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AbstractThe advent of effective treatments for HIV has begun a new era in the worldwide HIV epidemic. Many new political, social, economic, medical, and psychological issues arise in the struggle to contain this epidemic. Mental health providers must understand the context in which people with HIV find themselves making decisions about their health care and the future directions of their lives.

Despite the recent international effort to expand access to highly active antiretroviral therapy (HAART) in developing countries, its coverage still varies significantly from country to country and is strongly correlated with per capita income. However, regional and political variables are also important. Cross-country regressions indicate that, controlling for political and economic characteristics and the scale of the HIV epidemic, Latin American and African countries have better coverage than predicted. Whereas the level of HIV prevalence was a significantly (negative) factor when accounting for HAART coverage in June 2004, this effect had disappeared by December 2004. The improvement appears to have benefited democratic countries in particular.

Despite unprecedented international mobilisation to support universal provision of highly active antiretroviral therapy (HAART), national governments continue to play the key role in determining access to treatment. Whereas some AIDS-affected countries have performed as well as or better than expected given their level of development, institutional characteristics and demographic challenges (e.g. Thailand and Brazil), others (notably South Africa) have not. This article argues that the 'economics' of antiretroviral drug delivery is at heart a political-economy of access to treatment. It depends on commitment on the part of national governments to negotiate with pharmaceutical companies over patented antiretroviral drug prices, on their policy towards compulsory licensing, and on the approach they adopt to delivering HAART. Civil society has an important role to play in encouraging governments to become, and remain, committed to taking action to ensure sustainable and widespread access to HAART.

7‐11 November 2010, Tenth International Congress on Drug Therapy in HIV Infection, Glasgow, UK

South African AIDS policy has long been characterised by suspicion on the part of President Mbeki and his Health Ministers towards antiretroviral therapy.1,2 The Minister of Health, Manto Tshabalala-Msimang, resisted the introduction of antiretrovirals for mother-to-child transmission prevention (MTCTP) until forced to do by a Constitutional Court ruling – and she resisted the introduction of highly active antiretroviral therapy (HAART) for AIDS-sick people until a cabinet revolt in late 2003 forced her to back down on this too. Since then, the public sector rollout of HAART has gained momentum, but it has been uneven across the provinces and continues to be constrained by a marked absence of political will at high levels.

BACKGROUND:While South Africa spends approximately 7.4% of GDP on healthcare, only 43% of these funds are spent in the public system, which is tasked with the provision of care to the majority of the population including a large proportion of those in need of antiretroviral treatment (ART). South Africa is currently debating the introduction of a National Health Insurance (NHI) system. Because such a universal health system could mean increased public healthcare funding and improved access to human resources, it could improve the sustainability of ART provision. This paper considers the minimum resources that would be required to achieve the proposed universal health system and contrasts these with the costs of scaled up access to ART between 2010 and 2020. METHODS: The costs of ART and universal coverage (UC) are assessed through multiplying unit costs, utilization and estimates of the population in need during each year of the planning cycle. Costs are from the provider's perspective reflected in real 2007 prices. RESULTS: The annual costs of providing ART increase from US$1 billion in 2010 to US$3.6 billion in 2020. If increases in funding to public healthcare only keep pace with projected real GDP growth, then close to 30% of these resources would be required for ART by 2020. However, an increase in the public healthcare resource envelope from 3.2% to 5%-6% of GDP would be sufficient to finance both ART and other services under a universal system (if based on a largely public sector model) and the annual costs of ART would not exceed 15% of the universal health system budget. CONCLUSIONS: Responding to the HIV-epidemic is one of the many challenges currently facing South Africa. Whether this response becomes a "resource for democracy" or whether it undermines social cohesiveness within poor communities and between rich and poor communities will be partially determined by the steps that are taken during the next ten years. While the introduction of a universal system will be complex, it could generate a health system responsive to the needs of all South Africans.

In August 2003, the South African government announced its support for the provision of highly active antiretroviral therapy (HAART) in the public sector. This was a major break-through (antiretrovirals are now explicitly recognised as beneficial) but the Cabinet statement was very cautiously worded about actual implementation. The Ministry of Health has been instructed to develop a 'detailed operational plan' but it is increasingly clear that one of the major constraints on the scale and pace of the roll-out will be the amount of resources allocated to it. Given the discourse of 'unaffordability' which has dogged South African AIDS policy making over the past five years (Nattrass, 2004 forthcoming) it is likely that South Africa will opt for a limited intervention on the grounds that resources are best spent elsewhere.

Published Article ; In response to the Human Immunodeficiency Virus (HIV) epidemic in the country, the South African Government started with the provisioning of Antiretroviral Therapy (ART) in the public health sector. Monitoring and evaluating the effectiveness of the ART programme is of the utmost importance. The current patient information system could not supply the required information to manage the rollout of the ART programme. A data warehouse, consisting of several data marts, was developed that integrated several disparate systems related to HIV/AIDS/ART into one system. It was, however, not possible to trace a patient across all the data marts in the data warehouse. No unique identifiers existed for the patient records in the different data marts and they also had different structures. Record linkage in conjunction with a mapping process was used to link all the data marts and in so doing identify the same patient in all the data marts. This resulted in a longitudinal patient record of an ART patient that displayed all the treatments received by the patient in all public health care facilities in the province.

AbstractIntroductionSignificant gaps persist in providing HIV treatment to all who are in need. Restricting care delivery to healthcare facilities will continue to perpetuate this gap in limited resource settings. We assessed a large‐scale community‐based programme for effectiveness in identifying people living with HIV and linking them to antiretroviral treatment.MethodsA retrospective secular trend study of 14 high burden local government areas of Nigeria was conducted in which two models of community antiretroviral treatment delivery were implemented: Model A (on‐site initiation) and Model B (immediate referral) clusters. Model A cluster offered services within communities, from HIV diagnosis to immediate antiretroviral therapy initiation and some follow‐up. Model B cluster offered services for HIV diagnosis up to baseline evaluation and provided referral for antiretroviral therapy initiation to nearest health facility providing HIV services. For controls, we selected and cluster‐matched 34 local government areas where community antiretroviral treatment delivery was not implemented. Outcomes of interest were: the number of people identified as HIV positive and the number of HIV‐positive individuals started on antiretroviral treatment; from June 2014 to May 2016. We used interrupted time‐series analysis to estimate outcome levels and trends across the pre‐and post‐intervention periods.ResultsBefore community antiretrovial treatment introduction, Model A cluster identified, per 100,000 catchment population, 500 HIV‐positives (95% CI: 399.66 to 601.41) and initiated 216 HIV‐positives on antiretroviral treatment (95% CI: 152.72 to 280.10). Model B cluster identified 32 HIV‐positives (95% CI: 25.00 to 40.51) and initiated 8 HIV‐positives on antiretroviral treatment (95% CI: 5.54 to 10.33). After commART introduction, Model A cluster showed an immediate significant increase in 744 HIV‐positive persons (p = 0.00, 95% CI: 360.35 to 1127.77) and 560 HIV‐positives initiated on treatment (p = 0.00, 95% CI: 260.56 to 859.64). Model B cluster showed an immediate significant increase in 30 HIV‐positive persons identified (p = 0.01, 95% CI: 8.38 to 51.93) but not in the number of HIV‐positives initiated on treatment. Model B cluster showed increased month‐on‐month trends of both outcomes of interest (3.4, p = 0.02, 95% CI: 0.44 to 6.38).ConclusionBoth community‐models had similar population‐level effectiveness for rapidly identifying people living with HIV but differed in effectively transitioning them to treatment. Comprehensiveness, integration and attention to barriers to care are important in the design of community antiretroviral treatment delivery.