How Much Does It Cost to Provide Antiretroviral Therapy for HIV/AIDS in Africa?

Background: Many African countries are rapidly expanding HIV/AIDS treatment programs. Empirical information on the cost of delivering antiretroviral therapy (ART) for HIV/AIDS is needed for program planning and budgeting. Methods: We searched published and gray sources for estimates of the cost of providing ART in service delivery (non-research) settings in sub-Saharan Africa. Estimates were included if they were based on primary local data for input prices. Results: 17 eligible cost estimates were found. Of these, 10 were from South Africa. The cost per patient per year ranged from $396 to$2,761. It averaged approximately $850/patient/year in countries outside South Africa and$1,700/patient/year in South Africa. The most recent estimates for South Africa averaged $1,200/patient/year. Specific cost items included in the average cost per patient per year varied, making comparison across studies problematic. All estimates included the cost of antiretroviral drugs and laboratory tests, but many excluded the cost of inpatient care, treatment of opportunistic infections, and/or clinic infrastructure. Antiretroviral drugs comprised an average of one third of the cost of treatment in South Africa and one half to three quarters of the cost in other countries. Conclusions: There is very little empirical information available about the cost of providing antiretroviral therapy in non-research settings in Africa. Methods for estimating costs are inconsistent, and many estimates combine data drawn from disparate sources. Cost analysis should become a routine part of operational research on the treatment rollout in Africa

Infographic: Division 1 - Power 5 Football Stars in STEM

In this infographic, football stars studying degrees in science, technology, engineering, and math (STEM) are showcased. The infographic focuses on racial/ethnic minoritized students who pursue STEM degrees and play football at a university in a National Collegiate Athletic Association (NCAA) Division 1 - Power 5 conference. For each football star, their name, university and major are included. While pursuing majors such as biology, engineering and psychology, these diverse individuals provide counterexamples of who can pursue rigorous majors and high-demand sports

Clinical utility of rosuvastatin and other statins for cardiovascular risk reduction among the elderly

Age is one of the strongest predictors of cardiovascular disease (CVD) risk. Treatment with statins can significantly reduce CVD events and mortality in both primary and secondary prevention. Yet despite the high CVD risk among the elderly, there is underutilization of statins in this population (ie, the treatment-risk paradox). Few studies have investigated the use of statins in the elderly, particularly for primary prevention and, as a result, guidelines for treating the elderly are limited. This is likely due to: uncertainties of risk assessment in older individuals where the predictive value of individual risk factors is decreased; the need to balance the benefits of primary prevention with the risks of polypharmacy, health care costs, and adverse medication effects in a population with decreased life expectancy; the complexity of treating patients with many other comorbidities; and increasingly difficult social and economic concerns. As life expectancy increases and the total elderly population grows, these issues become increasingly important. JUPITER (Justification for the Use of statins in Prevention: an Intervention Trial Evaluating Rosuvastatin) is the largest primary prevention statin trial to date and enrolled a substantial number of elderly adults. Among the 5695 JUPITER participants ≥70 years of age, the absolute CVD risk reduction associated with rosuvastatin was actually greater than for younger participants. The implications of this JUPITER subanalysis and the broader role of statins among older adults is the subject of this review

Treatment initiation among persons diagnosed with drug resistant tuberculosis in Johannesburg, South Africa

In South Africa, roughly half of the drug-resistant TB cases diagnosed are reported to have been started on treatment. We determined the proportion of persons diagnosed with rifampicin resistant (RR-) TB who initiated treatment in Johannesburg after the introduction of decentralized RR-TB care in 2011

The net cost of incorporating resistance testing into HIV/AIDS treatment in South Africa: a Markov model with primary data

<p>Abstract</p> <p>Background</p> <p>Current guidelines for providing antiretroviral therapy (ART) in South Africa's public sector programme call for switching patients from first-line to second-line treatment upon virologic failure as indicated by two consecutive viral loads above 5000 copies/ml, but without laboratory evidence of viral resistance. We modelled the net cost of adding resistance testing for patients with virological failure and retaining patients without resistance on first-line therapy, rather than switching all failures to second-line therapy.</p> <p>Methods</p> <p>Costs were estimated for three scenarios: routine maintenance (standard care without resistance testing, switch all failures to second line); resistance testing (resistance test for patients with failure, switch those with resistance); and limited testing (resistance test for patients with failure in the first three years, switch those with resistance). A Markov model was used to estimate the cost of each arm over five years after first line initiation. Rates of treatment failure, viral resistance and treatment costs were estimated with primary data from a large HIV treatment cohort at a public facility in Johannesburg. Future costs were discounted at 3%.</p> <p>Results</p> <p>Virological failure rates over five years were 19.8% in routine maintenance and 20.2% in resistance testing and limited testing; 16.8% and 11.4% of failures in routine and limited testing, respectively, did not have any resistance mutations, resulting in 3.1% and 2.0% fewer patients switching to second-line ART by the end of five years. Treatment costs were estimated at US$526 and$1268 per patient per year on first-line and second-line therapy, respectively; a resistance test cost $242. The total average cost per patient over five years was$2780 in routine maintenance; $2775 in resistance testing; and$2763 in limited testing.</p> <p>Conclusions</p> <p>Incorporating resistance testing into treatment guidelines in South Africa is potentially cost-neutral and can identify other reasons for failure, conserve treatment options, and generate information about emerging resistance patterns.</p

Retention in care, resource utilization, and costs for adults receiving antiretroviral therapy in Zambia: a retrospective cohort study

BACKGROUND: Of the estimated 800,000 adults living with HIV in Zambia in 2011, roughly half were receiving antiretroviral therapy (ART). As treatment scale up continues, information on the care provided to patients after initiating ART can help guide decision-making. We estimated retention in care, the quantity of resources utilized, and costs for a retrospective cohort of adults initiating ART under routine clinical conditions in Zambia. METHODS: Data on resource utilization (antiretroviral [ARV] and non-ARV drugs, laboratory tests, outpatient clinic visits, and fixed resources) and retention in care were extracted from medical records for 846 patients who initiated ART at ≥15 years of age at six treatment sites between July 2007 and October 2008. Unit costs were estimated from the provider’s perspective using site- and country-level data and are reported in 2011 USD. RESULTS: Patients initiated ART at a median CD4 cell count of 145 cells/μL. Fifty-nine percent of patients initiated on a tenofovir-containing regimen, ranging from 15% to 86% depending on site. One year after ART initiation, 75% of patients were retained in care. The average cost per patient retained in care one year after ART initiation was $243 (95$194-$293), ranging from$184 (95% CI, $172-$195) to $304 (95$290-$319) depending on site. Patients retained in care one year after ART initiation received, on average, 11.4 months’ worth of ARV drugs, 1.5 CD4 tests, 1.3 blood chemistry tests, 1.4 full blood count tests, and 6.5 clinic visits with a doctor or clinical officer. At all sites, ARV drugs were the largest cost component, ranging from 38% to 84% of total costs, depending on site. CONCLUSIONS: Patients initiate ART late in the course of disease progression and a large proportion drop out of care after initiation. The quantity of resources utilized and costs vary widely by site, and patients utilize a different mix of resources under routine clinical conditions than if they were receiving fully guideline-concordant care. Improving retention in care and guideline concordance, including increasing the use of tenofovir in first-line ART regimens, may lead to increases in overall treatment costs

Impact of acute stress, sex, and childhood maltreatment on fear learning and fear generalization in a fear-potentiated startle paradigm

Many researchers approach the etiology of trauma-, stressor-, and anxiety-related mental disorders from the perspective of classical conditioning processes gone awry. According to this view, abnormal associative relationships between conditioned and unconditioned stimuli may underlie pathological anxiety and result in unusually intense fear memories or fear memories that cannot be properly extinguished. Recent work has expanded on this view by showing that many psychological disorders involving pathological anxiety are associated with an exaggerated form of stimulus generalization, leading individuals with such disorders to respond with fear and anxiety to a variety of contexts and cues that should not be threatening. It is well-known that stress, biological sex, childhood maltreatment, and certain dispositional factors can increase one’s susceptibility for pathological anxiety and significantly impact fear learning; thus, it is possible that these factors, alone or in combination, contribute to clinical anxiety by influencing fear generalization processes. In the present study, 478 healthy undergraduate students were exposed to the socially-evaluated cold pressor test immediately or 30 min prior to learning to associate one geometrical shape, but not another, with an aversive stimulus in a fear-potentiated startle paradigm. The next day, participants were tested for fear generalization by measuring their fear responses to a variety of stimuli that were similar to, but different from, the shapes observed on Day 1. Objective and subjective measures of stress were collected on Day 1, and childhood maltreatment was quantified with the Childhood Trauma Questionnaire. The results revealed that, across both stress time points, greater heart rate and greater cortisol levels in response to stress were associated with weaker fear acquisition and a flatter generalization gradient. These effects were influenced by participant sex and trait anxiety. We also found evidence to suggest that greater childhood maltreatment was associated with impaired fear acquisition in males but enhanced fear acquisition in females. These findings reveal a complex interaction between acute stress, biological sex, childhood maltreatment, dispositional anxiety, and fear learning that may lend insight into the etiology of certain stress-related psychological disorders

Tunnel vision, false memories, and intrusive memories following exposure to the Trier Social Stress Test

Most research examining the impact of stress on learning and memory has exposed participants to a stressor and measured how it affects learning and memory for unrelated material (e.g., list of words). Such work has been helpful, but it has not been the most translational to the human condition. When considering phenomena such as intrusive memories in post-traumatic stress disorder (PTSD) or an eyewitness\u27s memory for a crime, it is most useful to know what an individual remembers about the stress experience itself, not unrelated information. In prior work, investigators used a modified version of the Trier Social Stress Test (TSST) to quantify participant memory for the stressor. We aimed to replicate this work by examining participant memory for the TSST and extend on it by quantifying false and intrusive memories that result from TSST exposure. Forty-six undergraduate students from Ohio Northern University were exposed to the TSST or the friendly-TSST (f-TSST). The TSST required participants to deliver a ten-minute speech in front of two lab panel members as part of a mock job interview; the f-TSST required participants to casually converse with the panel members about their interests and hobbies. In both conditions, the panel members interacted with (central) or did not interact with (peripheral) several objects sitting on a desk in front of them. Participants’ anxiety levels were assessed before and after the TSST or f-TSST, and saliva samples were collected to assay for cortisol. The next day, participants’ memory for the objects that were present on Day 1 was assessed with recall and recognition tests. We also quantified participants’ intrusive memories for each task by having them complete an intrusive memory questionnaire on Days 2, 4, 6, and 8. Participants exposed to the TSST exhibited greater recall of central objects than participants exposed to the f-TSST. There were no differences observed for the recall of peripheral objects or for recognition memory. Interestingly, TSST exposure increased false recall in males, but reduced it in females. Females exposed to the TSST also showed greater evidence of intrusive memories than males exposed to the TSST. Consistent with prior work, these findings show that stress enhances memory for the central details of a stressful experience. They also extend on prior work by showing that stressful experiences sex-dependently impact the manifestation of false and intrusive memories. This is the first study of which we are aware to quantify intrusive memory formation with the TSST; the modified TSST paradigm may be useful in understanding differential susceptibility to intrusive memory formation and the development of PTSD