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

The application of warfare ecology to belligerent occupations

Insofar as warfare ecology aims to examine all war-related conditions, belligerent occupations are a necessary stage in its broad taxonomy. Under international law, belligerent occupations are covered by a distinctive subset of jus in bello (humanitarian law), which is imprecise regarding ecological changes. This chapter examines the potential role of warfare ecology in studying belligerent occupations, highlighting the multiple, often indirect, means by which such occupations shape ecological processes. Particular attention is paid to the Israeli occupation of Palestinian territory, due to its protracted duration, although also discussed are environmental effects associated with the US and UK occupation of Iraq. The onus on the occupying power, under international humanitarian law, to protect the conditions of life for civilians can plausibly be applied to the environmental resources of the resident population. It is argued that warfare ecology can make a significant contribution both to assessing the effects of occupations and, through the generation of policy advice, to promote conflict outcomes more sensitive towards ecological processes