Cost of illness due to typhoid fever in five Asian countries

Objective To generate community‐based estimates of the public (paid by the government) and private (paid by households) costs of blood culture‐confirmed typhoid fever in Hechi, China; North Jakarta, Indonesia; Kolkata, India; Karachi, Pakistan and Hue, Vietnam. Methods To measure out‐of‐pocket costs of illness and lost earnings, families with culture‐proven cases were surveyed 7, 14 and 90 days after onset of illness. Public costs of treatment were measured at local health facilities using a micro costing (bottom‐up) method. Results The costs of hospitalized cases ranged from USD 129 in Kolkata to USD 432 in North Jakarta (hospitalization rates varied from 2% in Kolkata to 40% in Hechi) and the costs of non‐hospitalized cases ranged from USD 13 in Kolkata to USD 67 in Hechi. Where costs were highest (Hechi, North Jakarta and Karachi), the bulk of the costs of hospitalized cases was borne by families, comprising up to 15% of annual household income. Conclusion Although these estimates may understate true costs due to the fact that higher quality treatment may have been provided earlier‐than‐usual, this multi‐country community‐based study contributes to evidence on the public and private costs of typhoid fever in developing countries. These cost estimates were used in a cost‐effectiveness analysis of typhoid vaccines and will help policymakers respond to World Health Organization’s updated typhoid fever immunization recommendations.     

Met and unmet palliative care needs of people living with HIV/AIDS in Rwanda

The rising number of people living with HIV/AIDS (PLWHA) worldwide has made health care professionals and policy makers search for accessible health care that will meet the needs of people who are suffering from the disease and enhance their quality of life (QoL). This study investigated met and unmet palliative care needs of PLWHA in selected areas in Rwanda. The study sample included 306 participants: PLWHA, health care professionals and coordinators of HIV/AIDS units. Quantitative and qualitative methodologies were used. The data were analysed separately and then triangulated. In the findings, over 50% of PLWHA had symptoms related to HIV/AIDS most of the time, with the most common symptom being pain. Participation in activities of daily living was significantly associated with the health status of PLWHA (p<0.001). The most common perceived palliative care needs of PLWHA were medical needs, psychosocial needs and the need for financial assistance (77%); home-based care (47%); nutritional support (44%); and pain relief and management of other symptoms (43%). Most PLWHA indicated these palliative care needs were unmet, in particular the need for pain relief, symptom management, financial assistance and nutritional support. Over 50% of health care professionals reported they were not trained in palliative care. They indicated that inadequate policy and resources were the main obstacles to the provision of optimal palliative care. Addressing unmet palliative care needs would enhance the QoL of PLWHA. In addition, developing policy related to the provision of palliative care and building the capacity of health care providers is essential for the provision of adequate palliative care services in Rwanda.     

Supporting adherence to highly active antiretroviral therapy and protected sex among people living with HIV/AIDS: the role of patient-provider communication in Rio de Janeiro, Brazil

This exploratory study examined patient-provider communication dynamics regarding adherence to highly active antiretroviral therapy (HAART) and protective sexual behavior among people living with HIV/AIDS (PLWHA). We conducted 20 direct observations of routine consultations between PLWHA and care providers in two large public health clinics providing free HIV medications and clinical care to PLWHA in the greater Rio de Janeiro area of Brazil. Immediately after these observations, 20 semistructured in-depth interviews were conducted with observation participants regarding their communication with providers, overall clinic experience, and questions and concerns about adherence to HAART and safe sex. Findings from observations showed that patient-provider communication focused almost exclusively on biomedical aspects of HIV-related treatment such as symptom management. In most observations, adherence to HAART was addressed. However, questions posed by providers regarding adherence were generally close-ended and leading, discouraging an open exchange regarding potential difficulties related to adherence. HIV/sexually transmitted infection (STI)- related protective behaviors were seldom addressed except when the patient displayed STI symptoms or was thought to be pregnant. In qualitative interviews, patients generally reported satisfaction with their providers, but also reported a variety of concerns and challenges related to adherence to HAART and protective sexual behavior that were not expressed in patient-provider interactions. We conclude that one way in which adherence to HAART and protective sexual behavior among PLWHA could be facilitated is by improving patient- provider communication on these topics, including increasing the frequency of openended, nonjudgmental dialogue initiated by care providers.     

Cost effectiveness of highly active antiretroviral therapy in HIV-infected patients. Swiss HIV Cohort Study.

BACKGROUND: Highly active antiretroviral therapy (HAART) has become the most important strategy for treating HIV infection in developed countries; however, access to HAART might vary under different funding policies. The Swiss health care system provides unrestricted access to HAART for all patients who need these newer combination therapies. This study investigated the impact of this funding policy on the society and health care system. METHODS: A cost-effectiveness analysis with natural history data and productivity estimates was based on the Swiss HIV Cohort Study. A random sample of patient charts was used to estimate health care costs. In addition to a base-case scenario, a pessimistic and an optimistic scenario of natural disease history was developed. Costs were expressed in 1997 Swiss francs (100 CHF correspond to about US$67) and effects as projected years of life gained. RESULTS: In the analysis limited to health care costs, on the basis of projected survival in each scenario, the cost-effectiveness ratio was 33,000 CHF (base case), 14,000 CHF (optimistic), and 45,000 CHF (pessimistic) per year of life gained. When changes in productivity were included, cost savings occurred in the base-case and optimistic scenarios. The cost-effectiveness ratio was 11,000 CHF per year of life gained in the pessimistic scenario. CONCLUSIONS: HAART increases expected survival and health care costs. However, when productivity gains are included, society will probably save costs or pay a low price for substantial health benefits. The study provides strong arguments, from a societal perspective, to continue the current policy of providing unrestricted access to HAART in Switzerland. The presented results also suggest that this policy could be of interest for other developed countries. Decision makers in developed countries where access to HAART is limited should re-evaluate their policy for the benefit of the society at large.     

Effectiveness and cost-effectiveness of strategies to expand antiretroviral therapy in St. Petersburg, Russia

OBJECTIVE: To assess the effectiveness and cost-effectiveness of treating HIV-infected injection drug users (IDUs) and non-IDUs in Russia with highly active antiretroviral therapy HAART. DESIGN AND METHODS: A dynamic HIV epidemic model was developed for a population of IDUs and non-IDUs. The location for the study was St. Petersburg, Russia. The adult population aged 15 to 49 years was subdivided on the basis of injection drug use and HIV status. HIV treatment targeted to IDUs and non-IDUs, and untargeted treatment interventions were considered. Health care costs and quality-adjusted life years (QALYs) experienced in the population were measured, and HIV prevalence, HIV infections averted, and incremental cost-effectiveness ratios of different HAART strategies were calculated. RESULTS: With no incremental HAART programs, HIV prevalence reached 64% among IDUs and 1.7% among non-IDUs after 20 years. If treatment were targeted to IDUs, over 40 000 infections would be prevented (75% among non-IDUs), adding 650 000 QALYs at a cost of USD 1501 per QALY gained. If treatment were targeted to non-IDUs, fewer than 10 000 infections would be prevented, adding 400 000 QALYs at a cost of USD 2572 per QALY gained. Untargeted strategies prevented the most infections, adding 950 000 QALYs at a cost of USD 1827 per QALY gained. Our results were sensitive to HIV transmission parameters. CONCLUSIONS: Expanded use of antiretroviral therapy in St. Petersburg, Russia would generate enormous population-wide health benefits and be economically efficient. Exclusively treating non-IDUs provided the least health benefit, and was the least economically efficient. Our findings highlight the urgency of initiating HAART for both IDUs and non-IDUs in Russia.     

中盖项目7城市的HIV/AIDS病人对社区小组服务需求调查

目的更好地了解艾滋病病毒（HIV）感染者和艾滋病（AIDS）病人（PLWHA）的状况,及对感染者社区组织提供服务的需求情况,以便为该人群提供更加有针对性的支持提供依据。方法在中盖项目覆盖的7个城市（北京、昆明、南京、天津、武汉、青岛、西安）中,对正在接受当地感染者社区小组所提供服务的PLWHA进行问卷调查。结果 552名被调查对象的家庭年收入普遍偏低,有28.1%的人没有享受到任何医疗保障,60%以上的调查对象认为,感染HIV后给其个人及家庭带来了负面影响;被调查对象希望能够得到多方面的支持,因被调查对象性别、收入水平和传播途径等不同,希望获得的支持和服务内容也不同。结论 PLWHA的基本情况普遍低于一般人群,且需求存在多样化。应结合具体的情况,为其提供有针对性的支持与帮助。     

Cost of Treatment of Multiple Myeloma in a Public Sector Tertiary Care Hospital of North India

Multiple myeloma (MM) is a neoplastic disorder, which accounts for 13% of all hematological malignancies globally. While, conventional chemotherapy used to be the mainstay treatment for the disease, the landscape of treatment witnessed a paradigm shift with the introduction of high-dose chemotherapy and autologous stem cell transplant (ASCT). In this paper, we present a cost analysis of various services provided to multiple myeloma patients, using either of the two modalities of treatments i.e. conventional chemotherapy or ASCT. Bottom-up costing methodology was used to collect data on all health system resources, i.e. capital or recurrent, which were used to provide various services to MM patients. Capital costs were annualized for their useful life using a discount rate of 5%. Out of pocket expenditure on treatment was also ascertained. Cost was assessed for various services, including outpatient consultation, bed day hospitalization in general ward, high dependency unit intensive care setting and bone marrow transplant unit. Unit costs were calculated from both health system and patient perspective. The overall cost per patient for ASCT (including high dose chemotherapy) and conventional chemotherapy from societal perspective was INR 395,527 (USD 6085) and INR 62,785 (USD 966) respectively. Estimates on cost from our study could be used for planning health services, and evaluating cost effectiveness of different modalities of care for multiple myeloma.     

Care for people living with HIV/AIDS: an assessment of day care centers in northern Thailand

A cross-sectional survey of 271 day care center (DCC) members at 9 district hospitals was undertaken using an interviewer-administered questionnaire to assess the psychosocial and economic impact of the services provided by DCCs to people living with HIV/AIDS (PLWHA) and the costs of attending DCCs in Chiang Rai Province in Thailand. Data on the socioeconomic and demographic background of the participants, their reasons for attending DCCs, their medical services usage, the changes DCCs made on their lives, and the cost of attending DCCs were collected. "Receiving information" (37%) and "meeting friends" (32%) were the two most common reasons while fewer participants gave "physical examination" (6%) and "counseling" (0.4%) as their reasons for attending DCCs. Nearly half became more positive about their lives and 40% learned how to live with the disease. Through DCCs, 24% and 58% were receiving prophylaxis for tuberculosis and Pneumocystis carinii pneumonia respectively, and 15% were taking antiretrovirals. The majority (85%) lived with 30 minutes of DCCs, and incurred travel cost up to 30 Baht (1 USD approximately 40 Baht). The mean monthly income of those with jobs was 1,565 Baht and 42% lost wages when attending DCCs, more than half of whom were the main income earners in their families. In conclusion, DCCs benefit PLWHA through their educational and psychological support. However, they can be further utilized for their medical services. As an expansion of antiretroviral treatment is planned in Thailand, the DCCs' role should be fully explored and clearly defined. Minimizing economic and geographical barriers to access are some of the most immediate challenges.     

Operational assessment of access to ART in rural Africa: the example of Kisantu in Democratic Republic of the Congo

Despite the availability of large funds and considerable efforts to improve access to antiretroviral therapy (ART), coverage of treatment with ART remains low in Democratic Republic of the Congo (DRC). We identified the bottlenecks for adults' access to ART in a semi-rural health zone in DRC, compared ART coverage in the urban and rural area and described the outcomes and yield of different HIV testing settings. An operational model was used to examine bottlenecks in the flow of patients. The study period covered the start of the HIV care programme in April 2006, until December 2008. An estimated 505 People Living With HIV/AIDS (PLWHA), of whom 201 were in need of ART, lived in the health zone. The proportion of PLWHA in need of ART who were actually receiving ART was estimated at 53%. About 6451 adults were tested for HIV, 266 of them were HIV-positive and 163 accessed the HIV care programme. About 106 of the 126-159 eligible patients initiated ART. The main bottleneck was situated at HIV detection. Access to the HIV care programme for the patients testing HIV-positive was identified as the second biggest bottleneck. About 41% of the PLWHA identified in urban areas accessed the HIV care programme, versus 11% of the rural PLWHA, showing a serious inequity. The tuberculosis (TB) programme detected 75% of the total estimated 92 co-infected patients of the health zone. Only 13% of women testing positive in the Prevention of Mother-To-Child Transmission programme accessed the HIV care programme, showing that this bottleneck is greatly accentuated in this specific group. By testing all pregnant women and all TB patients in the health zone, 28% of all PLWHA could potentially be detected in a period of 33 months, showing its great potential in settings with a relatively low HIV prevalence.     

State-level spending on health care and social services for people living with HIV/AIDS in the USA: a systematic review

Every year for the past decade, approximately 50,000 people have been diagnosed with HIV or AIDS in the USA, and the incidence of HIV/AIDS varies considerably from state to state. Studies have shown that health care services, most notably treatment with combination antiretroviral therapy, can help people living with HIV/AIDS (PLWHA) live healthier, longer lives, and prevent the spread of HIV from person to person. In addition, social services, such as housing support and provision of meals, have also shown to be important for helping PLWHA adhere to antiretroviral treatment and maintain contact with health care providers for improved health outcomes. Although spending on health care and social services for PLWHA varies across the USA, the relationship between state-level spending on these services and HIV/AIDS-related outcomes is not clear. We therefore conducted a systematic review of peer-reviewed literature to identify studies that explore state-level spending on health care services and/or social services for PLWHA and HIV/AIDS-related health outcomes in the USA.     

Indian Society of Hematology and Blood Transfusion (ISHBT) Consensus Document on Hematological Practice During COVID-19 Pandemic

The SARS-CoV-2 (COVID-19) pandemic is a worldwide public health emergency with widespread impact on health care delivery. Unforeseen challenges have been noted during administration of usual haematology care in these unusual COVID-19 times. Medical services have been overstretched and frontline health workers have borne the brunt of COVID-19 pandemic. Movement restrictions during lockdown prevented large sections of population from accessing health care, blood banks from holding blood drives, and disrupted delivery of diagnostic hematology services. The disruption in hematology care due to COVID-19 pandemic in India has been disproportionately higher compared to other subspecialities as hematology practice in India remains restricted to major cities. In this review we chronicle the challenges encountered in caring for hematology patients during the COVID-19 pandemic in India and put forth recommendations for minimizing their impact on provision of hematology care with special emphasis on hematology practice in lower and middle income countries (LMICs).     

Cigarette Smoking and Mortality Among HIV-Infected Individuals in Seattle, Washington (1996–2008)

HIV-infected individuals with access to highly active antiretroviral therapy (HAART) are living longer and the causes of excess morbidity and mortality among people living with HIV/AIDS (PLWHA) are becoming comparable to individuals without HIV infection. However, many PLWHA smoke cigarettes—a well known contributor to excess morbidity and mortality. To investigate the association between smoking and mortality among PLWHA during the HAART era (1996+), we conducted a retrospective cohort study of 2,108 PLWHA enrolled in Seattle and King County’s Adult and Adolescent Spectrum of HIV Disease Study. Adjusted hazard ratios (aHRs) for all-cause and cause-specific mortality were obtained using Cox proportional hazards regression. Compared to never smokers, current smokers (aHR = 1.8, 95% CI: 1.3, 2.3) and individuals with an increased dose and/or duration of smoking were at greater risk of all-cause mortality. Although additional research is needed to evaluate the full effect of smoking on cause-specific mortality, smoking cessation programs should target PLWHA to further increase their life expectancy.     

An investigation into the health-related quality of life of individuals living with HIV who are receiving HAART

The health authorities have recently accepted the routine provision of highly active antiretroviral therapy to persons living with AIDS in South Africa. There is a need to investigate the impact of HAART on the health-related quality of life of people living with HIV/AIDS (PLWHA) in a resource-poor environment, as this will have an influence on compliance and treatment outcome. The aim of this study was to explore whether HAART is efficacious in improving the self-reported health-related quality of life (HRQoL) in a group of PWLA in WHO Stages 3 and 4 living in a resource-poor community. A quasi-experimental, prospective repeated measures design was used to monitor the HRQoL over time in participants recruited to an existing HAART programme. The HRQoL of 117 participants was determined through the use of the Xhosa version of the EQ-5D and measurements were taken at baseline, one, six and 12 months. At the time of the 12-month questionnaire, 95 participants had been on HAART for 12 months. Not all participants attended all follow-up visits, but only two participants had withdrawn from the HAART programme, after two or three months. At baseline, the rank order of problems reported in all domains of the EQ-5D was significantly greater than at 12 months. The mean score on the global rating of health status increased significantly (p < 0.001) from a mean of 61.7 (SD = 22.7) at baseline to 76.1 at 12 months (SD = 18.5) It is concluded that, even in a resource-poor environment, HRQoL can be greatly improved by HAART, and that the possible side effects of the drugs seem to have a negligible impact on the wellbeing of the subjects. This bodes well for the anticipated roll-out of HAART within the public health sector in South Africa.     

"I understand just a little…" Perspectives of HIV/AIDS service providers in South Africa of providing mental health care for people living with HIV/AIDS

Research conducted in South Africa and other parts of the world has revealed that people living with HIV/AIDS (PLWHA) are more at risk of developing a mental disorder than the general population. It makes sense to explore means of integrating HIV/AIDS and mental health care thereby facilitating access of PLWHA to prompt mental health care. We conducted qualitative interviews with 22 HIV/AIDS service providers of three occupational categories (10 nurses, six adherence counsellors and six patient advocates) at three primary health care clinics in the Western Cape, South Africa. We explored the issues of knowledge and practice in mental health care as well as the role of nurses and lay health workers in providing mental health care to PLWHA thereby attempting to integrate mental health and HIV/AIDS care. Although the majority of participants were in favour of mental health screening for PLWHA, they lacked confidence to conduct the screening themselves. Most participants displayed poor knowledge of mental disorders and reported that they referred to colleagues or to an external mental health service if they suspected a possible mental disorder in a patient. Integration of mental health and HIV/AIDS care has potential benefit to the public HIV/AIDS care system. Mental health training should be provided to HIV/AIDS service providers in this regard.     

我国5省艾滋病流行对个人和家庭影响情况调查

目的了解、分析艾滋病对个人和家庭影响的主要表现特征。方法采用问卷调查获得我国5个省份的相关数据,通过对比的方法,比较分析感染者家庭和非感染者家庭在婚姻、家庭结构、收入、消费等方面的差异特征。结果41．1％的感染者家庭是主干家庭,高于非感染者家庭的这一比例（33．4％）;感染者家庭中生活在低收入阶层的比例为49．5％,比非感染者家庭多16．0％;感染者家庭医疗花费占家庭全部消费支出的比例为17．4％,明显高于非感染者家庭（7．9％）;感染者家庭中60岁以上劳动参与率为55．9％,高于非感染者家庭（41．7％）;女性感染者的劳动时间（含家务）比男性感染者多2．2个小时,而非感染者家庭中女性的劳动时间比男性仅多0．7小时;目前只有40．4％的感染者家庭获得了相关的救助。结论艾滋病给感染者及其家庭带来了家庭结构改变、家庭功能削弱、贫困加剧、家庭消费结构改变等一系列问题,扩大贫富差距,加剧了性别不平等,普遍缺乏有效的应对措施,迫切需要持续的关怀和救助。     

The cost burden of diabetes mellitus: the evidence from Germany—the CoDiM Study

Aims/hypothesis The aim of this study was to identify the health care costs of diabetic patients in Germany in 2001, focusing on the influence of age, sex, and type of treatment.Subjects and methods Annual direct costs of medical care and indirect costs of inability to work and early retirement in diabetic subjects were compared with costs of age- and sex-matched non-diabetic control subjects. The analysis was based on routine health care data from a random sample (18.75%) taken from a database of 1.9 million insured persons. Incremental differences in medical and national expenditure between subjects with and without diabetes were calculated.Results Annual direct mean costs per diabetic patient were €5,262, and indirect costs were €5,019. In the control group, mean direct and indirect costs were €2,755 and €3,691, respectively. Analysis of cost components revealed that the high costs associated with the care of diabetic patients could be largely attributed to inpatient care and overall medication costs. Hypoglycaemic drugs amounted to only one-quarter of the medication costs. The total health care costs were correlated with the type of treatment. Direct excess costs increased with increasing age in insulin-treated patients, but were unaffected by age in patients receiving other types of treatment.Conclusions/interpretation The Costs of Diabetes Mellitus (CoDiM) study is the first comprehensive study to provide estimates of costs associated with diabetes care in Germany. Direct costs of diabetic patients account for 14.2% of total health care costs, which includes the proportion that specifically accounts for diabetes-related costs (6.8%).Electronic Supplementary Material Supplementary material is available for this article at     

Seeking information about HIV/AIDS: a qualitative study of health literacy among people living with HIV/AIDS in a low prevalence context

People living with HIV/AIDS in rural and low HIV prevalence areas face a number of challenges including stigma, limited access to specialized medical care, lack of an HIV/AIDS specialist and fear which may interfere with their ability to find and use information to manage their health. With a large number of HIV cases located in non-metropolitan and rural areas in the US, more research is needed to better understand the health seeking behaviors of individuals living in this context. This study examined how 16 individuals living with HIV sought out information to meet their health needs. In qualitative semi-structured interviews, we explored participants' primary sources of information, types of information sought, and barriers to accessing information. The sample was comprised of people living with HIV/AIDS (PLWHA) who resided in a predominantly rural area with low HIV prevalence. The majority of participants relied on a combination of sources including their HIV/AIDS physician, the Internet, a Ryan-White caseworker and a staff member of a community-based support organization to meet their informational needs. Information sought focused primarily on drug regimens, drug side effects, or drug research. Participants shared barriers to accessing information including stigma, fear, concern about disclosure, and feelings of futility and anger. Findings point to a need to expand health literacy research and interventions to address broader social and structural barriers to health improvement for PLWHA, especially among those living in rural and low HIV prevalence areas.     

Linking women who test HIV‐positive in pregnancy‐related services to long‐term HIV care and treatment services: a systematic review

Objectives To quantify attrition between women testing HIV‐positive in pregnancy‐related services and accessing long‐term HIV care and treatment services in low‐ or middle‐income countries and to explore the reasons underlying client drop‐out by synthesising current literature on this topic. Methods A systematic search in Medline, EMBASE, Global Health and the International Bibliography of the Social Sciences of literature published 2000–2010. Only studies meeting pre‐defined quality criteria were included. Results Of 2543 articles retrieved, 20 met the inclusion criteria. Sixteen (80%) drew on data from sub‐Saharan Africa. The pathway between testing HIV‐positive in pregnancy‐related services and accessing long‐term HIV‐related services is complex, and attrition was usually high. There was a failure to initiate highly active antiretroviral therapy (HAART) among 38–88% of known‐eligible women. Providing ‘family‐focused care’, and integrating CD4 testing and HAART provision into prevention of mother‐to‐child HIV transmission services appear promising for increasing women’s uptake of HIV‐related services. Individual‐level factors that need to be addressed include financial constraints and fear of stigma. Conclusions Too few women negotiate the many steps between testing HIV‐positive in pregnancy‐related services and accessing HIV‐related services for themselves. Recent efforts to stem patient drop‐out, such as the MTCT‐Plus Initiative, hold promise. Addressing barriers and enabling factors both within health facilities and at the levels of the individual woman, her family and society will be essential to improve the uptake of services.