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Data which accurately enumerate the economic costs of antimicrobial resistance (AMR) in low- and middle- income countries are essential. This study aimed to quantify the impact of third-generation cephalosporin resistant (3GC-R) bloodstream infection (BSI) on economic and health related quality of life outcomes for adult patients in Blantyre, Malawi. Participants were recruited from a prospective, longitudinal cohort study of hospitalised patients with bloodstream infection caused by Enterobacterales at Queen Elizabeth Central Hospital (QECH). Primary costing studies were used to estimate the direct medical costs associated with the inpatient stay. Recruited participants were asked about direct non-medical and indirect costs associated with their admission and their health-related quality of life was measured using the EuroQol EQ-5D questionnaire. Multiple imputation was undertaken to account for missing data. Costs were adjusted to 2019 US Dollars. Cost and microbiology surveillance data from QECH, Blantyre was used to model the annual cost of, and quality-adjusted life years lost to, 3GC-R and 3GC-Susceptible BSI from 1998 to 2030 in Malawi. The mean health provider cost per participant with 3GC-R BSI was US$110.27 (95%CR; 22.60-197.95), higher than for those with 3GC-S infection. Patients with resistant BSI incurred an additional indirect cost of US$155.48 (95%CR; -67.80, 378.78) and an additional direct non-medical cost of US$20.98 (95%CR; -36.47, 78.42). Health related quality of life outcomes were poor for all participants, but participants with resistant infections had an EQ-5D utility score that was 0.167 (95% CR: -0.035, 0.300) lower than those with sensitive infections. Population level burden estimates suggest that in 2016, 3GC-R accounted for 84% of annual societal costs from admission with bloodstream infection and 82% of QALYs lost. 3GC-R bloodstream infection was associated with higher health provider and patient level costs than 3GC-S infection, as well as poorer HRQoL outcomes. We demonstrate a substantial current and future economic burden to society as a result of 3GC-R E. coli and Klebsiella spp. BSI, data urgently needed by policy makers to provide impetus for implementing strategies to reduce AMR.
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BACKGROUND: Suboptimal tuberculosis (TB) diagnostics and HIV contribute to the high global burden of TB. We investigated costs and yield from systematic HIV-TB screening, including computer-aided digital chest X-ray (DCXR-CAD). METHODS AND FINDINGS: In this open, three-arm randomised trial, adults (≥18 years) with cough attending acute primary services in Malawi were randomised (1:1:1) to standard of care (SOC); oral HIV testing (HIV screening) and linkage to care; or HIV testing and linkage to care plus DCXR-CAD with sputum Xpert for high CAD4TBv5 scores (HIV-TB screening). Participants and study staff were not blinded to intervention allocation, but investigator blinding was maintained until final analysis. The primary outcome was time to TB treatment. Secondary outcomes included proportion with same-day TB treatment; prevalence of undiagnosed/untreated bacteriologically confirmed TB on day 56; and undiagnosed/untreated HIV. Analysis was done on an intention-to-treat basis. Cost-effectiveness analysis used a health-provider perspective. Between 15 November 2018 and 27 November 2019, 8,236 were screened for eligibility, with 473, 492, and 497 randomly allocated to SOC, HIV, and HIV-TB screening arms; 53 (11%), 52 (9%), and 47 (9%) were lost to follow-up, respectively. At 56 days, TB treatment had been started in 5 (1.1%) SOC, 8 (1.6%) HIV screening, and 15 (3.0%) HIV-TB screening participants. Median (IQR) time to TB treatment was 11 (6.5 to 38), 6 (1 to 22), and 1 (0 to 3) days (hazard ratio for HIV-TB versus SOC: 2.86, 1.04 to 7.87), with same-day treatment of 0/5 (0%) SOC, 1/8 (12.5%) HIV, and 6/15 (40.0%) HIV-TB screening arm TB patients (p = 0.03). At day 56, 2 SOC (0.5%), 4 HIV (1.0%), and 2 HIV-TB (0.5%) participants had undiagnosed microbiologically confirmed TB. HIV screening reduced the proportion with undiagnosed or untreated HIV from 10 (2.7%) in the SOC arm to 2 (0.5%) in the HIV screening arm (risk ratio [RR]: 0.18, 0.04 to 0.83), and 1 (0.2%) in the HIV-TB screening arm (RR: 0.09, 0.01 to 0.71). Incremental costs were US$3.58 and US$19.92 per participant screened for HIV and HIV-TB; the probability of cost-effectiveness at a US$1,200/quality-adjusted life year (QALY) threshold was 83.9% and 0%. Main limitations were the lower than anticipated prevalence of TB and short participant follow-up period; cost and quality of life benefits of this screening approach may accrue over a longer time horizon. CONCLUSIONS: DCXR-CAD with universal HIV screening significantly increased the timeliness and completeness of HIV and TB diagnosis. If implemented at scale, this has potential to rapidly and efficiently improve TB and HIV diagnosis and treatment. TRIAL REGISTRATION: clinicaltrials.gov NCT03519425.
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Coinfecção , Tosse/diagnóstico , Diagnóstico por Computador , Infecções por HIV/diagnóstico , Teste de HIV , Radiografia Torácica , Tuberculose/diagnóstico por imagem , Adulto , Fármacos Anti-HIV/uso terapêutico , Antituberculosos/uso terapêutico , Análise Custo-Benefício , Tosse/microbiologia , Diagnóstico por Computador/economia , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Teste de HIV/economia , Custos de Cuidados de Saúde , Acessibilidade aos Serviços de Saúde , Humanos , Malaui/epidemiologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prevalência , Atenção Primária à Saúde , Radiografia Torácica/economia , Tuberculose/tratamento farmacológico , Tuberculose/epidemiologia , Tuberculose/microbiologia , Adulto JovemRESUMO
The burden of disability among survivors and the socio-economic impact of snakebite have not been adequately researched. We reviewed original research articles, case reports and small case series relating to chronic physical, mental and psycho-social disability and economic burden of snakebite. Both physical and psychological health problems seem common in snakebite survivors and can lead to disability and loss of productivity. Chronic physical health effects, musculoskeletal disability being the commonest, can be largely attributed to limited and delayed access to optimal treatment of acute envenoming. The economic burden is considerable, and includes health system costs, out-of-pocket expenditure and opportunity costs, with regional variations. Health systems should be more responsive to needs and circumstances of bite victims, and a more holistic approach should be developed in the treatment of snakebite which incorporates the management of chronic health effects.
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Through scale-up of effective treatment and prevention, HIV incidence rates are falling across Southern and Eastern Africa. However, key population groups, including people living in fishing communities, continue to face an elevated risk of infection and have high rates of undiagnosed disease. We set out to investigate how intersecting inequalities make young fishermen working on the southern shores of Lake Malawi particularly vulnerable to HIV-infection. We used qualitative research methods including observations (over a 15-month period), in-depth interviews (59) and focus group discussions (16) with a range of male and female participants living and working in two fishing villages. We found that the roles that men occupied in the fishing industry depended on several factors, including their age, socio-economic position and the amount of experience they had in the industry. In turn these roles shaped their lives, including exposure to occupational risks, mobility, living conditions, economic remuneration and social standing within the community. In this context, younger and poorer men occupied roles with the lowest social standing in the industry. Nevertheless, in these communities where poverty was pervasive, young fishermen were able to exert the power they gained through access to money and fish over poorer younger women - pressuring them into sex and increasing the risk of HIV for both men and women. Drawing on an intersectionality framework, we contextualised these findings to consider how young men's social location, relationships and experiences of both privilege and marginalisation were shaped by broader economic and political processes. We conclude that interventions to prevent HIV in fishing communities need to address how power plays out in the broader social and economic environment.
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Infecções por HIV , África Oriental , Animais , Feminino , Grupos Focais , Infecções por HIV/epidemiologia , Humanos , Malaui/epidemiologia , Masculino , Pesquisa QualitativaRESUMO
INTRODUCTION: Patients with tuberculosis (TB) symptoms have high prevalence of HIV, and should be prioritised for HIV testing. METHODS: In a prospective cohort study in Bangwe primary care clinic, Blantyre, Malawi, all adults (18 years or older) presenting with an acute illness were screened for TB symptoms (cough, fever, night sweats, weight loss). Demographic characteristics were linked to exit interview by fingerprint bioidentification. Multivariable logistic regression models were constructed to estimate the proportion completing same-visit HIV testing, comparing between those with and without TB symptoms. RESULTS: There were 5427 adult attendees between 21/5/2018 and 6/9/2018. Exit interviews were performed for 2402 (44%). 276 patients were excluded from the analysis, being already on antiretroviral therapy (ART). Presentation with any TB symptom was common for men (54.6%) and women (57.4%). Overall 27.6% (585/ 2121) attenders reported being offered testing and 21.5% (455/2121) completed provider-initiated HIV testing and counselling (PITC) and received results. The proportions offered testing were similar among participants with and without TB symptoms (any TB symptom: 29.0% vs. 25.7%). This was consistent for each individual symptom; cough, weight loss, fever and night sweats. Multivariable regression models indicated men, younger adults and participants who had previously tested were more likely to complete PITC than women, older adults and those who had never previously tested. CONCLUSIONS: Same-visit completion of HIV testing was suboptimal, especially among groups known to have high prevalence of undiagnosed HIV. As countries approach universal coverage of ART, identifying and prioritising currently underserved groups for HIV testing will be essential.
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Infecções por HIV/diagnóstico , Tuberculose/diagnóstico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Infecções por HIV/epidemiologia , Humanos , Malaui/epidemiologia , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Atenção Primária à Saúde , Estudos Prospectivos , Tuberculose/epidemiologia , Cobertura Universal do Seguro de Saúde , Adulto JovemRESUMO
Introduction: Antimicrobial resistance is a global public health concern, but the problems are context specific, with each county or setting facing differing challenges. In Africa, third-generation cephalosporin resistant Enterobacterales (3GCR-E) are of particular concern, given the widespread reliance on ceftriaxone for treatment of severe infection in this setting. In Malawi, despite the rising prevalence of 3GCR-E, the health impact of these infections has not been described. This study is designed to estimate attributable mortality, morbidity and economic cost of 3GC-R bloodstream infection (BSI) in a large, urban hospital. Methods: This study will investigate the burden of antimicrobial resistance by recruiting a a prospective longitudinal cohort of patients who have bloodstream infection with 3GCR-E, at Queen Elizabeth Central Hospital, Blantyre, Malawi. Patients whose blood culture is positive for either 3GC-S or 3GC-R Enterobacterales will be enrolled and provide clinical and healthcare economic data. Patients will be followed throughout their hospital stay and to 6-months post discharge. Mortality, direct and indirect costs and other health outcomes will be compared between patients with 3GC-R and comparable 3GC-sensitive BSI. Based on our observation that some patients with clinical suspicion of sepsis and 3GC-R BSI are surviving without an effective antibiotic, we review each patient prospectively and classify what role the isolated bacteria is playing in the patient's clinical presentation. These classifications will then be incorporated into our analysis. Ethics and dissemination: The study protocol has been approved by the Malawi College of Medicine Research Ethics Committee and by the Liverpool School of Tropical Medicine Research Ethics committee. Written informed consent will be obtained from study participants or their parents/guardians. Results will be submitted to international peer-reviewed journals, presented at international conferences and shared with participating communities and collaborators.
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BACKGROUND: Health outcomes and causality are usually assessed with individual level sociodemographic variables. Studies that consider only individual-level variables can suffer from residual confounding. This can result in individual variables that are unrelated to risk behaving as proxies for uncaptured information. There is a scarcity of literature on risk factors for snakebite. In this study, we evaluate the individual-level risk factors of snakebite in Sri Lanka and highlight the impact of spatial confounding on determining the individual-level risk effects. METHODS: Data was obtained from the National Snakebite Survey of Sri Lanka. This was an Island-wide community-based survey. The survey sampled 165,665 individuals from all 25 districts of the country. We used generalized linear models to identify individual-level factors that contribute to an individual's risk of experiencing a snakebite event. We fitted separate models to assess risk factors with and without considering spatial variation in snakebite incidence in the country. RESULTS: Both spatially adjusted and non-adjusted models revealed that middle-aged people, males, field workers and individuals with low level of education have high risk of snakebites. The model without spatial adjustment showed an interaction between ethnicity and income levels. When the model included a spatial adjustment for the overall snakebite incidence, this interaction disappeared and income level appeared as an independent risk factor. Both models showed similar effect sizes for gender and age. HEmployment and education showed lower effect sizes in the spatially adjusted model. CONCLUSIONS: Both individual-level characteristics and local snakebite incidence are important to determine snakebite risk at a given location. Individual level variables could act as proxies for underling residual spatial variation when environmental information is not considered. This can lead to misinterpretation of risk factors and biased estimates of effect sizes. Both individual-level and environmental variables are important in assessing causality in epidemiological studies.
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Geografia , Adolescente , Adulto , Etnicidade , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Modelos Teóricos , Probabilidade , Medição de Risco , Fatores de Risco , Mordeduras de Serpentes/epidemiologia , Sri Lanka/epidemiologia , Adulto JovemRESUMO
INTRODUCTION: Cryptococcal meningitis is responsible for around 15% of all HIV-related deaths globally. Conventional treatment courses with amphotericin B require prolonged hospitalisation and are associated with multiple toxicities and poor outcomes. A phase II study has shown that a single high dose of liposomal amphotericin may be comparable to standard treatment. We propose a phase III clinical endpoint trial comparing single, high-dose liposomal amphotericin with the WHO recommended first-line treatment at six sites across five counties. An economic analysis is essential to support wide-scale implementation. METHODS AND ANALYSIS: Country-specific economic evaluation tools will be developed across the five country settings. Details of patient and household out-of-pocket expenses and any catastrophic healthcare expenditure incurred will be collected via interviews from trial patients. Health service patient costs and related household expenditure in both arms will be compared over the trial period in a probabilistic approach, using Monte Carlo bootstrapping methods. Costing information and number of life-years survived will be used as the input to a decision-analytic model to assess the cost-effectiveness of a single, high-dose liposomal amphotericin to the standard treatment. In addition, these results will be compared with a historical cohort from another clinical trial. ETHICS AND DISSEMINATION: The AMBIsome Therapy Induction OptimisatioN (AMBITION) trial has been evaluated and approved by the London School of Hygiene and Tropical Medicine, University of Botswana, Malawi National Health Sciences, University of Cape Town, Mulago Hospital and Zimbabwe Medical Research Council research ethics committees. All participants will provide written informed consent or if lacking capacity will have consent provided by a proxy. The findings of this economic analysis, part of the AMBITION trial, will be disseminated through peer-reviewed publications and at international and country-level policy meetings. TRIAL REGISTRATION: ISRCTN 7250 9687; Pre-results.
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Anfotericina B/administração & dosagem , Custos de Medicamentos , Gastos em Saúde/estatística & dados numéricos , Meningite Criptocócica/tratamento farmacológico , África Subsaariana/epidemiologia , Anfotericina B/economia , Antifúngicos/administração & dosagem , Antifúngicos/economia , Análise Custo-Benefício , Relação Dose-Resposta a Droga , Esquema de Medicação , Seguimentos , Humanos , Meningite Criptocócica/economia , Meningite Criptocócica/epidemiologia , Estudos ProspectivosRESUMO
Like the other WHO-listed Neglected Tropical Diseases (NTDs), snakebite primarily affects rural, impoverished tropical communities that lack adequate health resources. The annual 138 000 deaths and 400 000 disabilities suffered by these subsistence farming communities means that snakebite is an additional cause and consequence of tropical poverty. Unlike most of the NTDs, however, snakebite is a medical emergency, and requires rapid treatment in a hospital equipped with effective antivenom, beds and appropriately trained staff. The lack of such facilities in the remote areas most affected by snakebite, and the high treatment costs, explains why most victims, particularly in sub-Saharan Africa, consult traditional healers rather than seek hospital care. Whilst affordable, there is no evidence that traditional treatments are effective. The number of snakebite victims that die, unregistered, in the community is threefold higher than hospital-recorded deaths. After decades of inertia, WHO benefitted from advocacy interventions and the support of key agencies, including Médecins Sans Frontières, the Wellcome Trust, the Kofi Annan Foundation and the Global Snakebite Initiative, to recently institute transformative actions for reducing the public health burden of tropical snakebite. It is imperative that WHO and the other stakeholders now gain the support and investment of governments, research funders and donor agencies to ensure that this recent momentum for change is translated into sustained benefit to snakebite victims.
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Antivenenos/uso terapêutico , Doenças Negligenciadas/tratamento farmacológico , Mordeduras de Serpentes/tratamento farmacológico , Medicina Tropical/organização & administração , Animais , Antivenenos/economia , Educação em Saúde , Promoção da Saúde , Acessibilidade aos Serviços de Saúde , Humanos , Doenças Negligenciadas/economia , Doenças Negligenciadas/epidemiologia , Pobreza , População Rural , Mordeduras de Serpentes/economia , Mordeduras de Serpentes/epidemiologia , Organização Mundial da SaúdeRESUMO
In 2018, WHO issued guidelines for the diagnosis, prevention, and management of HIV-related cryptococcal disease. Two strategies are recommended to reduce the high mortality associated with HIV-related cryptococcal meningitis in low-income and middle-income countries (LMICs): optimised combination therapies for confirmed meningitis cases and cryptococcal antigen screening programmes for ambulatory people living with HIV who access care. WHO's preferred therapy for the treatment of HIV-related cryptococcal meningitis in LMICs is 1 week of amphotericin B plus flucytosine, and the alternative therapy is 2 weeks of fluconazole plus flucytosine. In the ACTA trial, 1-week (short course) amphotericin B plus flucytosine resulted in a 10-week mortality of 24% (95% CI -16 to 32) and 2 weeks of fluconazole and flucytosine resulted in a 10-week mortality of 35% (95% CI -29 to 41). However, with widely used fluconazole monotherapy, mortality because of HIV-related cryptococcal meningitis is approximately 70% in many African LMIC settings. Therefore, the potential to transform the management of HIV-related cryptococcal meningitis in resource-limited settings is substantial. Sustainable access to essential medicines, including flucytosine and amphotericin B, in LMICs is paramount and the focus of this Personal View.
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Anfotericina B/uso terapêutico , Antifúngicos/uso terapêutico , Quimioterapia Combinada/métodos , Fluconazol/uso terapêutico , Flucitosina/uso terapêutico , Infecções por HIV/mortalidade , Meningite Criptocócica/tratamento farmacológico , África/epidemiologia , Anfotericina B/agonistas , Anfotericina B/provisão & distribuição , Antifúngicos/economia , Antifúngicos/provisão & distribuição , Coinfecção , Cryptococcus neoformans/efeitos dos fármacos , Cryptococcus neoformans/patogenicidade , Países em Desenvolvimento , Gerenciamento Clínico , Esquema de Medicação , Quimioterapia Combinada/economia , Fluconazol/economia , Fluconazol/provisão & distribuição , Flucitosina/economia , Flucitosina/provisão & distribuição , Guias como Assunto , Infecções por HIV/patologia , Infecções por HIV/virologia , Humanos , Renda , Meningite Criptocócica/microbiologia , Meningite Criptocócica/mortalidade , Meningite Criptocócica/patologia , Análise de SobrevidaRESUMO
BACKGROUND: Cryptococcal meningitis (CM) is a major cause of mortality in HIV programmes in Africa despite increasing access to antiretroviral therapy (ART). Mortality is driven in part by limited availability of amphotericin-based treatment, drug-induced toxicities of amphotericin B deoxycholate and prolonged hospital admissions. A single, high-dose of liposomal amphotericin (L-AmB, Ambisome) on a fluconazole backbone has been reported as non-inferior to 14 days of standard dose L-AmB in reducing fungal burden. This trial examines whether single, high-dose L-AmB given with high-dose fluconazole and flucytosine is non-inferior to a seven-day course of amphotericin B deoxycholate plus flucytosine (the current World Health Organization [WHO] recommended treatment regimen). METHODS: An open-label phase III randomised controlled non-inferiority trial conducted in five countries in sub-Saharan Africa: Botswana, Malawi, South Africa, Uganda and Zimbabwe. The trial will compare CM induction therapy with (1) a single dose (10 mg/kg) of L-AmB given with 14 days of fluconazole (1200 mg/day) and flucytosine (100 mg/kg/day) to (2) seven days amphotericin B deoxycholate (1 mg/kg/day) given alongside seven days of flucytosine (100 mg/kg/day) followed by seven days of fluconazole (1200 mg/day). The primary endpoint is all-cause mortality at ten weeks with a non-inferiority margin of 10% and 90% power. Secondary endpoints are early fungicidal activity, proportion of grade III/IV adverse events, pharmacokinetic parameters and pharmacokinetic/pharmacodynamic associations, health service costs, all-cause mortality within the first two and four weeks, all-cause mortality within the first ten weeks (superiority analysis) and rates of CM relapse, immune reconstitution inflammatory syndrome and disability at ten weeks. A total of 850 patients aged ≥ 18 years with a first episode of HIV-associated CM will be enrolled (425 randomised to each arm). All patients will be followed for 16 weeks. All patients will receive consolidation therapy with fluconazole 800 mg/day to complete ten weeks of treatment, followed by fluconazole maintenance and ART as per local guidance. DISCUSSION: A safe, sustainable and easy to administer regimen of L-AmB that is non-inferior to seven days of daily amphotericin B deoxycholate therapy may reduce the number of adverse events seen in patients treated with amphotericin B deoxycholate and shorten hospital admissions, providing a highly favourable and implementable alternative to the current WHO recommended first-line treatment. TRIAL REGISTRATION: ISRCTN, ISRCTN72509687 . Registered on 13 July 2017.
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Anfotericina B/administração & dosagem , Antifúngicos/administração & dosagem , Cryptococcus neoformans/efeitos dos fármacos , Meningite Criptocócica/tratamento farmacológico , África Subsaariana , Anfotericina B/efeitos adversos , Anfotericina B/economia , Anfotericina B/farmacocinética , Antifúngicos/efeitos adversos , Antifúngicos/economia , Antifúngicos/farmacocinética , Ensaios Clínicos Fase III como Assunto , Análise Custo-Benefício , Cryptococcus neoformans/patogenicidade , Esquema de Medicação , Custos de Medicamentos , Quimioterapia Combinada , Estudos de Equivalência como Asunto , Fluconazol/administração & dosagem , Flucitosina/administração & dosagem , Humanos , Quimioterapia de Indução , Meningite Criptocócica/economia , Meningite Criptocócica/microbiologia , Meningite Criptocócica/mortalidade , Estudos Multicêntricos como Assunto , Fatores de Tempo , Resultado do TratamentoRESUMO
INTRODUCTION: Although HIV infection and its associated co-morbidities remain the commonest reason for hospitalisation in Africa, their impact on economic costs and health-related quality of life (HRQoL) are not well understood. This information is essential for decision-makers to make informed choices about how to best scale-up anti-retroviral treatment (ART) programmes. This study aimed to quantify the impact of HIV infection and ART on economic outcomes in a prospective cohort of hospitalised patients with high HIV prevalence. METHODS: Sequential medical admissions to Queen Elizabeth Central Hospital, Malawi, between June-December 2014 were followed until discharge, with standardised classification of medical diagnosis and estimation of healthcare resources used. Primary costing studies estimated total health provider cost by medical diagnosis. Participants were interviewed to establish direct non-medical and indirect costs. Costs were adjusted to 2014 US$ and INT$. HRQoL was measured using the EuroQol EQ-5D. Multivariable analyses estimated predictors of economic outcomes. RESULTS: Of 892 eligible participants, 80.4% (647/892) were recruited and medical notes found. In total, 447/647 (69.1%) participants were HIV-positive, 339/447 (75.8%) were on ART prior to admission, and 134/647 (20.7%) died in hospital. Mean duration of admission for HIV-positive participants not on ART and HIV-positive participants on ART was 15.0 days (95%CI: 12.0-18.0) and 12.2 days (95%CI: 10.8-13.7) respectively, compared to 10.8 days (95%CI: 8.8-12.8) for HIV-negative participants. Mean total provider cost per hospital admission was US$74.78 (bootstrap 95%CI: US$25.41-US$124.15) higher for HIV-positive than HIV-negative participants. Amongst HIV-positive participants, the mean total provider cost was US$106.87 (bootstrap 95%CI: US$25.09-US$106.87) lower for those on ART than for those not on ART. The mean total direct non-medical and indirect cost per hospital admission was US$87.84. EQ-5D utility scores were lower amongst HIV-positive participants, but not significantly different between those on and not on ART. CONCLUSIONS: HIV-related hospital care poses substantial financial burdens on health systems and patients; however, per-admission costs are substantially lower for those already initiated onto ART prior to admission. These potential cost savings could offset some of the additional resources needed to provide universal access to ART.
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Antirretrovirais , Infecções por HIV , Hospitalização , Qualidade de Vida , Adolescente , Adulto , Antirretrovirais/administração & dosagem , Antirretrovirais/economia , Custos e Análise de Custo , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/economia , Infecções por HIV/epidemiologia , Humanos , Malaui/epidemiologia , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos ProspectivosRESUMO
Background: Human immunodeficiency virus self-testing (HIVST) is effective, with scale-up underway in sub-Saharan Africa. We assessed cost-effectiveness of adding HIVST to existing facility-based HIV testing and counseling (HTC) services. Both 2010 (initiate at CD4 <350 cells/µL) and 2015 (initiate all) World Health Organization (WHO) guidelines for antiretroviral treatment (ART) were considered. Methods: A microsimulation model was developed to evaluate cost-effectiveness, from both health provider and societal perspectives, of an HIVST service implemented in a cluster-randomized trial (CRT; ISRCTN02004005) in Malawi. Costs and health outcomes were evaluated over a 20-year time horizon, using a discount rate of 3%. Probabilistic sensitivity analysis was conducted to account for parameter uncertainty. Results: From the health provider perspective and 20-year time horizon, facility HTC using 2010 WHO ART guidelines was the least costly ($294.71 per person; 95% credible interval [CrI], 270.79-318.45) and least effective (11.64 quality-adjusted life-years [QALYs] per person; 95% CrI, 11.43-11.86) strategy. Compared with this strategy, the incremental cost-effectiveness ratio (ICER) for facility HTC using 2015 WHO ART guidelines was $226.85 (95% CrI, 198.79-284.35) per QALY gained. The strategy of facility HTC plus HIVST, using 2010 WHO ART guidelines, was extendedly dominated. The ICER for facility HTC plus HIVST, using 2015 WHO ART guidelines, was $253.90 (95% CrI, 201.71-342.02) per QALY gained compared with facility HTC and using 2015 WHO ART guidelines. Conclusions: HIVST may be cost-effective in a Malawian population with high HIV prevalence. HIVST is suited to an early HIV diagnosis and treatment strategy. Clinical Trials registration: ISRCTN02004005.
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Antirretrovirais/uso terapêutico , Infecções por HIV/diagnóstico , HIV/isolamento & purificação , Adolescente , Adulto , Análise Custo-Benefício , Aconselhamento , Feminino , HIV/efeitos dos fármacos , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Infecções por HIV/virologia , Humanos , Malaui/epidemiologia , Masculino , Programas de Rastreamento/economia , Pessoa de Meia-Idade , Prevalência , Avaliação de Programas e Projetos de Saúde , Anos de Vida Ajustados por Qualidade de Vida , Autocuidado , Adulto JovemRESUMO
BACKGROUND: Individuals with HIV have a high prevalence of physical and psychological symptoms throughout their disease course. Despite the clinical and public health implications of unresolved pain and symptoms, little is known about the effect of anti-retroviral therapy (ART) on these outcomes. This study aimed to assess the impact on symptom burden for the year after ART initiation in individuals with a CD4 count <200 cells/uL in Uganda. METHODS: HIV-infected, ART-naive adults referred from voluntary testing and counseling services in rural Uganda for enrollment into a randomized controlled trial to test fluconazole as primary prophylaxis against cryptococcal disease were invited to complete the Memorial Symptom Assessment Scale-Short Form (MSAS-SF) prior to commencing ART and at two subsequent follow up visits. This tool measures self-reported 7-day period prevalence and associated burden of physical and psychological symptoms. Changes in the total number of symptoms and distress indices with time on ART and trial arm were investigated through fitting Linear Mixed Models for repeated measures. RESULTS: During the first year of ART initiation the prevalence of most individual symptoms remained constant. The notable exceptions which improved after commencing ART are as follow; prevalence of pain (prevalence changed from 79% to 60%), weight loss (67% to 31%), lack of appetite (46% to 28%), feeling sad (52% to 25%) and difficulty sleeping (35% to 23%). The total number of symptoms and distress indices reduced after treatment commenced. Of concern was that half or more study participants remained with symptoms of pain (60%), itching (57%), skin changes (53%) and numbness in hands and feet (52%) after starting ART. Sixteen symptoms remained with a burden of 25% or more. CONCLUSION: Despite the beneficial effect of ART on reducing symptoms, some patients continue to experience a high symptom burden. It is essential that HIV services in sub-Saharan Africa integrate management of symptoms into their programmes. TRIAL REGISTRATION: CRYPTOPRO [ISRCTN 76481529 ], November 2004.
Assuntos
Antirretrovirais/farmacologia , Contagem de Linfócito CD4 , Infecções por HIV/tratamento farmacológico , Adulto , Antirretrovirais/uso terapêutico , Linfócitos T CD4-Positivos/metabolismo , Estudos de Coortes , Efeitos Psicossociais da Doença , Feminino , Infecções por HIV/psicologia , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Prevalência , População Rural/tendências , Autorrelato , UgandaRESUMO
BACKGROUND: Snakebite is a major problem affecting the rural poor in many of the poorest countries in the tropics. However, the scale of the socio-economic burden has rarely been studied. We undertook a comprehensive assessment of the burden in Sri Lanka. METHODS: Data from a representative nation-wide community based household survey were used to estimate the number of bites and deaths nationally, and household and out of pocket costs were derived from household questionnaires. Health system costs were obtained from hospital cost accounting systems and estimates of antivenom usage. DALYs lost to snakebite were estimated using standard approaches using disability weights for poisoning. FINDINGS: 79% of victims suffered economic loss following a snakebite with a median out of pocket expenditure of $11.82 (IQR 2-28.57) and a median estimated loss of income of $28.57 and $33.21 for those in employment or self-employment, respectively. Family members also lost income to help care for patients. Estimated health system costs for Sri Lanka were $ 10,260,652 annually. The annual estimated total number of DALYS was 11,101 to 15,076 per year for envenoming following snakebite. INTERPRETATION: Snakebite places a considerable economic burden on the households of victims in Sri Lanka, despite a health system which is accessible and free at the point of care. The disability burden is also considerable, similar to that of meningitis or dengue, although the relatively low case fatality rate and limited physical sequelae following bites by Sri Lankan snakes means that this burden may be less than in countries on the African continent.
Assuntos
Custos de Cuidados de Saúde , Mordeduras de Serpentes/economia , Mordeduras de Serpentes/terapia , Animais , Antivenenos/economia , Antivenenos/uso terapêutico , Humanos , Renda , Mordeduras de Serpentes/epidemiologia , Sri Lanka/epidemiologiaRESUMO
BACKGROUND: The scale-up of HIV self-testing (HIVST) in Africa is recommended, but little is known about how this novel approach influences economic outcomes following subsequent antiretroviral treatment (ART) compared with established facility-based HIV testing and counseling (HTC) approaches. SETTING: HIV clinics in Blantyre, Malawi. METHODS: Consecutive HIV-positive participants, diagnosed by HIVST or facility-based HTC as part of a community cluster-randomized trial (ISRCTN02004005), were followed from initial assessment for ART until 1-year postinitiation. Healthcare resource use was prospectively measured, and primary costing studies undertaken to estimate total health provider costs. Participants were interviewed to establish direct nonmedical and indirect costs over the first year of ART. Costs were adjusted to 2014 US$ and INT$. Health-related quality of life was measured using the EuroQol EQ-5D at each clinic visit. Multivariable analyses estimated predictors of economic outcomes. RESULTS: Of 325 participants attending HIV clinics for assessment for ART, 265 were identified through facility-based HTC, and 60 through HIVST; 168/265 (69.2%) and 36/60 (60.0%), respectively, met national ART eligibility criteria and initiated treatment. The mean total health provider assessment costs for ART initiation were US$22.79 (SE: 0.56) and US$19.92 (SE: 0.77) for facility-based HTC and HIVST participants, respectively, and was US$2.87 (bootstrap 95% CI: US$1.01 to US$4.73) lower for the HIVST group. The mean total health provider costs for the first year of ART were US$168.65 (SE: 2.02) and US$164.66 (SE: 4.21) for facility-based HTC and HIVST participants, respectively, and comparable between the 2 groups (bootstrap 95% CI: -US$12.38 to US$4.39). EQ-5D utility scores immediately before and one year after ART initiation were comparable between the 2 groups. EQ-5D utility scores 1 year after ART initiation had increased by 0.129 (SE: 0.011) and 0.139 (SE: 0.027) for facility-based HTC and HIVST participants, respectively. CONCLUSIONS: Once HIV self-testers are linked into HIV services, their economic outcomes are comparable to those linking to services after facility-based HTC.
Assuntos
Aconselhamento/economia , Infecções por HIV/diagnóstico , Instalações de Saúde/economia , Programas de Rastreamento/economia , Qualidade de Vida/psicologia , Adolescente , Adulto , Análise por Conglomerados , Aconselhamento/estatística & dados numéricos , Autoavaliação Diagnóstica , Feminino , Infecções por HIV/economia , Infecções por HIV/psicologia , Custos de Cuidados de Saúde , Instalações de Saúde/estatística & dados numéricos , Humanos , Malaui/epidemiologia , Masculino , Programas de Rastreamento/métodos , Adesão à Medicação , Estudos Prospectivos , Adulto JovemRESUMO
BACKGROUND: HIV self-testing (HIVST) has been found to be highly effective, but no cost analysis has been undertaken to guide the design of affordable and scalable implementation strategies. METHODS: Consecutive HIV self-testers and facility-based testers were recruited from participants in a community cluster-randomised trial ( ISRCTN02004005 ) investigating the impact of offering HIVST in addition to facility-based HIV testing and counselling (HTC). Primary costing studies were undertaken of the HIVST service and of health facilities providing HTC to the trial population. Costs were adjusted to 2014 US$ and INT$. Recruited participants were asked about direct non-medical and indirect costs associated with accessing either modality of HIV testing, and additionally their health-related quality of life was measured using the EuroQol EQ-5D. RESULTS: A total of 1,241 participants underwent either HIVST (n = 775) or facility-based HTC (n = 446). The mean societal cost per participant tested through HIVST (US$9.23; 95 % CI: US$9.14-US$9.32) was lower than through facility-based HTC (US$11.84; 95 % CI: US$10.81-12.86). Although the mean health provider cost per participant tested through HIVST (US$8.78) was comparable to facility-based HTC (range: US$7.53-US$10.57), the associated mean direct non-medical and indirect cost was lower (US$2.93; 95 % CI: US$1.90-US$3.96). The mean health provider cost per HIV positive participant identified through HIVST was higher (US$97.50) than for health facilities (range: US$25.18-US$76.14), as was the mean cost per HIV positive individual assessed for anti-retroviral treatment (ART) eligibility and the mean cost per HIV positive individual initiated onto ART. In comparison to the facility-testing group, the adjusted mean EQ-5D utility score was 0.046 (95 % CI: 0.022-0.070) higher in the HIVST group. CONCLUSIONS: HIVST reduces the economic burden on clients, but is a costlier strategy for the health provider aiming to identify HIV positive individuals for treatment. The provider cost of HIVST could be substantially lower under less restrictive distribution models, or if costs of oral fluid HIV test kits become comparable to finger-prick kits used in health facilities.
Assuntos
Aconselhamento/economia , Autoavaliação Diagnóstica , Infecções por HIV/diagnóstico , Infecções por HIV/economia , Custos de Cuidados de Saúde , Instalações de Saúde/economia , Qualidade de Vida , Adolescente , Adulto , Aconselhamento/estatística & dados numéricos , Feminino , Infecções por HIV/epidemiologia , Infecções por HIV/terapia , Soropositividade para HIV/diagnóstico , Soropositividade para HIV/economia , Soropositividade para HIV/epidemiologia , Soropositividade para HIV/terapia , HIV-1/imunologia , Custos de Cuidados de Saúde/estatística & dados numéricos , Instalações de Saúde/estatística & dados numéricos , Humanos , Malaui/epidemiologia , Masculino , Programas de Rastreamento/economia , Programas de Rastreamento/métodos , Pessoa de Meia-Idade , Testes Sorológicos/economia , Testes Sorológicos/estatística & dados numéricos , Padrão de Cuidado/economia , Padrão de Cuidado/estatística & dados numéricos , Adulto JovemAssuntos
Pesquisa Biomédica/organização & administração , Fortalecimento Institucional/organização & administração , Pesquisadores/organização & administração , África Subsaariana , Pesquisa Biomédica/economia , Fortalecimento Institucional/economia , Apoio Financeiro , Saúde Global , Humanos , Pesquisadores/economiaRESUMO
BACKGROUND: The evidence on determinants of individuals' choices for anti-malarial drug treatments is scarce. This study sought to measure the strength of preference for adult antimalarial drug treatment attributes of heads of urban, rural and peri-urban households in a resource-limited malaria-endemic area of sub-Saharan Africa. METHODS: Discrete choice experiments were conducted with 508 heads of household interviewed face-to-face for a household population survey of health-seeking behavior in Zomba District, Malawi. The interviews were held in Chichewa and the choice experiment questions were presented with cartoon aids. The anti-malarial drug attributes included in the stated preference experiment were: speed of fever resolution, side effects (pruritus) risk, protection (duration of prophylactic effect), price, duration of treatment course and recommendation by a health professional. Sixteen treatment profiles from a fractional factorial design by orthogonal array were paired into choice scenarios, and scenarios were randomly assigned to participants so that each participant was presented with a series of eight pairwise choice scenarios. Respondents had the option to state indifference between the two profiles or decline to choose. Data were analysed in a mixed logit model, with normally distributed coefficients for all six attributes. RESULTS: The sex ratio was balanced in urban areas, whereas 63% of participants in rural areas were male. The proportion of individuals with no education was considerably higher in the rural group (25%) than in the urban (5%) and peri-urban (6%) groups. All attributes investigated had the expected influence, and traded-off in most respondents' choices. There were heterogeneous effects of price, pruritus risk, treatment recommendation by a professional, and duration of prophylaxis across respondents, only partly explained by their differences in education, household per capita expenditure, sex and age. Individuals' demand elasticity (simulated median, inter-quartile range) was highest (most responsive) to speed of symptom resolution (0.88, 0.80-0.89) and pruritus risk (0.25, 0.08-0.62). CONCLUSIONS: Most adult antimalarial users are willing to use treatments without recommendation from health professional, and may be influenced by price. Future studies should investigate the magnitude of differences in price and treatment attribute sensitivity between adult anti-malarial drug users in rural, peri-urban and urban areas in order to determine optimal price subsidies.
Assuntos
Antimaláricos/uso terapêutico , Doenças Endêmicas , Malária/tratamento farmacológico , Preferência do Paciente , Adulto , Antimaláricos/efeitos adversos , Antimaláricos/economia , Países em Desenvolvimento , Feminino , Grupos Focais , Inquéritos Epidemiológicos , Humanos , Malária/epidemiologia , Malaui , Masculino , Modelos Teóricos , Motivação , Aceitação pelo Paciente de Cuidados de Saúde , Honorários por Prescrição de Medicamentos , Prurido/induzido quimicamente , População Rural , Estudos de Amostragem , População Suburbana , Inquéritos e Questionários , Fatores de Tempo , População UrbanaRESUMO
The accuracy of a novel community health worker antiretroviral therapy eligibility assessment tool was examined in community members in Blantyre, Malawi. Nurses independently performed World Health Organization (WHO) staging and CD4 counts. One hundred ten (55.6%) of 198 HIV-positive participants had a CD4 count of <350 cells per cubic millimeter. The community health worker tool significantly outperformed WHO clinical staging in identifying CD4 count of <350 cells per cubic millimeter in terms of sensitivity (41% vs. 19%), positive predictive value (75% vs. 68%), negative predictive values (53% vs. 47%), and area under the receiver-operator curve (0.62 vs. 0.54; P = 0.017). Reliance on WHO staging is likely to result in missed and delayed antiretroviral therapy initiation.