Articles tagged as "Resources/ Impact/ Development"

The power of PEPFAR programmes: estimates of infections averted and life years gained in Africa

Estimating the impact of the US President's Emergency Plan for AIDS Relief on HIV treatment and prevention programmes in Africa.

Heaton LM, Bouey PD, Fu J, Stover J, Fowler TB, Lyerla R, Mahy M. Sex Transm Infect. 2015 Dec;91(8):615-20. doi: 10.1136/sextrans-2014-051991. Epub 2015 Jun 8.

Background: Since 2004, the US President's Emergency Plan for AIDS Relief (PEPFAR) has supported the tremendous scale-up of HIV prevention, care and treatment services, primarily in sub-Saharan Africa. We evaluate the impact of antiretroviral treatment (ART), prevention of mother-to-child transmission (PMTCT) and voluntary medical male circumcision (VMMC) programmes on survival, mortality, new infections and the number of orphans from 2004 to 2013 in 16 PEPFAR countries in Africa.

Methods: PEPFAR indicators tracking the number of persons receiving ART for their own health, ART regimens for PMTCT and biomedical prevention of HIV through VMMC were collected across 16 PEPFAR countries. To estimate the impact of PEPFAR programmes for ART, PMTCT and VMMC, we compared the current scenario of PEPFAR-supported interventions to a counterfactual scenario without PEPFAR, and assessed the number of life years gained (LYG), number of orphans averted and HIV infections averted. Mathematical modelling was conducted using the SPECTRUM modelling suite V.5.03.

Results: From 2004 to 2013, PEPFAR programmes provided support for a cumulative number of     24 565 127 adults and children on ART, 4 154 878 medical male circumcisions, and ART for PMTCT among 4 154 478 pregnant women in 16 PEPFAR countries. Based on findings from the model, these efforts have helped avert 2.9 million HIV infections in the same period. During 2004-2013, PEPFAR ART programmes alone helped avert almost 9 million orphans in 16 PEPFAR countries and resulted in 11.6 million LYG.

Conclusions: Modelling results suggest that the rapid scale-up of PEPFAR-funded ART, PMTCT and VMMC programmes in Africa during 2004-2013 led to substantially fewer new HIV infections and orphaned children during that time and longer lives among people living with HIV. Our estimates do not account for the impact of the PEPFAR-funded non-biomedical interventions such as behavioural and structural interventions included in the comprehensive HIV prevention, care and treatment strategy used by PEPFAR countries. Therefore, the number of HIV infections and orphans averted and LYG may be underestimated by these models.

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Editor’s notes: The President’s Emergency Plan for AIDS Relief (PEPFAR) was initiated in 2004 with $42 billion spent up until the end of 2013. Despite limitations in monitoring the overall contribution of PEPFAR to individual programmes, this article attempts to provide an overview of PEPFAR support for ART, prevention of mother to child transmission and voluntary medical male circumcision (VMMC) programmes using the 2014 version of Spectrum Software model. The Spectrum modules used included DemProj, AIDS Impact Model (AIM) and Goals, which interact to model the impact and future course of the HIV epidemic at the population level.  An estimate of PEPFAR’s contribution was obtained by subtracting it from the total for the national programme statistics reported by UNAIDS on ART, PMTCT and VMMC.

The baseline scenario of PEPFAR-supported programmes in 2013 was compared to a counterfactual scenario, which subtracts the direct contribution of PEPFAR. The results estimate that the combined programmes have averted 2.7 million infections in Africa, with over 11.5 million life years gained and the aversion of almost nine million orphans. Other key population programmes that the funding supported including gender equity and health strengthening were not evaluated and therefore, the estimate for impact may be conservative. A limitation of the analysis is that it is unable to predict the national response without PEPFAR and the impact of ART calculated by the model is sensitive to the distribution of new ART patients by CD4 count at the initiation of treatment. In addition, few countries have sufficient death registration systems to validate mortality estimates, which may result in the accomplishments of PEPFAR’s impact being overestimated. However, with the operation of PEPFAR in a larger context of partnership consortiums, an improvement in evaluation methods will be necessary. 

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‘Cash, care and classroom’: social protection to reduce adolescents’ risk of HIV

Applying a family-level economic strengthening intervention to improve education and health-related outcomes of school-going AIDS-orphaned children: lessons from a randomized experiment in southern Uganda.

Ssewamala FM, Karimli L, Torsten N, Wang JS, Han CK, Ilic V, Nabunya P. Prev Sci. 2016 Jan;17(1):134-43. doi: 10.1007/s11121-015-0580-9.

Children comprise the largest proportion of the population in sub-Saharan Africa. Of these, millions are orphaned. Orphanhood increases the likelihood of growing up in poverty, dropping out of school, and becoming infected with HIV. Therefore, programs aimed at securing a healthy developmental trajectory for these orphaned children are desperately needed. We conducted a two-arm cluster-randomized controlled trial to evaluate the effectiveness of a family-level economic strengthening intervention with regard to school attendance, school grades, and self-esteem in AIDS-orphaned adolescents aged 12-16 years from 10 public rural primary schools in southern Uganda. Children were randomly assigned to receive usual care (counseling, school uniforms, school lunch, notebooks, and textbooks), "bolstered" with mentorship from a near-peer (control condition, n = 167), or to receive bolstered usual care plus a family-level economic strengthening intervention in the form of a matched Child Savings Account (Suubi-Maka treatment arm, n = 179). The two groups did not differ at baseline, but 24 months later, children in the Suubi-Maka treatment arm reported significantly better educational outcomes, lower levels of hopelessness, and higher levels of self-concept compared to participants in the control condition. Our study contributes to the ongoing debate on how to address the developmental impacts of the increasing numbers of orphaned and vulnerable children and adolescents in sub-Saharan Africa, especially those affected by HIV/AIDS. Our findings indicate that innovative family-level economic strengthening programs, over and above bolstered usual care that includes psychosocial interventions for young people, may have positive developmental impacts related to education, health, and psychosocial functioning.

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Editor’s notes: The HIV epidemic has left many sub-Saharan countries with an extraordinarily large youth population, many of whom lost one or both parents to HIV-associated mortality. As a result, younger children tend to have much less support to stay in education and older children often have increased responsibility to support the household. There is thus a need to provide orphaned children with both financial and psycho-social support to achieve their educational goals, and on a broader scale, to prepare the youth for the workforce. This study found that providing orphaned children with a package of school supplies and support services as well as financial services (opening a matched child savings account and workshops on microenterprise development) yielded better educational outcomes than the package without the additional financial services. However, how either group compares to non-orphaned children is unclear. Future research would benefit from a third comparison group, in which non-orphaned children’s educational outcomes are also compared.

The effect of the programme on both educational and mental outcomes among orphans is important. Educational outcomes may have been driven by improved self-confidence and motivation as a result of the savings account and microenterprise training. It is unclear whether these supplemental activities were simply a signal of the community support for the orphaned children, which in turn increased self-confidence, or if the children were directly influenced by their improved economic prospects. Further research to uncover the actual mechanism of the improved outcomes would be useful for future programme design. 

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Determinants of HIV prevention costs at scale in India

What determines HIV prevention costs at scale? Evidence from the Avahan programme in India.

Lépine A, Chandrashekar S, Shetty G, Vickerman P, Bradley J, Alary M, Moses S, Group CI, Vassall A. Health Econ. 2016 Feb;25 Suppl 1:67-82. doi: 10.1002/hec.3296. Epub 2016 Jan 14.

Expanding essential health services through non-government organisations (NGOs) is a central strategy for achieving universal health coverage in many low-income and middle-income countries. Human immunodeficiency virus (HIV) prevention services for key populations are commonly delivered through NGOs and have been demonstrated to be cost-effective and of substantial global public health importance. However, funding for HIV prevention remains scarce, and there are growing calls internationally to improve the efficiency of HIV prevention programmes as a key strategy to reach global HIV targets. To date, there is limited evidence on the determinants of costs of HIV prevention delivered through NGOs; and thus, policymakers have little guidance in how best to design programmes that are both effective and efficient. We collected economic costs from the Indian Avahan initiative, the largest HIV prevention project conducted globally, during the first 4 years of its implementation. We use a fixed-effect panel estimator and a random-intercept model to investigate the determinants of average cost. We find that programme design choices such as NGO scale, the extent of community involvement, the way in which support is offered to NGOs and how clinical services are organised substantially impact average cost in a grant-based payment setting.

Abstract  Full-text [free] access

Editor’s notes: This paper was published in the journal Health Economics, as part of a supplement on methods for economic evaluation in low-income and middle-income countries. The supplement eloquently summarizes the current state of the art for economic evaluation in these countries, providing a good background for readers who are less familiar with this field.  It also reflects challenges for the design, conduct, and use of economic evaluations in these settings and highlights some of the methodological innovations arising out of these challenges. 

This contribution reflects the importance of using cost functions when conducting economic evaluations of programmes that need to be scaled up. The authors present average costs for 138 non-governmental organisations providing HIV prevention services to key populations across four years in India, as part of the Avahan project. They find that scale is an important determinant of cost, with average costs falling as scale increases. They also find that community mobilization activities can reduce costs, potentially by encouraging uptake of other services.  Further, the way in which NGOs are supported can impact on costs. 

This article presents an important methodological step towards informing better decision-making and programme design. Understanding of cost drivers can also facilitate programme monitoring and resource allocation. This is one of the first studies fully powered to analyse the determinants of costs for NGO-delivered HIV prevention services.  The authors use a wealth of cost data which are not often available to researchers working in lower and middle income countries. As noted in the foreword for this supplement, further analysis of cost functions will be essential to inform future global and national-level decision-making in these countries. This will require investment in additional large-scale cost studies globally to generate data for this type of analysis.

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Would an HIV vaccine be cost-effective? Possibly…

Exploring the potential health impact and cost-effectiveness of AIDS vaccine within a comprehensive HIV/AIDS response in low- and middle-income countries.

Harmon TM, Fisher KA, McGlynn MG, Stover J, Warren MJ, Teng Y, Naveke A. PLoS One. 2016 Jan 5;11(1):e0146387. doi: 10.1371/journal.pone.0146387. eCollection 2016.

Background: The Investment Framework Enhanced (IFE) proposed in 2013 by the Joint United Nations Programme on HIV/AIDS (UNAIDS) explored how maximizing existing interventions and adding emerging prevention options, including a vaccine, could further reduce new HIV infections and AIDS-related deaths in low- and middle-income countries (LMICs). This article describes additional modeling which looks more closely at the potential health impact and cost-effectiveness of AIDS vaccination in LMICs as part of UNAIDS IFE.

Methods: An epidemiological model was used to explore the potential impact of AIDS vaccination in LMICs in combination with other interventions through 2070. Assumptions were based on perspectives from research, vaccination and public health experts, as well as observations from other HIV/AIDS interventions and vaccination programs. Sensitivity analyses varied vaccine efficacy, duration of protection, coverage, and cost.

Results: If UNAIDS IFE goals were fully achieved, new annual HIV infections in LMICs would decline from 2.0 million in 2014 to 550 000 in 2070. A 70% efficacious vaccine introduced in 2027 with three doses, strong uptake and five years of protection would reduce annual new infections by 44% over the first decade, by 65% the first 25 years and by 78% to 122 000 in 2070. Vaccine impact would be much greater if the assumptions in UNAIDS IFE were not fully achieved. An AIDS vaccine would be cost-effective within a wide range of scenarios.

Interpretation: Even a modestly effective vaccine could contribute strongly to a sustainable response to HIV/AIDS and be cost-effective, even with optimistic assumptions about other interventions. Higher efficacy would provide even greater impact and cost-effectiveness, and would support broader access. Vaccine efficacy and cost per regimen are critical in achieving cost-effectiveness, with cost per regimen being particularly critical in low-income countries and at lower efficacy levels.

Abstract  Full-text [free] access

Editor’s notes: Developing a vaccine against HIV has been an enormous scientific challenge. However, an effective vaccine could revolutionise the field of HIV prevention. A late-stage clinical trial is set to start at the end of 2016 and there are currently more than 30 early-stage clinical studies to evaluate vaccine candidates. This paper has modelled the potential health impacts and cost-effectiveness of an HIV vaccine. They used primary assumptions from the Investment Framework Enhanced from UNAIDS, which models the impact of different prevention programmes in 24 countries accounting for some 85% of new HIV infections. They also carried out sensitivity analyses on vaccine efficacy, duration of protection, coverage and cost.

The authors found that a 70% efficacious vaccine introduced in 2027 with three doses, strong uptake would reduce annual new infections by 78% by 2070. The vaccine would be cost-effective under several scenarios explored. At a cost of $5 per dose, the vaccine would be cost-effective under all vaccine effectiveness scenarios (30%-90%).  At 70% effectiveness, the vaccine would also be cost-effectives in a range of costs per dose ($5-$20).

This study is valuable in that it presents the scenarios in which the introduction of a vaccine against HIV could potentially be cost-effective; it gives an idea of feasibility under certain conditions. However (and the authors acknowledge this) the model is based on assumptions for which there is scant evidence. So far clinical trials have only achieved a vaccine that is 30% effective so 70% effectiveness is still a pipe dream. Secondly, given the enormous amount of resources that may yet need to be invested to develop a vaccine, the cost per vaccine may be much higher than estimated here (even higher than the ‘very high price’ scenario). In addition, the cost of targeting the vaccine to most at risk populations is not discussed; this could also raise the cost per dose considerably.  A probabilistic sensitivity analysis as well as further threshold analysis in this area would be valuable exercises to follow up the findings in this paper. 

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Viral load monitoring could be cost-effective

Sustainable HIV treatment in Africa through viral-load-informed differentiated care.

Working Group on Modelling of Antiretroviral Therapy Monitoring Strategies in Sub-Saharan Africa, Phillips A, Shroufi A, Vojnov L, Cohn J, Roberts T, Ellman T, Bonner K, Rousseau C, Garnett G, Cambiano V, Nakagawa F, Ford D, Bansi-Matharu L, Miners A, Lundgren JD, Eaton JW, Parkes-Ratanshi R, Katz Z, Maman D, Ford N, Vitoria M, Doherty M, Dowdy D, Nichols B, Murtagh M, Wareham M, Palamountain KM, Chakanyuka Musanhu C, Stevens W, Katzenstein D, Ciaranello A, Barnabas R, Braithwaite RS, Bendavid E, Nathoo KJ, van de Vijver D, Wilson DP, Holmes C, Bershteyn A, Walker S, Raizes E, Jani I, Nelson LJ, Peeling R, Terris-Prestholt F, Murungu J, Mutasa-Apollo T, Hallett TB, Revill P. Nature. 2015 Dec 3;528(7580):S68-76. doi: 10.1038/nature16046.

There are inefficiencies in current approaches to monitoring patients on antiretroviral therapy in sub-Saharan Africa. Patients typically attend clinics every 1 to 3 months for clinical assessment. The clinic costs are comparable with the costs of the drugs themselves and CD4 counts are measured every 6 months, but patients are rarely switched to second-line therapies. To ensure sustainability of treatment programmes, a transition to more cost-effective delivery of antiretroviral therapy is needed. In contrast to the CD4 count, measurement of the level of HIV RNA in plasma (the viral load) provides a direct measure of the current treatment effect. Viral-load-informed differentiated care is a means of tailoring care so that those with suppressed viral load visit the clinic less frequently and attention is focussed on those with unsuppressed viral load to promote adherence and timely switching to a second-line regimen. The most feasible approach to measuring viral load in many countries is to collect dried blood spot samples for testing in regional laboratories; however, there have been concerns over the sensitivity and specificity of this approach to define treatment failure and the delay in returning results to the clinic. We use modelling to synthesize evidence and evaluate the cost-effectiveness of viral-load-informed differentiated care, accounting for limitations of dried blood sample testing. We find that viral-load-informed differentiated care using dried blood sample testing is cost-effective and is a recommended strategy for patient monitoring, although further empirical evidence as the approach is rolled out would be of value. We also explore the potential benefits of point-of-care viral load tests that may become available in the future.

Abstract Full-text [free] access

 Editor’s notes: There has been much debate concerning how best to monitor antiretroviral therapy (ART) in resource-limited settings. In the early stages of ART roll-out, there were concerns that if ART monitoring required laboratory testing, the high cost would divert resources away from treatment delivery. Guidelines were drawn up to allow monitoring based on clinical features, alone or with CD4 count monitoring. However, clinical and CD4 monitoring proved to be neither sensitive nor specific when compared to viral load monitoring. In practice, the number of people switched to second-line ART in resource-limited settings has been lower than predicted, particularly where monitoring is clinical or CD4-based. This raises concerns that, in the absence of viral load monitoring, some people will acquire resistance to first-line ART, and this will remain undetected, with the person receiving ineffective treatment for a prolonged period, resulting in the accumulation of resistance mutations. This could threaten the effectiveness of future treatment options, and increases the risk of transmission of drug-resistant viruses. In addition, the poor specificity of clinical and CD4-based definitions of “treatment failure” means that if these definitions are used to make decisions about switching to second line ART, many people who, in reality, have virologic suppression may be inappropriately switched to second-line ART.

Increasingly, there are calls for viral load monitoring to be made more widely available. This is technically challenging, particularly in remote areas. Dried blood spot samples are an alternative method for specimen collection and transport which is practical for remote facilities. Viral load monitoring using dried blood spots has been implemented in some settings. Interpretation of results needs to take account of the lower sensitivity and specificity when compared to viral load assays based on plasma.

This study used a mathematical model to explore outcomes and cost-effectiveness of a range of ART monitoring strategies. The authors found that monitoring based on viral load measurements using dried blood spots was cost-effective. The model assumed that in scenarios with clinical and/or CD4 monitoring patient visits would be three-monthly, whereas in the viral load monitoring scenario, individuals with suppressed viral load would attend clinic for monitoring less frequently (hence the term “viral load-informed differentiated care”). The reduction in visit frequency for people with suppressed viral load was the main driver of cost saving in this scenario.

The cost-effectiveness estimates considered only health sector costs and ignored any patient costs.  Even when treatment and care are free of charge, people incur substantial costs to attend clinics for HIV care, particularly because of loss of income and transport costs. If patient costs had been included, the savings due to reduced visit frequency would almost certainly be even greater.

The accuracy of models is inevitably dependent on the underlying assumptions (described in detail and with admirable clarity in the paper’s accompanying on-line supplement). Cost-effectiveness was sensitive to the cost of viral load monitoring, assumed to be $22 per test based on dried blood spots. These results support efforts to increase access to viral load monitoring. As the authors comment, empirical data from programmes employing viral load-informed differentiated care as a monitoring strategy would be very useful. 

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Harm reduction under fire – people who inject drugs in Kabul, Afghanistan

Hepatitis C and HIV incidence and harm reduction program use in a conflict setting: an observational cohort of injecting drug users in Kabul, Afghanistan.

Todd CS, Nasir A, Stanekzai MR, Fiekert K, Sipsma HL, Vlahov D, Strathdee SA. Harm Reduct J. 2015 Oct 16;12:22. doi: 10.1186/s12954-015-0056-z.

Background: Armed conflict may increase the risk of HIV and other pathogens among injecting drug users (IDUs); however, there are few prospective studies. This study aimed to measure incidence and potential predictors, including environmental events and needle and syringe distribution and collection program (NSP) use, of hepatitis C virus (HCV) and HIV among IDUs in Kabul, Afghanistan.

Methods: Consenting adult IDUs completed interviews quarterly in year 1 and semi-annually in year 2 and HCV and HIV antibody testing semi-annually through the cohort period (November 2007-December 2009). Interviews detailed injecting and sexual risk behaviors, NSP service use, and conflict-associated displacement. Quarters with peak conflict or local displacement were identified based on literature review, and key events, including insurgent attacks and deaths, were reported with simple counts. Incidence and predictors of HCV and HIV were measured with Cox proportional hazards models.

Results: Of 483 IDUs enrolled, 385 completed one or more follow-up visits (483.8 person-years (p-y)). All participants were male with a median age of 28 years and a median duration of injecting of 2 years. Reported NSP use among the participants ranged from 59.9 to 70.5 % in the first year and was 48.4 and 55.4 % at 18 and 24 months, respectively. There were 41 confirmed deaths, with a crude death rate of 93.4/1000 p-y (95 % confidence interval (CI) 67.9-125) and overdose as the most common cause. HCV and HIV incidence were 35.6/100 p-y (95 % CI 28.3-44.6) and 1.5/100 p-y (95 % CI 0.6-3.3), respectively. Changing from injecting to smoking was protective for HCV acquisition (adjusted hazard ratio (AHR) = 0.53, 95 % CI 0.31-0.92), while duration of injecting (AHR = 1.09, 95 % CI 1.01-1.18/year) and sharing syringes (AHR = 10.09, 95 % CI 1.01-100.3) independently predicted HIV infection.

Conclusion: There is high HCV incidence and high numbers of reported deaths among male Kabul IDUs despite relatively consistent levels of harm reduction program use; peak violence periods did not independently predict HCV and HIV risk. Programming should increase awareness of HCV transmission and overdose risks, prepare clients for harm reduction needs during conflict or other causes of displacement, and continue efforts to engage community and police force support.

Abstract  Full-text [free] access

Editor’s notes: This is a relatively rare study, documenting HIV and Hepatitis C infection (HCV) among people who inject drugs in Kabul in Afghanistan.  By combining survey data with information on conflict events from literature/media, the authors can look not only at levels of infection but also how these levels are affected by the conflict. In line with findings from other places experiencing conflict, the authors illustrate that violence did not increase the risk of infection. However, the findings do illustrate the value of needle-syringe distribution and collection programmes in reducing HCV incidence, as the men moved from injecting to smoking. Relatively low levels of HIV prevalence in the Kabul area resulted in low HIV-incidence among the study population. If HIV-prevalence were to rise this could change, as reflected in the high levels of Hepatitis C infection. The authors point to the many challenges of providing services for key populations, such as the men they worked with who injected drugs, in many parts of the world. Growing instability and the displacement of a number of the study population because of the closure of the shelter that housed them, made the research challenging.  A shortage of resources for harm reduction in places like Afghanistan, compounds the problems programmes to support people who inject drugs, face.

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Early treatment initiation reduces costs in Indonesia

Costs of HIV/AIDS treatment in Indonesia by time of treatment and stage of disease.

Siregar AY, Tromp N, Komarudin D, Wisaksana R, van Crevel R, van der Ven A, Baltussen R. BMC Health Serv Res. 2015 Sep 30;15(1):440. doi: 10.1186/s12913-015-1098-3.

Background: We report an economic analysis of Human Immunodeficiency Virus (HIV) care and treatment in Indonesia to assess the options and limitations of costs reduction, improving access, and scaling up services.

Methods: We calculated the cost of providing HIV care and treatment in a main referral hospital in West Java, Indonesia from 2008 to 2010, differentiated by initiation of treatment at different CD4 cell count levels (0-50, 50-100, 100-150, 150-200, and >200 cells/mm3); time of treatment; HIV care and opportunistic infections cost components; and the costs of patients for seeking and undergoing care.

Discussion: Before antiretroviral treatment (ART) initiation, costs were dominated by laboratory tests (>65 %), and after initiation, by antiretroviral drugs (≥60 %). Average treatment costs per patient decreased with time on treatment (e.g. from US$580 per patient in the first 6 month to US$473 per patient in months 19-24 for those with CD4 cell counts under 50 cells/mm3). Higher CD4 cell counts at initiation resulted in lower laboratory and opportunistic infection treatment costs. Transportation cost dominated the costs of patients for seeking and undergoing care (>40 %).

Conclusions: Costs of providing ART are highest during the early phase of treatment. Costs reductions can potentially be realized by early treatment initiation and applying alternative laboratory tests with caution. Scaling up ART at the community level in certain high prevalence settings may improve early uptake, adherence, and reduce transportation costs.

Abstract  Full-text [free] access

Editor’s notes: There is a growing evidence base on the costs of HIV treatment and care, however much of the evidence to date is from sub-Saharan African settings. A review conducted by Siapka et al. in 2014 found 31 studies reporting unit costs for antiretroviral therapy, only 10 of which were outside of Africa and only four of which were set in Asia and the Pacific. This study provides necessary evidence on ART costs in Indonesia. This will be important for Indonesian policy makers as they seek to scale up HIV treatment - especially in the context of recent guideline reforms for ART provision.

Findings from this study largely confirm what has been found elsewhere. Antiretroviral drug costs are primary cost drivers, followed closely by treatment of opportunistic infections. Costs of ART provision are therefore highest during the treatment initiation phase, and drop off as people are established on care. For the same reason, this study also found that costs for treating people with a CD4 count > 200 were significantly lower than costs for treating people with a CD4 count < 200. 

Unit costs per person per year range from $1699 to $2346. This is higher than previously published costs from studies in Thailand, Viet Nam and India, as reported by Siapka et al. It is difficult to tell whether it is representative of ART costs generally in Indonesia as this is the first study reporting costs from this country. 

The authors note that delivering HIV treatment at the community level may reduce costs. It is difficult to tell from the results of this study whether this is indeed the case, as costs are estimated for only one health facility (the largest public referral hospital in West Java province). However, it poses an interesting question for further research. Further evidence on costs for provision of HIV treatment and care across a variety of settings in Indonesia would improve policy relevance and help decision-makers identify potential avenues for improving efficiency.

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How many people have really died of HIV/AIDS in South Africa?

HIV/AIDS in South Africa: how many people died from the disease between 1997 and 2010?

Bradshaw D, Msemburi W, Dorrington R, Pillay-van Wyk V, Laubscher R, Groenewald P, team SN. AIDS. 2015 Oct 27. [Epub ahead of print]

Objectives: Empirical estimates of the number of HIV/AIDS deaths are important for planning, budgeting, and calibrating models. However, there is an extensive misattribution of HIV/AIDS as an underlying cause-of-death. This study estimates the true numbers of AIDS deaths from South African vital statistics between 1997 and 2010.

Methods: Individual-level cause-of-death data were grouped according to a local burden of disease list and source causes (i.e. causes under which AIDS deaths are misclassified) that recorded a rapid increase. After adjusting for completeness of registration, mortality rate of the source causes, by age and sex, was regressed on lagged HIV prevalence to estimate the rate of increase correlated with HIV. Background trends in the source-cause mortality rates were estimated from the trend experienced among 75-84 year olds.

Results: Of 214 causes considered, 19 were identified as potential sources for cause misattribution. High proportions of deaths from tuberculosis, lower respiratory infections (mostly pneumonia), diarrhoeal diseases, and ill-defined natural causes were estimated to be HIV-related, with only 7% of the estimated AIDS deaths being recorded as HIV. Estimated HIV/AIDS deaths increased rapidly, then reversed after 2006, totalling 2.8 million deaths over the whole period. The number was lower than model estimates from UNAIDS and the Global Burden of Disease Study.

Conclusion: Empirically based estimates confirm the considerable loss of life from HIV/AIDS and should be used for calibrating models of the AIDS epidemic which generally appear too low for infants but too high for other ages. Doctors are urged to specify HIV on death notifications to provide reliable cause-of-death statistics.

Abstract access 

Editor’s notesIn many countries, the true number of HIV-associated deaths is significantly under-reported in national vital registration data making it difficult to monitor the epidemic trends from this source. This study describes new estimates of HIV-associated mortality based on empirical vital registration data which aimed to provide accurate estimates of the numbers of HIV-associated deaths in South Africa. The study estimates that, from 1997-2010, 2.86 million deaths in South Africa were due to HIV – over one-third of all deaths. However, relatively few deaths, 7%, were registered as HIV-associated. At the peak of the epidemic in 2006 the vital registration derived estimates show lower trends than other models. All models estimated a decline in the number of HIV-associated deaths post-2008, a finding which is consistent with the extensive roll-out of antiretroviral therapy in South Africa, and with trends reported from verbal autopsy data for all deaths in rural South African demographic surveillance sites. This paper highlights the importance of reporting accurate causes for HIV-associated deaths in the death registration process - however, without de-stigmatisation of HIV, this is going to be difficult to achieve.

South Africa
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Workplace provision of ART: potentially cost-saving in high prevalence settings

The impact of company-level ART provision to a mining workforce in South Africa: a cost-benefit analysis.

Meyer-Rath G, Pienaar J, Brink B, van Zyl A, Muirhead D, Grant A, Churchyard G, Watts C, Vickerman P. PLoS Med. 2015 Sep 1;12(9):e1001869. doi: 10.1371/journal.pmed.1001869. eCollection 2015.

Background: HIV impacts heavily on the operating costs of companies in sub-Saharan Africa, with many companies now providing antiretroviral therapy (ART) programmes in the workplace. A full cost-benefit analysis of workplace ART provision has not been conducted using primary data. We developed a dynamic health-state transition model to estimate the economic impact of HIV and the cost-benefit of ART provision in a mining company in South Africa between 2003 and 2022.

Methods and findings: A dynamic health-state transition model, called the Workplace Impact Model (WIM), was parameterised with workplace data on workforce size, composition, turnover, HIV incidence, and CD4 cell count development. Bottom-up cost analyses from the employer perspective supplied data on inpatient and outpatient resource utilisation and the costs of absenteeism and replacement of sick workers. The model was fitted to workforce HIV prevalence and separation data while incorporating parameter uncertainty; univariate sensitivity analyses were used to assess the robustness of the model findings. As ART coverage increases from 10% to 97% of eligible employees, increases in survival and retention of HIV-positive employees and associated reductions in absenteeism and benefit payments lead to cost savings compared to a scenario of no treatment provision, with the annual cost of HIV to the company decreasing by 5% (90% credibility interval [CrI] 2%-8%) and the mean cost per HIV-positive employee decreasing by 14% (90% CrI 7%-19%) by 2022. This translates into an average saving of US$950 215 (90% CrI US$220 879-US$1.6 million) per year; 80% of these cost savings are due to reductions in benefit payments and inpatient care costs. Although findings are sensitive to assumptions regarding incidence and absenteeism, ART is cost-saving under considerable parameter uncertainty and in all tested scenarios, including when prevalence is reduced to 1%-except when no benefits were paid out to employees leaving the workforce and when absenteeism rates were half of what data suggested. Scaling up ART further through a universal test and treat strategy doubles savings; incorporating ART for family members reduces savings but is still marginally cost-saving compared to no treatment. Our analysis was limited to the direct cost of HIV to companies and did not examine the impact of HIV prevention policies on the miners or their families, and a few model inputs were based on limited data, though in sensitivity analysis our results were found to be robust to changes to these inputs along plausible ranges.

Conclusions: Workplace ART provision can be cost-saving for companies in high HIV prevalence settings due to reductions in healthcare costs, absenteeism, and staff turnover. Company-sponsored HIV counselling and voluntary testing with ensuing treatment of all HIV-positive employees and family members should be implemented universally at workplaces in countries with high HIV prevalence.

Abstract  Full-text [free] access

Editor’s notes: HIV-associated diseases generally hit adults at the prime of their working life, which in turn takes a heavy economic toll on private companies. The infection increases rates of absenteeism, labour force turnover and costs of company operations. HIV care has been provided by mining companies in South Africa since 2002 (before the provision of ART in the public sector). Although the cost and cost-effectiveness of public sector HIV provision in South Africa has been estimated, the cost and impact of ART provision at the workplace level has not been establish. This paper explores cost and impact of both HIV and ART in a mining company in South Africa.

A dynamic Markov health-state transition model, the Workplace Impact Model (WIM), was developed to evaluate both the past and future impact and costs of introducing ART into the workforce from the perspective of the employer. Two scenarios are explored: no ART provision, and scale-up of ART provision in the workforce. Costs and impacts are projected over a 20-year period starting in 2003.

The results illustrate that as ART coverage increases, there are increases in survival and employee retention, as well as reductions in absenteeism and benefit payments. These lead to cost savings compared to the no ART provision scenario. Annual cost of HIV to the company dropped by 5% and the mean cost per HIV-positive employee decreased by 14%. The biggest savings are due to reductions in benefit payment for death and ill-health retirement and in the cost of employee healthcare use. Importantly, the finding that ART is cost-saving is robust to the uncertainty around the model parameters as well as to other changes in the assumptions made in the model.

This paper is very strong due to the nuances built into the model, as well as due to the quality and precision of the data used. The model takes into account different factors associated to workforce profile, HIV progression, health effects of ART initiation, age groups, and job grade categories, to mention a few. It also includes CD4 progression data from the specific population for every trimester from 2003-2010. Additionally, it includes company-specific bottom-up cost data on the costs of providing ART (medications, monitoring costs, etc.). The potential policy implications, namely that it is cost-saving for employers to provide HIV care, is a substantial one. Provision of services by private companies may not only make business sense, they may also provide a respite to public sector HIV service provision programmes.

It would be interesting to see how these findings relate to other industries. Different industries have different features. Mining, for example, is a labour-intensive, high profit industry. Others are not. Understanding the costs and effects in other types of companies, and whether ART provision remains cost-saving, would be worthwhile in order to create more specific policy guidelines. 

South Africa
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In which settings is Xpert® MTB/RIF and LED microscopy screening for Tuberculosis for people living with HIV cost-effective?

Screening for tuberculosis among adults newly diagnosed with HIV in sub-Saharan Africa: a cost-effectiveness analysis.

Zwerling AA, Sahu M, Ngwira LG, Khundi M, Harawa T, Corbett EL, Chaisson RE, Dowdy DW. J Acquir Immune Defic Syndr. 2015 Sep 1;70(1):83-90. doi: 10.1097/QAI.0000000000000712.

Objective: New tools, including light-emitting diode (LED) fluorescence microscopy and the molecular assay Xpert® MTB/RIF, offer increased sensitivity for tuberculosis (TB) in persons with HIV but come with higher costs. Using operational data from rural Malawi, we explored the potential cost-effectiveness of on-demand screening for TB in low-income countries of sub-Saharan Africa.

Design and methods: Costs were empirically collected in 4 clinics and in 1 hospital using a microcosting approach, through direct interview and observation from the national TB program perspective. Using decision analysis, newly diagnosed persons with HIV were modeled as being screened by 1 of the 3 strategies: Xpert®, LED, or standard of care (ie, at the discretion of the treating physician).

Results: Cost-effectiveness of TB screening among persons newly diagnosed with HIV was largely determined by 2 factors: prevalence of active TB among patients newly diagnosed with HIV and volume of testing. In facilities screening at least 50 people with a 6.5% prevalence of TB, or at least 500 people with a 2.5% TB prevalence, Xpert® is likely to be cost-effective. At lower prevalence-including that observed in Malawi-LED microscopy may be the preferred strategy, whereas in settings of lower TB prevalence or small numbers of eligible patients, no screening may be reasonable (such that resources can be deployed elsewhere).

Conclusions: TB screening at the point of HIV diagnosis may be cost-effective in low-income countries of sub-Saharan Africa, but only if a relatively large population with high prevalence of TB can be identified for screening.

Abstract access 

Editor’s notes: This study provides guidance on when screening people newly diagnosed with HIV for tuberculosis (TB) using Xpert® MTB/RIF or LED microscopy is likely to be cost-effective. Previous studies suggest that both TB screening technologies may be cost-effective, but that cost-effectiveness will depend on how tests are implemented. In highly resource constrained settings, the affordability of TB screening, particularly using Xpert® MTB/RIF, remains a concern. It therefore may not be feasible to place screening equipment at all locations, and more guidance is required on the types of setting where these investments may have the most benefit.

The study finds that two factors are particularly important in the choice of TB screening at any specific site. First, the authors find that test volumes are critical to cost-effectiveness. This finding supports earlier studies from South Africa prior to Xpert® MTB/RIF roll-out – that suggest that ‘economies of scale’ drive the unit costs per test. The authors of this study add to this previous evidence by providing a detailed example from a low income setting. Second, on the effect side, TB prevalence is found to be a key driver of cost-effectiveness.

The authors provide an illustration of a simple approach and model that can be used by countries to select the different TB screening tests required. It should be noted however, that the authors are not able to fully consider some factors that may have an important impact on the cost-effectiveness of TB screening, due to data scarcity. For example, the extent and speed to which people are appropriately treated for TB under each option (including the standard of care). This has been shown to be an important consideration in other studies investigating the cost-effectiveness of Xpert® MTB/RIF. It should also be noted that the study determines cost-effectiveness using an approach that may not fully reflect financial constraints. Therefore additional analyses, using local data, are still required before applying the study’s results in different settings.  

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