Articles tagged as "Close the resource gap"

Starting ART earlier may not only improve health outcomes, but perhaps save money too?

Time and money: the true costs of health care utilization for patients receiving 'free' HIV/TB care and treatment in rural KwaZulu-Natal.

Chimbindi N, Bor J, Newell ML, Tanser F, Baltusen R, Hontelez J, de Vlas S, Lurie M, Pillay D, Bärnighausen T. J Acquir Immune Defic Syndr. 2015 Jun 18. [Epub ahead of print]

Background: HIV and TB services are provided free-of-charge in many sub-Saharan African countries, but patients still incur costs.

Methods: Patient-exit interviews were conducted with a representative sample of 200 HIV-infected patients not yet on ART (pre-ART), 300 ART patients, and 300 TB patients receiving public sector care in rural South Africa. For each group, we calculated health expenditures across different spending categories, time spent traveling to and utilizing services, and how patients financed their spending. Associations between patient group and costs were assessed in multivariate regression models.

Results: Total monthly health expenditures (7.3 South African Rand: 1 USD) were: 171 (95%CI 134-207) for pre-ART, 164 (95%CI 141-187) for ART, and 122 (95%CI 105-140) for TB patients. Total monthly time costs (in hours) were: 3.4 (95%CI 3.3-3.5) for pre-ART, 5.0 (95%CI 4.7-5.3) for ART and 3.2 (95%CI 2.9-3.4) for TB patients. Though costs were similar across groups, pre-ART patients spent significantly more on traditional healers, chemists, and private doctors, while ART and TB patients spent more on transport to clinic visits. 31% of pre-ART, 39% of ART and 41% of TB patients borrowed money or sold assets to finance health costs.

Conclusions: Patients receiving nominally free care for HIV/TB face large private costs. Subsidized transport, fewer clinic visits, and drug pick-up points closer to home could reduce costs for ART patients, potentially improving adherence and retention. Large expenditure on alternative care among pre-ART patients suggests that transitioning patients to ART earlier, as under TASP, may not impose substantial costs on patients.

Abstract access

Editor’s notes: At the time of this study, in 2010 in South Africa, people living with HIV and on antiretroviral therapy (ART) made monthly visits to the clinic to collect their medication and for clinic observation in their first year on ART. They visited every other month in subsequent years. People receiving TB treatment also attended the clinic once a month. People living with HIV who had not yet started ART visited the clinic every six or 12 months, depending on the CD4 cell count. The authors were surprised to find that for the third group, people who they term ‘pre-ART’, the costs of health care utilisation were roughly equivalent to the costs for people receiving monthly or bi-monthly ART and/or TB treatment.  The difference is attributed in this paper to the time and money spent by people living with HIV yet to commence ART on traditional healers and self-medication. Hence, the conclusion that the earlier initiation of ART is unlikely to increase health utilisation costs. Indeed, alternative treatment schedules, with people on ART visiting health facilities less frequently as their years on treatment progress, can reduce costs further for people on ART. The assumption made in the paper is that pre-ART people starting treatment cease to access alternative care. Given the context of this study, where the authors claim that the use of alternative therapies for people on ART is not common, this may be correct. The possibility exists that given that data were collected through patient-exit interviews, people taking ART or TB medication may have been cautious about disclosing their use of alternative therapies. Concerns over sharing such information with interviewers attached to a medical research organisation, are not uncommon. This is an area in need of further, mixed methods, research to investigate the ‘true costs of health care utilisation’. This current paper takes us a step towards that goal. 

Africa
South Africa
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How the type of chronic illness in a household affects a child’s risk of abuse: findings from South Africa

Household illness, poverty and physical and emotional child abuse victimisation: findings from South Africa's first prospective cohort study.

Meinck F, Cluver LD, Boyes ME. BMC Public Health. 2015 May 1;15(1):444. doi: 10.1186/s12889-015-1792-4.

Background: Physical and emotional abuse of children is a large scale problem in South Africa, with severe negative outcomes for survivors. Although chronic household illness has shown to be a predictor for physical and emotional abuse, no research has thus far investigated the different pathways from household chronic illness to child abuse victimisation in South Africa.

Methods: Confidential self-report questionnaires using internationally utilised measures were completed by children aged 10-17 (n = 3515, 56.7% female) using door-to-door sampling in randomly selected areas in rural and urban locations of South Africa. Follow-up surveys were conducted a year later (96.7% retention rate). Using multiple mediation analyses, this study investigated direct and indirect effects of chronic household illness (AIDS or other illness) on frequent (monthly) physical and emotional abuse victimisation with poverty and extent of the ill person's disability as hypothesised mediators.

Results: For children in AIDS-ill families, a positive direct effect on physical abuse was obtained. In addition, positive indirect effects through poverty and disability were established. For boys, a positive direct and indirect effect of AIDS-illness on emotional abuse through poverty were detected. For girls, a positive indirect effect through poverty was observed. For children in households with other chronic illness, a negative indirect effect on physical abuse was obtained. In addition, a negative indirect effect through poverty and positive indirect effect through disability was established. For boys, positive and negative indirect effects through poverty and disability were found respectively. For girls, a negative indirect effect through poverty was observed.

Conclusions: These results indicate that children in families affected by AIDS-illness are at higher risk of child abuse victimisation, and this risk is mediated by higher levels of poverty and disability. Children affected by other chronic illness are at lower risk for abuse victimisation unless they are subject to higher levels of household disability. Interventions aiming to reduce poverty and increase family support may help prevent child abuse in families experiencing illness in South Africa.

Abstract  Full-text [free] access

Editor’s notes: Research has illustrated that children in an HIV- affected household in sub-Saharan Africa are at an increased risk of child maltreatment. This is the first longitudinal study to examine pathways from household chronic illness to child abuse in the developing world through multiple mediation analysis. Using confidential self-report questionnaires the study collected data from 3515 children (aged 10 to 17 years) in South Africa.

What is striking in their findings is the difference that they found in the relationship between risk of child abuse and the type of illness affecting the household, mediated by poverty and disability. They noted higher levels of physical and emotional abuse among HIV-affected households compared to households without HIV. However, they also found that households affected by other chronic illness had lower abuse prevalence rates. Given that diabetes and high blood pressure are more likely to affect older age people, the authors hypothesise that the ill member of the household would likely have access to a state pension and thus benefit from some protection from the risk of poverty. The exception to this hypothesis were households within this group who had high levels of disability.

This study provides a valuable contribution because previous research has primarily focused on AIDS or cancer-affected households. These households are likely to need to manage higher levels of associated stigma, a shorter perceived life expectancy and more complex treatment options. As such previous research may have presented a more extreme relationship between illness status of household and a child’s risk of abuse. The findings highlight the significance for activities and programming in identifying two groups of households which are at heightened risk for child abuse: HIV affected households; and households affected by other chronic conditions. 

Africa
South Africa
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Donor pull-out: how much will it cost to fill the gap for HIV testing in Viet Nam?

Expenditure analysis of HIV testing and counseling services using the cascade framework in Vietnam.

Nguyen VT, Nguyen HT, Nguyen QC, Duong PT, West G. PLoS One. 2015 May 15;10(5):e0126659. doi: 10.1371/journal.pone.0126659. eCollection 2015.

Objectives: Currently, HIV testing and counseling (HTC) services in Vietnam are primarily funded by international sources. However, international funders are now planning to withdraw their support and the Government of Vietnam (GVN) is seeking to identify domestic funding and generate client fees to continue services. A clear understanding of the cost to sustain current HTC services is becoming increasingly important to facilitate planning that can lead to making HTC and other HIV services more affordable and sustainable in Vietnam. The objectives of this analysis were to provide a snapshot of current program costs to achieve key program outcomes including 1) testing and identifying PLHIV unaware of their HIV status and 2) successfully enrolling HIV (+) clients in care.

Methods: We reviewed expenditure data reported by 34 HTC sites in nine Vietnamese provinces over a one-year period from October 2012 to September 2013. Data on program outcomes were extracted from the HTC database of 42 390 client records. Analysis was carried out from the service providers' perspective.

Results: The mean expenditure for a single client provided HTC services (testing, receiving results and referral for care/treatment) was US $7.6. The unit expenditure per PLHIV identified through these services varied widely from US $22.8 to $741.5 (median: $131.8). Excluding repeat tests, the range for expenditure to newly diagnose a PLHIV was even wider (from US $30.8 to $1483.0). The mean expenditure for one successfully referred HIV client to care services was US $466.6. Personnel costs contributed most to the total cost.

Conclusions: Our analysis found a wide range of expenditures by site for achieving the same outcomes. Re-designing systems to provide services at the lowest feasible cost is essential to making HIV services more affordable and treatment for prevention programs feasible in Vietnam. The analysis also found that understanding the determinants and reasons for variance in service costs by site is an important enhancement to the cascade of HIV services framework now adapted for and extensively used in Vietnam for planning and evaluation.

Abstract  Full-text [free] access

Editor’s notes: Some 91% of expenditure for HIV testing and counselling (HTC) in Viet Nam is funded by international donors. As donors start to reduce their contributions in the coming years, more of the costs will have to be fronted by the government of Viet Nam. Consequently, this paper looks at the cost around diagnosing HIV within the context of the care and treatment cascade, including not only the cost per person diagnosed, but also the cost of successfully enrolling people who have tested positive for HIV into care and treatment. This is particularly important in the context of Viet Nam, where only 29% of people estimated to be living with HIV have ever been enrolled in care and treatment services. 

An important finding of the paper is in the break-down of costs by input by facilities. The authors found that the cost of personnel account for 40% of total costs. More importantly, they also found that the personnel costs vary widely between facilities, which may suggest that some facilities are over-staffed and are not allocating tasks efficiently. This is a key finding. As financial resources become scarcer, savings may need to be found by determining the optimal level of staffing and task-shifting.

The paper illustrates, as is to be expected, that the cost per person successfully enrolled in care and treatment is substantially higher than the costs per person tested and per person testing positive.  However, it is not entirely clear whether the extra cost is explained simply by the fact that the overhead and start-up costs are allocated to a smaller number of people, or whether there are additional costs involved in a successful referral. This area needs further exploration. Additionally, an interesting follow-up to this paper could take on the costing from a societal perspective with the aim to understand the relation between patient-level costs and the successful link between testing and referral to care and treatment services.

Asia
Viet Nam
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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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The impact of cash transfers on orphans and other children made vulnerable by HIV

Effects of cash transfers on children's health and social protection in sub-Saharan Africa: differences in outcomes based on orphan status and household assets.

Crea TM, Reynolds AD, Sinha A, Eaton JW, Robertson LA, Mushati P, Dumba L, Mavise G, Makoni JC, Schumacher CM, Nyamukapa CA, Gregson S. BMC Public Health. 2015 May 28;15:511. doi: 10.1186/s12889-015-1857-4.

Background: Unconditional and conditional cash transfer programmes (UCT and CCT) show potential to improve the well-being of orphans and other children made vulnerable by HIV/AIDS (OVC). We address the gap in current understanding about the extent to which household-based cash transfers differentially impact individual children's outcomes, according to risk or protective factors such as orphan status and household assets.

Methods: Data were obtained from a cluster-randomised controlled trial in eastern Zimbabwe, with random assignment to three study arms - UCT, CCT or control. The sample included 5331 children ages 6-17 from 1697 households. Generalized linear mixed models were specified to predict OVC health vulnerability (child chronic illness and disability) and social protection (birth registration and 90% school attendance). Models included child-level risk factors (age, orphan status); household risk factors (adults with chronic illnesses and disabilities, greater household size); and household protective factors (including asset-holding). Interactions were systematically tested.

Results: Orphan status was associated with decreased likelihood for birth registration, and paternal orphans and children for whom both parents' survival status was unknown were less likely to attend school. In the UCT arm, paternal orphans fared better in likelihood of birth registration compared with non-paternal orphans. Effects of study arms on outcomes were not moderated by any other risk or protective factors. High household asset-holding was associated with decreased likelihood of child's chronic illness and increased birth registration and school attendance, but household assets did not moderate the effects of cash transfers on risk or protective factors.

Conclusion: Orphaned children are at higher risk for poor social protection outcomes even when cared for in family-based settings. UCT and CCT each produced direct effects on children's social protection which are not moderated by other child- and household-level risk factors, but orphans are less likely to attend school or obtain birth registration. The effects of UCT and CCT are not moderated by asset-holding, but greater household assets predict greater social protection outcomes. Intervention efforts need to focus on ameliorating the additional risk burden carried by orphaned children. These efforts might include caregiver education, and additional incentives based on efforts made specifically for orphaned children.

Abstract  Full-text [free] access

Editor’s notes: In sub-Saharan Africa, there is growing evidence on the impact of cash transfers on youth HIV risk, health outcomes of orphans and other children made vulnerable by HIV and on social protection outcomes such as school attendance. Using data from a cluster randomised controlled trial in Zimbabwe, the authors sought to understand the extent to which individual level children’s risk factors and household asset accumulation influence the effects of cash transfers on child health (chronic illness and disability) and child social protection (birth registration status and school attendance) outcomes.

There was no evidence to illustrate that the type of orphan status, maternal or paternal or both, was associated with child disability or chronic illness. There was some evidence that suggested that orphan status predicted social vulnerability, i.e., risk for not obtaining birth registration. However the receipt of an unconditional cash transfer buffered this risk for paternal orphans, suggesting birth registration being a gendered activity and that mothers of paternal orphans might use cash incentives to invest in the human capital of their children. Results also demonstrate that cash transfers, both unconditional and conditional, and household accumulation of assets have positive effects on social protection outcomes including birth registration and school attendance, separately. But the effect of cash transfers is not influenced by the amount of assets held by a household. Furthermore, in contrast to other studies, there is no evidence from these findings to illustrate that cash transfers have an effect on health outcomes. However, asset holding seems to have a weak, but positive effect on children’s chronic illness, but no effect on chronic disability. This suggests that households with some assets are able to use these assets to access health care services to treat chronic illness. Furthermore these households with greater assets may also experience better living conditions which perhaps contribute to better health outcomes.

Given the financial burden of HIV on households caring for orphan and vulnerable children, programme efforts for HIV prevention should focus on addressing this burden. This study contributes to the evidence base from other countries in sub-Saharan Africa.  Findings from Malawi and Kenya, for example, have illustrated that the provision of cash transfers to HIV affected households provide a substantial boost that is effective in improving outcomes among vulnerable children, in particular certain social protection outcomes, such as school attendance.

Africa
Zimbabwe
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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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Economic strengthening programmes for people living with HIV may increase their quality of life

The impact of social services interventions in developing countries: a review of the evidence of impact on clinical outcomes in people living with HIV.

Bateganya MH, Dong M, Oguntomilade J, Suraratdecha C. J Acquir Immune Defic Syndr. 2015 Apr 15;68 Suppl 3:S357-67. doi: 10.1097/QAI.0000000000000498.

Background: Social service interventions have been implemented in many countries to help people living with HIV (PLHIV) and household members cope with economic burden as a result of reduced earning or increased spending on health care. However, the evidence for specific interventions-economic strengthening and legal services-on key health outcomes has not been appraised.

Methods: We searched electronic databases from January 1995 to May 2014 and reviewed relevant literature from resource-limited settings on the impact of social service interventions on mortality, morbidity, retention in HIV care, quality of life, and ongoing HIV transmission and their cost-effectiveness.

Results: Of 1685 citations, 8 articles reported the health impact of economic strengthening interventions among PLHIV in resource-limited settings. None reported on legal services. Six of the 8 studies were conducted in sub-Saharan Africa: 1 reported on all 5 outcomes and 2 reported on 4 and 2 outcomes, respectively. The remaining 5 reported on 1 outcome each. Seven studies reported on quality of life. Although all studies reported some association between economic strengthening interventions and HIV care outcomes, the quality of evidence was rated fair or poor because studies were of low research rigor (observational or qualitative), had small sample size, or had other limitations. The expected impact of economic strengthening interventions was rated as high for quality of life but uncertain for all the other outcomes.

Conclusions: Implementation of economic strengthening interventions is expected to have a high impact on the quality of life for PLHIV but uncertain impact on mortality, morbidity, retention in care, and HIV transmission. More rigorous research is needed to explore the impact of more targeted intervention components on health outcomes.

Abstract access 

Editor’s notes: To mitigate the impact of HIV on people living with HIV and their households, economic strengthening programmes and legal services have often been implemented. However, few have been rigorously evaluated in terms of their impact on HIV outcomes. This review of the literature reveals a limited and weak evidence base on the impact of such social services programmes for people living with HIV on mortality, morbidity, retention in HIV care, quality of life, and ongoing HIV transmission. It only identifies eight studies, all of them on economic strengthening activities, and most of them qualitative or observational in design. The authors conclude that the evidence suggests a high impact of such programmes on the quality of life for people living with HIV, which was consistently reported in the studies identified. Access to other confounding services, such as ART and broader community-based support, requires these findings to be interpreted with caution.     

The study clearly highlights the need for more rigorous impact and economic evaluations in this area. Indeed, the review did not identify any studies considering costs or cost-effectiveness. The authors also recommend more research into the feasibility and sustainability of these programmes, as well as greater focus of the implemented programmes on population groups in the greatest need.  

Africa, Asia, Latin America
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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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