up of ART. Under the Health Policy Project, we conducted modeling analyses for 97 countries to estimate eligibility for and numbers on ART from 2015 to 2020, along with the facility-level financial resources required. We compared the estimated financial requirements to estimated funding available. METHODS AND FINDINGS Current coverage levels and future need for treatment were based on country-specific epidemiological and demographic data. Simulated annual numbers of individuals on treatment were derived from three scenarios: (1) continuation of countries' current policies of eligibility for ART, (2) universal adoption of aspects of the WHO 2013 eligibility guidelines, and (3) expanded eligibility as per the WHO 2015 guidelines and meeting the Joint United Nations Programme on HIV/AIDS "90-90-90" ART targets. We modeled uncertainty in the annual resource requirements for antiretroviral drugs, laboratory tests, and facility-level personnel and overhead. We estimate that 25.7 (95% CI 25.5, 26.0) million adults and 1.57 (95% CI 1.55, 1.60) million children could receive ART by 2020 if countries maintain current eligibility plans and increase coverage based on historical rates, which may be ambitious. If countries uniformly adopt aspects of the WHO 2013 guidelines, 26.5 (95% CI 26.0 27.0) million adults and 1.53 (95% CI 1.52, 1.55) million children could be on ART by 2020. Under the 90-90-90 scenario, 30.4 (95% CI 30.1, 30.7) million adults and 1.68 (95% CI 1.63, 1.73) million children could receive treatment by 2020. The facility-level financial resources needed for scaling up ART in these countries from 2015 to 2020 are estimated to be US$45.8 (95% CI 45.4, 46.2) billion under the current scenario, US$48.7 (95% CI 47.8, 49.6) billion under the WHO 2013 scenario, and US$52.5 (95% CI 51.4, 53.6) billion under the 90-90-90 scenario. After projecting recent external and domestic funding trends, the estimated 6-y financing gap ranges from US$19.8 billion to US$25.0 billion, depending on the costing scenario and the U.S. President's Emergency Plan for AIDS Relief contribution level, with the gap for ART commodities alone ranging from US$14.0 to US$16.8 billion. The study is limited by excluding above-facility and other costs essential to ART service delivery and by the availability and quality of country- and region-specific data. CONCLUSIONS The projected number of people receiving ART across three scenarios suggests that countries are unlikely to meet the 90-90-90 treatment target (81% of people living with HIV on ART by 2020) unless they adopt a test-and-offer approach and increase ART coverage. Our results suggest that future resource needs for ART scale-up are smaller than stated elsewhere but still significantly threaten the sustainability of the global HIV response without additional resource mobilization from domestic or innovative financing sources or efficiency gains. As the world moves towards adopting the WHO 2015 guidelines, advances in technology, including the introduction of lower-cost, highly effective antiretroviral regimens, whose value are assessed here, may prove to be "game changers" that allow more people to be on ART with the resources available.
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Factors Associated with Retention to Care in an HIV Clinic in Gabon, Central Africa. PLoS One 2015; 10:e0140746. [PMID: 26473965 PMCID: PMC4608719 DOI: 10.1371/journal.pone.0140746] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 09/30/2015] [Indexed: 01/30/2023] Open
Abstract
Background Retention to HIV care is vital for patients’ survival, to prevent onward transmission and emergence of drug resistance. Travelling to receive care might influence adherence. Data on the functioning of and retention to HIV care in the Central African region are limited. Methods This retrospective study reports outcomes and factors associated with retention to HIV care at a primary HIV clinic in Lambaréné, Gabon. Adult patients who presented to this clinic between January 2010 and January 2012 were included. Outcomes were retention in care (defined as documented show-up for clinical visits, regardless of delay) or LTFU (defined as a patient not retained in care; on ART or ART naïve, not returning to care during the study period with a patient delay for scheduled visits of more than 6 months), and mortality. Cox regression analysis was used to assess factors associated with respective outcomes. Qualitative data on reasons for LTFU were obtained from focus-group discussions. Results Of 223 patients included, 67.3% were female. The mean age was 40.5 (standard deviation 11.4) years and the median CD4 count 275 (interquartile range 100.5–449.5) cells/μL. In total, 34.1% were lost to follow up and 8.1% died. Documented tuberculosis was associated with increased risk of being LTFU (adjusted hazard ratio (aHR) 1.80, 95% confidence interval (95% CI) 1.05–3.11, P = 0.03), whereas early starting anti-retroviral therapy (ART) was associated with a decreased risk of LTFU (aHR 0.43, 95%CI 0.24–0.76, P = 0.004), as was confirmed by qualitative data. Conclusions Retention to HIV care in a primary clinic in Gabon is relatively poor and interventions to address this should be prioritized in the HIV program. Early initiation of ART might improve retention in care.
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A standards-based approach to quality improvement for HIV services at Zambia Defence Force facilities: results and lessons learned. AIDS 2015; 29 Suppl 2:S145-53. [PMID: 26102625 DOI: 10.1097/qad.0000000000000720] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The Zambia Defence Force adopted the Standards-Based Management and Recognition approach to improve the quality of the HIV-related services at its health facilities. This quality improvement intervention relies on comprehensive, detailed assessment tools to communicate and verify adherence to national standards of care, and to test and implement changes to improve performance. METHODS A quasi-experimental evaluation of the intervention was conducted at eight Zambia Defence Force primary health facilities (four facilities implemented the intervention and four did not). Data from three previous analyses are combined to assess the effect of Standards-Based Management and Recognition on three domains: facility readiness to provide services; observed provider performance during antiretroviral therapy (ART) and antenatal care consultations; and provider perceptions of the work environment. RESULTS Facility readiness scores for ART improved on four of the eight standards at intervention sites, and one standard at comparison sites. Facility readiness scores for prevention of mother-to-child transmission (PMTCT) of HIV increased by 15 percentage points at intervention sites and 7 percentage points at comparison sites. Provider performance improved significantly at intervention sites for both ART services (from 58 to 84%; P < 0.01) and PMTCT services (from 58 to 73%; P = 0.003); there was no significant change at comparison sites. Providers' perceptions of the work environment generally improved at intervention sites and declined at comparison sites; differences in trends between study groups were significant for eight items. CONCLUSIONS A standards-based approach to quality improvement proved effective in supporting healthcare managers and providers to deliver ART and PMTCT services in accordance with evidence-based standards in a health system suffering from staff shortages.
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Defining and analyzing retention-in-care among pregnant and breastfeeding HIV-infected women: unpacking the data to interpret and improve PMTCT outcomes. J Acquir Immune Defic Syndr 2014; 67 Suppl 2:S150-6. [PMID: 25310122 DOI: 10.1097/qai.0000000000000355] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The prevent mother-to-child transmission (PMTCT) "cascade" describes the programmatic steps for pregnant and breastfeeding women that influence HIV transmission rates. To this end, HIV-infected pregnant women and mothers need access to health services and adhere to antiretroviral (ARV) prophylaxis or lifetime treatment. Within the cascade, the concept of "retention-in-care" is commonly used as a proxy for adherence to ARV interventions and, even, viral suppression. Yet surprisingly, there is no standard definition of retention-in-care either for the purposes of HIV surveillance or implementation research. Implicit to the concept of retention-in-care is the sense of continuity and receipt of care at relevant time points. In the context of PMTCT, the main challenge for surveillance and implementation research is to estimate effective coverage of ARV interventions over a prolonged period of time. These data are used to inform program management and also to estimate postnatal MTCT rates. Attendance of HIV-infected mothers at clinic at 12-month postpartum is often equated with full retention in PMTCT programs over this period. Yet, measurement approaches that fail to register missed visits, or inconsistent attendance or other missing data in the interval period, fail to capture patterns of attendance and care received by mothers and children and risk introducing systematic errors and bias. More importantly, providing only an aggregated rate of attendance as a proxy for retention-in-care fails to identify specific gaps in health services where interventions to improve retention along the PMTCT cascade are most needed. In this article, we discuss how data on retention-in-care can be understood and analyzed, and what are the implications and opportunities for programs and implementation research.
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