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McGuire F, Mohan S, Walker S, Nabyonga-Orem J, Ssengooba F, Kataika E, Revill P. Adapting Economic Evaluation Methods to Shifting Global Health Priorities: Assessing the Value of Health System Inputs. Value Health Reg Issues 2024; 39:31-39. [PMID: 37976775 DOI: 10.1016/j.vhri.2023.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 07/11/2023] [Accepted: 08/07/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVES We highlight the importance of undertaking value assessments for health system inputs if allocative efficiency is to be achieve with health sector resources, with a focus on low- and middle-income countries. However, methodological challenges complicated the application of current economic evaluation techniques to health system input investments. METHODS We undertake a review of the literature to examine how assessments of investments in health system inputs have been considered to date, highlighting several studies that have suggested ways to address the methodological issues. Additionally, we surveyed how empirical economic evaluations of health system inputs have approached these issues. Finally, we highlight the steps required to move toward a comprehensive standardized framework for undertaking economic evaluations to make value assessments for investments in health systems. RESULTS Although the methodological challenges have been illustrated, a comprehensive framework for value assessments of health system inputs, guiding the evidence required, does not exist. The applied literature of economic evaluations of health system inputs has largely ignored the issues, likely resulting in inaccurate assessments of cost-effectiveness. CONCLUSIONS A majority of health sector budgets are spent on health system inputs, facilitating the provision of healthcare interventions. Although economic evaluation methods are a key component in priority setting for healthcare interventions, such methods are less commonly applied to decision making for investments in health system inputs. Given the growing agenda for investments in health systems, a framework will be increasingly required to guide governments and development partners in prioritizing investments in scarce health sector budgets.
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Affiliation(s)
- Finn McGuire
- Centre for Health Economics, University of York, York, England, UK.
| | - Sakshi Mohan
- Centre for Health Economics, University of York, York, England, UK
| | - Simon Walker
- Centre for Health Economics, University of York, York, England, UK
| | - Juliet Nabyonga-Orem
- Inter-Country Support Team for Eastern and Southern Africa, UHC Life Course Cluster, World Health Organization, Brazzaville, Republic of Congo; Centre for Health Professions Education, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
| | - Freddie Ssengooba
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, Kampala, Uganda
| | - Edward Kataika
- East, Central and Southern Africa Health Community, Arusha, Tanzania
| | - Paul Revill
- Centre for Health Economics, University of York, York, England, UK
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Baltussen R, Surgey G, Vassall A, Norheim OF, Chalkidou K, Siddiqi S, Nouhi M, Youngkong S, Jansen M, Bijlmakers L, Oortwijn W. The use of cost-effectiveness analysis for health benefit package design - should countries follow a sectoral, incremental or hybrid approach? COST EFFECTIVENESS AND RESOURCE ALLOCATION 2023; 21:75. [PMID: 37814257 PMCID: PMC10563323 DOI: 10.1186/s12962-023-00484-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 10/03/2023] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND Countries around the world are increasingly rethinking the design of their health benefit package to achieve universal health coverage. Countries can periodically revise their packages on the basis of sectoral cost-effectiveness analyses, i.e. by evaluating a broad set of services against a 'doing nothing' scenario using a budget constraint. Alternatively, they can use incremental cost-effectiveness analyses, i.e. to evaluate specific services against current practice using a threshold. In addition, countries may employ hybrid approaches which combines elements of sectoral and incremental cost-effectiveness analysis - a country may e.g. not evaluate the comprehensive set of all services but rather relatively small sets of services targeting a certain condition. However, there is little practical guidance for countries as to which kind of approach they should follow. METHODS The present study was based on expert consultation. We refined the typology of approaches of cost-effectiveness analysis for benefit package design, identified factors that should be considered in the choice of approach, and developed recommendations. We reached consensus among experts over the course of several review rounds. RESULTS Sectoral cost-effectiveness analysis is especially suited in contexts with large allocative inefficiencies in current service provision and can, in theory, realize large efficiency gains. However, it may be challenging to implement a comprehensive redesign of the package in practice. Incremental cost-effectiveness analysis is especially relevant in contexts where specific new services may impact the sustainability of the health system. It may potentially support efficiency improvement, but its focus has typically been on new services while existing inefficiencies remain unchallenged. The use of hybrid approach may be a way forward to address the strengths and weaknesses of sectoral and incremental analysis areas. Such analysis may be especially useful to target disease areas with suspected high inefficiencies in service provision, and would then make good use of the available research capacity and be politically rewarding. However, disease-specific analyses bear the risk of not addressing resource allocation inefficiencies across disease areas. CONCLUSIONS Countries should carefully select their approach of cost-effectiveness analyses for benefit package design, based on their decision-making context.
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Affiliation(s)
- Rob Baltussen
- Radboud University Medical Center, P.O. Box 9101, Nijmegen, 6500 HB, The Netherlands.
| | - Gavin Surgey
- Radboud University Medical Center, P.O. Box 9101, Nijmegen, 6500 HB, The Netherlands
| | - Anna Vassall
- London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | - Mojtaba Nouhi
- Ministry of Health and Medical Education, Tehran, Iran
- Tehran University of Medical Sciences, Tehran, Iran
| | | | - Maarten Jansen
- Radboud University Medical Center, P.O. Box 9101, Nijmegen, 6500 HB, The Netherlands
| | - Leon Bijlmakers
- Radboud University Medical Center, P.O. Box 9101, Nijmegen, 6500 HB, The Netherlands
| | - Wija Oortwijn
- Radboud University Medical Center, P.O. Box 9101, Nijmegen, 6500 HB, The Netherlands
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Akanbi MO, Bilaver LA, Achenbach C, Hirschhorn LR, Rivera AS, Adekolujo OS, Adekola KUA, Silas OA, Agaba PA, Agbaji O, Shehu NY, Sagay SA, Hou L, Murphy RL. Incident Kaposi sarcoma during the expansion of antiretroviral therapy eligibility in Nigeria: a retrospective cohort study. BMC Cancer 2023; 23:890. [PMID: 37735371 PMCID: PMC10512500 DOI: 10.1186/s12885-023-11402-3] [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: 01/26/2023] [Accepted: 09/13/2023] [Indexed: 09/23/2023] Open
Abstract
INTRODUCTION The expansion of antiretroviral therapy (ART) eligibility could lead to earlier initiation of Human Immunodeficiency Virus (HIV) treatment and consequently reduce the risk of HIV-associated Kaposi Sarcoma (KS). We investigated the impact of changes in the Nigerian HIV treatment guidelines on KS incidence among adults enrolled in HIV care in Nigeria. METHODS We analyzed data of adults who enrolled for HIV care from January 2006 to December 2016 at one of Nigeria's largest HIV treatment centers. Based on changes in HIV treatment guidelines, we classified 2006-2009 as the pre-expansion period and 2010-2016 as the post-expansion period. We used Kaplan Meier curves to compare the incidence of KS in the pre-expansion to the post-expansion period. We used Cox regression models to assess the hazard for incident KS between the two periods after adjusting for potential confounders. RESULTS Among 14,479 patients with HIV, the overall KS incidence was 2.35; 95% CI 2.01-2.74/1,000 person-years. The incidence of KS decreased from 2.53 to 1.58 per 1,000 person-years from 2006 to 2009 to 2010-2016. In models adjusting for age, sex, CD4-T cell count, and ART use, the risk for KS remained lower in 2010-2016 compared to 2006-2009. In analyses restricted to time on ART, there was no significant difference in KS incidence between HIV patients who enrolled in 2006-2009 and 2010-2016 after adjusting for age, sex, and CD4 T-cell count. CONCLUSION The expansion of ART eligibility was associated with a reduced incidence of HIV-associated KS among adults initiating HIV care in Jos, Nigeria. The reduction was likely driven by earlier enrollment for HIV care and ART initiation.
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Affiliation(s)
- Maxwell O Akanbi
- Department of Hematology & Clinical Oncology, Michigan State University/ McLaren Greater Lansing, 2900 Collins Road, Michigan, 48910, USA.
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
- Department of Medicine, McLaren Hospital, Flint, MI, USA.
- College of Medicine, University of Jos, Jos, Plateau State, Nigeria.
| | - Lucy A Bilaver
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Chad Achenbach
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Lisa R Hirschhorn
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Adovich S Rivera
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | | | | | - Patricia A Agaba
- College of Medicine, University of Jos, Jos, Plateau State, Nigeria
| | - Oche Agbaji
- College of Medicine, University of Jos, Jos, Plateau State, Nigeria
| | - Nathan Y Shehu
- College of Medicine, University of Jos, Jos, Plateau State, Nigeria
| | - Solomon A Sagay
- College of Medicine, University of Jos, Jos, Plateau State, Nigeria
| | - Lifang Hou
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Robert L Murphy
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Bozzani FM, McCreesh N, Diaconu K, Govender I, White RG, Kielmann K, Grant AD, Vassall A. Cost-effectiveness of tuberculosis infection prevention and control interventions in South African clinics: a model-based economic evaluation informed by complexity science methods. BMJ Glob Health 2023; 8:e010306. [PMID: 36792227 PMCID: PMC9933667 DOI: 10.1136/bmjgh-2022-010306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 12/16/2022] [Indexed: 02/17/2023] Open
Abstract
INTRODUCTION Nosocomial Mycobacterium tuberculosis (Mtb) transmission substantially impacts health workers, patients and communities. Guidelines for tuberculosis infection prevention and control (TB IPC) exist but implementation in many settings remains suboptimal. Evidence is needed on cost-effective investments to prevent Mtb transmission that are feasible in routine clinic environments. METHODS A set of TB IPC interventions was codesigned with local stakeholders using system dynamics modelling techniques that addressed both core activities and enabling actions to support implementation. An economic evaluation of these interventions was conducted at two clinics in KwaZulu-Natal, employing agent-based models of Mtb transmission within the clinics and in their catchment populations. Intervention costs included the costs of the enablers (eg, strengthened supervision, community sensitisation) identified by stakeholders to ensure uptake and adherence. RESULTS All intervention scenarios modelled, inclusive of the relevant enablers, cost less than US$200 per disability-adjusted life-year (DALY) averted and were very cost-effective in comparison to South Africa's opportunity cost-based threshold (US$3200 per DALY averted). Two interventions, building modifications to improve ventilation and maximising use of the existing Central Chronic Medicines Dispensing and Distribution system to reduce the number of clinic attendees, were found to be cost saving over the 10-year model time horizon. Incremental cost-effectiveness ratios were sensitive to assumptions on baseline clinic ventilation rates, the prevalence of infectious TB in clinic attendees and future HIV incidence but remained highly cost-effective under all uncertainty analysis scenarios. CONCLUSION TB IPC interventions in clinics, including the enabling actions to ensure their feasibility, afford very good value for money and should be prioritised for implementation within the South African health system.
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Affiliation(s)
- Fiammetta Maria Bozzani
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Nicky McCreesh
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Karin Diaconu
- Institute of Global Health and Development, Queen Margaret University Edinburgh, Musselburgh, UK
| | - Indira Govender
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
- Africa Health Research Institute, School of Laboratory Medicine and Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, Kwa-Zulu Natal, South Africa
| | - Richard G White
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Karina Kielmann
- Institute of Global Health and Development, Queen Margaret University Edinburgh, Musselburgh, UK
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Alison D Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
- Africa Health Research Institute, School of Laboratory Medicine and Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, Kwa-Zulu Natal, South Africa
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
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Lambiris MJ, Venga GN, Ssempala R, Balogun V, Galactionova K, Musiitwa M, Kagwire F, Olosunde O, Emedo E, Luketa S, Sangare M, Buj V, Delvento G, Tshefu A, Okitawutshu J, Omoluabi E, Awor P, Signorell A, Hetzel MW, Lee TT, Brunner NC, Cereghetti N, Visser T, Napier HG, Burri C, Lengeler C. Health system readiness and the implementation of rectal artesunate for severe malaria in sub-Saharan Africa: an analysis of real-world costs and constraints. Lancet Glob Health 2023; 11:e256-e264. [PMID: 36565705 DOI: 10.1016/s2214-109x(22)00507-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 11/08/2022] [Accepted: 11/10/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Rectal artesunate, an efficacious pre-referral treatment for severe malaria in children, was deployed at scale in Uganda, Nigeria, and DR Congo. In addition to distributing rectal artesunate, implementation required additional investments in crucial but neglected components in the care for severe malaria. We examined the real-world costs and constraints to rectal artesunate implementation. METHODS We collected primary data on baseline health system constraints and subsequent rectal artesunate implementation expenditures. We calculated the equivalent annual cost of rectal artesunate implementation per child younger than 5 years at risk of severe malaria, from a health system perspective, separating neglected routine health system components from incremental costs of rectal artesunate introduction. FINDINGS The largest baseline constraints were irregular health worker supervisions, inadequate referral facility worker training, and inadequate malaria commodity supplies. Health worker training and behaviour change campaigns were the largest startup costs, while supervision and supply chain management accounted for most annual routine costs. The equivalent annual costs of preparing the health system for managing severe malaria with rectal artesunate were US$2·63, $2·20, and $4·19 per child at risk and $322, $219, and $464 per child treated in Uganda, Nigeria, and DR Congo, respectively. Strengthening the neglected, routine health system components accounted for the majority of these costs at 71·5%, 65·4%, and 76·4% of per-child costs, respectively. Incremental rectal artesunate costs accounted for the minority remainder. INTERPRETATION Although rectal artesunate has been touted as a cost-effective pre-referral treatment for severe malaria in children, its real-world potential is limited by weak and under-financed health system components. Scaling up rectal artesunate or other interventions relying on community health-care providers only makes sense alongside additional, essential health system investments sustained over the long term. FUNDING Unitaid. TRANSLATION For the French translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Mark J Lambiris
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland.
| | - Guy Ndongala Venga
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | | | | | | | | | | | | | | | | | | | - Valentina Buj
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland; UNICEF, New York, NY, USA
| | - Giulia Delvento
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | - Antoinette Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Jean Okitawutshu
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland; Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | | | - Phyllis Awor
- Makerere University School of Public Health, Kampala, Uganda
| | - Aita Signorell
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | - Manuel W Hetzel
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | - Tristan T Lee
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | - Nina C Brunner
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | - Nadja Cereghetti
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | | | | | - Christian Burri
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | - Christian Lengeler
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
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Mukose AD, Bastiaens H, Makumbi F, Buregyeya E, Naigino R, Musinguzi J, Van Geertruyden JP, Wanyenze RK. Challenges and commonly used countermeasures in the implementation of lifelong antiretroviral therapy for PMTCT in Central Uganda: Health providers' perspective. PLoS One 2023; 18:e0280893. [PMID: 36662894 PMCID: PMC9858842 DOI: 10.1371/journal.pone.0280893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 01/10/2023] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Uganda has implemented lifelong antiretroviral therapy for the prevention of mother-to-child HIV transmission since September 2012. Implementation of this strategy has been met with health provider and client challenges which have persisted up to date. This study explored providers' perspectives on the challenges and countermeasures of the implementation and scale-up of lifelong ART among pregnant and breastfeeding women. METHODS A qualitative descriptive study was conducted whereby 54 purposively selected participants from six facilities in three districts of Central Uganda namely; Masaka, Mityana, and Luwero were recruited. A key informant interview guide was used to collect data from the study participants. The data were thematically analysed using Atlas-ti, Version 7. RESULTS Study participants reported challenges under the themes of 1) inadequacy of HIV service delivery (lack of relevant training, health provider shortages, inadequate counselling, stock-outs of essential HIV commodities); 2) Non-utilization of HIV services (Non-disclosure of HIV- positive results, denial of HIV positive results, fear to be followed up, unwillingness to be referred, large catchment area, lack of transport); and 3) Suboptimal treatment adherence (fear of ART side effects, preference for traditional medicines, low male partner involvement in care and treatment). Strategies such as on-job training, mentorship, task shifting, redistribution of HIV commodities across facilities, accompanying of women to mother-baby care points, ongoing counseling of women, peers, and family support groups were commonly used countermeasures. CONCLUSIONS This study highlights key challenges that health providers face in implementing lifelong antiretroviral therapy services among pregnant and postpartum women. Context-specific, innovative, and multilevel system interventions are required at national, district, health facility, community and individual levels to scale up and sustain the lifelong antiretroviral therapy strategy among pregnant and breastfeeding women.
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Affiliation(s)
- Aggrey David Mukose
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Epidemiology and Social Medicine, Faculty of Medicine and Health Sciences, Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Hilde Bastiaens
- Department of Epidemiology and Social Medicine, Faculty of Medicine and Health Sciences, Global Health Institute, University of Antwerp, Antwerp, Belgium
- Department of Family Medicine and Population Health, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Fredrick Makumbi
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Esther Buregyeya
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Rose Naigino
- Makerere University School of Public Health, Kampala, Uganda
| | | | - Jean-Pierre Van Geertruyden
- Department of Epidemiology and Social Medicine, Faculty of Medicine and Health Sciences, Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Rhoda K. Wanyenze
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
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Comins CA, Guddera V, Parmley LE, Young K, Mcingana M, Mulumba N, Mishra S, Phetlhu DR, Hausler H, Schwartz S, Baral S. Opportunities and considerations for the design of decentralized delivery of antiretroviral therapy for female sex workers living with HIV in South Africa. BMC Health Serv Res 2022; 22:1166. [PMID: 36114501 PMCID: PMC9482230 DOI: 10.1186/s12913-022-08506-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 08/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In South Africa, 60% of female sex workers (FSW) are living with HIV, many of whom experience structural and individual barriers to antiretroviral therapy (ART) initiation and adherence. Community-based decentralized treatment provision (DTP) may mitigate these barriers. To characterize optimal implementation strategies, we explored preferences for DTP among FSW living with HIV in Durban, South Africa. METHODS Thirty-nine semi-structured in-depth interviews were conducted with FSW living with HIV (n = 24), and key informants (n = 15) including HIV program implementers, security personnel, and brothel managers. Participants were recruited using maximum variation and snowball sampling. Interviews were conducted in English or isiZulu between September-November 2017 and analyzed using grounded theory in Atlas.ti 8. RESULTS DTP was described as an intervention that could address barriers to ART adherence and retention, minimizing transport costs, time and wage loss from clinic visits, and act as a safety net to address FSW mobility and clinic access challenges. Respondents highlighted contextual considerations for DTP and suggested that DTP should be venue-based, scheduled during less busy times and days, and integrate comprehensive health services including psychological, reproductive, and non-communicable disease services. ART packaging and storage were important for community-based delivery, and participants suggested DTP should be implemented by sex work sensitized staff with discrete uniform and vehicle branding. CONCLUSIONS Incorporating FSW preferences may support implementation optimization and requires balancing of tensions between preferences and feasibility. These data suggest the potential utility of DTP for FSW as a strategy to address those most marginalized from current ART programs in South Africa.
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Affiliation(s)
- Carly A Comins
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA.
| | | | - Lauren E Parmley
- United States Agency for International Development, Pretoria, South Africa
| | | | | | | | - Sharmistha Mishra
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Deliwe R Phetlhu
- School of Health Care Sciences, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
| | | | - Sheree Schwartz
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, USA
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, USA
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Bulstra CA, Hontelez JAC, Otto M, Stepanova A, Lamontagne E, Yakusik A, El-Sadr WM, Apollo T, Rabkin M, Atun R, Bärnighausen T. Integrating HIV services and other health services: A systematic review and meta-analysis. PLoS Med 2021; 18:e1003836. [PMID: 34752477 PMCID: PMC8577772 DOI: 10.1371/journal.pmed.1003836] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 10/05/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Integration of HIV services with other health services has been proposed as an important strategy to boost the sustainability of the global HIV response. We conducted a systematic and comprehensive synthesis of the existing scientific evidence on the impact of service integration on the HIV care cascade, health outcomes, and cost-effectiveness. METHODS AND FINDINGS We reviewed the global quantitative empirical evidence on integration published between 1 January 2010 and 10 September 2021. We included experimental and observational studies that featured both an integration intervention and a comparator in our review. Of the 7,118 unique peer-reviewed English-language studies that our search algorithm identified, 114 met all of our selection criteria for data extraction. Most of the studies (90) were conducted in sub-Saharan Africa, primarily in East Africa (55) and Southern Africa (24). The most common forms of integration were (i) HIV testing and counselling added to non-HIV services and (ii) non-HIV services added to antiretroviral therapy (ART). The most commonly integrated non-HIV services were maternal and child healthcare, tuberculosis testing and treatment, primary healthcare, family planning, and sexual and reproductive health services. Values for HIV care cascade outcomes tended to be better in integrated services: uptake of HIV testing and counselling (pooled risk ratio [RR] across 37 studies: 1.67 [95% CI 1.41-1.99], p < 0.001), ART initiation coverage (pooled RR across 19 studies: 1.42 [95% CI 1.16-1.75], p = 0.002), time until ART initiation (pooled RR across 5 studies: 0.45 [95% CI 0.20-1.00], p = 0.050), retention in HIV care (pooled RR across 19 studies: 1.68 [95% CI 1.05-2.69], p = 0.031), and viral suppression (pooled RR across 9 studies: 1.19 [95% CI 1.03-1.37], p = 0.025). Also, treatment success for non-HIV-related diseases and conditions and the uptake of non-HIV services were commonly higher in integrated services. We did not find any significant differences for the following outcomes in our meta-analyses: HIV testing yield, ART adherence, HIV-free survival among infants, and HIV and non-HIV mortality. We could not conduct meta-analyses for several outcomes (HIV infections averted, costs, and cost-effectiveness), because our systematic review did not identify sufficient poolable studies. Study limitations included possible publication bias of studies with significant or favourable findings and comparatively weak evidence from some world regions and on integration of services for key populations in the HIV response. CONCLUSIONS Integration of HIV services and other health services tends to improve health and health systems outcomes. Despite some scientific limitations, the global evidence shows that service integration can be a valuable strategy to boost the sustainability of the HIV response and contribute to the goal of 'ending AIDS by 2030', while simultaneously supporting progress towards universal health coverage.
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Affiliation(s)
- Caroline A. Bulstra
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
- * E-mail:
| | - Jan A. C. Hontelez
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Moritz Otto
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
| | - Anna Stepanova
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
| | - Erik Lamontagne
- Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
- Aix-Marseille School of Economics, CNRS, EHESS, Centrale Marseille, Aix-Marseille University, Les Milles, France
| | - Anna Yakusik
- Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
| | - Wafaa M. El-Sadr
- ICAP, Columbia University, New York, New York, United States of America
| | | | - Miriam Rabkin
- ICAP, Columbia University, New York, New York, United States of America
| | | | - Rifat Atun
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, United States of America
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, United States of America
- Africa Health Research Institute, KwaZulu-Natal, South Africa
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Adawiyah RA, Saweri OPM, Boettiger DC, Applegate TL, Probandari A, Guy R, Guinness L, Wiseman V. The costs of scaling up HIV and syphilis testing in low- and middle-income countries: a systematic review. Health Policy Plan 2021; 36:939-954. [PMID: 33693731 PMCID: PMC8227996 DOI: 10.1093/heapol/czab030] [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] [Accepted: 02/24/2021] [Indexed: 12/18/2022] Open
Abstract
Around two-thirds of all new HIV infections and 90% of syphilis cases occur in low- and middle-income countries (LMICs). Testing is a key strategy for the prevention and treatment of HIV and syphilis. Decision-makers in LMICs face considerable uncertainties about the costs of scaling up HIV and syphilis testing. This paper synthesizes economic evidence on the costs of scaling up HIV and syphilis testing interventions in LMICs and evidence on how costs change with the scale of delivery. We systematically searched multiple databases (Medline, Econlit, Embase, EMCARE, CINAHL, Global Health and the NHS Economic Evaluation Database) for peer-reviewed studies examining the costs of scaling up HIV and syphilis testing in LMICs. Thirty-five eligible studies were identified from 4869 unique citations. Most studies were conducted in Sub-Saharan Africa (N = 17) and most explored the costs of rapid HIV in facilities targeted the general population (N = 19). Only two studies focused on syphilis testing. Seventeen studies were cost analyses, 17 were cost-effectiveness analyses and 1 was cost-benefit analysis of HIV or syphilis testing. Most studies took a modelling approach (N = 25) and assumed costs increased linearly with scale. Ten studies examined cost efficiencies associated with scale, most reporting short-run economies of scale. Important drivers of the costs of scaling up included testing uptake and the price of test kits. The 'true' cost of scaling up testing is likely to be masked by the use of short-term decision frameworks, linear unit-cost projections (i.e. multiplying an average cost by a factor reflecting activity at a larger scale) and availability of health system capacity and infrastructure to supervise and support scale up. Cost data need to be routinely collected alongside other monitoring indicators as HIV and syphilis testing continues to be scaled up in LMICs.
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Affiliation(s)
- Rabiah Al Adawiyah
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia
| | - Olga P M Saweri
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia.,Population Health and Demography, Papua New Guinea Institute of Medical Research, PO Box 60 Homate Street, Goroka, Papua New Guinea
| | - David C Boettiger
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia
| | - Tanya L Applegate
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia
| | - Ari Probandari
- Department of Public Health, Faculty of Medicine, Universitas Sebelas Maret, Jl. Ir. Sutami 36A. Surakarta, 57126, Indonesia
| | - Rebecca Guy
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia
| | - Lorna Guinness
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.,Centre for Global DevelopmentEurope, Great Peter House, Great College St, London SW1P 3SE, UK
| | - Virginia Wiseman
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia.,London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
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10
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Dakum P, Ajav-Nyior J, Attah TA, Kayode GA, Gomwalk A, Omuh H, Ibrahim H, Omozuafoh M, Alash’le A, Mensah C, Oluokun Y, Akolawole F. Effect of community antiretroviral therapy on treatment outcomes among stable antiretroviral therapy patients in Nigeria: A quasi experimental study. PLoS One 2021; 16:e0250345. [PMID: 33901199 PMCID: PMC8075245 DOI: 10.1371/journal.pone.0250345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 04/05/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES This study evaluates the effect of Community Anti-retroviral Groups on Immunologic, Virologic and clinical outcomes of stable Antiretroviral Therapy patients in Nigeria. METHOD A cohort of 251 eligible adults (≥18 years) on first-line ART for at least 6 months with CD4 counts >200 cells/mm3 and viral load <1000 c/ml were devolved from 10 healthcare facilities to 51 community antiretroviral therapy groups. Baseline immunologic, virologic and clinical parameters were collected and community antiretroviral therapy group patients were followed up for a year after which Human Immunodeficiency Virus treatment outcomes at the baseline and a year after follow-up were compared using paired sample t-test. All the analyses were performed in STATA version 14. RESULT Out of the 251 stable antiretroviral therapy adults enrolled, 186 (75.3%) were female, 52 (22.7%) had attained post-secondary education and the mean age of participants was 38 years (SD: 9.5). Also, 66 (27.9%) were employed while 125 (52.7%) were self-employed and 46(19.41%) unemployed. 246 (98.0%) of the participants were retained in care. While there was no statistically significant change in the CD4 counts (456cells/mm3 vs 481cells/mm3 P-0.489) and Log10 viral load (3.54c/ml vs 3.69c/ml P-0.359) after one year of devolvement into the community, we observed a significant increase in body weight (60.8 vs 65, P-0.01). CONCLUSION This study demonstrates that community antiretroviral therapy has a potential of maintaining optimum treatment outcomes while improving adherence and retention, and reducing the burden of HIV treatment on the health facility. This study provides baseline information for further research and vital information for HIV program implementers planning to decentralize the management of stable antiretroviral therapy clients.
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Affiliation(s)
- Patrick Dakum
- Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
- Institute of Human Virology University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Juliet Ajav-Nyior
- Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
| | - Timothy A. Attah
- Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
| | - Gbenga A. Kayode
- Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
- International Research Centre of Excellence, Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
| | - Asabe Gomwalk
- Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
| | - Helen Omuh
- Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
| | - Halima Ibrahim
- Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
| | - Mercy Omozuafoh
- Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
| | - Abimiku Alash’le
- Institute of Human Virology University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- International Research Centre of Excellence, Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
| | - Charles Mensah
- Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
| | - Young Oluokun
- Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
| | - Franca Akolawole
- Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
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11
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Building resource constraints and feasibility considerations in mathematical models for infectious disease: A systematic literature review. Epidemics 2021; 35:100450. [PMID: 33761447 PMCID: PMC8207450 DOI: 10.1016/j.epidem.2021.100450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 11/20/2020] [Accepted: 03/10/2021] [Indexed: 02/01/2023] Open
Abstract
Mathematical model capabilities to explore complex systems now enable priority-setting to consider local resource constraints. Common objectives of model-based analyses incorporating constraints are to assess real-world feasibility or allocate resources efficiently. Constraints may be incorporated via (i) model-based estimation; (ii) linkage of mathematical and health system models; or (iii) optimisation. Models can then project constrained intervention effects and costs and resource requirement s for delivering interventions at full scale. 'Health system constraints' should be systematically defined for routine operationalisation in model-based priority-setting.
Priority setting for infectious disease control is increasingly concerned with physical input constraints and other real-world restrictions on implementation and on the decision process. These health system constraints determine the ‘feasibility’ of interventions and hence impact. However, considering them within mathematical models places additional demands on model structure and relies on data availability. This review aims to provide an overview of published methods for considering constraints in mathematical models of infectious disease. We systematically searched the literature to identify studies employing dynamic transmission models to assess interventions in any infectious disease and geographical area that included non-financial constraints to implementation. Information was extracted on the types of constraints considered and how these were identified and characterised, as well as on the model structures and techniques for incorporating the constraints. A total of 36 studies were retained for analysis. While most dynamic transmission models identified were deterministic compartmental models, stochastic models and agent-based simulations were also successfully used for assessing the effects of non-financial constraints on priority setting. Studies aimed to assess reductions in intervention coverage (and programme costs) as a result of constraints preventing successful roll-out and scale-up, and/or to calculate costs and resources needed to relax these constraints and achieve desired coverage levels. We identified three approaches for incorporating constraints within the analyses: (i) estimation within the disease transmission model; (ii) linking disease transmission and health system models; (iii) optimising under constraints (other than the budget). The review highlighted the viability of expanding model-based priority setting to consider health system constraints. We show strengths and limitations in current approaches to identify and quantify locally-relevant constraints, ranging from simple assumptions to structured elicitation and operational models. Overall, there is a clear need for transparency in the way feasibility is defined as a decision criteria for its systematic operationalisation within models.
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12
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Okal J, Lango D, Matheka J, Obare F, Ngunu-Gituathi C, Mugambi M, Sarna A. "It is always better for a man to know his HIV status" - A qualitative study exploring the context, barriers and facilitators of HIV testing among men in Nairobi, Kenya. PLoS One 2020; 15:e0231645. [PMID: 32294124 PMCID: PMC7159816 DOI: 10.1371/journal.pone.0231645] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 03/28/2020] [Indexed: 01/20/2023] Open
Abstract
HIV testing services are an important component of HIV program and provide an entry point for clinical care for persons newly diagnosed with HIV. Although uptake of HIV testing has increased in Kenya, men are still less likely than women to get tested and access services. There is, however, limited understanding of the context, barriers and facilitators of HIV testing among men in the country. Data are from in-depth interviews with 30 men living with HIV and 8 HIV testing counsellors that were conducted to gain insights on motivations and drivers for HIV testing among men in the city of Nairobi. Men were identified retroactively by examining clinical CD4 registers on early and late diagnosis (e.g. CD4 of ≥500 cells/mm, early diagnosis and <500 cells/mm, late diagnosis). Analysis involved identifying broad themes and generating descriptive codes and categories. Timing for early testing is linked with strong social support systems and agency to test, while cost of testing, choice of facility to test and weak social support systems (especially poor inter-partner relations) resulted in late testing. Minimal discussions occurred prior to testing and whenever there was dialogue it happened with partners or other close relatives. Interrelated barriers at individual, health-care system, and interpersonal levels hindered access to testing services. Specifically, barriers to testing included perceived providers attitudes, facility location and set up, wait time/inconvenient clinic times, low perception of risk, limited HIV knowled ge, stigma, discrimination and fear of having a test. High risk perception, severe illness, awareness of partner's status, confidentiality, quality of services and supplies, flexible/extended opening hours, and pre-and post-test counselling were facilitators. Experiences between early and late testers overlapped though there were minor differences. In order to achieve the desired impact nationally and to attain the 90-90-90 targets, multiple interventions addressing both barriers and facilitators to testing are needed to increase uptake of testing and to link the positive to care.
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Affiliation(s)
- Jerry Okal
- Population Council, Nairobi, Kenya
- * E-mail:
| | | | | | | | | | - Mary Mugambi
- National HIV and STI Control Programme (NASCOP), Nairobi, Kenya
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13
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Mukamba N, Chilyabanyama ON, Beres LK, Simbeza S, Sikombe K, Padian N, Holmes C, Sikazwe I, Geng E, Schwartz SR. Patients' Satisfaction with HIV Care Providers in Public Health Facilities in Lusaka: A Study of Patients who were Lost-to-Follow-Up from HIV Care and Treatment. AIDS Behav 2020; 24:1151-1160. [PMID: 31673912 PMCID: PMC7082366 DOI: 10.1007/s10461-019-02712-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Prognosis among those who are HIV infected has improved but long-term retention is challenging. Health systems may benefit from routinely measuring patient satisfaction which is a potential driver of engagement in HIV care, but it is not often measured in Africa, and Zambia in particular. This study aims to internally validate a patient satisfaction tool, assess satisfaction among patients previously lost-to-follow up (LTFU) from HIV care in Lusaka province and to measure association between patient satisfaction with their original clinic and re-engagement in HIV care. A cross-sectional assessment of satisfaction was conducted by tracing sampled patients drawn from public health facilities. Our findings suggest that satisfaction tool, previously validated in USA, exhibits high internal consistency for measuring patient satisfaction in the Zambian health system. Patient satisfaction with healthcare providers is associated with re-engagement in HIV care. Future interventions on patient-centred care are likely to optimize and support retention in care.
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Affiliation(s)
- Njekwa Mukamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
| | | | - Laura K Beres
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | - Nancy Padian
- Division of Epidemiology, University of California, Berkeley, Berkeley, CA, USA
| | - Charles Holmes
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Centre for Global Health and Quality, Georgetown University Medical Center, Washington, DC, USA
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Elvin Geng
- Division of HIV, ID and Global Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Sheree R Schwartz
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA.
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14
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Bulstra CA, Hontelez JA, Ogbuoji O, Bärnighausen T. Which delivery model innovations can support sustainable HIV treatment? AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2020; 18:315-323. [PMID: 31779572 DOI: 10.2989/16085906.2019.1686033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The rapid scale-up of antiretroviral treatment (ART) for HIV since the mid-2000s, mostly through disease-specific or "vertical" programmes, has been a highly successful undertaking, which averted millions of deaths and prevented many new infections. However, the dynamics of the HIV epidemic and changing political and financial commitment to fight the disease will likely require new models for the delivery of ART over the coming decades if the promises of universal treatment are to be met. Delivery model innovations for ART are intended to improve both the effectiveness and efficiency of the HIV treatment cascade, reaching new people who require ART and providing ART to more people without an increase in resources. We describe twelve models for ART delivery, which could be achieved through five categories of delivery innovations: integrating ART ("vertical ART plus", "partially-integrated ART" and "fully-integrated ART"); modifying steps in the ART value chain ("professional task-shifted ART", "people task-shifted ART" and "technology-supported ART"); eliminating steps in the ART value chain ("immediate ART" and "less frequent ART pick-up"); changing ART locations ("private-sector ART", "traditional-sector ART" and "ART outside the health sector"); and keeping the status quo ("vertical ART"). The different delivery model innovations are not mutually exclusive and several could be combined, such as "vertical ART plus" with "task-shifted ART". Suitability of the models will highly depend on local and national contexts, including existing health systems resources, available funding, and type of HIV epidemic. Future implementation research needs to identify which models are the best fit for different contexts.
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Affiliation(s)
- Caroline A Bulstra
- Erasmus Medical Centre, Department of Public Health, Rotterdam, The Netherlands.,Institute of Global Health, University of Heidelberg, Germany
| | - Jan Ac Hontelez
- Erasmus Medical Centre, Department of Public Health, Rotterdam, The Netherlands.,Institute of Global Health, University of Heidelberg, Germany
| | - Osondu Ogbuoji
- Center for Policy Impact in Global Health, Duke University, Durham, USA
| | - Till Bärnighausen
- Institute of Global Health, University of Heidelberg, Germany.,Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, USA.,Africa Health Research Institute, Durban, South Africa
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15
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Roberts DA, Tan N, Limaye N, Irungu E, Barnabas RV. Cost of Differentiated HIV Antiretroviral Therapy Delivery Strategies in Sub-Saharan Africa: A Systematic Review. J Acquir Immune Defic Syndr 2019; 82 Suppl 3:S339-S347. [PMID: 31764272 PMCID: PMC6884078 DOI: 10.1097/qai.0000000000002195] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Efficient and scalable models for HIV treatment are needed to maximize health outcomes with available resources. By adapting services to client needs, differentiated antiretroviral therapy (DART) has the potential to use resources more efficiently. We conducted a systematic review assessing the cost of DART in sub-Saharan Africa compared with the standard of care. METHODS We searched PubMed, Embase, Global Health, EconLit, and the grey literature for studies published between 2005 and 2019 that assessed the cost of DART. Models were classified as facility-vs. community-based and individual- vs group-based. We extracted the annual per-patient service delivery cost and incremental cost of DART compared with standard of care in 2018 USD. RESULTS We identified 12 articles that reported costs for 16 DART models in 7 countries. The majority of models were facility-based (n = 12) and located in Uganda (n = 7). The annual cost per patient within DART models (excluding drugs) ranged from $27 to $889 (2018 USD). Of the 11 models reporting incremental costs, 7 found DART to be cost saving. The median incremental saving per patient per year among cost-saving models was $67. Personnel was the most common driver of reduced costs, but savings were sometimes offset by higher overheads or utilization. CONCLUSIONS DART models can save personnel costs by task shifting and reducing visit frequency. Additional economic evidence from community-based and group models is needed to better understand the scalability of DART. To decrease costs, programs will need to match DART models to client needs without incurring substantial overheads.
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Affiliation(s)
- D Allen Roberts
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Nicholas Tan
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Nishaant Limaye
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Elizabeth Irungu
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Ruanne V. Barnabas
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
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16
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Improving the Validity of Mathematical Models for HIV Elimination by Incorporating Empirical Estimates of Progression Through the HIV Treatment Cascade. J Acquir Immune Defic Syndr 2019; 79:596-604. [PMID: 30272631 DOI: 10.1097/qai.0000000000001852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Optimism regarding prospects for eliminating HIV by expanding antiretroviral treatment has been emboldened in part by projections from several mathematical modeling studies. Drawing from a detailed empirical assessment of rates of progression through the entire HIV care cascade, we quantify for the first time the extent to which models may overestimate health benefits from policy changes when they fail to incorporate a realistic understanding of the cascade. SETTING Rural KwaZulu-Natal, South Africa. METHODS We estimated rates of progression through stages of the HIV treatment cascade using data from a longitudinal population-based HIV surveillance system in rural KwaZulu-Natal. Incorporating empirical estimates in a mathematical model of HIV progression, infection transmission, and care, we estimated life expectancy and secondary infections averted under a range of treatment scale-up scenarios reflecting expanding treatment eligibility thresholds. We compared the results with those implied by the conventional assumptions that have been commonly adopted by existing models. RESULTS Survival gains from expanding the treatment eligibility threshold from CD4 350-500 cells/μL and from 500 cells/μL to treating everyone irrespective of their CD4 count may be overestimated by 3.60 and 3.79 times in models that fail to capture realities of the care cascade. HIV infections averted from raising the threshold from CD4 200 to 350, 350 to 500, and 500 cells/μL to treating everyone may be overestimated by 1.10, 2.65, and 1.18 times, respectively. CONCLUSIONS Models using conventional assumptions about cascade progression may substantially overestimate health benefits. As implementation of treatment scale-up proceeds, it is important to assess the effects of required scale-up efforts in a way that incorporates empirical realities of how people move through the HIV cascade.
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17
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The influence of constraints on the efficient allocation of resources for HIV prevention: authors' response. AIDS 2019; 33:1950-1951. [PMID: 31490215 DOI: 10.1097/qad.0000000000002315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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19
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Stopard IJ, McGillen JB, Hauck K, Hallett TB. The influence of constraints on the efficient allocation of resources for HIV prevention. AIDS 2019; 33:1241-1246. [PMID: 30649065 PMCID: PMC6511422 DOI: 10.1097/qad.0000000000002158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 01/08/2019] [Accepted: 01/10/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To investigate how 'real-world' constraints on the allocative and technical efficiency of HIV prevention programmes affect resource allocation and the number of infections averted. DESIGN Epidemiological modelling and economic analyses in Benin, South Africa and Tanzania. METHODS We simulated different HIV prevention programmes, and first determined the most efficient allocation of resources, in which the HIV prevention budget is shared among specific interventions, risk-groups and provinces to maximize the number of infections averted. We then identified the efficient allocation of resources and achievable impact given the following constraints to allocative efficiency: earmarking [provinces with budgets fund pre-exposure prophylaxis (PrEP) for low-risk women first], meeting targets [provinces with budgets fund universal test-and-treat (UTT) first] and minimizing changes in the geographical distribution of funds. We modelled technical inefficiencies as a reduction in the coverage of PrEP or UTT, which were factored into the resource allocation process or took effect following the allocation. Each scenario was investigated over a range of budgets, such that the impact reaches its maximum. RESULTS The 'earmarking', 'meeting targets' and 'minimizing change' constraints reduce the potential impact of HIV prevention programmes, but at the higher budgets these constraints have little to no effect (approximately 35 billion US$ in Tanzania). Over-estimating technical efficiency can result in a loss of impact compared to what would be possible if technical efficiencies were known accurately. CONCLUSION Failing to account for constraints on allocative and technical efficiency can result in the overestimation of the health gains possible, and for technical inefficiencies the allocation of an inefficient strategy.
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Affiliation(s)
- Isaac J Stopard
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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20
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Sumner T, Bozzani F, Mudzengi D, Hippner P, Houben RM, Cardenas V, Vassall A, White RG. Estimating the Impact of Tuberculosis Case Detection in Constrained Health Systems: An Example of Case-Finding in South Africa. Am J Epidemiol 2019; 188:1155-1164. [PMID: 30824911 PMCID: PMC6545281 DOI: 10.1093/aje/kwz038] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 02/05/2019] [Accepted: 02/06/2019] [Indexed: 11/13/2022] Open
Abstract
Mathematical models are increasingly being used to compare strategies for tuberculosis (TB) control and inform policy decisions. Models often do not consider financial and other constraints on implementation and may overestimate the impact that can be achieved. We developed a pragmatic approach for incorporating resource constraints into mathematical models of TB. Using a TB transmission model calibrated for South Africa, we estimated the epidemiologic impact and resource requirements (financial, human resource (HR), and diagnostic) of 9 case-finding interventions. We compared the model-estimated resources with scenarios of future resource availability and estimated the impact of interventions under these constraints. Without constraints, symptom screening in public health clinics and among persons receiving care for human immunodeficiency virus infection was predicted to lead to larger reductions in TB incidence (9.5% (2.5th–97.5th percentile range (PR), 8.6–12.2) and 14.5% (2.5th–97.5th PR, 12.2–16.3), respectively) than improved adherence to diagnostic guidelines (2.7%; 2.5th–97.5th PR, 1.6–4.1). However, symptom screening required large increases in resources, exceeding future HR capacity. Even under our most optimistic HR scenario, the reduction in TB incidence from clinic symptom screening was 0.2%–0.9%—less than that of improved adherence to diagnostic guidelines. Ignoring resource constraints may result in incorrect conclusions about an intervention’s impact and may lead to suboptimal policy decisions. Models used for decision-making should consider resource constraints.
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Affiliation(s)
- Thomas Sumner
- TB Modelling Group, TB Centre, Centre for the Mathematical Modelling of Infectious Disease, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Fiammetta Bozzani
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | - Rein M Houben
- TB Modelling Group, TB Centre, Centre for the Mathematical Modelling of Infectious Disease, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Richard G White
- TB Modelling Group, TB Centre, Centre for the Mathematical Modelling of Infectious Disease, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
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21
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Using Contact Patterns to Inform HIV Interventions in Persons Who Inject Drugs in Northern Vietnam. J Acquir Immune Defic Syndr 2019; 78:1-8. [PMID: 29389769 DOI: 10.1097/qai.0000000000001632] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Population mixing patterns can greatly inform allocation of HIV prevention interventions such as treatment as prevention or preexposure prophylaxis. Characterizing contact patterns among subgroups can help identify the specific combinations of contact expected to result in the greatest number of new infections. SETTING Baseline data from an intervention to reduce HIV-related risk behaviors in male persons who inject drugs (PWID) in the Northern Vietnamese province of Thai Nguyen were used for the analysis. METHODS Egocentric network data were provided by PWID who reported any drug-injection equipment sharing in the previous 3 months. Age-dependent mixing was assessed to explore its epidemiological implications on risk of HIV transmission risk (among those HIV-infected) and HIV acquisition risk (among those not infected) in PWID. RESULTS A total of 1139 PWID collectively reported 2070 equipment-sharing partnerships in the previous 3 months. Mixing by age identified the 30-34 and 35-39 years age groups as the groups from whom the largest number of new infections was transmitted, making them primary targets for treatment as prevention. Among the uninfected, 25-29, 30-35, and 35-39 years age groups had the highest HIV acquisition rate, making them the primary targets for preexposure prophylaxis. CONCLUSIONS Collection and analysis of contact patterns in PWID is feasible and can greatly inform infectious disease dynamics and targeting of appropriate interventions. Results presented also provide much needed empirical data on mixing to improve mathematical models of disease transmission in this population.
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Kim LH, Vail D, Azad TD, Bentley JP, Zhang Y, Ho AL, Fatemi P, Feng A, Varshneya K, Desai M, Veeravagu A, Ratliff JK. Expenditures and Health Care Utilization Among Adults With Newly Diagnosed Low Back and Lower Extremity Pain. JAMA Netw Open 2019; 2:e193676. [PMID: 31074820 PMCID: PMC6512284 DOI: 10.1001/jamanetworkopen.2019.3676] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Low back pain (LBP) with or without lower extremity pain (LEP) is one of the most common reasons for seeking medical care. Previous studies investigating costs in this population targeted patients receiving surgery. Little is known about health care utilization among patients who do not undergo surgery. OBJECTIVES To assess use of health care resources for LBP and LEP management and analyze associated costs. DESIGN, SETTING, AND PARTICIPANTS This cohort study used a retrospective analysis of a commercial database containing inpatient and outpatient data for more than 75 million individuals. Participants were US adults who were newly diagnosed with LBP or LEP between 2008 and 2015, did not have a red-flag diagnosis, and were opiate naive prior to diagnosis. Dates of analysis were October 6, 2018, to March 7, 2019. EXPOSURES Newly diagnosed LBP or LEP. MAIN OUTCOMES AND MEASURES The primary outcome was total cost of care within the first 6 and 12 months following diagnosis, stratified by whether patients received spinal surgery. An assessment was performed to determine whether patients who did not undergo surgery received care in accordance with proposed guidelines for conservative LBP and LEP management. Costs resulting from use of different health care services were estimated. RESULTS A total of 2 498 013 adult patients with a new LBP or LEP diagnosis (median [interquartile range] age, 47 [36-58] years; 1 373 076 [55.0%] female) were identified. More than half (55.7%) received no intervention. Only 1.2% of patients received surgery, but they accounted for 29.3% of total 12-month costs ($784 million). Total costs of care among the 98.8% of patients who did not receive surgery were $1.8 billion. Patients who did not undergo surgery frequently received care that was inconsistent with clinical guidelines for LBP and LEP: 32.3% of these patients received imaging within 30 days of diagnosis and 35.3% received imaging without a trial of physical therapy. CONCLUSIONS AND RELEVANCE The findings suggest that surgery is rare among patients with newly diagnosed LBP and LEP but remains a significant driver of spending. Early imaging in patients who do not undergo surgery was also a major driver of increased health care expenditures. Avoidable costs among patients with typically self-limited conditions result in considerable economic burden to the US health care system.
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Affiliation(s)
- Lily H. Kim
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Daniel Vail
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Tej D. Azad
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Jason P. Bentley
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
| | - Yi Zhang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Allen L. Ho
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Paras Fatemi
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Austin Feng
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Kunal Varshneya
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Manisha Desai
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - John K. Ratliff
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
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Hontelez JAC, Bor J, Tanser FC, Pillay D, Moshabela M, Bärnighausen T. HIV Treatment Substantially Decreases Hospitalization Rates: Evidence From Rural South Africa. Health Aff (Millwood) 2019; 37:997-1004. [PMID: 29863928 DOI: 10.1377/hlthaff.2017.0820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The effect of HIV treatment on hospitalization rates for HIV-infected people has never been established. We quantified this effect in a rural South African community for the period 2009-13. We linked clinical data on HIV treatment start dates for more than 2,000 patients receiving care in the public-sector treatment program with five years of longitudinal data on self-reported hospitalizations from a community-based population cohort of more than 100,000 adults. Hospitalization rates peaked during the first year of treatment and were about five times higher, compared to hospitalization rates after four years on treatment. Earlier treatment initiation could save more than US$300,000 per 1,000 patients over the first four years of HIV treatment, freeing up scarce resources. Future studies on the cost-effectiveness of HIV treatment should include these effects.
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Affiliation(s)
- Jan A C Hontelez
- Jan A. C. Hontelez ( ) is an assistant professor at Erasmus University Medical Center, in Rotterdam, the Netherlands, and at the Heidelberg Institute of Public Health, Heidelberg University, in Germany
| | - Jacob Bor
- Jacob Bor is an assistant professor in the Departments of Global Health and Epidemiology, Boston University School of Public Health, in Massachusetts
| | - Frank C Tanser
- Frank C. Tanser is a professor of epidemiology at the University of KwaZulu-Natal and senior faculty member of the Africa Health Research Institute. He also holds an honorary professorship in the Research Department of Infection and Population Health, University College London, and is a research associate of the Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal
| | - Deenan Pillay
- Deenan Pillay is director of the Africa Health Research Institute
| | - Mosa Moshabela
- Mosa Moshabela is head of the Department of Rural Health, University of KwaZulu-Natal, and a senior researcher at the Africa Health Research Institute
| | - Till Bärnighausen
- Till Bärnighausen is the Alexander von Humboldt University Professor and director of the Heidelberg Institute of Public Health, Heidelberg University. He is also senior faculty at the Africa Health Research Institute in Somkhele, South Africa, and an adjunct professor of global health at the Harvard T. H. Chan School of Public Health, in Boston
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Yotebieng M, Brazier E, Addison D, Kimmel AD, Cornell M, Keiser O, Parcesepe AM, Onovo A, Lancaster KE, Castelnuovo B, Murnane PM, Cohen CR, Vreeman RC, Davies M, Duda SN, Yiannoutsos CT, Bono RS, Agler R, Bernard C, Syvertsen JL, Sinayobye JD, Wikramanayake R, Sohn AH, von Groote PM, Wandeler G, Leroy V, Williams CF, Wools‐Kaloustian K, Nash D. Research priorities to inform "Treat All" policy implementation for people living with HIV in sub-Saharan Africa: a consensus statement from the International epidemiology Databases to Evaluate AIDS (IeDEA). J Int AIDS Soc 2019; 22:e25218. [PMID: 30657644 PMCID: PMC6338103 DOI: 10.1002/jia2.25218] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 11/07/2018] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION "Treat All" - the treatment of all people with HIV, irrespective of disease stage or CD4 cell count - represents a paradigm shift in HIV care that has the potential to end AIDS as a public health threat. With accelerating implementation of Treat All in sub-Saharan Africa (SSA), there is a need for a focused agenda and research to identify and inform strategies for promoting timely uptake of HIV treatment, retention in care, and sustained viral suppression and addressing bottlenecks impeding implementation. METHODS The Delphi approach was used to develop consensus around research priorities for Treat All implementation in SSA. Through an iterative process (June 2017 to March 2018), a set of research priorities was collectively formulated and refined by a technical working group and shared for review, deliberation and prioritization by more than 200 researchers, implementation experts, policy/decision-makers, and HIV community representatives in East, Central, Southern and West Africa. RESULTS AND DISCUSSION The process resulted in a list of nine research priorities for generating evidence to guide Treat All policies, implementation strategies and monitoring efforts. These priorities highlight the need for increased focus on adolescents, men, and those with mental health and substance use disorders - groups that remain underserved in SSA and for whom more effective testing, linkage and care strategies need to be identified. The priorities also reflect consensus on the need to: (1) generate accurate national and sub-national estimates of the size of key populations and describe those who remain underserved along the HIV-care continuum; (2) characterize the timeliness of HIV care and short- and long-term HIV care continuum outcomes, as well as factors influencing timely achievement of these outcomes; (3) estimate the incidence and prevalence of HIV-drug resistance and regimen switching; and (4) identify cost-effective and affordable service delivery models and strategies to optimize uptake and minimize gaps, disparities, and losses along the HIV-care continuum, particularly among underserved populations. CONCLUSIONS Reflecting consensus among a broad group of experts, researchers, policy- and decision-makers, PLWH, and other stakeholders, the resulting research priorities highlight important evidence gaps that are relevant for ministries of health, funders, normative bodies and research networks.
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Affiliation(s)
| | - Ellen Brazier
- Institute for Implementation Science in Population HealthCity University of New YorkNew YorkNYUSA
- Department of Epidemiology and BiostatisticsGraduate School of Public Health and Health PolicyCity University of New YorkNew YorkNYUSA
| | - Diane Addison
- Institute for Implementation Science in Population HealthCity University of New YorkNew YorkNYUSA
- Department of Epidemiology and BiostatisticsGraduate School of Public Health and Health PolicyCity University of New YorkNew YorkNYUSA
| | - April D Kimmel
- Department of Health Behavior and PolicyVirginia Commonwealth University School of MedicineRichmondVAUSA
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology& ResearchSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Olivia Keiser
- Institute of Global HealthUniversity of GenevaGenevaSwitzerland
| | | | - Amobi Onovo
- University of North Carolina at Chapel HillChapel HillNCUSA
| | | | | | - Pamela M Murnane
- Center for AIDS Prevention StudiesDepartment of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive SciencesBixby Center for Global Reproductive HealthUniversity of California San FranciscoSan FranciscoCAUSA
| | - Rachel C Vreeman
- Department of PediatricsIndiana University School of MedicineIndianapolisINUSA
| | - Mary‐Ann Davies
- School of Public Health and Family MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | | | | | - Rose S Bono
- Department of Health Behavior and PolicyVirginia Commonwealth University School of MedicineRichmondVAUSA
| | | | - Charlotte Bernard
- InsermCentre INSERM U1219‐Epidémiologie‐BiostatistiqueSchool of Public Health (ISPED)University of BordeauxBordeauxFrance
| | | | | | - Radhika Wikramanayake
- Institute for Implementation Science in Population HealthCity University of New YorkNew YorkNYUSA
- Department of Epidemiology and BiostatisticsGraduate School of Public Health and Health PolicyCity University of New YorkNew YorkNYUSA
| | - Annette H Sohn
- TREAT AsiaamfAR – The Foundation for AIDS ResearchBangkokThailand
| | - Per M von Groote
- Institute of Social and Preventive Medicine (ISPM)University of BernBernSwitzerland
| | - Gilles Wandeler
- Institute of Social and Preventive Medicine (ISPM)University of BernBernSwitzerland
| | - Valeriane Leroy
- Inserm (French Institute of Health and Medical Research)UMR 1027 Université Toulouse 3ToulouseFrance
| | - Carolyn F Williams
- Epidemiology BranchDivision of AIDS at National Institute of Allergy and Infectious Diseases (NIAID)National Institute of Health (NIH)RockvilleMDUSA
| | | | - Denis Nash
- Institute for Implementation Science in Population HealthCity University of New YorkNew YorkNYUSA
- Department of Epidemiology and BiostatisticsGraduate School of Public Health and Health PolicyCity University of New YorkNew YorkNYUSA
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25
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Kimmel AD, Bono RS, Keiser O, Sinayobye JD, Estill J, Mujwara D, Tymejczyk O, Nash D. Mathematical modelling to inform 'treat all' implementation in sub-Saharan Africa: a scoping review. J Virus Erad 2018; 4:47-54. [PMID: 30515314 PMCID: PMC6248854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE Despite widespread uptake, only half of sub-Saharan African countries have fully implemented the World Health Organization's 'treat all' policy, hindering achievement of global HIV targets. We examined literature on mathematical modelling studies that sought to inform scale-up and implementation of 'treat all' in sub-Saharan Africa. METHODS We conducted a scoping review, a research synthesis to assess emerging evidence and identify gaps, of peer-reviewed literature, extracting study characteristics on 'treat all' policies and assumptions, setting, key populations, outcomes and findings. Studies were narratively summarised and potential gaps characterised. RESULTS We identified 16 studies examining 'treat all' alone (n=12) or with expanded testing (n=7) and/or care continuum improvements (n=6). Twelve studies examined 'treat all' for Southern African countries, while none did so for Central Africa. Four included the role of resistance; one evaluated any key population. A range of health and economic outcomes were reported, although fewer studies formally assessed budget impact. Fourteen studies involved co-authors with any in-country affiliation; one study also had co-authors with local government affiliation. Overall, 'treat all' improves health outcomes and is cost-effective compared to deferred HIV treatment; 'treat all' with expanded testing or care continuum improvements may provide further health benefits. However, studies generally used optimistic assumptions about the implementation of expanded testing or care continuum improvements. CONCLUSIONS The modelling literature demonstrates improved health and economic benefits of 'treat all'. Using mathematical modelling to inform real-world implementation of 'treat all' requires realistic assumptions about expanded testing and care continuum interventions across a wide range of settings and populations.
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Affiliation(s)
- April D Kimmel
- Department of Health Behavior and Policy, Virginia Commonwealth University,
Richmond VA,
USA
| | - Rose S Bono
- Department of Health Behavior and Policy, Virginia Commonwealth University,
Richmond VA,
USA
| | - Olivia Keiser
- Institute of Global Health, University of Geneva,
Switzerland
| | - Jean D Sinayobye
- Research and Clinical Education Division, Rwanda Military Hospital,
Kigali,
Rwanda
| | | | - Deo Mujwara
- Department of Health Behavior and Policy, Virginia Commonwealth University,
Richmond VA,
USA
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26
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Kimmel AD, Bono RS, Keiser O, Sinayobye JD, Estill J, Mujwara D, Tymejczyk O, Nash D. Mathematical modelling to inform ‘treat all’ implementation in sub-Saharan Africa: a scoping review. J Virus Erad 2018. [DOI: 10.1016/s2055-6640(20)30345-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Baltussen R, Jansen M, Bijlmakers L. Stakeholder participation on the path to universal health coverage: the use of evidence-informed deliberative processes. Trop Med Int Health 2018; 23:1071-1074. [PMID: 30112816 DOI: 10.1111/tmi.13138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Rob Baltussen
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherland
| | - Maarten Jansen
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherland
| | - Leon Bijlmakers
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherland
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28
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Zakumumpa H, Dube N, Damian RS, Rutebemberwa E. Understanding the dynamic interactions driving the sustainability of ART scale-up implementation in Uganda. Glob Health Res Policy 2018; 3:23. [PMID: 30123838 PMCID: PMC6091155 DOI: 10.1186/s41256-018-0079-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 07/16/2018] [Indexed: 01/01/2023] Open
Abstract
Background Despite increasing recognition that health-systems constraints are the fundamental barrier to attaining anti-retroviral therapy (ART) scale-up targets in Sub-Saharan Africa, current discourses are dominated by a focus on financial sustainability. Utilizing the health system dynamics framework, this study aimed to explore the interactions in health system components and their influence on the sustainability of ART scale-up implementation in Uganda. Methods This study entailed qualitative organizational case-studies within a two-phased mixed-methods sequential explanatory research design. In Phase One, a survey of 195 health facilities across Uganda which commenced ART services between 2004 and 2009 was conducted. In Phase Two, six health facilities were purposively selected for in-depth examination involving i) In-depth interviews (n = 44) ii) and semi-structured interviews (n = 35). Qualitative data was analyzed by coding and thematic analysis. Descriptive statistics were managed in STATA (v 13). Results Five dynamic interactions in ART program sustainability drivers were identified; i) Failure to update basic ART program records contributed to chronic ART medicines stock-outs ii) Health workforce shortages and escalating patient volumes prompted adaptations in ART service delivery models iii) Broader governance issues manifested in poor road networks undermined ART medicines supply chains iv) Sustained financing for ART programs was influenced by external donors v) The values associated with the ownership-type of a health facility affected ART service delivery and coverage. Conclusion The sustainability of ART programs at the facility-level in Uganda is a function of a complex interaction in elements of the health system and must be understood beyond sustaining international funding for ART scale-up.
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Affiliation(s)
- Henry Zakumumpa
- 1School of Public Health, Makerere University, Kampala, Uganda
| | - Nkosiyazi Dube
- 2School of Health and Community Development, University of the Witwatersrand, Johannesburg, South Africa
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29
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Bozzani FM, Mudzengi D, Sumner T, Gomez GB, Hippner P, Cardenas V, Charalambous S, White R, Vassall A. Empirical estimation of resource constraints for use in model-based economic evaluation: an example of TB services in South Africa. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2018; 16:27. [PMID: 30069166 PMCID: PMC6065151 DOI: 10.1186/s12962-018-0113-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 07/23/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Evidence on the relative costs and effects of interventions that do not consider 'real-world' constraints on implementation may be misleading. However, in many low- and middle-income countries, time and data scarcity mean that incorporating health system constraints in priority setting can be challenging. METHODS We developed a 'proof of concept' method to empirically estimate health system constraints for inclusion in model-based economic evaluations, using intensified case-finding strategies (ICF) for tuberculosis (TB) in South Africa as an example. As part of a strategic planning process, we quantified the resources (fiscal and human) needed to scale up different ICF strategies (cough triage and WHO symptom screening). We identified and characterised three constraints through discussions with local stakeholders: (1) financial constraint: potential maximum increase in public TB financing available for new TB interventions; (2) human resource constraint: maximum current and future capacity among public sector nurses that could be dedicated to TB services; and (3) diagnostic supplies constraint: maximum ratio of Xpert MTB/RIF tests to TB notifications. We assessed the impact of these constraints on the costs of different ICF strategies. RESULTS It would not be possible to reach the target coverage of ICF (as defined by policy makers) without addressing financial, human resource and diagnostic supplies constraints. The costs of addressing human resource constraints is substantial, increasing total TB programme costs during the period 2016-2035 by between 7% and 37% compared to assuming the expansion of ICF is unconstrained, depending on the ICF strategy chosen. CONCLUSIONS Failure to include the costs of relaxing constraints may provide misleading estimates of costs, and therefore cost-effectiveness. In turn, these could impact the local relevance and credibility of analyses, thereby increasing the risk of sub-optimal investments.
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Affiliation(s)
- Fiammetta M. Bozzani
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | | | - Tom Sumner
- TB Modelling Group, TB Centre, CMMID, London School of Hygiene & Tropical Medicine, London, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Gabriela B. Gomez
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | | | | | - Salome Charalambous
- TB Modelling Group, TB Centre, CMMID, London School of Hygiene & Tropical Medicine, London, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard White
- TB Modelling Group, TB Centre, CMMID, London School of Hygiene & Tropical Medicine, London, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
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Tromp N, Prawiranegara R, Siregar A, Wisaksana R, Pinxten L, Pinxten J, Lesmana Putra A, Kurnia Sunjaya D, Jansen M, Hontelez J, Maurits S, Maharani F, Bijlmakers L, Baltussen R. Translating international HIV treatment guidelines into local priorities in Indonesia. Trop Med Int Health 2018; 23:279-294. [PMID: 29327397 DOI: 10.1111/tmi.13031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE International guidelines recommend countries to expand antiretroviral therapy (ART) to all HIV-infected individuals and establish local-level priorities in relation to other treatment, prevention and mitigation interventions through fair processes. However, no practical guidance is provided for such priority-setting processes. Evidence-informed deliberative processes (EDPs) fill this gap and combine stakeholder deliberation to incorporate relevant social values with rational decision-making informed by evidence on these values. This study reports on the first-time implementation and evaluation of an EDP in HIV control, organised to support the AIDS Commission in West Java province, Indonesia, in the development of its strategic plan for 2014-2018. METHODS Under the responsibility of the provincial AIDS Commission, an EDP was implemented to select priority interventions using six steps: (i) situational analysis; (ii) formation of a multistakeholder Consultation Panel; (iii) selection of criteria; (iv) identification and assessment of interventions' performance; (v) deliberation; and (vi) selection of funding and implementing institutions. An independent researcher conducted in-depth interviews (n = 21) with panel members to evaluate the process. RESULTS The Consultation Panel included 23 stakeholders. They identified 50 interventions and these were evaluated against four criteria: impact on the epidemic, stigma reduction, cost-effectiveness and universal coverage. After a deliberative discussion, the Consultation Panel prioritised a combination of several treatment, prevention and mitigation interventions. CONCLUSION The EDP improved both stakeholder involvement and the evidence base for the strategic planning process. EDPs fill an important gap which international guidelines and current tools for strategic planning in HIV control leave unaddressed.
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Affiliation(s)
- Noor Tromp
- Department of Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,KIT (Royal Tropical Institute), Amsterdam, The Netherlands
| | - Rozar Prawiranegara
- Department of Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Faculty of Medicine, Padjadjaran University, Bandung, Indonesia
| | - Adiatma Siregar
- Faculty Economics and Business, Padjadjaran University, Bandung, Indonesia
| | - Rudi Wisaksana
- Faculty of Medicine, Padjadjaran University, Bandung, Indonesia
| | - Lucas Pinxten
- Nijmegen Institute for Scientist-Practitioners in Addiction, Radboud University, Nijmegen, The Netherlands.,Faculty of Psychology and Neuroscience, Department of Work and Social Psychology, Maastricht University, Maastricht, The Netherlands
| | - Juul Pinxten
- Social Protection and Jobs Global Practice, World Bank, Jarkarta, Indonesia
| | - Arry Lesmana Putra
- United Nations Development Programme Indonesia, Jakarta, Indonesia.,West Java Provincial AIDS commission, Bandung, Indonesia
| | | | - Maarten Jansen
- Department of Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan Hontelez
- Department of Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Heidelberg Institute of Public Health, Faculty of Medicine, Heidelberg University, Heidelberg, Germany
| | - Scott Maurits
- Department of Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Leon Bijlmakers
- Department of Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rob Baltussen
- Department of Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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McRobie E, Matovu F, Nanyiti A, Nonvignon J, Abankwah DNY, Case KK, Hallett TB, Hanefeld J, Conteh L. National responses to global health targets: exploring policy transfer in the context of the UNAIDS '90-90-90' treatment targets in Ghana and Uganda. Health Policy Plan 2018; 33:17-33. [PMID: 29040476 PMCID: PMC5886235 DOI: 10.1093/heapol/czx132] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2017] [Indexed: 12/11/2022] Open
Abstract
Global health organizations frequently set disease-specific targets with the goal of eliciting adoption at the national-level; consideration of the influence of target setting on national policies, programme and health budgets is of benefit to those setting targets and those intended to respond. In 2014, the Joint United Nations Programme on HIV/AIDS set 'ambitious' treatment targets for country adoption: 90% of HIV-positive persons should know their status; 90% of those on treatment; 90% of those achieving viral suppression. Using case studies from Ghana and Uganda, we explore how the target and its associated policy content have been adopted at the national level. That is whether adoption is in rhetoric only or supported by programme, policy or budgetary changes. We review 23 (14 from Ghana, 9 from Uganda) national policy, operational and strategic documents for the HIV response and assess commitments to '90-90-90'. In-person semi-structured interviews were conducted with purposively sampled key informants (17 in Ghana, 20 in Uganda) involved in programme-planning and resource allocation within HIV to gain insight into factors facilitating adoption of 90-90-90. Interviews were transcribed and analysed thematically, inductively and deductively, guided by pre-existing policy theories, including Dolowitz and Marsh's policy transfer framework to describe features of the transfer and the Global Health Advocacy and Policy Project framework to explain observations. Regardless of notable resource constraints, transfer of the 90-90-90 targets was evident beyond rhetoric with substantial shifts in policy and programme activities. In both countries, there was evidence of attempts to minimize resource constraints by seeking programme efficiencies, prioritization of programme activities and devising domestic financing mechanisms; however, significant resource gaps persist. An effective health network, comprised of global and local actors, mediated the adoption and adaptation, facilitating a shift in the HIV programme from 'business as usual' to approaches targeting geographies and populations.
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Affiliation(s)
- Ellen McRobie
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
| | - Fred Matovu
- School of Economics, Makerere University, Kampala, Uganda
- Policy Analysis & Development Research Institute, Kampala, Uganda
| | - Aisha Nanyiti
- School of Economics, Makerere University, Kampala, Uganda
| | - Justice Nonvignon
- Department of Health Policy, Planning & Management, School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Daniel Nana Yaw Abankwah
- Department of Social and Behavioural Sciences, School of Public Health, University of Ghana, Accra, Ghana
| | - Kelsey K Case
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
| | - Timothy B Hallett
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
| | - Johanna Hanefeld
- Anthropology, Politics and Policy Group, Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Lesong Conteh
- Health Economics Group, School of Public Health, Imperial College London, London, UK
- Medical Research Council Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
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Jansen MP, Baltussen R, Mikkelsen E, Tromp N, Hontelez J, Bijlmakers L, van der Wilt GJ. Evidence-Informed Deliberative Processes - Early Dialogue, Broad Focus and Relevance: A Response to Recent Commentaries. Int J Health Policy Manag 2018; 7:96-97. [PMID: 29325411 PMCID: PMC5745876 DOI: 10.15171/ijhpm.2017.88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 07/16/2017] [Indexed: 12/04/2022] Open
Affiliation(s)
- Maarten P Jansen
- Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Rob Baltussen
- Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Evelinn Mikkelsen
- Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Noor Tromp
- KIT (Royal Tropical Institute), Amsterdam, The Netherlands
| | - Jan Hontelez
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Institute of Public Health, Heidelberg University, Heidelberg, Germany.,Africa Health Research Institute, Mtubatuba, South Africa
| | - Leon Bijlmakers
- Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Gert Jan van der Wilt
- Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
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Abstract
In a Perspective, Amitabh Suthar and Till Bärnighausen discuss progress made so far in reducing HIV-related mortality in South Africa and keys towards further population mortality reductions going forward.
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Affiliation(s)
- Amitabh B. Suthar
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- * E-mail:
| | - Till Bärnighausen
- Africa Health Research Institute, Mtubatuba, South Africa
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Heidelberg Institute of Public Health, Heidelberg, Germany
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Mikkelsen E, Hontelez JA, Nonvignon J, Amon S, Asante FA, Aikins MK, van de Haterd J, Baltussen R. The costs of HIV treatment and care in Ghana. AIDS 2017; 31:2279-2286. [PMID: 28991025 PMCID: PMC5642329 DOI: 10.1097/qad.0000000000001612] [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] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 07/15/2017] [Accepted: 07/24/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine cost functions that describe the dynamics of costs of HIV treatment and care in Ghana by CD4 cell count at treatment initiation and over time on antiretroviral therapy (ART). DESIGN We used detailed longitudinal healthcare utilization data from clinical health records of HIV-infected patients at seven Ghanaian ART clinics to estimate cost functions of treatment and care by CD4 cell count at treatment initiation and time on ART. METHODS We developed two linear regression models; one with individual random effects to determine the relationship between CD4 cell count at ART initiation and costs of treatment and care, and one with individual fixed effects to determine the causal effect of time in care on costs of treatment and care. RESULTS Costs for treatment and care were lowest (-7.9 US$) for patients with CD4 cell counts of at least 350 cells/μl at ART initiation, compared with patients with 50 cells/μl or less at ART initiation, yet the difference was not significant. The per-patient costs peaked during the first 6 months on ART at 112.6 US$, and significantly decreased by 70% after 4 years on treatment. CONCLUSION Our findings show that an accurate analysis of resource needs of HIV treatment and care should take into account that healthcare costs for HIV-infected people are dynamic rather than constant. The cost functions derived from our study are valuable input for cost-effectiveness analyses and research allocation exercises for HIV treatment in sub-Saharan Africa.
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Affiliation(s)
- Evelinn Mikkelsen
- Department for Health Evidence, Radboud University Medical Centre, Institute for Health Sciences, Nijmegen
| | - Jan A.C. Hontelez
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Heidelberg Institute of Public Health, Faculty of Medicine, Heidelberg University, Heidelberg, Germany
| | - Justice Nonvignon
- Department of Health Policy, Planning & Management, School of Public Health, College of Health Sciences
| | - Sam Amon
- Department of Health Policy, Planning & Management, School of Public Health, College of Health Sciences
| | - Felix A. Asante
- Institute of Statistical, Social & Economic Research (ISSER), University of Ghana, Accra Ghana
| | - Moses K. Aikins
- Department of Health Policy, Planning & Management, School of Public Health, College of Health Sciences
| | - Julie van de Haterd
- Department for Health Evidence, Radboud University Medical Centre, Institute for Health Sciences, Nijmegen
| | - Rob Baltussen
- Department for Health Evidence, Radboud University Medical Centre, Institute for Health Sciences, Nijmegen
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Doherty T, Besada D, Goga A, Daviaud E, Rohde S, Raphaely N. "If donors woke up tomorrow and said we can't fund you, what would we do?" A health system dynamics analysis of implementation of PMTCT option B+ in Uganda. Global Health 2017; 13:51. [PMID: 28747196 PMCID: PMC5530517 DOI: 10.1186/s12992-017-0272-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 06/26/2017] [Indexed: 01/12/2023] Open
Abstract
Background In October 2012 Uganda extended its prevention of mother to child HIV transmission (PMTCT) policy to Option B+, providing lifelong antiretroviral treatment for HIV positive pregnant and breastfeeding women. The rapid changes and adoptions of new PMTCT policies have not been accompanied by health systems research to explore health system preparedness to implement such programmes. The implementation of Option B+ provides many lessons which can inform the shift to ‘Universal Test and Treat’, a policy which many sub-Saharan African countries are preparing to adopt, despite fragile health systems. Methods This qualitative study of PMTCT Option B+ implementation in Uganda three years following the policy adoption, uses the health system dynamics framework to explore the impacts of this programme on ten elements of the health system. Qualitative data were gathered through rapid appraisal during in-country field work. Key informant interviews and focus group discussions (FGDs) were undertaken with the Ministry of Health, implementing partners, multilateral agencies, district management teams, facility-based health workers and community cadres. A total of 82 individual interviews and 16 focus group discussions were completed. We conducted a simple manifest analysis, using the ten elements of a health system for grouping data into categories and themes. Results Of the ten elements in the health system dynamics framework, context and resources (finances, infrastructure & supplies, and human resources) were the most influential in the implementation of Option B+ in Uganda. Support from international actors and implementing partners attempted to strengthen resources at district level, but had unintended consequences of creating dependence and uncertainty regarding sustainability. Conclusions The health system dynamics framework offers a novel approach to analysis of the effects of implementation of a new policy on critical elements of the health system. Its emphasis on relationships between system elements, population and context is helpful in unpacking impacts of and reactions to pressures on the system, which adds value beyond some previous frameworks.
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Affiliation(s)
- Tanya Doherty
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa. .,School of Public Health, University of the Western Cape, Cape Town, South Africa. .,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
| | - Donnela Besada
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Ameena Goga
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.,Department of Paediatrics, University of Pretoria, Pretoria, South Africa
| | - Emmanuelle Daviaud
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Sarah Rohde
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Nika Raphaely
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,Gender and Health Research Unit, South African Medical Research Council, Pretoria, South Africa
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Vassall A, Siapka M, Foster N, Cunnama L, Ramma L, Fielding K, McCarthy K, Churchyard G, Grant A, Sinanovic E. Cost-effectiveness of Xpert MTB/RIF for tuberculosis diagnosis in South Africa: a real-world cost analysis and economic evaluation. Lancet Glob Health 2017; 5:e710-e719. [PMID: 28619229 PMCID: PMC5471605 DOI: 10.1016/s2214-109x(17)30205-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 04/28/2017] [Accepted: 05/09/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND In 2010 a new diagnostic test for tuberculosis, Xpert MTB/RIF, received a conditional programmatic recommendation from WHO. Several model-based economic evaluations predicted that Xpert would be cost-effective across sub-Saharan Africa. We investigated the cost-effectiveness of Xpert in the real world during national roll-out in South Africa. METHODS For this real-world cost analysis and economic evaluation, we applied extensive primary cost and patient event data from the XTEND study, a pragmatic trial examining Xpert introduction for people investigated for tuberculosis in 40 primary health facilities (20 clusters) in South Africa enrolled between June 8, and Nov 16, 2012, to estimate the costs and cost per disability-adjusted life-year averted of introducing Xpert as the initial diagnostic test for tuberculosis, compared with sputum smear microscopy (the standard of care). FINDINGS The mean total cost per study participant for tuberculosis investigation and treatment was US$312·58 (95% CI 252·46-372·70) in the Xpert group and $298·58 (246·35-350·82) in the microscopy group. The mean health service (provider) cost per study participant was $168·79 (149·16-188·42) for the Xpert group and $160·46 (143·24-177·68) for the microscopy group of the study. Considering uncertainty in both cost and effect using a wide range of willingness to pay thresholds, we found less than 3% probability that Xpert introduction improved the cost-effectiveness of tuberculosis diagnostics. INTERPRETATION After analysing extensive primary data collection during roll-out, we found that Xpert introduction in South Africa was cost-neutral, but found no evidence that Xpert improved the cost-effectiveness of tuberculosis diagnosis. Our study highlights the importance of considering implementation constraints, when predicting and evaluating the cost-effectiveness of new tuberculosis diagnostics in South Africa. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Anna Vassall
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK,Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK,Correspondence to: Prof Anna Vassall, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UKCorrespondence to: Prof Anna VassallDepartment of Global Health and DevelopmentLondon School of Hygiene & Tropical MedicineKeppel StreetLondonWC1E 7HTUK
| | - Mariana Siapka
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Nicola Foster
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Lucy Cunnama
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Lebogang Ramma
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Kerrigan McCarthy
- Aurum Institute, Johannesburg, South Africa,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa,Division of Public Health, Surveillance and Response, National Institute for Communicable Disease of the National Health Laboratory Service, Johannesburg, South Africa
| | - Gavin Churchyard
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK,Aurum Institute, Johannesburg, South Africa,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa,Advancing Treatment and Care for TB/HIV, South African Medical Research Council, Johannesburg, South Africa
| | - Alison Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa,Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Edina Sinanovic
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Maheu-Giroux M, Vesga JF, Diabaté S, Alary M, Baral S, Diouf D, Abo K, Boily MC. Population-level impact of an accelerated HIV response plan to reach the UNAIDS 90-90-90 target in Côte d'Ivoire: Insights from mathematical modeling. PLoS Med 2017; 14:e1002321. [PMID: 28617810 PMCID: PMC5472267 DOI: 10.1371/journal.pmed.1002321] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 05/09/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND National responses will need to be markedly accelerated to achieve the ambitious target of the Joint United Nations Programme on HIV/AIDS (UNAIDS). This target aims for 90% of HIV-positive individuals to be aware of their status, for 90% of those aware to receive antiretroviral therapy (ART), and for 90% of those on treatment to have a suppressed viral load by 2020, with each individual target reaching 95% by 2030. We aimed to estimate the impact of various treatment-as-prevention scenarios in Côte d'Ivoire, one of the countries with the highest HIV incidence in West Africa, with unmet HIV prevention and treatment needs, and where key populations are important to the broader HIV epidemic. METHODS AND FINDINGS An age-stratified dynamic model was developed and calibrated to epidemiological and programmatic data using a Bayesian framework. The model represents sexual and vertical HIV transmission in the general population, female sex workers (FSW), and men who have sex with men (MSM). We estimated the impact of scaling up interventions to reach the UNAIDS targets, as well as the impact of 8 other scenarios, on HIV transmission in adults and children, compared to our baseline scenario that maintains 2015 rates of testing, ART initiation, ART discontinuation, treatment failure, and levels of condom use. In 2015, we estimated that 52% (95% credible intervals: 46%-58%) of HIV-positive individuals were aware of their status, 72% (57%-82%) of those aware were on ART, and 77% (74%-79%) of those on ART were virologically suppressed. Reaching the UNAIDS targets on time would avert 50% (42%-60%) of new HIV infections over 2015-2030 compared to 30% (25%-36%) if the 90-90-90 target is reached in 2025. Attaining the UNAIDS targets in FSW, their clients, and MSM (but not in the rest of the population) would avert a similar fraction of new infections (30%; 21%-39%). A 25-percentage-point drop in condom use from the 2015 levels among FSW and MSM would reduce the impact of reaching the UNAIDS targets, with 38% (26%-51%) of infections averted. The study's main limitation is that homogenous spatial coverage of interventions was assumed, and future lines of inquiry should examine how geographical prioritization could affect HIV transmission. CONCLUSIONS Maximizing the impact of the UNAIDS targets will require rapid scale-up of interventions, particularly testing, ART initiation, and limiting ART discontinuation. Reaching clients of FSW, as well as key populations, can efficiently reduce transmission. Sustaining the high condom-use levels among key populations should remain an important prevention pillar.
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Affiliation(s)
- Mathieu Maheu-Giroux
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Québec, Canada
- * E-mail:
| | - Juan F. Vesga
- Department of Infectious Disease Epidemiology, Imperial College London, St Mary’s Hospital, London, United Kingdom
| | - Souleymane Diabaté
- Centre de recherche du CHU de Québec - Université Laval, Québec, Canada
- Département d’infectiologie et santé publique, Université Alassane Ouattara, Bouaké, Côte d’Ivoire
| | - Michel Alary
- Centre de recherche du CHU de Québec - Université Laval, Québec, Canada
- Département de médecine sociale et préventive, Université Laval, Québec, Canada
- Institut national de santé publique du Québec, Québec, Canada
| | - Stefan Baral
- Key Populations Program, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - Kouamé Abo
- Programme National de Lutte contre le SIDA, Ministère de la Santé et de l’Hygiène Publique, Abidjan, Côte d’Ivoire
| | - Marie-Claude Boily
- Department of Infectious Disease Epidemiology, Imperial College London, St Mary’s Hospital, London, United Kingdom
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Iwuji C, Newell ML. Towards control of the global HIV epidemic: Addressing the middle-90 challenge in the UNAIDS 90-90-90 target. PLoS Med 2017; 14:e1002293. [PMID: 28464003 PMCID: PMC5412986 DOI: 10.1371/journal.pmed.1002293] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
In a Perspective, Collins Iwuji and Marie-Louise Newell discuss early findings from Richard Hayes and colleagues' PopART study on HIV testing and treatment.
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Affiliation(s)
- Collins Iwuji
- Research Department of Infection and Population Health, University College London, London, United Kingdom
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- * E-mail:
| | - Marie-Louise Newell
- Human Development and Health and Global Health Research Institute, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
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Zuma T, Wight D, Rochat T, Moshabela M. Traditional health practitioners' management of HIV/AIDS in rural South Africa in the era of widespread antiretroviral therapy. Glob Health Action 2017; 10:1352210. [PMID: 28771116 PMCID: PMC5645651 DOI: 10.1080/16549716.2017.1352210] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 07/05/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Traditional health practitioners (THPs) have been identified as a key local resource in the fight against human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) in South Africa. However, their approaches to the treatment of people living with HIV (PLHIV) have been met with scepticism by some biomedical practitioners amid increasing access to antiretroviral therapy (ART). OBJECTIVE In light of this ambivalence, this study aims to document and identify treatment approaches of THPs to the management of illness among PLHIV in the current era of widespread access to ART. METHODS The study was conducted as part of a larger trial of Treatment as Prevention (TasP) in rural northern Kwa-Zulu Natal, intended to treat PLHIV regardless of CD4 count. Nine THPs were enrolled using purposive and snowballing techniques. Repeat group discussions, triangulated with community walks and photovoice techniques, were conducted. A thematic analysis approach was used to analyse the data. RESULTS Eight of the nine THPs had received training in biomedical aspects of HIV. THPs showed a multilayered decision-making process in managing illness among PLHIV, influenced by the attributes and choices of the THPs. THPs assessed and managed illness among PLHIV based on THP training in HIV/AIDS, THP type, as well as knowledge and experience in the traditional healing practice. Management of illness depended on the patients' report of their HIV status or willingness to test for HIV. CONCLUSIONS THPs' approaches to illness in PLHIV appear to be shifting in light of increasing exposure to HIV/AIDS-related information. Importantly, disclosure of HIV status plays a major role in THPs' management of illness among PLHIV, as well as linkage to HIV testing and care for their patients. Therefore, THPs can potentially enhance the success of ART for PLHIV when HIV status is known.
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Affiliation(s)
- Thembelihle Zuma
- Africa Health Research Institute, Mtubatuba, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Daniel Wight
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Tamsen Rochat
- Human Sciences Research Council/Human and Social Development (HSD) and MRC Developmental Pathways to Health Research Unit, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Mosa Moshabela
- Africa Health Research Institute, Mtubatuba, South Africa
- Discipline of Rural Health, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
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