Cost of a dedicated ART clinic

Background. The provision of antiretroviral therapy (ART) is being rolled out across South Africa. Little evidence exists on the cost of running clinics for ART provision.Objectives. To determine the cost per patient-month enrolled in an ART programme and per patient-visit for a dedicated, public-sector ART clinic in a South African peri-urban setting in 2004/05 and 2005/06, as the clinic moved from a temporary to a permanent site.Methods. A retrospective costing study was performed from a programme perspective. Two years of expenditure data for the clinic were collected from primary sources. Costs per patientvisit and per patient-month were calculated in Rand and converted to 2004 US$(R6.4347 = US$1).Results. The total cost of running the site, excluding patient-specific items (medicines and medical tests), was $174 072 in 2004/05 and$421 872 in 2005/06. Cost per patient-month fell from $40.29 to$36.47, a 9% decrease; cost per patient-visit fell from $54.79 to$41.62, a 24% decrease. In 2005/06, 68% of all expenditure was on medical and pharmacy staff (versus 62% in 2004/05), 23% was on the employment of peer adherence counsellors (versus 35%), and the remaining 9% was on capital costs and supplies (versus 3%).Conclusions. The increase in scale of operation for the provision of ART at this clinic allowed economies of scale to be reaped. Staff costs, both medical and support, comprised the large majority of total clinic costs, such that the erection of a dedicated building for the clinic had little impact on the economic cost of care

Leveraging Contact Network Structure in the Design of Cluster Randomized Trials

Background: In settings like the Ebola epidemic, where proof-of-principle trials have succeeded but questions remain about the effectiveness of different possible modes of implementation, it may be useful to develop trials that not only generate information about intervention effects but also themselves provide public health benefit. Cluster randomized trials are of particular value for infectious disease prevention research by virtue of their ability to capture both direct and indirect effects of intervention; the latter of which depends heavily on the nature of contact networks within and across clusters. By leveraging information about these networks – in particular the degree of connection across randomized units – we propose a novel class of connectivity-informed cluster trial designs that aim both to improve public health impact (speed of control l epidemics) while preserving the ability to detect intervention effects. Methods: We consider cluster randomized trials with staggered enrollment, in each of which the order of enrollment is based on the total number of ties (contacts) from individuals within a cluster to individuals in other clusters. These designs can accommodate connectivity based either on the total number of inter-cluster connections at baseline or on connections only to untreated clusters, and include options analogous both to traditional Parallel and Stepped Wedge designs. We further allow for control clusters to be “held-back” from re-randomization for some period. We investigate the performance of these designs in terms of epidemic control (time to end of epidemic and cumulative incidence) and power to detect vaccine effect by simulating vaccination trials during an SEIR-type epidemic outbreak using a network-structured agent-based model. Results: In our simulations, connectivity-informed designs lead to lower peak infectiousness than comparable traditional study designs and a 20% reduction in cumulative incidence, but have little impact on epidemic length. Power to detect differences in incidence across clusters is reduced in all connectivity-informed designs. However the inclusion of even a brief “holdback” restores most of the power lost in comparison to a traditional Stepped Wedge approach. Conclusions: Incorporating information about cluster connectivity in design of cluster randomized trials can increase their public health impact, especially in acute outbreak settings. Using this information helps control outbreaks – by minimizing the number of cross-cluster infections – with modest cost in power to detect an effective intervention

A proposed role for sepsis in the pathogenesis of myocardial calcification

Myocardial calcification is a rare and life-threatening condition that is a recognised complication of ischaemic heart disease, cardiac surgery, rheumatic fever and myocarditis. It is distinct from coronary artery or valvular calcification, and can be seen in patients with abnormal calcium metabolism1 . Its presence in the context of sepsis is less well recognised and the mechanisms responsible are poorly understood. We review the relevant literature and propose a mechanistic theory for its pathogenesi

Effect of multi-level interventions on mental health outcomes among adolescents in sub-Saharan Africa: a systematic review

Objective: In sub-Saharan Africa (SSA), multiple factors contribute to the considerable burden of mental health disorders among adolescents, highlighting the need for interventions that address underlying risks at multiple levels. We reviewed evidence of the effectiveness of community or family-level interventions, with and without individual level interventions, on mental health disorders among adolescents in SSA. // Design: Systematic review using the Grades of Recommendation, Assessment, Development and Evaluation approach. // Data sources: A systematic search was conducted on Cochrane Library, MEDLINE, EMBASE, PSYCINFO and Web of Science up to 31 March 2021. // Eligibility criteria: Studies were eligible for inclusion in the review if they were randomised controlled trials (RCTs) or controlled quasi-experimental studies conducted in sub-Saharan African countries and measured the effect of an intervention on common mental disorders in adolescents aged 10–24 years. // Data extraction and synthesis: We included studies that assessed the effect of interventions on depression, anxiety, post-traumatic stress disorder and substance abuse. Substance abuse was only considered if it was measured alongside mental health disorders. The findings were summarised using synthesis without meta-analysis, where studies were grouped according to the type of intervention (multi-level, community-level) and participants. // Results: Of 1197 studies that were identified, 30 studies (17 RCTs and 3 quasi-experimental studies) were included in the review of which 10 delivered multi-level interventions and 20 delivered community-level interventions. Synthesised findings suggest that multi-level interventions comprise economic empowerment, peer-support, cognitive behavioural therapy were effective in improving mental health among vulnerable adolescents. Majority of studies that delivered interventions to community groups reported significant positive changes in mental health outcomes. // Conclusions: The evidence from this review suggests that multi-level interventions can reduce mental health disorders in adolescents. Further research is needed to understand the reliability and sustainability of these promising interventions in different African contexts. // PROSPERO registration number: CRD42021258826

Effects of education and age on the experience of youth violence in a very low-resource setting: a fixed-effects analysis in rural Burkina Faso

Objective: The study aimed to investigate the effects of education and age on the experience of youth violence in low-income and middle-income country settings. Design: Using a standardised questionnaire, our study collected two waves of longitudinal data on sociodemographics, health practices, health outcomes and risk factors. The panel fixed-effects ordinary least squares regression models were used for the analysis. Settings: The study was conducted in 59 villages and the town of Nouna with a population of about 100 000 individuals, 1 hospital and 13 primary health centres in Burkina Faso. Participants: We interviewed 1644 adolescents in 2017 and 1291 respondents in 2018 who participated in both rounds. Outcome and exposure measures: We examined the experience of physical attacks in the past 12 months and bullying in the past 30 days. Our exposures were completed years of age and educational attainment. Results: A substantial minority of respondents experienced violence in both waves (24.1% bullying and 12.2% physical attack), with males experiencing more violence. Bullying was positively associated with more education (β=0.12; 95% CI 0.02 to 0.22) and non-significantly with older age. Both effects were stronger in males than females, although the gender differences were not significant. Physical attacks fell with increasing age (β=−0.18; 95% CI −0.31 to –0.05) and this association was again stronger in males than females; education and physical attacks were not substantively associated. Conclusions: Bullying and physical attacks are common for rural adolescent Burkinabe. The age patterns found suggest that, particularly for males, there is a need to target violence prevention at younger ages and bullying prevention at slightly older ones, particularly for those remaining in school. Nevertheless, a fuller understanding of the mechanisms behind our findings is needed to design effective interventions to protect youth in low-income settings from violence

Cost of a dedicated ART clinic

Background. The provision of antiretroviral therapy (ART) is being rolled out across South Africa. Little evidence exists on the cost of running clinics for ART provision. Objectives. To determine the cost per patient-month enrolled in an ART programme and per patient-visit for a dedicated, public-sector ART clinic in a South African peri-urban setting in 2004/05 and 2005/06, as the clinic moved from a temporary to a permanent site. Methods. A retrospective costing study was performed from a programme perspective. Two years of expenditure data for the clinic were collected from primary sources. Costs per patient visit and per patient-month were calculated in Rand and converted to 2004 US$(R6.4347 = US$1). Results. The total cost of running the site, excluding patientspecific items (medicines and medical tests), was $174 072 in 2004/05 and$421 872 in 2005/06. Cost per patient-month fell from $40.29 to$36.47, a 9% decrease; cost per patient-visit fell from $54.79 to$41.62, a 24% decrease. In 2005/06, 68% of all expenditure was on medical and pharmacy staff (versus 62% in 2004/05), 23% was on the employment of peer adherence counsellors (versus 35%), and the remaining 9% was on capital costs and supplies (versus 3%). Conclusions. The increase in scale of operation for the provision of ART at this clinic allowed economies of scale to be reaped. Staff costs, both medical and support, comprised the large majority of total clinic costs, such that the erection of a dedicated building for the clinic had little impact on the economic cost of care. South African Medical Journal Vol. 97 (8) 2007: pp. 593-59