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Importance: Bacterial vaginosis (BV) is a well-known risk factor for preterm birth. Molecular diagnosis of BV is now available. Its impact in the screening and treatment of BV during pregnancy on preterm births has not been evaluated to date. Objective: To evaluate the clinical and economic effects of point-of-care quantitative real-time polymerase chain reaction screen and treat for BV in low-risk pregnant women on preterm birth. Design, Setting, and Participants: The AuTop trial was a prospective, multicenter, parallel, individually randomized, open-label, superiority trial conducted in 19 French perinatal centers between March 9, 2015, and December 18, 2017. Low-risk pregnant women before 20 weeks' gestation without previous preterm births or late miscarriages were enrolled. Data were analyzed from October 2021 to November 2022. Interventions: Participants were randomized 1:1 to BV screen and treat using self-collected vaginal swabs (n = 3333) or usual care (n = 3338). BV was defined as Atopobium vaginae (Fannyhessea vaginae) load of 108 copies/mL or greater and/or Gardnerella vaginalis load of 109 copies/mL or greater, using point-of-care quantitative real-time polymerase chain reaction assays. The control group received usual care with no screening of BV. Main Outcomes and Measures: Overall rate of preterm birth before 37 weeks' gestation and total costs were calculated in both groups. Secondary outcomes were related to treatment success as well as maternal and neonate health. Post hoc subgroup analyses were conducted. Results: Among 6671 randomized women (mean [SD] age, 30.6 [5.0] years; mean [SD] gestational age, 15.5 [2.8] weeks), the intention-to-treat analysis of the primary clinical and economic outcomes showed no evidence of a reduction in the rate of preterm birth and total costs with the screen and treat strategy compared with usual care. The rate of preterm birth was 3.8% (127 of 3333) in the screen and treat group and 4.6% (153 of 3338) in the control group (risk ratio [RR], 0.83; 95% CI, 0.66-1.05; P = .12). On average, the cost of the intervention was 203.6 (US $218.0) per participant, and the total average cost was 3344.3 (US $3580.5) in the screen and treat group vs 3272.9 (US $3504.1) in the control group, with no significant differences being observed. In the subgroup of nulliparous women (n = 3438), screen and treat was significantly more effective than usual care (RR, 0.62; 95% CI, 0.45-0.84; P for interaction = .003), whereas no statistical difference was found in multiparous (RR, 1.30; 95% CI, 0.90-1.87). Conclusion and Relevance: In this clinical trial of pregnant women at low risk of preterm birth, molecular screening and treatment for BV based on A vaginae (F vaginae) and/or G vaginalis quantification did not significantly reduce preterm birth rates. Post hoc analysis suggests a benefit of screen and treat in low-risk nulliparous women, warranting further evaluation in this group. Trial Registration: ClinicalTrials.gov Identifier: NCT02288832.
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Nascimento Prematuro , Vaginose Bacteriana , Gravidez , Feminino , Recém-Nascido , Humanos , Adulto , Adolescente , Nascimento Prematuro/prevenção & controle , Vaginose Bacteriana/diagnóstico , Vaginose Bacteriana/tratamento farmacológico , Estudos Prospectivos , Idade Gestacional , Resultado do TratamentoRESUMO
While social inequality is widely recognised as being a risk factor for COVID-19 infection or serious forms of the disease, many questions still remain concerning the perception of hazard and protective measures by the most vulnerable populations. This mixed-methods study aimed (1) to describe the self-perceived health and protective measures linked to COVID-19 of homeless people in one of the largest and poorest cities in France, and (2) to assess which skills and resources they used to address the COVID-19 pandemic. The quantitative survey addressed these questions among a sample of 995 homeless people living either on the streets, in homeless shelters or in squats/slums, whereas the qualitative survey was constructed from 14 homeless interviewees. Both data collections were carried out between June and July 2020. Results showed that COVID-19 infection was clearly perceived by homeless people as a risk, but the experience of being homeless placed this risk among several others. Different practices of protection were observed according to the type of living place. Lockdown of the general population severely impacted the survival systems of the populations furthest from housing, with alarming rates of people without access to water or food. 77% of homeless participants reported that they encountered significant financial difficulties. All interviewees were particularly attentive to their health, with awareness and even a familiarity with the risks of infectious diseases long before the pandemic. Using a capability framework, our study showed a predominant lack of external health-related resources for homeless people, while internal health-related resources were more developed than expected. None of the places and lifestyles studied was favourable to health: collective shelters due to a greater restriction of people's choices, slums and street life due to a greater lack of basic resources.
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BACKGROUND: There is no quality evidence of the benefit of defunctioning ileostomy (DI) in ileal pouch-anal anastomoses (IPAAs) performed for inflammatory bowel disease (IBD), but most surgical teams currently resort to DI. In the case of a staged procedure with subtotal colectomy first, completion proctectomy with IPAA is performed for healthy patients, namely, after nutritional support, inflammation reduction and immunosuppressive agent weaning. Therefore, the aim of this trial is to assess the need for systematic DI after completion proctectomy and IPAA for IBD. METHODS/DESIGN: This is a multicenter randomized open trial comparing completion proctectomy and IPAA without (experimental) or with (control) DI in patients presenting with ulcerative colitis or indeterminate colitis. Crohn's disease patients will not be included. The design is a superiority trial. The main objective is to compare the 6-month global postoperative morbidity, encompassing both surgical and medical complications, between the two groups. The morbidity of DI closure will be included, as appropriate. The sample size calculation is based on the hypothesis that the overall 6-month morbidity rate is 30% in the case of no stoma creation (i.e., experimental group) vs. 55% otherwise (control group). With the alpha risk and power are fixed to 0.05 and 0.80, respectively, and considering a dropout rate of 10%, the objective is set to 194 patients. The secondary objectives are to compare both strategies in terms of morbi-mortality at 6 months and functional results as well as quality of life at 12 months, namely, the 6-month major morbidity and unplanned reoperation rates, 6-month anastomotic leakage rate, 6-month mortality, length of hospital stay, 6-month unplanned readmission rate, quality of life assessed 3 and 12 months from continuity restoration (i.e., either IPAA or stoma closure), functional results assessed 3 and 12 months from continuity restoration, 12-month pouch results, 12-month cost-utility analysis, and 12-month global morbidity. DISCUSSION: The IDEAL trial is a nationwide multicenter study that will help choose the optimal strategy between DI and no ileostomy in completion proctectomy with IPAA for IBD. TRIAL REGISTRATION: ClinicalTrial.gov: NCT03872271, date of registration March 13th, 2019.
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Colite Ulcerativa/cirurgia , Colite/cirurgia , Ileostomia/métodos , Proctocolectomia Restauradora/métodos , Reto/cirurgia , Adulto , Fístula Anastomótica , Análise Custo-Benefício , Feminino , Humanos , Ileostomia/efeitos adversos , Ileostomia/economia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Proctocolectomia Restauradora/efeitos adversos , Proctocolectomia Restauradora/economia , Qualidade de Vida , Reoperação , Resultado do TratamentoRESUMO
OBJECTIVES: To examine the lifetime, 5-year and past-year prevalence of homelessness among European citizens in eight European nations. DESIGN: A nationally representative telephone survey using trained bilingual interviewers and computer-assisted telephone interview software. SETTING: The study was conducted in France, Ireland, Italy, the Netherlands, Poland, Portugal, Spain and Sweden. PARTICIPANTS: European adult citizens, selected from opt-in panels from March to December 2017. Total desired sample size was 5600, with 700 per country. Expected response rates of approximately 30% led to initial sample sizes of 2500 per country. MAIN OUTCOME MEASURES: History of homelessness was assessed for lifetime, past 5 years and past year. Sociodemographic data were collected to assess correlates of homelessness prevalence using generalised linear models for clustered and weighted samples. RESULTS: Response rates ranged from 30.4% to 33.5% (n=5631). Homelessness prevalence was 4.96% for lifetime (95% CI 4.39% to 5.59%), 1.92% in the past 5 years (95% CI 1.57% to 2.33%) and 0.71% for the past year (95% CI 0.51% to 0.98%) and varied significantly between countries (pairwise comparison difference test, p<0.0001). Time spent homeless ranged between less than a week (21%) and more than a year (18%), with high contrasts between countries (p<0.0001). Male gender, age 45-54, lower secondary education, single status, unemployment and an urban environment were all independently strongly associated with lifetime homelessness (all OR >1.5). CONCLUSIONS: The prevalence of homelessness among the surveyed nations is significantly higher than might be expected from point-in-time and homeless service use statistics. There was substantial variation in estimated prevalence across the eight nations. Coupled with the well-established health impacts of homelessness, medical professionals need to be aware of the increased health risks of those with experience of homelessness. These findings support policies aiming to improve health services for people exposed to homelessness.
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Pessoas Mal Alojadas/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Europa (Continente)/epidemiologia , Feminino , Humanos , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Prevalência , Fatores de Risco , Fatores Socioeconômicos , Inquéritos e Questionários , Fatores de Tempo , Adulto JovemRESUMO
BACKGROUND: Social isolation potentiates the risk of death by cancer in the older cancer patient population. The PREDOMOS study investigates the impact of establishing a Program of Social intervention associated with techniques of Domotic and Remote assistance on the improvement of quality of life of older isolated patients, treated for locally advanced or metastatic cancer. This paper updates the pilot trial protocol. METHODS/DESIGN: The original protocol was published in Trials, accessible at https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-017-1894-7 . This update reports on the eligibility criteria expansion and on the adjunction of a cost-utility analysis. We widened the eligible population to patients with locally advanced or metastatic cancer including malignant hemopathies (except acute myeloid leukemia) and to patients in the first and second lines of oncologic treatment. We restricted the inclusion to patients with a Mini Mental State Examination score strictly over 24. In addition to the secondary outcomes outlined in the protocol, a medico-economic analysis has been added to evaluate both the health benefits and costs of the two strategies and calculate the incremental cost-utility ratio of the innovative program assessed, compared to the standard practice. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02829762 . Registered on 29 June 2016.
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Envelhecimento/psicologia , Serviços de Assistência Domiciliar , Neoplasias/terapia , Isolamento Social , Fatores Etários , Idoso , Análise Custo-Benefício , Feminino , França , Avaliação Geriátrica , Custos de Cuidados de Saúde , Serviços de Assistência Domiciliar/economia , Visita Domiciliar , Humanos , Masculino , Saúde Mental , Testes de Estado Mental e Demência , Neoplasias/economia , Neoplasias/mortalidade , Neoplasias/psicologia , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Tecnologia de Sensoriamento Remoto , Assistentes Sociais , Telefone , Fatores de Tempo , Resultado do TratamentoRESUMO
ALK rearrangement and EGFR/KRAS mutations constitute the primary biomarkers tested to provide targeted or nontargeted therapies in advanced nonsmall cell lung cancer (NSCLC) patients. Our objective was to assess the cost-effectiveness of biomarker testing for NSCLC.Between 2013 and 2014, 843 treatment-naive patients were prospectively recruited at 19 French hospitals into a longitudinal observational cohort study. Two testing strategies were compared, i.e. with "at least one biomarker status known" and "at least KRAS status known", in addition to "no biomarker testing" as the reference strategy. The Kaplan-Meier approach was employed to assess restricted mean survival time. Direct medical costs incurred by hospitals were estimated with regard to treatment, inpatient care and biomarker testing.Compared with "no biomarker testing", the "at least one biomarker status known" strategy yielded an incremental cost-effectiveness ratio of EUR13â230 per life-year saved, which decreased to EUR7444 per life-year saved with the "at least KRAS status known" testing strategy. In sensitivity analyses, biomarker testing strategies were less costly and more effective in 41% of iterations.In summary, molecular testing prior to treatment initiation proves to be cost-effective in advanced NSCLC management and may assist decision makers in defining conditions for further implementation of these innovations in general practice.
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Carcinoma Pulmonar de Células não Pequenas/economia , Carcinoma Pulmonar de Células não Pequenas/genética , Análise Mutacional de DNA/economia , Testes Genéticos/economia , Neoplasias Pulmonares/economia , Neoplasias Pulmonares/genética , Adulto , Idoso , Idoso de 80 Anos ou mais , Quinase do Linfoma Anaplásico/genética , Biomarcadores , Análise Custo-Benefício , Tomada de Decisões , Receptores ErbB/genética , Feminino , França , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Mutação , Proteínas Proto-Oncogênicas p21(ras)/genética , Pneumologia/economia , Pneumologia/métodosRESUMO
BACKGROUND: Delayed gastric emptying (DGE) is the most frequent pancreatic specific complication (PSC) after pancreaticoduodenectomy (PD). Several gastric decompression systems exist to manage DGE. Patients with a pancreatic tumor require prolonged nutrition; however, controversies exist concerning nutrition protocol after PD. The aim of the study was to assess the safety and efficacy of nasogastric (NG), gastrostomy (GT), and gastrojejunostomy (GJ) tubes with different feeding systems on postoperative courses. METHODS: Between January 2013 and March 2016, 86 patients underwent PD with pancreaticogastrostomy. Patients were divided into three groups: GJ group with enteral nutrition (EN, n = 12, 14%), NG (n = 31, 36%) and GT groups (n = 43, 50%), both with total parenteral nutrition (TPN). RESULTS: Patients in the GJ (n = 9, 75%) and GT (n = 18, 42%) groups had an American Society of Anesthesiologists (ASA) score of 3 more often than those in the NG group (n = 5, 16%, p ≤ 0.01). Multivariate analysis identified the GT tube with TPN as an independent risk factor of severe morbidity (p = 0.02) and DGE (p < 0.01). An ASA score of 3, jaundice, common pancreatic duct size ≤3 mm and soft pancreatic gland texture (p < 0.05) were found as independent risk factors of PSCs. Use of a GJ tube with EN, GT tube with TPN, jaundice, and PSCs were identified as independent risk factors for greater postoperative length of hospital stay (p < 0.01). Mean global hospitalization cost did not differ between groups. CONCLUSION: GT tube insertion with TPN was associated with increased severe postoperative morbidity and DGE and should not be recommended. EN through a GJ tube after PD is feasible but does not have clear advantages on postoperative courses compared to an NG tube.
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Apoio Nutricional/métodos , Neoplasias Pancreáticas/epidemiologia , Neoplasias Pancreáticas/terapia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Nutrição Enteral/economia , Feminino , Seguimentos , Derivação Gástrica , Gastrostomia , Humanos , Intubação Gastrointestinal , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Morbidade , Neoplasias Pancreáticas/economia , Pancreaticoduodenectomia , Nutrição Parenteral Total/economia , Complicações Pós-Operatórias/economia , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: International recommendations in favor of screening for vaginal infection in pregnancy are based on heterogeneous criteria. In most developed countries, the diagnosis of bacterial vaginosis is only recommended for women with high-risk of preterm birth. The Nugent score is currently used, but molecular quantification tools have recently been reported with a high sensitivity and specificity. Their value for reducing preterm birth rates and related complications remains unexplored. This trial was designed to assess the cost-effectiveness of a systematic screen-and-treat program based on a point-of-care technique for rapid molecular diagnosis, immediately followed by an appropriate antibiotic treatment, to detect the presence of abnormal vaginal flora (specifically, Atopobium vaginae and Gardnerella vaginalis) before 20 weeks of gestation in pregnant women in France. We hypothesized that this program would translate into significant reductions in both the rate of preterm births and the medical costs associated with preterm birth. METHODS/DESIGN: A multicenter, open-label randomized controlled trial (RCT) will be conducted in which 20 French obstetrics and gynecology centers will recruit eligible pregnant women at less than 20 weeks gestation with singleton pregnancy and with a low-risk factor for preterm birth. Interventions will include a) an experimental group that will receive a systematic rapid screen-and-treat program from a point-of-care analysis using a molecular quantification method and b) a control group that will receive usual care management. Randomization will be in a 1:1 allocation ratio. The primary endpoint that will be assessed over a period of 12 months will be the incremental cost-effectiveness ratio (ICER) expressed as cost per avoided preterm birth before 37 weeks. Secondary endpoints will include ICER per avoided preterm birth before 24, 28 and 32 weeks, obstetrical outcomes, neonatal outcomes, rates of treatment failure and recurrence episodes for positive women. Uncertainty surrounding these estimates will be addressed using nonparametric bootstrapping and represented using cost-effectiveness acceptability curves. A total of 6,800 pregnant women will be included. DISCUSSION: This appropriate randomized controlled design will provide insight into the cost-effectiveness and therefore the potential cost savings of a rapid screen-and-treat strategy for molecular abnormal vaginal flora in pregnant women. National and international recommendations could be updated based on the findings of this study. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02288832 (registration date: 30 October 2014); Eudract: 2014-001559-22.
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Actinobacteria/efeitos dos fármacos , Antibacterianos/uso terapêutico , Gardnerella vaginalis/efeitos dos fármacos , Sistemas Automatizados de Assistência Junto ao Leito , Testes Imediatos , Complicações Infecciosas na Gravidez/tratamento farmacológico , Nascimento Prematuro/prevenção & controle , Vaginose Bacteriana/tratamento farmacológico , Actinobacteria/genética , Actinobacteria/isolamento & purificação , Antibacterianos/economia , Carga Bacteriana , Técnicas Bacteriológicas , Protocolos Clínicos , Análise Custo-Benefício , DNA Bacteriano/genética , Custos de Medicamentos , Feminino , França , Gardnerella vaginalis/genética , Gardnerella vaginalis/isolamento & purificação , Idade Gestacional , Custos Hospitalares , Humanos , Sistemas Automatizados de Assistência Junto ao Leito/economia , Testes Imediatos/economia , Valor Preditivo dos Testes , Gravidez , Complicações Infecciosas na Gravidez/diagnóstico , Complicações Infecciosas na Gravidez/economia , Complicações Infecciosas na Gravidez/microbiologia , Nascimento Prematuro/economia , Nascimento Prematuro/microbiologia , Reação em Cadeia da Polimerase em Tempo Real , Projetos de Pesquisa , Fatores de Risco , Resultado do Tratamento , Vaginose Bacteriana/diagnóstico , Vaginose Bacteriana/economia , Vaginose Bacteriana/microbiologiaRESUMO
OBJECTIVE: Scaling up antiretroviral treatment (ART) through decentralization of HIV care is increasingly recommended as a strategy toward ensuring equitable access to treatment. However, there have been hitherto few attempts to empirically examine the performance of this policy, and particularly its role in protecting against the risk of catastrophic health expenditures (CHE). This article therefore seeks to assess whether HIV care decentralization has a protective effect against the risk of CHE associated with HIV infection. DATA SOURCE AND STUDY DESIGN: We use primary data from the cross-sectional EVAL-ANRS 12-116 survey, conducted in 2006-2007 among a random sample of 3,151 HIV-infected outpatients followed up in 27 hospitals in Cameroon. DATA COLLECTION AND METHODS: Data collected contain sociodemographic, economic, and clinical information on patients as well as health care supply-related characteristics. We assess the determinants of CHE among the ART-treated patients using a hierarchical logistic model (n = 2,412), designed to adequately investigate the separate effects of patients and supply-related characteristics. PRINCIPAL FINDINGS: Expenditures for HIV care exceed 17 percent of household income for 50 percent of the study population. After adjusting for individual characteristics and technological level, decentralization of HIV services emerges as the main health system factor explaining interclass variance, with a protective effect on the risk of CHE. CONCLUSION: The findings suggest that HIV care decentralization is likely to enhance equity in access to ART. Decentralization appears, however, to be a necessary but insufficient condition to fully remove the risk of CHE, unless other innovative reforms in health financing are introduced.
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Atenção à Saúde/economia , Infecções por HIV/terapia , Gastos em Saúde/tendências , Acessibilidade aos Serviços de Saúde/economia , Administração de Serviços de Saúde/economia , Adulto , Camarões/epidemiologia , Estudos Transversais , Atenção à Saúde/estatística & dados numéricos , Atenção à Saúde/tendências , Feminino , Infecções por HIV/economia , Infecções por HIV/epidemiologia , Gastos em Saúde/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/tendências , Administração de Serviços de Saúde/estatística & dados numéricos , Administração de Serviços de Saúde/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Atenção Primária à Saúde/economia , Fatores de Risco , Adulto JovemRESUMO
PURPOSE OF REVIEW: In the face of increasing economic constraints, it is critically important to evaluate how best to utilize available resources. In this article, we review the growing number of cost-effectiveness analyses of HIV treatment with antiretroviral therapy (ART) in resource-limited settings. We focus on studies that evaluate when to start therapy, what therapy to start with and what to switch to based on what criteria. RECENT FINDINGS: Recent findings show that earlier ART initiation based on CD4 cell count criteria (CD4 cell counts <350 cells/microl) can be cost effective in most resource-limited settings. They also suggest that initiating ART with tenofovir as a component of the first-line regimen is an efficient use of resources compared with initiating ART with stavudine. Finally, they show that HIV RNA monitoring combined with CD4 monitoring is more effective than CD4 monitoring alone, although this strategy was not yet found to be cost effective in all studies. Nearly all studies demonstrate, however, that the cost-effectiveness ratio of HIV RNA monitoring will become more attractive as the cost of HIV RNA tests and second-line ART regimens decrease. SUMMARY: Substantial research shows that ART for HIV disease in resource-limited settings is cost effective. Improved initial regimens and increased laboratory monitoring may provide both clinical benefit and good value for money. Further price reductions of laboratory tests and recent antiretroviral drugs are needed to guarantee the cost-effectiveness of these required improvements.
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Fármacos Anti-HIV/economia , Fármacos Anti-HIV/uso terapêutico , Terapia Antirretroviral de Alta Atividade/economia , Infecções por HIV/tratamento farmacológico , Infecções por HIV/economia , Custos de Cuidados de Saúde , Adenina/análogos & derivados , Adenina/economia , Adenina/uso terapêutico , Contagem de Linfócito CD4 , Análise Custo-Benefício , Países em Desenvolvimento , Monitoramento de Medicamentos/métodos , Humanos , Organofosfonatos/economia , Organofosfonatos/uso terapêutico , RNA Viral/sangue , Estavudina/economia , Estavudina/uso terapêutico , Tenofovir , Carga Viral/métodosRESUMO
Encouraging seropositive people to voluntarily disclose their serostatus has been promoted as a key component of HIV prevention. Among other reasons, HIV disclosure to one's main partner is believed to be an incentive for serodiscordant couples to practice safe sex. The present article investigated this issue by conducting a cross-sectional survey of a large sample of HIV-infected women attending HIV care centers in Cameroon (N=1014). Overall, 86.3% of these women had disclosed their serostatus to their main partner. With respect to sexual activity with their main partner during the previous three months, 35.0% had practiced abstinence and 47.4% only safe sex, whereas 17.6% had engaged in unsafe sex at least once. HIV disclosure to one's main partner was related to safe sexual practices in multivariate analysis. Some of the factors associated with disclosure and safe sex were illustrative of the positive roles of improved access to care and women's empowerment. On the contrary, beliefs overestimating the effectiveness of antiretroviral therapies were quite widespread among respondents and predictive of both concealment of HIV status and unsafe sex.
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Transmissão de Doença Infecciosa/prevenção & controle , Infecções por HIV/transmissão , Soropositividade para HIV/psicologia , Autorrevelação , Sexo sem Proteção/psicologia , Sexo sem Proteção/estatística & dados numéricos , Adulto , Análise de Variância , Camarões , Estudos Transversais , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Acessibilidade aos Serviços de Saúde , Humanos , Masculino , Análise Multivariada , Poder Psicológico , Sexo Seguro/psicologia , Sexo Seguro/estatística & dados numéricos , Parceiros Sexuais , Fatores Socioeconômicos , Inquéritos e QuestionáriosRESUMO
CONTEXT: The national antiretroviral treatment (ART) program in Cameroon has reached one of the highest rate of coverage in Western and Central Africa (58% of the estimated eligible HIV-infected population in June 2008). OBJECTIVES: To assess the extent to which decentralized delivery of HIV care at the district level has contributed to increased access to ART. METHODS: Comparison of ART-treated and non-ART-treated in the sub-sample of medically eligible HIV-positive patients (n=2566) in the cross-sectional ANRS-EVAL survey was carried out among patients seeking HIV care in 14 hospitals at central level (Yaoundé, Douala and capitals of 8 provinces) and 13 at district levels. Logistic regressions and multivariate analysis were carried out to identify factors related to non-access to ART at both levels of care. RESULTS: Only 7% of eligible patients did not have access to ART. After adjustment for time since initial HIV diagnosis and CD4 counts (at initiation of treatment for those ART-treated and at time of survey for those who were not), younger and male patients, as well as those who only had a primary level education were less likely to be ART-treated at central but not at district level, whereas those who were unemployed were less likely to be treated at both levels. Patients were less likely to be treated in central hospitals with higher workload per medical staff member and absence of task shifting policy, and in district hospitals with non-availability of equipment for CD4 counts and larger size (150 beds or more). CONCLUSION: Main persisting barriers in access to ART in Cameroon are rather due to insufficient access to HIV testing and difficulties in patients' referral to ART delivery centers after HIV diagnosis, since the overwhelming majority of eligible patients already seeking HIV care had effective access. However, health systems strengthening (HSS) is still needed to overcome some remaining barriers in access to ART and to guarantee its long-term sustainability.
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Antirretrovirais/uso terapêutico , Infecções por HIV/tratamento farmacológico , Acessibilidade aos Serviços de Saúde/organização & administração , Disparidades em Assistência à Saúde/estatística & dados numéricos , Camarões , Estudos Transversais , Feminino , Infecções por HIV/terapia , Humanos , Modelos Logísticos , Masculino , Classe Social , Inquéritos e QuestionáriosRESUMO
BACKGROUND: The aim of this study was to assess the cost-effectiveness of HIV treatment alternatives - with and without highly active antiretroviral therapy (HAART) - within alternative strata based on the CD4+ T-cell count at the initiation of treatment in a low-resource setting. METHODS: A retrospective observational study was conducted following 286 HIV-positive individuals admitted to the principal teaching hospital in Casablanca, Morocco, between 1995 and 2002. Patients were stratified by CD4+ T-cell count and regression models were fitted to determine risk of opportunistic infection. Data on healthcare resource use were derived from patient records and were evaluated from the hospital perspective. RESULTS: HAART led to a significant reduction in the number of HIV-related opportunistic infections (P<0.0001), extended survival (61.3 versus 55.2 months; P<0.0001) and reduced hospital stays (P<0.0001) in comparison with care in the absence of HAART. When medical care and drug costs were considered together, HAART was more costly than providing treatment for opportunistic infections. The incremental cost-effectiveness ratio was lower than gross domestic product (GDP) per capita for patients starting HAART with a CD4+ T-cell count <200 cells/mm3, but this increased to nearly three times GDP per capita when HAART was initiated at CD4+ T-cell counts above this threshold. CONCLUSIONS: HAART is more cost-effective than treating HIV-related opportunistic infections and, contrary to conclusions drawn in developed countries, HAART is more cost-effective when the CD4+ T-cell count drops to <200 cells/mm3.
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Terapia Antirretroviral de Alta Atividade , Infecções por HIV/tratamento farmacológico , HIV-1 , Pobreza , Infecções Oportunistas Relacionadas com a AIDS/tratamento farmacológico , Infecções Oportunistas Relacionadas com a AIDS/epidemiologia , Infecções Oportunistas Relacionadas com a AIDS/mortalidade , Adulto , Terapia Antirretroviral de Alta Atividade/economia , Terapia Antirretroviral de Alta Atividade/métodos , Contagem de Linfócito CD4 , Análise Custo-Benefício , Atenção à Saúde , Esquema de Medicação , Feminino , Infecções por HIV/imunologia , Infecções por HIV/mortalidade , Infecções por HIV/virologia , Humanos , Incidência , Masculino , Marrocos/epidemiologia , Fatores de RiscoRESUMO
The last international consensus conference about hepatitis C virus (HCV) treatment emphasized the importance of treatment for persons coinfected with HCV and human immunodeficiency virus (HIV). As liver biopsy precedes treatment, we aimed to identify factors associated with the performance of liver biopsy among HIV-HCV coinfected drug users during a 5-year follow-up to study their access to HCV treatment. Of the 296 patients followed in the HIV hospital departments of Nice and Marseilles and with retrievable records about HCV diagnosis and care, 166 were eligible for analysis having had detectable HCV RNA at least once during the study period. Overall, 45.2% of patients underwent liver biopsy during follow-up. Using proportional hazard models, predictors of having had a liver biopsy were high social support, complete abstinence from drug injection, and lack of immunosuppression as well as male gender, no history of multiple incarcerations, more recent onset of drug use, and an increase of liver enzyme levels. These results suggest that specific efforts should be devoted to HIV-HCV coinfected drug users to assist with stabilizing these patients to optimize their access to HCV care whenever possible.
Assuntos
Biópsia/estatística & dados numéricos , Infecções por HIV/patologia , Hepatite C/patologia , Fígado/patologia , Alanina Transaminase/análise , Antirretrovirais/uso terapêutico , Aspartato Aminotransferases/análise , Feminino , França , Fidelidade a Diretrizes , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Acessibilidade aos Serviços de Saúde , Hepacivirus/enzimologia , Hepacivirus/genética , Hepatite C/complicações , Hepatite C/terapia , Departamentos Hospitalares , Humanos , Técnicas Imunoenzimáticas/estatística & dados numéricos , Fígado/enzimologia , Estudos Longitudinais , Masculino , Modelos de Riscos Proporcionais , Fatores Sexuais , Abuso de Substâncias por Via Intravenosa/complicações , Abuso de Substâncias por Via Intravenosa/virologiaRESUMO
Some screening programs have very high costs per life-year saved and require large financial support. Public policies decision-makers need criteria to appreciate the costs and benefices of such programs. The safety of blood transfusions is a specific example of such a situation, in which the decision to reduce residual risks could be a highly debatable use of resources when the additional effectiveness is small. This article analyzes various economic evaluations of hepatitis C virus screening strategies and discusses the results. The screening of blood donations for hepatitis C virus antibodies is cost-effective and enzyme-linked immunoblot assay testing appears to be the most efficient and reliable test for daily processing of a large number of samples in a large blood bank. In contrast, new tests proposed to increase safety in blood donations, such as the adjunction of polymerase chain reaction testing, do not compare favorably with socially-acceptable threshold in health economics.
RESUMO
OBJECTIVES: To access the cost-effectiveness of French recommendations for hepatitis C virus (HCV) screening and the extent to which earlier identification of carriers may or not improve the cost-effectiveness of therapeutic strategies. METHODS: Cost-effectiveness analysis were performed using decision-tree analysis and a Markov model. Four alternative strategies were compared: no screening and no treatment; initiation of HCV treatment after the diagnosis of cirrhosis; and two alternative strategies refer to the current French policies of HCV testing, i.e., two enzyme immunoblot assay (EIA) tests in series, or a polymerase chain reaction (PCR) analysis after the first positive EIA test. Costs were computed from the viewpoint of the health care system. The analysis has been applied to populations particularly at risk of infection, as well as the general population. RESULTS: The "wait and treat cirrhosis" strategy was more cost-effective in the general population and in transfusion recipients. The incremental cost-effectiveness ratio of this strategy compared with baseline strategy was 3,476 of euros and Euro15,300 in respective cohorts. Considering the HCV screening strategy, the additional cost would be of Euro4,933 and Euro240,250 per additional year of life saved, respectively. In the intravenous drug user (IDU) population, the "two ElA" screening strategy was the more cost-effective alternative, with an additional cost of Euro3,825 per additional year of life saved. CONCLUSIONS: HCV screening would be discarded for transfusion recipients but should be encouraged for IDUs and also for the general population, in which the additional cost of screening is an order of magnitude more acceptable.