Effect of changing antiretroviral treatment eligibility criteria on patient load in Kampala, Uganda

Konde-Lule, Joseph; Makumbi, Fred; Pakker, Nadine; Muyinda, Asad; Mubiru, Mesach; Cobelens, Frank

doi:10.1080/09540121.2010.498869

Cited by 8 publications

(2 citation statements)

References 14 publications

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“…First of all, by being aware of the workload involved with changed recommendations. For example, stakeholders in Uganda estimated a 60% increase in health-seeking behaviour as a result of the adoption of the new WHO guidelines [36]. Task shifting from doctors to nurses prescribing ART is one solution whose effectiveness has been demonstrated [37].…”

Section: Earlier Start Of Artmentioning

confidence: 99%

HIV treatment and care in resource‐constrained environments: challenges for the next decade

Eholié

Aoussi

Ouattara

et al. 2012

Journal of the International AIDS Society

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Many successes have been achieved in HIV care in low- and middle-income countries (LMIC): increased number of HIV-infected individuals receiving antiretroviral treatment (ART), wide decentralization, reduction in morbidity and mortality and accessibility to cheapest drugs. However, these successes should not hide existing failures and difficulties. In this paper, we underline several key challenges. First, ensure long-term financing, increase available resources, in order to meet the increasing needs, and redistribute the overall budget in a concerted way amongst donors. Second, increase ART coverage and treat the many eligible patients who have not yet started ART. Competition amongst countries is expected to become a strong driving force in encouraging the least efficient to join better performing countries. Third, decrease early mortality on ART, by improving access to prevention, case-finding and treatment of tuberculosis and invasive bacterial diseases and by getting people to start ART much earlier. Fourth, move on from WHO 2006 to WHO 2010 guidelines. Raising the cut-off point for starting ART to 350 CD4/mm3 needs changing paradigm, adopting opt-out approach, facilitating pro-active testing, facilitating task shifting and increasing staff recruitments. Phasing out stavudine needs acting for a drastic reduction in the costs of other drugs. Scaling up routine viral load needs a mobilization for lower prices of reagents and equipments, as well as efforts in relation to point-of-care automation and to maintenance. The latter is a key step to boost the utilization of second-line regimens, which are currently dramatically under prescribed. Finally, other challenges are to reduce lost-to-follow-up rates; manage lifelong treatment and care for long-term morbidity, including drug toxicity, residual AIDS and HIV-non-AIDS morbidity and aging-related morbidity; and be able to face unforeseen events such as socio-political and military crisis. An old African proverb states that the growth of a deep-rooted tree cannot be stopped. Our tree is well rooted in existing field experience and is, therefore, expected to grow. In order for us to let it grow, long-term cost-effectiveness approach and life-saving evidence-based programming should replace short-term budgeting approach.

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Section: Earlier Start Of Artmentioning

confidence: 99%

HIV treatment and care in resource‐constrained environments: challenges for the next decade

Eholié

Aoussi

Ouattara

et al. 2012

Journal of the International AIDS Society

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“…However, in 2009, only 53.5% of Ugandan adults with CD4 count below 250 cells/μL were receiving cART [14] and with the current WHO and National recommended ART eligibility criteria of CD4 count < 350 cell/μL [11,13],the coverage of ART drops to 47% [13]. Additionally, adoption of the 2010 revised WHO guidelines is expected to increase the number of patients on cART and the work load of HIV programs, and consequently increase costs associated with cART provision [15]. In general, the adoption of the WHO recommendations seems to be delayed in countries with relatively low health expenditure per capita and as well as low gross domestic product per capita, and costs associated with availability of cART is often cited as a reason for delayed initiation of cART [16].…”

Section: Introductionmentioning

confidence: 99%

Cost-effectiveness of early initiation of first-line combination antiretroviral therapy in Uganda

et al. 2012

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BackgroundUgandan national guidelines recommend initiation of combination antiretroviral therapy (cART) at CD4+ T cell (CD4) count below 350 cell/μl, but the implementation of this is limited due to availability of medication. However, cART initiation at higher CD4 count increases survival, albeit at higher lifetime treatment cost. This analysis evaluates the cost-effectiveness of initiating cART at a CD4 count between 250–350 cell/μl (early) versus <250 cell/μl (delayed).MethodsLife expectancy of cART-treated patients, conditional on baseline CD4 count, was modeled based on published literature. First-line cART costs $192 annually, with an additional $113 for patient monitoring. Delaying initiation of cART until the CD4 count falls below 250 cells/μl would incur the cost of the bi-annual CD4 count tests and routine maintenance care at $85 annually. We compared lifetime treatment costs and disability adjusted life-expectancy between early vs. delayed cART for ten baseline CD4 count ranges from 250-350 cell/μl. All costs and benefits were discounted at 3% annually.ResultsTreatment delay varied from 6–18 months. Early cART initiation increased life expectancy from 1.5-3.5 years and averted 1.33–3.10 disability adjusted life years (DALY’s) per patient. Lifetime treatment costs were $4,300–$5,248 for early initiation and $3,940–$4,435 for delayed initiation. The cost/DALY averted of the early versus delayed start ranged from $260–$270.ConclusionsIn HIV-positive patients presenting with CD4 count between 250-350 cells/μl, immediate initiation of cART is a highly cost-effective strategy using the recommended one-time per capita GDP threshold of $490 reported for Uganda. This would constitute an efficient use of scarce health care funds.

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Feasibility and benefits of scaling up antiretroviral treatment provision with the 2010 WHO antiretroviral therapy guidelines in rural Lesotho

Bygrave

Saranchuk

Makakole³

et al. 2012

International Health

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The latest WHO guidelines (2010) for antiretroviral therapy (ART) in adults and adolescents recommend that countries should progressively reduce the use of stavudine in favour of tenofovir or zidovudine and that ART initiation commence at an earlier CD4 threshold of <350 cell/mm(3). In Lesotho, a high-burden, resource-limited setting, these two changes had been recommended since late 2007. A number of practical steps were taken to support implementation of Lesotho's national ART guidelines at the program level including: development of guidelines tailored to nurses working in primary care settings; training and clinical mentorship of different levels of health care workers; laboratory support; pharmacy support; and monitoring and evaluation. Clinical and programmatic benefits included decreased mortality, toxicity, and simplified patient management that was supportive of the decentralized, nurse-led model of care. This experience demonstrates that, despite limited resources, it was feasible to provide a standard of care similar to that of western guidelines and that these changes were supportive of simplified patient management.

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Effect of changing antiretroviral treatment eligibility criteria on patient load in Kampala, Uganda

Cited by 8 publications

References 14 publications

HIV treatment and care in resource‐constrained environments: challenges for the next decade

HIV treatment and care in resource‐constrained environments: challenges for the next decade

Cost-effectiveness of early initiation of first-line combination antiretroviral therapy in Uganda

Feasibility and benefits of scaling up antiretroviral treatment provision with the 2010 WHO antiretroviral therapy guidelines in rural Lesotho

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