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Background The mismatch between the global burden of surgical disease and global health funding for surgical illness exacerbates disparities in surgical care access worldwide. Amidst competing priorities, governments need to rationally allocate scarce resources to address local needs. To build an investment case for surgery, economic data on surgical care delivery is needed. This study focuses on femur fractures. Methods This prospective cohort study at Soroti Regional Referral Hospital (SRRH), captured demographic, clinical, and cost data from all surgical inpatients and their caregivers at SRRH from February 2018 through July 2019. We performed descriptive and inferential analyses. We estimated the cost effectiveness of intramedullary nailing relative to traction for femur fractures by using primary data and making extrapolations using regional data. Results Among the 546 patients, 111 (20.3%) had femur fractures and their median [IQR] length of hospitalization was 27 days [14, 36 days]. The total societal cost and Quality Adjusted Life Year (QALY) gained was USD 61,748.10 and 78.81 for femur traction and USD 23,809 and 85.47 for intramedullary nailing. Intramedullary nailing was dominant over traction of femur fractures with an Incremental Cost Effectiveness Ratio of USD 5,681.75 per QALY gained. Conclusion Femur fractures are the most prevalent and most expensive surgical condition at SRRH. Relative to intramedullary nailing, the use of femur traction at SRRH is not cost effective. There is a need to explore and adopt more cost-effective approaches like internal fixation.

The unmet need for pediatric surgery incurs enormous health and economic consequences globally, predominantly shouldered by Sub-Saharan Africa (SSA) where children comprise almost half of the population. Lack of economic impact data on improving pediatric surgical infrastructure in SSA precludes informed allocation of limited resources towards the most cost-effective interventions to bolster global surgery for children. We assessed the cost-effectiveness of installing and maintaining a pediatric operating room in a hospital in Nigeria with a pre-existing pediatric surgical service by constructing a decision tree model of pediatric surgical delivery at this facility over a year, comparing scenarios before and after the installation of two dedicated pediatric operating rooms (ORs), which were funded philanthropically. Health outcomes measured in disability-adjusted life years (DALYs) averted were informed by the hospital’s operative registry and prior literature. A societal perspective included costs incurred by the hospital system, charity, and patients’ families. Costs were annualized and reported in 2021 United States dollars ($). The incremental cost-effectiveness ratios (ICERs) of the annualized OR installation were presented from charity and societal perspectives. One-way and probabilistic sensitivity analyses were performed. We found that the installation and maintenance of two pediatric operating rooms averted 1145 DALYs and cost $155,509 annually. Annualized OR installation cost was $87,728 (56% of the overall cost). The ICER of the OR installation was $152 per DALY averted (95% uncertainty interval [UI] 147-156) from the societal perspective, and $77 per DALY averted (95% UI 75-81) from the charity perspective. These ICERs were well under the cost-effectiveness threshold of the country’s half-GDP per capita in 2020 ($1043) and remained cost-effective in one-way and probabilistic sensitivity analyses. Installation of additional pediatric operating rooms in SSA with pre-existing pediatric surgical capacity is therefore very cost-effective, supporting investment in children’s global surgical infrastructure as an economically sound intervention.

Background Hepatitis B vaccination is recommended for persons with current or past sexually transmitted infections (STI). Our aim is to systematically assess the association of hepatitis B virus (HBV) sero-markers for current or past infection with syphilis, chlamydia, gonorrhoea, or unspecified STIs. Methods: We conducted a systematic review and meta-analysis. PubMed, Embase, and Web of Science from 1982 to 2018 were searched using medical subject headings (MeSH) terms for HBV, STIs and epidemiology. We included studies conducted in Organisation for Economic Cooperation and Development countries or Latin America that permit the calculation of prevalence ratios (PRs) for HBV and STIs and extracted PRs and counts by HBV and STI status. Results: Of 3144 identified studies, 43 met inclusion requirements, yielding 72 PRs. We stratified outcomes by HBV sero-markers [surface antigen (HBsAg), hepatitis B core antibody (anti-HBc), combined], STI pathogen (syphilis, gonorrhoea/chlamydia, unspecified), and STI history (current, past) resulting in 18 potential outcome groups, for which results were available for 14. For the four outcome groups related to HBsAg, PR point estimates ranged from 1.65 to 6.76. For the five outcome groups related to anti-HBc, PRs ranged from 1.30 to 1.82; and for the five outcome groups related to combined HBV markers, PRs ranged from 1.15 to 1.89). The median HBsAg prevalence among people with a current or past STI was 4.17; not all studies reported HBsAg. Study settings and populations varied. Conclusion: This review found evidence of association between HBV infection and current or past STIs.

Intensive psychotherapy assisted with 3,4-methylenedioxymethamphetamine (MDMA-AT) was shown in Phase 3 clinical trials to substantially reduce post-traumatic stress disorder (PTSD) symptoms compared to psychotherapy with placebo. This study estimates potential costs, health benefits, and net savings of expanding access to MDMA-AT to eligible US patients with chronic and severe PTSD.Using a decision-analytic model, we compared the costs, deaths averted, and quality-adjusted life years (QALYs) gained of three, 10-year MDMA-AT coverage targets (25%, 50%, and 75%) compared to providing standard of care to the same number of eligible patients with chronic and severe PTSD. We used a payer perspective and discounted costs (in US$) and QALYs to 2020. We conducted one-way, scenario, and probabilistic sensitivity analyses and calculated the net monetary value of MDMA-AT using a cost-effectiveness threshold of $100,000 per QALY gained.Expanding access to MDMA-AT to 25-75% of eligible patients is projected to avert 43,618-106,932 deaths and gain 3.3-8.2 million QALYs. All three treatment targets are dominant or cost-saving compared to standard of care. Our sensitivity analyses found that accounting for parameter uncertainty and changes in various assumptions did not alter the main finding-MDMA-AT is dominant compared to standard of care.Expanding access to MDMA-AT to patients with chronic and severe PTSD will provide substantial health and financial benefits. The precise magnitude is uncertain and will depend on the number of eligible patients and other inputs.

Background Surgical disease increasingly contributes to global mortality and morbidity. The Lancet Commission on Global Surgery found that global cost-effectiveness data are lacking for a wide range of essential surgical procedures. This study helps to address this gap by defining the cost-effectiveness of exploratory laparotomies in a regional referral hospital in Uganda. Materials and methods A time-and-motion analysis was utilized to calculate operating theater personnel costs per case. Ward personnel, administrative, medication, and supply costs were recorded and calculated using a microcosting approach. The cost in 2018 US Dollars (USD, $) per disability-adjusted life year (DALY) averted was calculated based on age-specific life expectancies for otherwise fatal cases. Results Data for 103 surgical patients requiring exploratory laparotomy at the Soroti Regional Referral Hospital were collected over 8 mo. The most common cause for laparotomy was small bowel obstruction (32% of total cases). The average cost per patient was $75.50. The postoperative mortality was 11.7%, and 7.8% of patients had complications. The average number of DALYs averted per patient was 18.51. The cost in USD per DALY averted was $4.08. Conclusions This investigation provides evidence that exploratory laparotomy is cost-effective compared with other public health interventions. Relative cost-effectiveness includes a comparison with bed nets for malaria prevention ($6.48-22.04/DALY averted), tuberculosis, tetanus, measles, and polio vaccines ($12.96-25.93/DALY averted), and HIV treatment with multidrug antiretroviral therapy ($453.74-648.20/DALY averted). Given that the total burden of surgically treatable conditions in DALYs is more than that of malaria, tuberculosis, and HIV combined, our findings strengthen the argument for greater investment in primary surgical capacity in low- and middle-income countries.

The past decade has seen a growing emphasis on the production of high-quality costing data to improve the efficiency and cost-effectiveness of global health interventions. The need for such data is especially important for decision making and priority setting across HIV services from prevention and testing to treatment and care. To help address this critical need, the Global Health Cost Consortium was created in 2016, in part to conduct a systematic search and screening of the costing literature for HIV and TB interventions in low- and middle-income countries (LMIC). The purpose of this portion of the remit was to compile, standardise, and make publicly available published cost data (peer-reviewed and gray) for public use. We limit our analysis to a review of the quantity and characteristics of published cost data from HIV interventions in sub-Saharan Africa. First, we document the production of cost data over 25 years, including density over time, geography, publication venue, authorship and type of intervention. Second, we explore key methods and reporting for characteristics including urbanicity, platform type, ownership and scale. Although the volume of HIV costing data has increased substantially on the continent, cost reporting is lacking across several dimensions. We find a dearth of cost estimates from HIV interventions in west Africa, as well as inconsistent reporting of key dimensions of cost including platform type, ownership and urbanicity. Further, we find clear evidence of a need for renewed focus on the consistent reporting of scale by authors of costing and cost-effectiveness analyses.Keywords: costing, HIV/AIDS, LMIC, cost-effectiveness, systematic review

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.Keywords: tuberculosis, database, reference case, systematic review

Objective: To estimate facility-level average cost for ART services and explore unit cost variations using pooled facility-level cost estimates from four HIV empirical cost studies conducted in five African countries .Methods: Through a literature search we identified studies reporting facility-level costs for ART programmes. We requested the underlying data and standardised the disparate data sources to make them comparable. Subsequently, we estimated the annual cost per patient served and assessed the cost variation among facilities and other service delivery characteristics using descriptive statistics and meta-analysis. All costs were converted to 2017 US dollars ($).Results: We obtained and standardised data from four studies across five African countries and 139 facilities. The weighted average cost per patient on ART was $251 (95% CI: 193–308). On average, 46% of the mean unit cost correspond to antiretroviral (ARVs) costs, 31% to personnel costs, 20% other recurrent costs, and 2% to capital costs. We observed a lot of variation in unit cost and scale levels between countries. We also observed a negative relationship between ART unit cost and the number of patients served in a year.Conclusion: Our approach allowed us to explore unit cost variation across contexts by pooling ART costs from multiple sources. Our research provides an example of how to estimate costs based on heterogeneous sources reconciling methodological differences across studies and contributes by giving an example on how to estimate costs based on heterogeneous sources of data. Also, our study provides additional information on costs for funders, policy-makers, and decision-makers in the process of designing or scaling-up HIV interventions.Keywords: HIV, treatment, efficiency, cost variatio

Background Severe posttraumatic stress disorder (PTSD) is a prevalent and debilitating condition in the United States. and globally. Using pooled efficacy data from six phase 2 trials, therapy using 3,4-methylenedioxymethamphetamine (MDMA) appeared cost-saving from a payer’s perspective. This study updates the cost-effectiveness analysis of this novel therapy using data from a new phase 3 trial, including the incremental cost-effectiveness of the more intensive phase 3 regimen compared with the shorter phase 2 regimen. Methods We adapted a previously-published Markov model to portray the costs and health benefits of providing MDMA-assisted therapy (MDMA-AT) to patients with chronic, severe, or extreme PTSD in a recent phase 3 trial, compared with standard care. Inputs were based on trial results and published literature. The trial treated 90 patients with a clinician administered PTSD scale (CAPS-5) total severity score of 35 or greater at baseline, and duration of PTSD symptoms of 6 months or longer. The primary outcome was assessed 8 weeks after the final experimental session. Patients received three 90-minute preparatory psychotherapy sessions, three 8-hour active MDMA or placebo sessions, and nine 90-minute integrative psychotherapy sessions. Our model calculates the per-patient cost of MDMA-AT, net all-cause medical costs, mortality, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). We reported results from the U.S. health care payer’s perspective for multiple analytic time horizons, (base-case is 30 years), and conducted extensive sensitivity analyses. Costs and QALYs were discounted by 3% annually. Costs were adjusted to 2020 U.S. dollars according to the medical component of the U.S. Bureau of Labor Statistics’ Consumer Price Index (CPI). Results MDMA-AT as conducted in the phase 3 trial costs $11,537 per patient. Compared to standard of care for 1,000 patients, MDMA-AT generates discounted net health care savings of $132.9 million over 30 years, accruing 4,856 QALYs, and averting 61.4 premature deaths. MDMA-AT breaks even on cost at 3.8 years while delivering 887 QALYs. A third MDMA session generates additional medical savings and health benefits compared with a two-session regimen. Hypothetically assuming no savings in health care costs, MDMA-AT has an ICER of $2,384 per QALY gained. Conclusions MDMA-AT provided to patients with severe or extreme chronic PTSD is cost-saving from a payer’s perspective, while delivering substantial clinical benefit.

We systematically reviewed the literature to assess the effectiveness of school-based programs to prevent HIV and other sexually transmitted infections (STI) among adolescents in the USA. We searched six databases including PubMed for studies published through May 2017. Eligible studies included youth ages 10-19 years and assessed any school-based programs in the USA that reported changes in HIV/STI incidence or testing. We used Cochrane tool to assess the risk of bias and GRADE to determine the evidence quality for each outcome. Three RCTs and six non-RCTs, describing seven interventions, met study inclusion criteria. No study reported changes in HIV incidence or prevalence. One comprehensive intervention, assessed in a non-RCT and delivered to pre-teens, reduced STI incidence into adulthood (RR 0.36, 95% CI 0.23-0.56). A non-RCT examining chlamydia and gonorrhea incidence before and after a condom availability program found a significant effect at the city level among young men 3 years later (RR 0.43, 95% CI 0.23-0.80). The remaining four interventions found no effect. The effect on STI prevalence was also not significant (pooled RR 0.83 from two non-RCTs, RR 0.70 from one RCT). Only one non-RCT showed an increase in HIV testing (RR 3.19, 95% CI 1.24-8.24). The quality of evidence for all outcomes was very low. Studies, including the RCTs, were of low methodological quality and had mixed findings, thus offering no persuasive evidence for the effectiveness of school-based programs. The most effective intervention spanned 6 years, was a social development-based intervention with multiple components, rather than a sex education program, and started in first grade.

Background: Transmission of SARS-CoV-2 in health care facilities poses a challenge against pandemic control. Health care workers (HCWs) have frequent and high-risk interactions with COVID-19 patients. We undertook a cost-effectiveness analysis to determine optimal testing strategies for screening HCWs to inform strategic decision-making in health care settings. Methods: We modeled the number of new infections, quality-adjusted life years lost, and net costs related to five testing strategies: (1) no tests, (2) only PCR test, (3) only IgG test, (4) conditional PCR test if IgG test is positive, and (5) concurrent PCR and IgG tests. We applied our model to four strata of HCWs, defined by the presence and timing of clinical presentation. We conducted sensitivity analyses to account for uncertainty in inputs. Findings: When screening asymptomatic and recently symptomatic HCWs, conducting only a PCR test offers the best health outcomes and fewest costs; it is associated with 28-144 fewer new infections over two weeks per 100 HCWs screened compared to no test, and saves between $810-$4,600 per test. When screening HCWs in the late clinical disease stage, PCR testing is associated with 49·5 additional infections per 100 HCWs screened compared to no screening. Depending on the degree of immunity conferred, IgG testing may avoid up to 3·7 additional infections. Interpretation: PCR testing is a beneficial strategy to identify infected HCWs and reduce transmission of SARS-CoV-2 in health care settings. Utility of IgG testing depends on the time when the test is administered and immunity characteristics. More evidence is needed on the latter to better inform policy decisions. Funding: None received. Declaration of Interests: Authors declare no conflicts of interest.

Femoral shaft fractures are one of the most common injuries seen by surgeons in low- and middle-income countries (LMICs). Surgical repair in LMICs is often dismissed as not being cost-effective or unsafe, though little evidence exists to support this notion. Therefore, the goal of this study is to determine the cost of intramedullary nailing of femoral shaft fractures in Tanzania. We used micro-costing methods to estimate the fixed and variable costs of intramedullary nailing of femoral shaft fractures. Variable costs assessed included medical personnel costs, ward personnel costs, implants, medications, and single-use supplies. Fixed costs included costs for surgical instruments and administrative and ancillary staff. 46 adult femoral shaft fracture patients admitted to Muhimbili Orthopaedic Institute between June and September 2014 were enrolled and treated with intramedullary fixation. The total cost per patient was $530.87 (SD $129.99). The mean variable cost per patient was $419.87 (SD $129.99), the largest portion coming from ward personnel $144.47 (SD $123.30), followed by implant $134.10 (SD $15.00) medical personnel $106.86 (SD $28.18), and medications/supplies $30.05 (SD $12.28). The mean fixed cost per patient was $111.00, consisting of support staff, $103.50, and surgical instruments, $7.50. Our study provides empirical information on the variable and fixed costs of intramedullary nailing of femoral shaft fractures in LMICs. Importantly, the lack of surgical capacity was the primary driver of the largest cost for this procedure, preoperative ward personnel time. Our results provide the cost data for a formal cost-effectiveness analysis on this intervention.

Kahn, Mwai, Kazi, and Marseille explain how economics brings together estimates of disease burden and the costs needed to reduce that burden so that policymakers can choose which intervention strategies will maximize health gains with available resources. The authors introduce and illustrate key health economics methods, including econometrics, cost-benefit analysis, micro-costing, behavioural economics, work force projections, financing, and discrete choice experimentation. They describe methods for calculating Disability-Adjusted Life Years, a standard summary metric that combines health losses due to mortality and morbidity, thus permitting comparison and summation across diseases and populations. The authors explain cost-effectiveness analysis, which compares health intervention costs with reductions in burden of disease, yielding the widely used Incremental Cost-Effectiveness Ratio, and discuss the ethical underpinnings of cost-effectiveness.

Objectives Pneumonia is the largest infectious cause of death in children under 5 years globally, and limited resource settings bear an overwhelming proportion of this disease burden. Bubble continuous positive airway pressure (bCPAP), an accepted supportive therapy, is often thought of as cost-prohibitive in these settings. We hypothesise that bCPAP is a cost-effective intervention in a limited resource setting and this study aims to determine the cost-effectiveness of bCPAP, using Malawi as an example. Design Cost-effectiveness analysis. Setting District and central hospitals in Malawi. Participants Children aged 1 month–5 years with severe pneumonia, as defined by WHO criteria. Interventions Using a decision tree analysis, we compared standard of care (including low-flow oxygen and antibiotics) to standard of care plus bCPAP. Primary and secondary outcome measures For each treatment arm, we determined the costs, clinical outcomes and averted disability-adjusted life years (DALYs). We assigned input values from a review of the literature, including applicable clinical trials, and calculated an incremental cost-effectiveness ratio (ICER). Results In the base case analysis, the cost of bCPAP per patient was $15 per day and $41 per hospitalisation, with an incremental net cost of $64 per pneumonia episode. bCPAP averts 5.0 DALYs per child treated, with an ICER of $12.88 per DALY averted compared with standard of care. In one-way sensitivity analyses, the most influential uncertainties were case fatality rates (ICER range $9–32 per DALY averted). In a multi-way sensitivity analysis, the median ICER was $12.97 per DALY averted (90% CI, $12.77 to $12.99). Conclusion bCPAP is a cost-effective intervention for severe paediatric pneumonia in Malawi. These results may be used to inform policy decisions, including support for widespread use of bCPAP in similar settings.

Background: Globally, there is a large unmet need for family planning in the postpartum period: 90% of women in this group want family planning for birth spacing or to avoid unintended pregnancies and stop child bearing once desired family size has been reached. In total 76% of Rwandan women want family planning postpartum, yet a 26% unmet need remains. Currently, the four most commonly used postpartum family planning methods in Rwanda are injections, subdermal implants, pills, and condoms. The economic and health benefit impact of the current method selection has not yet been evaluated. Methods: To evaluate the impact of current usage rates and method types, this cost effectiveness analysis (CEA) compared the most frequently used family planning methods in Rwanda broken into two categories, longer-acting reversible contraception (LARC) (injections and subdermal implants) and shorter-acting reversible contraceptives (non-LARC) (pills and condoms). A time horizon of 24 months was used to reflect the World Health Organization suggested two-year spacing from birth until the next pregnancy, and was conducted from a health systems perspective. This CEA compared two service package options to provide a comparator for the two method types, thus enabling insights to differences between the two. Results: For women of reproductive age (15-49 years) in Rwanda, including LARC postpartum family planning methods in the options, saves $18.73 per pregnancy averted, compared to family planning options that offer non-LARC methods exclusively. Conclusion: There is an opportunity to avert unplanned pregnancies associated with increased utilization of LARC methods. The full benefits of LARC are not yet realized in Rwanda. Under the conditions presented in this study, a service package that includes LARC has the potential to be cost-saving compared with one non-LARC methods. Effective health messaging of LARC use for the postpartum population could both enhance health and reduce costs.

Background: Highly active antiretroviral therapy (HAART) provides dramatic health benefits for HIV-infected individuals in Africa, and widespread implementation of HAART is proceeding rapidly. Little is known about the cost and cost effectiveness of HAART programmes. Objective: To determine the incremental cost effectiveness of a home-based HAART programme in rural Uganda. Methods: A computer-based, deterministic cost-effectiveness model was used to assess a broad range of economic inputs and health outcomes. From the societal perspective, the cost effectiveness of HAART and cotrimoxazole prophylaxis was compared with cotrimoxazole alone, and with the period before either intervention. Data for 24 months were derived from a trial of home-based HAART in 1045 patients in the Tororo District in eastern Uganda. Costs and outcomes were projected out to 15 years. All costs are in year 2004 values. The main outcome measures were HAART programme costs, health benefits accruing to HAART recipients, averted HIV infections in adults and children and the resulting effects on medical care costs. The first-line HAART regimen consisted of standard doses of stavudine, lamivudine, and either nevirapine or, for patients with active tuberculosis, efavirenz. Second-line therapy consisted of tenofovir, didanosine and lopinavir/ritonavir. For children, first-line HAART consisted of zidovudine, lamivudine and nevirapine syrup; second-line therapy was stavudine, didanosine and lopinavir/ritonavir. Results: The HAART programme, standardized for 1000 patients, cost an incremental $US1.39 million in its first 2 years. Compared with cotrimoxazole prophylaxis alone, the programme reduced mortality by 87%, and averted 6861 incremental disability-adjusted life-years (DALYs). Benefits were accrued from reduced mortality in HIV-infected adults (67.5% of all benefits), prevention of death in HIV-negative children (20.7%), averted HIV infections in adults (9.1%) and children (1.0%), and improved health status (1.7%). The net programme cost, including the medical cost implications of these health benefits, was $US4.10 million. The net cost per DALY averted was $US597 compared with cotrimoxazole alone. Many HIV interventions have a cost-effectiveness ratio in the range of $US1-150 per DALY averted. Conclusions: This study suggests that a home-based HAART programme in rural Africa may be more cost effective than most previous estimates for facility-based HAART programmes, but remains less cost effective than many HIV prevention and care interventions, including cotrimoxazole prophylaxis.

Background: A rapid scaling up of HIV interventions in India is anticipated, but systematic information on how costs of HIV interventions change over time and programme scale is not available to inform planning. Methods: We studied the changes in unit costs of two major interventions, voluntary counseling and testing (VCT) and sex worker programmes in the south Indian state of Andhra Pradesh between 2002-2003 and 2005-2006 fiscal years. Economic costs (from the provider perspective) and output data from 17 publicly funded VCT centers and 14 sex worker programmes were collected using standardized methods. We calculated unit costs for each programme in each period and explored possible reasons for the changes seen. Results: In 2005-2006, the VCT centers served 66445 clients and the sex worker programmes served 32 550. The unit cost of providing VCT dropped over 3 years by half to Indian Rupees (INR) 147.5 (US$3.33) mainly because the number of clients doubled. There was no decrease in the average time spent counseling each client. The unit cost of providing services to sex workers increased 2.4 times over 3 years to INR 1401 (US$31.6) as a result of increases in male condom distribution, staff salaries and training, and treatment for sexually transmitted infections, all suggesting improved services. Conclusion: The unit cost of these two interventions changed dramatically over a 3-year period, but in opposite directions. The current unit cost for VCT in Andhra Pradesh is much lower than the estimated global average for low-income settings. These local longitudinal cost data are useful to inform the currently planned scaling up of HIV interventions in India.

OBJECTIVE. We undertook a decision analysis to evaluate the economic and health effects and incremental cost-effectiveness of using targeted tuberculin skin testing, compared with universal screening or no screening, before kindergarten.METHODS. We constructed a decision tree to determine the costs and clinical outcomes of using targeted testing compared with universal screening or no screening. Baseline estimates for input parameters were taken from the medical literature and from California health jurisdiction data. Sensitivity analyses were performed to determine plausible ranges of associated outcomes and costs. We surveyed California health jurisdictions to determine the prevalence of mandatory universal tuberculin skin testing.RESULTS. In our base-case scenario, the cost to prevent an additional case of tuberculosis by using targeted testing, compared with no screening, was $524897. The cost to prevent an additional case by using universal screening, compared with targeted testing, was $671398. The incremental cost of preventing a case through screening remained above $100000 unless the prevalence of tuberculin skin testing positivity increased to >10%. More than 51% of children entering kindergarten in California live where tuberculin skin testing is mandatory.CONCLUSIONS. The cost to prevent a case of tuberculosis by using either universal screening or targeted testing of kindergarteners is high. If targeted testing replaced universal tuberculin skin testing in California, then $1.27 million savings per year would be generated for more cost-effective strategies to prevent tuberculosis. Improving the positive predictive value of the risk factor tool or applying it to groups with higher prevalence of latent tuberculosis would make its use more cost-effective. Universal tuberculin skin testing should be discontinued, and targeted testing should be considered only when the prevalence of risk factor positivity and the prevalence of tuberculin skin testing positivity among risk factor–positive individuals are high enough to meet acceptable thresholds for cost-effectiveness.

Background: Daily prophylaxis with trimethoprim-sulfamethoxazole (cotrimoxazole) by persons with HIV reduces morbidity and mortality and is recommended by Joint United Nations Program on HIV/AIDS and World Health Organization (WHO), but there are limited published cost-effectiveness data for this intervention. We assessed the cost-effectiveness of cotrimoxazole prophylaxis for persons living with HIV in rural Uganda. Methods: We modeled the cost-effectiveness of daily cotrimoxazole prophylaxis based on clinical results and operational data from a prospective cohort study of home-based care delivery to adults and children with HIV in rural Uganda who were older than the age of 5 years. Main outcome measures were net program cost and disabilityadjusted life-years (DALYs) gained. We examined the provision of cotrimoxazole prophylaxis for (A) all HIV-infected individuals regardless of immunologic or clinical criteria; (B) those with WHO stage 2 or more advanced disease; (C) those with CD4 cell counts ,500 cells/mL; and (D) those meeting criteria B or C, the current WHO recommendation. We calculated the costs and effectiveness of these 4 screening algorithms compared with no cotrimoxazole prophylaxis and calculated incremental cost-effectiveness ratios. We performed univariate and multivariate sensitivity analyses. Results: Cotrimoxazole prophylaxis for all HIV-infected individuals (algorithm A) produced 7.3 life-years and 7.55 DALYs per 100 persons over 1 year compared with no prophylaxis. Using this screening algorithm, the intervention saved $2.50 per person-year. The program costs and the DALYs gained by algorithms A, B, and D were more favorable than those for algorithm C. Among algorithms A, B, and D, strategies using screening algorithms for WHO stage or CD4 cell counts were more costly and marginally less effective than providing cotrimoxazole prophylaxis to all HIV-infected individuals. Conclusions: Daily cotrimoxazole prophylaxis for HIV-infected individuals is highly cost-effective in rural Uganda. The use of screening algorithms to identify individuals with advanced HIV disease may result in higher program costs and less favorable costeffectiveness.

summarizes the methods and key finding of a recent appraisal of the economics of the HIVNET 012 regimen in sub-Saharan Africa.3

There is wide agreement that an effective response to the global HIV epidemic requires very substantial resources. This consensus has been partially translated into increasing contributions to combat the epidemic (UNAIDS 2004). The need to spend this money efficiently can hardly be overstated: the lives of millions depend upon how effectively available funds are allocated. Available studies on the cost and cost-effectiveness of HIV prevention programs in developing countries are very limited in number, as well as in the range of prevention strategies and geographic settings examined (Marseille, Hofmann, and Kahn 2002). “Prevent AIDS: Network for Cost-Effectiveness Analysis” (PANCEA), is a three-year, five-country study funded by the U.S. National Institutes of Health. It has the purpose of providing essential information and analysis for an improved allocation of HIV prevention funds in developing countries. The study includes five countries: India, Mexico, Russia, South Africa, and Uganda. This article reviews PANCEA's data collection methods. Our purpose is two-fold. First, we aim to explicate the methods and data sources used in PANCEA. Second, we want to give other health services researchers sufficient information to judge the potential suitability of adapting PANCEA's approach to their own efforts. Further details on the project and key documents (e.g., instruments) can be found in the online-only Appendix to this article available at http://www.blackwell-synergy.com, at the PANCEA link at http://hivinsite.ucsf.edu/InSite?page=pancea, and from the authors. The remainder of the paper addresses PANCEA's conceptual approach, data collection tools, data collection process, challenges and limitations, early findings, and applications for other health program assessments.

Each year about 2 million babies are born to HIV-1- infected women. Despite widespread knowledge of proven methods to prevent mother-to-child transmission (MTCT) of the virus most infants at risk of contracting the infection from their mothers receive no prophylactic intervention. This inaction leads to the infection and ultimate death of about 800 000 children per year. It has been known since 1994 that MTCT is largely preventable and interventions appropriate for use in the developing world have been available since 1999. Singledose intrapartum and neonatal nevirapine—the simplest and perhaps most effective of the short-course antiretroviral regimens studied—has been available free of charge from the manufacturer since 2000. Nevertheless few women have access to MTCT-prevention services. In the more than 3 years since its inception the donation programme has shipped only 189 000 courses of the drug a tiny fraction (

Background: Pneumonia is the second leading cause of death in children under five globally, and resource-limited settings bear an overwhelming proportion of the disease burden. Although often thought of as cost-prohibitive in limited resource settings, bubble continuous positive airway pressure (bCPAP) is a widely accepted supportive therapy. This study addresses the cost-effectiveness of bCPAP in Malawi. Methods: We …

Summary Data on the cost-effectiveness of HIV prevention in sub-Saharan Africa and on highly active antiretroviral therapy (HAART) indicate that prevention is at least 28 times more cost effective than HAART. We aim to show that funding HAART at the expense of prevention means greater loss of life. To maximise health benefits, the next major increments of HIV funding in sub-Saharan Africa should be devoted mainly to prevention and to some non-HAART treatment and care. Funds should be allocated to HAART primarily for demonstration projects that will help prepare for scaled-up HAART provision following broad population coverage by prevention programmes. UNAIDS and the London School of Hygiene and Tropical Medicine recently estimated that at least US$9·2 billion annually is required to mount an appropriate response to the HIV pandemic, including substantial funding for HAART. To date, US$1·96 billion has been committed to the newly-established UN Global Fund to Fight AIDS, Tuberculosis, and Malaria. It is a moral imperative that expanded programmes to control HIV be implemented without delay, and that the goal of US$9·2 billion or more in annual spending be attained as rapidly as possible. The findings and recommendations of this analysis pertain to the phasing in of additional HIV-related activities during the current period of improved but inadequate funding.

Each year more than 350,000 babies acquire HIV infection from their mother, mainly in Africa. As sadly constant as this fact is, the policy environment around crafting an effective response has changed rapidly and unpredictably. Sequential advances in antiretroviral therapy, preserving effectiveness with far more practical regimens, have repeatedly upped the ante for action, and have also transformed policy issues. This paper relates a modeling story-something of a saga in its meandering course-closely intertwined with evolving policy. Our models have achieved a modicum of success. They have framed several policy discussions and have at least once led directly to an important policy development, as we discuss below. What made that possible? We've identified four elements: solid modeling, which establishes credibility; connected and savvy collaborators, who permit us to reach key decisionmakers (both logistically and in the sense of gaining their serious interest); our policy orientation, which has kept the models practical; and quick adaptations of the model, allowing our participation in fast-moving policy developments. Our models portray the risk of mother-to-child HIV transmission during pregnancy, delivery, and breast-feeding. They also portray the reduction in risk associated with the use of antiretroviral therapy (typically a 40 to 60 percent reduction), and with use of formula feeding instead of breast-feeding. Finally, the models estimate the costs of HIV testing, intervention, and HIV disease in children-in order to estimate the net Costs per HIV infection averted and per Disability Adjusted Life Year (DALY) gained.

Summary Background Identification of economical interventions to decrease HIV-1 transmission to children is an urgent public-health priority in sub-Saharan Africa. We assessed the cost effectiveness of the HIVNET 012 nevirapine regimen. Methods We assessed cost effectiveness in a hypothetical cohort of 20 000 pregnant women in sub-Saharan Africa. Our main outcome measures were programme cost, paediatric HIV-1 cases averted, cost per case averted, and cost per disability-adjusted life-year (DALY). We compared HIVNET 012 with other short-course antiretroviral regimens. We also compared two implementation strategies: counselling and HIV-1 testing before treatment (targeted treatment), or nevirapine for all pregnant women (universal treatment, no counselling and testing). We did univariate and multivariate sensitivity analyses. Findings For universal treatment with 30% HIV-1 seroprevalence, the HIVNET 012 regimen would avert 603 cases of HIV-1 in babies, cost US$83 333, and generate 15 862 DALYs. The associated cost-effectiveness ratios were $138 per case averted or $5·25 per DALY. At 15% seroprevalence, the universal treatment option would cost $83 333 and avert 302 cases at $276 per case averted or $10·51 per DALY. For targeted treatment at 30% seroprevalence, HIVNET 012 would cost $141 922 and avert 476 cases at $298 per case averted or $11·29 per DALY. With seroprevalence higher than 3·0% for universal and 4·5% for targeted treatment, the HIVNET 012 regimen was likely to be as cost effective as other public-health interventions. The cost effectiveness of HIVNET 012 was robust under a wide range of parameters in the sensitivity analysis. Interpretation The HIVNET 012 regimen can be highly cost-effective in high seroprevalence settings. In lower seroprevalence areas, when multidose regimens are not cost effective, nevirapine therapy could have a major public-health impact at a reasonable cost.

Gestational diabetes mellitus (GDM) is associated with elevated risks of perinatal complications and type 2 diabetes mellitus, and screening and intervention can reduce these risks. We quantified the cost, health impact and cost-effectiveness of GDM screening and intervention in India and Israel, settings with contrasting epidemiologic and cost environments.We developed a decision-analysis tool (the GeDiForCE™) to assess cost-effectiveness. Using both local data and published estimates, we applied the model for a general medical facility in Chennai, India and for the largest HMO in Israel. We computed costs (discounted international dollars), averted disability-adjusted life years (DALYs) and net cost per DALY averted, compared with no GDM screening.The programme costs per 1000 pregnant women are $259,139 in India and $259,929 in Israel. Net costs, adjusted for averted disease, are $194,358 and $76,102, respectively. The cost per DALY averted is $1626 in India and $1830 in Israel. Sensitivity analysis findings range from $628 to $3681 per DALY averted in India and net savings of $72,420-8432 per DALY averted in Israel.GDM interventions are highly cost-effective in both Indian and Israeli settings, by World Health Organization standards. Noting large differences between these countries in GDM prevalence and costs, GDM intervention may be cost-effective in diverse settings.

In a Perspective accompanying Hill and colleagues, Elliot Marseille and James Kahn compare the history of pricing and availability of ART for HIV with that of the new HCV drugs and discuss strategies for providing treatment in LMIC even in the face of high costs.

Gestational diabetes mellitus (GDM) is increasingly recognized as an opportunity for early prevention of diabetes and other diseases over the lifespan, and may be responsible for up to 30% of cases of type 2 diabetes. A newly developed mathematical model (the GDModel) provides provisional estimates of the cost and health impact of various GDM screening and management choices, and calculates averted disability-adjusted life-years (DALYs). The model was piloted in 5 different healthcare facilities in India and Israel. Universal screening of pregnant women followed by postpartum lifestyle management yielded net savings of US$78 per woman with GDM in India and US$1945 per woman in Israel. The estimated DALYs averted were 2.33 in India and 3.10 in Israel. With lower GDM prevalence, intervention efficacy, and type 2 diabetes incidence, the intervention had a net cost in India, with a cost per DALY averted of US$11.32. This was far below the WHO definition of "very cost-effective," set at annual GDP per capita. The intervention in Israel remained cost-saving. GDM screening and postpartum lifestyle management are either cost-saving or have a net cost but an attractive cost-effectiveness ratio. Some input values are currently being refined. Nevertheless, the current findings of cost-savings or favorable cost-effectiveness are robust to a wide range of plausible input values, including highly unfavorable values. The GDModel will be further developed into a user-friendly tool that can guide policy-makers on decisions regarding GDM screening strategies and guidelines.

The association between gestational diabetes mellitus (GDM), perinatal complications and long-term morbidity is gaining increased attention. However, the global burden of GDM and the existing responses are not fully understood. We aimed to assess country prevalence and to summarize practices related to GDM screening and management.Data on prevalence and country practices were obtained from a survey administered to diabetologists, obstetricians and others working on GDM in 173 countries.GDM prevalence estimates range from1% to 28%, with data derived from expert estimates, and single-site, multi-site and national prevalence assessments. Seventy-four percent of countries that completed the survey have national GDM guidelines or recommendations. Countries use a variety of screening approaches. In the countries where universal screening is recommended, the percentage of pregnant women screened ranges from 10% to90%.We found large variations in estimated GDM prevalence, but direct comparison between countries is difficult due to different diagnostic strategies and subpopulations. Many countries do not perform systematic screening for GDM, and practices often diverge from guidelines. Countries need to carefully assess the cost and health impact of scaling up GDM screening and management in order to identify the best policy option for their population.

textabstractBackground: Trials in Africa indicate that medical adult male circumcision (MAMC) reduces the risk of HIV by 60%. MAMC may avert 2 to 8 million HIV infections over 20 years in sub-Saharan Africa and cost less than treating those who would have been infected. This paper estimates the financial and human resources required to roll out MAMC and the net savings due to reduced infections. Methods: We developed a model which included costing, demography and HIV epidemiology. We used it to investigate 14 countries in sub-Saharan Africa where the prevalence of male circumcision was lower than 80% and HIV prevalence among adults was higher than 5%, in addition to Uganda and the Nyanza province in Kenya. We assumed that the roll-out would take 5 years and lead to an MC prevalence among adult males of 85%. We also assumed that surgery would be done as it was in the trials. We calculated public program cost, number of full-time circumcisers and net costs or savings when adjusting for averted HIV treatments. Costs were in USD, discounted to 2007. 95% percentile intervals (95% PI) were estimated by Monte Carlo simulations. Results: In the first 5 years the number of circumcisers needed was 2 282 (95% PI: 2 018 to 2 959), or 0.24 (95% PI: 0.21 to 0.31) per 10 000 adults. In years 6-10, the number of circumcisers needed fell to 513 (95% PI: 452 to 664). The estimated 5-year cost of rolling out MAMC in the public sector was $919 million (95% PI: 726 to 1 245).The cumulative net cost over the first 10 years was $672 million (95% PI: 437 to 1 021) and over 20 years there were net savings of $2.3 billion (95% PI: 1.4 to 3.4). Conclusion: A rapid roll-out of MAMC in sub-Saharan Africa requires substantial funding and a high number of circumcisers for the first five years. These investments are justified by MAMC's substantial health benefits and the savings accrued by averting future HIV infections. Lower ongoing costs and continued care savings suggest long-term sustainability.

© 2016 American Medical Association. All rights reserved. Importance Novel treatments for hepatitis C virus (HCV) infection are highly efficacious but costly. Thus, many insurers cover therapy only in advanced fibrosis stages. The added health benefits and costs of early treatment are unknown. Objective To assess the cost-effectiveness of (1) treating all patients with HCV vs only those with advanced fibrosis and (2) treating each stage of fibrosis. Design, Setting, and Participants This study used a decision-analytic model for the treatment of HCV genotype 1. The model used a lifetime horizon and societal perspective and was representative of all US patients with HCV genotype 1 who had not received previous treatment. Comparisons in the model included antiviral treatment of all fibrosis stages (METAVIR [Meta-analysis of Histological Data in Virial Hepatitis] stages F0 [no fibrosis] to F4 [cirrhosis]) vs treatment of stages F3 (numerous septa without cirrhosis) and F4 only and by specific fibrosis stage. Data were collected from March 1 to September 1, 2014, and analyzed from September 1, 2014, to June 30, 2015. Interventions Six HCV therapy options (particularly combined sofosbuvir and ledipasvir therapy) or no treatment. Main Outcomes and Measures Cost and health outcomeswere measured using total medical costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs), calculated as the difference in costs between strategies divided by the difference inQALYs. Results We simulated 1000 individuals, but present the Results normalized to a single HCV-infected person. In the base-case analysis, among patients receiving 8 or 12 weeks of sofosbuvir-ledipasvir treatment, treating all fibrosis stages compared with treating stages F3 and F4 adds 0.73 QALYs and $28 899, for an ICER of $39 475 per QALY gained. Treating at stage F2 (portal fibrosis with rare septa) costs $19 833 per QALY gained vs waiting until stage F3; treating at stage F1 (portal fibrosis without septa), $81 165 per QALY gained compared with waiting until stage F2; and treating at stage F0, $187 065 per QALY gained compared with waiting until stage F1. Results for other regimens show a similar pattern. At base-case drug prices, treating 50% of all eligible US patients with HCV genotype 1 would cost $53 billion. In sensitivity analyses, the ICER for treating all stages vs treating stages F3 and F4 was most sensitive to cohort age, drug costs, utility values in stages F1 and F2, and percentage of patients eligible for 8-week therapy. Except for patients aged 70 years, the ICER remains less than $100 000 per QALY gained. A 46%reduction in cost of sofosbuvir-ledipasvir therapy decreases the ICER for treating at all fibrosis stages by 48%. Conclusions and Relevance In this simulated model, treating HCV infection at early stages of fibrosis appeared to improve health outcomes and to be cost-effective but incurred substantial aggregate costs. The findings may have implications for health care coverage policies and clinical decision making.

Background Economic theory and limited empirical data suggest that costs per unit of HIV prevention program output (unit costs) will initially decrease as small programs expand. Unit costs may then reach a nadir and start to increase if expansion continues beyond the economically optimal size. Information on the relationship between scale and unit costs is critical to project the cost of global HIV prevention efforts and to allocate prevention resources efficiently. Methods The "Prevent AIDS: Network for Cost-Effectiveness Analysis" (PANCEA) project collected 2003 and 2004 cost and output data from 206 HIV prevention programs of six types in five countries. The association between scale and efficiency for each intervention type was examined for each country. Our team characterized the direction, shape, and strength of this association by fitting bivariate regression lines to scatter plots of output levels and unit costs. We chose the regression forms with the highest explanatory power (R2). Results Efficiency increased with scale, across all countries and interventions. This association varied within intervention and within country, in terms of the range in scale and efficiency, the best fitting regression form, and the slope of the regression. The fraction of variation in efficiency explained by scale ranged from 26% – 96%. Doubling in scale resulted in reductions in unit costs averaging 34.2% (ranging from 2.4% to 58.0%). Two regression trends, in India, suggested an inflection point beyond which unit costs increased. Conclusion Unit costs decrease with scale across a wide range of service types and volumes. These country and intervention-specific findings can inform projections of the global cost of scaling up HIV prevention efforts.

Author(s): Jain, Vivek; Chang, Wei; Byonanebye, Dathan M; Owaraganise, Asiphas; Twinomuhwezi, Ellon; Amanyire, Gideon; Black, Douglas; Marseille, Elliot; Kamya, Moses R; Havlir, Diane V; Kahn, James G | Abstract: BackgroundEvidence favoring earlier HIV ART initiation at high CD4+ T-cell counts (CD4g350/uL) has grown, and guidelines now recommend earlier HIV treatment. However, the cost of providing ART to individuals with CD4g350 in Sub-Saharan Africa has not been well estimated. This remains a major barrier to optimal global cost projections for accelerating the scale-up of ART. Our objective was to compute costs of ART delivery to high CD4+count individuals in a typical rural Ugandan health center-based HIV clinic, and use these data to construct scenarios of efficient ART scale-up.MethodsWithin a clinical study evaluating streamlined ART delivery to 197 individuals with CD4+ cell counts g350 cells/uL (EARLI Study: NCT01479634) in Mbarara, Uganda, we performed a micro-costing analysis of administrative records, ART prices, and time-and-motion analysis of staff work patterns. We computed observed per-person-per-year (ppy) costs, and constructed models estimating costs under several increasingly efficient ART scale-up scenarios using local salaries, lowest drug prices, optimized patient loads, and inclusion of viral load (VL) testing.FindingsAmong 197 individuals enrolled in the EARLI Study, median pre-ART CD4+ cell count was 569/uL (IQR 451-716). Observed ART delivery cost was $628 ppy at steady state. Models using local salaries and only core laboratory tests estimated costs of $529/$445 ppy (+/-VL testing, respectively). Models with lower salaries, lowest ART prices, and optimized healthcare worker schedules reduced costs by $100-200 ppy. Costs in a maximally efficient scale-up model were $320/$236 ppy (+/- VL testing). This included $39 for personnel, $106 for ART, $130/$46 for laboratory tests, and $46 for administrative/other costs. A key limitation of this study is its derivation and extrapolation of costs from one large rural treatment program of high CD4+ count individuals.ConclusionsIn a Ugandan HIV clinic, ART delivery costs--including VL testing--for individuals with CD4g350 were similar to estimates from high-efficiency programs. In higher efficiency scale-up models, costs were substantially lower. These favorable costs may be achieved because high CD4+ count patients are often asymptomatic, facilitating more efficient streamlined ART delivery. Our work provides a framework for calculating costs of efficient ART scale-up models using accessible data from specific programs and regions.

The objective of this study is to assess the costs cost-effectiveness and HIV epidemic impact of 3 antiretroviral therapy (ART) policy options. We constructed an epidemiologic model to predict the course of the HIV epidemic in the absence of expanded ART availability. Based on background studies of the willingness to pay for ART among patients with AIDS of the costs to the government of the alternative treatment interventions and of ARTs likely effects on HIV transmission we simulated the consequences of 3 possible alternative government ART policies. A program to reduce the negative consequences of the currently unstructured private-sector provision of ART is the most cost-effective of the 3 options at a 10% discount rate and least cost-effective at a 3% rate. The costs and cost-effectiveness of all options are highly sensitive to the effect of ART on condom use. The design of ART policy should capitalize on the potential of ART to decrease HIV transmission through institutional arrangements that reward effective prevention programs thereby raising the likelihood that treatment has beneficial rather than negative external effects. (authors)

Safe water systems (SWSs) have been shown to reduce diarrhea and death. We examined the cost-effectiveness of SWS for HIV-affected households using health outcomes and costs from a randomized controlled trial in Tororo, Uganda. SWS was part of a home-based health care package that included rapid diarrhea diagnosis and treatment of 196 households with relatively good water and sanitation coverage. SWS use averted 37 diarrhea episodes and 310 diarrhea-days, representing 0.155 disability-adjusted life year (DALY) gained per 100 person-years, but did not alter mortality. Net program costs were 5.21 dollars/episode averted, 0.62 dollars/diarrhea-day averted, and 1,252 dollars/DALY gained. If mortality reduction had equaled another SWS trial in Kenya, the cost would have been 11 dollars/DALY gained. The high SWS cost per DALY gained was probably caused by a lack of mortality benefit in a trial designed to rapidly treat diarrhea. SWS is an effective intervention whose cost-effectiveness is sensitive to diarrhea-related mortality, diarrhea incidence, and effective clinical management.

The objective of this study was to determine the financial incentives that companies have to treat HIV-infected employees, in a health care services company in Kampala, Uganda.Cost-benefit analysis from the company's perspective of three interventions to treat HIV-infected employees.The costs and benefits of each intervention were compared with no intervention and with each other: cotrimoxazole prophylaxis (CTX) starting at WHO stage 2; highly active antiretroviral therapy (HAART) plus CTX starting at WHO stage 2; and a 'hybrid' strategy that begins with CTX at WHO stage 2 and later includes HAART. The 5-year health and economic outcomes were calculated using a Markov model. Inputs for disease progression rates and effects of HIV on company costs were derived from published and unpublished data and a survey administered to company officers.The analysis showed that the 'hybrid' intervention is the most cost-effective. For 100 skilled employees it would save the company 38,939 US dollars and 73 disability adjusted life-years (DALYs). For unskilled workers 'CTX' is the most cost effective and would save 16,417 US dollars and 60 DALYs. 'Hybrid' has an incremental cost-effectiveness ratio of 45 US dollars per DALY for unskilled workers whereas HAART is far less economical at an incremental cost per DALY of 4118 US dollars. For 'CTX', net savings are preserved across the full range of input values.A 'hybrid' intervention combining CTX prophylaxis followed by HAART would generate savings to a Ugandan company. Governments and other donors may find opportunities to share costs with the private sector as part of their phase-in strategy for antiretroviral therapy.

Demand for HIV voluntary counselling and testing (VCT) will increase as HIV prevention and treatment scale up in South Africa. Understanding the cost of delivering VCT will inform funding decisions.To determine the cost per client completing VCT (pretest counselling, testing and post-test counselling) in a non-research- based programme using rapid-test technology.One year of expenditure and output data were collected retrospectively as part of the PANCEA (Prevent AIDS: Network for Cost-Effectiveness Analysis) study. Market prices were determined for donated resources.An urban, church-based, non-profit organisation that offers rapid-test VCT services in KwaZulu-Natal, South Africa.Financial expenditure for the 2002/2003 fiscal year was 39,761 dollars (calculated using an average conversion rate for July 2003, which was 0.133). Using market prices for donated resources, the economic cost for the year was estimated at 67,248 dollars. Six hundred and sixty-two clients completed VCT, resulting in financial expenditure of 60.06 dollars per client and an economic cost of 101.58 dollars per client. Financial expenditures and economic costs per client decreased over the year by 66% because expenses remained stable as more clients were served.The cost of providing VCT services was higher than previously reported, but declined with expanding scale.

The largest investments in AIDS prevention targeted to the general population are being made in interventions where the evidence for large-scale impact is uncertain.

Objective: To assess the potential cost-effectiveness of short-course antiviral regimens to prevent mother-to-child transmission (MCT) of HIV in sub-Saharan Africa. Design: Cost-effectiveness analysis. Methods: No intervention was compared with three regimens of twice daily zidovudine and lamivudine: regimen A, starting at 36 weeks of gestation and continuing to 1 week postpartum; regimen B, from intrapartum through 1 week postpartum; and regimen C, intrapartum only. Model inputs were estimated from published and unpublished data. Absolute percentage reductions in HIV transmission extrapolated from zidovudine monotherapy trials were estimated at 12.4, 8.6 and 4.3% for regimens A, B, and C, respectively. Outcome measures were net costs to the public sector health-care system, cost per infection averted, and cost per disability-adjusted life-year (DALY) gained. Multiple sensitivity analyses were conducted. Results: Based on the hypothetical efficacy estimates, regimen C was the most cost-effective. For a cohort of 100 women with 15% HIV prevalence, net costs to the public sector health-care systems were estimated at US$ 3617 for regimen A, US$ 1667 for regimen B, and US$ 351 for regimen C. Regimen C had a cost of US$ 1129 per HIV infection averted and a cost of US$ 60 per DALY. Regimens B and A cost US$ 2680 and 5134 per infection averted and US$ 143 and 274 per DALY, respectively. Cost-effectiveness declined rapidly at efficacy below 10% or HIV prevalence below 7%. Results were very sensitive to antiviral drug costs. For example, at 20% of current prices, the cost per DALY for regimen A fell to US$ 64, and to about US$ 42 for regimens B and C. Conclusion: Antiviral therapy may be cost-effective compared with other health interventions if HIV prevalence is high, if clinical trials confirm estimated efficacies, and if drug prices are reduced.

The cost-effectiveness of public health cataract programs in low-income countries has been well documented. Equity, another important dimension of program quality which has received less attention is analyzed here by comparisons of surgical coverage rates for major sub-groups within the intended beneficiary population of the Nepal blindness program (NBP). Substantial differences in surgical coverage were found between males and females and between different age groups of the same gender. Among the cataract blind, the surgical coverage of males was 70% higher than that of females. For both genders, the cataract blind over 55 received proportionately fewer services than younger people blind from cataract. Blind males aged 45–54 had a 500% higher rate of surgical coverage than blind males over 65. Blind females aged 35–44 had nearly a 600% higher rate of surgical coverage than blind females over 65. There was wide variation in overall surgical coverage between geographic zones, but little variation by terrain type, an indicator of the logistical difficulties in delivery of services. Members of the two highest caste groupings had somewhat lower surgical coverage than members of lower castes. Program managers should consider developing methods to increase services to women and to those over 65. Reaching these populations will become increasingly important as those most readily served receive surgery and members of the under-served groups form a growing portion of the remaining cataract backlog.

In this issue, Long and Stavert1 present an insightful analysis of the cost-effectiveness of combinations of biomedical interventions for HIV in South Africa, a country hard-hit by HIV and in need of effective intervention strategies. Their examination of portfolios of interventions is timely and valuable, for two reasons. First, more biological interventions now have solid empirical data on effectiveness. Second, with increased focus on efforts to sharply curtail HIV, realistic combination strategies are desperately needed. Our analysis showed that the epidemic in South Africa could be minimized over time with aggressive scale-up of anti-retroviral therapy (ART) combined with enhanced prevention,2 but without Long and Stavert’s attention to specific intervention options. This paper finds that biological interventions are not equally efficient. Figure 2 offers a summary of findings, with quality-adjusted life years (QALYs) on the vertical axis and costs (in international dollars) on the horizontal. Among individual interventions, circumcision saves money while providing health benefit (in cost-effectiveness lexicon, is “dominant”), moving left on the graph. All other strategies move right and up, with costs and QALYs rising. A steeper slope (more QALYs per dollar) is preferable. After circumcision, HIV screening alone and with ART provides a relatively attractive $1,033 per QALY gained. Of note, any strategy that involves PrEP has a substantially less attractive cost-effectiveness, due to PrEP’s $9,000 per QALY gained. The “combination portfolio” that includes all five interventions costs about $3,000 per QALY gained compared with the status quo, and $9,937 per QALY gained compared with screening and ART. As noted by Padian3 for modeling portfolios of interventions, “reliability of the outputs cannot exceed the quality of the inputs … particular care must be given to … defining the combination of interventions to be evaluated … [and] choosing valid counterfactuals.” Long and Stavert succeeded admirably in examining uncertainty in inputs with probabilistic sensitivity analyses. We might have modeled longer than 10 years, to see delayed effects, and decision-makers might prefer different combinations of interventions. Despite these minor reservations, the article is a very instructive, informative, and valuable step to understanding HIV epidemic control options.

Using data from the Lumbini Zonal Eye Care Program in Nepal, the authors estimated marginal costs, capital costs, and average recurring costs for a public health cataract program with and without donor agency overhead expenditures. Each estimate is useful for guiding decisions under certain conditions. Marginal costs are appropriate for short-term planning. Average in-country recurring cost figures are needed to project budgets for longer term program costs or major program expansion. A portion of donor agency overhead costs should be included if expansion requires more donor agency contributions. Marginal costs are estimated at US $3.01 per case. In-country recurring costs are about $13.91. Capital costs excluding hospital construction are an additional $2.42. Seva's USA administrative expenditures in support of the cataract component of the program add about another $5.38. Total costs were about $21.71 per case.