Suchergebnisse

AbstractIntroductionIn 2017, the Aurum Institute, with support from Unitaid, launched an initiative to expand short‐course therapy for the prevention of tuberculosis (TB) in 12 high‐burden countries. This study aimed to investigate the importance of "catalytic" effects beyond the original project timeframe when estimating cost‐effectiveness of such large investments.MethodsWe estimated the cost‐effectiveness of the IMPAACT4TB (I4TB) initiative from a health system perspective, using a 10‐year time horizon. We first conservatively estimated costs using a "top‐down" approach considering only the direct health benefits of providing TB preventive therapy to people initiating antiretroviral therapy (ART) through I4TB activities. We then re‐estimated the incremental cost‐effectiveness of I4TB incorporating the costs and health benefits of potential catalytic effects beyond the program itself.ResultsWe estimated that TB preventive therapy through the I4TB initiative alone would prevent 14 201 cases of active TB and 1562 TB deaths over 10 years with an up‐front investment of $52.5 million; the estimated incremental cost‐effectiveness was $1580 per disability‐adjusted life year (DALY) averted. If this initiative could achieve its desired catalytic effects, an additional 375 648 cases and 41 321 deaths could be averted, at an incremental cost of $546 million and cost‐effectiveness of $713 per DALY averted.ConclusionsOur findings provide donors with reasonable evidence of value for money to support investment in short‐course TB preventive therapy for people initiating ART in high‐burden settings. Our study also illustrates the importance of considering long‐term secondary ("catalytic") effects when evaluating the cost‐effectiveness of large‐scale initiatives designed to change a global policy landscape.

AbstractIntroductionPreventive therapy is essential for reducing tuberculosis (TB) burden among people living with HIV (PLWH) in high‐burden settings. Short‐course preventive therapy regimens, such as three‐month weekly rifapentine and isoniazid (3HP) and one‐month daily rifapentine and isoniazid (1HP), may help facilitate uptake of preventive therapy for latently infected patients, but the comparative cost‐effectiveness of these regimens under different conditions is uncertain.MethodsWe used a Markov state‐transition model to estimate the incremental costs and effectiveness of 1HP versus 3HP in a simulated cohort of patients attending an HIV clinic in Uganda, as an example of a low‐income, high‐burden setting in which TB preventive therapy might be prescribed to PLWH. Our primary outcome was the incremental cost‐effectiveness ratio, expressed as 2019 US dollars per disability‐adjusted life year (DALY) averted. We estimated cost‐effectiveness under different conditions of treatment completion and efficacy of 1HP versus 3HP, latent TB prevalence and rifapentine price.ResultsAssuming equivalent clinical outcomes using 1HP and 3HP and a rifapentine price of $0.21 per 150 mg, 1HP would cost an additional $4.66 per patient treated. Assuming equivalent efficacy but 20% higher completion with 1HP versus 3HP, 1HP would cost $1,221 per DALY averted relative to 3HP. This could be reduced to $18 per DALY averted if 1HP had 5% greater efficacy than 3HP and the price of rifapentine were 50% lower. At a rifapentine price of $0.06 per 150 mg, 1HP would become cost‐neutral relative to 3HP.Conclusions1HP has the potential to be cost‐effective under many realistic circumstances. Cost‐effectiveness depends on rifapentine price, relative completion and efficacy, prevalence of latent TB and local willingness‐to‐pay.

OBJECTIVES: To mitigate the economic burden of tuberculosis (TB), it is important to fully understand the costs of TB treatment from the patient perspective. We therefore sought to quantify the patient-incurred cost of TB treatment in rural Malawi, with specific focus on costs borne by patients requiring inpatient hospitalization. METHODS: We conducted a cross-sectional survey of 197 inpatients and 156 outpatients being treated for TB in rural Malawi. We collected data on out-of-pocket costs and lost wages, including costs to guardians. Costs for inpatient TB treatment were estimated and compared to costs for outpatient TB treatment. We then explored the equity distribution of inpatient TB treatment cost using concentration curves. RESULTS: Despite free government services, inpatients were estimated to incur a mean of $137 (standard deviation: $147) per initial TB episode, corresponding to > 50% of annual household spending among patients in the lowest expenditure quintile. Non-medical hospitalization costs accounted for 88% of this total. Patients treated entirely as outpatients incurred estimated costs of $25 (standard deviation: $15) per episode. The concentration curves showed that, among individuals hospitalized for an initial TB episode, poorer patients shouldered a much greater proportion of inpatient TB treatment costs than wealthier ones (concentration index: −0.279). CONCLUSION: Patients hospitalized for TB in resource-limited rural Malawi experience devastating costs of TB treatment. Earlier diagnosis and treatment must be prioritized if we are to meet goals of effective TB control, avoidance of catastrophic costs, and provision of appropriate patient-centered care in such settings.

IntroductionGlobally, hepatitis B virus (HBV) infection is the leading cause of liver‐related mortality. Newborn vaccination, maternal antiviral therapy and administering hepatitis B immune globulin shortly after birth can greatly reduce the risk of perinatal and infant infection. However, evidence‐based policy regarding these interventions in Africa is hampered by gaps in knowledge of HBV epidemiology. We describe maternal chronic hepatitis B (CHB) prevalence and infant infection during the first year of life within a cohort of women living with HIV.MethodsWe recruited and prospectively followed pregnant women living with HIV and their infants from prenatal clinics in an urban area of South Africa. Hepatitis B surface antigen, anti‐hepatitis B surface antibodies and HBV DNA were assessed in all women. Hepatitis B testing was also performed at 6 and 52 weeks for all infants born to mothers with either positive surface antigen or detectable HBV DNA.ResultsWe enrolled 189 women with a median age of 29 years and median CD4 count of 348 cells/mm3. Fourteen had a positive surface antigen (7.4%), of which six were positive for "e" antigen. An additional three had detectable HBV DNA without positive surface antigen. One infant developed CHB and three others had evidence of transmission based on positive HBV DNA assays. HBV vaccinations were delivered at six weeks of life to all infants.ConclusionsOur findings highlight the risk of peripartum HBV transmission in this setting. Approaches to reducing this transmission should be considered.