The cost of a rapid-test VCT clinic in South Africa.

CONTEXT: Demand for HIV voluntary counselling and testing (VCT) will increase as HIV prevention and treatment scale up in South Africa. Understanding the cost of delivering VCT will inform funding decisions. OBJECTIVE: To determine the cost per client completing VCT (pretest counselling, testing and post-test counselling) in a non-research- based programme using rapid-test technology. DESIGN: One year of expenditure and output data were collected retrospectively as part of the PANCEA (Prevent AIDS: Network for Cost-Effectiveness Analysis) study. Market prices were determined for donated resources. SETTING: An urban, church-based, non-profit organisation that offers rapid-test VCT services in KwaZulu-Natal, South Africa. RESULTS: Financial expenditure for the 2002/2003 fiscal year was 39,761 dollars (calculated using an average conversion rate for July 2003, which was 0.133). Using market prices for donated resources, the economic cost for the year was estimated at 67,248 dollars. Six hundred and sixty-two clients completed VCT, resulting in financial expenditure of 60.06 dollars per client and an economic cost of 101.58 dollars per client. Financial expenditures and economic costs per client decreased over the year by 66% because expenses remained stable as more clients were served. CONCLUSIONS: The cost of providing VCT services was higher than previously reported, but declined with expanding scale.     

Linkage to care following a home-based HIV counselling and testing intervention in rural South Africa

Introduction

Efforts to increase awareness of HIV status have led to growing interest in community-based models of HIV testing. Maximizing the benefits of such programmes requires timely linkage to care and treatment. Thus, an understanding of linkage and its potential barriers is imperative for scale-up.

Methods

This study was conducted in rural South Africa. HIV-positive clients (n=492) identified through home-based HIV counselling and testing (HBHCT) were followed up to assess linkage to care, defined as obtaining a CD4 count. Among 359 eligible clients, we calculated the proportion that linked to care within three months. For 226 clients with available data, we calculated the median CD4. To determine factors associated with the rate of linkage, Cox regression was performed on a subsample of 196 clients with additional data on socio-demographic factors and personal characteristics.

Results

We found that 62.1% (95% CI: 55.7 to 68.5%) of clients from the primary sample (n=359) linked to care within three months of HBHCT. Among those who linked, the median CD4 count was 341 cells/mm³ (interquartile range [IQR] 224 to 542 cells/mm³). In the subsample of 196 clients, factors predictive of increased linkage included the following: believing that drugs/supplies were available at the health facility (adjusted hazard ratio [aHR] 1.78; 95% CI: 1.07 to 2.96); experiencing three or more depression symptoms (aHR 2.09; 95% CI: 1.24 to 3.53); being a caregiver for four or more people (aHR 1.93; 95% CI: 1.07 to 3.47); and knowing someone who died of HIV/AIDS (aHR 1.68; 95% CI: 1.13 to 2.49). Factors predictive of decreased linkage included the following: younger age – 15 to 24 years (aHR 0.50; 95% CI: 0.28 to 0.91); living with two or more adults (aHR 0.52; 95% CI: 0.35 to 0.77); not believing or being unsure about the test results (aHR 0.48; 95% CI: 0.30 to 0.77); difficulty finding time to seek health care (aHR 0.40; 95% CI: 0.24 to 0.67); believing that antiretroviral treatment can make you sick (aHR 0.56; 95% CI: 0.35 to 0.89); and drinking alcohol (aHR 0.52; 95% CI: 0.34 to 0.80).

Conclusions

The findings highlight barriers to linkage following an increasingly popular model of HIV testing. Further, they draw attention to ways in which practical interventions and health education strategies could be used to improve linkage to care.     

The cost of treating serious abdominal firearm-related injuries in South Africa.

INTRODUCTION: Firearms, the leading external cause of non-natural deaths in South Africa, claim approximately 15,000 lives annually. Up to 127,000 firearm-injured victims seek state health care assistance per annum. The fiscal burden of treating these injuries is not known. METHODS: All serious abdominal firearm-related injuries (requiring admission to hospital and emergency surgery) presenting to a state hospital over a 6-month period were reviewed. A cost analysis using five variables was performed: operating theatre time, duration of hospital and high-care unit stay, pharmaceutical and blood products used, laboratory services used and diagnostic imaging studies performed. RESULTS: Twenty-three patients with serious abdominal gunshot injuries were admitted, of whom 21 (91%) were treated at the hospital from admission until discharge. Each admission cost approximately US dollars 1,467. Hospital stay (47%) and operating theatre (30%) costs accounted for most of the total cost. Pharmaceuticals and blood products (20%), laboratory services (2%) and imaging studies (1%) contributed less than 25% to the total cost. CONCLUSION: Serious abdominal gunshot injuries cost at least 13-fold more than the annual per capita South African government expenditure on health. This fiscal burden of approximately US dollars 2.9 million, almost 4% of the annual health budget, does not include the cost of treating other serious gunshot injuries. These findings highlight the need for successful violence prevention strategies in South African.     

Families as catalysts for peer adherence support in enhancing hope for people living with HIV/AIDS in South Africa

Introduction

Hope is an essential dimension of successful coping in the context of illnesses such as HIV/AIDS, because positive expectations for the future alleviate emotional distress, enhance quality of life and have been linked to the capacity for behavioural change. The social environment (e.g. family, peers) is a regulator of hope for people living with HIV/AIDS (PLWHA). In this regard, the dual aim of this article is (1) to analyze the influence of a peer adherence support (PAS) intervention and the family environment on the state of hope in PLWHA and (2) to investigate the interrelationship between the two determinants.

Methods

The Effective AIDS Treatment and Support in the Free State study is a prospective randomized controlled trial. Participants were recruited from 12 public antiretroviral treatment (ART) clinics across five districts in the Free State Province of South Africa. Each of these patients was assigned to one of the following groups: a control group receiving standard care, a group receiving additional biweekly PAS or a group receiving PAS and nutritional support. Latent cross-lagged modelling (Mplus) was used to analyse the impact of PAS and the family environment on the level of hope in PLWHA.

Results

The results of the study indicate that neither PAS nor the family environment has a direct effect on the level of hope in PLWHA. Subsequent analysis reveals a positive significant interaction between family functioning and PAS at the second follow-up, indicating that better family functioning increases the positive effect of PAS on the state of hope in PLWHA.

Conclusions

The interplay between well-functioning families and external PAS generates higher levels of hope, which is an essential dimension in the success of lifelong treatment. This study provides additional insight into the important role played by family dynamics in HIV/AIDS care, and it underscores the need for PAS interventions that are sensitive to the contexts in which they are implemented.     

A methodology for resource allocation in health care for South Africa. Part II. The British experience and its relevance to South Africa

This second article in the series on resource allocation in health care, argues for a formula-based method of resource allocation in South Africa. The model employed in England since 1976 and its application in a number of developed and developing countries is reviewed. The international experience is related to South African conditions and the principal elements necessary for a formula to achieve greater spatial equity in South African health-resource distribution are discussed.     

The cost and appropriateness of health care technology in South Africa. A plea for the development of a local medical equipment industry

Some of the main reasons for the increase in the cost of health care technology are summarized. Local problems in the health care delivery system are not being solved effectively by imported medical equipment. The expertise required for the local solution of problems is available in the RSA and should be developed further. A private-sector consortium with matching funding from the State should serve as a clearing house for developing and evaluating assessment criteria, promoting the use of existing cost-efficient medical technologies, and identifying obsolete and inappropriate ones. The formation of a local health care technology corporation should be considered seriously.     

Trauma care systems in South Africa

AIM: To provide an overview of the provision of trauma care in South Africa, a middle income country emerging into a democratic state. METHODS: Literature review. CONCLUSIONS: South Africa is gripped by an almost hidden epidemic of intentional and non-intentional injury, largely driven by alcohol and substance abuse, against a background of poverty and rapid urbanisation. Gross inequities exist in the provision of trauma care. Access to pre-hospital care and overloading of tertiary facilities are the major inefficiencies to be addressed. The burden of disease due to trauma presents unique opportunities for reconstruction and clinical research.     

The cost of neonatal care.

A medical and financial assessment of the Neonatal Unit at Groote Schuur Hospital showed that the emphasis was on high care provided at a cost of R265 per patient per day. Intensive care cost R530 and low care R88 per day. The average was R172 per day. Infants of very low birth weight (< 1,500 g) accounted for 58% of expenditure. Half of this amount was spent on infants of below 1,000 g; the cost was R14 621 per survivor and R344 per quality-adjusted life-year. The cost declined progressively for infants of greater birth weight. There are a paucity of comparable local data, but the cost of the care was very reasonable.     

The statutory noise level in South Africa.

Noise legislation in South Africa was introduced in 1974. However, in industry, compliance with the recommended maximum equivalent noise level of 85 dB(A) is poor. The subject of noise exposure is reviewed briefly and a tentative proposal for a temporary raising of the statutory limit is put forward.     

A methodology for resource allocation in health care for South Africa. Part III. A South African health resource allocation formula

A formula to calculate the proportion of the public sector budget that should be allocated to various geographical regions of South Africa is described. The formula is broadly classified into curative and preventive components. Using data that are routinely available, indices of need are calculated for each of these components. It is concluded that resource allocation on a macro level should closely approximate regional population distribution if cross-border flow of patients and additional teaching-hospital expenditure are ignored.