National Treatment Program Research Articles

Cost-Effectiveness and Cost Thresholds of Generic and Brand Drugs in a National Chronic Hepatitis B Treatment Program in China

Chronic liver disease and liver cancer associated with chronic hepatitis B (CHB) are leading causes of death among adults in China. Although newborn hepatitis B immunization has successfully reduced the prevalence of CHB in children, about 100 million Chinese adults remain chronically infected. If left unmanaged, 15–25% will die from liver cancer or liver cirrhosis. Antiviral treatment is not necessary for all patients with CHB, but when it is indicated, good response to treatment would prevent disease progression and reduce disease mortality and morbidity, and costly complications. The aim of this study is to analyze the cost-effectiveness of generic and brand antiviral drugs for CHB treatment in China, and assessing various thresholds at which a highly potent, low resistance antiviral drug would be cost-saving and/or cost-effective to introduce in a national treatment program. We developed a Markov simulation model of disease progression using effectiveness and cost data from the medical literature. We measured life-time costs, quality adjusted life years (QALYs), incremental cost-effectiveness ratios (ICERs), and clinical outcomes. The no treatment strategy incurred the highest health care costs ($12,932-$25,293) per patient, and the worst health outcomes, compared to the antiviral treatment strategies. Monotherapy with either entecavir or tenofovir yielded the most QALYs (14.10–19.02) for both HBeAg-positive and negative patients, with or without cirrhosis. Threshold analysis showed entercavir or tenofovir treatment would be cost saving if the drug price is $32–75 (195–460 RMB) per month, highly cost-effective at $62–110 (379–670 RMB) per month and cost-effective at $63–120 (384–734 RMB) per month. This study can support policy decisions regarding the implementation of a national health program for chronic hepatitis B treatment in China at the population level.

Znaczna poprawa kliniczna pacjenta leczonego sildenafilem z powodu nadciśnienia płucnego związanego z nadciśnieniem wrotnym

We report a case of the 59-year-old men with portal hypertension and liver cirrhosis, who developed pulmonary arterial hypertension. The first line treatment with sildenafil 20 mg 3 times daily was introduced as part of a Polish National Treatment Program. At a 6-month follow-up we noticed a significant clinical improvement: the patient’s exercise capacity and echocardiographic parameters were substantially better. In addition, the B-type natriuretic propeptide significantly decreased.

Rusmisbruk, angst og depresjon etter 10 år: En prospektiv undersøkelse av stoffmisbrukere med og uten LAR-behandling

Substance abuse, anxiety and depression after 10 years: A prospective study of drug users in and outside OMT treatment Aims The national Opiate Maintenance Treatment (OMT) program in Norway started officially in 1998. The same year a treatment study was initiated, including the most used treatment measures for drug users in Norway. The main aim in the present study was to investigate the prevalence of live OMT patients in the total sample after 10 years, and to compare the outcome of primarily substance abuse, anxiety and depression among OMT patients versus non-OMT patients. Design & Methods Four hundred and seven patients, in Oslo and the nearby regions, who started in 16 different in- and outpatients programs, were followed from intake to treatment and during ten years (1998-2009). Patients in the sample were interviewed after one, two, seven and ten years, and they were divided into three different treatment groups: inpatient residency for grown-ups, outpatient psychiatric youth teams and youths living in collectives. Data was collected through use of EuropASI and HSCL-25 at all follow-ups. Results After ten years 15 % were deceased. Of the 333 persons left, 73 % (n=248) were interviewed after ten years. Forty percent (n=99) were then in OMT. After ten years there were no gender differences regarding attendance to OMT, but the OMT-group was older (30 vs .28 yrs, p<0.05), and they used more benzodiazepines (p<0.000) and cannabis (p<0.01) than the others. The OMT-group reported to a larger extent more anxiety and depression throughout the total observation period than the non OMT participants. Use of heroin and criminality were significantly reduced in both groups. Conclusions In spite of reduced use of heroin, the OMT patients seemed to have more difficulties in reducing the use of benzodiazepines and cannabis, whereas the anxiety and depression scores were high and stable through the total observation time.

Reconciling the science and policy divide: The reality of scaling up antiretroviral therapy in South Africa.

With the world’s largest national treatment programme and over 340 000 incident cases annually, the response to HIV in South Africa is hotly contested and there is sometimes a dissonance between activism, science and policy. Too often, policy, whilst well intentioned, is informed only by epidemiological data. The state of the healthcare system and sociocultural factors drive and shape the epidemic and its response. By analysis of the financial, infrastructural, human resources for health, and governance landscape in South Africa, we assess the feasibility and associated costs of implementing a universal test and treat programme. We situate a universal test and treat strategy within the governance, fiscal, human resources for health, and infrastructural landscape in South Africa. We argue that the response to the epidemic must be forward thinking, progressive and make the most of the benefits from treatment as prevention. However, the logistics of implementing a universal test and treat strategy mean that this option is problematic in the short term. We recommend a health systems strengthening HIV treatment and prevention approach that includes scaling up treatment (for treatment and prevention) along with a range of other prevention strategies.

Health insurance coverage and healthcare utilization among infants of mothers in the national methadone maintenance treatment program in Taiwan

BackgroundChildren of heroin-using women have a higher risk of unfavorable health and developmental outcomes. Although methadone maintenance treatment (MMT) has been widely used to treat heroin-using pregnant women, potential effects on accessibility and utilization of healthcare service for their offspring are less explored. MethodsWe used four national registry and health insurance datasets in Taiwan from 2004 to 2009 to form a population-based matched retrospective cohort study. A total of 1056 neonates born to women in the MMT program (857 born before mother's enrollment in the MMT program [BM], 199 born after mother's enrollment in the MMT program [AM]) was established; 10547 matched non-drug [ND] exposed neonates were identified for comparison. Outcome variables included offspring's health insurance coverage and utilization of preventive, outpatient, and emergency room cares in the first year after birth. ResultsInfants born to mothers on MMT were more likely to have no or incomplete insurance coverage (BM: adjusted odds ratio [aOR]=1.29, 95% CI: 1.10–1.53; AM: aOR=1.56, 95% CI: 1.14–2.13) as compared with the socioeconomic status-matched ND group. The BM infants appeared to have fewer preventive care visits (adjusted relative risk [aRR]=0.85, 95% CI: 0.80–0.90), whereas the AM infants utilized outpatient and emergency room services more frequently (outpatient: aRR=1.11, 95% CI: 1.01–1.23; emergency: aRR=1.46, 95% CI: 1.11–1.90). ConclusionsAddiction treatment and harm reduction programs for women of childbearing ages should be delivered in the coordinated framework that ensures comprehensiveness and continuity in healthcare and social services.

P149: Interim analysis for sofosbuvir national treatment program in Egypt

Journal of Viral HepatitisVolume 22, Issue S2 p. 94-94 Poster PresentationFree Access P149: Interim analysis for sofosbuvir national treatment program in Egypt First published: 25 June 2015 https://doi.org/10.1111/jvh.137_12425AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. Volume22, IssueS2Special Issue: 15th International Symposium on Viral Hepatitis and Liver Diseases (ISVHLD) held from June 26th to 28th, 2015, in Berlin, GermanyJune 2015Pages 94-94 RelatedInformation

The efficacy of implement national latent tuberculosis infection treatment program in a regional hospital in southern Taiwan

presentation; zoster and neutrophlic dermatoses were the most common cutaneous manifestations not directly related to NTMs. There was no specific time-sequence in the appearance of zoster, salmonellosis and NTM infections. Three different clinical courses were recorded and most of our patients (75.8%) required long-term anti-mycobacterial therapy. Conclusions: Despite anti-mycobacterial therapy, the clinical course of most patients with anti-IFN-g autoantibodies and dNTM infections is protracted and recalcitrant. In addition to microbial infections, the other common clinical presentations include neutrophilic dermatoses and T-cell/macrophage linage-associated malignancies. In the future, further study is needed to elucidate the characteristics of this disease.

Informing the design of a national screening and treatment programme for chronic viral hepatitis in primary care: qualitative study of at-risk immigrant communities and healthcare professionals.

BackgroundEffective strategies are needed to provide screening and treatment for hepatitis B and C to immigrant groups in the UK at high risk of chronic infection. This study aimed to build an understanding of the knowledge, beliefs and attitudes towards these conditions and their management in a range of high-risk minority ethnic communities and health professionals, in order to inform the design of a screening and treatment programme in primary care.MethodsQualitative data collection consisted of three sequential phases- (i) semi-structured interviews with key informants (n = 17), (ii) focus groups with people from Chinese, Pakistani, Roma, Somali, and French- and English-speaking African communities (n = 95), and (iii) semi-structured interviews with general practitioners (n = 6). Datasets from each phase were analysed using the Framework method.ResultsKey informants and general practitioners perceived that there was limited knowledge and understanding about hepatitis B and C within high-risk immigrant communities, and that chronic viral hepatitis did not typically feature in community discourses about serious illness. Many focus group participants were confused about the differences between types of viral hepatitis, held misconceptions regarding transmission, and were unaware of the asymptomatic nature of chronic infection. Most welcomed the idea of a screening programme, but key informants and focus group participants also identified numerous practical barriers to engagement with primary care-based screening and treatment; including language and communication difficulties, limited time (due to long working hours), and (for some) low levels of trust and confidence in general practice-based care. General practitioners expressed concerns about the workload implications and sustainability of screening and treating immigrant patients for chronic viral hepatitis in primary care.ConclusionsStrategies to reduce the burden of chronic viral hepatitis in immigrant communities will need to consider how levels of understanding about hepatitis B and C within these communities, and barriers to accessing healthcare, may affect capacity to engage with screening and treatment. Services may need to work with community groups and language support services to provide information and wider encouragement for screening. Primary care services will need ongoing consultation regarding their support needs to deliver hepatitis screening and treatment programmes.

Effect of preventive and curative interventions on hepatitis C virus transmission in Egypt (ANRS 1211): a modelling study.

Most hepatitis C virus (HCV) transmission in Egypt is related to medical injections and procedures. To control the spread of HCV, the Egyptian Ministry of Health initiated awareness and education campaigns, strengthened infection control in health-care facilities, and subsidised anti-HCV treatment. We aimed to investigate the effect of these interventions on the spread of HCV by mathematical modelling. We developed a mathematical model of HCV transmission in Zawyat Razin, a typical rural community. Our model assumes that each individual has two distinct types of medical procedures: injections and more invasive medical procedures. To quantify the severity of the spread of HCV, we used the notion of the basic reproduction number R0, a standard threshold parameter signalling whether transmission of an infectious disease is self-sustained and maintains an epidemic. If R0 is greater than 1, HCV is self-sustained; if R0 is 1 or less, HCV transmission is not self-sustained. We investigated whether heterogeneity in the rate of injection or invasive medical procedures is the determinant factor for HCV transmission and whether most iatrogenic transmission is caused by a small group of individuals who receive health-care interventions frequently. We then assessed whether interventions targeted at this group could reduce the spread of HCV. The R0 of the spread of HCV without treatment was 3·54 (95% CI 1·28-6·18), suggesting a self-sustained spread. Furthermore, the present national treatment programme only decreased R0 from 3·54 to 3·03 (95% CI 1·10-5·25). Individuals with high rates of medical injections seem to be responsible for the spread of HCV in Egypt; the R0 of the spread of HCV without treatment would be 0·64 (95% CI 0·41-0·93) if everybody followed the average behaviour. The effect of treatment on HCV transmission is greatly enhanced if treatment is provided a mean of 2·5 years (95% CI 0·1-9·2) after chronic infection and with drug regimens with more than 80% efficacy. With these treatment parameters, preventive and curative interventions targeting individuals with high rates of medical injections might decrease R0 below 1 for treatment coverage lower than 5%. Targeting preventive and curative interventions to individuals with high rates of medical injections in Egypt would result in a greater reduction the spread of HCV than would untargeted allocation. Such an approach might prove beneficial in other resource-limited countries with health-care-driven epidemics. Agence Nationale de Recherche sur le SIDA et les Hépatites Virales (ANRS 1211), ANR grant Labex Integrative Biology of Emerging Infectious Diseases.

Maximizing benefits of new strategies to prevent mother-to-child HIV transmission without harming existing services.

Maximizing benefits of new strategies to prevent mother-to-child HIV transmission without harming existing services.

Transmitted Drug Resistance and Antiretroviral Treatment Outcomes in Non-Subtype B HIV-1–Infected Patients in South East Asia

We compared treatment outcomes of transmitted drug resistance (TDR) in patients on fully or partially sensitive drug regimens. Factors associated with survival and failure were analyzed using Cox proportional hazards and discrete time conditional logistic models. TDR, found in 60 (4.1%) of 1471 Asian treatment-naive patients, was one of the significant predictors of failure. Patients with TDR to >1 drug in their regimen were >3 times as likely to fail compared to no TDR. TDR was associated with failure in the context of non-fully sensitive regimens. Efforts are needed to incorporate resistance testing into national treatment programs.

Using HIV-attributable mortality to assess the impact of antiretroviral therapy on adult mortality in rural Tanzania

Background The Tanzanian national HIV care and treatment programme has provided free antiretroviral therapy (ART) to HIV-positive persons since 2004. ART has been available to participants of the Kisesa open cohort study since 2005, but data to 2007 showed a slow uptake of ART and a modest impact on mortality. Additional data from the 2010 HIV serological survey provide an opportunity to update the estimated impact of ART in this setting. Methods The Kisesa Health and Demographic Surveillance Site (HDSS) has collected HIV serological data and demographic data, including verbal autopsy (VA) interviews since 1994. Serological data to the end of 2010 were used to make two estimates of HIV-attributable mortality, the first among HIV positives using the difference in mortality between HIV positives and HIV negatives, and the second in the population using the difference between the observed mortality rate in the whole population and the mortality rate among the HIV negatives. Four time periods (1994–1999, 2000–2004, 2005–2007, and 2008–2010) were used and HIV-attributable mortality estimates were analysed in detail for trends over time. A computer algorithm, InterVA-4, was applied to VA data to estimate the HIV-attributable mortality for the population, and this was compared to the estimates from the serological survey data. Results Among HIV-positive adults aged 45–59 years, high mortality rates were observed across all time periods in both males and females. In HIV-positive men, the HIV-attributable mortality was 91.6% (95% confidence interval (CI): 84.6%–95.3%) in 2000–2004 and 86.3% (95% CI: 71.1%–93.3%) in 2008–2010, while among women, the HIV-attributable mortality was 87.8% (95% CI: 71.1%–94.3%) in 2000–2004 and 85.8% (95% CI: 59.6%–94.4%) in 2008–2010. In the whole population, using the serological data, the HIV-attributable mortality among men aged 30–44 years decreased from 57.2% (95% CI: 46.9%–65.3%) in 2000–2004 to 36.5% (95% CI: 18.8%–50.1%) in 2008–2010, while among women the corresponding decrease was from 57.3% (95% CI: 49.7%–63.6%) to 38.7% (95% CI: 27.4%–48.2%). The HIV-attributable mortality in the population using estimates from the InterVA model was lower than that from HIV sero-status data in the period prior to ART, but slightly higher once ART became available. Discussion In the Kisesa HDSS, ART availability corresponds with a decline in adult overall mortality, although not as large as expected. Using InterVA to estimate HIV-attributable mortality showed smaller changes in HIV-related mortality following ART availability than the serological results.

The geographic distribution patterns of HIV-, HCV- and co-infections among drug users in a national methadone maintenance treatment program in Southwest China

BackgroundHIV-, HCV- and HIV/HCV co-infections among drug users have become a rapidly emerging global public health problem. In order to constrain the dual epidemics of HIV/AIDS and drug use, China has adopted a methadone maintenance treatment program (MMTP) since 2004. Studies of the geographic heterogeneity of HIV and HCV infections at a local scale are sparse, which has critical implications for future MMTP implementation and health policies covering both HIV and HCV prevention among drug users in China. This study aimed to characterize geographic patterns of HIV and HCV prevalence at the township level among drug users in a Yi Autonomous Prefecture, Southwest of China.MethodsData on demographic and clinical characteristics of all clients in the 11 MMTP clinics of the Yi Autonomous Prefecture from March 2004 to December 2012 were collected. A GIS-based geographic analysis involving geographic autocorrelation analysis and geographic scan statistics were employed to identify the geographic distribution pattern of HIV-, HCV- and co-infections among drug users.ResultsA total of 6690 MMTP clients was analyzed. The prevalence of HIV-, HCV- and co-infections were 25.2%, 30.8%, and 10.9% respectively. There were significant global and local geographic autocorrelations for HIV-, HCV-, and co-infection. The Moran’s I was 0.3015, 0.3449, and 0.3155, respectively (P < 0.0001). Both the geographic autocorrelation analysis and the geographic scan statistical analysis showed that HIV-, HCV-, and co-infections in the prefecture exhibited significant geographic clustering at the township level. The geographic distribution pattern of each infection group was different.ConclusionHIV-, HCV-, and co-infections among drug users in the Yi Autonomous Prefecture all exhibited substantial geographic heterogeneity at the township level. The geographic distribution patterns of the three groups were different. These findings imply that it may be necessary to inform or invent site-specific intervention strategies to better devote currently limited resource to combat these two viruses.

From methadone to buprenorphine: Changes during a 10 year period within a national opioid maintenance treatment programme

Opioid maintenance treatment (OMT) is the most widely used treatment for opioid dependence. Maintenance programmes differ in various aspects and may also change over time. This paper investigates the changes in treatment practices within a national OMT programme during a 10year period (2002–2011), especially with regard to the prescribing of methadone and buprenorphine. Data (n=34,001) were collected by annual assessments questionnaires. In 2002, only 16% of the OMT patients received buprenorphine as their maintenance medication. By 2011 this percentage had increased significantly (p<.001) to 50.3%. In the same period the number of patients more than tripled (from 1,984 to 6,640, p<.001), and programme attrition rates decreased (p=.020). This relatively rapid shift is a part of the increasing reliance of addiction medicine upon a range of medications administered by different routes which has not been previously charted within a national treatment programme.

Outcomes and Impact of HIV Prevention, ART and TB Programs in Swaziland – Early Evidence from Public Health Triangulation

IntroductionSwaziland’s severe HIV epidemic inspired an early national response since the late 1980s, and regular reporting of program outcomes since the onset of a national antiretroviral treatment (ART) program in 2004. We assessed effectiveness outcomes and mortality trends in relation to ART, HIV testing and counseling (HTC), tuberculosis (TB) and prevention of mother to child transmission (PMTCT).MethodsData triangulated include intervention coverage and outcomes according to program registries (2001-2010), hospital admissions and deaths disaggregated by age and sex (2001-2010) and population mortality estimates from the 1997 and 2007 censuses and the 2007 demographic and health survey.ResultsBy 2010, ART reached 70% of the estimated number of people living with HIV/AIDS with CD4<350/mm3, with progressively improving patient retention and survival. As of 2010, 88% of health facilities providing antenatal care offered comprehensive PMTCT services. The HTC program recorded a halving in the proportion of adults tested who were HIV-infected; similarly HIV infection rates among HIV-exposed babies halved from 2007 to 2010. Case fatality rates among hospital patients diagnosed with HIV/AIDS started to decrease from 2005–6 in adults and especially in children, contrasting with stable case fatality for other causes including TB. All-cause child in-patient case fatality rates started to decrease from 2005–6. TB case notifications as well as rates of HIV/TB co-infection among notified TB patients continued a steady increase through 2010, while coverage of HIV testing and CPT for co-infected patients increased to above 80%.ConclusionAgainst a background of high, but stable HIV prevalence and decreasing HIV incidence, we documented early evidence of a mortality decline associated with the expanded national HIV response since 2004. Attribution of impact to specific interventions (versus natural epidemic dynamics) will require additional data from future household surveys, and improved routine (program, surveillance, and hospital) data at district level.

Abstract supplement: HIV Drug Therapy in the Americas Congress 13–15 June 2013, São Paulo, Brazil

Abstract supplement: HIV Drug Therapy in the Americas Congress 13–15 June 2013, São Paulo, Brazil

Pretreatment HIV-1 drug resistance in Africa

476 www.thelancet.com/infection Vol 13 June 2013 1 Hamers RL, Schuurman R, Sigaloff KCE, et al, for the PharmAccess African Studies to Evaluate Resistance (PASER) Investigators. Eff ect of pretreatment HIV-1 drug resistance on immunological, virological, and drugresistance outcomes of fi rst-line antiretroviral treatment in sub-Saharan Africa: a multicentre cohort study. Lancet Infect Dis 2012;12: 307–17. 2 Lynen L, Fransen K, Van Griensven J, Colebunders R. Pretreatment HIV-1 drug resistance testing in sub-Saharan Africa. Lancet Infect Dis 2012; 12: 911. 3 Roberts T, Bygrave H, Fajardo E, Ford N. Challenges and opportunities for the implementation of virological testing in resource-limited settings. J Int AIDS Soc; 15: 17324. 4 Hamers RL, Sawyer AW, Tuohy M, Stevens WS, Rinke de Wit TF, Hill AM. Cost-eff ectiveness of laboratory monitoring for management of HIV treatment in sub-Saharan Africa: a model-based analysis. AIDS 2012; 26: 1663–72. 5 Sigaloff KC, Hamers RL, Wallis CL, et al. Unnecessary antiretroviral treatment switches and accumulation of HIV resistance mutations; two arguments for viral load monitoring in Africa. J Acquir Immune Defi c Syndr 2011; 58: 23–31. 6 Nichols BE, Sigaloff KC, Kityo C, et al. Benefi ts of early antiretroviral treatment initiation outweigh risk of transmitted HIV drug resistance: a modelling study of two east African settings. 20th Conference on Retroviruses and Opportunistic Infections; March 3–6, 2013; Atlanta, GA. Abstr 1116. 7 Phillips AN, Pillay D, Garnett G, et al. Eff ect on transmission of HIV-1 resistance of timing of implementation of viral load monitoring to determine switches from fi rst to second-line antiretroviral regimens in resource-limited settings. AIDS 2011; 25: 843–50. 8 Gupta RK, Jordan MR, Sultan BJ, et al. Global trends in antiretroviral resistance in treatment-naive individuals with HIV after rollout of antiretroviral treatment in resource-limited settings: a global collaborative study and meta-regression analysis. Lancet 2012, 380: 1250–58. test ing and alternative fi rst-line regimens. Accurate ident ifi cation of virological failure will preserve drug options by avoiding the incremental cost of unnecessary switches and reducing drugresistance accumulation. Moreover, mathematical models predict that access to viral-load monitoring and second-line regimens might mitigate transmitted drug resistance. A shift to protease inhibitors in fi rst-line ART is regarded as a last resort by many experts, since this would have major programmatic implications, increase drug cost, and restrict options for constructing eff ective second-line regimens. Routine pretreatment drug-resistance testing is not feasible for most ART programmes because of restricted resources and laboratory capacity. As levels of transmitted drug resistance increase in east and southern Africa, we argue that improved functioning of national HIV treatment programmes will be crucial to preserve the longterm eff ectiveness of available ART regimens. Functioning would be improved by an uninterrupted drug supply, optimised patient adherence and retention, and access to viral-load monitoring.

Ten Year Trends in Community HIV Viral Load in Barbados: Implications for Treatment as Prevention

BackgroundTreatment as prevention is a paradigm in HIV medicine which describes the public health benefit of antiretroviral therapy (ART). It is based on research showing substantial reductions in the risk of HIV transmission in persons with optimally suppressed HIV-1 Viral Loads (VL). The present study describes ten year VL trends at the national HIV treatment unit and estimates VL suppression at a population level in Barbados, a Caribbean island with a population of 277,000, an estimated adult HIV prevalence of 1.2%, and served by a single treatment unit.MethodsThe national HIV treatment centre of the Barbados Ministry of Health has a client VL database extending back to inception of the clinic in 2002 (n = 1,462 clients, n = 17,067 VL measurements). Optimal VL suppression was defined at a threshold value of ≤200 viral copies/mL.ResultsAnalysis of VL trends showed a statistically significant improvement in VL suppression between 2002 to 2011, from 33.6% of clients achieving the 200 copies/mL threshold in 2002 to 70.3% in 2011 (P<0.001). Taking into account the proportion of clients alive and in care and on ART, the known diagnosed HIV population in Barbados, and estimates of unknown HIV infections, this translates into an estimated 26.2% VL suppression at a population level at the end of 2010.ConclusionsWe have demonstrated a significant trend towards optimal VL suppression in clients utilizing the services of the national HIV treatment program in Barbados over a 10-year period. Estimates of VL suppression at a population level are similar to reports in developed countries that applied similar methodologies and this could suggest a public health benefit of ART in minimizing the risk of sexual transmission of HIV. Continued efforts are warranted to extend HIV testing to hidden populations in Barbados and linking infected persons to care earlier in their disease.

Epidemiology and management of coexisting heart failure and atrial fibrillation in an outpatient setting

Atrial fibrillation (AF) is the most common arrhythmia complicating heart failure (HF). The coexistence of these diseases may be partially explained by the presence of common risk factors. Although the effect of AF on the prognosis in HF is still debatable, it is associated with specific complications and affects therapy. The aim of this analysis was to evaluate epidemiology and management of coexisting HF and AF among Polish outpatients. The present study was performed within the framework of the Polish National Cardiovascular Disease Prevention and Treatment Program, POLKARD 2003-2005, and included patients with HF treated in a representative number of 400 outpatient clinics. Data was collected using questionnaires and included demographic characteristics as well as information about coexisting diseases and treatment, provided by patients and physicians on the basis of the available medical records. The study involved 3682 patients with HF (mean age 67.1 ±11.7 years; 58% of patients were men). AF was present in 38% of the patients. The prevalence of arrhythmia increased with the New York Heart Association class. We observed significant differences between the subgroups of patients with AF and those with sinus rhythm in terms of demographic parameters, risk factors, concomitant diseases, and therapy. Although the use of angiotensin-converting enzyme inhibitors and β-blockers was significantly lower in the subgroup with AF, a multivariable analysis showed that it was associated with specific demographic characteristics and comorbidities rather than with arrythmia itself. Specialty patient care was associated with increased use of therapy aimed to improve the prognosis of HF patients. Patients with AF constitute a particular subgroup within the population of patients with HF. A specific distribution of risk factors with a significant effect of noncardiac diseases may confound HF therapy in this patient group. Specialty care may be able to optimize treatment in patients with coexisting HF and AF.

Effects of AIDS-related disability on workforce participation and earned income in Botswana: A quasi-experimental evaluation

Background: Botswana is regarded as a leader of progressive HIV/AIDS policy, as the first country in sub-Saharan Africa to establish a free, national antiretroviral therapy program. In light of such programmatic successes, it is important to evaluate the potentially changing relationship of HIV/AIDS to the wellbeing of individuals, households, and institutions in the country. Methods: We evaluate the effects of HIV-related illness on absenteeism and earnings several years after the start of the national treatment program among a random sample of adults in Botswana using survey data from 3999 individuals aged 15 to 49, using quasi-experimental methods. We compare absenteeism between individuals with and without HIV-related illness, using a propensity score matching approach. We then estimate the effect of HIV-related illness on earnings using a Heckman selection model to account for selection into the workforce. We stratify our analyses by sex. Results: Men and women with HIV-related illness were absent by about 5.2 and 3.3 additional days, respectively, in the month prior to the survey compared to matched controls, and earned approximately 38% and 43% less, respectively, in the month prior to the survey compared to those without HIV-related illness. Conclusions: HIV-related illness appears to increase absenteeism in this sample and dramatically reduce earnings. The findings suggest a need for policies that confer greater financial security to individuals with HIV/AIDS in Botswana.