Articles tagged as "Resources/ Impact/ Development"

Household food insecurity is associated with poor adherence to antiretroviral therapy

Household food insecurity associated with antiretroviral therapy adherence among HIV-infected patients in Windhoek, Namibia.

Hong SY, Fanelli TJ, Jonas A, Gweshe J, Tjituka F, Sheehan HM, Wanke C, Terrin N, Jordan MR, Tang AM. J Acquir Immune Defic Syndr. 2014 Dec 1;67(4):e115-22. doi: 10.1097/QAI.0000000000000308.

Objective: Food insecurity is emerging as an important barrier to antiretroviral therapy (ART) adherence. The objective of this study was to determine if food insecurity is associated with poor ART adherence among HIV-positive adults in a resource-limited setting that uses the public health model of delivery.

Design: A cross-sectional study using a 1-time questionnaire and routinely collected pharmacy data.

Methods: Participants were HIV-infected adults on ART at the public ART clinics in Windhoek, Namibia: Katutura State Hospital, Katutura Health Centre, and Windhoek Central Hospital. Food insecurity was measured by the Household Food Insecurity Access Scale (HFIAS). Adherence was assessed by the pharmacy adherence measure medication possession ratio (MPR). Multivariate regression was used to assess whether food insecurity was associated with ART adherence.

Results: Among 390 participants, 7% were food secure, 25% were mildly or moderately food insecure and 67% were severely food insecure. In adjusted analyses, severe household food insecurity was associated with MPR <80% [odds ratio (OR), 3.84; 95% confidence interval (CI): 1.65 to 8.95]. Higher household health care spending (OR, 1.92; 95% CI, 1.02 to 3.57) and longer duration of ART (OR, 0.82; 95% CI: 0.70 to 0.97) were also associated with <80% MPR.

Conclusions: Severe household food insecurity is present in more than half of the HIV-positive adults attending a public ART clinic in Windhoek, Namibia and is associated with poor ART adherence as measured by MPR. Ensuring reliable access to food should be an important component of ART delivery in resource-limited settings using the public health model of care.

Abstract access

Editor’s notes:  United Nations Subcommittee on Nutrition defines food insecurity as “the limited or uncertain availability of nutritionally adequate, safe foods, or the inability to acquire personally acceptable foods in socially acceptable ways.” Qualitative studies in resource-limited settings have identified food insecurity as a potential risk for antiretroviral (ART) non-adherence. This is one of the first quantitative studies to analyse this issue. The findings from this cross-sectional survey of people living with HIV on ART in Namibia, are striking.  Four of the ten top reasons given for missing a medication dose, were related to food insecurity, e.g. “Did not take ARVs because they make me hungry and I did not have enough food” or, “Did not take ARVs because I cannot afford good food while taking medicine”. After adjusting for potential confounders, severe household food insecurity was significantly and positively associated with poor ART adherence. Depression and travel to the clinic via walking, biking or hitchhiking were also significantly associated with poor adherence. Research into the potential causal pathway between food insecurity and ART adherence is required, including evaluation of programmes to assess the relative effectiveness of nutritional versus livelihood programmes. 

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Disease-specific Global Fund grants may be preventing the realisation of system-wide synergies for increased human resources for health

Global Fund investments in human resources for health: innovation and missed opportunities for health systems strengthening.

Bowser D, Sparkes SP, Mitchell A, Bossert TJ, Bärnighausen T, Gedik G, Atun R. Health Policy Plan. 2014 Dec;29(8):986-97. doi: 10.1093/heapol/czt080. Epub 2013 Nov 6.

Background: Since the early 2000s, there have been large increases in donor financing of human resources for health (HRH), yet few studies have examined their effects on health systems.

Objective: To determine the scope and impact of investments in HRH by the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), the largest investor in HRH outside national governments.

Methods: We used mixed research methodology to analyse budget allocations and expenditures for HRH, including training, for 138 countries receiving money from the Global Fund during funding rounds 1-7. From these aggregate figures, we then identified 27 countries with the largest funding for human resources and training and examined all HRH-related performance indicators tracked in Global Fund grant reports. We used the results of these quantitative analyses to select six countries with substantial funding and varied characteristics-representing different regions and income levels for further in-depth study: Bangladesh (South and West Asia, low income), Ethiopia (Eastern Africa, low income), Honduras (Latin America, lower-middle income), Indonesia (South and West Asia, lower-middle income), Malawi (Southern Africa, low income) and Ukraine (Eastern Europe and Central Asia, upper-middle income). We used qualitative methods to gather information in each of the six countries through 159 interviews with key informants from 83 organizations. Using comparative case-study analysis, we examined Global Fund's interactions with other donors, as well as its HRH support and co-ordination within national health systems.

Results: Around US$1.4 billion (23% of total US$5.1 billion) of grant funding was allocated to HRH by the 138 Global Fund recipient countries. In funding rounds 1-7, the six countries we studied in detail were awarded a total of 47 grants amounting to US$1.2 billion and HRH budgets of US$276 million, of which approximately half were invested in disease-focused in-service and short-term training activities. Countries employed a variety of mechanisms including salary top-ups, performance incentives, extra compensation and contracting of workers for part-time work, to pay health workers using Global Fund financing. Global Fund support for training and salary support was not co-ordinated with national strategic plans and there were major deficiencies in the data collected by the Global Fund to track HRH financing and to provide meaningful assessments of health system performance.

Conclusion: The narrow disease focus and lack of co-ordination with national governments call into question the efficiency of funding and sustainability of Global Fund investments in HRH and their effectiveness in strengthening recipient countries' health systems. The lessons that emerge from this analysis can be used by both the Global Fund and other donors to improve co-ordination of investments and the effectiveness of programmes in recipient countries.

Abstract access 

Editor’s notes: This study describes Global Fund’s budget allocations, expenditures and specific activities on human resources for health (HRH) from 2002 to 2010. The authors were particularly interested in exploring whether and how these investments contributed to health system strengthening through a more detailed qualitative analysis of six geographically and programmatically different countries.  

They find that the 27 countries with the largest budgeted HRH expenditures allocated some 29.6% to HRH, and had a ratio of 1.35 health workers trained in comparison to the total national health workforce, suggesting duplication of training activities and programme inefficiency. This reflects the confirmed lack of coordination with national HRH training programmes that the authors documented, particularly in Ethiopia, Bangladesh and Malawi. In terms of coordinating HRH salary support and financing plans, only Honduras and Malawi had developed plans for absorbing some of the health workers that were being covered by Global Fund grants. In other countries, the top-ups and monetary compensation/ incentives funded through Global Fund grants to increase retention and motivation, were considered short-term and would not be sustained. Of the six country case studies, it is only in Malawi that the Global Fund coordinated its efforts with the national HRH strategy and other donor programmes.

The study highlights the need for a paradigm shift away from disease-focused grants to co-investments in HIV, tuberculosis and malaria that would allow the realisation of remarkable synergies and efficiency gains.

Africa, Asia, Europe, Latin America
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Can community based health care form part of a wider primary health care strategy in sub-Saharan Africa?

Integration of community home based care programmes within national primary health care revitalisation strategies in Ethiopia, Malawi, South-Africa and Zambia: a comparative assessment.

Aantjes C, Quinlan T, Bunders J. Global Health. 2014 Dec 11;10(1):85. [Epub ahead of print]

Background: In 2008, the WHO facilitated the primary health care (PHC) revitalisation agenda. The purpose was to strengthen African health systems in order to address communicable and non-communicable diseases. Our aim was to assess the position of civil society-led community home based care programmes (CHBC), which serve the needs of patients with HIV, within this agenda. We examined how their roles and place in health systems evolved, and the prospects for these programmes in national policies and strategies to revitalise PHC, as new health care demands arise.

Methods: The study was conducted in Ethiopia, Malawi, South Africa and Zambia and used an historical, comparative research design. We used purposive sampling in the selection of countries and case studies of CHBC programmes. Qualitative methods included semi-structured interviews, focus group discussions, service observation and community mapping exercises. Quantitative methods included questionnaire surveys.

Results: The capacity of PHC services increased rapidly in the mid-to-late 2000s via CHBC programme facilitation of community mobilisation and participation in primary care services and the exceptional investments for HIV/AIDS. CHBC programmes diversified their services in response to the changing health and social care needs of patients on lifelong anti-retroviral therapy and there is a general trend to extend service delivery beyond HIV-infected patients. We observed similarities in the way the governments of South Africa, Malawi and Zambia are integrating CHBC programmes into PHC by making PHC facilities the focal point for management and state-paid community health workers responsible for the supervision of community-based activities. Contextual differences were found between Ethiopia, South Africa, Malawi and Zambia, whereby the policy direction of the latter two countries is to have in place structures and mechanisms that actively connect health and social welfare interventions from governmental and non-governmental actors.

Conclusions: Countries may differ in the means to integrate and co-ordinate government and civil society agencies but the net result is expanded PHC capacity. In a context of changing health care demands, CHBC programmes are a vital mechanism for the delivery of primary health and social welfare services.

Abstract  Full-text [free] access

Editor’s notes: This paper presents a comprehensive overview of the integration of community home based care (CHBC) with primary health care (PHC) strategies in four countries in sub-Saharan Africa. It emphasises the co-ordination of efforts between government and civil society. Using a multi method approach drawing on surveys, key informant interviews, focus group discussions and in-depth interviews the authors sought to gain an historical perspective on the changing form and content of CHBC and PHC in Ethiopia, Malawi, South Africa and Zambia. They focused on programmes that had been active for more than 10 years, were nationally representative and offered diversity of care. Their findings reveal a commitment to integration of care within PHC strategies in all the countries. This reflects the recent call by WHO to revitalise primary health care approaches in developing countries. The authors identified similarities across the countries, especially government commitment to revitalise PHC, a strong presence of actors providing CHBC, and the extension of focus beyond one disease such as HIV to the care and support for people with chronic conditions. They also identified three different approaches taken. These included supervision by the government (Malawi, Zambia), contracting (South Africa) and referral (Ethiopia). This reveals that approaches to integration need to be context-driven. This is a very useful paper to understand how HIV care is now being integrated into broader medical and social care and lessons learned from innovative HIV care are being applied more widely and in a more coordinated way.

Ethiopia, Malawi, South Africa, Zambia
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Providing more than pills – health care workers and access to essential medicine in South Africa

Frontline health workers as brokers: provider perceptions, experiences and mitigating strategies to improve access to essential medicines in South Africa.

Magadzire B, Budden A, Ward K, Jeffery R, Sanders D. BMC Health Serv Res. 2014 Nov 5;14(1):520. [Epub ahead of print]

Background: Front-line health providers have a unique role as brokers (patient advocates) between the health system and patients in ensuring access to medicines (ATM). ATM is a fundamental component of health systems. This paper examines in a South African context supply- and demand- ATM barriers from the provider perspective using a five dimensional framework: availability (fit between existing resources and clients’ needs); accessibility (fit between physical location of healthcare and location of clients); accommodation (fit between the organisation of services and clients’ practical circumstances); acceptability (fit between clients’ and providers’ mutual expectations and appropriateness of care) and affordability (fit between cost of care and ability to pay).

Methods: This cross-sectional, qualitative study uses semi-structured interviews with nurses, pharmacy personnel and doctors. Thirty-six providers were purposively recruited from six public sector Community Health Centres in two districts in the Eastern Cape Province representing both rural and urban settings. Content analysis combined structured coding and grounded theory approaches. Finally, the five dimensional framework was applied to illustrate the interconnected facets of the issue.

Results: Factors perceived to affect ATM were identified. Availability of medicines was hampered by logistical bottlenecks in the medicines supply chain; poor public transport networks affected accessibility. Organization of disease programmes meshed poorly with the needs of patients with comorbidities and circular migrants who move between provinces searching for economic opportunities, proximity to services such as social grants and shopping centres influenced where patients obtain medicines. Acceptability was affected by, for example, HIV related stigma leading patients to seek distant services. Travel costs exacerbated by the interplay of several ATM barriers influenced affordability. Providers play a brokerage role by adopting flexible prescribing and dispensing for 'stable' patients and aligning clinic and social grant appointments to minimise clients’ routine costs. Occasionally they reported assisting patients with transport money.

Conclusion: All five ATM barriers are important and they interact in complex ways. Context-sensitive responses which minimise treatment interruption are needed. While broad-based changes encompassing all disease programmes to improve ATM are needed, a beginning could be to assess the appropriateness, feasibility and sustainability of existing brokerage mechanisms.

Abstract Full-text [free] access

Editor’s notes: The literature on health care providers and interactions with people accessing their services often casts the providers in a negative light. This paper focuses only on the providers and their observations on access to essential medicines in South Africa for treating HIV, TB, Type-2 diabetes and depression. The health care providers including nurses, doctors and pharmacy staff, talk of the challenges they face in providing care. Stock outs, transport problems, the mobility of their patients, who as a consequence miss appointments, and the poverty and hardship people face which hamper access to care. The authors provide a nuanced picture of the frustrations that the medical staff face as they try to provide care in an over-stretched public health system. Stories of their efforts to bend the rules to help mobile patients who need extra drugs while they travel, or the money given to help a very poor person get home are set alongside details of supply problems in remote rural clinics. The strength of this paper is that not only do the authors set out the barriers providers face in giving care, but also describe individual efforts made to improve things for people accessing services. These are not silent workers in the health service. They face challenges, yes, but they also have many ideas for how to make things better.

South Africa
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Laboratory monitoring of paediatric antiretroviral therapy not found to be cost-effective; but cotrimoxazole prophylaxis is

Opportunities for improving the efficiency of paediatric HIV treatment programmes: lessons from the ARROW trial.

Revill PA, Walker S, Mabugu T, Nathoo KJ, Mugyenyi P, Kekitinwa A, Munderi P, Bwakura-Dangarembizi M, Musiime V, Bakeera-Kitaka S, Nahirya-Ntege P, Walker AS, Sculpher MJ, Gibb DP. AIDS. 2014 Nov 13. [Epub ahead of print]

Objectives: To conduct two economic analyses addressing whether to: routinely monitor HIV-infected children on antiretroviral therapy (ART) clinically or with laboratory tests; continue or stop cotrimoxazole prophylaxis when children become stabilized on ART.

Design and methods: The ARROW randomized trial investigated alternative strategies to deliver paediatric ART and cotrimoxazole prophylaxis in 1206 Ugandan/Zimbabwean children. Incremental cost-effectiveness and value of implementation analyses were undertaken. Scenario analyses investigated whether laboratory monitoring (CD4 tests for efficacy monitoring; haematology/biochemistry for toxicity) could be tailored and targeted to be delivered cost-effectively. Cotrimoxazole use was examined in malaria-endemic and non-endemic settings.

Results: Using all trial data, clinical monitoring delivered similar health outcomes to routine laboratory monitoring, but at a reduced cost, so was cost-effective. Continuing cotrimoxazole improved health outcomes at reduced costs. Restricting routine CD4 monitoring to after 52 weeks following ART initiation and removing toxicity testing was associated with an incremental cost-effectiveness ratio of $6084 per quality-adjusted life-year (QALY) across all age groups, but was much lower for older children (12+ years at initiation; incremental cost-effectiveness ratio = $769/QALY).Committing resources to improve cotrimoxazole implementation appears cost-effective. A healthcare system that could pay $600/QALY should be willing to spend up to $12.0 per patient-year to ensure continued provision of cotrimoxazole.

Conclusion: Clinically driven monitoring of ART is cost-effective in most circumstances. Routine laboratory monitoring is generally not cost-effective at current prices, except possibly CD4 testing amongst adolescents initiating ART. Committing resources to ensure continued provision of cotrimoxazole in health facilities is more likely to represent an efficient use of resources.

Abstract access 

Editor’s notes: The authors set out to compare the cost-effectiveness of laboratory monitoring versus clinical monitoring of paediatric antiretroviral therapy (ART), and to determine the cost-effectiveness of continuing cotrimoxazole prophylaxis on children after being stabilised on ART. Using data from a trial in Uganda and Zimbabwe, they found that delivering ART with laboratory monitoring was generally more costly when compared with clinical monitoring. This was despite the two approaches having similar health outcomes. Laboratory monitoring was found not to be cost-effective, except potentially in cases of adolescents aged 12 and older (and without carrying out associated toxicity tests). The authors also found that discontinuing cotrimoxazole prophylaxis was both more costly and less effective than continuing provision. Reductions in cost of hospitalisations and prescriptions for malaria and other infections exceeded the costs of providing cotrimoxazole itself. Cost-reductions were similar in both malaria-endemic and non-malaria-endemic settings.

The questions addressed by this study are important because of the context of paediatric HIV in sub-Saharan Africa. As of 2013 only about 32% of children in need, in the region received ART. This background of poor health infrastructure and large gaps in paediatric treatment makes decision-making on limited resource allocation all the more important. The findings on the effectiveness of co-delivery of cotrimoxazole are further evidence of the need for governments and funders alike to think of effective and creative ways of integrating HIV care and treatment priorities within the wider health system.

This study should also be observed in light of changing national and international guidelines on detection of treatment failure. As of 2013, WHO has recommended viral load monitoring as the preferred method. When compared to CD4 testing, viral load monitoring tends to lead to better health outcomes but also requires sophisticated laboratory technology and highly trained technicians. Changing from CD4 to viral load monitoring may be unaffordable and logistically unfeasible in many settings.

Additionally, more countries in sub-Saharan Africa are rolling out point-of-care CD4 testing technologies. As more competitors in the field enter the point-of-care market, prices are likely to decrease. Although the authors have accounted for these future possibilities in their analysis, cost-effectiveness of monitoring of paediatric ART ought to be revisited at a later time once the costs related to point-of-care technologies have been more thoroughly understood.

Uganda, Zimbabwe
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Facility-level costs for antiretroviral therapy are much lower than previously understood

Multi-country analysis of treatment costs for HIV/AIDS (MATCH): facility-level ART unit cost analysis in Ethiopia, Malawi, Rwanda, South Africa and Zambia.

Tagar E, Sundaram M, Condliffe K, Matatiyo B, Chimbwandira F, Chilima B, Mwanamanga R, Moyo C, Chitah BM, Nyemazi JP, Assefa Y, Pillay Y, Mayer S, Shear L, Dain M, Hurley R, Kumar R, McCarthy T, Batra P, Gwinnell D, Diamond S, Over M. PLoS One. 2014 Nov 12;9(11):e108304. doi: 10.1371/journal.pone.0108304. eCollection 2014.

Background: Today's uncertain HIV funding landscape threatens to slow progress towards treatment goals. Understanding the costs of antiretroviral therapy (ART) will be essential for governments to make informed policy decisions about the pace of scale-up under the 2013 WHO HIV Treatment Guidelines, which increase the number of people eligible for treatment from 17.6 million to 28.6 million. The study presented here is one of the largest of its kind and the first to describe the facility-level cost of ART in a random sample of facilities in Ethiopia, Malawi, Rwanda, South Africa and Zambia.

Methods & Findings: In 2010-2011, comprehensive data on one year of facility-level ART costs and patient outcomes were collected from 161 facilities, selected using stratified random sampling. Overall, facility-level ART costs were significantly lower than expected in four of the five countries, with a simple average of $208 per patient-year (ppy) across Ethiopia, Malawi, Rwanda and Zambia. Costs were higher in South Africa, at $682 ppy. This included medications, laboratory services, direct and indirect personnel, patient support, equipment and administrative services. Facilities demonstrated the ability to retain patients alive and on treatment at these costs, although outcomes for established patients (2-8% annual loss to follow-up or death) were better than outcomes for new patients in their first year of ART (77-95% alive and on treatment).

Conclusions: This study illustrated that the facility-level costs of ART are lower than previously understood in these five countries. While limitations must be considered, and costs will vary across countries, this suggests that expanded treatment coverage may be affordable. Further research is needed to understand investment costs of treatment scale-up, non-facility costs and opportunities for more efficient resource allocation.

Abstract Full-text [free] access

Editor’s notes: This paper describes the facility-level costs for antiretroviral therapy (ART) delivery in 161 facilities across five countries. The scale of this study is impressive. At 161 facilities, it is one of the largest existing evaluations of facility-level costs for delivering ART. Collecting detailed cost data is a time- and resource-intensive process, and there is remarkable value in this quantity of cost data being made available.

The results are also surprising. The average cost for ART at the facility level in four of five countries ($208 per person per year) is consistently much lower than previously understood. Primary costing studies in low- and middle-income settings typically find some level of inconsistency between facilities, reflecting room to improve efficiency. This study found more variation in South Africa than in other settings, but relatively little variation overall. It would be interesting to find out in more detail whether this was a function of missing data, or whether the facilities included in the analysis were consistently efficient. If the latter, this may be an indication of improving efficiency in delivery of HIV treatment services.

The most exciting outcome from this study is the low costs found across settings. A number of existing studies of ART costs, all published between 2004-2008, find average facility costs ranging from $650 to $1000 per person, per year. The authors explain their lower costs as a reflection of reduced ART drug prices over the last ten years. Such a dramatic drop in costs is encouraging, particularly in the context of current efforts to expand access to ART.

Ethiopia, Malawi, Rwanda, South Africa, Zambia
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Targeted HIV prevention is extremely cost-effective at scale

Cost-effectiveness of HIV prevention for high-risk groups at scale: an economic evaluation of the Avahan programme in south India.

Vassall A, Pickles M, Chandrashekar S, Boily MC, Shetty G, Guinness L, Lowndes CM, Bradley J, Moses S, Alary M, Charme India G, Vickerman P. Lancet Glob Health. 2014 Sep;2(9):e531-40. doi: 10.1016/S2214-109X(14)70277-3. Epub 2014 Aug 27.

Background: Avahan is a large-scale, HIV preventive intervention, targeting high-risk populations in south India. We assessed the cost-effectiveness of Avahan to inform global and national funding institutions who are considering investing in worldwide HIV prevention in concentrated epidemics.

Methods: We estimated cost effectiveness from a programme perspective in 22 districts in four high-prevalence states. We used the UNAIDS Costing Guidelines for HIV Prevention Strategies as the basis for our costing method, and calculated effect estimates using a dynamic transmission model of HIV and sexually transmitted disease transmission that was parameterised and fitted to locally observed behavioural and prevalence trends. We calculated incremental cost-effective ratios (ICERs), comparing the incremental cost of Avahan per disability-adjusted life-year (DALY) averted versus a no-Avahan counterfactual scenario. We also estimated incremental cost per HIV infection averted and incremental cost per person reached.

Findings: Avahan reached roughly 150 000 high-risk individuals between 2004 and 2008 in the 22 districts studied, at a mean cost per person reached of US$327 during the 4 years. This reach resulted in an estimated 61 000 HIV infections averted, with roughly 11 000 HIV infections averted in the general population, at a mean incremental cost per HIV infection averted of $785 (SD 166). We estimate that roughly 1 million DALYs were averted across the 22 districts, at a mean incremental cost per DALY averted of $46 (SD 10). Future antiretroviral treatment (ART) cost savings during the lifetime of the cohort exposed to HIV prevention were estimated to be more than $77 million (compared with the slightly more than $50 million spent on Avahan in the 22 districts during the 4 years of the study).

Interpretation: This study provides evidence that the investment in targeted HIV prevention programmes in south India has been cost effective, and is likely to be cost saving if a commitment is made to provide ART to all that can benefit from it. Policy makers should consider funding and sustaining large-scale targeted HIV prevention programmes in India and beyond.

Abstract  Full-text [free] access

Editor’s notes: This study evaluates the cost-effectiveness of Avahan, one of the largest targeted HIV prevention programmes in the world. The authors find that prevention activities targeted to high-risk populations is extremely cost-effective, and likely to be cost-saving in the long run. Although there have been previous studies to the same effect on small projects or pilot programmes, these results are important for several reasons. First, the large scale of the study provides solid evidence on the cost-effectiveness of this activity in the real world, and at scale. Second, the inclusion of costs above the NGO level is unique, and reflects a vital investment for countries seeking to scale up HIV prevention activities. Further, the precision of estimates due to the comprehensive original data collection and fitting of the model is unparalleled. This study should encourage confidence in policy makers of the continuing strength of ‘prevention as prevention’ in the effort to stem the HIV epidemic in the context of scarce resources for HIV programmes. 

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Investing in the education of the children of parents on antiretroviral therapy may be an efficient way to retain people in care

Cost-effectiveness of socioeconomic support as part of HIV care for the poor in an urban community-based antiretroviral program in Uganda.

Stella-Talisuna A, Bilcke J, Colebunders R, Beutels P. J Acquir Immune Defic Syndr. 2014 Oct 1;67(2):e76-83. doi: 10.1097/QAI.0000000000000280.

Background: Socioeconomic support reduced nonretention in a community-based antiretroviral therapy (ART) program in Uganda. However, resource implications of expanding socioeconomic support are large, and cost-effectiveness analysis can inform budget priorities. We compared the incremental benefits and costs of providing education, food, or both forms of support (dual support) with existing ART services from a health care provider's perspective.

Methods: Costs and outcome data were collected from a cohort of 2371 adult patients with HIV receiving education, food, or dual support from Reach Out Mbuya between 2004 and 2010. The primary outcome was averted loss to follow-up. The number of follow-up days was calculated for each patient along with accrued service and fixed program costs for the alternative forms of socioeconomic support in USD by standard costing methods. The socioeconomic support types were compared incrementally over the study period.

Results: After 7 years, 762 (33%) of the patients were loss to follow-up with 42% of them receiving food. In the presence of providing ART, education support was less costly and more effective than the alternatives. The average unit cost for education, food, and dual support were $237, $538, and $776, respectively. The average total annual costs were $88 643 for education, $538 005 for food, and $103 045 for dual support.

Conclusions: Compared with food or dual support, investing in education of the children of ART patients is less costly and more effective in improving patient retention. Reach Out Mbuya should embrace this paradigm shift and channel its resources more efficiently and effectively by focusing on education support.

Abstract access 

Editor’s notes: The importance of socioeconomic factors for the initiation and retention of people in antiretroviral therapy (ART) is increasingly recognised. Programmes are adopting various approaches to improve retention. This study considers the technical efficiency of socioeconomic support provided in an NGO, Reach Out Mbuya’s, ART programme in Uganda over a significant period of time (2004-2010). It estimates the costs of food support for food-insecure ART individuals and their households, education support for the children of people on ART, and dual support. By comparing these costs to the number of cases of loss-to-follow-up averted by each support package, it analyses which support would be most cost-efficient. This is a useful starting point when considering what socioeconomic support to provide ART individuals, and specifically what would be most affordable. The study does not adjust for the different patient mix in the different programme categories, making it difficult to compare their outcomes. Indeed, it is highly likely that the people receiving food and dual support were also the most vulnerable and the most likely to be lost to follow-up. Nonetheless, the high costs estimated for direct food support raise concerns for programme scale up and sustainability. This suggests that education support may be better value for money from the perspective of retention in ART care. The potential spill-over benefits for household economic well-being, child survival and school attendance were not captured and may improve the economic case for food support, as a broader development programme with multiple objectives.

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Do not ignore higher level costs - only 35% of programme costs for service delivery in Indian HIV prevention programmes

The costs of scaling up HIV prevention for high risk groups: lessons learned from the Avahan programme in India.

Chandrashekar S, Guinness L, Pickles M, Shetty GY, Alary M, Vickerman P, Group C-E, Vassall A. PLoS One. 2014 Sep 9;9(9):e106582. doi: 10.1371/journal.pone.0106582. eCollection 2014.

Objective: The study objective is to measure, analyse costs of scaling up HIV prevention for high-risk groups in India, in order to assist the design of future HIV prevention programmes in South Asia and beyond.

Design: Prospective costing study.

Methods: This study is one of the most comprehensive studies of the costs of HIV prevention for high-risk groups to date in both its scope and size. HIV prevention included outreach, sexually transmitted infections (STI) services, condom provision, expertise enhancement, community mobilisation and enabling environment activities. Economic costs were collected from 138 non-government organisations (NGOs) in 64 districts, four state level lead implementing partners (SLPs), and the national programme level (Bill and Melinda Gates Foundation (BMGF)) office over four years using a top down costing approach, presented in US$ 2011.

Results: Mean total unit costs (2004-08) per person reached at least once a year and per monthly contact were US$ 235(56-1864) and US$ 82(12-969) respectively. 35% of the cost was incurred by NGOs, 30% at the state level SLP and 35% at the national programme level. The proportion of total costs by activity were 34% for expertise enhancement, 37% for programme management (including support and supervision), 22% for core HIV prevention activities (outreach and STI services) and 7% for community mobilisation and enabling environment activities. Total unit cost per person reached fell sharply as the programme expanded due to declining unit costs above the service level (from US$ 477 per person reached in 2004 to US$ 145 per person reached in 2008). At the service level also unit costs decreased slightly over time from US$ 68 to US$ 64 per person reached.

Conclusions: Scaling up HIV prevention for high risk groups requires significant investment in expertise enhancement and programme administration. However, unit costs decreased with programme expansion in spite of an increase in the scope of activities.

Abstract  Full-text [free] access

Editor’s notes: This paper captures the costs of one of the largest HIV prevention programmes among key populations to date. In the four states of study, Avahan focussed on a comprehensive set of activities among female sex workers and men who have sex with men. In addition to intervening with key populations the programme also focussed on strengthening technical expertise among providers. Most costing studies have focussed on costs at the service delivery level. It is widely acknowledged that the costs incurred at higher levels of the system are largely unknown. This study applies a top down cost allocation, which followed funding from the national, state and district levels as well the service delivery level. Only 35% of programme costs were at the service level, though this increases as programmes mature and scale up. This emphasises how detrimental ignoring higher level costs can be when making projections of budget impact and may provide insights into why so many new programmes and individual activities are not sustained.

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Hunger hinders antiretroviral therapy adherence

Does food insecurity undermine adherence to antiretroviral therapy? A systematic review.

Singer AW, Weiser SD, McCoy SI. AIDS Behav. 2014 Aug 6. [Epub ahead of print]

A growing body of research has identified food insecurity as a barrier to antiretroviral therapy (ART) adherence. We systematically reviewed and summarized the quantitative literature on food insecurity or food assistance and ART adherence. We identified nineteen analyses from eighteen distinct studies examining food insecurity and ART adherence. Of the thirteen studies that presented an adjusted effect estimate for the relationship between food insecurity and ART adherence, nine found a statistically significant association between food insecurity and sub-optimal ART adherence. Four studies examined the association between food assistance and ART adherence, and three found that ART adherence was significantly better among food assistance recipients than non-recipients. Across diverse populations, food insecurity is an important barrier to ART adherence, and food assistance appears to be a promising intervention strategy to improve ART adherence among persons living with HIV. Additional research is needed to determine the effectiveness and cost-effectiveness of food assistance in improving ART adherence and other clinical outcomes among people living with HIV in the era of widespread and long-term treatment.

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Editor’s notes: A number of qualitative studies have found that a lack of food is given as a reason for non-adherence to anti-retroviral therapy (ART). The authors wanted to see if quantitative studies on food security and adherence supported this view. As with many systematic reviews the number of quantitative studies included in the final analysis was small: fourteen. However, the majority of these studies did find an association between the availability of food and adherence. The authors very carefully describe the difference methods used to measure both food security and ART adherence.  These findings show both the wide range of methods used for measurement and definitions of adherence and food security, which made comparisons difficult. So, while the authors did find that food insecurity is a barrier to adherence, they could not say why. Given that food insecurity may be a threat to adherence for the some of the increasing numbers of people starting ART, further research is urgently needed. We need to understand more about the association between food and ART adherence. 

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