Objectives: To undertake a structured review and
critical appraisal of methods for the model-based
cost–utility analysis of screening programmes. Also to
develop guidelines and an assessment checklist of good
practice in the development of screening models.
Data sources: Major electronic databases of
healthcare and operational research literatures were
searched up to June 2003.
Review methods: Searches of the literature were
undertaken to identify applied and methodological
studies of economic evaluations of healthcare screening
programmes. All applied screening models were also
reviewed in three broad disease areas (cancer,
cardiovascular disease and diabetes), as well as
antenatal screening. A second-level review focused on
particular aspects of the modelling process through
case study assessments of screening models for three
specific disease areas (colorectal cancer, abdominal
aortic aneurysms and antenatal screening for
haemoglobinopathies). A separate literature review of
studies reporting the utility effects of screening was
also undertaken. Guidelines and an assessment
checklist for good practice for screening modelling
were developed.
Results: Few relevant methodological studies were
identified, and no studies reporting direct empirical
comparisons of alternative methodologies were
retrieved. From the review of disease-based screening
models, it was apparent that many alternative
modelling methods had been applied, including some
relatively new approaches that had not been widely
disseminated. Natural history modelling is the
preferred approach. Alternative modelling approaches
were generally only used to extrapolate the observed
effects of screening and were unsuitable for evaluating
unobserved screening options. More complex model
structures may incorporate important additional
aspects of the disease natural history, although any
benefits should outweigh the consequences of
additional unobservable input parameters and increased preferred general method of evaluation for screening
programmes. State transition models have generally
been used to represent disease natural histories, with
individual sampling models more prevalent than in
treatment intervention evaluations. No comparative
methodological studies were identified, so no empirical
data were available to inform the relative merits of
alternative methodologies. The defined guidelines and complexity in implementing the model. No direct
comparisons of more detailed and less detailed
screening model structures informed areas in which
more realistic representations of the disease process
may be most beneficial, so only general aspects of good
practice could be defined. Two structural aspects that
were not well handled by existing screening models
included post-diagnosis disease progression and
screening uptake. Most models described the former
using historical mortality rates, rather than treatment
models that are representative of current treatment
patterns for different stages of the disease. Constant
screening uptake rates were applied to all screening
programmes and attendance was not linked to disease
incidence or progression. Evidence exists to inform a
more detailed representation of screening uptake. The
most commonly applied modelling techniques were
cohort Markov models and individual sampling
simulation models. Individual sampling simulation
models may provide more flexibility in their
representation of a screening decision problem, but any
benefits should outweigh the consequences of the need
to assess both variability and uncertainty. Complex
mathematical models describing input parameters as
continuous variables have analysed the costeffectiveness
of screening; these require further
development to estimate the cost–utility of screening
directly, or to inform a more detailed representation
of the preclinical section of a natural history model
(with a traditional state-based model describing
pathways’ post-clinical presentation). Calibration is a
common aspect of screening models, whereby models
are fitted to observed data describing outputs of the
model in order to populate unobserved input
parameters. The review concluded that the estimation
of a reference case input parameter set is not
recommended.
Conclusions: The review of methods for the modelbased
cost–utility analysis of screening programmes
identified the natural history modelling approach as theassessment checklist are informed, therefore, by
theoretical interpretations of the impact of alternative
approaches to different components of the modelling
process when applied to the cost–utility analysis of
screening programmes. Further research is needed into
methods with the potential to improve the accuracy of
screening models, and to respond to the needs of
model users.

/pdf/a-review-and-critique-of-modelling-in-prioritising-and-43qjtwm4gv.pdf

A review and critique of modelling in prioritising and designing screening programmes.

This paper provides an overview of the arguments for the central role of families, defined very broadly, and we emphasise the importance of efforts to strengthen families to support children affected by HIV and AIDS. We draw on work conducted in the Joint Learning Initiative on Children and AIDS's Learning Group 1: Strengthening Families, as well as published data and empirical literature to provide the rationale for family strengthening. We close with the following recommendations for strengthening families to ameliorate the effects of HIV and AIDS on children. Firstly, a developmental approach to poverty is an essential feature of responses to protect children affected by HIV and AIDS, necessary to safeguard their human capital. For this reason, access to essential services, such as health and education, as well as basic income security, must be at the heart of national strategic approaches. Secondly, we need to ensure that support garnered for children is directed to families. Unless we adopt a family oriented approach, we will not be in a position to interrupt the cycle of infection, provide treatment to all who need it and enable affected individuals to be cared for by those who love and feel responsible for them. Thirdly, income transfers, in a variety of forms, are desperately needed and positively indicated by available research. Basic economic security will relieve the worst distress experienced by families and enable them to continue to invest in the health care and education of their children. Lastly, interventions are needed to support distressed families and prevent knock-on negative outcomes through programmes such as home visiting, and protection and enhancement of children's potential through early child development efforts.

/pdf/strengthening-families-to-support-children-affected-by-hiv-5a8edt0igd.pdf

Strengthening families to support children affected by HIV and AIDS.

Objective: To assess the cost effectiveness of vertical transmission prevention strategies by using a mathematical simulation model. Design: A Markov chain model was used to simulate the cost effectiveness of four formula feeding strategies, three antiretroviral interventions, and combined formula feeding and antiretroviral interventions on a cohort of 20 000 pregnancies. All children born to HIV positive mothers were followed up until age of likely death given current life expectancy and a cost per lifeyear gained calculated for each strategy. Setting: Model of working class, urban South African population. Results: Low cost antiretroviral regimens were almost as effective as high cost ones and more cost effective when formula feeding interventions were added. With or without formula feeding, low cost antiretroviral interventions were likely to save lives and money. Interventions that allowed breast feeding early on, to be replaced by formula feeding at 4 or 7 months, seemed likely to save fewer lives and offered poorer value for money. Conclusions: Antiretroviral interventions are probably cost effective across a wide range of settings, with or without formula feeding interventions. The appropriateness of formulafeeding was highly cost effective only in settings with high seroprevalence and reasonable levels of child survival and dangerous where infant mortality was high or the protective effect of breastfeeding substantial. Pilot projects are now needed to ensure the feasibility of implementation

https://www.bmj.com/content/bmj/318/7199/1650.full.pdf

Prevention of vertical transmission of HIV: analysis of cost effectiveness of options available in South Africa

List of tables and figures. List of contributors. Foreword. Acknowledgements. 1: Introduction. Section One: Psychosocial Issues. 2: The Sociocultural Aspects of HIV/AIDS. 3: HIV and Women. 4: Masculinity and HIV/AIDS. 5: HIV and Youth: A Behavioural perspective. 6: Infants and Young Children affected by HIV/AIDS. 7: Poverty and HIV and AIDS. 8: HIV and Stigma in South Africa. Section Two: Prevention and Treatment. 9: The Politics and Psychology of AIDS Denialism. 10: Local Level Responses to HIV/AIDS in South Africa. 11: Social Movements and HIV/AIDS in South Africa. 12: Approaches to HIV Counselling and Testing: Strengths and Weaknesses, and challenges for the Way Forward. 13: Vertical transmission of HIV - Pregnancy and Infant issues. 14: HIV/AIDS, nutrition and structural interventions in South Africa: A move in the right direction. 15: Strengthening Community Responses to AIDS: Possibilities and Challenges. 16: HIV, religion and spirituality. Section Three: Persons Living with HIV/AIDS. 17: Experiences of People Living with HIV. 18: Positive Prevention: HIV Risk Reduction for People Living with HIV/AIDS. Section Four: New directions in HIV research. 19: HIV/AIDS and Persons with Disabilities. 20: HIV/AIDS and the Prison System. 21: HIV and Circumcision. 22: Participation in HIV Vaccine Trials. 23: Bridging the Gap between HIV and Mental Health Services in South Africa

HIV/AIDS in South Africa 25 Years On

Objectives

The study of HIV and issues of reproduction is women-focused. HIV-positive men are overlooked and understudied. This study examined views on reproduction of heterosexual HIV-positive men.



Methods

Systematic questionnaire data were gathered from HIV-positive men (n=32) attending an HIV clinic in London.



Results

Heterosexual men were rarely given medical advice on reproduction (only 9.4%). Few felt fully informed (21.9%), while many felt uninformed (46.9%) or needed more information (28.1%). Over half would value fertility/fathering consultations, up-to-date information and quick referral to fertility clinics. Nearly half (43.8%) had considered having children and 37.5% had had a child prior to HIV diagnosis. HIV status affected views on fathering, and the advent of new treatments changed views in over half of the men. Almost half (41%) believed they would experience discrimination if they conceived a baby and a quarter would withhold their HIV status when attending antenatal clinics. The majority (81%) believed that a child gave meaning to life and something to live for – only 3.1% felt a child would be a burden. Most men overestimated potential vertical transmission and would value time to discuss fathering and fatherhood.



Conclusions

There are gaps in provision. The majority of men felt that children gave meaning to life and a reason to live. Reproduction issues are not raised with HIV-positive men who are uninformed and unclear where to turn for information. Fatherhood should not be shunned as an issue for all HIV-positive men.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1468-1293.2004.00218.x

Fatherhood and HIV‐positive heterosexual men

Objective: To estimate the cost effectiveness of universal, voluntary HIV screening of pregnant women in England Design: Cost effectiveness analysis. Cost estimates of caring for HIV positive children were based on the stage of HIV infection and calculated using data obtained from a London hospital between 1986 and 1996. These were combined with estimates of the health benefits and costs of antenatal screening so that the cost effectiveness of universal, voluntary antenatal screening for HIV infection in England could be estimated. Main outcome measures: Lifetime, direct costs of medical care of childhood HIV infection; life years gained as a result of the screening programme; net cost per life year gained for different pretest counselling costs; and different prevalence rates of pregnant women who were unaware that they were HIV positive. Results: Estimated direct lifetime medical and social care costs of childhood HIV infection were £178 300 using a 5% discount rate for time preference (1995-6 prices). In high prevalence areas screening pregnant women for HIV is estimated to be a cost effective intervention with a net cost of less than £4000 for each life year gained. For areas with comparatively low prevalence rates, cost effectiveness could be less than £20 000 per life year gained, depending on the number of pregnant women who are unaware that they are infected and local screening costs Conclusions: Our results confirm recent recommendations that universal, voluntary antenatal HIV screening should be implemented in the London area. Serious consideration of the policy should be given for other areas in England depending on local prevalence and screening costs.

https://www.bmj.com/content/bmj/318/7199/1656.full.pdf

Universal HIV screening of pregnant women in England: cost effectiveness analysis

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Universal HIV screening of pregnant women in England: cost effectiveness analysis