A systematic review of the cost-effectiveness of emergency interventions for stroke in low- and middle-income countries.

BACKGROUND: Stroke is a leading cause of death and disability globally, with an increasing incidence in low- and middle-income countries (LMICs). The successful treatment of acute stroke requires an organized, efficient and well-resourced emergency care system. However, debate exists surrounding the prioritization of stroke treatment programs given the high costs of treatment and the increased incidence of hemorrhagic stroke in LMICs. Economic data is helpful to guide evidence-based priority setting in health systems development, particularly in low-resource settings where scarcity requires careful stewardship of resources. This systematic review surveys the existing evidence surrounding the cost-effectiveness of interventions to address acute stroke in LMIC settings. METHODS: The authors conducted a PRISMA style systematic review of economic evaluations of interventions to address acute stroke in LMICs. Five databases were systematically searched for articles, which were then reviewed for inclusion. RESULTS: Of the 153 unique articles identified, 11 met the inclusion criteria. Four studies demonstrate the heavy economic burden on patients and households due to stroke. Two studies estimate that preventive measures are more cost-effective than acute treatments. Four studies directly examine the cost-effectiveness of thrombolysis and thrombectomy in three middle-income countries (Iran, China, and Brazil) with results ranging from roughly $2578 to $34,052 (2019 USD) per quality adjusted life-year saved. These results are similar to the cost-effectiveness ratios estimated in high-income settings. Finally, one study examined a care bundle that included acute treatment elements. CONCLUSIONS: The findings reinforce the need for additional research support informed decision-making. The available evidence suggests that preventive measures should be prioritized over emergency treatment for acute stroke, particularly in settings of resource scarcity. Cost-effectiveness ratios do not compare favorably to estimates for other emergency care interventions in LMICs, such as basic emergency care training, implementation of triage systems, and basic trauma care. Cost-effectiveness is also likely to vary depending on local epidemiology. Overall, decision-makers should balance the economic evidence alongside social, political and cultural priorities when making resource allocation choices.

Cost-effectiveness and return on investment of protecting health workers in low- and middle-income countries during the COVID-19 pandemic.

BACKGROUND: In this paper, we predict the health and economic consequences of immediate investment in personal protective equipment (PPE) for health care workers (HCWs) in low- and middle-income countries (LMICs). METHODS: To account for health consequences, we estimated mortality for HCWs and present a cost-effectiveness and return on investment (ROI) analysis using a decision-analytic model with Bayesian multivariate sensitivity analysis and Monte Carlo simulation. Data sources included inputs from the World Health Organization Essential Supplies Forecasting Tool and the Imperial College of London epidemiologic model. RESULTS: An investment of $9.6 billion USD would adequately protect HCWs in all LMICs. This intervention would save 2,299,543 lives across LMICs, costing $59 USD per HCW case averted and $4,309 USD per HCW life saved. The societal ROI would be $755.3 billion USD, the equivalent of a 7,932% return. Regional and national estimates are also presented. DISCUSSION: In scenarios where PPE remains scarce, 70-100% of HCWs will get infected, irrespective of nationwide social distancing policies. Maintaining HCW infection rates below 10% and mortality below 1% requires inclusion of a PPE scale-up strategy as part of the pandemic response. In conclusion, wide-scale procurement and distribution of PPE for LMICs is an essential strategy to prevent widespread HCW morbidity and mortality. It is cost-effective and yields a large downstream return on investment.

Economic evaluation of facility-based HIV self-testing among adult outpatients in Malawi.

INTRODUCTION: HIV self-testing (HIVST) in outpatient departments (OPD) is a promising strategy for HIV testing in Malawi, given high OPD patient volumes and substantial wait times. To evaluate the relative cost and expected impact of facility-based HIVST (FB-HIVST) at OPDs in Malawi for increasing HIV status awareness, we conducted an economic evaluation of an HIVST cluster-randomized controlled trial. METHODS: A cluster-randomized trial was conducted at 15 sites in Malawi from September 2017 to February 2018 with three arms: 1) Standard provider-initiated-testing-and-counselling (PITC); 2) Optimized PITC (additional provider training and job-aids) and 3) FB-HIVST (HIVST demonstration, distribution and kit use in OPD, private kit interpretation and optional HIV counselling). The total production cost per newly identified positive and per person newly initiated on ART were calculated by study arm. These were calculated as the total cost of testing everyone divided by the number of newly identified positives; and the total cost of testing everyone divided by the number of those initiated on ART. Cost-outcomes were calculated under three cost scenarios: (1) full study costs, (2) routine implementation costs and (3) routine implementation + reduced cost for HIVST kits. RESULTS: The average cost per person newly diagnosed in the full study cost scenario was $101, $156 and $189, and cost per person initiated on ART was $121, $156 and $279 for Standard PITC, Optimized PITC and FB-HIVST respectively. In the routine implementation cost scenario, the average cost per person newly diagnosed was reduced to $83, and $93, and cost per person initiated on ART to $83, and $137 for Optimized PITC and FB-HIVST respectively. In the negotiated HIVST cost scenario, the average cost per person newly diagnosed was reduced to $55 and cost per person newly initiated on ART reduced to $81 in the FB-HIVST arm. CONCLUSIONS: While the cost per new ART initiation through FB-HIVST was higher than Standard PITC, FB-HIVST could become cost-saving compared to PITC if the cost of kits is reduced or if treatment linkage rate were increased in the FB-HIVST arm. For high volume OPDs, HIVST may increase facility capacity and increase the number of newly diagnosed positives.

Evaluating the integration of HIV self-testing into low-resource health systems: study protocol for a cluster-randomized control trial from EQUIP Innovations.

BACKGROUND: Throughout sub-Saharan Africa HIV-testing rates remain low. Barriers to testing, such as inconvenient service hours and long wait times, lack of privacy, and fear of unwanted disclosure, continue to impede service utilization. HIV self-testing (HIVST) is one strategy that addresses these barriers and has been shown to increase use of HIV-testing when distributed through community-based settings. However, the scalability of HIVST is limited because it has yet to be fully integrated into existing health systems and routine care. To address this gap, we designed a study to test the effect of offering HIVST to routine outpatient department (OPD) clients on uptake of HIV-testing as compared to standard of care and optimized standard of care. METHODS/DESIGN: This is a non-blinded, multi-site, cluster-randomized control trial. The health facility is the unit of randomization (cluster). Fifteen facilities were randomized to one of three arms: (1) Standard of care using routine provider-initiated testing and counseling (PITC); (2) Optimized standard of care using optimized PITC defined by additional training, job aids, and monitoring of PITC strategies with OPD providers and support staff; and (3) HIVST defined by HIVST demonstrations for OPD clients, HIVST kit distribution, and private spaces for HIVST kit use and/or interpretation. The primary outcome is the proportion of OPD clients tested for HIV on the day that they accessed OPD services. Secondary outcome measures are the proportion of OPD clients newly identified as HIV-positive and antiretroviral therapy (ART) initiation. Costs and cost-effectiveness will be evaluated. Nested studies will determine the acceptability of facility-based HIVST among OPD clients and health care providers, the presence of adverse events, such as coercion to test or unwanted status disclosure, and a process evaluation to determine feasibility and scale-up of facility-based HIVST for the future. DISCUSSION: This study protocol tests whether facility-based HIVST can positively contribute to HIV-testing among OPD clients in resource-limited settings. This will be one of the first studies to test the integration of HIVST into facility-based, primary health services in sub-Saharan Africa. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT03271307 . Registered on 31 August 2017. Pan African Clinical Trials: PACTR201711002697316 . Registered on 1 November 2017.