Articles tagged as "Resources/ Impact/ Development"

Economics

Bachmann MO, Booysen FL. Economic causes and effects of AIDS in South African households. AIDS 2006;20:1861-67.

Photo credit: UNAIDS/ L. Alyanak
Photo credit: UNAIDS/ L. Alyanak
Bachmann and Booysen investigated the magnitude and temporal directionality of associations between illness and death, and income and expenditure, in households affected by HIV. A cohort study with repeated measures was conducted in one rural and one urban area of South Africa among 405 households (1913 occupants) known to have HIV-infected occupants, and their neighbours. Interview surveys of household heads were conducted at baseline and five more times, semi-annually, providing information on household economics, illnesses and deaths. Regression analyses used marginal structural models and 'before-after' models to analyse changes. In marginal structural models, current or previous AIDS illness was independently associated with 34% (95% CI 23-43%) lower monthly expenditure, and current or recent poverty was associated with 1.74 (95% CI 0.94-3.2) times higher odds of an AIDS death. In before-after models, each AIDS death was independently associated with a 23% (95% CI 11-34%) greater expenditure decline over 3 years. A US$100 higher monthly expenditure at baseline was associated with 0.31 (95% CI 0.13-0.74) times as many AIDS deaths and with 0.41 (95% CI 0.27-0.64) times as many AIDS illness episodes over 3 years. The authors conclude that AIDS deaths and illnesses predicted declining expenditure, and poverty predicted AIDS, suggesting that both welfare and effective treatment are needed.

Editors’ note: This study demonstrates that AIDS itself is impoverishing but also that increased household resources can slow disease progression. This is likely due, in part, to the direct effect of adequate nutrition but may also involve other factors. It speaks for the importance of both nutritional support and micro-finance and other economic strategies to increase household resources.


Goldie SJ, Yazdanpanah Y, et al. Cost-effectiveness of HIV treatment in resource-poor settings--the case of Cote d'Ivoire. N Engl J Med 2006;355:1141-53. http://content.nejm.org/cgi/content/full/355/11/1141

As antiretroviral therapy is increasingly used in settings with limited resources, key questions about the timing of treatment and use of diagnostic tests to guide clinical decisions must be addressed. Goldie and colleagues assessed the cost-effectiveness of treatment strategies for a cohort of HIV-infected adults in Cote d'Ivoire (mean age 33 years; CD4 cell count 331 per cubic millimeter; HIV RNA level 5.3 log copies per milliliter). Using a computer-based simulation model that incorporates the CD4 cell count and HIV RNA level as predictors of disease progression, the authors compared the long-term clinical and economic outcomes associated with no treatment, trimethoprim-sulfamethoxazole prophylaxis alone, antiretroviral therapy alone, and trimethoprim-sulfamethoxazole prophylaxis with antiretroviral therapy. Compared with trimethoprim-sulfamethoxazole alone, life expectancy increased by 10.7 months with antiretroviral therapy and trimethoprim-sulfamethoxazole prophylaxis initiated on the basis of clinical criteria and 45.9 months with antiretroviral therapy and trimethoprim-sulfamethoxazole prophylaxis initiated on the basis of CD4 testing and clinical criteria. The incremental cost per year of life gained was US$240 for trimethoprim-sulfamethoxazole prophylaxis alone, US$620 for antiretroviral therapy and trimethoprim-sulfamethoxazole prophylaxis without CD4 testing, and US$1180 for antiretroviral therapy and trimethoprim-sulfamethoxazole prophylaxis with CD4 testing. None of the strategies that used antiretroviral therapy alone were as cost-effective as those that also used trimethoprim-sulfamethoxazole prophylaxis. Life expectancy was increased by 30% with use of a second line of antiretroviral therapy after failure of the first-line regimen. The authors conclude that a strategy of trimethoprim-sulfamethoxazole prophylaxis and antiretroviral therapy, with the use of clinical criteria alone or in combination with CD4 testing to guide the timing of treatment, is an economically attractive health investment in settings with limited resources.

 Editors’ note: This study provides unequivocal support from an economics perspective for the standard inclusion of trimethoprim-sulfamethoxazole prophylaxis in treatment regimes but it also highlights the survival advantage (close to 3 additional years) of adding CD4 testing to clinical criteria for treatment initiation. Successful efforts to reduce the cost, complexity and unavailability of CD4 testing would have tangible survival benefits.
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Knowledge Translation for best practice

van Kerkhoff L, Szlezak N. Linking local knowledge with global action: examining the Global Fund to Fight AIDS, Tuberculosis and Malaria through a knowledge system lens. Bull World Health Organ 2006;84:629-635.http://www.who.int/bulletin/volumes/84/8/05-028704.pdf

Photo credit: UNAIDS/R. Bowman
Photo credit: UNAIDS/R. Bowman
New global public health institutions are increasingly emphasizing transparency in decision-making, developing-country ownership of projects and programmes, and merit- and performance-based funding. Such principles imply an institutional response to the challenge of bridging the "know-do gap" by basing decisions explicitly on results, evidence and best practice. Using a knowledge systems framework, van Kerkhoff and Szlezak examined how the Global Fund to Fight AIDS, Tuberculosis and Malaria has affected the ways in which knowledge is used in efforts to combat these three diseases. They outline the formal knowledge system embedded in current rules and practices associated with the Global Fund's application process, and give three examples that illustrate the complexity of the knowledge system in action: HIV policy in China; successful applications from Haiti; and responses to changing research on malaria. These examples show that the Global Fund has created strong incentives for knowledge to flow to local implementers, but with little encouragement and few structures for the potentially valuable lessons from implementation to flow back to global best practice or research-based knowledge. The Global Fund could play an influential role in fostering much-needed learning from implementation. The authors suggest that three initial steps are required to start this process: acknowledging shared responsibility for learning across the knowledge system; analysing the Global Fund's existing data (and refining data collection over time); and supporting recipients and technical partners to invest resources in linking implementation with best practice and research.

Editors’ note: We will just not get on top of this epidemic if we all work in silos, not sharing successes and failures, not building incremental, iterative learning into the response. Knowledge translation, horizontal learning, experience informing policy and programming have to become vibrant, catalytic components of the response.
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Resource Tracking

Lu C, Michaud CM, Khan K, Murray CJ. Absorptive capacity and disbursements by the Global Fund to Fight AIDS, Tuberculosis and Malaria: analysis of grant implementation. Lancet 2006;368:483-88. http://www.sciencedirect.com/

The Global Fund was launched in 2002 to attract and rapidly disburse money to fight AIDS, tuberculosis and malaria. However, some commentators believe that poor countries cannot effectively use such resources to increase delivery of their health programmes – referred to as a lack of absorptive capacity. Lu and colleagues investigated the major determinants of grant implementation in low- and middle-income countries. With information available publicly on the Global Fund's website, the authors did random-effects analysis to investigate the effect of grant characteristics, types of primary recipient and local fund agent, and country attributes on disbursements that were made between 2003 and 2005 (phase one of Global Fund payments). To check the robustness of findings, regression results from alternative estimation methods and model specifications were also tested. Grant characteristics - such as size of commitment, lag time between signature and first disbursement, and funding round - had significant effects on grant implementation. Enhanced political stability was associated with high use of grants. Low-income countries, and those with less-developed health systems for a given level of income, were more likely to have a higher rate of grant implementation than nations with higher incomes or more-developed health systems. The authors conclude that the higher rate of grant implementation seen in countries with low income and low health-spending lends support to proponents of major increases in health assistance for the poorest countries and argues that focusing resources on low-income nations, particularly those with political stability, will not create difficulties of absorptive capacity. This analysis was restricted to grant implementation, which is one part of the issue of absorptive capacity. In the future, assessment of the effect of Global Fund grants on intervention coverage will be vital.

Editors’ note: These are interesting findings, using publicly available data, which put paid to concerns that grants cannot be rapidly profiled in those countries most in need of support - low-income countries with less developed health systems.

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Financial Initiatives

Vasan A, Hoos D, et al. The pricing and procurement of antiretroviral drugs: an observational study of data from the Global Fund. Bull World Health Organ 2006;84:393-98. http://www.who.int/bulletin/volumes/84/5/393.pdf

Vasan et al analysed the ARV transaction data in the Purchase price report (Global Fund, 2004) to examine the procurement behaviour of principal recipients of Global Fund grants in low and middle income countries. They found that, with a few exceptions for specific products (e.g. lamivudine) and regions (e.g. eastern Europe), prices in low-income countries were broadly consistent or lower than the lowest differential prices quoted by the research and development sector of the pharmaceutical industry. In lower middle-income countries, prices were more varied and in several instances (lopinavir/ritonavir, didanosine, and zidovudine/lamivudine) were very high compared with the per capita income of the country. In all low- and lower middle-income countries, ARV prices were still significantly high given limited local purchasing power and economic strength, thus reaffirming the need for donor support to achieve rapid scale-up of antiretroviral therapy. However, the authors conclude, the price of ARVs will have to decrease to render scale-up financially sustainable for donors and eventually for governments themselves. An important first step in reducing prices will be to make available in the public domain as much ARV transaction data as possible to provide a factual basis for discussions on pricing. The price of ARVs has considerable implications for the sustainability of AIDS treatment in low and middle-income countries.

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Costing

Soorapanth S, Sansom S, Bulterys M, et al. Cost-effectiveness of HIV Rescreening During Late Pregnancy to Prevent Mother-to-child HIV Transmission in South Africa and Other Resource-limited Settings. J Acquir Immune Defic Syndr 2006 Apr 24; [Epub ahead of print]

The authors used a decision analysis model, from a health care system perspective, to assess the cost-effectiveness of HIV re-screening during late pregnancy to prevent perinatal HIV transmission in South Africa, a country with high HIV prevalence and incidence among pregnant women. Because new HIV prenatal prophylactic and pediatric ART regimens are becoming more widely available, the study was carried out with different combinations of the two. With an estimated HIV incidence during pregnancy of 2.3/100 person-years, HIV re-screening would prevent additional infant infections and result in net savings when zidovudine plus single-dose nevirapine or single-dose nevirapine is used for perinatal HIV prevention, and ART was available to treat perinatally HIV-infected children. The cost savings were robust over a wide range of parameter values when ART was available to treat perinatally HIV-infected children but were more sensitive to variations around the baseline when ART was not available. The minimum time interval between the initial and repeat screens would be from 3 to 18 weeks, depending on prophylactic and treatment regimens, for HIV re-screening to be cost saving. Overall, HIV re-screening late in pregnancy in high-prevalence, resource-limited settings such as South Africa would be a cost-effective strategy for reducing mother-to-child transmission.

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