Douglas J. McCready

Effect of selenium supplementation on CD4 T-cell recovery, viral suppression, morbidity and quality of life of HIV-infected patients in Rwanda: study protocol for a randomized controlled trial

BackgroundLow levels of serum selenium are associated with increased risk of mortality among HIV+ patients in East Africa. We aim to assess the effect of selenium supplementation on CD4 cell count, HIV viral load, opportunistic infections, and quality of life in HIV-infected patients in Rwanda.Methods and DesignA 24-month, multi-centre, patient and provider-blinded, randomized, placebo-controlled clinical trial involving 300 pre-antiretroviral therapy (ART) HIV-infected patients will be carried out at two sites in Rwanda. Patients ≥ 21 years of age with documented HIV infection, CD4 cell count of 400-650 cells/mm3, and not yet on ART will be recruited. Patients will be randomized at each study site using a randomized block design to receive either the selenium micronutrient supplement or an identically appearing placebo taken once daily. The primary outcome is a composite of time from baseline to reduction of CD4 T lymphocyte count below 350 cells/mm3 (confirmed by two measures at least one week apart), or start of ART, or the emergence of a documented CDC-defined AIDS-defining illness. An intention-to-treat analysis will be conducted using stepwise regression and structural equation modeling.DiscussionMicronutrient interventions that aim to improve CD4 cell count, decrease opportunistic infections, decrease HIV viral load, and ultimately delay initiation of more costly ART may be beneficial, particularly in resource-constrained settings, such as sub-Saharan Africa. Additional trials are needed to determine if micro-supplementation can delay the need for more costly ART among HIV-infected patients. If shown to be effective, selenium supplementation may be of public health importance to HIV-infected populations, particularly in sub-Saharan Africa and other resource-constrained settings.Trial RegistrationNCT01327755

Costing and Pricing of Police Services

Examines the principles which underlie the costing of police services when these services do not fit the rubric of being purely “public” goods. In such instances, it is necessary to determine a unit cost for charging a user fee. As the unit price (marginal cost) of the goods is charged, either across the agency or to outsiders who purchase the service, efficiency in terms of appropriate allocation of resources is enhanced. Also, the police board is then in a better position to argue for funding for those services which contain a greater degree of “publicness”, since the benefits of these remaining police services clearly have some element of indivisibility, and thus benefit society rather than individuals.

Funding human services: fixed utility versus fixed budget.

It is argued in this paper that government allocations for human services based on inputs rather than outcomes, reduce efficiency in social and health service provision. An alternative system of budgeting or contracting on the basis of cost-per-closed case and case outcome is discussed. An interdependency between fixed budget and fixed utility models of allocation is affirmed. The locus of decision-making for operationalizing this interdependency is seen as the program and budget review panel to which operating agencies and government departments must submit financial and program accounting information from year to year. In isolation, the fixed budget approach degenerates into routine allocation or contract renewal with a focus on such input and output variables as volume of service and unit cost, and the fixed utility approach, into political stalemate. Simulated examples are given to demonstrate how allocation on the basis of inputs and outputs alone provides an incentive to inefficiency, and a fixed utility orientation to efficiency.