Increasing Coverage of Antiretroviral Therapy and Male Medical Circumcision in HIV Hyperendemic Countries: A Cost-Benefit Analysis

HIV continues to cause the largest number of disability-adjusted life years of any disease in HIV hyperendemic countries (i.e., countries with an adult HIV prevalence >15%). We compare the benefits and costs of two proven biological interventions to reduce the health losses due to the HIV epidemic in hyperendemic countries from 2015 through 2030: 1) increasing ART coverage to 90% among HIV-infected adults with a CD4-cell count <350 cells/microliter, before expanding the HIV treatment scale-up to people with higher CD4-cell counts; and 2) increasing male medical circumcision coverage to at least 90% among HIV-uninfected adult men. We developed a mathematical model to determine the benefits and costs of increasing the coverage of both ART under different CD4-cell count thresholds and of circumcision in HIV-hyperendemic countries. The results show that scaling up ART and circumcision are both cost-beneficial. However, the benefit-to-cost ratio (BCR) for circumcision is significantly higher than for ART: 7.4 vs. 3.0 (at US$1,000 per life year and a 5$5,000 per life year and a 3% discount rate). The additional cost of scaling up circumcision is approximately $US500 million while the additional cost of increasing ART coverage lies between$US17 and $US19 billion. We conclude that increasing the coverage of ART among HIV-infected adults with a CD4-cell count <350 cells/microliter and, in particular, scaling up male medical circumcision among HIV-negative men are both highly cost-beneficial interventions to reduce the health burdens resulting from the HIV epidemic in hyperendemic countries over the next 15 years

The Socio-Demographic Characteristics of Diabetes, Hypertension, and Cardiovascular Disease Risk in India

Cardiovascular disease (CVD) is the leading cause of mortality in India. Yet, the evidence is sparse on how diabetes, hypertension, and predicted CVD risk vary between population groups in the country. This dissertation aimed to determine how the prevalence of diabetes, hypertension, and predicted CVD risk in India varies by state, rural-urban location, and individual-level socio-demographic characteristics. Data were pooled from the Annual Health Survey (2012-2013) and the District-Level Household Survey-4 (2012-2014). Diabetes was defined as a plasma glucose 126 mg/dl if fasted or 200 mg/dl if non-fasted, and hypertension as a systolic blood pressure (BP) 140mmHg or a diastolic BP 90mmHg. Predicted 10-year CVD risk was calculated for each participant aged 30 to 74 years using the Framingham risk score, and dichotomized into high (30%) or low risk (<30%). 1,320,555 adults aged 18 years were included in the diabetes and hypertension analysis, and 797,932 adults aged 30 to 74 years in the CVD risk analysis. The crude prevalence of diabetes, hypertension, and high CVD risk was 7.3% (7.1 - 7.4), 23.6% (23.4 – 23.7), and 14.6% (14.4 – 14.8) among females, respectively, and 7.8% (7.6 - 8.0), 27.3% (27.1 – 27.5), and 31.7% (31.4 – 32.0) among males, respectively. There was substantial variation in the prevalence of each outcome among states. Being in the richest compared to the poorest household wealth quintile was associated with only a modestly higher probability of diabetes (rural: 2.8 [2.5 - 3.1] percentage points; and urban: 3.5 [3.0 - 3.9] percentage points) and hypertension (rural: 4.2 [3.7 - 4.6] percentage points; and urban: 3.0 [2.4 - 3.7] percentage points). The differences in the probability of all conditions by educational category were generally small. The prevalence of diabetes and hypertension in India is high, and predicted CVD risk was approximately twice as high as has been estimated for the United States. The important variation in the prevalence of each outcome by state and socio-demographic characteristics can inform planning and resource allocation as well as effective targeting of CVD programs to reach those most in need

Evaluation of a community health worker intervention and the World Health Organization’s Option B versus Option A to improve antenatal care and PMTCT outcomes in Dar es Salaam, Tanzania: study protocol for a cluster-randomized controlled health systems implementation trial

Background: Mother-to-child transmission of HIV remains an important public health problem in sub-Saharan Africa. As HIV testing and linkage to PMTCT occurs in antenatal care (ANC), major challenges for any PMTCT option in developing countries, including Tanzania, are delays in the first ANC visit and a low overall number of visits. Community health workers (CHWs) have been effective in various settings in increasing the uptake of clinical services and improving treatment retention and adherence. At the beginning of this trial in January 2013, the World Health Organization recommended either of two medication regimens, Option A or B, for prevention of mother-to-child transmission of HIV (PMTCT). It is still largely unclear which option is more effective when implemented in a public healthcare system. This study aims to determine the effectiveness, cost-effectiveness, acceptability, and feasibility of: (1) a community health worker (CWH) intervention and (2) PMTCT Option B in improving ANC and PMTCT outcomes. Methods/Design This study is a cluster-randomized controlled health systems implementation trial with a two-by-two factorial design. All 60 administrative wards in the Kinondoni and Ilala districts in Dar es Salaam were first randomly allocated to either receiving the CHW intervention or not, and then to receiving either Option B or A. Under the standard of care, facility-based health workers follow up on patients who have missed scheduled appointments for PMTCT, first through a telephone call and then with a home visit. In the wards receiving the CHW intervention, the CHWs: (1) identify pregnant women through home visits and refer them to antenatal care; (2) provide education to pregnant women on antenatal care, PMTCT, birth, and postnatal care; (3) routinely follow up on all pregnant women to ascertain whether they have attended ANC; and (4) follow up on women who have missed ANC or PMTCT appointments. Trial registration ClinicalTrials.gov: EJF22802. Registration date: 14 May 2013. Electronic supplementary material The online version of this article (doi:10.1186/1745-6215-15-359) contains supplementary material, which is available to authorized users

The efficiency of chronic disease care in sub-Saharan Africa

The number of people needing chronic disease care is projected to increase in sub-Saharan Africa as a result of expanding human immunodeficiency virus (HIV) treatment coverage, rising life expectancies, and lifestyle changes. Using nationally representative data of healthcare facilities, Di Giorgio et al. found that many HIV clinics in Kenya, Uganda, and Zambia appear to have considerable untapped capacity to provide care for additional patients. These findings highlight the potential for increasing the efficiency of clinical processes for chronic disease care at the facility level. Important questions for future research are how estimates of comparative technical efficiency across facilities change, when they are adjusted for quality of care and the composition of patients by care complexity. Looking ahead, substantial research investment will be needed to ensure that we do not forgo the opportunity to learn how efficiency changes, as chronic care is becoming increasingly differentiated by patient type and integrated across diseases and health systems functions. Please see related article: http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-0653-zVersion of Recor

Regional mobility and COVID-19 vaccine hesitancy: Evidence from China

China’s Zero-COVID Policy imposed stringent restrictions on citizens’ mobility to curb the spread of COVID-19. While effective in reducing viral transmission, these measures may have inadvertently delayed or deterred vaccine uptake by fostering a heightened sense of security. This study examines the relationships between intra- and inter-regional travel mobility and individual hesitancy towards COVID-19 vaccines (HCV), leveraging the Baidu Mobility Index and data from a cross-sectional survey of 12,000 participants. Our descriptive analysis reveals that (a) individual attitudes toward COVID-19 vaccines are more polarized across regions with different mobility levels than toward vaccines in general and (b) regions with higher population mobility exhibit lower levels of hesitancy toward COVID-19 vaccines. Our OLS and IV results further demonstrate that a one-standard-deviation increase in inter-provincial travel rates is associated with a decrease of 0.0112–0.0195 standard deviations in HCV, whereas intra-provincial mobility is not correlated. Overall, this paper suggests prioritizing the roll-out of COVID-19 vaccines or similar initiatives in areas with higher mobility levels, where residents perceive greater risks and exhibit a higher likelihood of seeking vaccination.info:eu-repo/semantics/publishedVersio

Community Health Workers to Improve Antenatal Care and PMTCT Uptake in Dar es Salaam, Tanzania: A Quantitative Performance Evaluation

Background: Home visits by community health workers (CHW) could be effective in identifying pregnant women in the community before they have presented to the health system. CHW could thus improve the uptake of antenatal care (ANC), HIV testing, and prevention of mother-to-child transmission (PMTCT) services. Methods: Over a 16-month period, we carried out a quantitative evaluation of the performance of CHW in reaching women early in pregnancy and before they have attended ANC in Dar es Salaam, Tanzania. Results: As part of the intervention, 213 CHW conducted more than 45,000 home visits to about 43,000 pregnant women. More than 75% of the pregnant women identified through home visits had not yet attended ANC at the time of the first contact with a CHW and about 40% of those who had not yet attended ANC were in the first trimester of pregnancy. Over time, the number of pregnant women the CHW identified each month increased, as did the proportion of women who had not yet attended ANC. The median gestational age of pregnant women contacted for the first time by a CHW decreased steadily and significantly over time (from 21/22 to 16 weeks, P-value for test of trend <0.0001). Conclusions: A large-scale CHW intervention was effective in identifying pregnant women in their homes early in pregnancy and before they had attended ANC. The intervention thus fulfills some of the conditions that are necessary for CHW to improve timely ANC uptake and early HIV testing and PMTCT enrollment in pregnancy

Quasi-experiments to establish causal effects of HIV care and treatment and to improve the cascade of care

Purpose of review Randomized, population-representative trials of clinical interventions are rare. Quasi-experiments have been used successfully to generate causal evidence on the cascade of HIV care in a broad range of real-world settings. Recent findings Quasi-experiments exploit exogenous, or quasi-random, variation occurring naturally in the world or because of an administrative rule or policy change to estimate causal effects. Well designed quasi-experiments have greater internal validity than typical observational research designs. At the same time, quasi-experiments may also have potential for greater external validity than experiments and can be implemented when randomized clinical trials are infeasible or unethical. Quasi-experimental studies have established the causal effects of HIV testing and initiation of antiretroviral therapy on health, economic outcomes and sexual behaviors, as well as indirect effects on other community members. Recent quasi-experiments have evaluated specific interventions to improve patient performance in the cascade of care, providing causal evidence to optimize clinical management of HIV. Summary Quasi-experiments have generated important data on the real-world impacts of HIV testing and treatment and on interventions to improve the cascade of care. With the growth in large-scale clinical and administrative data, quasi-experiments enable rigorous evaluation of policies implemented in real-world settings

Use of lifestyle interventions in primary care for individuals with newly diagnosed hypertension, hyperlipidaemia or obesity: a retrospective cohort study

Abstract Summary Objective Lifestyle interventions can be efficacious in reducing cardiovascular disease risk factors and are recommended as first-line interventions in England. However, recent information on the use of these interventions in primary care is lacking. We investigated for how many patients with newly diagnosed hypertension, hyperlipidaemia or obesity, lifestyle interventions were recorded in their primary care electronic health record. Design A retrospective cohort study. Setting English primary care, using UK Clinical Practice Research Datalink. Participants A total of 770,711 patients who were aged 18 years or older and received a new diagnosis of hypertension, hyperlipidaemia or obesity between 2010 and 2019. Main outcome measures Record of lifestyle intervention and/or medication in 12 months before to 12 months after initial diagnosis (2-year timeframe). Results Analyses show varying results across conditions: While 55.6% (95% CI 54.9–56.4) of individuals with an initial diagnosis of hypertension were recorded as having lifestyle support (lifestyle intervention or signposting) within the 2-year timeframe, this number was reduced to 45.2% (95% CI 43.8–46.6) for hyperlipidaemia and 52.6% (95% CI 51.1–54.1) for obesity. For substantial proportions of individuals neither lifestyle support nor medication (hypertension: 12.2%, 95% CI 11.9–12.5; hyperlipidaemia: 32.2%, 95% CI 31.2–33.3; obesity: 43.9%, 95% CI 42.3–45.4) were recorded. Sensitivity analyses confirm that limited proportions of patients had lifestyle support recorded in their electronic health record before they were first prescribed medication (diagnosed and undiagnosed), ranging from 12.1% for hypertension to 19.7% for hyperlipidaemia, and 19.5% for obesity (23.4% if restricted to Orlistat). Conclusions Limited evidence of lifestyle support for individuals with cardiovascular risk factors (hypertension, hyperlipidaemia, obesity) recommended by national guidelines in England may stem from poor recording in electronic health records but may also represent missed opportunities. Given the link between progression to cardiovascular disease and modifiable lifestyle factors, early support for patients to manage their conditions through non-pharmaceutical interventions by establishing lifestyle modification as first-line treatment is crucial