OpenUCT :: Browsing by Author "Sinanovic, Edina"

Browsing by Author "Sinanovic, Edina"

Now showing 1 - 20 of 37

Open Access
Absorptive capacity to finance HIV/AIDS treatment in South Africa: Where are the bottlenecks?
(2010) Irurzun Lopez, Maria Teresa; Sinanovic, Edina; Booysen, Frikkie
This research investigates absorptive capacity in South Africa's public health sector in relation to scaling up financing for HIV/AIDS treatment. The thesis constructs a conceptual framework, which follows the flow of public funding for HIV/AIDS treatment. The study combines a quantitative budget analysis, which looks at expenditure and spending patterns, with qualitative in-depth interviews with key stakeholders exploring causes and consequences, which are the main pillar of the primary research. The study applies the conceptual framework nationally, as well as in the Free State and Western Cape provinces. The contributions of the thesis are two-fold: At the conceptual level, the study defines and constructs an analytical framework of absorptive capacity and related bottlenecks in the context of funding for HIV/AIDS treatment in the public health sector. It identifies five major areas where bottlenecks may arise: financial, human, infrastructural, institutional (within the health system) and structural (outside the health system). At the empirical level, the study assesses and compares absorptive capacity and major bottlenecks encountered nationally and in the Free State and Western Cape provinces in respect of the public sector funding for the HIV/AIDS treatment programme. The results confirm that absorptive capacity is not merely about spending funding. Spending should not compromise other programs or elements of the public health system, and it should be efficient, equitable and sustainable. The findings show that South Africa's absorptive capacity was constrained by several obstacles, such as poor practices and a shortage of human resources, insufficient financial capacity and demanding requirements of conditional funding, inadequate infrastructure, and inadequate national leadership. To overcome these obstacles, the mere injection of even more funding would be an insufficient response. Consequently, the study indicates which other reforms are required, including: further integrating antiretroviral treatment services within the public health structures; further decentralising antiretroviral treatment towards primary health care; task shifting; iii balancing the conditional grant and equitable share; and enhancing coordination between the National and Provincial Departments of Health and with Treasury.
Open Access
Additional costs of FAS and PFAS learners in the classroom: An estimate for public primary schools in the Western Cape
(2018) Makin, Emma; London, Leslie; Sinanovic, Edina
Background: The Western Cape province of South Africa has the highest recorded prevalence rates of Fetal Alcohol Spectrum Disorders (FASD) in the world. In the last decade rates of fetal alcohol syndrome (FAS) and partial fetal alcohol syndrome (PFAS) prevalence of 68.0 - 89.2 per 1000 (May et al., 2007), 67.2 per 1000 (Urban et al., 2008), and 59.3 - 91.0 per 1000 (May et al., 2013) have been published after research was conducted in towns in the Western Cape (WC). Educating learners with FASD is a challenge as a result of the large range of cognitive impairments associated with heavy prenatal alcohol exposure. Determining a burden of cost to the education system may be one way to motivate for the development of prevention and intervention strategies. Methods: I designed questionnaires that were distributed to the educator and principal of a cohort of learners including learners with FAS and PFAS. Data were collected on educational impacts of variables associated with educator time use. Additional costs as a result of the use of educator's time by learners with FAS/PFAS were scaled up using risk differences and published statistics to reflect a cost burden to the WC Education Department. Results: The additional cost burden of disruptions caused by learners with FAS and PFAS for the WC Education Department is USD 7,010,166 in educator time for one academic year. The additional burden for learners with FAS/PFAS requiring additional assistance with lesson content to the WC is USD 5,754,885 in educator time for one academic year. The additional cost burden of public primary school learners with FAS/PFAS who had repeated a year of schooling was USD 3,876,565 in educator time based on 2012 salaries. Conclusions: These findings indicate that there is a large burden of cost to the education system when educator time is viewed as an economic input in education. Efforts need to be directed towards prevention programs to reduce the prevalence of learners with FAS/PFAS in the classroom. Educator training programs must be created to ensure that educators are equipped to manage the challenges posed by learners with FAS/PFAS in the classroom.
Open Access
Addressing Health Equity in Cost-Effectiveness Analysis: A Review of Distributional and Extended Cost-Effectiveness Analysis
(2021) Lewis, Ian Storm; Sinanovic, Edina
Background Equity is rarely included in health economic evaluations, partly because the techniques for addressing equity have been inadequate. Since 2013 health economists have developed two competing health economic technologies: distributional costeffectiveness analysis (DCEA) and extended cost-effectiveness analysis (ECEA). Both technologies represent a significant advance, and each provides a framework to address equity considerations in cost-effectiveness analysis. Methods A scoping literature review was used to identify and synthesise the relevant literature on incorporating equity concerns into economic evaluations. A second focused review identified literature which discussed or applied DCEA and ECEA. Key themes in the literature were identified using NVivo qualitative data analysis software. Results The review revealed three key areas of difference between DCEA and ECEA: First, the analysis of trade-offs between improving health and reducing inequity; second, the analysis of financial impacts of health policies; and third, the incorporation of opportunity costs. ECEA can analyse financial risk protection while DCEA can analyse opportunity costs and trade-offs between improving equity and reducing health. ECEA is designed for low- and middle-income countries, whereas DCEA is better suited to developed health systems such as the National Health Service in the United Kingdom. To date, there have been 27 studies using ECEA and five studies using DCEA. Future developments for DCEA and ECEA include incorporating alternative methods to simplify the data requirements for the techniques, providing methods to assist decision makers to clarify their equity concerns, and improving the presentation of outcomes to make them accessible to non-specialists. Conclusions DCEA and ECEA are both economic frameworks which address equity considerations in cost-effectiveness analysis. This study examines and compares these two techniques in order to assist policymakers and decision makers to determine which of the two methods is best able to address their specific needs for their particular circumstances.
Open Access
Alcohol addiction treatment in Cape Town: Exploratory investigation of the public-private mix
(2010) Fleming, Laura; Sinanovic, Edina
Public health and safety are compromised by the effects of alcohol addiction. Some of the consequences include transmission of infectious diseases, disproportionate use of medical and social services, traffic accidents, and street crimes. Additionally, when dealing with alcohol addiction, many expenses are incurred by public services such as the criminal justice system, emergency medical care centers, foster home placement centers, employee assistance programs and family violence centers. The clinical and economic benefits of addiction treatment are therefore clear. The aim of this study was to investigate Cape Town's alcohol addiction treatment center public-private mix and to determine quality of care and access. Document review and semi-structured interviews were the methods used. Provider reporting on quality of care and the limited number of sites interviewed were the main research limitations. Nevertheless, the thesis reached its objectives and contributed to the limited information on alcohol addiction treatment public-private mix, quality of care and access in South Africa. It is notable that there were few differences in the quality of care reported by public, public-private mix, private registered and private unregistered facilities. Quality of care was found to be good across sectors. Public and public-private mix facilities provided superior access in terms of income. Private facilities had the shortest wait-time. Geographic access was a pronounced issue for the poor population that resides in the Southern suburbs, far from affordable primary care alcohol addiction treatment services. Both horizontal and vertical inequities were identified in terms of access to primary care alcohol addiction treatment services in the Cape Town metropole. A strong case is made for involving more of the private sector in public-private partnerships in order to scale up alcohol addiction treatment within the South African setting. This will allow quality of care to be maintained while improving access.
Open Access
Analysing costs of a facility-based lay health worker intervention focused on improving health outcomes for HIV positive women and children
(2014) Zeelie, Jean-Pierre; Sinanovic, Edina
South Africa is facing a health care worker shortage which is contributing to poor health outcomes, especially in mother-to-child transmission of HIV. In order for Prevention of Mother to Child Transmission (PMTCT) programmes to achieve success, coverage needs to be dramatically increased. This paper aims to provide specifics on the costs of integrating a Lay Health Worker (LHW) into a clinic to improve patient uptake and retention of PMTCT services, in what was previously the Motheo district, Free State.
Open Access
Assessment of essential drug management in the public health facilities in Uganda
(2007) Nahamya, David; Sinanovic, Edina
The main aim of the study is to evaluate the management of essential drugs in thepublic health facilities in Uganda. This is a cross-sectional study carried out in the districts of Kampala and Mbale employing both qualitative and quantitative methods. Standard outcome indicators as described in the WHO Operational Package for Monitoring and Assessing the Pharmaceutical Situation in Countries are adapted and used in this study.
Open Access
The change in malaria treatment policy in Uganda : extent of adherence to antimalarial drug policy in Rakai and Kampala Districts
(2005) Kimera, Deogratius; Sinanovic, Edina
Changes in Antimalarial Drug Policies are intended to improve case management and reduce both social and financial burden associated with malaria. To achieve this providers have to translate the policy into practice since they have the privilege of being the primary contact to those affected by malaria. The main aim of this study is to examine the extent of implementation of the change in antimalarial drug policy in Uganda, from chloroquine monotherapy to combination therapy of CQ+SP for management of uncomplicated malaria. Prescribing practice of health personnel in selected health facilities in Rakai and Kampala Districts is used as a measure of level of adherence to the change in policy.
Open Access
A comparative cost analysis of two screening strategies for colorectal cancer in Lynch Syndrome in a tertiary hospital, South Africa
(2017) Johnson, Yasmina; Sinanovic, Edina; Moodley, Jennifer; Goldberg, Paul A
Individuals with Lynch Syndrome (LS) have a 25% to 75% lifetime risk of colorectal cancer and the cancer generally presents at an early age. Establishing the costs of strategies to prevent or delay the onset of cancer is, thus, desirable. This study compared the cost of two screening approaches - colonoscopy only (Strategy 1) versus genetic testing for LS followed by colonoscopy for the individuals that tested positive for LS (Strategy 2). A comparative cost analysis was conducted at a tertiary hospital, from the health provider perspective, using a micro-costing, ingredient approach. Probands that were selected, according to the Revised Bethesda Criteria, for genetic testing between 01 November 2014 and 30 October 2015, and their first degree relatives (high risk relatives) were evaluated according to Strategy 1 and Strategy 2. Total costs per strategy were estimated and compared. Sensitivity analyses were performed on adherence rates to colonoscopy, positivity rates of relatives and discount rates. A total of 40 families were studied. The total cost for Strategy 1 amounted to R4 932 718 ($332 617) compared to R390 308 ($26 319) for Strategy 2 (Discount rate 3%; Adherence 75% and Positivity rate of relatives 45%). Base case analysis indicated a difference of 92% less in the total cost for Strategy 2 compared to Strategy 1. Univariate sensitivity analyses showed that the difference in cost between the two strategies was not sensitive to changes in discount rates, adherence rates or positivity rates of relatives. Compared to colonoscopy screening only, colonoscopy combined with genetic testing presented a less costly option by identifying patients at high risk of colorectal cancer for screening. Testing of relatives should be facilitated since, compared to probands, genetic testing of relatives is less costly and is likely to have more benefit. Effectiveness of the screening programmes should be established through further research.
Open Access
A comparative study of cost and quality of care of malaria treatment in public and private health facilities in Nigeria a case study of Lagos state
(2006) Dele, Araoyinbo Idowu; Sinanovic, Edina
The study explores the cost and quality of malaria care in public and private heatlh facilties at the primary health level in an urban community in south western Nigeria. A pre-tested questionnaire is adminstered to patients attending either public or private health facilities to estimate the direct and indirect cost of accessing healthcare services. Costs was estimated from the providers's perspective by using interviews and review of financial records to assess the total and unit cost of such services. Structural quality (adequacy of equipment and staff mix) and process quality (interpersonal relationship, use of treatment guidelines and algorithms) are assessed using structured checklist, observation and proxies such as patients' satisfaction.
Open Access
A cost analysis of community-based distribution programmes and clinic-based services for contraceptives in selected areas in Khayelitsha
(1997) Sinanovic, Edina
Family planning services in South Africa are now provided by the provincial and local authorities through clinics, hospitals, day hospitals, and mobile clinics. Both service providers and recipients have identified a range of problems with the current family planning service delivery system. Community-based distribution of contraceptives (CBD) has become a generally accepted alternative to clinic-based programmes for the distribution of contraceptives in many developing countries. The piloting of community-based distribution of contraceptives project in Khayelitsha, Cape Town / South Africa, is being undertaken by The Planned Parenthood Association of South Africa (a non-governmental organization), in collaboration with two other NGOs who run preventive and promotive health projects, SACLA and Zibonele. The objective of this study was to perform a cost analysis of alternative methods for providing effective contraceptive services. Clinic-based services for contraceptives, day hospital-based contraceptive services, and community-based distribution (CBD) of contraceptives programmes were evaluated. The following items were costed: salaries, contraceptives, buildings, equipment, vehicle, transport, repairs & maintenance, utilities, initial training, short-in-service training, and consultancy.
Open Access
A cost comparison analysis of paediatric intermediate care in a tertiary hospital and an intermediate, step-down facility
(2017) Duncan, Kristal; Sinanovic, Edina
Background: According to the National Cancer Registry of South Africa 600-700 new cases of paediatric cancers have been reported every year for the past 25 years. While in the year 2000 HIV/AIDS was responsible for 42 479 deaths in children under five. However support for and research in general for the paediatric intermediate care (encompasses palliative, sub-acute and respite care) needed by these children remains sparse. Costing studies are even rarer, with the few studies conducted in South Africa reporting a broad range of average costs per inpatient day. Methods: A retrospective cost analysis for the period April 2014-March 2015 was undertaken from the provider perspective. Costs of paediatric intermediate care were estimated for an intermediate stepdown facility and a tertiary hospital in Cape Town, South Africa. A step down costing approach was employed, and the costs were inflated to 2016 values and expressed in Rand and USD using an exchange rate of 1 USD = R14.87. Results: Cost per inpatient day was USD 713.09 at the hospital and USD 695.17 at the step-down facility. The cost for a paediatric patient who is HIV/TB co-infected was USD 7130.94 and USD 6951.67 at the hospital and step-down facility respectively, assuming an average length of stay (ALOS) of 10 days. For a patient who has a terminal brain carcinoma the cost was USD 19966.63 and USD 19464.69 at the hospital and step-down facility respectively, assuming an ALOS of 28 days. Personnel costs accounted for 60% of the total cost at the hospital, compared to only 17% of the total costs at the step-down facility. Overhead costs accounted for 12.33% at the step-down facility, almost 3 times that of the hospital (4.48%). Conclusions: The study highlights that the drivers of cost are not uniform across settings. Providing intermediate care at a step-down facility can be more cost-saving than providing this care at a hospital, there are however areas in which more savings could be realized. The costs presented in this study were considerably higher than those found in other studies, however, the paucity of cost data available in the area of paediatric intermediate care makes comparisons difficult.
Open Access
A cost effectiveness analysis of different ways of analyzing sputum for turberculosis diagnosis: direct smear microscopy, natural sedimentation and centrifugation
(2009) Phiri, Mafayo C; Sinanovic, Edina
In Malawi, sputum smear microscopy (Ziehl-Neelsen) is a major diagnostic technique for pulmonary tuberculosis (TB). Though relatively rapid, it tends to be poorly sensitive since it requires a large number of organisms to be present in the specimen before they can be detected. Two approaches that improve sensitivity of direct smear microscopy are sputum liquefaction with chemicals such as sodium hypochlorite (household bleach) and subsequent concentration with gravity (natural) sedimentation and centrifugation. This study estimated the costs and cost-effectiveness of these techniques in processing sputum for detecting new cases of pulmonary tuberculosis in Malawi. Bleach natural sedimentation and bleach centrifugation methods were compared with direct smear microscopy. Cost and effectiveness data were collected from a randomized controlled trial from one major TB health facility. Effectiveness was determined by number of smear positive TB cases detected by each method. Cost-effectiveness was estimated from a provider's perspective in terms of cost per TB cases diagnosed and cost per smear positive TB case detected. Cost per positive TB case detected was least in natural (gravity) sedimentation (US $9.35), compared to centrifugation (US $11.48) and direct smear microscopy (US $15.93). The study findings indicate that natural sedimentation can significantly reduce cost of sputum processing. There is a strong economic case supporting the use of natural sedimentation for diagnosing tuberculosis in Malawi. In addition, bleach digests sputum making it less infectious and easy to work with thereby increasing the safety of specimens to clinicians. Therefore, introducing natural sedimentation technique would not only reduce costs but also improve safety to health workers.
Open Access
Cost effectiveness of community-based (DOT) and self-supervised treatment of tuberculosis in Maracha Arua, Uganda
(2002) Owiny, Vincent; Sinanovic, Edina
Tuberculosis is the leading infectious killer of people living with HIV/AIDS. Millions of tuberculosis deaths could be prevented by the widespread use of the less expensive strategy of directly observed treatment (DOT). The cost-effectiveness of DOT however varies with its method of supervision. This study evaluated the cost-effectiveness of community-based and self-supervision strategies of DOT in Maracha, Arua District, Uganda. Patients', community's and health system's costs were obtained through interviews and expenditure statements. For effectiveness measures, historical follow-up of the cohort belonging to each the tB treatmentt supervison strategy was done. Systematic random sampling was done to identify the 20 patients from each treatment strategy for interviews to estimate their treatment costs. Due to low number of patients in the available TB registers, all the 129 patients were enrolled for the study. The findings showed that community-based supervision of DOT was a more cost-effective TB treatment supervision option than that by self-supervision and was therefore recommended to Maracha HSD and Arua District for more support and expansion. However, the accuracy of this study was limited by method used and generalizability of the results could be affected by the small sample size.
Open Access
A cost-effectiveness analysis of managing chronic diarrhoea diseases in Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome adult patients in an academic hospital in Lusaka, Zambia
(2001) Yavwa, Felistah M K; Sinanovic, Edina
The high burden of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) related chronic diarrhoea diseases (CDD) has strained the meager resources of the health sector and yet the effectiveness of management strategies leaves much to be desired. As study was done at a university teaching hospital (UTH) in Lusaka to evaluate two management strategies for these patients. The first strategy involved managing patients without investigations, while the other included investigations in the management strategy.
Open Access
Cost-effectiveness analysis of MVA85 vaccine: a new TB vaccine candidate
(2013) Channing, Liezl; Sinanovic, Edina
Tuberculosis (TB) remains a major public health concern. The BCG vaccine is, currently, the only vaccine against TB and, although it provides some protection against disseminated forms of TB, its effectiveness in preventing primary infection and disease progression to pulmonary TB is highly varied. A number of potential new TB vaccine candidates have been identified and are, currently, undergoing clinical trials. One such candidate is MVA85A. This study aims to assess the potential cost-effectiveness of a new TB vaccine, the MVA85A vaccine. The study compares two TB vaccine strategies, from the perspective of the South African Government: i. BCG, given at birth, which is the current standard of care in South Africa; and ii BCG, given at birth, together with a booster vaccine (MVA85A) given at 4 months, which is the potential new strategy. The study employs Decision Analytical Modelling, through the use of a Markov model, to estimate the costs and outcomes of the two strategies. The cumulative costs and outcomes of each intervention are used to calculate the cost-effectiveness ratio (CER) (i.e. the cost per TB case averted and the cost per TB death averted) for each intervention. These two cost-effectiveness ratios are compared using an incremental cost-effectiveness ratio (ICER), which represents the additional cost per additional benefit received. The results of the cost-effectiveness analysis indicate that the MVA85A strategy is both more costly and more effective – there are fewer TB cases and deaths from TB – than BCG alone. The Government would need to spend an additional USD 1,105 for every additional TB case averted and USD 284,017 for every additional TB death averted. Given the disappointing results of the MVA85A vaccine clinical trial – showing an efficacy of only 17.3%, this study will predominantly contribute to establishing an efficacy threshold for future vaccines. Our research also contributes to the body of knowledge on economic evaluations involving new TB vaccines as - to the best of our knowledge - this is the first cost-effectiveness analysis conducted using trial data involving a novel TB vaccine and providing a direct comparison with BCG vaccination. Furthermore, it provides a standardized Markov model, which is relatively simple to adapt to local settings and, which could be used in the future, to estimate the potential cost-effectiveness of new TB vaccines in children between the ages of 0–10 years.
Open Access
Cost-effectiveness of different screening and diagnostic strategies for sexually transmitted infections and bacterial vaginosis in women
(2020) van Der Walt, Elise; Sinanovic, Edina
Genital inflammation associated with sexually transmitted infections (STIs) and Bacterial Vaginosis (BV) is considered a key driver in the HIV/AIDS epidemic. A new rapid point-of-care (POC) test that detects genital inflammation in women was recently developed by researchers at the University of Cape Town. The objective of this study was to establish the cost-effectiveness of this novel intervention in comparison to other relevant screening and diagnostic strategies for the management of STIs and BV in women. It follows prior research on the cost and affordability of national implementation of screening with this technology. This research indicated that it might not affordable policy option given current health budget constraints. A decision analysis model was developed to estimate the cost and health outcomes associated with five different screening and diagnostic strategies for women seeking care in the South African public health sector. A decision tree was constructed, and all cost and effectiveness parameters were obtained from published and unpublished literature. The model incorporated all clinic-level and treatment costs associated with diagnosing and treating a single episode of disease. The main outcome measure was the effectiveness of each approach in correctly diagnosing an STI or BV in women, proxied by its sensitivity measure. One-way sensitivity analyses and threshold analysis were conducted to test key uncertainties and assumptions in the model. In the base-case scenario, screening with GIFT and treating GIFT-positive cases based on syndromic management guidelines, was the most cost-effective strategy with an ICER of $2.60 per women diagnosed with an STI(s) and/or BV. This strategy remained the most cost-effective even when a variety of parameters were varied in one-way sensitivity analyses. A threshold analyses on GIFT's sensitivity revealed that the strategy would remain the most cost-effective unless the sensitivity of the test assay decreased below 14.83%. From the perspective of the South African government, screening with GIFT and treating positive cases according to syndromic management guidelines is a highly cost-effective strategy for the management of STIs and BV in women in the reproductive age, but affordability considerations cannot be ignored. The newly developed rapid POC can significantly improve the management of STIs and BV in women through identifying asymptomatic women and at the same time, reducing their risk of HIV infection, but further research is required to inform decision-making.
Open Access
Determinants of home based care services provision for the people living with HIV/AIDS: A case study of Hope ('Tumaini') Home Based Care Programme in Tanzania
(2012) Mahunga, P; Sinanovic, Edina
The higher increase in the number of HIV/AIDS patients in the country has necessitated the expansion of Home Based Care (HBC) programmes and has called for the need to strengthen the HBC services in Tanzania. Since scaling up of HBC services is fundamental and the resources dedicated into HBC programs are supposed to be utilized efficiently, the factors hindering the provision of HBC services should be known and resolved. A cross sectional study was applied in studying the factors that influence the provision of HBC services and a quantitative method of data collection and analysis was used. A sample of 8 civil society organisations out of 23 carrying out HBC activities under 'Hope' HBC program were selected, representing organizations from rural and peri urban areas.
Open Access
Does the inclusion of the cost and burden of adverse drug reactions associated with drug-resistant TB treatment affect the incremental cost-effectiveness of new treatment regimens? A case study from the introduction of bedaquiline in South Africa National TB Programme
(2018) Bistline, Kathryn Lou; Sinanovic, Edina; Firnhaber, Cynthia
South Africa has one of the world’s highest burdens of TB, HIV/TB co-infection, and drug-resistant TB. Second-line TB treatment is less effective, more expensive, and more toxic than treatment for drug-sensitive TB. Nearly 1 in every 5 persons who starts treatment for drug-resistant TB in South Africa will die; 1 in every 3 persons who survives treatments experiences permanent, profound hearing loss. For decades there was little progress in TB research, however, and so treatment with old regimens continued despite safety concerns. In 2012 the US and European regulatory authorities approved a new drug, bedaquiline, but only for treatment in cases with no other options. In 2015, the South African Medicines Control Council approved bedaquiline for drug-resistant TB, but only a limited number of doses were approved in the 2016/2017 annual budget and the focus, again, was only for the patients who had no other options. In order to inform policy makers in planning and budgeting for drug-resistant TB treatment, the aim of this thesis was to determine whether the simple calculation that bedaquiline was too expensive relative to standard regimens using kanamycin was too simple. Particularly, given the high burden of adverse drug reactions (ADR) associated with kanamycin, would the inclusion of the cost and burden of ADR affect the incremental cost effectiveness ratio of a new treatment regimen where bedaquiline replaces kanamycin? Analysis of the national drug-resistant TB case register showed that mortality during second-line treatment was early, primarily in the first 6 months of treatment, even when patients do not have extensive drug resistance. HIV-positive patients not on anti-retroviral therapy (ART) at initiation of drug-resistant TB treatment have the highest risk of mortality. The high early mortality is a real risk that clinicians have to balance when deciding to initiate ART and effective second-line TB treatment both as quickly as possible. Daily injections coupled with taking more than 10 pills each day are a heavy burden for patient compliance, but also pose concerns in terms of overlapping and compounding toxicities; this burden was confirmed through a meta-analysis of the pooled frequency of adverse events among cohorts with at least 25% of the patients HIV-positive. A competing risk analysis of a cohort of drug-resistant TB patients from Johannesburg – addressing the reality that patients may not have experienced an ADR because they died rather than because they were at lower risk – indicated that HIV-infected patients who are not yet stable on ART and second-line TB treatment are at the highest risk of ADR. A Markov model built and parameterized using the data from the South African national TB programme indicates that bedaquiline for all drug-resistant TB led to a small gain in effectiveness at a cost that was under the costs of the drug itself, due to savings from daily injection visits. While cost-effective, it was not clear that South African policy makers needed to move beyond the offer of bedaquiline for patients with extensive drug resistance. However, the calculation, and the decision point, were different once the costs and disability associated with ADRs was included in the analysis. Bedaquiline-based regimens offer a cost-saving and more effective alternative to an injection-based regimen for drug-resistant TB patients treated in the public sector in South Africa.
Open Access
The economic consequences and coping mechanisms used by households affected by HIV
(2008) Mirimo, Faith; Sinanovic, Edina
This study was aimed at examining the economic consequences and the coping mechanisms used by households affected by HIV/AIDS. There is concern that even with the provision of free Antiretroviral Therapy (ART); HIV/AIDS may exert negative economic consequences on People Living with HIV/AIDS (PLWHA) and their households. Households then come up with coping mechanisms in response to the economic burden of HIV/AIDS. In addition, social capital available to households may positively influence households' ability to cope with the economic burden of HIV/AIDS.
Open Access
Economic evaluation of models of prevention of mother-to-child transmission of HIV intervention for large scale implementation
(2021) Cunnama, Lucy; Sinanovic, Edina; Myer, Benjamin
Background: Huge successes have been seen in the prevention of mother-to-child transmission of HIV (PMTCT) towards its elimination. Now amidst a landscape of universal antiretroviral therapy (ART), focus has been placed on different models of care to support and retain mother-infant pairs in the vulnerable postpartum phase. Methods The aim was to establish economic evidence for scaling-up approaches and models of care for PMTCT particularly during the postpartum period in Southern Africa. The economic data were collected during three studies, Safe Generations (Eswatini), MCH-ART and PACER (South Africa), using mixed bottom-up and top-down methodology. Outcomes of these studies were used to estimate the cost-effectiveness using an incremental cost effectiveness ratio (ICER, calculated by the difference in cost divided by the difference in effects) of lifelong ART in comparison to Option A (the standard of care at the time) in Eswatini; and to estimate the annual costs, costeffectiveness and budget impact of three models of care (Model I: Routine Care - mothers in general ART and infants in well-baby clinics; Model II: Integrated Care - mothers-infant pairs in integrated care in midwife obstetric unit; and Model III: Community Care - mothers in community adherence clubs and infants in well-baby clinics) in South Africa, from the provider and patient's perspectives. Costs are presented in 2019 United States Dollars (US $). Results Lifelong ART can be considered cost-effective in Eswatini with an ICER of US $984 per mother retained in care to six months postpartum. In Cape Town, South Africa, Routine Care cost US $226 per mother-infant pair per annum; Integrated Care cost US $341; and Community Care cost US $254. Annual patient costs (direct and indirect costs) for Models I-III, were US $30-55, US $23-45 and US $76 per mother-infant pair respectively. Comparatively Community Care was the most cost-effective model with an ICER of US $97 per mother-infant pair retained and mother virally suppressed. Scaling-up Community Care nationally in South Africa would require US $5 720 096 more than Routine Care, 0.2% of the total health budget for 2020/21. Conclusions This work has generated novel empirical data in the form of new cost estimates and cost comparisons across different models of care. It has also provided a unique comparison of the different models of care using a cost-effectiveness analysis; and further a novel budget impact analysis of different approaches to rolling these strategies out. This data has helped to fill the gap in the evidence base for instance lifelong ART was implemented in Eswatini as a direct result of the Safe Generations study findings. Community Care was found to be cost-effective and if scaled up nationally in South Africa would only require a small increment of the total health budget. However, we recommend a mixture of models of care to cater for the needs and preferences of patients. Decision makers can use the empirical findings to help set realistic budgets in Southern Africa and explore ideal model implementation to support mother-infant pairs in the crucial postpartum phase.