In-kind nutritional supplementation for household contacts of persons with tuberculosis would be cost-effective for reducing tuberculosis incidence and mortality in India: a modeling study.

Background: Undernutrition is the leading cause of tuberculosis (TB) globally, but nutritional interventions are often considered cost prohibitive. The RATIONS study demonstrated that nutritional support provided to household contacts of persons with TB can reduce TB incidence. However, the long-term cost-effectiveness of this intervention is unclear. Methods: We assessed the cost-effectiveness of a RATIONS-style intervention (daily 750 kcal dietary supplementation and multi-micronutrient tablet). Using a Markov state transition model we simulated TB incidence, treatment, and TB-attributable mortality among household contacts receiving the RATIONS intervention, as compared to no nutritional support. We calculated health outcomes (TB cases, TB deaths, and disability-adjusted life years [DALYs]) over the lifetime of intervention recipients and assessed costs from government and societal perspectives. We tested the robustness of results to parameter changes via deterministic and probabilistic sensitivity analysis. Findings: Over two years, household contacts receiving the RATIONS intervention would experience 39% (95% uncertainty interval (UI): 23-52) fewer TB cases and 59% (95% UI: 44-69) fewer TB deaths. The intervention was estimated to avert 13,775 (95% UI: 9036-20,199) TB DALYs over the lifetime of the study cohort comprising 100,000 household contacts and was cost-effective from both government (incremental cost-effectiveness ratio: $229 per DALY averted [95% UI: 133-387]) and societal perspectives ($184 per DALY averted [95% UI: 83-344]). The results were most sensitive to the cost of the nutritional supplement. Interpretation: Prompt nutritional support for household contacts of persons with TB disease would be cost-effective in reducing TB incidence and mortality in India. Summary: Undernutrition is the leading cause of tuberculosis in India. Using a Markov state-transition model, we found that food baskets for household contacts of persons with tuberculosis would be cost-effective in reducing tuberculosis incidence and mortality in India. Research in context: Evidence before this study: Undernutrition is the leading risk factor for TB worldwide. Recently, the RATIONS study demonstrated a roughly 40% reduction in incident TB among household contacts who received in-kind macronutrient and micronutrient supplementation. Added value of this study: Although the RATIONS study demonstrated a dramatic reduction in incident TB, it is unclear if nutritional interventions to prevent TB are cost-effective. Previously, only one cost-effectiveness analysis of nutritional interventions for household contacts has been published. Due to lack of published data, that study had to make assumptions regarding the impact of nutritional interventions on TB incidence and mortality. In this study, we conducted an economic evaluation of a RATIONS-style intervention to reduce incident TB and mortality in India using observed data. Implications of all the available evidence: In-kind nutritional supplementation for household contacts of individuals with TB disease would be cost-effective in reducing incident TB and TB mortality, particularly if TB programs leverage economies of scale to bring down the cost of the nutritional intervention.

Cost-effectiveness of Zinc Supplementation for Prevention of Childhood Diarrhoea in Tanzania.

OBJECTIVE: To assess the cost-effectiveness of prophylactic zinc supplementation for preventing diarrhoea in young children in Tanzania. DESIGN: Cost-effectiveness analysis using decision-analytic modelling. Cost-effectiveness ratios were calculated as the incremental cost (2019 USD) per disability-adjusted life year (DALY) averted, from a societal perspective, and with a 3% discount rate applied to future outcomes. Sensitivity analyses were performed to test the robustness of results to alternative assumptions. SETTING: Tanzania. PARTICIPANTS: A hypothetical cohort of 10,000 children ages 6 weeks to 18 months. RESULTS: The intervention costs of zinc supplementation were estimated as $109,800 (95% uncertainty interval: 61,716-171,507). Zinc supplementation was estimated to avert 2,200 (776-3,737) diarrhoeal episodes, 14,080 (4,692-25,839) sick days, 1,584 (522-2,927) outpatient visits, 561 (160-1,189) inpatient bed-days, 0.51 (0.15-1.03) deaths, and 19.3 (6.1-37.5) DALYs (discounted at 3% per year). Zinc supplementation reduced diarrhoea care costs by $12, 887 (4,089-25,058). The incremental cost per DALY averted was $4,950 (1,678-17,933). Incremental cost-effectiveness ratios (ICERs) estimated from a health system perspective were similar to the results from the societal perspective. ICERs were substantially lower (more favourable) when future outcomes were not discounted, but all ICERs were above contemporary thresholds for cost-effectiveness in this setting. CONCLUSION: Prophylactic zinc reduced diarrhoea incidence and associated healthcare utilization; however it did not appear to be cost-effective for prevention of childhood diarrhoea in the scenario examined in this study. Reducing intervention costs, or identifying high risk groups for intervention targeting, may be needed to improve cost-effectiveness in this setting.

Cost-effectiveness analysis of integrating screening and treatment of selected non-communicable diseases into HIV/AIDS treatment in Uganda.

INTRODUCTION: Despite growing enthusiasm for integrating treatment of non-communicable diseases (NCDs) into human immunodeficiency virus (HIV) care and treatment services in sub-Saharan Africa, there is little evidence on the potential health and financial consequences of such integration. We aim to study the cost-effectiveness of basic NCD-HIV integration in a Ugandan setting. METHODS: We developed an epidemiologic-cost model to analyze, from the provider perspective, the cost-effectiveness of integrating hypertension, diabetes mellitus (DM) and high cholesterol screening and treatment for people living with HIV (PLWH) receiving antiretroviral therapy (ART) in Uganda. We utilized cardiovascular disease (CVD) risk estimations drawing from the previously established Globorisk model and systematic reviews; HIV and NCD risk factor prevalence from the World Health Organization's STEPwise approach to Surveillance survey and global databases; and cost data from national drug price lists, expert consultation and the literature. Averted CVD cases and corresponding disability-adjusted life years were estimated over 10 subsequent years along with incremental cost-effectiveness of the integration. RESULTS: Integrating services for hypertension, DM, and high cholesterol among ART patients in Uganda was associated with a mean decrease of the 10-year risk of a CVD event: from 8.2 to 6.6% in older PLWH women (absolute risk reduction of 1.6%), and from 10.7 to 9.5% in older PLWH men (absolute risk reduction of 1.2%), respectively. Integration would yield estimated net costs between $1,400 and $3,250 per disability-adjusted life year averted among older ART patients. CONCLUSIONS: Providing services for hypertension, DM and high cholesterol for Ugandan ART patients would reduce the overall CVD risk among these patients; it would amount to about 2.4% of national HIV/AIDS expenditure, and would present a cost-effectiveness comparable to other standalone interventions to address NCDs in low- and middle-income country settings.

Integrating care for non-communicable diseases into routine HIV services: key considerations for policy design in sub-Saharan Africa.

INTRODUCTION: There is great interest for integrating care for non-communicable diseases (NCDs) into routine HIV services in sub-Saharan Africa (SSA) due to the steady rise of the number of people who are ageing with HIV. Suggested health system approaches for intervening on these comorbidities have mostly been normative, with little actionable guidance on implementation, and on the practical, economic and ethical considerations of favouring people living with HIV (PLHIV) versus targeting the general population. We summarize opportunities and challenges related to leveraging HIV treatment platforms to address NCDs among PLHIV. We emphasize key considerations that can guide integrated care in SSA and point to possible interventions for implementation. DISCUSSION: Integrating care offers an opportunity for effective delivery of NCD services to PLHIV, but may be viewed to unfairly ignore the larger number of NCD cases in the general population. Integration can also help maintain the substantial health and economic benefits that have been achieved by the global HIV/AIDS response. Implementing interventions for integrated care will require assessing the prevalence of common NCDs among PLHIV, which can be achieved via increased screening during routine HIV care. Successful integration will also necessitate earmarking funds for NCD interventions in national budgets. CONCLUSIONS: An expanded agenda for addressing HIV-NCD comorbidities in SSA may require adding selected NCDs to conditions that are routinely monitored in PLHIV. Attention should be given to mitigating potential tradeoffs in the quality of HIV services that may result from the extra responsibilities borne by HIV health workers. Integrated care will more likely be effective in the context of concurrent health system reforms that address NCDs in the general population, and with synergies with other HIV investments that have been used to strengthen health systems.

Cost-effectiveness of community-based screening and treatment of moderate acute malnutrition in Mali.

INTRODUCTION: Moderate acute malnutrition (MAM) causes substantial child morbidity and mortality, accounting for 4.4% of deaths and 6.0% of disability-adjusted life years (DALY) lost among children under 5 each year. There is growing consensus on the need to provide appropriate treatment of MAM, both to reduce associated morbidity and mortality and to halt its progression to severe acute malnutrition. We estimated health outcomes, costs and cost-effectiveness of four dietary supplements for MAM treatment in children 6-35 months of age in Mali. METHODS: We conducted a cluster-randomised MAM treatment trial to describe nutritional outcomes of four dietary supplements for the management of MAM: ready-to-use supplementary foods (RUSF; PlumpySup); a specially formulated corn-soy blend (CSB) containing dehulled soybean flour, maize flour, dried skimmed milk, soy oil and a micronutrient pre-mix (CSB++; Super Cereal Plus); Misola, a locally produced, micronutrient-fortified, cereal-legume blend (MI); and locally milled flour (LMF), a mixture of millet, beans, oil and sugar, with a separate micronutrient powder. We used a decision tree model to estimate long-term outcomes and calculated incremental cost-effectiveness ratios (ICERs) comparing the health and economic outcomes of each strategy. RESULTS: Compared to no MAM treatment, MAM treatment with RUSF, CSB++, MI and LMF reduced the risk of death by 15.4%, 12.7%, 11.9% and 10.3%, respectively. The ICER was US$9821 per death averted (2015 USD) and US$347 per DALY averted for RUSF compared with no MAM treatment. CONCLUSION: MAM treatment with RUSF is cost-effective across a wide range of willingness-to-pay thresholds. TRIAL REGISTRATION: NCT01015950.

Cost analysis of the treatment of severe acute malnutrition in West Africa.

We present an updated cost analysis to provide new estimates of the cost of providing community-based treatment for severe acute malnutrition, including expenditure shares for major cost categories. We calculated total and per child costs from a provider perspective. We categorized costs into three main activities (outpatient treatment, inpatient treatment, and management/administration) and four cost categories within each activity (personnel; therapeutic food; medical supplies; and infrastructure and logistical support). For each category, total costs were calculated by multiplying input quantities expended in the Médecins Sans Frontières nutrition program in Niger during a 12-month study period by 2015 input prices. All children received outpatient treatment, with 43% also receiving inpatient treatment. In this large, well-established program, the average cost per child treated was €148.86, with outpatient and inpatient treatment costs of €75.50 and €134.57 per child, respectively. Therapeutic food (44%, €32.98 per child) and personnel (35%, €26.70 per child) dominated outpatient costs, while personnel (56%, €75.47 per child) dominated in the cost of inpatient care. Sensitivity analyses suggested lowering prices of medical treatments, and therapeutic food had limited effect on total costs per child, while increasing program size and decreasing use of expatriate staff support reduced total costs per child substantially. Updated estimates of severe acute malnutrition treatment cost are substantially lower than previously published values, and important cost savings may be possible with increases in coverage/program size and integration into national health programs. These updated estimates can be used to suggest approaches to improve efficiency and inform national-level resource allocation.