Antiretroviral therapy is cost-effective

Posted on by — No Comments ↓

As the resource implications of expanding anti-retroviral therapy (ART) are likely to be large, there is a need to explore its cost-effectiveness. We therefore assessed the cost-effectiveness of ART for routine clinical practice in a district hospital setting in Ethiopia.

We estimated the unit cost of HIV-related care from the 2004/5 fiscal year expenses of Arba Minch Hospital in southern Ethiopia. We estimated outpatient and in-patient service use from HIV-infected patients who received care and treatment at the hospital between January 2003 and March 2006. We measured the health effect as life years gained (LYG) for patients receiving ART compared with those not receiving such treatment. The study adopted a health care provider perspective and included both direct and overhead costs. We used Markov model to estimate the lifetime costs, health benefits and cost-effectiveness of ART.

ART yielded an undiscounted 9.4 years expected survival, and resulted in 7.1 extra LYG compared to patients not receiving ART. The lifetime incremental cost is US$2,215 and the undiscounted incremental cost per LYG is US$314. When discounted at 3%, the additional LYG decreases to 5.5 years and the incremental cost per LYG increases to US$325.

The undiscounted and discounted incremental costs per LYG from introducing ART were less than the per capita GDP threshold at the base year. Thus, ART could be regarded as cost-effective in a district hospital setting in Ethiopia.

____________

Bikilla AD, Jerene DS, Robberstad B and Lindtjørn B. Cost-effectiveness of anti-retroviral therapy at a district hospital in southern Ethiopia. Cost Effectiveness and Resource Allocation 2009, 7:13doi:10.1186/1478-7547-7-13

Also see [intlink id=”146″ type=”post”]previous post on cost of HIV treatment[/intlink]:

Bikilla AD , Jerene D, Robberstad B and Lindtjorn B. Cost estimates of HIV care and treatment with and without anti-retroviral therapy at Arba Minch Hospital in southern Ethiopia. Cost Effectiveness and Resource Allocation 2009, 7:6doi:10.1186/1478-7547-7-6

Impact factor and Tropical medicine

Posted on by — No Comments ↓

The latest edition of Thomson Reuter’s Journal Citation Reports has just been released. Two BioMed Central Journal rank as number 1 and number 2 in the TROPICAL MEDICINE category. The Malaria Journal is the leading journal in this category, with an impact factor of 2.91.

Increasingly many researchers from developing countries now use BMC Public Health (impact factor 2.03).

Traditionally, Tropical Medicine journals had low impact factors, with most journals having values below 1.

Since I am an associate editor of BMC Public Health, I am biased. But I find it encouraging to see that international health and tropical medicine has become more widely accessible with Open Access Journals

Doctors and non-physician clinicians (NPC)

Posted on by — No Comments ↓

There is a severe shortage of trained health staff in rural Africa. We try to solve this issue by using doctors and non-physician clinicians (NPC). A recent problem we have seen in south Ethiopia is that these two categories of health personnel do not collaborate.

As non-physician clinicians (NPC) take over doing surgical tasks, the doctors withdraw from this important part of the work. General practitioners work on internal medicine and paediatrics, leaving surgery and obstetrics to NPC. In one hospital we have also seen the physician, who has only one year of clinical experience, leave the hospital when the non-physician clinician (NPC) started work.

This is a trend that worries us, and we need to find mechanisms to promote the collaboration between the two professions.

Any suggestions to solve this unhealthy competition?

Sustainability and task shifting in Africa

Posted on by — No Comments ↓

Recently Kathryn Chu and colleagues  wrote  a very good discussion on the topic of using non-physician clinician in emergency surgery (see Chu K, Rosseel P, Gielis P, Ford N (2009) Surgical Task Shifting in Sub-Saharan Africa. PLoS Med 6(5): e1000078. doi:10.1371/journal.pmed.1000078)

In a response to their paper, I wrote a comment on PLoSMedicine:

Kathryn Chu and colleagues are to be commended for their paper on “Surgical Task Shifting in Sub-Saharan Africa”.

I work on a project to train non-physician clinicians (NPC) in Emergency Obstetrics and surgery in south Ethiopia. The Ministry of Health collaborates and recognizes the training. It is a programme for public institutions, and it consists of four months basic training, followed by two months of supervisory visits to their home institutions. An important part of the project is also to support the peripheral institutions with essential equipment.

Our experience is similar to those from Mozambique and shows that using NPC for essential surgery and obstetrics is workable. Complication rates are low. As expected, we see that staff with some years of clinical experience perform better that those coming directly from school.

As many institutions have only one trained NPC, their sustainability is often threatened, and work might be discontinued during week-ends, vacations and needed travels. Each institution needs more than one team to become sustainable.

Too often, staff receive training and acquire basic skills to return to their home institution where it is not possible to do the tasks they trained for because of lack of follow up, surgical equipment or materials. For programmes to succeed, we think it is important to continue supporting the peripheral institutions.

As most peripheral hospitals and health centres are public, and to ensure sustainable performance, we believe the national or regional health authorities should own or be a part of the programme. This would allow for needed professional and political recognition, provision of necessary incentives and continued recruitment of essential staff.

Drug resistance to artemesinin family of drugs?

Posted on by — No Comments ↓

BBC recently reported drug resistance to artesunate drugs (artemesinin family of drugs for malaria treatment) in western Cambodia.

Out of about 90 patients that American scientists studied so far, about a third to half were still positive for malaria parasites after three days, some even after four or five days. This means the drug is not able to kill the parasites quickly enough, and the parasite may develop tolerance or resistance. The reason for resistance is still not known.

If this is a new form of drug resistance that spreads to other countries, its spread would be a global health disaster. Resistance to previous malaria such as chloroquin and fansidar (SF) caused many unnecessary deaths in Africa.

In our study in Chano near Arba Minch, Eskindir Loha is starting a study to monitor possible resistance to Artemether – Lumefantrine  in a few months.

Non-physician clinicians

Posted on by — No Comments ↓

We have good experience from sub-Saharan Africa, that task shifting from doctors to non-physician clinicians can address the HIV/AIDS treatment, improve tuberculosis control and manage health problems in children (IMC). Similarly, some operations usually done by surgeons and anaesthesiologists can be safely done non- specialists.

Surgical care is the safe provision of preoperative, operative, and post-operative surgical and anaesthesia services. Unfortunately, there are too few surgeons in Africa, and it is unlikely that a modest increase in the number of surgeons and anaesthesiologists will occur.

In HIV care, we recognized the Western model of care with medical specialists in secondary and tertiary hospitals, could not be copied in Africa. By adapting and selecting treatment protocols and task shifting, it was possible to treat millions of patients received antiretroviral drugs. Similarly, it is important in the surgical fields to avoid creating “islands of excellence in a sea of under provision”.

By enabling non-physician clinicians to do some essential operations, we may increase benefits while lessening harm among populations where the unmet need of surgical care is great.

Please also see a very good discussion on this topic written by Chu K, Rosseel P, Gielis P, Ford N (2009) Surgical Task Shifting in Sub-Saharan Africa. PLoS Med 6(5): e1000078. doi:10.1371/journal.pmed.1000078

For more information about our training programme in Ethiopia click here.

Climate change and health

Posted on by — No Comments ↓

Climate change will have more far-reaching effects on health than predicted. The greatest effect will be on the world’spoorest people. This is the main conclusion of a comprehensive report in The Lancet (Lancet 2009; 373: 1693–1733). The indirect effects of climate change on water, food, security,population, migration, and extreme climatic events are likely to have the biggest effect on global health, greater than the increase in vector borne diseases.

Recently, Lafferty (Ecology, 2009, 90: 888–900) wrote that although the globe is warmer than it was a century ago, there is little evidence that climate change has already favoured infectious diseases. Recent models predict range shifts in disease distributions, with some increase of vector borne diseases.

The Lancet report identified some challenges that scientists, doctors, and policy makers need to address:

There is a large information gap, particularly in low and middle-income countries.

The effects of climate change would hit the poor the hardest.

Rich countries should massively reduce their emissions.

There is a  lack of technologies to help people adapt to changes in climate such as measures to boost food production and for storing and treating water

Economic growth is needed in the poor countries to help people to adapt to global warming.

Improving tuberculosis control in Ethiopia

Posted on by — No Comments ↓

By using community health workers in stead of health professionals such as nurses and doctors at institutions, Daniel Datiko at Centre for International Health has shown:

The community based approach (Community DOTS) identifies about 70% of expected tuberculosis cases, compared with only 30 % when patients have to travel to health centres and hospitals

About 90% of the tuberculosis patients were cured when they received treatment in their local communities, compared with 80% at institutions

The community based approach reduced the costs of treatment by 60%.

Most of patients treated by Community DOTS are women. This is a significant improvement from the institutional based tuberculosis control.

The community based DOTS is an approach that improves access to treatment.

These ideas are now being implemented in Ethiopia. As a start it will be carried out in the Southern Nations, Nationalities and Peoples’ Regional State in Ethiopia.

Preventing HIV among adolescents and youth in rural Ethiopia

Posted on by — No Comments ↓

Mitike Molla is on May 28, 2009 defending her PhD at the University of Bergen.

The title is: Preventing HIV among young people: A community based study from Butajira on traditional norms, sexual health and HIV associated deaths. 

The health needs of young adults in Ethiopia are often neglected.  HIV is one of the major health problems among young people in Ethiopia, where the transmission often starts to pick up at the age of 15-24 years.

She interviewed 3743 young adults about sexual behaviours and sexually transmitted infections. She also asked about the attitude, opinion and knowledge of health providers towards young adults reproductive health needs. She used data from the Butajira Rural Health Programme, Demographic Surveillance Site to assess mortality trends among young adults aged 10-24 years.

She found the traditional norm of keeping virginity until marriage is still followed among the youth in rural South Central Ethiopia. Only 3% of the never-married youth had premarital sex, while almost all married youth started their union as celibates. Young adults who used alcohol, chewed khat, and did not believe in the traditional norm were more likely to have premarital sex. However, the study also showed that married women are vulnerable to HIV and other sexually transmitted diseases because of risky sexual behaviours among their husbands.

4% had had a sexually transmitted disease during the year preceding the study. Most of these were married women. Half of them who had STI symptoms did not seek help, mainly because of shame of having the infection in marriage and taboos related to premarital sex. Lack of readiness of the health services for the youth, unfavourable attitude of health professionals, women’s subordinate position in the society, and lack of knowledge about STIs among youth are possible reasons for low health seeking behaviour among young people. Six out seven of the sexually active young adults never used condoms.

Among young adults, the deaths rates declined during the period 1987-2004, with only a few deaths caused by HIV.

Upholding the traditional norm of virginity, prevention programmes should encourage HIV counselling and testing (HCT) before marriage, and faithfulness in marriage. Condom use among non-users should be encouraged and strengthened among ever-users to bring about consistent use in all non-mutual monogamous relations. The health services should be reoriented towards young adults’ SRH to improve use.

Mitike Molla’s PhD publications:

Molla M, Byass, P: Berhane Y, Lindtjørn B. Mortality decreases among young adults in south-central Ethiopia. Ethiop J Hlth Dev 2008; 22: 218-225.

Molla M, Berhane Y, Lindtjørn B. Traditional values of virginity and sexual behaviour in rural Ethiopian youth: results from a cross-sectional study. BMC Public Health. 2008;8:9.

Mitike Molla, Maria Emmelin, Yemane Berhane, and Bernt Lindtjørn. Youth in rural Ethiopia hesitate to seek health services for sexually transmitted infections: A mixed method research in Butajira, Central Ethiopia. African Journal of AIDS Research 2009, 8(2): 135–146

M. Molla A. Nordrehaug Åstrøm , Y. Berhane Y: Applicability of the theory of planned behavior to intended and self reported condom use in a rural Ethiopian population. AIDS Care, 2007, 19 (3):425-431.