Sydney Rosen

Retention in HIV Care between Testing and Treatment in Sub-Saharan Africa: A Systematic Review

In this systematic review, Sydney Rosen and Matthew Fox find that less than one-third of patients who tested positive for HIV, but were not eligible for antiretroviral therapy (ART) when diagnosed, were retained in pre-ART care continuously.

Patient retention in antiretroviral therapy programs up to three years on treatment in sub-Saharan Africa, 2007-2009: systematic review

Objectives  To estimate the proportion of all‐cause adult patient attrition from antiretroviral therapy (ART) programs in service delivery settings in sub‐Saharan Africa through 36 months on treatment.

THE IMPACT OF HIV/AIDS ON LABOUR PRODUCTIVITY IN KENYA

Objectives  To estimate the impact of HIV/AIDS on individual labour productivity during disease progression.

Thresholds for the cost–effectiveness of interventions: alternative approaches

Abstract Many countries use the cost–effectiveness thresholds recommended by the World Health Organization’s Choosing Interventions that are Cost–Effective project (WHO-CHOICE) when evaluating health interventions. This project sets the threshold for cost–effectiveness as the cost of the intervention per disability-adjusted life-year (DALY) averted less than three times the country’s annual gross domestic product (GDP) per capita. Highly cost–effective interventions are defined as meeting a threshold per DALY averted of once the annual GDP per capita. We argue that reliance on these thresholds reduces the value of cost–effectiveness analyses and makes such analyses too blunt to be useful for most decision-making in the field of public health. Use of these thresholds has little theoretical justification, skirts the difficult but necessary ranking of the relative values of locally-applicable interventions and omits any consideration of what is truly affordable. The WHO-CHOICE thresholds set such a low bar for cost–effectiveness that very few interventions with evidence of efficacy can be ruled out. The thresholds have little value in assessing the trade-offs that decision-makers must confront. We present alternative approaches for applying cost–effectiveness criteria to choices in the allocation of health-care resources.

Why are antiretroviral treatment patients lost to follow-up? A qualitative study from South Africa.

Objectives  To better understand the reasons why patients default from antiretroviral treatment (ART) programmes to help design interventions that improve treatment retention and ultimately, patient outcomes.

Retention of Adult Patients on Antiretroviral Therapy in Low- and Middle-Income Countries: Systematic Review and Meta-analysis 2008–2013

Background:We previously published systematic reviews of retention in care after antiretroviral therapy initiation among general adult populations in sub-Saharan Africa. We estimated 36-month retention at 73% for publications from 2007 to 2010. This report extends the review to cover 2008–2013 and expands it to all low- and middle-income countries. Methods:We searched PubMed, Embase, Cochrane Register, and ISI Web of Science from January 1, 2008, to December 31, 2013, and abstracts from AIDS and IAS from 2008–2013. We estimated retention across cohorts using simple averages and interpolated missing times through the last time reported. We estimated all-cause attrition (death, loss to follow-up) for patients receiving first-line antiretroviral therapy in routine settings in low- and middle-income countries. Results:We found 123 articles and abstracts reporting retention for 154 patient cohorts and 1,554,773 patients in 42 countries. Overall, 43% of all patients not retained were known to have died. Unweighted averages of reported retention were 78%, 71%, and 69% at 12, 24, and 36 months, after treatment initiation, respectively. We estimated 36-month retention at 65% in Africa, 80% in Asia, and 64% in Latin America and the Caribbean. From lifetable analysis, we estimated retention at 12, 24, 36, 48, and 60 months at 83%, 74%, 68%, 64%, and 60%, respectively. Conclusions:Retention at 36 months on treatment averages 65%–70%. There are several important gaps in the evidence base, which could be filled by further research, especially in terms of geographic coverage and duration of follow-up.

Strategies to improve patient retention on antiretroviral therapy in sub‐Saharan Africa

The scale‐up of antiretroviral therapy (ART) has been one of the success stories of sub‐Saharan Africa, where coverage has increased from about 2% in 2003 to more than 40% 5 years later. However, tempering this success is a growing concern about patient retention (the proportion of patients who are alive and remaining on ART in the health system). Based on the personal experience of the authors, 10 key interventions are presented and discussed that might help to improve patient retention. These are (1) the need for simple and standardized monitoring systems to track what is happening, (2) reliable ascertainment of true outcomes of patients lost to follow‐up, (3) implementation of measures to reduce early mortality in patients both before and during ART, (4) ensuring uninterrupted drug supplies, (5) consideration of simple, non‐toxic ART regimens, (6) decentralization of ART care to health centres and the community, (7) a reduction in indirect costs for patients particularly in relation to transport to and from clinics, (8) strengthening links within and between health services and the community, (9) the use of ART clinics to deliver other beneficial patient or family‐orientated packages of care such as insecticide‐treated bed nets, and (10) innovative (thinking ‘out of the box’) interventions. High levels of retention on ART are vital for individual patients, for credibility of programmes and for on‐going resource and financial support.

Early loss to follow up after enrolment in pre-ART care at a large public clinic in Johannesburg, South Africa

Objective  To estimate loss to follow up (LTFU) between initial enrolment and the first scheduled return medical visit of a pre‐antiretroviral therapy (ART) care program for patients not eligible for ART.

The private sector and HIV/AIDS in Africa: taking stock of 6 years of applied research.

Background:Until recently, little was known about the costs of the HIV/AIDS epidemic to businesses in Africa or about business responses to the epidemic. This paper synthesizes the results of a set of studies conducted between 1999 and 2006. Methods:Data for the studies included were drawn from human resource, financial, and medical records of 16 large companies and from 7 surveys of small, medium-sized, and large companies in South Africa, Uganda, Kenya, Zambia, Ethiopia, and Rwanda. Results:Estimated workforce HIV prevalence ranged from 5 to 37%. The average cost per employee lost to AIDS varied from 0.5 to 5.6 times the average annual compensation of the employee affected. Labor cost increases were estimated at 0.6–10.8% but exceeded 3% at only two of 14 companies. Antiretroviral treatment at a cost of US

The Impact and Cost of Scaling up GeneXpert MTB/RIF in South Africa

360/patient per year was found to have positive financial returns for most but not all companies. Managers of small and medium-sized enterprises (SME) reported low AIDS-related employee attrition, little concern about the impacts of AIDS, and relatively little interest in taking action. AIDS was estimated to increase the average operating costs of SME by less than 1%. Conclusion:For most companies, AIDS is causing a moderate increase in labor costs, with costs determined mainly by HIV prevalence, employee skill level, and employment policies. Treatment of HIV-positive employees is a good investment for many large companies. Small companies have less capacity to respond to workforce illness and little concern about it. Research on the effectiveness of workplace interventions is needed.