Articles tagged as "Resources/ Impact/ Development"

Provider-perceived barriers and facilitators to viral load monitoring for HIV-positive individuals in resource-limited settings

On the front line of HIV virological monitoring: barriers and facilitators from a provider perspective in resource-limited settings.

Rutstein SE, Golin CE, Wheeler SB, Kamwendo D, Hosseinipour MC, Weinberger M, Miller WC, Biddle AK, Soko A, Mkandawire M, Mwenda R, Sarr A, Gupta S, Mataya R. AIDS Care. 2015 Aug 17:1-10. [Epub ahead of print]

Scale-up of viral load (VL) monitoring for HIV-infected patients on antiretroviral therapy (ART) is a priority in many resource-limited settings, and ART providers are critical to effective program implementation. We explored provider-perceived barriers and facilitators of VL monitoring. We interviewed all providers (n = 17) engaged in a public health evaluation of dried blood spots for VL monitoring at five ART clinics in Malawi. All ART clinics were housed within district hospitals. We grouped themes at patient, provider, facility, system, and policy levels. Providers emphasized their desire for improved ART monitoring strategies, and frustration in response to restrictive policies for determining which patients were eligible to receive VL monitoring. Although many providers pled for expansion of monitoring to include all persons on ART, regardless of time on ART, the most salient provider-perceived barrier to VL monitoring implementation was the pressure of work associated with monitoring activities. The work burden was exacerbated by inefficient data management systems, highlighting a critical interaction between provider-, facility-, and system-level factors. Lack of integration between laboratory and clinical systems complicated the process for alerting providers when results were available, and these communication gaps were intensified by poor facility connectivity. Centralized second-line ART distribution was also noted as a barrier: providers reported that the time and expenses required for patients to collect second-line ART frequently obstructed referral. However, provider empowerment emerged as an unexpected facilitator of VL monitoring. For many providers, this was the first time they used an objective marker of ART response to guide clinical management. Providers' knowledge of a patient's virological status increased confidence in adherence counselling and clinical decision-making. Results from our study provide unique insight into provider perceptions of VL monitoring and indicate the importance of policies responsive to individual and environmental challenges of VL monitoring program implementation. Findings may inform scale-up by helping policy-makers identify strategies to improve feasibility and sustainability of VL monitoring.

Abstract access 

Editor’s notes: Viral load monitoring for HIV-positive individuals is gaining prominence as a method for monitoring responses to antiretroviral therapy (ART) and for identifying treatment failure. It is considered more accurate (in terms of its sensitivity and specificity) than alternative methods (e.g., CD4 cell counts). ART providers are critical to the implementation of viral load scale-up as it tends to be resource heavy and providers are tasked with numerous responsibilities in order to achieve individual and public health benefits. Using data from in-person interviews with providers on the frontline of ART management in five ART clinics in Malawi, this study explored multi-level barriers to, and facilitators for incorporating viral load monitoring into daily clinical practice. Study results illustrated a complex set of interconnected provider–identified barriers and facilitators that occurred at multiple levels. In terms of facilitators, high patient demand for viral load testing reinforced provider-perceived benefits of viral load monitoring. In addition, placing an emphasis on provider empowerment during viral load scale-up activities was thought to increase providers’ willingness to adopt additional responsibilities. Barriers identified by providers included the additional burden associated with viral load monitoring such as the time required in completing adherence assessment forms. Related to this was a barrier identified at the facility level by providers around shortage of staff. This was in particular identified as an impediment to completing viral load monitoring activities. Furthermore, inconsistent staffing alongside reluctance of rotating staff to participate in viral load monitoring activities were cited as contributors to people’s failure to return to scheduled clinic visits. Barriers at the system level were around time and expenses required for people to collect second-line ART which then obstructed referrals to viral load monitoring. Further, providers expressed frustration over a policy in Malawi that dictates only certain time points from ART exposure in order to be eligible for viral load monitoring. Hence, they felt forced to ration a service that was considered useful for guiding clinical practice and counselling people.

In order to address some of these barriers, the authors suggest that issues around workload burden and shortage of trained staff at facilities be addressed by expanding provider-to-patient ratios at ART clinics, broadening the scope of practice and training a lower cadre of health workers to facilitate programme sustainability. Furthermore, to synchronise facility, system and policy level interfaces, shortcomings in data management systems needed to be overcome. To that end, improving coverage of mobile networks and internet connectivity to outlying clinics would help facilitate reliable clinic-laboratory communication. Also, decentralised distribution of second-line ART drugs along with improved supply chain procedures should be considered to minimise stock-outs for individuals seeking viral load monitoring in more remote areas. Further, in order to address the issue around Malawi’s strict eligibility criteria, policy-makers need to make an effort to design provider trainings and patient education materials with clarity around the criteria in order to optimise access to limited viral load monitoring opportunities for people at highest risk of ART failure. Another option to improve access is ‘catch up’ testing where every individual on ART for more than two years receives a single test and then returns to biannual eligibility. Even though the results from this study are exploratory, they do provide useful insights into the perceived barriers and facilitators faced by providers around viral load monitoring. Overall, viral load monitoring can be used as a tool to help providers improve the quality of HIV care they deliver, if certain barriers are overcome.

Africa
Malawi
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Xpert testing - rationalise with chest X-ray or HIV pre-screening?

Implementation research to inform the use of Xpert MTB/RIF in primary health care facilities in high TB and HIV settings in resource constrained settings.

Muyoyeta M, Moyo M, Kasese N, Ndhlovu M, Milimo D, Mwanza W, Kapata N, Schaap A, Godfrey Faussett P, Ayles H. PLoS One. 2015 Jun 1;10(6):e0126376. doi: 10.1371/journal.pone.0126376. eCollection 2015.

Background: The current cost of Xpert MTB RIF (Xpert) consumables is such that algorithms are needed to select which patients to prioritise for testing with Xpert.

Objective: To evaluate two algorithms for prioritisation of Xpert in primary health care settings in a high TB and HIV burden setting.

Method: Consecutive, presumptive TB patients with a cough of any duration were offered either Xpert or Fluorescence microscopy (FM) test depending on their CXR score or HIV status. In one facility, sputa from patients with an abnormal CXR were tested with Xpert and those with a normal CXR were tested with FM ("CXR algorithm"). CXR was scored automatically using a Computer Aided Diagnosis (CAD) program. In the other facility, patients who were HIV positive were tested using Xpert and those who were HIV negative were tested with FM ("HIV algorithm").

Results: Of 9482 individuals pre-screened with CXR, Xpert detected TB in 2090/6568 (31.8%) with an abnormal CXR, and FM was AFB positive in 8/2455 (0.3%) with a normal CXR. Of 4444 pre-screened with HIV, Xpert detected TB in 508/2265 (22.4%) HIV positive and FM was AFB positive in 212/1920 (11.0%) in HIV negative individuals. The notification rate of new bacteriologically confirmed TB increased; from 366 to 620/100 000/yr and from 145 to 261/100 000/yr at the CXR and HIV algorithm sites respectively. The median time to starting TB treatment at the CXR site compared to the HIV algorithm site was: 1(IQR 1-3 days) and 3 (2-5 days) (p<0.0001) respectively.

Conclusion: Use of Xpert in a resource-limited setting at primary care level in conjunction with pre-screening tests reduced the number of Xpert tests performed. The routine use of Xpert resulted in additional cases of confirmed TB patients starting treatment. However, there was no increase in absolute numbers of patients starting TB treatment. Same day diagnosis and treatment commencement was achieved for both bacteriologically confirmed and empirically diagnosed patients where Xpert was used in conjunction with CXR.

Abstract  Full-text [free] access

Editor’s notes: Although many countries have begun to deploy molecular TB diagnostics, the cost of these technologies remains prohibitive for widespread use in low- and middle-income countries. This study in Zambian primary health care clinics aimed to explore whether the use of Xpert® MTB/RIF could be rationalised by pre-screening individuals with cough, either by chest X-ray (CXR) or by HIV testing. CXR screening only marginally reduced the use of Xpert® (as three-quarters of people screened had an abnormal CXR, using digital X-ray and computerised interpretation). Restricting use of Xpert® to those known to be HIV-positive reduced the number of Xpert® tests by around half. Under both algorithms, the proportion testing Xpert® positive was very high (22-32%), suggesting that too few people were being identified as needing TB investigation. Similar to other studies of Xpert® implementation, the overall number of people starting TB treatment did not increase with the introduction of Xpert®. However, the proportion of people starting TB treatment who had microbiological confirmation did increase substantially under both algorithms. Empirical TB treatment (meaning initiation of treatment without microbiological confirmation) remained common, in the X-ray algorithm particularly where a third of people with an abnormal CXR but a negative Xpert® were started on TB treatment. This study was not designed to determine how many people who genuinely had TB were missed by each algorithm. Also this paper did not include cost-effectiveness analyses. Based on this evidence, neither of these algorithms can be clearly recommended. Further evaluation of different screening and testing strategies will be important to inform the scale-up of molecular diagnostics.   

Avoid TB deaths
Africa
Zambia
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Harnessing the successful political prioritisation of HIV to reduce the burden of congenital syphilis

Prevention of mother-to-child transmission of syphilis and HIV in China: What drives political prioritization and what can this tell us about promoting dual elimination?

Wu D, Hawkes S, Buse K. Int J Gynaecol Obstet. 2015 Apr 29. pii: S0020-7292(15)00202-7. doi: 10.1016/j.ijgo.2015.04.005. [Epub ahead of print]

Objective: The present study aims to identify reasons behind the lower political priority of mother-to-child transmission (MTCT) of syphilis compared with HIV, despite the former presenting a much larger and growing burden than the latter, in China, over the 20 years prior to 2010.

Methods: We undertook a comparative policy analysis, based on informant interviews and documentation review of control of MTCT of syphilis and HIV, as well as nonparticipant observation of relevant meetings/trainings to investigate agenda-setting prior to 2010.

Results: We identified several factors contributing to the lower priority accorded to MTCT of syphilis: relative neglect at a global level, dearth of international financial and technical support, poorly unified national policy community with weak accountability mechanisms, insufficient understanding of the epidemic and policy options, and a prevailing negative framing of syphilis that resulted in significant stigmatization.

Conclusion: A dual elimination goal will only be reached when prioritization of MTCT of syphilis is enhanced in both the international and national agendas.

Abstract  Full-text [free] access

Editor’s notes:  In 2009, China had nearly 11 000 reported cases of congenital syphilis, compared to 57 cases of mother-to-child HIV transmission, yet congenital syphilis was not a policy priority. The authors investigate and compare the policy responses to the two infections in order to understand the determinants of prioritisation in Chinese health policy. The national policy response to the mother-to-child transmission of HIV highlights the importance of global agendas. These include reporting mechanisms, international financial and technical assistance, credible indicators, as well as cohesive national policy communities that coalesce around a formal mechanism of coordination and policy influence, namely the Chinese National Centre for Women and Children’s Health. In addition, the specific national policy environment and other focusing events were critical to the prioritisation of the mother-to-child transmission of HIV. The new leadership was moving towards a socio-economic equality agenda, and the recent severe acute respiratory syndrome (SARS) outbreak had further underscored the importance of controlling infectious diseases. Alongside this, the national ‘blood selling’ scandal, during which hundreds of thousands of rural Chinese acquired HIV through blood selling in the 90s, was receiving increasing attention in international media. This contributed to a different framing of the HIV issue, away from the stigmatising ‘immoral’ narrative to an ‘innocent victims’ narrative. Congenital syphilis, unfortunately, continued to suffer from a stigmatising framing. However, delivery platforms for the effective prevention of mother-to-child transmission of HIV have been established and could be used for a dual control and elimination approach, with greater health benefits. The authors conclude that greater policy prioritisation could be achieved with a more nuanced framing of the two infections as being linked when it comes to underlying vulnerability and feasibility of solutions. It will require a strong partnership and collaboration between the mother-to-child transmission of syphilis and HIV policy communities.       

Asia
China
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Hospitalization and treatment failure remain a significant cost for treating drug-resistant TB in South Africa

Cost per patient of treatment for rifampicin-resistant tuberculosis in a community-based program in Khayelitsha, South Africa.

Cox H, Ramma L, Wilkinson L, Azevedo V, Sinanovic E. Trop Med Int Health. 2015 May 15. doi: 10.1111/tmi.12544. [Epub ahead of print]

Objectives: The high cost of rifampicin-resistant tuberculosis (RR-TB) treatment hinders treatment access. South Africa has a high RR-TB burden, and national policy outlines decentralisation to improve access and reduce costs. We analysed health system costs associated with RR-TB treatment by drug-resistance profile and treatment outcome in a decentralised programme.

Methods: Retrospective, routinely collected patient-level data were combined with unit cost data to determine costs for each patient in a cohort treated between January 2009 and December 2011. Drug costs were based on recommended regimens according to drug-resistance and treatment duration. Hospitalisation costs were estimated based on admission/discharge dates, while clinic visit and diagnostic/monitoring costs were estimated according to recommendations and treatment duration. Missing data were imputed.

Results: Among 467 patients (72% HIV-infected), 49% were successfully treated. Treatment was initiated in primary care for 62%, with the remainder as inpatients. The mean cost per patient treated was $7916 (range 260-87 140); ranging from $5369 among patients who did not complete treatment to $23 006 for treatment failure. Mean cost for successful treatment was $8359 (2585-32 506). Second-line drug resistance was associated with a mean cost of $15 567 versus $6852 for only first-line resistance, with the major cost difference due to hospitalisation. Costs reported in 2013 USD.

Conclusions: RR-TB treatment cost was high, and varied according to treatment outcome. Despite decentralisation, hospitalisation remained a significant cost, particularly among those with more extensive resistance and those with treatment failure. These cost estimates can be used to model the impact of new interventions to improve patient outcomes.

Abstract  Full-text [free] access

Editor’s notes: Prior to 2011, South African guidelines recommended all multidrug-resistant tuberculosis (MDR-TB) patients be hospitalized for at least six months, or until culture conversion.  This policy was changed in 2011 to allow for decentralized ambulatory care for sputum smear-negative patients. This paper evaluates the cost of treating rifampicin-resistant TB in Khayelitsha, South Africa using patient-level data in order to accurately represent real-world patient pathways under the new policy.

The authors find that the cost of TB treatment under this new policy varies substantially according to drug resistance profile and treatment outcomes. Treatment was successful only in about half of the sample in this study. Treatment failed for roughly 20% (including ‘treatment failure’ and ‘death’ outcomes), and about 30% of people were lost from treatment.  People for whom treatment failed were the most costly, at a mean cost of $23 006. These people were more often admitted to hospital during treatment, and had a longer average length of stay in hospital. People infected with TB strains which were defined as pre-extensively drug resistant or extensively drug resistant (XDR) were more likely to experience treatment failure. As a result they incurred a much higher cost than individuals with rifampicin mono-resistance or MDR-TB.  People treated successfully incurred a mean cost of $8359. This is substantially lower than the mean cost of $17 164 under previous treatment guidelines.   

These findings indicate that the new policy is less costly overall than the policy of hospitalization for all MDR-TB patients. However, costs still vary substantially according to drug resistance and treatment outcomes.  In order to see further reduction of costs and improvement of cost-effectiveness, therefore, treatment failure must be further reduced.  

Africa
South Africa
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Screening for and treating cryptococcal infection – better evidence of impact necessary

Cryptococcal antigen screening and early antifungal treatment to prevent cryptococcal meningitis: a review of the literature.

Kaplan JE, Vallabhaneni S, Smith RM, Chideya-Chihota S, Chehab J, Park B. J Acquir Immune Defic Syndr. 2015 Apr 15;68 Suppl 3:S331-9. doi: 10.1097/QAI.0000000000000484.

Background: Screening individuals with AIDS for serum cryptococcal antigen (CrAg), followed by treatment of CrAg positives with antifungals, may prevent cryptococcal meningitis. This review examined data on CrAg screening and treatment in resource-limited settings.

Methods: We searched articles published during 2007-2014 on the effectiveness and cost-effectiveness of CrAg screening and treatment on the outcomes of mortality, morbidity, retention in care, quality of life, and/or prevention of ongoing HIV transmission. We rated overall quality of individual articles, summarized the body of evidence, the expected impact, and cost-effectiveness for each outcome.

Results: We identified 2613 articles. Eight met all inclusion criteria. Five studies addressed mortality and/or morbidity outcomes; all were observational and had small sample sizes; 3 lacked a comparison group. Ratings of study quality ranged from "medium" to "weak," and the quality of the overall body of evidence for mortality and morbidity outcomes was rated as "fair." The intervention's expected impact on mortality and morbidity was rated as "moderate." The 4 cost-effectiveness studies included in the analysis showed that CrAg screening and treatment interventions are highly cost-effective. No studies addressed retention in care, quality of life, or HIV transmission.

Conclusions: Although limited, the body of evidence regarding CrAg screening and treatment suggests that the intervention may have an impact on preventing cryptococcal meningitis and death in persons with AIDS. Additional research is needed to quantify the intervention's effectiveness and identify optimal treatment dosing and implementation best practices.

Abstract access 

Editor’s notes: This systematic review was one of a series aimed at evaluating the impact of services supported by the US President’s Emergency Plan for AIDS Relief (PEPFAR). The review set out to assess the evidence around the impact of targeted cryptococcal antigen (CrAg) testing and antifungal treatment for people with advanced HIV disease. In 2011 World Health Organization (WHO) gave a conditional recommendation, based on low quality evidence, that adults with CD4 count <100 cells per μL, in populations where the CrAg prevalence is above 3%, should undergo CrAg screening and be provided with antifungal treatment if CrAg positive.

The quality of the evidence was rated using a system adapted from the US Preventive Services Task Force. Five observational studies that evaluated the impact of the CrAg screening and antifungal treatment approach on mortality were included. Most of these did not have a comparator. One study used a historical control group from the same facility and another study compared mortality in people who received fluconazole following a positive CrAg, to people who did not. All studies had a very small number of deaths. In the five studies, mortality in people testing CrAg positive and receiving fluconazole varied between 0 and 29%. Based on these studies it would be difficult to evaluate the true impact of the strategy on mortality.

Four cost-effectiveness studies from different settings were also reviewed. All four studies suggested that a strategy with CrAg screening and antifungal treatment would be cost-effective. However, the cost-effectiveness modelling was based on data from the observational studies mentioned above and required other assumptions based on low quality evidence, leading to substantial uncertainty around the cost-effectiveness estimates.

Although a few countries have already implemented CrAg screening and antifungal treatment strategies, better quality evidence is necessary to inform management more broadly in countries with a high burden of cryptococcal disease. Some evidence has already appeared, with a randomised controlled trial in Tanzania and Zambia demonstrating a reduction in mortality with a CrAg screening strategy combined with a community support package during the early phase of antiretroviral therapy (see HIV This Month Issue 4). In addition there are three other randomised controlled trials exploring the impact of CrAg screening, ongoing or planned in Uganda, Zimbabwe and Viet Nam (NCT01535469, NCT02434172, and NCT02334670). It is hoped that the evidence generated by these studies will improve our understanding of the impact of a CrAg screening strategy and also give further insight into how best to implement this in different health care settings.   

Avoid TB deaths
Africa, Asia
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Community-based services strengthen the continuum of care and are cost-effective

Cost-effectiveness of community-based strategies to strengthen the continuum of HIV care in rural South Africa: a health economic modelling analysis.

Smith JA, Sharma M, Levin C, Baeten JM, van Rooyen H, Celum C, Hallett TB, Barnabas RV. Lancet HIV. 2015 Apr 1;2(4):e159-e168.

Background: Home HIV counselling and testing (HTC) has been shown to achieve high testing coverage and linkage to care compared to existing facility-based HTC, particularly among asymptomatic persons. This study evaluates the population-level health impact and cost-effectiveness of a community-based home HTC package in KwaZulu-Natal, South Africa.

Methods: We parameterized an individual-based model with data from home HTC and linkage field studies that achieved high coverage (91%) and linkage to ART (80%) in rural KwaZulu-Natal, South Africa. Costs were derived from a linked micro-costing study. The model simulated 10 000 individuals over ten years and incremental cost-effectiveness ratios (ICERs) were calculated for the intervention relative to the existing 'status quo' of facility-based testing, with costs discounted at 3% annually.

Findings: Implementing home HTC in addition to current practice is predicted by the model to decrease HIV-associated morbidity by 10-22% and HIV infections by 9-47% with increasing CD4 threshold for ART initiation. Incremental programme costs were US$2.7-4.4 million higher in the intervention scenarios compared to baseline with higher costs associated with increasing ART initiation criteria; ART accounted for 48-87% of total costs. Across all ART initiation thresholds, ICERs were US$1340, $1090, $1150 and $1360 per DALY averted at ≤200, ≤350, ≤500 cells/mm3 and universal ART access, respectively.

Interpretation: Increases in HIV testing and linkage to care following community-based HTC propagate into population-level health outcomes. The ICERS are <20% of GDP per capita in South Africa and therefore considered very cost-effective. Home HTC should be considered a viable means by which programs can achieve ambitious new targets for HIV treatment.

Abstract  Full-text [free] access

Editor’s notes: HIV testing and linkage to care are essential to prevent future morbidity and mortality.  There has been effort recently to increase access to facility-based HIV testing and counselling, for example through integrated provider-initiated counselling and testing. However, these have not achieved the coverage necessary to meet the UNAIDS 90-90-90 target, which aims to have 90% of all people living with HIV to know their status, 90% of all people diagnosed with HIV receiving sustained antiretroviral therapy, and 90% of all people receiving ART with viral suppression by 2020. A growing body of literature indicates that community-based HIV testing and counselling (HTC) for HIV achieves high testing coverage and linkage to care. However it has previously been warned that the cost-effectiveness of such strategies must be considered before such a programme was implemented.

This modelling analysis evaluates the cost-effectiveness of a community-based package of HIV testing and counselling and linkage to care services. The package includes home-based HTC, together with community mobilization and sensitization, point-of-care CD4 testing, screening for clinical indicators for ART initiation, and follow-up visits by a community health worker to support ART uptake and adherence. The model uses high quality primary cost data, paired with a detailed HIV transmission model. The study finds this package highly cost-effective, with the most costly scenario only $1360 per DALY averted (14 to19% of GDP), and the least costly scenario $310 per DALY averted. 

This study adds to a growing body of literature supporting community-based HTC as a viable means of expanding access to HIV diagnosis and care. These results should encourage policy makers to begin considering community-based HTC as a cost-effective way to meet the ambitious new targets for HIV testing and treatment.  

Africa
South Africa
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Need for further water, sanitation and hygiene programmes among people living with HIV

The impact of water, sanitation, and hygiene interventions on the health and well-being of people living with HIV: a systematic review.

Yates T, Lantagne D, Mintz E, Quick R. J Acquir Immune Defic Syndr. 2015 Apr 15;68 Suppl 3:S318-30. doi: 10.1097/QAI.0000000000000487.

Background: Access to improved water supply and sanitation is poor in low-income and middle-income countries. Persons living with HIV/AIDS (PLHIV) experience more severe diarrhea, hospitalizations, and deaths from diarrhea because of waterborne pathogens than immunocompetent populations, even when on antiretroviral therapy (ART).

Methods: We examined the existing literature on the impact of water, sanitation, and hygiene (WASH) interventions on PLHIV for these outcomes: (1) mortality, (2) morbidity, (3) retention in HIV care, (4) quality of life, and (5) prevention of ongoing HIV transmission. Cost-effectiveness was also assessed. Relevant abstracts and articles were gathered, reviewed, and prioritized by thematic outcomes of interest. Articles meeting inclusion criteria were summarized in a grid for comparison.

Results: We reviewed 3355 citations, evaluated 132 abstracts, and read 33 articles. The majority of the 16 included articles focused on morbidity, with less emphasis on mortality. Contaminated water, lack of sanitation, and poor hygienic practices in homes of PLHIV increase the risk of diarrhea, which can result in increased viral load, decreased CD4 counts, and reduced absorption of nutrients and antiretroviral medication. We found WASH programming, particularly water supply, household water treatment, and hygiene interventions, reduced morbidity. Data were inconclusive on mortality. Research gaps remain in retention in care, quality of life, and prevention of ongoing HIV transmission. Compared with the standard threshold of 3 times GDP per capita, WASH interventions were cost-effective, particularly when incorporated into complementary programs.

Conclusions: Although research is required to address behavioral aspects, evidence supports that WASH programming is beneficial for PLHIV.

Abstract access 

Editor’s notes: Researchers, implementers, and policy makers have been examining how to better integrate programmes with overlapping burdens of morbidity and mortality. This paper illustrates how access to clean water and good sanitation practices, or lack thereof, can impact the health of people living with HIV. Water, sanitation, and hygiene (WASH) programmes can improve the negative effects poor water quality and bad sanitation have on people living with HIV. They reduce or even eliminate diarrheal infections, which allow for better absorption of HIV treatment medication that leads to a reduction in viral load and increased CD4 counts. While this systematic review revealed evidence on the reduced burden of morbidity that WASH programmes can confer, little has been done in the way of research linking WASH programmes to mortality in people living with HIV, nor how they may affect adherence or retention in care. Side effects of HIV treatment is a common reason why people stop taking medications, and common side effects are nausea and diarrhoea. It is possible that intestinal issues caused by unsafe drinking water could exacerbate the impact of side effects on people already experiencing them, therefore reducing motivation to continue taking their ARVs. This paper also suggests that synergies in cost sharing and increasing cost effectiveness could be achieved by integrating programmes. However further research is necessary to fully understand the logistical and cost implications.

 

Africa, Asia
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Out of pocket spending on HIV care in India makes the poor even poorer

Consumption patterns and levels among households with HIV positive members and economic impoverishment due to medical spending in Pune city, India.

Sharma V, Krishnaswamy D, Mulay S. AIDS Care. 2015 Mar 4:1-5. [Epub ahead of print]

HIV infection poses a serious threat to the economy of a household. Out of pocket (OOP) health spending can be prohibitive and can drag households below poverty level. Based on the data collected from a cross-sectional survey of 401 households with HIV+ members in Pune city, India, this paper examines the consumption levels and patterns among households, and comments on the economic impoverishment resulting from OOP medical spending. Analysis reveals that households with HIV positive members spend a major portion of their monthly consumption expenditure on food items. Medical expenditure constitutes a large portion of their total consumption spending. Expenditure on children's education constitutes a minor proportion of total monthly spending. A high proportion of medical expenditure has a bearing on the economic condition of households with HIV positive members. Poverty increases by 20% among the studied HIV households when OOP health spending is adjusted. It increases 18% among male-headed households and 26% among female-headed households. The results reiterate the need of greater support from the government in terms of accessibility and affordability of health care to save households with HIV positive members from economic catastrophe.

Abstract access 

Editor’s notes: This paper describes expenditure patterns for households with one or more people living with HIV. The authors find that medical expenditure within a household with a member living with HIV is relatively high, some 9.6% of total expenditure. Overall, households were economically vulnerable, with health-associated spending often pushing people below the poverty line. This type of research is especially timely in the context of increasing interest in reducing out of pocket expenditure. Further research around the poverty effects of illness is critical to inform policies as universal access to health care becomes a greater international priority.  

Asia
India
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How to reduce attrition among community healthcare workers essential to HIV prevention programmes among female sex-workers

Peer outreach work as economic activity: implications for HIV prevention interventions among female sex workers.

George A, Blankenship KM. PLoS One. 2015 Mar 16;10(3):e0119729. doi: 10.1371/journal.pone.0119729. eCollection 2015.

Female sex workers (FSWs) who work as peer outreach workers in HIV prevention programs are drawn from poor socio-economic groups and consider outreach work, among other things, as an economic activity. Yet, while successful HIV prevention outcomes by such programs are attributed in part to the work of peers who have dense relations with FSW communities, there is scant discussion of the economic implications for FSWs of their work as peers. Using observational data obtained from an HIV prevention intervention for FSWs in south India, we examined the economic benefits and costs to peers of doing outreach work and their implications for sex workers' economic security. We found that peers considered their payment incommensurate with their workload, experienced long delays receiving compensation, and at times had to advance money from their pockets to do their assigned peer outreach work. For the intervention these conditions resulted in peer attrition and difficulties in recruitment of new peer workers. We discuss the implications of these findings for uptake of services, and the possibility of reaching desired HIV outcomes. Inadequate and irregular compensation to peers and inadequate budgetary outlays to perform their community-based outreach work could weaken peers' relationships with FSW community members, undermine the effectiveness of peer-mediated HIV prevention programs and invalidate arguments for the use of peers.

Abstract   Full-text [free] access

Editor’s notes: Many HIV prevention programmes among female sex worker populations recruit female sex workers to act as community health workers. Community health workers act as a bridge between health services and the community, tailoring activities to the local context and encouraging community ownership of programmes. Evidence suggests that female sex workers acting as community health workers can be critical to maximising benefit from HIV prevention programmes. They also provide a network for social and legal advocacy among female sex workers. Yet despite their importance to programmes, attrition among community health workers is often high and little research has been done to investigate why this might be. This paper gathers data from India and finds that an HIV prevention programme paid community health workers much less than they could have earned through sex-work, while the large workload meant they spent far more time on outreach activities than they were paid for. This encouraged attrition of the community health worker workforce, which could have substantially reduced the impact of the HIV prevention programme. The authors suggest that the importance of community health workers to programmes should be reflected by providing sufficient payment for outreach work. Although this study was carried out among a female sex worker population, these findings are relevant anywhere community health workers are used to deliver programmes elsewhere. Furthermore, other research has suggested that an important motivation for community health workers to take on work is to reduce their economic vulnerability. If programmes pay community health workers too little, or unreliably, they can actually increase the economic vulnerability of the very people they are seeking to protect.

Asia
India
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Is genotype resistance testing cost-effective for the ART naïve?

Cost-effectiveness of genotype testing for primary resistance in Brazil.

Luz PM, Morris BL, Grinsztejn B, Freedberg KA, Veloso VG, Walensky RP, Losina E, Nakamura YM, Girouard MP, Sax PE, Struchiner CJ, Paltiel AD. J Acquir Immune Defic Syndr. 2015 Feb 1;68(2):152-61. doi: 10.1097/QAI.0000000000000426.

Objective: HIV genotype-resistance testing can help identify more effective antiretroviral treatment (ART) regimens for patients, substantially increasing the likelihood of viral suppression and immune recovery. We sought to evaluate the cost-effectiveness of genotype-resistance testing before first-line ART initiation in Brazil.

Design: We used a previously published microsimulation model of HIV disease (CEPAC-International) and data from Brazil to compare the clinical impact, costs, and cost-effectiveness of initial genotype testing (Genotype) with no initial genotype testing (No genotype).

Methods: Model parameters were derived from the HIV Clinical Cohort at the Evandro Chagas Clinical Research Institute and from published data, using Brazilian sources whenever possible. Baseline patient characteristics included 69% male, mean age of 36 years (SD, 10 years), mean CD4 count of 347 per microliter (SD, 300/µL) at ART initiation, annual ART costs from 2012 US $1400 to US $13 400, genotype test cost of US $230, and primary resistance prevalence of 4.4%. Life expectancy and costs were discounted 3% per year. Genotype was defined as "cost-effective" compared with No Genotype if its incremental cost-effectiveness ratio was less than 3 times the 2012 Brazilian per capita GDP of US $12 300.

Results: Compared with No genotype, Genotype increased life expectancy from 18.45 to 18.47 years and reduced lifetime cost from US $45 000 to $44 770; thus, in the base case, Genotype was cost saving. Genotype was cost-effective at primary resistance prevalence as low as 1.4% and remained cost-effective when subsequent-line ART costs decreased to 30% of baseline value. Cost-inefficient results were observed only when simultaneously holding multiple parameters to extremes of their plausible ranges.

Conclusions: Genotype-resistance testing in ART-naive individuals in Brazil will improve survival and decrease costs and should be incorporated into HIV treatment guidelines in Brazil.

Abstract  Full-text [free] access

Editor’s notes: This study aims to provide guidance on when HIV genotype-resistance testing should be used during the course of antiretroviral therapy (ART). Previous studies in high income countries suggest that use prior to ART initiation may be cost-effective. In more resource constrained settings, two previous studies suggest that genotype-resistance testing may be cost-effective following first-line treatment failure. But none have examined use of these tests on the ART-naïve.

This study compares genotype-resistance testing prior to ART initiation to the current policy of testing post treatment failure, for the population of Brazil. The study finds that genotype-resistance testing is likely to be cost saving in Brazil. The authors predict modest increases in life expectancy for individuals on ART. Cost savings are achieved from predicted reductions in complications and the duration of expensive ART regimens. Costs savings are primarily incurred for non-nucleoside reverse-transcriptase inhibitors (NNRTI) resistant people. These savings outweigh the cost of the genotype-resistance test. The study usefully highlights that the extent of cost savings (and cost-effectiveness) depends primarily on test cost, future ART costs and prevalence of NNRTI resistance in the study population. For most plausible ranges of NNRTI prevalence and costs observed in Brazil, genotype-resistance testing prior to ART initiation is likely to be cost-effective. However, both costs and NNRTI prevalence vary by setting; as does the threshold by which technologies are judged to be cost-effective. These factors therefore need to be considered before applying these results to policy change around the use of genotype-resistance testing more broadly.

Latin America
Brazil
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