Where There Is A Will, There Is A Way: Enhancing Contraceptive Uptake In Pakistan.

OBJECTIVE: To assess the contribution of a series of interventions on contraceptive uptake and reduction in unmet need in areas covered by the Family Advancement for Life and Health project. Methods: The study was conducted from 2008-09 to 2011-12 in 14 districts across Pakistan. The sample comprised all urban and rural households in each district. A total or 40 blocks/villages were selected, with 13 households selected per block/village. Within each household, all married women of reproductive age 15-49 years were interviewed, and their husbands who were present at the time were also interviewed to a maximum of 5 per block. Baseline data was collected in 2008-09, while end line data was collected in 2010-11. Change in family planning uptake attributed to the project interventions were estimated. Besides, a situation analysis of service delivery points was also conducted. Data was analysed using SPSS 21. RESULTS: The panel comprised 5,304 women and 950 husbands. Interventions with the most robust effects were LHWs' home visits, attending women's group meetings, and watching family planning messages on television (p<0.05). The greatest changes were observed in Khyber Pakhtunkhwa province, in urban areas and among younger women (p<0.05). CONCLUSIONS: Investing in public-sector services does pay off in terms of meeting family planning needs, and so do better, wider and clearer communication.

Cost-effectiveness of Early Treatment of Hepatitis C Virus Genotype 1 by Stage of Liver Fibrosis in a US Treatment-Naive Population.

IMPORTANCE: Novel treatments for hepatitis C virus (HCV) infection are highly efficacious but costly. Thus, many insurers cover therapy only in advanced fibrosis stages. The added health benefits and costs of early treatment are unknown. OBJECTIVE: To assess the cost-effectiveness of (1) treating all patients with HCV vs only those with advanced fibrosis and (2) treating each stage of fibrosis. DESIGN, SETTING, AND PARTICIPANTS: This study used a decision-analytic model for the treatment of HCV genotype 1. The model used a lifetime horizon and societal perspective and was representative of all US patients with HCV genotype 1 who had not received previous treatment. Comparisons in the model included antiviral treatment of all fibrosis stages (METAVIR [Meta-analysis of Histological Data in Virial Hepatitis] stages F0 [no fibrosis] to F4 [cirrhosis]) vs treatment of stages F3 (numerous septa without cirrhosis) and F4 only and by specific fibrosis stage. Data were collected from March 1 to September 1, 2014, and analyzed from September 1, 2014, to June 30, 2015. INTERVENTIONS: Six HCV therapy options (particularly combined sofosbuvir and ledipasvir therapy) or no treatment. MAIN OUTCOMES AND MEASURES: Cost and health outcomes were measured using total medical costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs), calculated as the difference in costs between strategies divided by the difference in QALYs. RESULTS: We simulated 1000 individuals, but present the results normalized to a single HCV-infected person. In the base-case analysis, among patients receiving 8 or 12 weeks of sofosbuvir-ledipasvir treatment, treating all fibrosis stages compared with treating stages F3 and F4 adds 0.73 QALYs and $28,899, for an ICER of $39,475 per QALY gained. Treating at stage F2 (portal fibrosis with rare septa) costs $19,833 per QALY gained vs waiting until stage F3; treating at stage F1 (portal fibrosis without septa), $81,165 per QALY gained compared with waiting until stage F2; and treating at stage F0, $187,065 per QALY gained compared with waiting until stage F1. Results for other regimens show a similar pattern. At base-case drug prices, treating 50% of all eligible US patients with HCV genotype 1 would cost $53 billion. In sensitivity analyses, the ICER for treating all stages vs treating stages F3 and F4 was most sensitive to cohort age, drug costs, utility values in stages F1 and F2, and percentage of patients eligible for 8-week therapy. Except for patients aged 70 years, the ICER remains less than $100,000 per QALY gained. A 46% reduction in cost of sofosbuvir-ledipasvir therapy decreases the ICER for treating at all fibrosis stages by 48%. CONCLUSIONS AND RELEVANCE: In this simulated model, treating HCV infection at early stages of fibrosis appeared to improve health outcomes and to be cost-effective but incurred substantial aggregate costs. The findings may have implications for health care coverage policies and clinical decision making.

Men's use of sexual health services.

CONTEXT AND OBJECTIVE: Previous research on users of sexual health services has focused primarily on women. However, a focus on men also is needed to address sexual ill-health. This paper uses various data sources to describe the level of, and trends in, men's use of sexual health services in England. DATA SOURCES: Routine data are presented on clients of family planning clinics (FPCs), Brook Advisory Centres and attendances at genitourinary medicine (GUM) clinics. Cross-sectional surveys used include the National Survey of Sexual Attitudes and Lifestyles, Morbidity Statistics from General Practice and the National Gay Men's Sex Survey. RESULTS: The number of male clients attending FPCs has increased by 160% over the 1990s. Most of this increase is due to more men obtaining condoms. The ages of these clients are unknown, but data from Brook Advisory Centres show an increase among younger men. The one service for which male and female use is approximately equal is GUM. Male cases of sexually transmitted infections and other treatments have increased over the 1990s, although not at the same rate as female cases. Use of GUM clinics by homosexually active men is much greater than by all men. Recent data on men's use of general practice for sexual health are lacking. DISCUSSION AND CONCLUSIONS: While overall service use among men is still at a comparatively low level, it has increased over the 1990s for some services. Further in-depth research should question men's wants and demands from sexual health services.

Promoting sexual health services to young men: findings from focus group discussions.

CONTEXT: Recently, increasing interest has been shown in men's reproductive health, sexual behaviour and use of contraception. As the majority of sexual health service clients are female, however, little research has been done on the characteristics and needs of male clients. OBJECTIVE: Using data from focus group discussions, this paper considers whether young men need sexual health services, whether current services are appropriate and accessible, and what promotion strategies might increase service uptake. DESIGN: Nine focus group discussions with 75 men aged 13-21 years at different locations in England. RESULTS: Young men's decision-making around sexual health may involve seeking advice from a close friend, but is less likely in some male social groups. Use of services by young men is most likely to obtain free condoms, or to remedy a crisis situation. While a young man is becoming familiar with obtaining condoms from a service, the need for a quick, straightforward service seems important. The stereotypical view within the groups was that sexual health services are women-oriented. However, suggestions are given to make services more youth- and male-friendly. Promotion should aim to increase awareness and advance a positive image of a sexual health service. DISCUSSION AND CONCLUSIONS: Effective promotion campaigns (designed with the input of local young men), combined with appropriate and accessible services, should help to increase service use among young men.