Cost and cost-effectiveness of PPM-DOTS for tuberculosis control: evidence from India

OBJECTIVE: To assess the cost and cost-effectiveness of the Public-Private Mix DOTS (PPM-DOTS) strategy for tuberculosis (TB) control in India. METHODS: We collected data on the costs and effects of pilot PPM-DOTS projects in Delhi and Hyderabad using documentary data and interviews. The cost of PPM-DOTS was compared with public sector DOTS (i.e. DOTS delivered through public sector facilities only) and non-DOTS treatment in the private sector. Costs for 2002 in US$ were assessed for the public sector, private practitioners, and patients/attendants. Effectiveness was measured as the number of cases successfully treated. FINDINGS: The average cost per patient treated was US$ 111-123 for PPM-DOTS and public sector DOTS, and US$ 111-172 for non-DOTS treatment in the private sector. From the public sector's perspective, the cost per patient treated was lower in PPM-DOTS projects than in public sector DOTS programmes (US$ 24-33 versus US$ 63). DOTS implementation in either the public or private sectors improved treatment outcomes and substantially lowered costs incurred by patients and their attendants, compared to non-DOTS treatment in the private sector (US$ 50-60 for DOTS compared to over US$ 100 for non-DOTS). The average cost-effectiveness of PPM-DOTS and public sector DOTS was similar, at US$ 120-140 per patient successfully treated, compared to US$ 218-338 for non-DOTS private sector treatment. Incremental cost-effectiveness analysis showed that PPM-DOTS can improve effectiveness while also lowering costs. CONCLUSION: PPM-DOTS can be an affordable and cost-effective approach to improving TB control in India, and can substantially lower the economic burden of TB for patients.     

广东省艾滋病流行概况及预防控制策略

目的 分析广东省艾滋病(HIV/AIDS)流行概况和存在问题,提出控制策略.方法 用描述性流行病学方法 对广东省的HTV/AIDS报告资料和HIV常规、哨点、行为监测资料进行分析.结果 广东省1986年报告首例输入性HIV感染者,1986-1996年感染例数逐年有所上升,年平均增加10.2%.1996年底首次从静脉吸毒者中发现HIV感染者,1996-2005年呈快速增长的趋势,年平均增长160.3%,至2005年达到高峰,2006-2007年呈平稳状态.截止2007年底累计共报告HIV感染者22800例,其中AIDS病例2491例,死亡985例.报告的感染者主要集中在广州、佛山、深圳、江门、阳江、中山和东莞7市,占总病例教的84.5%.传播途径明确的14069例中,静脉吸毒传播占74.3%,异性传播占20.5%,男男同性传播占1.3%.哨点监测表明:戒毒人群平均HIV感染率从1996年的0.02%上升至2005年的5.5%;性病门诊就诊者平均HIV感染率从1997年的0.03%上升至2007年的0.40%;妇教所的暗娼于1998年首次检出HIV感染者(0.14%),但一直维持在较低的感染率,2007年检出率为0.21%;男男性接触者(MSM)人群2006、2007年HIV检出率分别为1.3%、2.75%.行为学监测表明:静脉吸毒者共用注射器的比例历年来变化不大,在53.3%～38.6%之间波动,吸毒者中约30%有购买性服务的行为,而且每次使用安全套的比例不足10%;暗娼中最近1次与客人发生性行为时安全套的使用率近年有所上升,目前维持在80%以上.结论 广东省HIV/AIDS疫情呈局部高流行、全省低流行态势;传播途径仍以静脉吸毒为主.但性途径传播逐年上升.近期的控制策略为提高各部门共同参与控制艾滋病的力度;加强能力建设;控制HIV在吸毒人群的传播,遏制经性途径传播的速度,预防二代传播,加强对MSM人群和流动人口的防治力度.     

Economic evaluation of hepatitis B vaccination in low-income countries: using cost-effectiveness affordability curves

OBJECTIVE: We sought to describe a method that explicitly considers both a health-care programmes cost-effectiveness and its affordability. For illustration, we apply the method to the programme to vaccinate infants against hepatitis B in the Gambia. METHODS: We synthesized selected data and developed a computer-based model from the societal and payer perspectives to evaluate the cost-effectiveness of routine infant vaccination against hepatitis B in the Gambia compared with no vaccination. The primary outcome measure was cost per averted disability-adjusted life year (DALY), which was expressed in 2002 US dollars. We used Monte Carlo methods for uncertainty analysis to examine the affordability of the programme from the payers perspective, and we derived an affordability curve and cost-effectiveness affordability curves for the programme. FINDINGS: In the Gambia, vaccinating infants against hepatitis B is highly cost-effective. Compared with offering no intervention, the vaccination programme would cost US$ 28 per DALY averted from the societal perspective or US$ 47 per DALY averted from the payers perspective. The programme also has the potential to be affordable, starting at a relatively low budget of US$ 160,000 per year. Combining the two dimensions of the outcome measure, the probability that vaccinating infants would be both cost-effective and affordable is 40% at an annual programme budget of US$ 182,000 (the estimated total programme cost from the payers perspective), given a threshold cost-effectiveness value of US$ 47 per DALY averted. CONCLUSION: In the face of uncertainties about both the health and economic consequences of a vaccine programme, as well as the availability and magnitude of resources needed to fund the programme, cost-effectiveness affordability curves can provide information to decision-makers about the probability that a programme will be both cost-effective and affordable: these are distinct but equally relevant considerations in resource-poor settings.     

Sputum concentration improves diagnosis of tuberculosis in a setting with a high prevalence of HIV

Sputum microscopy for acid-fast bacilli (AFB), although relatively insensitive, is still the cornerstone of tuberculosis (TB) diagnosis in the developing world. Its diagnostic value has been eroded owing to the increasing number of HIV-related smear-negative pulmonary TB cases. Concentration of sputum by centrifugation after liquefaction with sodium hypochlorite is a possible means of increasing the sensitivity of direct microscopy. This procedure has been studied recently in developing countries although with conflicting results. The aim of our study, performed in 1996 in Addis Ababa, Ethiopia, was to evaluate the sensitivity of the concentration method in a large cohort of consecutive patients with suspected pulmonary TB. We show that the overall sensitivity increased from 54.2% using conventional direct microscopy to 63.1% after concentration (P < 0x0015). In HIV-positive patients, sensitivity increased from 38.5% before to 50.0% after concentration (P < 0x0034). The significant increase in yield of AFB in HIV-positive patients suggests that this method has a place in routine diagnosis of pulmonary TB in countries with a high prevalence of HIV.     

Hormonal contraception and HIV prevalence in four African countries

BACKGROUND: The HIV seroprevalence among women aged 15-24 years was compared according to their pattern of contraceptive use in four African countries: Kenya, Lesotho, Malawi and Zimbabwe. STUDY DESIGN: Data were derived from Demographic and Health Surveys (DHS) conducted between 2003 and 2006 on representative samples, totaling 4549 women. RESULTS: It is indicated that users of depo-medroxyprogesterone acetate (DMPA) have a significantly higher seroprevalence than nonusers [odds ratio (OR)=1.82, 95% CI=1.63-2.03] and higher than users of oral contraceptives and users of traditional methods. The results were confirmed in a multivariate analysis including as controls, age, duration since first intercourse, urban residence, education, number of sexual partners in the last 12 months and marital status. A somewhat smaller net effect (OR=1.34, 95% CI=1.10-1.63) was found. In contrast, oral contraceptives and traditional methods did not show any risk for HIV (OR=0.96 and 0.92, respectively). CONCLUSION: The increased risk of DMPA was present in three of the four countries investigated, and significant in Zimbabwe and Lesotho, the countries with the highest HIV seroprevalence. The HIV risk attributable to DMPA remained small altogether and was estimated as 6% in the four countries combined.     

Costs, health effects and cost-effectiveness of alcohol and tobacco control strategies in Estonia

OBJECTIVE: To assess the population-level costs, effects and cost-effectiveness of different alcohol and tobacco control strategies in Estonia. DESIGN: A WHO cost-effectiveness modelling framework was used to estimate the total costs and effects of interventions. Costs were assessed in Estonian Kroon (EEK) for the year 2000, while effects were expressed in disability-adjusted life years (DALYs) averted. Regional cost-effectiveness estimates for Eastern Europe, were used as baseline and were contextualised by including country-specific input data. RESULTS: Increased excise taxes are the most cost-effective intervention to reduce both hazardous alcohol consumption and smoking: 759 EEK (euro 49) and 218 EEK (euro 14) per DALY averted, respectively. Imposing additional advertising bans would cost 1331 EEK (euro 85) per DALY averted to reduce hazardous alcohol consumption and 304 EEK (euro 19) to reduce smoking. Compared to WHO-CHOICE regional estimates, interventions were less costly and thereby more cost-effective in Estonia. CONCLUSIONS: Interventions in alcohol and tobacco control are cost-effective, and broad implementation of these interventions to upgrade current situation is warranted from the economic point of view. First priority is an increase in taxation, followed by advertising bans and other interventions. The differences between WHO-CHOICE regional cost-effectiveness estimates and contextualised results underline the importance of the country level analysis.     

A cost-effectiveness analysis of measles outbreak control strategies

This study compares the cost-effectiveness of six vaccination strategies during a measles outbreak: vaccination of all susceptibles 15 months of age or older and born after 1956 (the current routine strategy); lowering the recommended age at vaccination from 15 to 12 months (plus current routine strategy); lowering the recommended age at vaccination to six months (plus current routine strategy); revaccination of those vaccinated at 12-14 months of age (plus current routine strategy); vaccination of all students in school regardless of immune status; and vaccination of all residents 15 months to 28 years of age in the community regardless of immune status. The analysis is based on the hypothetical, early application of these strategies to a 1985 measles outbreak in Montana, which occurred despite appropriate application of current prevention and control recommendations. Although the results are applicable only to this particular outbreak, this analysis provides an approach which can be used in other settings to assess measles outbreak control strategies. Similar studies would need to be performed in a variety of settings to determine the most cost-effective measles outbreak control strategies overall.     

Reviewing the evidence on effectiveness and cost-effectiveness of HIV prevention strategies in Thailand

Background  

Following universal access to antiretroviral therapy in Thailand, evidence from National AIDS Spending Assessment indicates a decreasing proportion of expenditure on prevention interventions. To prompt policymakers to revitalize HIV prevention, this study identifies a comprehensive list of HIV/AIDs preventive interventions that are likely to be effective and cost-effective in Thailand.     

The costs of HIV prevention strategies in developing countries.

Since many evaluations of HIV (human immunodeficiency virus) prevention programmes do not include data on costs, a preliminary analysis of the costs and outputs of a sample of HIV prevention projects was attempted. Case studies, representing six broad HIV prevention strategies in developing countries with differing levels of per capita gross domestic product, were sought on the basis of availability of data and potential generalizability. The six prevention strategies studied were mass media campaigns, peer education programmes, sexually transmitted disease treatment, condom social marketing, safe blood provision, and needle exchange/bleach provision programmes. Financial cost data were abstracted from published studies or were obtained directly from project coordinators. Although estimates of cost-effectiveness were not made, calculations of the relative cost per common process measure of output were compared. Condom distribution costs ranged from US$ 0.02 to 0.70 per condom distributed, and costs of strategies involving personal educational input ranged from US$ 0.15 to 12.59 per contact.     

全球结核病流行特征与控制进展

结核病是一种严重危害人类健康的慢性传染病，是我国重点控制的疾病之一。经过人类长期对结核病的研究并与之斗争，这种被人们认为“病因明确”、“防有措施”、“治有办法”的疾病，仍然是21世纪严重危害人类健康的主要疾病之一。20世纪80年代中期，一些发达国家和地区结核病的流行基本控制，发展中国家结核病疫情仍然十分严重。此时，这些结核病疫情低的发达国家和地区对结核病控制工作忽视，     

Voluntary counselling and testing uptake and HIV prevalence among tuberculosis patients in Jogjakarta, Indonesia

We aimed to establish HIV prevalence and uptake of unlinked anonymous testing and voluntary counselling and testing (VCT) among tuberculosis (TB) patients in Jogjakarta, Indonesia. We introduced unlinked anonymous HIV testing for TB patients attending directly observed treatment, short-course services between April and December 2006. Patients were additionally offered VCT services. Of 1269 TB patients who were offered unlinked anonymous testing, 989 (77.9%; 95% CI 75.6-80.1%) accepted. HIV prevalence was 1.9% (95% CI 1.6-2.2%). HIV infections were less frequently diagnosed among TB patients who attended a public health centre [odds ratio (OR) 0.15; 95% CI 0.03-0.70] rather than public hospital. They were more frequent in TB patients with a university education background (OR 5.16; 95% CI 1.01-26.63) or a history of HIV testing (OR 57.87; 95% CI 9.42-355.62). Of the 989 patients who accepted unlinked anonymous testing, only 133 (13.4%; 95% CI 11.5-15.7%) expressed interest in VCT. Of these, 52 (39.1%; 95% CI 31.2-47.6%) attended VCT, but interest was higher among students and those offered VCT by public health centres. The HIV prevalence in Jogjakarta is higher than expected and needs to be monitored cautiously. Unlinked anonymous HIV testing is well accepted and can be implemented with modest additional efforts.     

The cost-effectiveness of preventing mother-to-child transmission of HIV in low- and middle-income countries: systematic review

Background

Although highly effective prevention interventions exist, the epidemic of paediatric HIV continues to challenge control efforts in resource-limited settings. We reviewed the cost-effectiveness of interventions to prevent mother-to-child transmission (MTCT) of HIV in low- and middle-income countries (LMICs). This article presents syntheses of evidence on the costs, effects and cost-effectiveness of HIV MTCT strategies for LMICs from the published literature and evaluates their implications for policy and future research.

Methods

Candidate studies were identified through a comprehensive database search including PubMed, Embase, Cochrane Library, and EconLit restricted by language (English or French), date (January 1st, 1994 to January 17^th, 2011) and article type (original research). Articles reporting full economic evaluations of interventions to prevent or reduce HIV MTCT were eligible for inclusion. We searched article bibliographies to identify additional studies. Two authors independently assessed eligibility and extracted data from studies retained for review. Study quality was appraised using a modified BMJ checklist for economic evaluations. Data were synthesised in narrative form.

Results

We identified 19 articles published in 9 journals from 1996 to 2010, 16 concerning sub-Saharan Africa. Collectively, the articles suggest that interventions to prevent paediatric infections are cost-effective in a variety of LMIC settings as measured against accepted international benchmarks. In concentrated epidemics where HIV prevalence in the general population is very low, MTCT strategies based on universal testing of pregnant women may not compare well against cost-effectiveness benchmarks, or may satisfy formal criteria for cost-effectiveness but offer a low relative value as compared to competing interventions to improve population health.

Conclusions and Recommendations

Interventions to prevent HIV MTCT are compelling on economic grounds in many resource-limited settings and should remain at the forefront of global HIV prevention efforts. Future cost-effectiveness analyses can help to ensure that pMTCT interventions for LMICs reach their full potential by focussing on unanswered questions in four areas: local assessment of rapidly evolving HIV MTCT options; strategies to improve coverage and reach underserved populations; evaluation of a more comprehensive set of MTCT approaches including primary HIV prevention and reproductive counselling; integration of HIV MTCT and other sexual and reproductive health services.     

Impact of immigration and HIV infection on tuberculosis incidence in an area of low tuberculosis prevalence

The aim of this study is to assess the effects of immigration from countries with a high prevalence of tuberculosis (HPCs), of HIV/AIDS prevalence, and the ageing of the indigenous population, on tuberculosis distribution in a low-prevalence area (LPCs), the Piedmont Region of Italy. Tuberculosis incidence and HIV cases were identified by linking records from the surveillance systems. Overall, 640 tuberculosis cases were identified and crude annual incidence was found to be 17.3/100000. The incidence rate ratio for HIV infection as a risk factor for tuberculosis (11.4 and 51.9 among individuals from HPCs and LPCs respectively) was greater than that for immigration from HPCs (6.7 and 30.9 among HIV+ and HIV- individuals). Immigration accounted for a larger number of incident cases [population attributable risk % (PAR %): 31.8 and 52.8% among HIV+ and HIV- individuals] than did HIV infection (PAR %: 5.4 and 11.1% among individuals from HPCs and LPCs). Efforts should be made to identify and treat young immigrants from HPCs.     

A cost-effectiveness analysis of vaccination strategies against N. meningitidis meningitis in sub-Saharan African countries

This analysis evaluates the cost-effectiveness (C/E) of routine vaccination against Neisseria meningitidis. Three different preventive strategies are analyzed: mass vaccination during epidemics (the current standard of care), routine preventive vaccination and a combination strategy of routine vaccination with mass vaccination during epidemics. A Markov model is used to simulate the epidemics of meningitis in a cohort of 5-year old children and compare these different strategies. The results show that mass vaccination strategy is dominated by the two other strategies. The incremental C/E ratios are US$50/QALY for the routine vaccination, and US$199/QALY for the combination strategy. The costs per fatal case averted are US$1161 for the routine vaccination, and US$2397 for the combination strategy. The C/E ratios are sensitive to: the incidence of meningococcal meningitis, the costs of treating cases, the costs of routine vaccination and the costs and effectiveness of mass immunization campaign. However the rank ordering of the strategies is almost never altered. In conclusion, the results of this analysis suggest that mass vaccination in sub-Saharan Africa in case of epidemics should be reconsidered. Routine vaccination against meningococcal meningitis at an early age, with or without mass vaccination during epidemics is more effective, with a C/E ratio within the range of other vaccination strategies currently in place in Africa.     

耐多药结核病流行现状及控制策略

<正>结核病是严重危害人类健康和生命安全的慢性呼吸道传染病,自1994年世界卫生组织(WHO)在全球推行DOTS(Directly Obsered Treament,short-course,直接面视下短程督导化疗)策略以来,促进了许多国家结核病防治规划(NTP)的进程,到2006年,DOTS策略已扩展到184个国家(占世界人口的93%),新涂阳肺结核患者发现率达70%以上,治疗     

Infection control in households of drug-resistant tuberculosis patients co-infected with HIV in Mumbai,India

Background: Mumbai has a population of 21 million, and an increasingly recognised epidemic of drug-resistant tuberculosis (DR-TB).Objective: To describe TB infection control (IC) measures implemented in households of DR-TB patients co-infected with the human immunodeficiency virus (HIV) under a Médecins Sans Frontières programme.Methods: IC assessments were carried out in patient households between May 2012 and March 2013. A simplified, standardised assessment tool was utilised to assess the risk of TB transmission and guide interventions. Administrative, environmental and personal protective measures were tailored to patient needs.Results: IC assessments were carried out in 29 houses. Measures included health education, segregating sleeping areas of patients, improving natural ventilation by opening windows, removing curtains and obstacles to air flow, installing fans and air extractors and providing surgical masks to patients for limited periods. Environmental interventions were carried out in 22 houses.Conclusions: TB IC could be a beneficial component of a comprehensive TB and HIV care programme in households and communities. Although particularly challenging in slum settings, IC measures that are feasible, affordable and acceptable can be implemented in such settings using simplified and standardised tools. Appropriate IC interventions at household level may prevent new cases of DR-TB, especially in households of patients with a lower chance of cure.     

Lowbury Lecture 2007: infection prevention and control strategies for tuberculosis in developing countries - lessons learnt from Africa

The World Health Organization ranks South Africa among the top ten of high-burden countries for tuberculosis (TB). The Western Cape Province has the highest prevalence of TB in the country. Studies performed in healthcare facilities both at Tygerberg Hospital and from Kwa-Zulu Natal province indicate a significant risk for nosocomial transmission of tuberculosis. An audit of provision for infection prevention and control (IPC) programmes revealed that although there were adequate supplies of protective clothing, the greatest need was for training and understanding of IPC principles among healthcare workers. In establishing national IPC guidelines for TB in South Africa, it has become evident that most of these were derived from existing guidelines in developed countries. Though the principles were sound, the practices were not realistic for developing economies and generally not implemented in healthcare facilities. Factors that influence a robust TB management programme are poverty, concurrent human immunodeficiency virus infection, overcrowding, ignorance of the disease and a varied level of health service delivery. It is recommended that a foundation of sound knowledge should be established upon which best practices should be built within the framework of good IPC principles.