Recent Publications

Patient benefits and costs associated with differentiated models of service delivery for HIV treatment in Sub-Saharan Africa

As of December 2018, 16.4 million people were reported to be receiving antiretroviral therapy (ART) for HIV in sub-Saharan Africa.To achieve global “90-90-90”targets for HIV diagnosis, treatment, and viral suppression, another three million patients must be added to national HIV treatment programs during the coming decade in eastern and southern Africa. At the same time, donor funding for HIV has plateaued, leading to calls for greater efficiency in service delivery. One response to this 

Optimizing viral load testing access for the last mile: Geospatial cost model for point of care instrument placement

Viral load (VL) monitoring programs have been scaled up rapidly, but are now facing the challenge of providing access to the most remote facilities (the “last mile”). For the hardestto-reach facilities in Zambia, we compared the cost of placing point of care (POC) viral load instruments at or near facilities to the cost of an expanded sample transportation network (STN) to deliver samples to centralized 

Optimal HIV testing strategies for South Africa: a model-based evaluation of population-level impact and cost-effectiveness

This paper compares the impact and cost effectiveness of several potential new testing strategies in South Africa, and assesses the prospects of achieving the UNAIDS target of 95% of HIV-positive adults diagnosed by 2030. We developed a mathematical model to evaluate the potential impact of home-based testing, mobile testing, assisted partner notification, testing in schools and workplaces, and testing of female sex workers (FSWs), men who have sex with men (MSM), family planning clinic 

The costs of diagnosing breast-related conditions at a large, public hospital in Johannesburg, South Africa

Breast cancer is the most common cancer among women in South Africa. Offering comprehensive breast care services requires careful planning; yet, there is limited literature on the costs of providing services in low-resource settings. We aimed to estimate the average costs per procedure and patient for the diagnosis of breast conditions in South Africa, including the impact of shifting to lower-cost imaging 

Treatment outcomes among children, adolescents, and adults on treatment for tuberculosis in two metropolitan municipalities in Gauteng Province, South Africa

We identified 182,890 children (<10 years), young adolescent (10–14), older adolescent (15–19), young adult (20–24), adult (25–49), and older adult (≥50) TB cases without known drug-resistance. ART coverage among HIV co-infected patients was highest for young adolescents (64.3%) and lowest for young adults (54.0%) compared to other age groups (all over 60%). Treatment success exceeded 80% in all age groups (n = 170,017). All-cause mortality increased with age. Compared to adults, 

Adherence clubs and decentralized medication delivery to support patient retention and sustained viral suppression in care: Results from a cluster-randomized evaluation of differentiated ART delivery models in South Africa

In this study, we found comparable DMD outcomes versus standard of care at facilities, a benefit for retention of patients in care with ACs, and apparent benefits in terms of retention (for AC patients) and sustained viral suppression (for DMD patients) among men. This suggests the importance of alternative service delivery models for men and of communitybased strategies to decongest primary healthcare facilities. Because these strategies also reduce patient inconvenience and decongest 

Cost-per-diagnosis as a metric for monitoring cost-effectiveness of HIV testing programmes in low-income settings in southern Africa: health economic and modelling analysis

The paper investigates the use of "cost per new HIV diagnosis" as a metric of the cost effectiveness of new HIV testing strategies, in contrast to more commonly used metrics, for two packages of testing modalities across several southern African countries. We found a very strong relationship between cost-per-diagnosis and cost-per-DALY-averted, with incremental cost-effectiveness ratios being below $500 per-DALY-averted as long as the cost-per-diagnosis was below $315. Across modalities and 

Cervical cancer risk in women living with HIV across four continents: A multicohort study

Vast global inequities in the burden of invasive cervical cancer (ICC) exist. While access to effective screening and treatment of precancerous cervical lesions has substantially reduced the risk of developing ICC in high-income countries, ICC remains a common cause of premature mortality and morbidity in women in low- and middle-income countries. ICC disproportionally affects women living with human immunodeficiency virus (HIV), who are more likely to have persistent coinfection with high-risk 

Keeping track of HIV and TB spending in South Africa: 2013/14 to 2020/21 Expenditure and Budget Review: Occasional Paper 2018-1. CEGAA.

This paper provides an analysis of the health HIV and TB budget and spending in South Africa over an eight-year period (2013/14 - 2020/21), with a special focus on the 2015/16 and 2016/17 provincial programme spending and the 2018/19 to 2020/21 budget. The analysis indicates government’s increasing financial commitment to HIV and TB against the backdrop of declining economic conditions. The problem of over- or under-spending by provinces has been partially attributed to poor estimation of 

The impact of adverse events on healthrelated quality of life among patients receiving treatment for drug-resistant tuberculosis in Johannesburg, South Africa

Adverse events (AEs) are common during treatment of drug-resistant tuberculosis (DR-TB). Little is known about the health-related quality of life (HRQoL) of patients receiving treatment for DR-TB or the effect of AEs on HRQoL. We enrolled 149 DR-TB patients (median age 36 years IQR 29–43, 55% male, 77.9% HIV-positive, 81% on ART, 61.8% on a standard long-course regimen and 44.3% on DR-TB treatment for less than 6 months). 58/149 (38.9%) patients reported a total of 122 AEs in the preceding 

Cost and impact of dried blood spot versus plasma separation card for scale-up of viral load testing in resource limited settings

Routine plasma viral load (VL) testing is the WHO-recommended method for monitoring HIV-infected patients on antiretroviral therapy (ART). In Zambia, VL scale-up is limited due to significant logistical obstacles around plasma specimen collection, storage, and transport to centralized laboratories. Dried blood spot (DBS) technology could circumvent many logistical challenges at the cost of reduced sensitivity and/or specificity. Recently, plasma separation cards (PSC) have become available and, 

Clinical predictor score to identify patients at risk of poor viral load suppression at six months on antiretroviral therapy: results from a prospective cohort study in Johannesburg, South Africa

As countries work toward 90:90:90 targets, early identification of patients with inadequate response to antiretroviral therapy (ART) is critical for achieving optimal HIV treatment outcomes. We developed and evaluated a clinical prediction score (CPS) to identify HIV-positive patients at risk of poor viral load suppression at 6 months on ART. Our findings suggest a 6-month CPS may have the potential to identify patients at risk of poor viral load suppression. The CPS may be used to target