Nutritional supplementation: the additional costs of managing children infected with HIV in resource-constrained settings.

OBJECTIVE: To explore the financial implications of applying the WHO guidelines for the nutritional management of HIV-infected children in a rural South African HIV programme. METHODS: WHO guidelines describe Nutritional Care Plans (NCPs) for three categories of HIV-infected children: NCP-A: growing adequately; NCP-B: weight-for-age z-score (WAZ) ≤-2 but no evidence of severe acute malnutrition (SAM), confirmed weight loss/growth curve flattening, or condition with increased nutritional needs (e.g. tuberculosis); NCP-C: SAM. In resource-constrained settings, children requiring NCP-B or NCP-C usually need supplementation to achieve the additional energy recommendation. We estimated the proportion of children initiating antiretroviral treatment (ART) in the Hlabisa HIV Programme who would have been eligible for supplementation in 2010. The cost of supplying 26-weeks supplementation as a proportion of the cost of supplying ART to the same group was calculated. RESULTS: A total of 251 children aged 6 months to 14 years initiated ART. Eighty-eight required 6-month NCP-B, including 41 with a WAZ ≤-2 (no evidence of SAM) and 47 with a WAZ >-2 with co-existent morbidities including tuberculosis. Additionally, 25 children had SAM and required 10-weeks NCP-C followed by 16-weeks NCP-B. Thus, 113 of 251 (45%) children were eligible for nutritional supplementation at an estimated overall cost of $11 136, using 2010 exchange rates. These costs are an estimated additional 11.6% to that of supplying 26-week ART to the 251 children initiated. CONCLUSIONS: It is essential to address nutritional needs of HIV-infected children to optimise their health outcomes. Nutritional supplementation should be integral to, and budgeted for, in HIV programmes.

Diminishing availability of publicly funded slots for antiretroviral initiation among HIV-infected ART-eligible patients in Uganda.

BACKGROUND: The impact of flat-line funding in the global scale up of antiretroviral therapy (ART) for HIV-infected patients in Africa has not yet been well described. METHODS: We evaluated ART-eligible patients and patients starting ART at a prototypical scale up ART clinic in Mbarara, Uganda between April 1, 2009 and May 14, 2010 where four stakeholders sponsor treatment - two PEPFAR implementing organizations, the Ugandan Ministry of Health - Global Fund (MOH-GF) and a private foundation named the Family Treatment Fund (FTF). We assessed temporal trends in the number of eligible patients, the number starting ART and tabulated the distribution of the stakeholders supporting ART initiation by month and quartile of time during this interval. We used survival analyses to assess changes in the rate of ART initiation over calendar time. FINDINGS: A total of 1309 patients who were eligible for ART made visits over the 14 month period of the study and of these 819 started ART. The median number of ART eligible patients each month was 88 (IQR: 74 to 115). By quartile of calendar time, PEPFAR and MOH sponsored 290, 192, 180, and 49 ART initiations whereas the FTF started 1, 2, 1 and 104 patients respectively. By May of 2010 (the last calendar month of observation) FTF sponsored 88% of all ART initiations. Becoming eligible for ART in the 3(rd) (HR = 0.58, 95% 0.45-0.74) and 4(th) quartiles (HR = 0.49, 95% CI: 0.36-0.65) was associated with delay in ART initiation compared to the first quartile in multivariable analyses. INTERPRETATION: During a period of flat line funding from multinational donors for ART programs, reductions in the number of ART initiations by public programs (i.e., PEPFAR and MOH-GF) and delays in ART initiation became apparent at the a large prototypical scale-up ART clinic in Uganda.

The effect of the Breast and Cervical Cancer Prevention and Treatment Act on Medicaid disenrollment.

BACKGROUND: The Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA) of 2000 created a new Medicaid option that allowed states to expand coverage to previously uninsured low-income women screened by certain public providers and found in need of treatment for those cancers. States also had the flexibility to allow any provider to screen for this new eligibility category and BCCPTA women were made eligible for all Medicaid services for the duration of their treatment. We have assessed the effect of this new program on the disenrollment patterns of women with breast/cervical cancer versus those with control cancers pre- and post-BCCPTA in Georgia. The post-BCCPTA period analyzed here was one in which Georgia BCCPTA women could self-report that they were in active treatment and, hence, still eligible. METHODS: The Georgia Comprehensive Cancer Registry (1999-2004) was linked to Medicaid enrollment files (1998-2005) to identify female Medicaid enrollees aged under 65 and enrolled in Medicaid at or after being diagnosed with breast (n = 2,265), cervical (n = 439) or one of five control cancers (n = 700). The rate of disenrollment (per 100 person-months) was computed for each cancer group pre- versus post-BCCPTA. We employed difference-in-differences analysis to adjust for any temporal changes other than BCCPTA that could affected the disenrollment rate of women with both the treatment (breast/cervical) and control cancers. We used a parametric hazard model with a Weibull distribution to analyze the odds of disenrollment. RESULTS: The unadjusted disenrollment rate declined 50% for women with breast and cervical cancers, whereas it increased over 30% for those with control cancers, pre- versus post-BCCPTA. The direction and magnitude of these results held after adjusting for socio-demographics and area characteristics that could affect disenrollment rates. CONCLUSION: Georgia BCCPTA has the potential to improve continuity of care for women with breast and cervical cancers because they experience more stable coverage and simpler recertification process under this new eligibility category.

Can the Veterans Affairs health care system continue to care for the poor and vulnerable?

Can the Veterans Affairs (VA) health care system, long an important part of the safety net for disabled and poor veterans, survive the loss of World War II veterans--once its largest constituency and still its most important advocates? A recent shift in emphasis from acute hospital-based care to care of chronic illness in outpatient settings, as well as changes in eligibility allowing many more nonpoor and nondisabled veterans into the VA system, will be key determinants of long-term survivability. Although allowing less needy veterans into the system runs the risk of diluting services to those most in need, the long-run effect may be to increase support among a larger and younger group of veterans, thereby enhancing political clout and ensuring survivability. It may be that the best way to maintain the safety net for veterans is to continue to cast it more widely.