Cost-effectiveness of parenteral artesunate for treating children with severe malaria in sub-Saharan Africa

Objective

To explore the cost-effectiveness of parenteral artesunate for the treatment of severe malaria in children and its potential impact on hospital budgets.

Methods

The costs of inpatient care of children with severe malaria were assessed in four of the 11 sites included in the African Quinine Artesunate Malaria Treatment trial, conducted with over 5400 children. The drugs, laboratory tests and intravenous fluids provided to 2300 patients from admission to discharge were recorded, as was the length of inpatient stay, to calculate the cost of inpatient care. The data were matched with pooled clinical outcomes and entered into a decision model to calculate the cost per disability-adjusted life year (DALY) averted and the cost per death averted.

Findings

The mean cost of treating severe malaria patients was similar in the two study groups: 63.5 United States dollars (US$) (95% confidence interval, CI: 61.7–65.2) in the quinine arm and US$ 66.5 (95% CI: 63.7–69.2) in the artesunate arm. Children treated with artesunate had 22.5% lower mortality than those treated with quinine and the same rate of neurological sequelae: (artesunate arm: 2.3 DALYs per patient; quinine arm: 3.0 DALYs per patient). Compared with quinine as a baseline, artesunate showed an incremental cost per DALY averted and an incremental cost per death averted of US$ 3.8 and US$ 123, respectively.

Conclusion

Artesunate is a highly cost-effective and affordable alternative to quinine for treating children with severe malaria. The budgetary implications of adopting artesunate for routine use in hospital-based care are negligible.     

Comparative impact assessment of child pneumonia interventions

Objective

To compare the cost-effectiveness of interventions to reduce pneumonia mortality through risk reduction, immunization and case management.

Methods

Country-specific pneumonia burden estimates and intervention costs from WHO were used to review estimates of pneumonia risk in children under 5 years of age and the efficacy of interventions (case management, pneumonia-related vaccines, improved nutrition and reduced indoor air pollution from household solid fuels). We calculated health benefits (disability-adjusted life years, DALYs, averted) and intervention costs over a period of 10 years for 40 countries, accounting for 90% of pneumonia child deaths.

Findings

Solid fuel use contributes 30% (90% confidence interval: 18–44) to the burden of childhood pneumonia. Efficacious community-based treatment, promotion of exclusive breastfeeding, zinc supplementation and Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae immunization through existing programmes showed cost-effectiveness ratios of 10–60 International dollars (I$) per DALY in low-income countries and less than I$ 120 per DALY in middle-income countries. Low-emission biomass stoves and cleaner fuels may be cost-effective in low-income regions. Facility-based treatment is potentially cost-effective, with ratios of I$ 60–120 per DALY. The cost-effectiveness of community case management depends on home visit cost.

Conclusion

Vaccines against Hib and S. pneumoniae, efficacious case management, breastfeeding promotion and zinc supplementation are cost-effective in reducing pneumonia mortality. Environmental and nutritional interventions reduce pneumonia and provide other benefits. These strategies combined may reduce total child mortality by 17%.     

Cost-effectiveness of malaria intermittent preventive treatment in infants (IPTi) in Mozambique and the United Republic of Tanzania

Objective

To estimate the cost-effectiveness of malaria intermittent preventive treatment in infants (IPTi) using sulfadoxine-pyrimethamine (SP).

Methods

In two previous IPTi trials in Ifakara (United Republic of Tanzania) and Manhiça (Mozambique), SP was administered three times to infants before 9 months of age through the Expanded Programme on Immunization. Based on the efficacy results of the intervention and on malaria incidence in the target population, an estimate was made of the number of clinical malaria episodes prevented. This number and an assumed case-fatality rate of 1.57% were used, in turn, to estimate the number of disability-adjusted life years (DALY) averted and the number of deaths averted. The cost of the intervention, including start-up and recurrent costs, was then assessed on the basis of these figures.

Findings

The cost per clinical episode of malaria averted was US$ 1.57 (range: US$ 0.8–4.0) in Ifakara and US$ 4.73 (range: US$ 1.7–30.3) in Manhiça; the cost per DALY averted was US$ 3.7 (range: US$ 1.6–12.2) in Ifakara and US$ 11.2 (range: US$ 3.6–92.0) in Manhiça; and the cost per death averted was US$ 100.2 (range: US$ 43.0–330.9) in Ifakara and US$ 301.1 (range: US$ 95.6–2498.4) in Manhiça.

Conclusion

From the health system and societal perspectives, IPTi with SP is expected to produce health improvements in a cost-effective way. From an economic perspective, it offers good value for money for public health programmes.     

Estimating the cost of new public health legislation

Objective

To develop a new method for estimating the cost to governments of enacting public health legislation.

Methods

We adopted a central government perspective in estimating costs. The parliamentary cost of legislative acts and regulations in New Zealand was calculated from the proportion of parliamentary time devoted to law-making (i.e. sitting days in the debating chamber), and the cost of associated policy advice from government agencies was calculated from the proportion of documented policy issues related to law-making. The relative costs of acts and regulations were estimated from the number of pages in the legislation.

Findings

We estimated that, between 1999 and 2010, 26.7% of parliamentary resources and 16.7% of policy advice from government agencies were devoted to generating new laws in New Zealand. The mean cost of an act was 2.6 million United States dollars (US$; 95% uncertainty interval, UI: 1.5 to 4.4 million) and the mean cost of a regulation was US$ 382 000 (95% UI: 221 000 to 665 000). For comparison, the average cost of a bill enacted by the 50 state governments in the United States of America between 2008 and 2009 was US$ 980 000.

Conclusion

We were able to estimate the cost of new legislation in New Zealand. Our method for estimating this cost seemed to capture the main government costs involved and appears to be generally applicable to other developed countries. Ideally such costs should be included in economic evaluations of public health interventions that involve new legislation.     

Peri-operative pulse oximetry in low-income countries: a cost–effectiveness analysis

Objective

To evaluate the cost–effectiveness of pulse oximetry – compared with no peri-operative monitoring – during surgery in low-income countries.

Methods

We considered the use of tabletop and portable, hand-held pulse oximeters among patients of any age undergoing major surgery in low-income countries. From earlier studies we obtained baseline mortality and the effectiveness of pulse oximeters to reduce mortality. We considered the direct costs of purchasing and maintaining pulse oximeters as well as the cost of supplementary oxygen used to treat hypoxic episodes identified by oximetry. Health benefits were measured in disability-adjusted life-years (DALYs) averted and benefits and costs were both discounted at 3% per year. We used recommended cost–effectiveness thresholds – both absolute and relative to gross domestic product (GDP) per capita – to assess if pulse oximetry is a cost–effective health intervention. To test the robustness of our results we performed sensitivity analyses.

Findings

In 2013 prices, tabletop and hand-held oximeters were found to have annual costs of 310 and 95 United States dollars (US$), respectively. Assuming the two types of oximeter have identical effectiveness, a single oximeter used for 22 procedures per week averted 0.83 DALYs per annum. The tabletop and hand-held oximeters cost US$ 374 and US$ 115 per DALY averted, respectively. For any country with a GDP per capita above US$ 677 the hand-held oximeter was found to be cost–effective if it prevented just 1.7% of anaesthetic-related deaths or 0.3% of peri-operative mortality.

Conclusion

Pulse oximetry is a cost–effective intervention for low-income settings.     

Global cost of correcting vision impairment from uncorrected refractive error

Objective

To estimate the global cost of establishing and operating the educational and refractive care facilities required to provide care to all individuals who currently have vision impairment resulting from uncorrected refractive error (URE).

Methods

The global cost of correcting URE was estimated using data on the population, the prevalence of URE and the number of existing refractive care practitioners in individual countries, the cost of establishing and operating educational programmes for practitioners and the cost of establishing and operating refractive care facilities. The assumptions made ensured that costs were not underestimated and an upper limit to the costs was derived using the most expensive extreme for each assumption.

Findings

There were an estimated 158 million cases of distance vision impairment and 544 million cases of near vision impairment caused by URE worldwide in 2007. Approximately 47 000 additional full-time functional clinical refractionists and 18 000 ophthalmic dispensers would be required to provide refractive care services for these individuals. The global cost of educating the additional personnel and of establishing, maintaining and operating the refractive care facilities needed was estimated to be around 20 000 million United States dollars (US$) and the upper-limit cost was US$ 28 000 million. The estimated loss in global gross domestic product due to distance vision impairment caused by URE was US$ 202 000 million annually.

Conclusion

The cost of establishing and operating the educational and refractive care facilities required to deal with vision impairment resulting from URE was a small proportion of the global loss in productivity associated with that vision impairment.     

Adult mortality and antiretroviral treatment roll-out in rural KwaZulu-Natal, South Africa

Objective

To investigate trends in adult mortality in a population serviced by a public-sector antiretroviral therapy (ART) programme in rural South Africa using a demographic surveillance system.

Methods

Verbal autopsies were conducted for all 7930 deaths observed between January 2000 and December 2006 in a demographic surveillance population of 74 500 in the Umkhanyakude district of northern KwaZulu-Natal province, South Africa. Age-standardized mortality rate ratios (SMRRs) were calculated for adults aged 25 to 49 years, the group most affected by HIV, for the 2 years before 2004 and the 3 subsequent years, during which ART had been available.

Findings

Between 2002–2003 (the period before ART) and 2004–2006 (the period after ART), HIV-related age-standardized mortality declined significantly, from 22.52 to 17.58 per 1000 person-years in women 25–49 years of age (P < 0.001; SMRR: 0.780; 95% confidence interval, CI: 0.691–0.881), and from 26.46 to 18.68 per 1000 person-years in men 25–49 years of age (P < 0.001; SMRR: 0.706; 95% CI: 0.615–0.811). On sensitivity analysis the results were robust to the possible effect of misclassification of HIV-related deaths.

Conclusion

Overall population mortality and HIV-related adult mortality declined significantly following ART roll-out in a community with a high prevalence of HIV infection. A clear public health message of the benefits of treatment, as revealed by these findings, should be part of a multi-faceted strategy to encourage people to find out their HIV serostatus and seek care.     

Implementing early infant diagnosis of HIV infection at the primary care level: experiences and challenges in Malawi

Problem

Malawi’s national guidelines recommend that infants exposed to the human immunodeficiency virus (HIV) be tested at 6 weeks of age. Rollout of services for early infant diagnosis has been limited and has resulted in the initiation of antiretroviral therapy (ART) in very few infants.

Approach

An early infant diagnosis programme was launched. It included education of pregnant women on infant testing, community sensitization, free infant testing at 6 weeks of age, active tracing of HIV-positive infants and referral for treatment and care.

Local setting

The programme was established in two primary care facilities in Blantyre, Malawi.

Relevant changes

Of 1214 HIV-exposed infants, 71.6% presented for early diagnosis, and 14.5% of those who presented tested positive for HIV. Further testing of 103 of these 126 apparently HIV-positive infants confirmed infection in 88; the other 15 results were false positives. The initial polymerase chain reaction testing of dried blood spots had a positive predictive value (PPV) of 85.4%. Despite active tracing, only 87.3% (110/126) of the mothers of infants who initially tested positive were told their infants’ test results. ART was initiated in 58% of the infants with confirmed HIV infection.

Lessons learnt

Early infant diagnosis of HIV infection at the primary care level in a resource-poor setting is challenging. Many children in the HIV diagnosis and treatment programme were lost to follow-up at various stages. Diagnostic tools with higher PPV and point-of-care capacity and better infrastructures for administering ART are needed to improve the management of HIV-exposed and HIV-infected infants.     

Scaling up antiretroviral therapy for HIV-infected children in C?te d’Ivoire: determinants of survival and loss to programme

Objective

To investigate deaths and losses to follow-up in a programme designed to scale up antiretroviral therapy (ART) for HIV-infected children in Côte d’Ivoire.

Methods

Between 2004 and 2007, HIV-exposed children at 19 centres were offered free HIV serum tests (polymerase chain reaction tests in those aged < 18 months) and ART. Computerized monitoring was used to determine: (i) the number of confirmed HIV infections, (ii) losses to the programme (i.e. death or loss to follow-up) before ART, (iii) mortality and loss-to-programme rates during 12 months of ART, and (iv) determinants of mortality and losses to the programme.

Findings

The analysis included 3876 ART-naïve children. Of the 1766 with HIV-1 infections (17% aged < 18 months), 124 (7.0%) died, 52 (2.9%) left the programme, 354 (20%) were lost to follow-up before ART, 259 (15%) remained in care without ART, and 977 (55%) started ART (median age: 63 months). The overall mortality rate during ART was significantly higher in the first 3 months than in months 4–12: 32.8 and 6.9 per 100 child-years of follow-up, respectively. Loss-to-programme rates were roughly double mortality rates and followed the same trend with duration of ART. Independent predictors of 12-month mortality on ART were pre-ART weight-for-age z-score < –2, percentage of CD4+ T lymphocytes < 10, World Health Organization HIV/AIDS clinical stage 3 or 4, and blood haemoglobin < 8 g/dl.

Conclusion

The large-scale programme to scale up paediatric ART in Côte d’Ivoire was effective. However, ART was often given too late, and early mortality and losses to programme before and just after ART initiation were major problems.     

Presumptive diagnosis of severe HIV infection to determine the need for antiretroviral therapy in children less than 18 months of age

Objective

To develop a new algorithm for the presumptive diagnosis of severe disease associated with human immunodeficiency virus (HIV) infection in children less than 18 months of age for the purpose of identifying children who require antiretroviral therapy (ART).

Methods

A conditional probability model was constructed and non-virologic parameters in various combinations were tested in a hypothetical cohort of 1000 children aged 6 weeks, 6 months and 12 months to assess the sensitivity, specificity, and positive and negative predictive values of these algorithms for identifying children in need of ART. The modelled parameters consisted of clinical criteria, rapid HIV antibody testing and CD4+ T-lymphocyte (CD4) count.

Findings

In children younger than 18 months, the best-performing screening algorithm, consisting of clinical symptoms plus antibody testing plus CD4 count, showed a sensitivity ranging from 71% to 80% and a specificity ranging from 92% to 99%. Positive and negative predictive values were between 61% and 97% and between 95% and 96%, respectively. In the absence of virologic tests, this alternate algorithm for the presumptive diagnosis of severe HIV disease makes it possible to correctly initiate ART in 91% to 98% of HIV-positive children who are at highest risk of dying.

Conclusion

The algorithms presented in this paper have better sensitivity and specificity than clinical parameters, with or without rapid HIV testing, for the presumptive diagnosis of severe disease in HIV-positive children less than 18 months of age. If implemented, they can increase the number of HIV-positive children successfully initiated on ART.     

Eliminating mother-to-child HIV transmission in South Africa

Problem

The World Health Organization has produced clear guidelines for the prevention of mother-to-child transmission (PMTCT) of the human immunodeficiency virus (HIV). However, ensuring that all PMTCT programme components are implemented to a high quality in all facilities presents challenges.

Approach

Although South Africa initiated its PMTCT programme in 2002, later than most other countries, political support has increased since 2008. Operational research has received more attention and objective data have been used more effectively.

Local setting

In 2010, around 30% of all pregnant women in South Africa were HIV-positive and half of all deaths in children younger than 5 years were associated with the virus.

Relevant changes

Between 2008 and 2011, the estimated proportion of HIV-exposed infants younger than 2 months who underwent routine polymerase chain reaction (PCR) tests to detect early HIV transmission increased from 36.6% to 70.4%. The estimated HIV transmission rate decreased from 9.6% to 2.8%. Population-based surveys in 2010 and 2011 reported transmission rates of 3.5% and 2.7%, respectively.

Lessons learnt

Critical actions for improving programme outcomes included: ensuring rapid implementation of changes in PMTCT policy at the field level through training and guideline dissemination; ensuring good coordination with technical partners, such as international health agencies and international and local nongovernmental organizations; and making use of data and indicators on all aspects of the PMTCT programme. Enabling health-care staff at primary care facilities to initiate antiretroviral therapy and expanding laboratory services for measuring CD4+ T-cell counts and for PCR testing were also helpful.     

Elimination of paediatric HIV in KwaZulu-Natal, South Africa: large-scale assessment of interventions for the prevention of mother-to-child transmission

Objective

To report the rates of mother-to-child transmission (MTCT) of the human immunodeficiency virus (HIV), and the coverage of interventions designed to prevent such transmission, in KwaZulu-Natal.

Methods

Mothers with infants aged ≤ 16 weeks and fathers or legal guardians with infants aged 4–8 weeks who, between May 2008 and April 2009, attended immunization clinics in six districts of KwaZulu-Natal were included. The mothers’ uptake of interventions for the prevention of MTCT was explored. Blood samples from infants aged 4–8 weeks were tested for anti-HIV antibodies and, if antibody-positive, for HIV desoxyribonucleic acid (DNA).

Findings

Of the 19 494 mothers investigated, 89·9% reported having had an HIV test in their recent pregnancy. Of the 19 138 mothers who reported ever having had an HIV test, 34.4% reported that they had been found HIV-positive and, of these, 13.7% had started lifelong antiretroviral treatment and 67.2% had received zidovudine and nevirapine. Overall, 40.4% of the 7981 infants tested were found positive for anti-HIV antibodies, indicating HIV exposure. Just 7.1% of the infants checked for HIV DNA (equating to 2.8% of the infants tested for anti-HIV antibodies) were found positive.

Conclusion

The low levels of MTCT observed among the infants indicate the rapid, successful implementation of interventions for the prevention of such transmission. Sampling at immunization clinics appears to offer a robust method of estimating the impact of interventions designed to reduce such transmission. Large-scale elimination of paediatric HIV infections appears feasible, although this goal has not yet been fully achieved in KwaZulu-Natal.     

Expansion of antiretroviral treatment to rural health centre level by a mobile service in Mumbwa district, Zambia

Problem

Despite the Government’s effort to expand services to district level, it is still hard for people living with HIV to access antiretroviral treatment (ART) in rural Zambia. Strong demands for expanding ART services at the rural health centre level face challenges of resource shortages.

Approach

The Mumbwa district health management team introduced mobile ART services using human resources and technical support from district hospitals, and community involvement at four rural health centres in the first quarter of 2007. This paper discusses the uptake of the mobile ART services in rural Mumbwa.

Local setting

Mumbwa is a rural district with an area of 23 000 km² and a population of 167 000. Before the introduction of mobile services, ART services were provided only at Mumbwa District Hospital.

Relevant changes

The mobile services improved accessibility to ART, especially for clients in better functional status, i.e. still able to work. In addition, these mobile services may reduce the number of cases “lost to follow-up”. This might be due to the closer involvement of the community and the better support offered by these services to rural clients.

Lessons learnt

These mobile ART services helped expand services to rural health facilities where resources are limited, bringing them as close as possible to where clients live.     

The Relationship Between Disability-Adjusted Life Years of Cataracts and Ambient Erythemal Ultraviolet Radiation in China

Background

Cataracts are one of the major public health problems worldwide. Ultraviolet radiation (UVR) is one of the risk factors for cataract development. We analyzed the relationship between disability-adjusted life year (DALY) rates of cataracts and UVR exposure in China.

Methods

DALY rates of cataracts and UVR exposure in 31 regions of China were calculated based on data from the Second China National Sample Survey on Disability and the United States’ National Aeronautics and Space Administration database. The relationship between the DALY rates of cataracts and UVR was estimated by Spearman rank correlation analysis and linear regression analysis.

Results

The elderly (≥65 years) had higher DALY rates of cataracts than the whole population. The DALY rate of cataracts in the agricultural population was higher than that observed in the non-agricultural population. The DALY rates of cataracts were positively associated with UVR The DALY rates of cataracts in regions with higher UVR were higher than those in regions with lower UVR. An increase in the daily ambient erythemal UVR of 1000 J/m² was associated with an increase in the DALY rates of cataracts by 92 DALYs/100 000 (R² = 0.676) among the whole population, 34 DALYs/100 000 among the population <65 years old (R² = 0.423), 607 DALYs/100 000 among the population aged 65–74 years (R² = 0.617), and by 1342 DALYs/100 000 among the population ≥75 years old (R² = 0.758).

Conclusions

DALY rates of cataracts increased with increases in UVR exposure in 31 regions of China. Greater exposure to UVR increases the disease burden of cataracts in the whole population, especially in the elderly and among the agricultural population.Key words: cataract, UVR exposure, disease burden, DALYs     

Financial barriers to HIV treatment in Yaound��, Cameroon: first results of a national cross-sectional survey

Objective

To assess the extent to which user fees for antiretroviral therapy (ART) represent a financial barrier to access to ART among HIV-positive patients in Yaoundé, Cameroon.

Methods

Sociodemographic, economic and clinical data were collected from a random sample of 707 HIV-positive patients followed up in six public hospitals of the capital city (Yaoundé) and its surroundings through face-to-face interviews carried out by trained interviewers independently from medical staff and medical questionnaires filled out by prescribing physicians. Logistic regression models were used to identify factors associated with self-reported financial difficulties in purchasing ART during the previous 3 months.

Findings

Of the 532 patients treated with ART at the time of the survey, 20% reported financial difficulty in purchasing their antiretroviral drugs during the previous 3 months. After adjustment for socioeconomic and clinical factors, reports of financial difficulties were significantly associated with lower adherence to ART (odds ratio, OR: 0.24; 95% confidence interval, CI: 0.15–0.40; P < 0.0001) and with lower CD4+ lymphocyte (CD4) counts after 6 months of treatment (OR: 2.14; 95% CI: 1.15–3.96 for CD4 counts < 200 cells/µl; P = 0.04).

Conclusion

Removing a financial barrier to treatment with ART by eliminating user fees at the point of care delivery, as recommended by WHO, could lead to increased adherence to ART and to improved clinical results. New health financing mechanisms based on the public resources of national governments and international donors are needed to attain universal access to drugs and treatment for HIV infection.     

The cost effectiveness of home-based provision of antiretroviral therapy in rural Uganda

Background

Highly active antiretroviral therapy (HAART) provides dramatic health benefits for HIV-infected individuals in Africa, and widespread implementation of HAART is proceeding rapidly. Little is known about the cost and cost effectiveness of HAART programmes.

Objective

To determine the incremental cost effectiveness of a home-based HAART programme in rural Uganda.

Methods

A computer-based, deterministic cost-effectiveness model was used to assess a broad range of economic inputs and health outcomes. From the societal perspective, the cost effectiveness of HAART and cotrimoxazole prophylaxis was compared with cotrimoxazole alone, and with the period before either intervention. Data for 24 months were derived from a trial of home-based HAART in 1045 patients in the Tororo District in eastern Uganda. Costs and outcomes were projected out to 15 years. All costs are in year 2004 values. The main outcome measures were HAART programme costs, health benefits accruing to HAART recipients, averted HIV infections in adults and children and the resulting effects on medical care costs. The first-line HAART regimen consisted of standard doses of stavudine, lamivudine, and either nevirapine or, for patients with active tuberculosis, efavirenz. Second-line therapy consisted of tenofovir, didanosine and lopinavir/ritonavir. For children, first-line HAART consisted of zidovudine, lamivudine and nevirapine syrup; second-line therapy was stavudine, didanosine and lopinavir/ritonavir.

Results

The HAART programme, standardized for 1000 patients, cost an incremental $US1.39 million in its first 2 years. Compared with cotrimoxazole prophylaxis alone, the programme reduced mortality by 87%, and averted 6861 incremental disability-adjusted life-years (DALYs). Benefits were accrued from reduced mortality in HIV-infected adults (67.5% of all benefits), prevention of death in HIV-negative children (20.7%), averted HIV infections in adults (9.1%) and children (1.0%), and improved health status (1.7%). The net programme cost, including the medical cost implications of these health benefits, was $US4.10 million. The net cost per DALY averted was $US597 compared with cotrimoxazole alone. Many HIV interventions have a cost-effectiveness ratio in the range of $US1-150 per DALY averted.

Conclusions

This study suggests that a home-based HAART programme in rural Africa may be more cost effective than most previous estimates for facility-based HAART programmes, but remains less cost effective than many HIV prevention and care interventions, including cotrimoxazole prophylaxis.     

The incremental cost of switching from Option?B to Option?B+ for the prevention of mother-to-child transmission of HIV

Objective

To estimate the incremental cost over 5 years of a policy switch from the Option B to the Option B+ protocol for the prevention of mother-to-child transmission (PMTCT) of the human immunodeficiency virus (HIV).

Methods

Data from cost studies and other published sources were used to determine the cost, per woman and per cohort (1000 breastfeeding and 1000 non-breastfeeding women), of switching from Option B (maternal triple antiretroviral [ARV] regimen during pregnancy and breastfeeding plus daily nevirapine for the infant for 6 weeks) to Option B+ (maternal triple ARV regimen initiated during pregnancy and continued for life). The variables used to model the different scenarios were maternal CD4+ T lymphocyte (CD4+ cell) count (350–500 versus > 500 cells/µl), rate of decline in CD4+ cells (average, rapid, slow), breastfeeding status (yes, no) and breastfeeding duration (12, 18 or 24 months).

Findings

For women with CD4+ cell counts of 350–500 cells/µl, the incremental cost per 1000 women was 157 345 United States dollars (US$) for breastfeeding women and US$ 92 813 for non-breastfeeding women. For women with CD4+ cell counts > 500 cells/µl, the incremental cost per 1000 women ranged from US$ 363 443 to US$ 484 591 for breastfeeding women and was US$ 605 739 for non-breastfeeding women.

Conclusion

From a cost perspective, a policy switch from Option B to Option B+ is feasible in PMTCT programme settings where resources are currently being allocated to Option B.     

Integrating antiretroviral therapy into antenatal care and maternal and child health settings: a systematic review and meta-analysis

Objective

To determine whether integrating antiretroviral therapy (ART) into antenatal care (ANC) and maternal and child health (MCH) clinics could improve programmatic and patient outcomes.

Methods

The authors systematically searched PubMed, Embase, African Index Medicus and LiLACS for randomized controlled trials, prospective cohort studies, or retrospective cohort studies comparing outcomes in ANC or MCH clinics that had and had not integrated ART. The outcomes of interest were ART coverage, ART enrolment, ART retention, mortality and transmission of human immunodeficiency virus (HIV).

Findings

Four studies met the inclusion criteria. All were conducted in ANC clinics. Increased enrolment of pregnant women in ART was observed in ANC clinics that had integrated ART (relative risk, RR: 2.09; 95% confidence interval, CI; 1.78–2.46; I²: 15%). Increased ART coverage was also noted in such clinics (RR: 1.37; 95% CI: 1.05–1.79; I²: 83%). Sensitivity analyses revealed a trend for the national prevalence of HIV infection to explain the heterogeneity in the size of the effect of ART integration on ART coverage (P = 0.13). Retention in ART was similar in ANC clinics with and without ART integration.

Conclusion

Although few data were available, ART integration in ANC clinics appears to lead to higher rates of ART enrolment and ART coverage. Rates of retention in ART remain similar to those observed in referral-based models.     

Estimating the Burden of Disease from Unsafe Injections in India: A Cost�Cbenefit Assessment of the Auto-disable Syringe in a Country with Low Blood-borne Virus Prevalence

Background:

Unsafe medical injections are a prevalent risk factor for viral hepatitis and HIV in India.

Objectives:

This review undertakes a cost–benefit assessment of the auto-disable syringe, now being introduced to prevent the spread of hepatitis B virus, hepatitis C virus, and human immunodeficiency virus (HIV).

Materials and Methods:

The World Health Organization methods for modeling the global burden of disease from unsafe medical injections are reproduced, correcting for the concentrated structure of the HIV epidemic in India. A systematic review of risk factor analyses in India that investigate injection risks is used in the uncertainty analysis.

Results:

The median population attributable fraction for hepatitis B carriage associated with recent injections is 46%, the median fraction of hepatitis C infections attributed to unsafe medical injections is 38%, and the median fraction of incident HIV infections attributed to medical injections is 12% in India. The modeled incidence of blood-borne viruses suggests that introducing the auto-disable syringe will impose an incremental cost of $46–48 per disability adjusted life year (DALY) averted. The epidemiological evidence suggests that the incremental cost of introducing the auto-disable syringe for all medical injections is between $39 and $79 per DALY averted.

Conclusions:

The auto-disable syringe is a cost-effective alternative to the reuse of syringes in a country with low prevalence of blood-borne viruses.     

Lost opportunities to complete CD4+ lymphocyte testing among patients who tested positive for HIV in South Africa

Objective

To estimate rates of completion of CD4+ lymphocyte testing (CD4 testing) within 12 weeks of testing positive for human immunodeficiency virus (HIV) at a large HIV/AIDS clinic in South Africa, and to identify clinical and demographic predictors for completion.

Methods

In our study, CD4 testing was considered complete once a patient had retrieved the test results. To determine the rate of CD4 testing completion, we reviewed the records of all clinic patients who tested positive for HIV between January 2008 and February 2009. We identified predictors for completion through multivariate logistic regression.

Findings

Of the 416 patients who tested positive for HIV, 84.6% initiated CD4 testing within the study timeframe. Of these patients, 54.3% were immediately eligible for antiretroviral therapy (ART) because of a CD4 cell count ≤ 200/µl, but only 51.3% of the patients in this category completed CD4 testing within 12 weeks of HIV testing. Among those not immediately eligible for ART (CD4 cells > 200/µl), only 14.9% completed CD4 testing within 12 weeks. Overall, of HIV+ patients who initiated CD4 testing, 65% did not complete it within 12 weeks of diagnosis. The higher the baseline CD4 cell count, the lower the odds of completing CD4 testing within 12 weeks.

Conclusion

Patient losses between HIV testing, baseline CD4 cell count and the start of care and ART are high. As a result, many patients receive ART too late. Health information systems that link testing programmes with care and treatment programmes are needed.