Comparative analyses of published cost effectiveness models highlight critical considerations which are useful to inform development of new models.

Background: Comparative analyses of published cost effectiveness models provide useful insights into critical issues to inform the development of new cost effectiveness models in the same disease area.Objective: The purpose of this study was to describe a comparative analysis of cost-effectiveness models and highlight the importance of such work in informing development of new models. This research uses genotypic antiretroviral resistance testing after first line treatment failure for Human Immunodeficiency Virus (HIV) as an example.Method: A literature search was performed, and published cost effectiveness models were selected according to predetermined eligibility criteria. A comprehensive comparative analysis was undertaken for all aspects of the models.Results: Five published models were compared, and several critical issues were identified for consideration when developing a new model. These include the comparator, time horizon and scope of the model. In addition, the composite effect of drug resistance prevalence, antiretroviral therapy efficacy, test performance and the proportion of patients switching to second-line ART potentially have a measurable effect on model results. When considering CD4 count and viral load, dichotomizing patients according to higher cost and lower quality of life (AIDS) versus lower cost and higher quality of life (non-AIDS) status will potentially capture differences between resistance testing and other strategies, which could be confirmed by cross-validation/convergent validation. A quality adjusted life year is an essential outcome which should be explicitly explored in probabilistic sensitivity analysis, where possible.Conclusions: Using an example of GART for HIV, this study demonstrates comparative analysis of previously published cost effectiveness models yields critical information which can be used to inform the structure and specifications of new models.

Stinging nettle and neem enhance antibody response to local killed and imported live infectious bursal disease vaccines in indigenous chicken in Kenya.

Immune responses are critical for protection of chickens from infectious bursal disease (IBD). In this study, the antibody response-enhancing effect of drinking water supplementation of 1% stinging nettle and neem on different IBD vaccines and vaccination regimes was evaluated, using 36 (n = 36) specific antibody negative indigenous chicks. The birds were allocated into 3 groups as follows: 1A-C, 2A-C, and 3A-B, while group 3C acted as the unvaccinated non-supplemented control. A local inactivated K1 and imported live attenuated D78 IBD vaccines were given to groups 1A-C and 3A-B at 14 and 28 d of age, respectively. A combination of K1 and D78 vaccines was given 30 d apart to groups 2A and 2B (D78 at 14 and 21 d and K1 at 44 d of age) and on the same d to group 2C at 14 and 28 d of age. Stinging nettle was given in water to groups 1B, 2B, and 2C, and neem to groups 1C, 2A, and 3B. Birds were bled weekly and immune responses monitored using indirect ELISA. Both neem and stinging nettle had antibody response-enhancing effects in groups 1B and 1C, receiving the local inactivated K1 vaccine. There were significant differences (P < 0.05) in antibody titers between groups 1A and 2C. Stinging nettle induced earlier onset of high antibody responses in group 2C and persistent titers (>3.8 log10) from the third week in group 2B. Imported live D78 vaccine induced higher antibody titers compared to the local inactivated K1 vaccine. Groups 2B and 2C receiving a combination of the local K1 and imported live attenuated D78 vaccines had the highest antibody titers. Adoption of stinging nettle supplementation and a prime-boost program involving use of a local virus isolates-derived vaccine is recommended.

Patterns of care in two HIV continuity clinics in Uganda, Africa: a time-motion study.

The study objectives were to identify opportunities to improve the quality of care in resource-limited settings by examining the workflow and patient activities at two large outpatient HIV clinics in Uganda. Using time motion study techniques, we collected detailed data on all activities of patients and clinicians in two government-sponsored HIV clinics in Uganda. Processes measured included amount of time clinicians (physicians, nurse practitioners and clinical officers) spend in clinic, the daily patient census and patient visit-length. We also recorded the time spent on various activities by providers and patients. We found that the mean time in clinic per workday at Masaka was 5.5 hours and at Mbarara 4.9 hours, with about 60% of this time spent in direct and indirect care of patients at both sites. Workday start-times varied by two hours in Masaka and one-and-a half hours in Mbarara and end-times by five and three hours respectively. One-hundred-and-nineteen patients (SD 34) visited Masaka each day and 107 (SD 45) visited Mbarara. The mean duration of the patient visit was 77 minutes at Masaka and 196 minutes at Mbarara, with 66% and 62% of the time spent at respective sites waiting for care. We conclude that clinicians in resource-poor settings spend limited amounts of time at the clinic site, with a large portion of the clinic-time taken up by tasks that do not require specialized patient-care skills. This study demonstrates that opportunities exist to improve clinic productivity and visit experience for patients, and provides a baseline for designing and evaluating the impact of process improvement interventions.