The costs and benefits of private sector provision of treatment to HIV-infected employees in Kampala, Uganda

Marseille, Elliot; Saba, Joseph; Muyingo, Sowedi; Kahn, James G.

doi:10.1097/01.aids.0000218556.36661.47

Cited by 18 publications

(11 citation statements)

References 12 publications

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“…We estimated net DALYs by subtracting the increase in DALYs due to adverse events from the reduction in DALYs due to HIA. We calculated the reduction in DALYs for HIV by multiplying HIA by previously reported discounted DALY changes with ART (ten DALYs) and without (21 DALYs), assuming 50% on ART [45]. For increases in DALYs, we estimated the frequency and duration of adverse events from the OF RCT.…”

Section: Methodsmentioning

confidence: 99%

Cost-Effectiveness of Male Circumcision for HIV Prevention in a South African Setting

2006

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BackgroundConsistent with observational studies, a randomized controlled intervention trial of adult male circumcision (MC) conducted in the general population in Orange Farm (OF) (Gauteng Province, South Africa) demonstrated a protective effect against HIV acquisition of 60%. The objective of this study is to present the first cost-effectiveness analysis of the use of MC as an intervention to reduce the spread of HIV in sub-Saharan Africa.Methods and FindingsCost-effectiveness was modeled for 1,000 MCs done within a general adult male population. Intervention costs included performing MC and treatment of adverse events. HIV prevalence was estimated from published estimates and incidence among susceptible subjects calculated assuming a steady-state epidemic. Effectiveness was defined as the number of HIV infections averted (HIA), which was estimated by dynamically projecting over 20 years the reduction in HIV incidence observed in the OF trial, including secondary transmission to women. Net savings were calculated with adjustment for the averted lifetime duration cost of HIV treatment. Sensitivity analyses examined the effects of input uncertainty and program coverage. All results were discounted to the present at 3% per year.For Gauteng Province, assuming full coverage of the MC intervention, with a 2005 adult male prevalence of 25.6%, 1,000 circumcisions would avert an estimated 308 (80% CI 189–428) infections over 20 years. The cost is $181 (80% CI $117–$306) per HIA, and net savings are $2.4 million (80% CI $1.3 million to $3.6 million). Cost-effectiveness is sensitive to the costs of MC and of averted HIV treatment, the protective effect of MC, and HIV prevalence. With an HIV prevalence of 8.4%, the cost per HIA is $551 (80% CI $344–$1,071) and net savings are $753,000 (80% CI $0.3 million to $1.2 million). Cost-effectiveness improves by less than 10% when MC intervention coverage is 50% of full coverage.ConclusionsIn settings in sub-Saharan Africa with high or moderate HIV prevalence among the general population, adult MC is likely to be a cost-effective HIV prevention strategy, even when it has a low coverage. MC generates large net savings after adjustment for averted HIV medical costs.

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Section: Methodsmentioning

confidence: 99%

Cost-Effectiveness of Male Circumcision for HIV Prevention in a South African Setting

2006

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“…We used our model published elsewhere to estimate health benefits after the first two years. 26 Mortality for individuals taking second-line HAART, derived from a study conducted in a South-African township, is set at 1.9% per month. 13 No third-line regimen is available.…”

Section: Deaths Averted-basedmentioning

confidence: 99%

“…Using estimates from a Markov model published previously on disease progression in a simulated Ugandan cohort, we found that each HIV infection prevented averted 7.2 DALYs. 26 This assumes that all of those who would have become infected would have received ART. 32 The DREAM cohort study (with ART) in Mozambique found a pediatric seroconversion rate of 5.5% at 12 months of age.…”

Section: Deaths Averted-basedmentioning

confidence: 99%

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

Marseille¹,

Kahn

Pitter

et al. 2009

Appl Health Econ Health Policy

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Context-Highly active anti-retroviral therapy (ART) provides dramatic health benefits for HIVinfected individuals in Africa, and widespread implementation of HAART is proceeding rapidly. Little is known about the cost and cost-effectiveness of HAART programs.Objective-To determine the incremental cost-effectiveness of a home-based HAART program in rural Uganda.Design, setting and patients-Computer-based, deterministic cost-effectiveness model to assess a broad range of economic inputs and health outcomes. From the societal perspective we compared the cost-effectiveness of HAART and cotrimoxazole prophylaxis with cotrimoxazole alone, and with the period before either intervention. Data for 24 months were derived from a trial of HAART in 1,045 patients in Tororo District in eastern Uganda. Costs and outcomes were projected out to 15 years. All costs are in 2004 U.S. dollars.Interventions-First-line HAART regimen consisted of standard doses of stavudine, lamivudine, and either nevirapine or, for clients with active tuberculosis, efavirenz. Second-line therapy consisted of tenofovir, didanosine, and lopinavir/ritonavir. For children, first-line HAART consisted of Correspondence to: Dr. Elliot Marseille, Health Strategies International, 1743 Carmel Drive #26, Walnut Creek, CA 94596, USA, Ph: +1-925-392-4444, emarseille@comcast.net. Conflict of Interest StatementAll authors declare that they have not conflicts of interest to declare. We will provide signed statements to that effect as needed. Contributor shipElliot Marseille (First author): Concept, Design, Parameter estimation, Literature review, Analysis, Writing. Dr. Marseille had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Ethical approvalNo ethical approval was required for this research. NIH Public Access Author ManuscriptAppl Health Econ Health Policy. Author manuscript; available in PMC 2010 July 29. Published in final edited form as:Appl Health Econ Health Policy. 2009 ; 7(4): 229-243. doi:10.2165/11318740-000000000-00000. NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript zidovudine, lamivudine and nevirapine syrup; second-line therapy was stavudine, didanosine and lopinavir/ritonavir.Main outcome measures-HAART program costs, the health benefits accruing to HAART recipients, averted HIV infections in adults and children, and resulting effects on medical care costs.Results-The HAART program standardized for 1,000 patients cost an incremental $1.39 million in its first two years. Compared with cotrimoxazole prophylaxis alone, the program reduced mortality by 87%, and averted 6,861 incremental disability adjusted life-years (DALYs). Benefits accrued from reduced mortality in HIV-infected adults, (67.5% of all benefits), prevention of death in HIVnegative children (20.7%), averted HIV infections in adults (9.1%) and children (1.0%), and improved health status (1.7%). The net program cost, including the medical cost implications of these ...

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“…Treatment with ART was estimated to avert 7.3 discounted DALYs among HIV-infected individuals who survived >16 weeks. This value was drawn from the same Zambian analysis used to estimate treatment costs, and it was obtained by comparing deaths in the Zambian ART program with deaths observed in a prior, well-characterized home-based AIDS care (HBAC) cohort of 466 HIV-infected patients not receiving ART in Tororo District, Uganda, adjusted for differences in CD4+ T-cell counts and sex distribution between groups [16,19,24,25]. …”

Section: Methodsmentioning

confidence: 99%

Estimating the cost-effectiveness of nutrition supplementation for malnourished, HIV-infected adults starting antiretroviral therapy in a resource-constrained setting

Koethe

Marseille²,

Giganti

et al. 2014

Cost Eff Resour Alloc

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BackgroundLow body mass index (BMI) individuals starting antiretroviral therapy (ART) for HIV infection in sub-Saharan Africa have high rates of death and loss to follow-up in the first 6 months of treatment. Nutritional supplementation may improve health outcomes in this population, but the anticipated benefit of any intervention should be commensurate with the cost given resource limitations and the need to expand access to ART in the region.MethodsWe used Markov models incorporating historical data and program-wide estimates of treatment costs and health benefits from the Zambian national ART program to estimate the improvements in 6-month survival and program retention among malnourished adults necessary for a combined nutrition support and ART treatment program to maintain cost-effectiveness parity with ART treatment alone. Patients were stratified according to World Health Organization criteria for severe (BMI <16.0 kg/m2), moderate (16.00-16.99 kg/m2), and mild (17.00-18.49 kg/m2) malnutrition categories.Results19,247 patients contributed data between May 2004 and October 2010. Quarterly survival and retention were lowest in the BMI <16.0 kg/m2 category compared to higher BMI levels, and there was less variation in both measures across BMI strata after 180 days. ART treatment was estimated to cost $556 per year and averted 7.3 disability-adjusted life years. To maintain cost-effectiveness parity with ART alone, a supplement needed to cost $10.99 per quarter and confer a 20% reduction in both 6-month mortality and loss to follow-up among BMI <16.0 kg/m2 patients. Among BMI 17.00-18.49 kg/m2 patients, supplement costs accompanying a 20% reduction in mortality and loss to follow-up could not exceed $5.18 per quarter. In sensitivity analyses, the maximum permitted supplement cost increased if the ART program cost rose, and fell if patients classified as lost to follow-up at 6 months subsequently returned to care.ConclusionsLow BMI adults starting ART in sub-Saharan Africa are at high risk of early mortality and loss to follow-up. The expense of providing nutrition supplementation would require only modest improvements in survival and program retention to be cost-effective for the most severely malnourished individuals starting ART, but interventions are unlikely to be cost-effective among those in higher BMI strata.

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The costs and benefits of private sector provision of treatment to HIV-infected employees in Kampala, Uganda

Abstract: A 'hybrid' intervention combining CTX prophylaxis followed by HAART would generate savings to a Ugandan company. Governments and other donors may find opportunities to share costs with the private sector as part of their phase-in strategy for antiretroviral therapy.

Cited by 18 publications

References 12 publications

Cost-Effectiveness of Male Circumcision for HIV Prevention in a South African Setting

Cost-Effectiveness of Male Circumcision for HIV Prevention in a South African Setting

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

Estimating the cost-effectiveness of nutrition supplementation for malnourished, HIV-infected adults starting antiretroviral therapy in a resource-constrained setting

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