Articles tagged as "Close the resource gap"

Patient expenditures for TB care are impoverishing and may prevent access to care

Household catastrophic payments for tuberculosis care in Nigeria: incidence, determinants, and policy implications for universal health coverage.

Ukwaja KN, Alobu I, Abimbola S, Hopewell PC. Infect Dis Poverty. 2013 Sep17;2(1):21. [Epub ahead of print]

Background: Studies on costs incurred by patients for tuberculosis (TB) care are limited as these costs are reported as averages, and the economic impact of the costs is estimated based on average patient/household incomes. Average expenditures do not represent the poor because they spend less on treatment compared to other economic groups. Thus, the extent to which TB expenditures risk sending households into, or further into, poverty and its determinants, is unknown. We assessed the incidence and determinants of household catastrophic payments for TB care in rural Nigeria.

Methods: Data used were obtained from a survey of 452 pulmonary TB patients sampled from three rural health facilities in Ebonyi State, Nigeria. Using household direct costs and income data, we analyzed the incidence of household catastrophic payments using, as thresholds, the traditional >10% of household income and the >=40% of non-food income, as recommended by the World Health Organization. We used logistic regression analysis to identify the determinants of catastrophic payments.

Results: Average direct household costs for TB were US$157 or 14% of average annual incomes. The incidence of catastrophic payment was 44%; with 69% and 15% of the poorest and richest household income-quartiles experiencing catastrophic activity, respectively. Independent determinants of catastrophic payments were: age >40 years (adjusted odds ratio [aOR] 3.9; 95% confidence interval [CI], 2.0, 7.8), male gender (aOR 3.0; CI 1.8, 5.2), urban residence (aOR 3.8; CI 1.9, 7.7), formal education (aOR 4.7; CI 2.5, 8.9), care at a private facility (aOR 2.9; 1.5, 5.9), poor household (aOR 6.7; CI 3.7, 12), household where the patient is the primary earner (aOR 3.8; CI 2.2, 6.6]), and HIV co-infection (aOR 3.1; CI 1.7, 5.6).

Conclusions: Current cost-lowering strategies are not enough to prevent households from incurring catastrophic out-of-pocket payments for TB care. Financial and social protection interventions are needed for identified at-risk groups, and community-level interventions may reduce inefficiencies in the care-seeking pathway. These observations should inform post-2015 TB strategies and influence policy-making on health services that are meant to be free of charge.

Abstract access 

Editor’s notes: Household health care expenditures can often push households into poverty. These payments, known as catastrophic payments, mean that households are giving up the consumption of basic goods and services to pay for health care.  This study uses individual level data on health care expenditures for TB services and income levels, to examine the extent to which TB involves catastrophic payments in Nigeria.  Although TB services are subsidized and supposed to be free, this survey confirms this is not the case with patients paying most frequently for drugs, laboratory tests and transport.   Of particular concern is the high level of pre-diagnostic costs; that the poor are more vulnerable and the situation is exacerbated for those with HIV co-infection. The findings are important for policy makers trying to improve access to TB care, HIV care and access to health care in general. They emphasize the importance of prepayment schemes to facilitate access to health care when individuals are at their most in need.  

Africa
Nigeria
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Some evidence of impact from external funding for HIV, TB and malaria - and the need for more

Impact of external funding for HIV, tuberculosis and malaria: systematic review.

de Jongh TE, Harnmeijer JH, Atun R, Korenromp EL, Zhao J, Puvimanasinghe J, Baltussen R. Health Health Policy Plan. 2013 Aug 5. [Epub ahead of print]

Background:  Since 2002, development assistance for health has substantially increased, especially investments for HIV, tuberculosis (TB) and malaria control. We undertook a systematic review to assess and synthesize the existing evidence in the scientific literature on the health impacts of these investments.

Methods and Findings:  We systematically searched databases for peer-reviewed and grey literature, using tailored search strategies. We screened studies for study design and relevance, using predefined inclusion criteria, and selected those that enabled us to link health outcomes or impact to increased external funding. For all included studies, we recorded dataset and study characteristics, health outcomes and impacts. We analysed the data using a causal-chain framework to develop a narrative summary of the published evidence. Thirteen articles, representing 11 individual studies set in Africa and Asia reporting impacts on HIV, tuberculosis and malaria, met the inclusion criteria. Only two of these studies documented the entire causal-chain spanning from funding to programme scale-up, to outputs, outcomes and impacts. Nonetheless, overall we find a positive correlation between consecutive steps in the causal chain, suggesting that external funds for HIV, tuberculosis and malaria programmes contributed to improved health outcomes and impact.

Conclusions:  Despite the large number of supported programmes worldwide and despite an abundance of published studies on HIV, TB and malaria control, we identified very few eligible studies that adequately demonstrated the full process by which external funding has been translated to health impact. Most of these studies did not move beyond demonstrating statistical association, as opposed to contribution or causation. We thus recommend that funding organizations and researchers increase the emphasis on ensuring data capture along the causal pathway to demonstrate effect and contribution of external financing. The findings of these comprehensive and rigorously conducted impact evaluations should also be made publicly accessible.

Keywords: Africa, Asia, Health financing, developing countries, donors, health outcomes, impact

Abstract access

Editor’s notes: In the current context of resource constraints and after a decade of unprecedented increases in development assistance for health (particularly for HIV, tuberculosis and malaria), donors are increasingly concerned about the value for money of their investments. This study reviewed available evidence on the impact of external funding, finding a paucity of rigorous scientific evaluation data on the efficiency, effectiveness and impact.

The identified HIV studies found associations between programme investments and increased access and adherence to ART, as well as reduced HIV-related mortality, but limited evidence of preventive impacts on rates of HIV infection. There were many study limitations, including the lack of randomization or robust controls, and relatively small (or statistically insignificant) observed effects. Few studies provided a full analysis of effectiveness along the causal chain from inputs to impact, and none considered the potential undesirable effects of external funding.

Although the aims of the study were ambitious, this paper highlights the challenges of documenting the impacts of financial investments, with the authors arguing that future evaluations need to adopt a more systemic approach to impact evaluation that better captures the causal pathway between investment inputs and impacts, as well as broader system-wide effects. 

Africa, Asia
Cameroon, China, India, Kenya, Malawi, Zambia
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Modelling combination prevention: the importance of joint effectiveness assumptions

Combination HIV Prevention: The Value and Interpretation of Mathematical Models.

Walensky RP, Curr HIV/AIDS Rep. 2013 Jun 25. [Epub ahead of print]

Mathematical models of HIV prevention interventions often provide critical insights related to programmatic design and economic efficiency. One recent dynamic model by Long et al. highlights that a combination prevention approach - with testing, treatment, circumcision, microbicides and PrEP - may decrease transmissions by over 60 % and may be very cost-effective in South Africa. In this analysis, the authors introduce the critical concept of joint effectiveness of preventions programs and demonstrate how some programs operate synergistically (HIV screening coupled with early treatment) while others may create redundancies (microbicides coupled with pre-exposure prophylaxis). Whether combination HIV prevention programs perform with additive, multiplicative or maximal effectiveness will be important to consider in anticipation of their combined transmission impact.

Abstract access

Editor’s notes: This commentary highlights important concepts and results from a recent modelling study of combination prevention for HIV in South Africa. A key concept discussed is that of ‘joint effectiveness’, which considers how two or more intervention programmes, might work together in the same population. While multiplicative effectiveness is often assumed, other options are to optimistically assume additive effectiveness, where distinct, non-interacting parts of the population use and benefit from the different interventions, or to conservatively assume maximal effectiveness, where it is the same individuals who use and/or benefit from all of the interventions, substantially reducing the overall impact. The commentary also highlights the synergies and redundancies found in the study between different intervention components, and illustrates how the discounting of future costs and benefits used in this and other cost-effectiveness studies can affect the relative cost-effectiveness of different interventions depending upon when costs are incurred and benefits accrued. These are all important considerations for future modelling and cost-effectiveness studies looking at combination HIV prevention.

Africa
South Africa
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Aid disbursements to reproductive health stable or slightly increasing

Reproductive health priorities: evidence from a resource tracking analysis of official development assistance in 2009 and 2010.

Hsu J, Berman P, Mills A. Lancet. 2013 May 18;381(9879):1772-82.

Background: Information is scarce about the extent to which official development assistance (ODA) is spent on reproductive health to provide childbirth care; support family planning; address sexual health; and prevent, treat, and care for sexually transmitted infections, including HIV. We analysed flows of ODA to reproductive health for 2009 and 2010, assessed their distribution by donor type and purpose, and investigated the extent to which disbursements respond to need. We aimed to provide global estimates of aid to reproductive health, to assess the allocation of resources across reproductive health activities, and to encourage donor accountability in targeting aid flows to those most in need.

Methods: We applied a standard definition of reproductive health across all donors, including a portion of disease-specific activities and health systems development. We analysed disbursements to reproductive health by donor type and purpose (e.g., family planning). We also reported on an indicator to monitor donor disbursements: ODA to reproductive health per woman aged 15-49 years. We analysed the extent to which funding is targeted to countries most in need, proxied by female life expectancy at birth and prevalence of HIV infection in adults.

Findings: Donor disbursements to reproductive health activities in all countries amounted to US$5579 million in 2009 and US$5637 million in 2010-an increase of 1.0%. ODA for such activities in the 74 Countdown priority countries increased more rapidly at 5.3%. More than half of the funding was directed towards prevention, treatment, and care of HIV infection for women of reproductive age (15-49 years of age). On average, ODA to general reproductive health activities amounted to 15.9% and ODA to family planning 7.2%. Aid to reproductive health was heavily dependent on the USA, the Global Fund, the UK, the United Nations Population Fund, and the World Bank.

Interpretation: Donors are prioritising reproductive health, and the slight increase in funding in 2009-10 is welcome, especially in the present economic climate. The large share of such funding for activities related to HIV infection in women of reproductive age affects the amount of ODA received by priority countries. It should thus be distinguished from resources directed to other reproductive health activities, such as family planning, which has been the focus of recent worldwide advocacy efforts. Tracking of donor aid to reproductive health should continue to allow investigation of the allocation of resources across reproductive health activities, and to encourage donor accountability in targeting aid flows to those most in need.

Abstract access 

Editor’s notes: This study analyzes the flows of official development assistance (ODA) to reproductive health in the context of the economic crisis. It is the first resource tracking to cover a more comprehensive set of female reproductive health activities, such as family planning and the treatment of sexually treated infections, including HIV. With a 1% increase in real terms, the study highlights the stability of ODA to reproductive health as promising, although the aggregate masks significant fluctuations by certain donors. Claiming more than half the total aid, funding for HIV activities dominates the package, while the 7.2% for family planning is of concern, given recent commitments. The study also finds that ODA disbursements are closely related to need and that this may even be improving slightly – this is encouraging in terms of the efficiency and effectiveness of aid to women’s health priorities.  

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New framework for delivering high-value care to patients with HIV/AIDS and co-occurring conditions

Redefining global health-care delivery.

Kim JY, Farmer P, Porter ME. Lancet. 2013 May 17. pii: S0140-6736(13)61047-8.

Initiatives to address the unmet needs of those facing both poverty and serious illness have expanded significantly over the past decade. But many of them are designed in an ad-hoc manner to address one health problem among many; they are too rarely assessed; best practices spread slowly. When assessments of delivery do occur, they are often narrow studies of the cost-effectiveness of a single intervention rather than the complex set of them required to deliver value to patients and their families. We propose a framework for global health-care delivery and evaluation by considering efforts to introduce HIV/AIDS care to resource-poor settings. The framework introduces the notion of care delivery value chains that apply a systems-level analysis to the complex processes and interventions that must occur, across a health-care system and over time, to deliver high-value care for patients with HIV/AIDS and co-occurring conditions, from tuberculosis to malnutrition. To deliver value, vertical or stand-alone projects must be integrated into shared delivery infrastructure so that personnel and facilities are used wisely and economies of scale reaped. Two other integrative processes are necessary for delivering and assessing value in global health: one is the alignment of delivery with local context by incorporating knowledge of both barriers to good outcomes (from poor nutrition to a lack of water and sanitation) and broader social and economic determinants of health and wellbeing (jobs, housing, physical infrastructure). The second is the use of effective investments in care delivery to promote equitable economic development, especially for those struggling against poverty and high burdens of disease. We close by reporting our own shared experience of seeking to move towards a science of delivery by harnessing research and training to understand and improve care delivery.

Abstract access 

Editor’s notes: In this conceptual article, the authors propose a framework to guide effective health care delivery in resource-poor settings that builds on the concept of value chains from business management, in which production processes within firms are a chain of activities that produce valuable goods and services. In this framework, value is defined as a measure of aggregate health outcomes achieved per dollar spent, rather than health programme results. Rather than considering the intervention for a particular disease or condition as the basic unit of analysis, this framework suggests that value can be created at four levels, i.e. by integrating care for every individual medical condition, by using shared delivery infrastructure, by incorporating knowledge of local socio-economic constraints into care delivery, and finally by designing health systems to maximize their contribution to economic development. The authors provide another compelling rationale for the integration of health service delivery and systems, as well as complex external determinants of heath.

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Improvements in ART initiation and virological suppression in North America.

Trends and Disparities in Antiretroviral Therapy Initiation and Virologic Suppression Among Newly Treatment-Eligible HIV-Infected Individuals in North America, 2001-2009.

Hanna DB, Buchacz K, Gebo KA, Hessol NA, Horberg MA, et al.; North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) of the International Epidemiologic Databases to Evaluate AIDS. Clin Infect Dis. 2013 Apr;56(8):1174-82. doi: 10.1093/cid/cit003. Epub 2013 Jan 11.

Background: Since the mid-1990s, effective antiretroviral therapy (ART) regimens have improved in potency, tolerability, ease of use, and class diversity. We sought to examine trends in treatment initiation and resulting human immunodeficiency virus (HIV) virologic suppression in North America between 2001 and 2009, and demographic and geographic disparities in these outcomes.

Methods: We analyzed data on HIV-infected individuals newly clinically eligible for ART (ie, first reported CD4 (+) count <350 cells/µL or AIDS-defining illness, based on treatment guidelines during the study period) from 17 North American AIDS Cohort Collaboration on Research and Design cohorts.

Outcomes included timely ART initiation (within 6 months of eligibility) and virologic suppression (≤500 copies/mL, within 1 year). We examined time trends and considered differences by geographic location, age, sex, transmission risk, race/ethnicity, CD4(+) count, and viral load, and documented psychosocial barriers to ART initiation, including non-injection drug abuse, alcohol abuse, and mental illness.

Results: Among 10 692 HIV-infected individuals, the cumulative incidence of 6-month ART initiation increased from 51% in 2001 to 72% in 2009 (Ptrend < .001). The cumulative incidence of 1-year virologic suppression increased from 55% to 81%, and among ART initiators, from 84% to 93% (both Ptrend < .001). A greater number of psychosocial barriers were associated with decreased ART initiation, but not virologic suppression once ART was initiated. We found significant heterogeneity by state or province of residence (P < .001).

Conclusions: In the last decade, timely ART initiation and virologic suppression have greatly improved in North America concurrent with the development of better-tolerated and more potent regimens, but significant barriers to treatment uptake remain, both at the individual level and system-wide.

Abstract access

Editor’s notes: This study provides strong evidence of increases in timely ART initiation and virologic suppression in North America over the last decade. Such large collaborations of cohorts provide valuable, well-collected data, but are unlikely to be fully representative of all settings. Nevertheless, interesting findings are worth examining in more detail. One of the strongest risk factors for delay in ART initiation was a score of the number of psychosocial barriers faced by a patient (defined as: documented histories of non-injection drug abuse, alcohol abuse and mental illness). However, following initiation of treatment this was not a risk factor for virologic suppression. This highlights a need to pay more attention to the social determinants that prevent many patients starting treatment. The study cohorts come from 14 states and three provinces in North America, with large variation in outcomes between them – the cumulative incidence of ART initiation after six months varied from 35% to 94% after adjusting for individual and cohort level characteristics, while virologic suppression at one year varied from 45% to 78%. Understanding the reasons behind these variations could provide valuable insights into improving programme outcomes.

Northern America
Canada, United States of America
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Scarcity of funding and well-trained health workers hampers large-scale implementation of ART in sub-Saharan Africa

Cost-effectiveness of nurse-led versus doctor-led antiretroviral treatment in South Africa: pragmatic cluster randomised trial

Garry R. Barton, Lara Fairall, Max O. Bachmann, Kerry Uebel, Venessa Timmerman, Carl Lombard and Merrick Zwarenstein. Trop Med Int Health. 2013 Mar 11. doi: 10.1111/tmi.12093. [Epub ahead of print]

OBJECTIVE: To estimate the cost-effectiveness of nurse-led versus doctor-led antiretroviral treatment (ART) for HIV-infected people.

DESIGN:  Cost-effectiveness analysis alongside a pragmatic cluster randomised controlled trial in 31 primary care clinics (16 intervention, 15 controls) in Free State Province, South Africa. Participants were HIV-infected patients, aged 16 years. Cohort 1 (CD4 count 350 cells/ μl, not yet receiving ART at enrolment): consisted of 5 390 intervention patients and 3 862 controls; Cohort 2 (already received ART for 6 months at enrolment) of 3 029 intervention patients and 3 202 controls. Nurses were authorised and trained to initiate and re-prescribe ART. Management and ART provision were decentralised to primary care clinics. In control clinics, doctors initiated and re-prescribed ART, nurses monitored ART. Main outcome measure(s) were health service costs, death (cohort 1) and undetectable viral load (<400 copies/ml) (cohort 2) during the 12 months after enrolment.

RESULTS: For Cohort 1, the intervention had an estimated incremental cost of US$102.52, an incremental effect of 0.42% fewer deaths and an incremental cost-effectiveness ratio (ICER) of US $24 500 per death averted. For Cohort 2, the intervention had an estimated incremental cost of US $59.48, an incremental effect of 0.47% more undetectable viral loads and an ICER of US$12 584 per undetectable viral load.

CONCLUSIONS: Nurse-led ART was associated with higher mean health service costs than doctor-led care, with small effects on primary outcomes, and a high associated level of uncertainty. Given this, and the shortage of doctors, further implementation of nurse-led ART should be considered, although this may increase health service costs.

Abstract access 

Editor’s notes: The large scale implementation of antiretroviral treatment in sub-Saharan Africa is hampered by a scarcity of finance and trained health workers (UNAIDS 2010). Task shifting of ART provision from doctors to other health workers is increasingly used to expand ART provision, and is being promoted as a means to scale up HIV treatment in an affordable way. Intervention clinics implemented STRETCH, a complex educational and organizational health systems intervention. This trial compared the impact of doctor and nurse led models of ART provision.  Importantly, the STRETCH intervention of nurse-led ART was associated with higher health service costs and a small statistically non-significant effect on mortality among patients awaiting ART and equivalent viral load suppression rates for patients already on treatment, compared with doctor-led ART. There were some improvements in TB detection, CD4 count and weight. However, levels of uncertainty were high, with wide confidence intervals around the incremental costs and effects. Surprisingly, however, the costs of nurse led care were higher, as a result of more frequent clinic visits with longer consultations. The findings provide some support for this shift as nurses were able to provide more contacts and spend more time with patients; they also achieved improvements in certain outcomes. Based on these results, implementation of nurse-led ART may, however, increase healthcare costs.

Africa
South Africa
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Economics

Economic Returns to Investment in AIDS Treatment in Low and Middle Income Countries

Resch S,  Korenromp E, Stover J, Blakley M, Krubiner C, Thorien K,Hecht R, Atun R. PLoS One. 2011;6(10):e25310. Epub 2011 Oct 5

Since the early 2000s, aid organizations and developing country governments have invested heavily in AIDS treatment. By 2010, more than five million people began receiving antiretroviral therapy (ART) – yet each year, 2.7 million people are becoming newly infected and another two million are dying without ever having received treatment. As the need for treatment grows without commensurate increase in the amount of available resources, it is critical to assess the health and economic gains being realized from increasingly large investments in antiretroviral treatment. This study estimates total program costs and compares them with selected economic benefits of antiretroviral treatment, for the current cohort of patients whose treatment is co-financed by the Global Fund to Fight AIDS, Tuberculosis, and Malaria. At end 2011, 3.5 million patients in low- and middle-income countries will be receiving ART through treatment programs co-financed by the Global Fund. Using 2009 ART prices and program costs, Resch and colleagues estimate that the discounted resource needs required for maintaining this cohort are $14.2 billion for the period 2011–2020. This investment is expected to save 18.5 million life-years and return $12 to $34 billion through increased labour productivity, averted orphan care, and deferred medical treatment for opportunistic infections and end-of-life care. Under alternative assumptions regarding the labour productivity effects of HIV infection, AIDS disease, and ART, the monetary benefits range from 81 per cent to 287 per cent of program costs over the same period. These results suggest that, in addition to the large health gains generated, the economic benefits of treatment will substantially offset, and likely exceed, program costs within 10 years of investment.

For abstract access click here. 

Editor’s note: Social and moral arguments have been used to justify continued international and domestic funding of antiretroviral treatment programmes in low- and middle-income countries but this paper packs a wallop with its cogent analyses of the economic returns on this investment. The stream of economic benefits produced by labour productivity gains, averted orphan support costs, and end-of-life treatment costs averted not only offset antiretroviral treatment programme costs. The gross benefit of 34 billion USD equals 240% of antiretroviral treatment programme costs over a 10-year period in which 18.5 million years are saved for the 3.5 million patients currently receiving treatment through Global Fund co-financed programmes. A very pessimistic sensitivity analysis in which baseline productivity of asymptomatic patients is just half that of other working age people and increases only 40-60% with treatment still shows that 81% of treatment programme costs would be recouped. If the costs of first-line regimens fall 5% per year and second-line regimens fall 15% per year through 2015, baseline benefit-cost estimates rise from 240% to 281%. This first assessment of the magnitude of the economic returns on investment in HIV treatment does not take into account the counterfactual (without antiretroviral treatment programmes) of second-order slowing of the economy through reduced savings and investment, erosion of human capital, or lower lifetime income for children whose education is compromised by caring for a sick adult or working to replace lost parental earnings. Policy makers, domestic and international, who are concerned about health budgets or economic stability and growth, would do well to read this paper attentively.

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Cost effectiveness

Cost-effectiveness of early versus standard antiretroviral therapy in HIV-Infected adults in Haiti

Koenig SP, Bang H, Severe P, Jean Juste MA, Ambroise A, Edwards A, Hippolyte J, Fitzgerald DW, McGreevy J, Riviere C, Marcelin S, Secours R, Johnson WD, Pape JW, Schackman BR, PLoS Med. 2011 Sep;8(9):e1001095. Epub 2011 Sep 20

In a randomized clinical trial of early versus standard antiretroviral therapy (ART) in HIV-infected adults with a CD4 cell count between 200 and 350 cells/mm(3) in Haiti, early ART decreased mortality by 75%. Koenig and colleagues assessed the cost-effectiveness of early versus standard ART in this trial. Trial data included use of ART and other medications, laboratory tests, outpatient visits, radiographic studies, procedures, and hospital services. Medication, laboratory, radiograph, labour, and overhead costs were from the study clinic, and hospital and procedure costs were from local providers. The authors evaluated cost per year of life saved, including patient and caregiver costs, with a median of 21 months and maximum of 36 months of follow-up, and with costs and life expectancy discounted at 3% per annum. Between 2005 and 2008, 816 participants were enrolled and followed for a median of 21 months. Mean total costs per patient during the trial were US$1,381 for early ART and US$1,033 for standard ART. After excluding research-related laboratory tests without clinical benefit, costs were US$1,158 (early ART) and US$979 (standard ART). Early ART patients had higher mean costs for ART (US$398 versus US$81) but lower costs for non-ART medications, CD4 cell counts, clinically indicated tests, and radiographs (US$275 versus US$384). The cost-effectiveness ratio after a maximum of 3 years for early versus standard ART was US$3,975/YLS (95% CI US$2,129/YLS-US$9,979/year of life saved) including research-related tests, and US$2,050/YLS excluding research-related tests (95% CI US$722/year of life saved-US$5,537/year of life saved). Initiating ART in HIV-infected adults with a CD4 cell count between 200 and 350 cells/mm(3) in Haiti, consistent with World Health Organization advice, was cost-effective (US$/YLS <3 times gross domestic product per capita) after a maximum of 3 years, after excluding research-related laboratory tests.

For abstract access click here.

Editor’s note: The World Health Organization changed it treatment guidelines in 2010 in part because of the findings of the CIPRA HT-001 trial in Haiti. The trial’s data safety and monitoring board (DSMB) had recommended stopping the trial early due to the substantial difference in mortality seen in those starting antiretroviral therapy when their CD4 count dropped to 350/μl compared to those who started at a CD4 count of 200/μl or less, the old WHO-recommended level. This study is the first to estimate cost-effectiveness of the new approach using trial data as opposed to simulation models. To do this fairly, all research-related costs had to be removed. The time horizon was short, limited by the 3–year length of the trial, which means that it is not possible to know whether the early group would continue to have a survival benefit over the long term once the later group starts on treatment or whether there will be differences in the need for more costly second line therapy. WHO designates health interventions as cost-effective if the cost per disability-adjusted life year (DALY) is less that 3 times a country’s gross domestic product (GDP) - Haiti’s is 785 US$ - or under a threshold per life year saved – Haiti’s in 2009 was 2355 US$. This study shows that early initiation of antiretroviral therapy is cost-effective for Haiti. Decision-makers in other countries facing budget constraints should consider economic analyses as a helpful element in setting priorities. Access to treatment and support for retention in care should ensured first for the sickest patients but expansion of treatment eligibility to get more people on treatment earlier in their HIV disease course should be the next step.

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Cost effectiveness

Cost-effectiveness of using HAART in prevention of mother-to-child transmission in the DREAM-project Malawi

Orlando S, Marazzi MC, Mancinelli S, Liotta G, Ceffa S, Giglio P, Alumando E, Ziegler I, Shawa M, Palombi L, J Acquir Immune Defic Syndr. 2010 Dec 15;55(5):631-4

Cost-effectiveness analysis is crucial in the management of the HIV epidemic, particularly in resource-limited settings. Such analyses have not been performed in the use of highly active antiretroviral therapy (HAART) for prevention of mother-to-child transmission (PMTCT). Orlando and colleagues conducted a cost-effectiveness analysis of HAART approach in Malawi for PMTCT. In 2 health centres in Malawi 6500 pregnant women were tested; 1118 pregnant women completed the entire Drug Resource Enhancement against AIDS and Malnutrition-Project Malawi (DREAM - PM) PMTCT protocol. The costs of the intervention were calculated using the ingredients method. Outcomes estimated were cost for infection averted and cost for DALY saved compared with no intervention. From a private perspective cost for HIV infection averted was US $998 and cost per DALY saved was US $35.36. From a public perspective, the result became negative as follows: -261 and -16.55, respectively (lower cost than the cost of the therapy for an HIV+ child). The univariate sensitivity analysis showed that the cost for DALY saved always remained under the threshold of US $50, largely under the threshold given by the per capita yearly income in Malawi (US $667 PPD). Administration of HAART in a PMTCT programme in resource-limited settings is cost-effective. Drugs and laboratory tests are the most significant costs, but further reduction of these expenses is possible.

For abstract access click here

Editor’s note: Although several protocols for the prevention of mother-to-child transmission (PMTCT) of HIV, differing in the drugs used and the length of time they are administered, are in use around the world, the cost-effectiveness of WHO’s option B had not been assessed before this study. In the DREAM project, pregnant women living with HIV were started on antiretroviral therapy with 3TC, zidovudine, or stavudine, and nevirapine at 25 weeks of pregnancy, regardless of CD4 count, and treated for malnutrition, tuberculosis, malaria, and sexually transmitted infections. Antiretroviral therapy was continued during breastfeeding for 6 months or infant weaning, if earlier. Drug costs and laboratory costs were the most significant costs to the programme. Whether from a private perspective or a public perspective, the administration of 3-drug antiretroviral therapy to pregnant and breastfeeding women in Malawi was cost-effective. External benefits were not assessed but these are all important: training of skilled personnel, prolongation of maternal life, reduction in stigma through improved quality of life, and declines in horizontal transmission to sexual partners. All PMTCT programmes should move as soon as possible to this option, and to Option B+, which sees women remain on antiretroviral therapy once they have started, through re-profiling of domestic funds and with international assistance.

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