Sexual health promotion and contraceptive services in local authorities: a systematic review of economic evaluations 2010-2015

Background Since 2013, health commissioners in England’s local authorities have been responsible for sexual health services, including contraception, HIV testing, STI testing and treatment, health education and specialist sexual health services. Effective commissioning requires information to indicate which interventions may, or may not, be cost-effective. However, current UK guidance and recent research on the cost-effectiveness of sexual health services provides patchy and fragmented evidence. This study aims systematically to review the evidence available on the cost-effectiveness of OECD-based interventions relevant to UK local authority-commissioned sexual health services. Methods Key informants, bibliographic database searches and reference lists of guidance documents and included studies were searched for potentially relevant research. Guided by key stakeholders, we sought economic evaluations of sexual health interventions within the responsibility of local authorities, and focused in the UK, on contraception and on health promotion, published between 2010 and 2015 in English. Eligible studies were full economic evaluations based in an OECD country. Studies were classified using a specifically developed tool and assessed for methodological risk of bias using one of three design-specific assessment tools. Descriptive frequencies of codes were analysed to provide a ‘map’ of research that informed stakeholder discussions to focus the subsequent synthesis. The characteristics of studies, quality ratings and cost outcomes from each included study were extracted into tables and findings summarised narratively. Studies were assessed for their relative cost-saving or cost-effectiveness according to NICE guidance. Results In total, 17,705 references were screened; of these, 29 met our inclusion criteria and were included in the synthesis. Nine studies were undertaken in the UK; the remainder were US based. Fifteen studies examined the economics of contraception and 14 evaluated health promotion. Overall, studies were of medium methodological quality. In general, economic evaluations of contraception reported cost-effectiveness or cost savings for ulipristal acetate (UPA) as emergency contraception, long-acting reversible contraceptives (LARCs) for regular, post-natal and post-abortion contraception, and targeting to high risk groups; none, however, reported costs per quality-adjusted life year (QALY) within NICE thresholds. Economic evaluations of sexual health promotion interventions indicated more mixed results. Only three interventions were found to be cost-effective according to the NICE thresholds for HIV or sexually transmitted infection (STI) outcomes: nurse-led rapid testing and tailored counselling; condom negotiations skills training for female sex workers; and a teacher-led STI prevention and skills training intervention. UK studies focused on health promotion and contraception, and supported the above findings. In general, there has been a reasonable amount of economic research into sexual health interventions since 2010, and these support current NICE sexual health guidance. Abstract Sexual health promotion and contraceptive services in local authorities: a systematic review of economic evaluations 2010-2015 vi Conclusions The broad nature of the research question posed in this systematic review resulted in the inclusion of a dataset very diverse in terms of populations, interventions, outcomes and types of economic evaluation designs. In considering the cost-effectiveness of these strategies in relation to their own commissioning climate, policy and decision makers should consider carefully the fit between their context and that of individual studies. Use of longer-term outcomes in trials used in economic evaluations would strengthen estimates of effects such as QALYs, as would the routine use of longitudinal cohort data

Cost of tuberculosis treatment in low- and middle-income countries: systematic review and meta-regression.

BACKGROUND: Despite a scarcity of tuberculosis (TB) cost data, a substantial body of evidence has been accumulating for drug-susceptible TB (DS-TB) treatment. In this study, we review unit costs for DS-TB treatment from a provider´s perspective. We also examine factors driving cost variations and extrapolate unit costs across low- and middle-income countries (LMICs).METHODS: We searched published and grey literature for any empirically collected TB cost estimates. We selected a subgroup of estimates looking at DS-TB treatment. We extracted information on activities and inputs included. We standardised costs into an average per person-month, fitted a multi-level regression model and cross-validated country-level predictions. We then extrapolated estimates for facility-based, directly observed DS-TB treatment across countries.RESULTS: We included 95 cost estimates from 28 studies across 17 countries. Costs predictions were sensitive to characteristics such as delivery mode, whether hospitalisation was included, and inputs accounted for, as well as gross domestic product per capita. Extrapolation results are presented with uncertainty intervals (UIs) for LMICs. Predicted median costs per 6 months of treatment were US$315.30 (95$222.60-US$417.20) for low-income, US$527.10 (95% CI US$395.70-US$743.70) for lower middle-income and US$896.40 (95$654.00-US$1214.40) for upper middle-income countries.CONCLUSIONS: Our study provides country-level DS-TB treatment cost estimates suitable for priority setting. These estimates, while not standing as a substitute for local high-quality primary data, can inform global, regional and national exercises

Developing the Global Health Cost Consortium Unit Cost Study Repository for HIV and TB: methodology and lessons learned.

Consistently defined, accurate, and easily accessible cost data are a valuable resource to inform efficiency analyses, budget preparation, and sustainability planning in global health. The Global Health Cost Consortium (GHCC) designed the Unit Cost Study Repository (UCSR) to be a resource for standardised HIV and TB intervention cost data displayed by key characteristics such as intervention type, country, and target population. To develop the UCSR, the GHCC defined a typology of interventions for each disease; aligned interventions according to the standardised principles, methods, and cost and activity categories from the GHCC Reference Case for Estimating the Costs of Global Health Services and Interventions; completed a systematic literature review; conducted extensive data extraction; performed quality assurance; grappled with complex methodological issues such as the proper approach to the inflation and conversion of costs; developed and implemented a study quality rating system; and designed a web-based user interface that flexibly displays large amounts of data in a user-friendly way. Key lessons learned from the extraction process include the importance of assessing the multiple uses of extracted data; the critical role of standardising definitions (particularly units of measurement); using appropriate classifications of interventions and components of costs; the efficiency derived from programming data checks; and the necessity of extraction quality monitoring by senior analysts. For the web interface, lessons were: understanding the target audiences, including consulting them regarding critical characteristics; designing the display of data in "levels"; and incorporating alert and unique trait descriptions to further clarify differences in the data

Cost effectiveness of potential ART adherence monitoring interventions in sub-saharan Africa

Background Interventions based around objective measurement of adherence to antiretroviral drugs for HIV have potential to improve adherence and to enable differentiation of care such that clinical visits are reduced in those with high adherence. It would be useful to understand the approximate upper limit of cost that could be considered for such interventions of a given effectiveness in order to be cost effective. Such information can guide whether to implement an intervention in the light of a trial showing a certain effectiveness and cost. Methods An individual-based model, calibrated to Zimbabwe, which incorporates effects of adherence and resistance to antiretroviral therapy, was used to model the potential impact of adherence monitoring-based interventions on viral suppression, death rates, disability adjusted life years and costs. Potential component effects of the intervention were: enhanced average adherence when on ART, reduced risk of ART discontinuation, and reduced risk of resistance acquisition. We considered a situation in which viral load monitoring is not available and one in which it is. In the former case, it was assumed that care would be differentiated based on the adherence level, with fewer clinic visits in those demonstrated to have high adherence. In the latter case, care was assumed to be primarily differentiated according to viral load level. The maximum intervention cost required to be cost effective was calculated based on a cost effectiveness threshold of $500 per DALY averted. Findings In the absence of viral load monitoring, an adherence monitoring-based intervention which results in a durable 6$50 per person-year on ART, mainly driven by the cost savings of differentiation of care. In the presence of viral load monitoring availability, an intervention with a similar effect on viral load suppression was cost-effective when costing $23-$32 per year, depending on whether the adherence intervention is used to reduce the level of need for viral load measurement. Conclusion The cost thresholds identified suggest that there is clear scope for adherence monitoringbased interventions to provide net population health gain, with potential cost-effective use in situations where viral load monitoring is or is not available. Our results guide the implementation of future adherence monitoring interventions found in randomized trials to have health benefit

Considering equity in priority setting using transmission models: Recommendations and data needs.

OBJECTIVES: Disease transmission models are used in impact assessment and economic evaluations of infectious disease prevention and treatment strategies, prominently so in the COVID-19 response. These models rarely consider dimensions of equity relating to the differential health burden between individuals and groups. We describe concepts and approaches which are useful when considering equity in the priority setting process, and outline the technical choices concerning model structure, outputs, and data requirements needed to use transmission models in analyses of health equity. METHODS: We reviewed the literature on equity concepts and approaches to their application in economic evaluation and undertook a technical consultation on how equity can be incorporated in priority setting for infectious disease control. The technical consultation brought together health economists with an interest in equity-informative economic evaluation, ethicists specialising in public health, mathematical modellers from various disease backgrounds, and representatives of global health funding and technical assistance organisations, to formulate key areas of consensus and recommendations. RESULTS: We provide a series of recommendations for applying the Reference Case for Economic Evaluation in Global Health to infectious disease interventions, comprising guidance on 1) the specification of equity concepts; 2) choice of evaluation framework; 3) model structure; and 4) data needs. We present available conceptual and analytical choices, for example how correlation between different equity- and disease-relevant strata should be considered dependent on available data, and outline how assumptions and data limitations can be reported transparently by noting key factors for consideration. CONCLUSIONS: Current developments in economic evaluations in global health provide a wide range of methodologies to incorporate equity into economic evaluations. Those employing infectious disease models need to use these frameworks more in priority setting to accurately represent health inequities. We provide guidance on the technical approaches to support this goal and ultimately, to achieve more equitable health policies

Considering equity in priority setting using transmission models : Recommendations and data needs

OBJECTIVES: Disease transmission models are used in impact assessment and economic evaluations of infectious disease prevention and treatment strategies, prominently so in the COVID-19 response. These models rarely consider dimensions of equity relating to the differential health burden between individuals and groups. We describe concepts and approaches which are useful when considering equity in the priority setting process, and outline the technical choices concerning model structure, outputs, and data requirements needed to use transmission models in analyses of health equity. METHODS: We reviewed the literature on equity concepts and approaches to their application in economic evaluation and undertook a technical consultation on how equity can be incorporated in priority setting for infectious disease control. The technical consultation brought together health economists with an interest in equity-informative economic evaluation, ethicists specialising in public health, mathematical modellers from various disease backgrounds, and representatives of global health funding and technical assistance organisations, to formulate key areas of consensus and recommendations. RESULTS: We provide a series of recommendations for applying the Reference Case for Economic Evaluation in Global Health to infectious disease interventions, comprising guidance on 1) the specification of equity concepts; 2) choice of evaluation framework; 3) model structure; and 4) data needs. We present available conceptual and analytical choices, for example how correlation between different equity- and disease-relevant strata should be considered dependent on available data, and outline how assumptions and data limitations can be reported transparently by noting key factors for consideration. CONCLUSIONS: Current developments in economic evaluations in global health provide a wide range of methodologies to incorporate equity into economic evaluations. Those employing infectious disease models need to use these frameworks more in priority setting to accurately represent health inequities. We provide guidance on the technical approaches to support this goal and ultimately, to achieve more equitable health policies

The costs of providing antiretroviral therapy services to HIV-infected individuals presenting with advanced HIV disease at public health centres in Dar es Salaam, Tanzania: Findings from a randomised trial evaluating different health care strategies.

BACKGROUND: Understanding the costs associated with health care delivery strategies is essential for planning. There are few data on health service resources used by patients and their associated costs within antiretroviral (ART) programmes in Africa. MATERIAL AND METHODS: The study was nested within a large trial, which evaluated screening for cryptococcal meningitis and tuberculosis and a short initial period of home-based adherence support for patients initiating ART with advanced HIV disease in Tanzania and Zambia. The economic evaluation was done in Tanzania alone. We estimated costs of providing routine ART services from the health service provider's perspective using a micro-costing approach. Incremental costs for the different novel components of service delivery were also estimated. All costs were converted into US dollars (US$) and based on 2012 prices. RESULTS: Of 870 individuals enrolled in Tanzania, 434 were enrolled in the intervention arm and 436 in the standard care/control arm. Overall, the median (IQR) age and CD4 cell count at enrolment were 38 [31, 44] years and 52 [20, 89] cells/mm3, respectively. The mean per patient costs over the first three months and over a one year period of follow up following ART initiation in the standard care arm were US$ 107 (95%CI 101-112) and US$265 (95$ 59 (p<0.001; 95%CI 52-67) and over a one year period was US$ 67(p<0.001; 95%CI 50-83). This is equivalent to an increase of 55% (95%CI 51%-59%) in the mean cost of care over the first three months, and 25% (95%CI 20%-30%) increase over one year of follow up

Digital Tools and COVID-19: Shifting Public–Private Boundaries

In this paper, we attempt to provide starting points for a discussion on immediate and longer term consequences of COVID-19-induced uses of digital technologies for the distinction of the public and the private spheres. We start with clarifying definitions of the public and the private spheres in relation to the concept of privacy. What is considered private is at least in part contextually determined by conventions and social, political, economic and technological developments. From this perspective, we set out to critically evaluate the COVID-19-induced large-scale introduction of new digital tools in two essential areas of life: the workplace and education. We discuss the role of technology and its immediate concomitant legal or ethical challenges. The paper concludes with reflections on the possible longer-term normative effects of the use of digital tools in the context of the COVID-19 containment on the demarcation of the public and private spheres

Digital Tools and COVID-19: Shifting Public–Private Boundaries

In this paper, we attempt to provide starting points for a discussion on immediate and longer term consequences of COVID-19-induced uses of digital technologies for the distinction of the public and the private spheres. We start with clarifying definitions of the public and the private spheres in relation to the concept of privacy. What is considered private is at least in part contextually determined by conventions and social, political, economic and technological developments. From this perspective, we set out to critically evaluate the COVID-19-induced large-scale introduction of new digital tools in two essential areas of life: the workplace and education. We discuss the role of technology and its immediate concomitant legal or ethical challenges. The paper concludes with reflections on the possible longer-term normative effects of the use of digital tools in the context of the COVID-19 containment on the demarcation of the public and private spheres