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As the economic burden of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) increases in sub-Saharan Africa, allocation of the burden among levels and sectors of society is changing. The private sector has more scope to avoid the economic burden of AIDS than governments, households, or nongovernmental organizations, and the burden is being systematically shifted away from the private sector. Common practices that transfer the burden to households and government include pre-employment screening, reductions in employee benefits, restructured employment contracts, outsourcing of low skilled jobs, selective retrenchments, and changes in production technologies. Between 1997 and 1999 more than two-thirds of large South African employers reduced the level of health care benefits or increased employee contributions. Most firms also have replaced defined-benefit retirement funds, which expose the firm to large annual costs but provide long-term support for families, with defined-contribution funds, which eliminate risks to the firm but provide little for families of younger workers who die of AIDS. Contracting out previously permanent jobs is also shielding firms from benefit and turnover costs, effectively shifting the responsibility to care for affected workers and their families to households, nongovernmental organizations, and the government. Many of these changes are responses to globalization that would have occurred in the absence of AIDS, but they are devastating for the households of employees with HIV/AIDS. We argue that the shift in the economic burden of AIDS is a predictable response by business to which a deliberate public policy response is needed. Countries should make explicit decisions about each sector's responsibilities if a socially desirable allocation is to be achieved.

As the economic burden of HIV/AIDS increases in sub-Saharan Africa, allocation of the burden among levels and sectors of society is changing. The private sector has more scope to avoid the economic burden of AIDS than governments, household, or nongovernmental organizations, and the burden is being systematically shifted away from the private sector. Common practices that transfer the burden to households and government include pre-employment screening, reductions in employee benefits, restructured employment contracts, outsourcing of low skilled jobs, selective retrenchment, and changes in production technologies. (InWent/DÜI)

BackgroundCurrent 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.MethodsCosts 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%.ResultsVirological 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.ConclusionsIncorporating 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.

IntroductionAs global policy evolves toward initiating lifelong antiretroviral therapy (ART) regardless of CD4 count, initiating individuals newly diagnosed with HIV on ART as efficiently as possible will become increasingly important. To inform progress, we conducted a systematic review of pre‐ART interventions aiming to increase ART initiation in sub‐Saharan Africa.MethodsWe searched PubMed, Embase and the ISI Web of Knowledge from 1 January 2008 to 1 March 2015, extended in PubMed to 25 May 2016, for English language publications pertaining to any country in sub‐Saharan Africa and reporting on general adult populations. We included studies describing interventions aimed at increasing linkage to HIV care, retention in pre‐ART or uptake of ART, which reported ART initiation as an outcome. We synthesized the evidence on causal intervention effects in meta‐analysis of studies belonging to distinct intervention categories.Results and discussionWe identified 22 studies, which evaluated 25 interventions and included data on 45,393 individual patients. Twelve of twenty‐two studies were observational. Rapid/point‐of‐care (POC) CD4 count technology (seven interventions) (relative risk, RR: 1.26; 95% confidence interval, CI: 1.02–1.55), interventions within home‐based testing (two interventions) (RR: 2.00; 95% CI: 1.36–2.92), improved clinic operations (three interventions) (RR: 1.36; 95% CI: 1.25–1.48) and a package of patient‐directed services (three interventions) (RR: 1.54; 95% CI: 1.20–1.97) were all associated with increased ART initiation as was HIV/TB service integration (three interventions) (RR: 2.05; 95% CI: 0.59–7.09) but with high imprecision. Provider‐initiated testing (three interventions) was associated with reduced ART initiation (RR: 0.91; 95% CI: 0.86–0.97). Counselling and support interventions (two interventions) (RR 1.08; 95% CI: 0.94–1.26) had no impact on ART initiation. Overall, the evidence was graded as low or moderate quality using the GRADE criteria.ConclusionsThe literature on interventions to increase uptake of ART is limited and of mixed quality. POC CD4 count and improving clinic operations show promise. More implementation research and evaluation is needed to identify how best to offer treatment initiation in a manner that is both efficient for service providers and effective for patients without jeopardizing treatment outcomes.

BackgroundWhile the number of HIV‐positive patients on antiretroviral therapy (ART) in resource‐limited settings has increased dramatically, some patients eligible for treatment do not initiate ART even when it is available to them. Understanding why patients opt out of care, or are unable to opt in, is important to achieving the goal of universal access.MethodsWe conducted a cross‐sectional survey among 400 patients on ART (those who were able to access care) and 400 patients accessing home‐based care (HBC), but who had not initiated ART (either they were not able to, or chose not to, access care) in two rural and two urban sites in Zambia to identify barriers to and facilitators of ART uptake.ResultsHBC patients were 50% more likely to report that it would be very difficult to get to the ART clinic than those on ART (RR: 1.48; 95% CI: 1.21‐1.82). Stigma was common in all areas, with 54% of HBC patients, but only 15% of ART patients, being afraid to go to the clinic (RR: 3.61; 95% CI: 3.12‐4.18). Cost barriers differed by location: urban HBC patients were three times more likely to report needing to pay to travel to the clinic than those on ART (RR: 2.84; 95% CI: 2.02‐3.98) and 10 times more likely to believe they would need to pay a fee at the clinic (RR: 9.50; 95% CI: 2.24‐40.3). In rural areas, HBC subjects were more likely to report needing to pay non‐transport costs to attend the clinic than those on ART (RR: 4.52; 95% CI: 1.91‐10.7). HBC patients were twice as likely as ART patients to report not having enough food to take ART being a concern (27% vs. 13%, RR: 2.03; 95% CI: 1.71‐2.41), regardless of location and gender.ConclusionsPatients in home‐based care for HIV/AIDS who never initiated ART perceived greater financial and logistical barriers to seeking HIV care and had more negative perceptions about the benefits of the treatment. Future efforts to expand access to antiretroviral care should consider ways to reduce these barriers in order to encourage more of those medically eligible for antiretrovirals to initiate care.

AbstractIntroductionIn recent years, many countries have adopted evidence‐based budgeting (EBB) to encourage the best use of limited and decreasing HIV resources. The lack of data and evidence for hard to reach, marginalized and vulnerable populations could cause EBB to further disadvantage those who are already underserved and who carry a disproportionate HIV burden (USDB). We outline the critical data required to use EBB to support USDB people in the context of the generalized epidemics of sub‐Saharan Africa (SSA).DiscussionTo be considered in an EBB cycle, an intervention needs at a minimum to have an estimate of a) the average cost, typically per recipient of the intervention; b) the effectiveness of the intervention and c) the size of the intervention target population. The methods commonly used for general populations are not sufficient for generating valid estimates for USDB populations. USDB populations may require additional resources to learn about, access, and/or successfully participate in an intervention, increasing the cost per recipient. USDB populations may experience different health outcomes and/or other benefits than in general populations, influencing the effectiveness of the interventions. Finally, USDB population size estimation is critical for accurate programming but is difficult to obtain with almost no national estimates for countries in SSA. We explain these limitations and make recommendations for addressing them.ConclusionsEBB is a strong tool to achieve efficient allocation of resources, but in SSA the evidence necessary for USDB populations may be lacking. Rather than excluding USDB populations from the budgeting process, more should be invested in understanding the needs of these populations.

IntroductionAfter almost 10 years of PEPFAR funding for antiretroviral therapy (ART) treatment programmes in Kenya, little is known about the cost of care provided to HIV‐positive patients receiving ART. With some 430,000 ART patients, understanding and managing costs is essential to treatment programme sustainability.MethodsUsing patient‐level data from medical records (n=120/site), we estimated the cost of providing ART at three treatment sites in the Rift Valley Province of Kenya (a clinic at a government hospital, a hospital run by a large agricultural company and a mission hospital). Costs included ARV and non‐ARV drugs, laboratory tests, salaries to personnel providing patient care, and infrastructure and other fixed costs. We report the average cost per patient during the first 12 months after ART initiation, stratified by site, and the average cost per patient achieving the primary outcome, retention in care 12 months after treatment initiation.ResultsThe cost per patient initiated on ART was $206, $252 and $213 at Sites 1, 2 and 3, respectively. The proportion of patients remaining in care at 12 months was similar across all sites (0.82, 0.80 and 0.84). Average costs for the subset of patients who remained in care at 12 months was also similar (Site 1, $229; Site 2, $287; Site 3, $237). Patients not retained in care cost substantially less (Site 1, $104; Site 2, $113; Site 3, $88). For the subset of patients who remained in care at 12 months, ART medications accounted for 51%, 44% and 50% of the costs, with the remaining costs split between non‐ART medications (15%, 11%, 10%), laboratory tests (14%, 15%, 15%), salaries to personnel providing patient care (9%, 11%, 12%) and fixed costs (11%, 18%, 13%).ConclusionsAt all three sites, 12‐month retention in care compared favourably to retention rates reported in the literature from other low‐income African countries. The cost of providing treatment was very low, averaging $224 in the first year, less than $20/month. The cost of antiretroviral medications, roughly $120 per year, accounted for approximately half of the total costs per patient retained in care after 12 months.

AbstractIntroductionSame‐day initiation (SDI) of antiretroviral therapy (ART) for HIV consistently increases ART uptake, but concerns remain about higher attrition from care after initiation. We analysed 12‐month retention in the SLATE SDI trials.MethodsSLATE I (Simplified Algorithms for Treatment Eligibility I, enrolment 06 March–28 July 2017) and SLATE II (enrolment 14 March–18 September 2018) were individually randomized trials at public outpatient clinics in Johannesburg that enrolled patients not yet on ART and administered the SLATE I or II algorithm. This included a symptom self‐report, medical history, brief physical examination and readiness questionnaire to assess the eligibility for SDI. The studies compared the offer of SDI using the SLATE algorithms to standard of care initiation procedures. ART uptake and early retention were previously reported. Using routine clinic records, we conducted a pooled analysis of retention in care and HIV viral suppression 14 months after study enrolment, a time point equivalent to 12 months potential on ART, with an additional month allowed on either end to initiate ART and to return for the 12‐month visit.Results and discussionWe enrolled 1193 study participants (standard arms, n = 599, 50%; intervention arms, n = 594, 50%) and analysed by originally assigned groups. By 14 months after enrolment, 50% of intervention arm patients and 46% of standard arm patients remained in care at the initiating site (crude risk difference 4% (95% confidence interval −1%‐10%); crude relative risk 1.10 (0.97–1.23), with similar viral suppression between arms. Observed attrition from care at site by 14 months was high in both study arms, but we found no evidence that the offer of SDI led to greater overall attrition or lower rates of viral suppression 1 year after starting ART and may have generated small improvements. SDI may have shifted some attrition from before to after dispensing of the first dose of medication.ConclusionsAn offer of SDI of ART, following a carefully designed protocol to identify patients who are eligible and ready to start treatment, is not inherently associated with an overall increase in patient attrition from care and leads to similar rates of viral suppression.Trial registrationClinicaltrials.gov NCT02891135, registered 01 September 2016. First participant enrolled 06 March 2017 in South Africa. Clinicaltrials.gov NCT03315013, registered 19 October 2017. First participant enrolled 14 March 2018.