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COST-EFFECTIVENESS OF EARLY VERSUS ANTIRETROVIRAL THERAPY

Thursday, 29th of September 2011

• COST-EFFECTIVENESS OF EARLY VERSUS STANDARD ANTIRETROVIRAL THERAPY

 Full text is at http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001095

 Serena P. Koenig1, Heejung Bang2, Patrice Severe3, Marc Antoine Jean Juste3, Alex Ambroise3, Alison

Edwards2, Jessica Hippolyte3, Daniel W. Fitzgerald4, Jolion McGreevy3, Cynthia Riviere3, Serge

Marcelin3, Rode Secours3, Warren D. Johnson4, Jean W. Pape3,4, Bruce R. Schackman2*

1 Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America, 2 Department of Public Health, Weill Cornell Medical

College, New York, New York, United States of America, 3 Groupe Haitien d’Etude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO), Port au Prince, Haiti,

4 Department of Medicine, Weill Cornell Medical College, New York, New York, United States of America

 

Abstract

Background: In a randomized clinical trial of early versus standard antiretroviral therapy (ART) in HIV-infected adults with a CD4 cell count between 200 and 350 cells/mm3 in Haiti, early ART decreased mortality by 75%. We assessed the costeffectiveness

of early versus standard ART in this trial.

 

Methods and Findings: Trial data included use of ART and other medications, laboratory tests, outpatient visits, radiographic studies, procedures, and hospital services. Medication, laboratory, radiograph, labor, and overhead costs were from the study clinic, and hospital and procedure costs were from local providers. We evaluated cost per year of life saved (YLS), including patient and caregiver costs, with a median of 21 months and maximum of 36 months of follow-up, and with costs and life expectancy discounted at 3% per annum. Between 2005 and 2008, 816 participants were enrolled and followed for a median of 21 months. Mean total costs per patient during the trial were US$1,381 for early ART and US$1,033 for standard ART. After excluding research-related laboratory tests without clinical benefit, costs were US$1,158 (early ART) and US$979 (standard ART). Early ART patients had higher mean costs for ART (US$398 versus US$81) but lower costs for non-ART medications, CD4 cell counts, clinically indicated tests, and radiographs (US$275 versus US$384). The costeffectiveness ratio after a maximum of 3 years for early versus standard ART was US$3,975/YLS (95% CI US$2,129/YLS–US$9,979/YLS) including research-related tests, and US$2,050/YLS excluding research-related tests (95% CI US$722/YLS–

US$5,537/YLS).

 

Conclusions: Initiating ART in HIV-infected adults with a CD4 cell count between 200 and 350 cells/mm3 in Haiti, consistent with World Health Organization advice, was cost-effective (US$/YLS ,3 times gross domestic product per capita) after a maximum of 3 years, after excluding research-related laboratory tests.

 

• MEETING CHOLERA'S CHALLENGE TO HAITI AND THE WORLD: A JOINT STATEMENT ON CHOLERA PREVENTION AND CARE

Full text, with graphics, is at http://www.plosntds.org/article/info%3Adoi%2F10.1371%2Fjournal.pntd.0001145

Paul Farmer1,2,3*, Charles Patrick Almazor4, Emily T. Bahnsen1,3, Donna Barry2,3, Junior Bazile4, Barry R. Bloom5, Niranjan Bose6, Thomas Brewer6, Stephen B. Calderwood7,8,9, John D. Clemens10, Alejandro Cravioto11, Eddy Eustache4, Gregory Jérôme4, Neha Gupta1, Jason B. Harris9,12, Howard H. Hiatt1,2, Cassia Holstein1,3, Peter J. Hotez13,14,15,16, Louise C. Ivers1,2,3, Vanessa B. Kerry1,17, Serena P. Koenig1,2,3, Regina C. LaRocque9, Fernet Léandre3,4, Wesler Lambert4, Evan Lyon3, John J. Mekalanos8, Joia S. Mukherjee1,2,3, Cate Oswald4, Jean-William Pape18,19, Anany Gretchko Prosper4, Regina Rabinovich6, Maxi Raymonville4, Jean-Renold Réjouit4, Laurence J. Ronan17, Mark L. Rosenberg20, Edward T. Ryan7,9,21, Jeffrey D. Sachs22, David A. Sack23, Claude Surena24, Arjun A. Suri1, Ralph Ternier4, Matthew K. Waldor25, David Walton1,2,3, Jonathan L. Weigel1,3

1 Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America, 2 Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America, 3 Partners In Health, Boston, Massachusetts, United States of America, 4 Zanmi Lasante (Partners In Health), Cange, Haiti, 5 Harvard School of Public Health, Boston, Massachusetts, United States of America, 6 Global Health Program, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America, 7 Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America, 8 Department of Microbiology and Molecular Genetics, Harvard Medical School, Boston, Massachusetts, United States of America, 9 Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America, 10 International Vaccine Institute, Seoul, Korea, 11 International Centre for Diarrhoeal Disease Research (ICDDR,B), Dhaka, Bangladesh, 12 Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America, 13 American Society of Tropical Medicine & Hygiene, Deerfield, Illinois, United States of America, 14 Department of Microbiology, Immunology and Tropical Medicine, The George Washington University, Washington, D.C., United States of America, 15 PLoS Neglected Tropical Diseases, San Francisco, California, United States of America, 16 Sabin Vaccine Institute, Washington, D.C., United States of America, 17 Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, United States of America, 18 Center for Global Health, Weill Cornell Medical College, New York, New York, United States of America, 19 GHESKIO Centre, Port-au-Prince, Haiti, 20 The Task Force for Global Health, Decatur, Georgia, United States of America, 21 Tropical & Geographic Medicine Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America, 22 The Earth Institute, Columbia University, New York, New York, United States of America, 23 Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America, 24 Haitian Medical Association, Port-au-Prince, Haiti, 25 Channing Laboratory, Brigham and Women's Hospital/Harvard Medical School and HHMI, Boston, Massachusetts, United States of America

Citation: Farmer P, Almazor CP, Bahnsen ET, Barry D, Bazile J, et al. (2011) Meeting Cholera's Challenge to Haiti and the World: A Joint Statement on Cholera Prevention and Care. PLoS Negl Trop Dis 5(5): e1145. doi:10.1371/journal.pntd.0001145

Editor: Pamela L. C. Small, University of Tennessee, United States of America

Published: May 31, 2011

Copyright: © 2011 Farmer et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: No specific funding was received for this work.

Competing interests: The authors have declared that no competing interests exist. The views and opinions contained in this paper reflect those of the authors alone and should in no way be construed to represent the official position of any organization or agency for which they work or to which they belong.

* E-mail: paul_farmer@hms.harvard.edu

Executive Summary

This joint statement argues for a comprehensive, integrated cholera response in Haiti. The cholera epidemic in Haiti is particularly devastating because of the vulnerability of Haiti's population after the January 12, 2010, earthquake, the long-standing weakness of its health, water, and sanitation systems, and the observed virulence of the El Tor hybrid strain. From October 19, 2010—when the first cases were confirmed in the National Public Health Laboratory—to April 4, 2011, 274,418 cases of cholera and 4,787 deaths related to cholera had been reported across all ten departments of Haiti [1].

The Haitian Ministère de la Santé Publique et de la Population (MSPP, the Ministry of Health) and the Direction Nationale de l'Eau Potable et de l'Assainissement (DINEPA, the government body charged with water and sanitation) have, with the support of many nongovernmental and international groups, made great strides against cholera. Case-fatality rates have dropped to 2.1% from 7% at the outset of the epidemic (and up to 10% in certain regions); incidence has also declined across Haiti, according to recent reports [1]. But fewer cases in the dry season (November–April) should not lead to complacency: seasonal variation is expected in epidemics of waterborne disease. Some have raised doubts about the sustainability of free water distribution within internally displaced persons (IDP) camps. But we believe that such efforts are an essential service that has contributed to the relatively few cases of cholera in the camps (as compared to other urban and rural areas).

Given the likelihood of case resurgence and endemicity of cholera in Haiti, this document argues for a comprehensive, integrated strategy for cholera prevention and care in Haiti. We must reduce suffering and preventable death in the short term, and we must build effective water, sanitation, and health delivery infrastructure to fortify Haiti against cholera and other diseases of poverty in the long term.

The document identifies three principal goals. First, we must continue aggressive case finding and scale up treatment efforts, including oral rehydration therapy, intravenous rehydration, antibiotic therapy (for moderate and severe cases), and complementary supplementation with zinc and vitamin A. Second, we must shore up Haiti's water infrastructure by building systems for consistent chlorination and filtration at public water sources and by distributing point-of-use water purification technologies. We must also strengthen sanitation infrastructure by improving and expanding waste management facilities (such as sewage systems and latrines) and waste monitoring. Third, we must link prevention to care by bolstering surveillance, education campaigns (about hand-washing, for example), and water, sanitation, and hygiene (WASH) efforts. Prevention must also include advocacy for scaled-up production of cholera vaccine and the development of a vaccine strategy for Haiti. A vaccination campaign should be implemented if adequate vaccine and resources can be mobilized without undermining efforts to treat acutely ill patients or strengthen water and sanitation infrastructure.

This document identifies key challenges and outlines the components of a comprehensive cholera response to aid medical and public health practitioners in Haiti and elsewhere. With leadership from the Haitian government, we must work together to bolster responses to the acute problem of cholera today and strengthen Haiti's health, water, and sanitation infrastructure to prevent similar outbreaks in the future.