Last data update: May 13, 2024. (Total: 46773 publications since 2009)
Records 1-12 (of 12 Records) |
Query Trace: Blandford J[original query] |
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Integrating 'undetectable equals untransmittable' into HIV counselling in South Africa: the development of locally acceptable communication tools using intervention mapping
Sineke T , Bor J , King R , Mokhele I , Dukashe M , Bokaba D , Inglis R , Kgowedi S , Richman B , Kinker C , Blandford J , Ruiter RAC , Onoya D . BMC Public Health 2024 24 (1) 1052 BACKGROUND: The global campaign for "Undetectable equals Untransmittable" (U = U) seeks to spread awareness of HIV treatment as prevention, aiming to enhance psychological well-being and diminish stigma. Despite its potential benefits, U = U faces challenges in Sub-Saharan Africa, with low awareness and hesitancy to endorse it. We sought to develop a U = U communications intervention to support HIV counselling in primary healthcare settings in South Africa. METHODS: We used Intervention Mapping (IM), a theory-based framework to develop the "Undetectable and You" intervention for the South African context. The six steps of the IM protocol were systematically applied to develop the intervention including a needs assessment consisting of a systematic review and qualitative research including focus group discussions (FGD) and key informant (KI) interviews. Program objectives and target population were determined before designing the intervention components and implementation plan. RESULTS: The needs assessment indicated low global U = U awareness, especially in Africa, and scepticism about its effectiveness. Lay counsellors and clinic managers stressed the need for a simple and standardized presentation of U = U addressing both patients' needs for encouragement and modelling of U = U success but also clear guidance toward ART adherence behaviour. Findings from each step of the process informed successive steps. Our final intervention consisted of personal testimonials of PLHIV role models and their partners, organized as an App to deliver U = U information to patients in primary healthcare settings. CONCLUSIONS: We outline an intervention development strategy, currently in evaluation stage, utilizing IM with formative research and input from key U = U stakeholders and people living with HIV (PLHIV). |
The promise of a "cure" for HIV: implications for the future of PEPFAR-supported HIV programmes
Raizes E , Blandford J , McCune JM , Dybul M . J Int AIDS Soc 2024 27 (1) e26206 As we commemorate the 20th anniversary of the U.S. President's Emergency for AIDS Relief (PEPFAR), there is much to celebrate: over 20 million persons with HIV are receiving life‐saving antiretroviral treatment (ART) in over 50 PEPFAR‐supported countries [1]. However, external financial support for HIV in low‐ and middle‐income countries (LMICs) remains flat, and overall resources are estimated to be at least $8 billion short of the $29 billion needed to reach the 2025 goals of 95‐95‐951 [2]. | | Even if these goals are realized, they will only be sustained if resources are provided indefinitely. The prospect of HIV “cure,” that is durable ART‐free suppression of HIV, represents an attractive alternative to such ongoing resource commitments—beckoning investment in an intervention that would extend lives, reduce new HIV acquisitions and obviate the need for continued ART. | | With this in mind, we read with interest the report in this journal by Guzauskas and Hallet [3] on “the long‐term impact and value of curative therapy for HIV.” Modelling the health benefits of such an intervention, they found that “HIV cure” would more rapidly lower HIV prevalence, prevent future acquisitions over time, increase life years in the population and reduce AIDS‐related deaths when compared to ART alone even in LMICs. These benefits were even more pronounced in settings with higher HIV burdens and lower ART adherence. They also found that such an intervention would be cost‐effective for the duration of HIV patients’ lifetimes if price aligned with a country's per capita income and disease burden. |
Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models
Eaton JW , Menzies NA , Stover J , Cambiano V , Chindelevitch L , Cori A , Hontelez JA , Humair S , Kerr CC , Klein DJ , Mishra S , Mitchell KM , Nichols BE , Vickerman P , Bakker R , Bärnighausen T , Bershteyn A , Bloom DE , Boily MC , Chang ST , Cohen T , Dodd PJ , Fraser C , Gopalappa C , Lundgren J , Martin NK , Mikkelsen E , Mountain E , Pham QD , Pickles M , Phillips A , Platt L , Pretorius C , Prudden HJ , Salomon JA , van de Vijver DA , de Vlas SJ , Wagner BG , White RG , Wilson DP , Zhang L , Blandford J , Meyer-Rath G , Remme M , Revill P , Sangrujee N , Terris-Prestholt F , Doherty M , Shaffer N , Easterbrook PJ , Hirnschall G , Hallett TB . Lancet Glob Health 2014 2 (1) e23-34 BACKGROUND: New WHO guidelines recommend initiation of antiretroviral therapy for HIV-positive adults with CD4 counts of 500 cells per μL or less, a higher threshold than was previously recommended. Country decision makers have to decide whether to further expand eligibility for antiretroviral therapy accordingly. We aimed to assess the potential health benefits, costs, and cost-effectiveness of various eligibility criteria for adult antiretroviral therapy and expanded treatment coverage. METHODS: We used several independent mathematical models in four settings-South Africa (generalised epidemic, moderate antiretroviral therapy coverage), Zambia (generalised epidemic, high antiretroviral therapy coverage), India (concentrated epidemic, moderate antiretroviral therapy coverage), and Vietnam (concentrated epidemic, low antiretroviral therapy coverage)-to assess the potential health benefits, costs, and cost-effectiveness of various eligibility criteria for adult antiretroviral therapy under scenarios of existing and expanded treatment coverage, with results projected over 20 years. Analyses assessed the extension of eligibility to include individuals with CD4 counts of 500 cells per μL or less, or all HIV-positive adults, compared with the previous (2010) recommendation of initiation with CD4 counts of 350 cells per μL or less. We assessed costs from a health-system perspective, and calculated the incremental cost (in US$) per disability-adjusted life-year (DALY) averted to compare competing strategies. Strategies were regarded very cost effective if the cost per DALY averted was less than the country's 2012 per-head gross domestic product (GDP; South Africa: $8040; Zambia: $1425; India: $1489; Vietnam: $1407) and cost effective if the cost per DALY averted was less than three times the per-head GDP. FINDINGS: In South Africa, the cost per DALY averted of extending eligibility for antiretroviral therapy to adult patients with CD4 counts of 500 cells per μL or less ranged from $237 to $1691 per DALY averted compared with 2010 guidelines. In Zambia, expansion of eligibility to adults with a CD4 count threshold of 500 cells per μL ranged from improving health outcomes while reducing costs (ie, dominating the previous guidelines) to $749 per DALY averted. In both countries results were similar for expansion of eligibility to all HIV-positive adults, and when substantially expanded treatment coverage was assumed. Expansion of treatment coverage in the general population was also cost effective. In India, the cost for extending eligibility to all HIV-positive adults ranged from $131 to $241 per DALY averted, and in Vietnam extending eligibility to patients with CD4 counts of 500 cells per μL or less cost $290 per DALY averted. In concentrated epidemics, expanded access for key populations was also cost effective. INTERPRETATION: Our estimates suggest that earlier eligibility for antiretroviral therapy is very cost effective in low-income and middle-income settings, although these estimates should be revisited when more data become available. Scaling up antiretroviral therapy through earlier eligibility and expanded coverage should be considered alongside other high-priority health interventions competing for health budgets. FUNDING: Bill & Melinda Gates Foundation, WHO. |
Global health and the US Centers for Disease Control and Prevention
Schuchat A , Tappero J , Blandford J . Lancet 2014 384 (9937) 98-101 Why is an article about global health included in a special issue on health in the USA? About half the produce that Americans consume is cultivated in other countries, 60 million Americans travel or work outside the USA, and most patients with measles and tuberculosis in the USA acquired their infection elsewhere. Emerging diseases, globalisation of foods and medicines, the rise in antimicrobial resistance, and the ease with which pathogens can be manipulated for good or harm increase each nation's vulnerability and interdependence. | The Centers for Disease Control and Prevention (CDC) has engaged in global health for more than 60 years. Although tackling infectious disease threats has been a constant, the agency has also provided humanitarian assistance in natural disasters, refugee crises, and famines; improved child survival; and strengthened scientific measurement of health metrics. CDC's workforce includes more than 300 internationally deployed public health professionals in addition to around 1330 locally employed staff working in about 60 countries (figure ). CDC's global health strategy aims to: achieve optimum health effects; strengthen global health capacity; improve global health security; and strengthen the organisation's capacity.1 This report describes selected programmes that illustrate these goals. |
The determinants of HIV treatment costs in resource limited settings
Menzies NA , Berruti AA , Blandford JM . PLoS One 2012 7 (11) e48726 BACKGROUND: Governments and international donors have partnered to provide free HIV treatment to over 6 million individuals in low and middle-income countries. Understanding the determinants of HIV treatment costs will help improve efficiency and provide greater certainty about future resource needs. METHODS AND FINDINGS: We collected data on HIV treatment costs from 54 clinical sites in Botswana, Ethiopia, Mozambique, Nigeria, Uganda, and Vietnam. Sites provided free HIV treatment funded by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), national governments, and other partners. Service delivery costs were categorized into successive six-month periods from the date when each site began HIV treatment scale-up. A generalized linear mixed model was used to investigate relationships between site characteristics and per-patient costs, excluding ARV expenses. With predictors at their mean values, average annual per-patient costs were $177 (95% CI: 127-235) for pre-ART patients, $353 (255-468) for adult patients in the first 6 months of ART, and $222 (161-296) for adult patients on ART for >6 months (excludes ARV costs). Patient volume (no. patients receiving treatment) and site maturity (months since clinic began providing treatment services) were both strong independent predictors of per-patient costs. Controlling for other factors, costs declined by 43% (18-63) as patient volume increased from 500 to 5,000 patients, and by 28% (6-47) from 5,000 to 10,000 patients. For site maturity, costs dropped 41% (28-52) between months 0-12 and 25% (15-35) between months 12-24. Price levels (proxied by per-capita GDP) were also influential, with costs increasing by 22% (4-41) for each doubling in per-capita GDP. Additionally, the frequency of clinical follow-up, frequency of laboratory monitoring, and clinician-patient ratio were significant independent predictors of per-patient costs. CONCLUSIONS: Substantial reductions in per-patient service delivery costs occur as sites mature and patient cohorts increase in size. Other predictors suggest possible strategies to reduce per-patient costs. |
PEPFAR, health system strengthening, and promoting sustainability and country ownership
Palen J , El-Sadr W , Phoya A , Imtiaz R , Einterz R , Quain E , Blandford J , Bouey P , Lion A . J Acquir Immune Defic Syndr 2012 60 Suppl 3 S113-9 Evidence demonstrates that scale-up of HIV services has produced stronger health systems and, conversely, that stronger health systems were critical to the success of the HIV scale-up. Increased access to and effectiveness of HIV treatment and care programs, attention to long-term sustainability, and recognition of the importance of national governance, and country ownership of HIV programs have resulted in an increased focus on structures that compromise the broader health system. Based on a review published literature and expert opinion, the article proposes 4 key health systems strengthening issues as a means to promote sustainability and country ownership of President's Emergency Plan for AIDS Relief and other global health initiatives. First, development partners need provide capacity building support and to recognize and align resources with national government health strategies and operational plans. Second, investments in human capital, particularly human resources for health, need to be guided by national institutions and supported to ensure the training and retention of skilled, qualified, and relevant health care providers. Third, a range of financing strategies, both new resources and improved efficiencies, need to be pursued as a means to create more fiscal space to ensure sustainable and self-reliant systems. Finally, service delivery models must adjust to recent advancements in areas of HIV prevention and treatment and aim to establish evidence-based delivery models to reduce HIV transmission rates and the overall burden of disease. The article concludes that there needs to be ongoing efforts to identify and implement strategic health systems strengthening interventions and address the inherent tension and debate over investments in health systems. |
PEPFAR'S past and future efforts to cut costs, improve efficiency, and increase the impact of global HIV programs
Holmes CB , Blandford JM , Sangrujee N , Stewart SR , Dubois A , Smith TR , Martin JC , Gavaghan A , Ryan CA , Goosby EP . Health Aff (Millwood) 2012 31 (7) 1553-60 Amid the global economic crisis, the President's Emergency Plan for AIDS Relief (PEPFAR) and other organizations have been pressed to do more with constrained resources to meet unmet needs in the worldwide HIV/AIDS pandemic. PEPFAR has approached this challenge through the development of an Impact and Efficiency Acceleration Plan, which includes improving the collection and use of economic and financial data, increasing the efficiency of HIV/AIDS program implementation, and collaborating with governments and multilateral organizations to maximize the impact of the resources provided by the United States. For example, by linking financial data with program outputs, PEPFAR was able to help its implementing partners in Mozambique reduce mean unit expenditures for people receiving antiretroviral treatment by 45 percent, from $265 to $145 per person, between 2009 and 2011. This article describes the plan's elements, provides examples of progress and challenges to its implementation, and assesses the prospects for further improvements in efficiency and impact. |
Cost-effectiveness of tuberculosis diagnostic strategies to reduce early mortality among persons with advanced HIV infection initiating antiretroviral therapy
Abimbola TO , Marston BJ , Date AA , Blandford JM , Sangrujee N , Wiktor SZ . J Acquir Immune Defic Syndr 2012 60 (1) e1-7 BACKGROUND: In sub-Saharan Africa, patients with advanced HIV experience high mortality during the first few months of antiretroviral therapy (ART), largely attributable to tuberculosis (TB). We evaluated the cost-effectiveness of TB diagnostic strategies to reduce this early mortality. METHODS: We developed a decision analytic model to estimate the incremental cost, deaths averted, and cost-effectiveness of 3 TB diagnostic algorithms. The model base case represents current practice (symptoms screening, sputum smear, and chest radiography) in many resource-limited countries in sub-Saharan Africa. We compared the current practice with World Health Organization (WHO)-recommended practice with culture and WHO-recommended practice with the Xpert mycobacterium tuberculosis and resistance to rifampicin test and considered relevant medical costs from a health system perspective using the timeframe of the first 6 months of ART. We conducted univariate and probabilistic sensitivity analyses on all parameters in the model. RESULTS: When considering TB diagnosis and treatment and ART costs, the cost per patient was $850 for current practice, $809 for the algorithm with Xpert test, and $879 for the algorithm with culture. Our results showed that both WHO-recommended algorithms avert more deaths among TB cases than does the current practice. The algorithm with Xpert test was least costly at reducing early mortality compared with the current practice. Sensitivity analyses indicated that cost-effectiveness findings were stable. CONCLUSIONS: Our analysis showed that culture or Xpert were cost-effective at reducing early mortality during the first 6 months of ART compared with the current practice. Thus, our findings provide support for ongoing efforts to expand TB diagnostic capacity. |
Expanding the generation and use of economic and financial data to improve HIV program planning and efficiency: a global perspective
Holmes CB , Atun R , Avila C , Blandford JM . J Acquir Immune Defic Syndr 2011 57 S104-S108 Cost information is needed at multiple levels of health care systems to inform the public health response to HIV. To date, most attention has been paid to identifying the cost drivers of providing antiretroviral treatment, and these data have driven interventions that have been successful in reducing drug and human resource costs. The need for further cost information, especially for less well-studied areas such as HIV prevention, is particularly acute given global budget constraints and ongoing efforts to extract the greatest possible value from money spent on the response. Cost information can be collected from multiple perspectives and levels of the health care system (site, program, and national levels), and it is critical to choose the appropriate methodology in order to generate the appropriate information for decision-making. Organizations such as United States President's Emergency Plan for AIDS Relief, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and other organizations are working together to bridge the divide between the fields of economics and HIV program implementation by accelerating the collection of cost data and building further local demand and capacity for their use. 2011 by Lippincott Williams & Wilkins. |
The cost of providing comprehensive HIV treatment in PEPFAR-supported programs
Menzies NA , Berruti AA , Berzon R , Filler S , Ferris R , Ellerbrock TV , Blandford JM . AIDS 2011 25 (14) 1753-60 PEPFAR, national governments, and other stakeholders are investing unprecedented resources to provide HIV treatment in developing countries. This study reports empirical data on costs and cost trends in a large sample of HIV treatment sites.In 2006-2007, we conducted cost analyses at 43 PEPFAR-supported outpatient clinics providing free comprehensive HIV treatment in Botswana, Ethiopia, Nigeria, Uganda, and Vietnam.We collected data on HIV treatment costs over consecutive 6-month periods from scale-up of dedicated HIV treatment services at each site. The study included all patients receiving HIV treatment and care at study sites (62,512 ART and 44,394 pre-ART patients). Outcomes were costs per-patient and total program costs, subdivided by major cost categories.Median annual economic costs were $202 (2009 USD) for pre-ART patients and $880 for ART patients. Excluding ARVs, per-patient ART costs were $298. Care for newly initiated ART patients cost 15-20% more than for established patients. Per-patient costs dropped rapidly as sites matured, with per-patient ART costs dropping 46.8% between first and second 6-month periods after the beginning of scale-up, and an additional 29.5% the following year. PEPFAR provided 79.4% of funding for service delivery, and national governments provided 15.2%.Treatment costs vary widely between sites, and high early costs drop rapidly as sites mature. Treatment costs vary between countries and respond to changes in ARV regimen costs and the package of services. While cost reductions may allow near-term program growth, programs need to weigh the trade-off between improving services for current patients and expanding coverage to new patients. |
Characteristics of HIV care and treatment in PEPFAR-supported sites
Filler S , Berruti AA , Menzies N , Berzon R , Ellerbrock TV , Ferris R , Blandford JM . J Acquir Immune Defic Syndr 2011 57 (1) e1-6 BACKGROUND: The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) has supported the extension of HIV care and treatment to 2.4 million individuals as of September 2009. With increasing resources targeted toward rapid scale-up, it is important to understand the characteristics of current PEPFAR-supported HIV care and treatment sites. METHODS: Forty-five sites in Botswana, Ethiopia, Nigeria, Uganda, and Vietnam were sampled. Data were collected retrospectively from successive 6-month periods through reviews of facility records and interviews with site personnel between April 2006 and March 2007. Facility size and scale-up rate, patient characteristics, staffing models, clinical and laboratory monitoring, and intervention mix were compared. RESULTS: Sites added a median of 293 patients per quarter. By the evaluation's end, sites supported a median of 1,649 HIV patients, 922 of them receiving antiretroviral therapy (ART). Patients were predominantly adult (97.4%) and the majority (96.5%) were receiving regimens based on nonnucleoside reverse transcriptase inhibitors (NNRTIs). The ratios of physicians to patients dropped substantially as sites matured. ART patients were commonly seen monthly or quarterly for clinical and laboratory monitoring, with CD4 counts being taken at 6-month intervals. One-third of sites provided viral load testing. Cotrimoxazole prophylaxis was the most prevalent supportive service. CONCLUSIONS: HIV treatment sites scaled up rapidly with the influx of resources and technical support through PEPFAR, providing complex health services to progressively expanding patient cohorts. Human resources are stretched thin, and delivery models and intervention mix differ widely between sites. Ongoing research is needed to identify best-practice service delivery models. |
Cost-effectiveness of routine rapid human immunodeficiency virus antibody testing before DNA-PCR testing for early diagnosis of infants in resource-limited settings
Menzies NA , Homsy J , Pitter JYC , Pitter C , Mermin J , Downing R , Finkbeiner T , Obonyo J , Kekitiinwa A , Tappero J , Blandford JM . Pediatr Infect Dis J 2009 28 (9) 819-825 BACKGROUND: Infants born to HIV-infected women should receive HIV testing to allow early diagnosis and treatment. Recommendations for resource-limited settings stress laboratory-based virologic assays. While effective, these tests are logistically complex and expensive. This study explored the cost-effectiveness of incorporating initial screening with rapid HIV tests (RHT) into the conventional testing algorithm to screen-out HIV-uninfected infants, thereby reducing the need for costly virologic testing. METHODS: Data on HIV prevalence, RHT sensitivity and specificity, and costs were collected from 820 HIV-exposed children (1.5-18 months) attending 2 postnatal screening programs in Uganda during July 2005 to December 2006. Cost-effectiveness models compared the conventional testing algorithm DNA polymerase chain reaction (DNA-PCR with Roche Amplicor v1.5) with a modified algorithm (initial RHT to screen-out HIV-uninfected infants before DNA-PCR). RESULTS: The model estimated that the conventional algorithm would identify 94.3% (91.8%-94.7%) of HIV-infected infants, compared with 87.8% (79.4%-90.5%) for a modified algorithm using RHT (HIV 1/2 Determine) and excluding the need for DNA-PCR for HIV antibody-negative infants. Costs per infant were $23.47 ($23.32-$23.76) for the conventional algorithm and between $22.75 ($21.89-$23.31) and $7.58 ($6.41-$10.75) for the modified algorithm, depending on infant age and symptoms. Compared with the conventional algorithm, costs per HIV-infected infant identified using the modified algorithm were higher in 1.5- to 3-month-old infants, but significantly lower in 3-month-old and older infants. Models replicating the whole infant testing program showed the modified algorithm would have marginally lower sensitivity, but would reduce total program costs by 27% to 40%, producing an incremental cost-effectiveness ratio of $1489 ($686-$6781) for the conventional versus modified algorithms. CONCLUSIONS: Screening infants with RHT before DNA-PCR is cost-effective in infants 3 months old or older. Incorporating RI-IT into early infant testing programs could improve cost-effectiveness and reduce program costs. |
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