Cost-effectiveness of home-based chlorination and safe water storage in reducing diarrhea among HIV-affected households in rural Uganda.

Safe water systems (SWSs) have been shown to reduce diarrhea and death. We examined the cost-effectiveness of SWS for HIV-affected households using health outcomes and costs from a randomized controlled trial in Tororo, Uganda. SWS was part of a home-based health care package that included rapid diarrhea diagnosis and treatment of 196 households with relatively good water and sanitation coverage. SWS use averted 37 diarrhea episodes and 310 diarrhea-days, representing 0.155 disability-adjusted life year (DALY) gained per 100 person-years, but did not alter mortality. Net program costs were 5.21 dollars/episode averted, 0.62 dollars/diarrhea-day averted, and 1,252 dollars/DALY gained. If mortality reduction had equaled another SWS trial in Kenya, the cost would have been 11 dollars/DALY gained. The high SWS cost per DALY gained was probably caused by a lack of mortality benefit in a trial designed to rapidly treat diarrhea. SWS is an effective intervention whose cost-effectiveness is sensitive to diarrhea-related mortality, diarrhea incidence, and effective clinical management.

The estimated direct medical cost of sexually transmitted diseases among American youth, 2000.

CONTEXT: Each year, millions of U.S. youth acquire sexually transmitted diseases (STDs). Estimates of the economic burden of STDs can help to quantify the impact of STDs on the nation's youth and on the payers of the cost of their medical care. METHODS: We synthesized the existing literature on STD costs to estimate the lifetime medical cost per case of eight major STDs-HIV, human papillomavirus (HPV), genital herpes simplex virus type 2, hepatitis B, chlamydia, gonorrhea, trichomoniasis and syphilis. We then estimated the total burden of disease by multiplying these cost-per-case estimates by the approximate number of new cases of STDs acquired by youth aged 15-24. RESULTS: The total estimated burden of the nine million new cases of these STDs that occurred among 15-24-year-olds in 2000 was $6.5 billion (in year 2000 dollars). Viral STDs accounted for 94% of the total burden ($6.2 billion), and nonviral STDs accounted for 6% of the total burden ($0.4 billion). HIV and HPV were by far the most costly STDs in terms of total estimated direct medical costs, accounting for 90% of the total burden ($5.9 billion). CONCLUSIONS: The large number of infections acquired by persons aged 15-24 and the high cost per case of viral STDs, particularly HIV, create a substantial economic burden.

The determinants of HIV treatment costs in resource limited settings.

BACKGROUND: Governments and international donors have partnered to provide free HIV treatment to over 6 million individuals in low and middle-income countries. Understanding the determinants of HIV treatment costs will help improve efficiency and provide greater certainty about future resource needs. METHODS AND FINDINGS: We collected data on HIV treatment costs from 54 clinical sites in Botswana, Ethiopia, Mozambique, Nigeria, Uganda, and Vietnam. Sites provided free HIV treatment funded by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), national governments, and other partners. Service delivery costs were categorized into successive six-month periods from the date when each site began HIV treatment scale-up. A generalized linear mixed model was used to investigate relationships between site characteristics and per-patient costs, excluding ARV expenses. With predictors at their mean values, average annual per-patient costs were $177 (95% CI: 127-235) for pre-ART patients, $353 (255-468) for adult patients in the first 6 months of ART, and $222 (161-296) for adult patients on ART for >6 months (excludes ARV costs). Patient volume (no. patients receiving treatment) and site maturity (months since clinic began providing treatment services) were both strong independent predictors of per-patient costs. Controlling for other factors, costs declined by 43% (18-63) as patient volume increased from 500 to 5,000 patients, and by 28% (6-47) from 5,000 to 10,000 patients. For site maturity, costs dropped 41% (28-52) between months 0-12 and 25% (15-35) between months 12-24. Price levels (proxied by per-capita GDP) were also influential, with costs increasing by 22% (4-41) for each doubling in per-capita GDP. Additionally, the frequency of clinical follow-up, frequency of laboratory monitoring, and clinician-patient ratio were significant independent predictors of per-patient costs. CONCLUSIONS: Substantial reductions in per-patient service delivery costs occur as sites mature and patient cohorts increase in size. Other predictors suggest possible strategies to reduce per-patient costs.

Cost-effectiveness of tuberculosis diagnostic strategies to reduce early mortality among persons with advanced HIV infection initiating antiretroviral therapy.

BACKGROUND: In sub-Saharan Africa, patients with advanced HIV experience high mortality during the first few months of antiretroviral therapy (ART), largely attributable to tuberculosis (TB). We evaluated the cost-effectiveness of TB diagnostic strategies to reduce this early mortality. METHODS: We developed a decision analytic model to estimate the incremental cost, deaths averted, and cost-effectiveness of 3 TB diagnostic algorithms. The model base case represents current practice (symptoms screening, sputum smear, and chest radiography) in many resource-limited countries in sub-Saharan Africa. We compared the current practice with World Health Organization (WHO)-recommended practice with culture and WHO-recommended practice with the Xpert mycobacterium tuberculosis and resistance to rifampicin test and considered relevant medical costs from a health system perspective using the timeframe of the first 6 months of ART. We conducted univariate and probabilistic sensitivity analyses on all parameters in the model. RESULTS: When considering TB diagnosis and treatment and ART costs, the cost per patient was $850 for current practice, $809 for the algorithm with Xpert test, and $879 for the algorithm with culture. Our results showed that both WHO-recommended algorithms avert more deaths among TB cases than does the current practice. The algorithm with Xpert test was least costly at reducing early mortality compared with the current practice. Sensitivity analyses indicated that cost-effectiveness findings were stable. CONCLUSIONS: Our analysis showed that culture or Xpert were cost-effective at reducing early mortality during the first 6 months of ART compared with the current practice. Thus, our findings provide support for ongoing efforts to expand TB diagnostic capacity.

PEPFAR's past and future efforts to cut costs, improve efficiency, and increase the impact of global HIV programs.

Amid the global economic crisis, the President's Emergency Plan for AIDS Relief (PEPFAR) and other organizations have been pressed to do more with constrained resources to meet unmet needs in the worldwide HIV/AIDS pandemic. PEPFAR has approached this challenge through the development of an Impact and Efficiency Acceleration Plan, which includes improving the collection and use of economic and financial data, increasing the efficiency of HIV/AIDS program implementation, and collaborating with governments and multilateral organizations to maximize the impact of the resources provided by the United States. For example, by linking financial data with program outputs, PEPFAR was able to help its implementing partners in Mozambique reduce mean unit expenditures for people receiving antiretroviral treatment by 45 percent, from $265 to $145 per person, between 2009 and 2011. This article describes the plan's elements, provides examples of progress and challenges to its implementation, and assesses the prospects for further improvements in efficiency and impact.

Expanding the generation and use of economic and financial data to improve HIV program planning and efficiency: a global perspective.

Cost information is needed at multiple levels of health care systems to inform the public health response to HIV. To date, most attention has been paid to identifying the cost drivers of providing antiretroviral treatment, and these data have driven interventions that have been successful in reducing drug and human resource costs. The need for further cost information, especially for less well-studied areas such as HIV prevention, is particularly acute given global budget constraints and ongoing efforts to extract the greatest possible value from money spent on the response. Cost information can be collected from multiple perspectives and levels of the health care system (site, program, and national levels), and it is critical to choose the appropriate methodology in order to generate the appropriate information for decision-making. Organizations such as United States President's Emergency Plan for AIDS Relief, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and other organizations are working together to bridge the divide between the fields of economics and HIV program implementation by accelerating the collection of cost data and building further local demand and capacity for their use.

Characteristics of HIV care and treatment in PEPFAR-supported sites.

BACKGROUND: The US President's Emergency Plan for AIDS Relief (PEPFAR) has supported the extension of HIV care and treatment to 2.4 million individuals as of September 2009. With increasing resources targeted toward rapid scale-up, it is important to understand the characteristics of current PEPFAR-supported HIV care and treatment sites. METHODS: Forty-five sites in Botswana, Ethiopia, Nigeria, Uganda, and Vietnam were sampled. Data were collected retrospectively from successive 6-month periods through reviews of facility records and interviews with site personnel between April 2006 and March 2007. Facility size and scale-up rate, patient characteristics, staffing models, clinical and laboratory monitoring, and intervention mix were compared. RESULTS: Sites added a median of 293 patients per quarter. By the evaluation's end, sites supported a median of 1649 HIV patients, 922 of them receiving antiretroviral therapy. Patients were predominantly adult (97.4%), and the majority (96.5%) were receiving regimens based on nonnucleoside reverse transcriptase inhibitors. The ratios of physicians to patients dropped substantially as sites matured. Antiretroviral therapy patients were commonly seen monthly or quarterly for clinical and laboratory monitoring, with CD4 counts being taken at 6-month intervals. One-third of sites provided viral load testing. Cotrimoxazole prophylaxis was the most prevalent supportive service. CONCLUSIONS: HIV treatment sites scaled up rapidly with the influx of resources and technical support through PEPFAR, providing complex health services to progressively expanding patient cohorts. Human resources are stretched thin, and delivery models and intervention mix differ widely between sites. Ongoing research is needed to identify best-practice service delivery models.

The cost of providing comprehensive HIV treatment in PEPFAR-supported programs.

BACKGROUND: PEPFAR, national governments, and other stakeholders are investing unprecedented resources to provide HIV treatment in developing countries. This study reports empirical data on costs and cost trends in a large sample of HIV treatment sites. DESIGN: In 2006-2007, we conducted cost analyses at 43 PEPFAR-supported outpatient clinics providing free comprehensive HIV treatment in Botswana, Ethiopia, Nigeria, Uganda, and Vietnam. METHODS: We collected data on HIV treatment costs over consecutive 6-month periods starting from scale-up of dedicated HIV treatment services at each site. The study included all patients receiving HIV treatment and care at study sites [62,512 antiretroviral therapy (ART) and 44,394 pre-ART patients]. Outcomes were costs per patient and total program costs, subdivided by major cost categories. RESULTS: Median annual economic costs were US$ 202 (2009 USD) for pre-ART patients and US$ 880 for ART patients. Excluding antiretrovirals, per patient ART costs were US$ 298. Care for newly initiated ART patients cost 15-20% more than for established patients. Per patient costs dropped rapidly as sites matured, with per patient ART costs dropping 46.8% between first and second 6-month periods after the beginning of scale-up, and an additional 29.5% the following year. PEPFAR provided 79.4% of funding for service delivery, and national governments provided 15.2%. CONCLUSION: Treatment costs vary widely between sites, and high early costs drop rapidly as sites mature. Treatment costs vary between countries and respond to changes in antiretroviral regimen costs and the package of services. Whereas cost reductions may allow near-term program growth, programs need to weigh the trade-off between improving services for current patients and expanding coverage to new patients.

The costs and effectiveness of four HIV counseling and testing strategies in Uganda.

OBJECTIVE: HIV counseling and testing (HCT) is a key intervention for HIV/AIDS control, and new strategies have been developed for expanding coverage in developing countries. We compared costs and outcomes of four HCT strategies in Uganda. DESIGN: A retrospective cohort of 84 323 individuals received HCT at one of four Ugandan HCT programs between June 2003 and September 2005. HCT strategies assessed were stand-alone HCT; hospital-based HCT; household-member HCT; and door-to-door HCT. METHODS: We collected data on client volume, demographics, prior testing and HIV diagnosis from project monitoring systems, and cost data from project accounts and personnel interviews. Strategies were compared in terms of costs and effectiveness at reaching key population groups. RESULTS: Household-member and door-to-door HCT strategies reached the largest proportion of previously untested individuals (>90% of all clients). Hospital-based HCT diagnosed the greatest proportion of HIV-infected individuals (27% prevalence), followed by stand-alone HCT (19%). Household-member HCT identified the highest percentage of discordant couples; however, this was a small fraction of total clients (<4%). Costs per client (2007 USD) were $19.26 for stand-alone HCT, $11.68 for hospital-based HCT, $13.85 for household-member HCT, and $8.29 for door-to-door-HCT. CONCLUSION: All testing strategies had relatively low per client costs. Hospital-based HCT most readily identified HIV-infected individuals eligible for treatment, whereas home-based strategies more efficiently reached populations with low rates of prior testing and HIV-infected people with higher CD4 cell counts. Multiple HCT strategies with different costs and efficiencies can be used to meet the UNAIDS/WHO call for universal HCT access by 2010.

Cost-effectiveness of routine rapid human immunodeficiency virus antibody testing before DNA-PCR testing for early diagnosis of infants in resource-limited settings.

BACKGROUND: Infants born to HIV-infected women should receive HIV testing to allow early diagnosis and treatment. Recommendations for resource-limited settings stress laboratory-based virologic assays. While effective, these tests are logistically complex and expensive. This study explored the cost-effectiveness of incorporating initial screening with rapid HIV tests (RHT) into the conventional testing algorithm to screen-out HIV-uninfected infants, thereby reducing the need for costly virologic testing. METHODS: Data on HIV prevalence, RHT sensitivity and specificity, and costs were collected from 820 HIV-exposed children (1.5-18 months) attending 2 postnatal screening programs in Uganda during July 2005 to December 2006. Cost-effectiveness models compared the conventional testing algorithm DNA polymerase chain reaction (DNA-PCR with Roche Amplicor v1.5) with a modified algorithm (initial RHT to screen-out HIV-uninfected infants before DNA-PCR). RESULTS: The model estimated that the conventional algorithm would identify 94.3% (91.8%-94.7%) of HIV-infected infants, compared with 87.8% (79.4%-90.5%) for a modified algorithm using RHT (HIV 1/2 Determine) and excluding the need for DNA-PCR for HIV antibody-negative infants. Costs per infant were $23.47 ($23.32-$23.76) for the conventional algorithm and between $22.75 ($21.89-$23.31) and $7.58 ($6.41-$10.75) for the modified algorithm, depending on infant age and symptoms. Compared with the conventional algorithm, costs per HIV-infected infant identified using the modified algorithm were higher in 1.5-to 3-month-old infants, but significantly lower in 3-month-old and older infants. Models replicating the whole infant testing program showed the modified algorithm would have marginally lower sensitivity, but would reduce total program costs by 27% to 40%, producing an incremental cost-effectiveness ratio of $1489 ($686-$6781) for the conventional versus modified algorithms. CONCLUSIONS: Screening infants with RHT before DNA-PCR is cost-effective in infants 3 months old or older. Incorporating RHT into early infant testing programs could improve cost-effectiveness and reduce program costs.

Cost-effectiveness of on-site antenatal screening to prevent congenital syphilis in rural eastern Cape Province, Republic of South Africa.

OBJECTIVES: On-site screening and same-day treatment of maternal syphilis in underresourced settings can avert greater numbers of congenital syphilis cases, but health outcomes and associated costs must be evaluated jointly. METHODS: We used decision analysis to estimate the incremental cost-effectiveness of two on-site antenatal syphilis screening strategies to avert congenital infections-qualitative RPR (on-site RPR) and treponemal immunochromatographic strip assay (on-site ICS)-compared to the current practice (off-site RPR/TPHA). FINDINGS: With antenatal active syphilis prevalence of 6.3%, the incremental cost-effectiveness of on-site ICS in averting congenital infections was estimated to be USD104, averting 82% of cases expected in absence of a program. The incremental cost-effectiveness of off-site RPR/TPHA was USD82 but would avert only 55% of congenital syphilis cases. On-site RPR was dominated by the other screening strategies. CONCLUSIONS: In settings of high maternal syphilis prevalence, on-site antenatal screening with ICS is a cost-effective approach to reduce the incidence of congenital syphilis.

On-site rapid antenatal syphilis screening with an immunochromatographic strip improves case detection and treatment in rural South African clinics.

OBJECTIVES: Congenital syphilis is a significant cause of adverse pregnancy outcomes. In South Africa, rural clinics perform antenatal screening offsite, but unreliable transport and poor client follow up impede effective treatment. We compared 3 syphilis screening strategies at rural clinics: on-site rapid plasma reagin (RPR), on-site treponemal immunochromatographic strip (ICS) test, and the standard practice offsite RPR with Treponema pallidum hemagglutination assay (RPR/TPHA). METHODS: Eight rural clinics performed the on-site RPR and ICS tests and provided immediate treatment. Results were compared with RPR/TPHA at a reference laboratory. Chart reviews at 8 standard practice clinics established diagnosis and treatment rates for offsite RPR/TPHA. FINDINGS: Seventy-nine (6.3%) of 1,250 women screened on-site had active syphilis according to the reference laboratory. The on-site ICS resulted in the highest percentage of pregnant women correctly diagnosed and treated for syphilis (89.4% ICS, 63.9% on-site RPR, 60.8% offsite RPR/TPHA). The on-site RPR had low sensitivity (71.4% for high-titer syphilis). The offsite approach suffered from poor client return rates. One percent of women screened with the ICS may have received penicillin unnecessarily. There were no adverse treatment outcomes. CONCLUSIONS: The on-site ICS test can reduce syphilis-related adverse outcomes of pregnancy through accurate diagnosis and immediate treatment of pregnant women with syphilis.

Productivity losses attributable to untreated chlamydial infection and associated pelvic inflammatory disease in reproductive-aged women.

BACKGROUND AND OBJECTIVES: The productivity losses attributable to disease-related morbidity and mortality impose a burden on society in general and on employers in particular. A reliable assessment of the productivity losses associated with untreated infection with Chlamydia trachomatis (Ct) would complement earlier work on direct medical costs and contribute to an estimate of the full cost of chlamydial disease. GOAL: The goal of this study was to estimate the discounted lifetime productivity losses attributable to untreated chlamydial infection in reproductive-aged women. STUDY DESIGN: We developed a cost model using Monte Carlo methods to estimate the lifetime discounted productivity losses attributable to untreated lower genital tract Ct infection among reproductive-aged women. The model considered the impact of disability resulting from acute pelvic inflammatory disease (PID) associated with untreated Ct infection and from the sequelae of acute PID, including chronic pelvic pain, ectopic pregnancy, and infertility. To accommodate disparate Ct infection rates and labor market characteristics across age groups, we matched age-based risk factors for Ct infection with labor market patterns. Data sources included the 2001 National Chlamydia Surveillance Data, the 2001 Current Population Survey, and published literature. RESULTS: Estimates indicate that the mean weighted productivity losses per untreated Ct infection were approximately US dollars 130 (in year 2001 dollars). Mean weighted productivity losses per case of acute PID were estimated at US dollars 649. Estimated productivity losses were highly correlated with age, reflecting age-dependent differences in labor market characteristics. CONCLUSIONS: The productivity losses attributable to untreated infection with Ct and to sequelae of this infection form a substantial portion of the total economic burden of disease. Effective programs to prevent chlamydial infection and effective screening, diagnosis, and treatment of Ct-infected women may reduce productivity losses and substantially lessen the economic burden of disease to employers.

The cost-effectiveness of single-dose azithromycin for treatment of incubating syphilis.

BACKGROUND: Treatment of incubating syphilis with intramuscular benzathine penicillin in exposed sex partners is not always practical in the field, and exposed partners may not adhere to referrals for treatment at clinical facilities. The availability of a single-dose oral therapy could increase the number of partners treated and reduce future infections. GOAL: The goal of the study was to evaluate the cost-effectiveness of directly observed oral administration of azithromycin as an alternative to referral for treatment with benzathine penicillin. STUDY DESIGN: Using published probability and cost estimates, we constructed a decision-analysis model to compare the direct costs and effectiveness of field treatment with azithromycin (1-g single dose) versus referral for standard benzathine penicillin therapy. RESULTS: At public-sector pricing ($11.50 U.S. dollars), directly observed field treatment with azithromycin is cost-saving from both the program and healthcare system perspectives at efficacy levels as low as 75%. Azithromycin therapy is cost-saving at the wholesale price of $17.32 U.S. dollars (sachet formulation) when efficacy is at least 90%. The more expensive tablet formulation (average wholesale price of $27.89 U.S. dollars) is not cost-saving from a program perspective, but it remains cost-saving from a healthcare system perspective if efficacy rates are at least 90%. Azithromycin therapy (1-g single dose) will result in fewer cases of early syphilis among exposed partners, provided that the drug's efficacy is at least 87%. CONCLUSIONS: Azithromycin is a cost-effective alternative treatment for incubating syphilis in settings where standard intramuscular therapy is not practical.

Estimates of the annual number and cost of new HIV infections among women attributable to trichomoniasis in the United States.

BACKGROUND: Clinical evidence suggests that trichomoniasis facilitates the sexual transmission and acquisition of HIV. GOAL: The goal of this study was to estimate the annual number and cost of new HIV infections among women in the United States attributable to trichomoniasis. STUDY: We used a mathematical model of HIV transmission to estimate the probability that a woman with trichomoniasis would acquire HIV as a result of her trichomoniasis-mediated increased susceptibility to HIV infection or as a result of increased HIV infectiousness in a trichomoniasis-infected male partner. RESULTS: Our results indicate that each year in the United States, an estimated 746 new HIV cases among women can be attributed to the facilitative effects of trichomoniasis on HIV transmission. The lifetime cost of treating these trichomoniasis-attributable HIV infections is approximately $167 million. CONCLUSIONS: Efforts to prevent trichomoniasis could help prevent HIV transmission and could reduce the economic burden associated with trichomoniasis-attributable HIV cases that occur each year. Because trichomoniasis is so common, however, a substantial number of cases would need to be detected and treated to have a discernible impact on HIV. Future research is needed to examine the cost-effectiveness of trichomoniasis prevention as a tool for HIV prevention.