Funder

United States Agency for International Development

United States Agency for International Development

Established by President John F. Kennedy in November 1961, the United States Agency for International Development (USAID) is a United States federal government agency that provides long-term support for developing countries. USAID provides assistance in the following focus regions: sub-Saharan Africa; Asia; Latin America and the Caribbean; Europe and Eurasia; and the Middle East.

USAID funds HE2RO’s Innovations Research on AIDS (INROADS) program which is a five year program running from October 2012 to September 2017. The purpose of the program is to promote innovation to improve patient outcomes in support of the South African National Strategic Plan on HIV, STIs and TB 2012-2016 (NSP). The framework for INROADS is based on NSP Strategic Objective 3, which aims to reduce deaths and disability from HIV and TB through universal access to diagnosis, care and treatment. By using the NSP as a guide for identifying priority activities, this framework ensures that program results will be relevant and useful to the South African Government (SAG), as well as to PEPFAR and other stakeholders.

www.usaid.gov

Projects

  • Assessing the Impact of Integration of HIV and TB Services into Primary Health Services in the Public Sector in South Africa: An Evaluation of Resource Utilisation at Facility Level

    Early in the HIV epidemic, in South Africa and other low income countries, HIV and TB services were provided in vertical programs as a result of disease-specific funding or approaches to service provision. Provision of separate services for specific health problems or specialisation usually means that patients need to visit separate and specialised clinics for their different health problems or needs, and can result in “missed opportunities” for service provision, fragmented and 
  • Retrospective Cost-Effectiveness Analysis for Nurse Initiated and Managed Antiretroviral Treatment for HIV/AIDS in South Africa

    In HIV/AIDS treatment programs in resource-constrained settings, one response to a shortage of doctors and other highly trained healthcare providers is “task-shifting” from doctors to less trained clinicians, such as nurses and community healthcare workers. In 2010, South Africa issued new guidelines for its antiretroviral treatment (ART) program to allow senior nurses to initiate and manage adult ART patients at primary health clinics. This policy, known as NIMART (Nurse Initiated and 
  • Attrition from HIV Care and Treatment Before and After an Increase in the CD4 Count Eligibility Threshold

    South Africa has recently announced that as of January 2015, it will be increasing its HIV treatment CD4 eligibility threshold from 350 cells/μl to 500 cells/μl1 making more patients eligible for treatment than ever before. However efforts to increase HIV treatment coverage may be minimized if losses to follow up, which have been shown to be high along the continuum of HIV care, offset gains from getting more people onto treatment. HE2RO will conduct a prospective cohort study of adult 
  • A Cost Description of HIV Counselling and Testing (HCT) Models in South Africa

    South Africa’s National Strategic Plan for 2011-2016 (NSP) aims to see a halving of HIV incidence over this period, and a realisation of 80% HIV treatment coverage, or 3 million patients on antiretroviral therapy (ART). The realisation of these goals relies on increased and equitable access to and uptake of HIV Counselling and Testing (HCT). Achieving sustained high levels of HCT in turn requires accurate cost data from which budgeting decisions can be extrapolated. Although a number of 
  • Establishing a Package of SRH Services for HIV-Positive and Negative Women

    South Africa has extensive guidelines and policies regarding the provision of sexual and reproductive (SRH) services; however, there are limited, if any, resources available which provide guidance on the current costs of service provision and the potential costs given new policy goals for increasing access. HE2RO staff are engaging policymakers at the national and provision level to establish a clearer understanding of SRH funding in the country and goals for shifting and/or scaling up access. 
  • Contraceptive Service Delivery

    South Africa recently launched new guidelines for contraceptive provision and approved the contraceptive implant for use in the country. The new guidelines provide targets for shifting the contraceptive method mix and increasing contraceptive prevalence over time. Integrated primary health care requires that patients are able to access all primary health services, including contraceptive services, at one facility. Dedicated HIV facilities have not historically offered these services, but there 
  • Managing Breast Conditions, Including Breast Cancer

    Breast cancer is the most common cancer among women worldwide. It also affects men. However, breast cancer is just one of many breast conditions which may require diagnosis and treatment. Access to comprehensive breast care services is extremely limited in South Africa. Further, little information exists as to the prevalence and epidemiology of breast masses in HIV-infected women and men across the country. HE2RO is partnering with the Breast Care Clinic at Helen Joseph Hospital, Right To Care 
  • Approaches for Diagnosis and Treatment of Sexually Transmitted Infections (STIs)

    South African guidelines call for syndromic management of most STIs, including HPV. With this approach, symptomatic individuals are given treatment for a diagnosed “syndrome” rather than a specific pathogen. Although this approach is recommended for low-resourced settings, the frequent lack of any or specific symptoms in women infected with (an) STI(s) may lead to over or under treatment and continued transmission of STIs and HIV. New technologies, including point-of-care diagnostics, may 
  • Costs and Cost Effectiveness of Alternatives for Cervical Cancer Screening and Treatment

    Cervical cancer is one of the most common cancers among women worldwide. Most is caused by persistent infection with high-risk human papillomavirus (HPV). Recent research shows that HIV is a major risk factor for both HPV infection and progression to cervical cancer. In South Africa, where HIV prevalence is high, HPV infection and cervical cancer are significant public health challenges. Scarcity of service delivery capacity in rural communities and specialist services in urban communities 
  • An Evaluation of an Automated Dispensing System for Pharmaceutical Services

    In both developed and developing countries, pharmaceutical management is a critical issue due to escalating health care costs and increased pressure to improve access to services. The past few decades have seen the role of pharmacy staff expanding. For example, in many resource limited settings burdened by HIV, the complexity of HIV-related medication, the increased life span of HIV-positive patients that comes with antiretrovirals, and the comorbidity of HIV/AIDS with other diseases has 
  • An Evaluation of the Acceptability and Feasibility of Booked Appointments in a Large HIV Clinic in Johannesburg, South Africa

    In many resource-limited settings, health care delivery systems face constraints due to increasing need for health expenditure and the large proportion of the population reliant on the public sector. In South Africa, the existing service delivery structure faces additional challenges related to the growing number of HIV-infected South Africans initiating antiretroviral therapy. Long queues, long wait times, and overcrowding are often characteristic of South Africa’s public health care 
  • Research Capacity Building

    Alongside its own research, HE2RO is committed to building capacity to conduct applied public health research in South Africa and neighboring countries.  The main disciplines that inform HE2RO’s own work are also the fields in which we provide training:  health economics, epidemiology, and program evaluation.  Our capacity building activities include formal training through short courses and degree program courses and on-the-job mentoring through fellowships and post-doctoral 
  • HIV Treatment Outcomes and Guidelines

    South Africa’s national antiretroviral therapy (ART) treatment program, the largest in the world with roughly 2.4 million people on treatment, has made substantial impact on reducing morbidity and mortality for HIV-infected people. As the national program matures, it faces significant challenges in expanding access to harder to reach populations while also maintaining quality of care for those for whom HIV has become a manageable chronic disease, including treatment fatigue, resistance 
  • Mentoring Opportunities

    For students and graduates with training in economics, epidemiology, or a related field, HE2RO has post-graduate internships, master’s level fellowships, and doctoral and post-doctoral opportunities.  Candidates work on HE2RO projects while also furthering their own research and learning from senior researchers in their fields.  For additional information about honour’s and master’s level fellowships, click here.  Doctoral and post-doctoral candidates should contact us directly at 
  • Development of Degree Program In Health Economics

    HE2RO is working with the School of Economics and Business Studies at Wits University to develop modules in health economics for honours and master’s students.  These courses are not yet offered, but it is still possible for Wits students to conduct thesis or project work with HE2RO.  If you are interested in this possibility, please contact us at 
  • Short Courses

    Each year, HE2RO offers a set of 3-5 day short courses aimed at program implementers, decision makers, and other researchers.  In 2014, courses included introductory and advanced epidemiology, program evaluation, and cost and cost-effectiveness analysis.  If you are interested in participating in a HE2RO course, please click here for details on the coming year’s 
  • Supporting the South African HIV/TB Investment Case

    Since 2011, UNAIDS and other international organisations have prompted countries to counter the downward trend in international funding for HIV programmes by developing an investment case for their national HIV responses. These cases aim to maximise the impact of programmes on HIV incidence and deaths by correcting any mismatch between the epidemic and the response, identifying how to go to the required scale and maintain it, cutting unnecessary costs and diversions of capacity while generating 
  • Analysing the Impact and Cost of Scaling up Xpert MTB/RIF Technology for TB Diagnosis: The National TB Cost Model (NTCM)

    In the South African context, smear microscopy and other conventional TB diagnostic technologies that have been used for decades, are no longer reliable, because many HIV-positive tuberculosis patients are smear-negative, and the long time to diagnosis means that many patients die without having started TB treatment. In December 2010 the GeneXpert System using the Xpert MTB/RIF assay received a strong recommendation from the World Health Organization as the initial test in individuals with HIV 
  • Building HIV Financial Planning and Budgeting Capacity at Provincial Level: The FIN-CAP Project

    While treatment guidelines and the overall funding envelope for antiretroviral treatment in South Africa are decided at the level of the national department of health, the implementation of programmes is the responsibility of each of the nine provinces. In the past, implementation was jeopardized by the lack of capacity for financial planning, expenditure tracking and performance monitoring at the level of provincial HIV and finance managers. The FIN-CAP project, implemented by staff from 
  • Modelling the Cost of the National ART Programme under Different Sets of Guidelines: The National ART Cost Model (NACM) and the Treatment as Prevention Cost Model (TasP Cost Model)

    On request of the South African Department of Health (NDoH), since 2009 HE2RO has used the detailled cost and outcomes data collected in other projects to develop mathematical models projecting the size of the treatment cohort under different scenarios of antiretroviral treatment (ART eligibility as well as the resulting costs). Our budget models, most notably the National ART Cost Model (NACM) and the Treatment as Prevention Cost Model (TasP Cost Model), have contributed to several sets of 
  • Financial Management at Primary Health Care Facilities

    Primary health care (PHC) clinics in South Africa often struggle to reach acceptable population coverage and treatment outcomes due to insufficient financial resources. One reason for this appears to be that prospective budgets for clinics are often underestimated, and needed resources are not requested in a timely manner. In order to provide adequate resources to clinics, provincial officials require information on service costs and projected service delivery volumes. However, in South Africa 
  • MHealth to Improve Community Health Worker Performance

    As part of the reengineering of primary health care in South Africa, the National Department of Health (NDoH) has prioritized the development of Ward-Based Outreach Teams (WBOTs) comprised of one nurse (the Team Leader) and 4 – 10 community health workers (CHWs). Each WBOT serves the population of an average administrative ward (~2,000 households); team CHWs provide home-based care and connect patients to clinics through referrals. During the next few years, the Anova Health Institute (Anova) 
  • Evaluation of a Standardized Treatment Regimen of Anti-Tuberculosis Drugs for Patients with MDR-TB (STREAM): Economic Evaluation at Sizwe Tropical Diseases Hospital

    Despite the widespread availability of an efficacious and affordable regimen and strategy for managing drug-susceptible tuberculosis (TB), the emergence of multidrug resistant (MDR) TB remains a major challenge for global TB control efforts. In 2010, data from Bangladesh indicated that a nine-month regimen achieves outcomes comparable to those of the existing, 18-24 month, WHO-approved MDR-TB regimen. The primary objective of the STREAM trial is to assess whether the Bangladesh regimen is 
  • Analysis of Drug Resistant Tuberculosis Population and Outcomes in South Africa, using the Electronic Drug Resistant Tuberculosis Register (EDRWeb)

    The South African Electronic Drug Resistant Tuberculosis Register (EDRWeb) is a national reporting database. We propose a retrospective analysis of this de-identified, established database of routinely reported patient-level data to describe the population and outcomes of drug-resistant TB as recorded within the EDRweb in order to inform treatment guidelines and practice for South Africa. Operational implementation across a broad number of sites is likely to differ from cohorts at 
  • The Costs and Outcomes of Paediatric Tuberculosis Treatment at Primary Health Clinics in Johannesburg, South Africa

    In South Africa, little up-to-date information is available about the costs of providing TB treatment to any population, and no information was found on the costs of providing TB treatment to a paediatric population. Despite the significant burden from paediatric TB, analysis of patient characteristics, contacts, and method of diagnosis is limited. The proposed study aims to begin to fill the information gap by generating descriptive analysis of the cost-outcomes of paediatric treatment for TB 
  • The Costs and Outcomes of Tuberculosis Treatment at Primary Health Care Clinics in an Urban Township, South Africa

    The actual implementation of DOTS across South Africa varies widely. Implementation of DOTS may differ between the intensive phase of treatment (first 2-3 months, with daily injections for the retreatment regimen and a 4-drug fixed combination pill for both first-line regimens) and the continuation phase of treatment (consisting of a daily, 2-drug fixed combination pill). In either phase, the treatment supervisor may be a nurse or counselor at a healthcare facility, a lay healthworker from the 
  • Adverse Events of Treatment in a Decentralized Drug-Resistant Tuberculosis Clinic in Johannesburg, South Africa

    The overall aim of this study is to review adverse events of decentralized, ambulatory drug-resistant TB (DR-TB) among a high proportion of rifampicin monoresistant TB patients at an outpatient specialized clinic in Johannesburg, South Africa. The study is a retrospective study and differs in two significant ways from previous studies of DR-TB in South Africa.  Firstly, a large proportion of the patients receiving decentralized care have rifampicin mono-resistant TB. All the previous studies 
  • Costs and Outcomes Analysis of Decentralized, Deinstitutionalized Drug-Resistant Tuberculosis Management at a Johannesburg Hospital

    The overall aim of this medical record review observational cohort study is to analyse the cost and outcomes of decentralized, deinstitutionalized drug-resistant TB (DR-TB) management at an outpatient specialized clinic in Johannesburg. In August 2011, the South African National Department of Health adopted guidelines regarding MDR-TB treatment, “Decentralised Management of Multidrug-Resistant Tuberculosis: A Policy Framework for South Africa.” These guidelines recommend that acid fast 
  • Linkages to Care for Patients Diagnosed with Drug-Resistant Tuberculosis within the City of Johannesburg

    Nationally, in the most recently reported cohort of patients (2011), only 56% of patients with laboratory-confirmed MDR-TB initiated 2nd line TB treatment. The National Strategic Plan for HIV, TB, and STIs 2012-2016 set an ambitious target of 100% initiation. Because of the complexity of the referral and linkage process and the fragmentation of the records amongst various registers, the proportion of patients completing each step (sample collection, diagnosis of resistance, reporting of 
  • Impact of Nutritional Supplementation on Physical Development, Retention in Care and Adherence to ART in HIV-Positive Infants and Children

    The study aims to determine whether a nutritional supplement, FutureLife HIGH-ENERGY Smart food, given to caregivers/guardians to give to their HIV-positive infants and children for 6 months concurrently with antiretroviral therapy (ART) compared to standard of care results in improved growth and physical development as measured by an increase in height-for-age Z score (HAZ), weight-for-age Z score (WAZ) and mid-upper arm circumference (MUAC) at 6, 12 and 24 months. Secondary outcomes 
  • Retention and Attrition from HIV Care

    With the rapid expansion of access to antiretroviral therapy (ART) in sub-Saharan Africa, the number of HIV-positive people on treatment has increased dramatically. In South Africa, scale-up of services has put pressure on the ability of treatment programs to maintain care for existing patients while continuing to expand access to new patients. With increased demand and limited capacity, many HIV-positive patients never access care, and many who do discontinue treatment. HE2RO staff, 
  • Linkage to National Databases to Enhance Programme Evaluation

    HIV care involves a web of local clinics and laboratories throughout South Africa. In the emergency phase of the epidemic, monitoring and evaluation took a backseat to HIV care. Currently HIV care takes place at over 3,000 local clinics throughout South Africa. Laboratory test from the labs and patient records from the clinics provide potentially useful sources of data for monitoring and evaluation of the National treatment programme currently and historically. Linkage of patient records to the 
  • Pregnant Women

    Treatment outcomes among pregnant women remain a critical indicator for monitoring and evaluation of the national treatment program over time. A long-standing collaboration with researchers from the University of North Carolina has enriched the analysis of longitudinal data on pregnant women by the researchers at 
  • Paediatric and Adolescent Populations

    Children and adolescents have been identified as priority populations with the greatest potential impact on the development of the HIV epidemic. HE2RO has used multiple sources of data to evaluate the outcomes of children and adolescents initiating ART at multiple clinics across Gauteng and Mpumalanga. We also utilize prospective cohorts to identify factors associated with treatment adherence and missed clinic visits among adolescents and plan to use national level laboratory data to produce 
  • Second and Third-Line Antiretroviral Regimens

    As South Africa continues its rapid expansion of access to first-line antiretroviral therapy (ART), more patients will need to be switched to second-line therapy as these first-line regimens fail. However, with little experience with second-line treatments in resource-limited settings, it is not clear how well patients will do on these medications if their first regimen fails. As the cost of second-line medications is much higher than first-line, it is critical to evaluate whether these 
  • First Line Regimen Durability and Adverse Events

    Understanding the implications of the side effect profile of individual antiretroviral drugs as well as the durability of drug regimens has considerable significance in settings where resources and drug options for HIV remain limited. HE2RO has explored these questions through longitudinal patient datasets with a particular interest in the effects of tenofovir upon introduction into the national programme. These analyses are ongoing as guidelines continue to evolve and current projects include 
  • Adult Treatment Outcomes and Opportunistic Infections

    As the HIV epidemic matured in South Africa and the national treatment programme reached 10 years since inception, the team at HE2RO has used longitudinal patient databases to evaluate treatment outcomes among adults initiating ART. We consider diverse factors that may influence the effect of ART and also the impact of changing national guidelines in an on-going 

Tools

  • The Testing Platform Cost Model

    This cost model provides a simple tool for analysts and decision-makers to determine the cost per test for a testing platform from a provider’s perspective. For many developing countries, the decision to introduce or scale-up certain laboratory tests is influenced by the associated costs and effectiveness. For example, introducing point-of-care (POC) testing, or low- volume testing technologies, into healthcare programmes may improve access, linkage to care and treatment. This tool can assist policy makers in answering questions related to the cost per test for different test technologies, for example CD4, viral load, Gene-Xpert etc., and ultimately improve programme efficiency.

  • The Healthcare Cost and Outcomes Model

    The Healthcare Cost and Outcomes Model (HCOM) provides a simple tool for analysts and decision-makers to determine the cost-effectiveness of a healthcare intervention in which resources are consumed to produce certain healthcare outcomes.