Incremental cost and cost-effectiveness of the addition of indoor residual spraying with pirimiphos-methyl in sub-Saharan Africa versus standard malaria control: results of data collection and analysis in the Next Generation Indoor Residual Sprays (NgenIRS) project, an economic-evaluation.

BACKGROUND: Malaria is a major cause of morbidity and mortality globally, especially in sub-Saharan Africa. Widespread resistance to pyrethroids threatens the gains achieved by vector control. To counter resistance to pyrethroids, third-generation indoor residual spraying (3GIRS) products have been developed. This study details the results of a multi-country cost and cost-effectiveness analysis of indoor residual spraying (IRS) programmes using Actellic®300CS, a 3GIRS product with pirimiphos-methyl, in sub-Saharan Africa in 2017 added to standard malaria control interventions including insecticide-treated bed nets versus standard malaria control interventions alone. METHODS: An economic evaluation of 3GIRS using Actellic®300CS in a broad range of sub-Saharan African settings was conducted using a variety of primary data collection and evidence synthesis methods. Four IRS programmes in Ghana, Mali, Uganda, and Zambia were included in the effectiveness analysis. Cost data come from six IRS programmes: one in each of the four countries where effect was measured plus Mozambique and a separate programme conducted by AngloGold Ashanti Malaria Control in Ghana. Financial and economic costs were quantified and valued. The main indicator for the cost was cost per person targeted. Country-specific case incidence rate ratios (IRRs), estimated by comparing IRS study districts to adjacent non-IRS study districts or facilities, were used to calculate cases averted in each study area. A deterministic analysis and sensitivity analysis were conducted in each of the four countries for which effectiveness evaluations were available. Probabilistic sensitivity analysis was used to generate plausibility bounds around the incremental cost-effectiveness ratio estimates for adding IRS to other standard interventions in each study setting as well as jointly utilizing data on effect and cost across all settings. RESULTS: Overall, IRRs from each country indicated that adding IRS with Actellic®300CS to the local standard intervention package was protective compared to the standard intervention package alone (IRR 0.67, [95% CI 0.50-0.91]). Results indicate that Actellic®300CS is expected to be a cost-effective (> 60% probability of being cost-effective in all settings) or highly cost-effective intervention across a range of transmission settings in sub-Saharan Africa. DISCUSSION: Variations in the incremental costs and cost-effectiveness likely result from several sources including: variation in the sprayed wall surfaces and house size relative to household population, the underlying malaria burden in the communities sprayed, the effectiveness of 3GIRS in different settings, and insecticide price. Programmes should be aware that current recommendations to rotate can mean variation and uncertainty in budgets; programmes should consider this in their insecticide-resistance management strategies. CONCLUSIONS: The optimal combination of 3GIRS delivery with other malaria control interventions will be highly context specific. 3GIRS using Actellic®300CS is expected to deliver acceptable value for money in a broad range of sub-Saharan African malaria transmission settings.

Trends and level of control of hypertension among adults attending an ambulatory HIV clinic in Kampala, Uganda: a retrospective study.

BACKGROUND: With an ageing HIV-positive population, sub-Saharan Africa is now facing a dual epidemic of communicable and non-communicable diseases (NCDs). This study aimed to assess trends in the prevalence of hypertension and factors associated with hypertension, among adults attending an ambulatory HIV clinic in Kampala, Uganda. METHODS: We conducted a retrospective chart review to identify patients with hypertension. We used a random number generator to select 400 patient charts from each year from 2009 to 2014. Blood pressure, age, body mass index (BMI), WHO disease stage and Karnofsky scores were extracted. Logistic regression was used to estimate the strength of the association between each of these factors and the presence of hypertension. RESULTS: In total, 1996 charts were included in this analysis. The mean age of participants was 31 years and 1311/1996 (65.7%) were female. The overall prevalence of hypertension was 418/1996 (20.9%). This rose from 16.9% in 2009 to 32.3% in 2013. Of the patients with hypertension, 96/418 (23.0%) were receiving adequate treatment. Patients >50 years of age had 3.12 times the odds of hypertension compared with patients aged 20-29 years (95% CI 2.00 to 4.85). Men had 1.65 times the odds of hypertension compared with women (95% CI 1.34 to 2.03) and patients with a BMI of 35-39 kg/m2 had 3.93 times the odds of hypertension compared with patients with a BMI <25 kg/m2. CONCLUSIONS: The prevalence of hypertension is rising in the Ugandan HIV-positive population. There remains inadequate management and control of hypertension in this group highlighting the need to better integrate NCD care within the HIV clinical settings.

Reducing turnaround time for laboratory test results does not improve retention of stable HIV-infected adults on POV program: experience from Uganda.

INTRODUCTION: HIV/ AIDS clinics in resource limited settings (RLS) face increasing numbers of patients and workforce shortage [1, 2]. To address these challenges, efficient models of care like pharmacy only visits (POV) and nurse only visits (NOV) are recommended [3]. The Makerere University Joint AIDS Program (MJAP), a PEPFAR funded program providing care to over 42,000 HIV infected adults has implemented the POV model since 2009. In this model, stable patients on antiretroviral therapy (ART) with adherence to ART >95% and Karnofsky score >90% are reviewed by a doctor every four months but visit pharmacy for ART re-fills every two months. A study conducted in August 2011 showed low retention on the POV program with symptomatic diseases, pending CD4 count, complete blood count results, and poor adherence to ART as the major reasons for the non-retention in the POV program. To improve retention on POV, the TAT (Turnaround Time) for laboratory results (the main reason for non-retention in the previous study) was reduced from one month to one week. In August 2012, the study was repeated to assess the effect of reducing TAT on improving retention one year after patients were placed on POV. MATERIALS AND METHODS: A cohort analysis of data from patients in August 2011 and in August 2012 on POV was done. We compared retention of POV before and after reducing the TAT for laboratory results. RESULTS: Retention on POV was 12.0% (95% CI 9.50-14.7) among 619 patients in 2011, (70% Females), mean age was 33 years, Standard Deviation (SD) 8.5 compared to 11.1% (95% CI 9.15-13.4) among 888 patients (70% Females), mean age 38.3 years, SD 8.9 in 2012 (p=0.59). The main reasons for non-retention on the POV program in 2012 were poor adherence to ART (23%) and missed clinic appointments (14%). CONCLUSIONS: Reducing TAT for laboratory test results did not improve retention of stable HIV-infected adults on POV in our clinic. Strategies for improving adherence to ART and keeping clinic appointments need to be employed to balance workload and management of patients without compromising quality of care, patients' clinical, immunological and adherence outcome.