Pharmaco Economic Analysis of HIV/AIDS Management at Murtala Muhammad Specialist Hospital, Kano, Nigeria
Chapter One
Aim and Objective of the Study
Aim of the study
The aim of this study is to determine the economic burden of management of HIV/AIDS patients at the Murtala Mohammed Specialist Hospital Kano, Nigeria.
Specific Objectives of the Study
- To determine the direct and indirect components of COI of HIV/AIDS on the health care sector
- To determine the direct and indirect components of the COI of HIV/AIDS of patients.
CHAPTER TWO
LITRATURE REVIEW
Overview of HIV/AIDS
HIV is a retrovirus that infects cells of the immune system, destroying or impairing their functions (WHO, 2008). HIV has a high affinity for the cluster of differentia 4 (CD4) receptor on T lymphocytes and its major effect on the immune system is a progressive depletion of CD4 T lymphocytes (Martindale, 2008). Thus, infection is followed by development of anti-HIV antibodies known as seroconversion, during which the patient may remain asymptomatic or have transient symptoms such as rash, sore throat, and lymphadenopathy (Martindale, 2008). Despite the presence of the anti-HIV antibodies, the infection progresses over a period of months to several years ultimately resulting to a persistent generalized lymphadenopathy (lymphadenopathy syndrome) or a more serious collection of symptoms known as AIDS-related complex (ARC), which include fatigue, weight loss, recurrent fever, diarrhoea, and persistent opportunistic infections (Martindale, 2008). AIDS is characterised by severe impairment of the immune system leading to the development of secondary infections – opportunistic infections (OIs) which could be life-threatening and include Pneumocystis carinii pneumonia (PCP), Toxoplasma encephalitis, oropharyngeal and oesophageal candidiasis, cryptococcal meningitis, cytomegalovirus retinitis, and tuberculosis (TB), or to secondary neoplasms such as Kaposi’s sarcoma, primary central nervous system (CNS) lymphomas, invasive cervical cancer, and non-Hodgkin’s lymphoma. Other complications may include dementia and thrombocytopenia (Martindale, 2008).
Two subtypes of HIV have been found – HIV-1, which is the most common and occurs worldwide and HIV-2, which is found mainly in Africa and is associated with a slower progression to AIDS than HIV-1 (Reeves et al., 2002). Thus, most untreated people infected with HIV-1 eventually develop AIDS. These individuals mostly die from OIs or malignancies associated with the progressive failure of the immune system. HIV progresses to AIDS at a variable rate influenced by the viral, host, and environmental factors; most will progress to AIDS within 10 years of HIV infection: some will have progressed much sooner, and some will take much longer (CASCADE EU, 2000). Treatment with antiretrovirals (ARVs) increases the life expectancy of people infected with HIV. Even after HIV has progressed to diagnosable AIDS, the average survival time with antiretroviral therapy (ART) was estimated to be more than 5 years as of 2005 (Schneider et al., 2005). Without ART, someone who has AIDS typically dies within a year (Morgan et al., 2002).
OIs, which may be caused by bacteria, virus, fungi or protozoa, are the major cause of morbidity and mortality in patients with HIV-1 infection. HIV/AIDS patients are especially susceptible to OIs because of their suppressed immune system, psychological stress which in turn can influence the immune system and depletion of nutritional status (Benson et al., 2009). OIs are sometimes the initial presentation of HIV disease and affected patients may have ignored the warning signs, attribute it to other illnesses or may just not have wanted a voluntary counselling and testing (VCT). Often, OIs may be the first signs of immunologic deterioration and tend to occur as CD4 counts drop though children < 1 year of age may get OIs with ―normal‖ CD4 counts (Benson et al., 2009).
The use of ART has reduced the incidence of OIs for patients with access to HIV care, however a number of patients in the developed and developing world do not have access to care and have OIs. Also, others who do not have a sustained response to ARV agents for multiple reasons which include poor adherence, drug toxicities, drug interactions, or initial acquisition of a drug-resistant strain of HIV-1 will have OIs. Thus, OIs will continue to cause substantial morbidity and mortality in HIV/AIDS patients especially in those with HIV-1 infection (Benson et al., 2009).
Thus, initiation of ART prevents OIs as well as help in resolution or improvement of certain OIs, most notably for those where specific treatment is not available. At times, patients who receive potent ART can have atypical presentations of OIs either early after the initiation of ART or after prolonged treatment (Benson et al., 2004).
OIs range from mild infections; particularly of skin and mucosal surfaces (examples include skin rashes and oral thrush) to severe life threatening infections like TB, cryptococcal meningitis, oesophageal candidiasis and PCP (Benson et al., 2004; CASCADE EU, 2000).
HIV/AIDS Timeline
The first recorded evidence of HIV has now been traced back to 1959. A team of British researchers stumbled on this evidence while working with preserved tissue samples of a Manchester sailor who died in 1959 of a disease that presented AIDS-like symptoms (Pence, 2008; Zhu et al., 1998). AIDS was first described in 1981 as a disease complex in heterosexual men in the United States of America. The journey HIV/AIDS have gone through can be outlined below:
In 1980, though an unknown disease at the time 31 people had died in the United States (US) of what would be known in later years as AIDS.
In 1981, the Centres‘ for Disease Control (CDC) published the first account of peculiar deaths from a syndrome that would later be named AIDS. The outbreak began when a rare cancer Kaposi‘s sarcoma and a rare pneumonia, PCP was noticed among otherwise healthy gay men in San Francisco. A total of 335 cases were diagnosed in the US and 158 died.
CHAPTER THREE
MATERIALS AND METHODS
Methodology
Study Hospital
Murtala Mohammed Specialist Hospital (MMSH), Kano, Nigeria is a state owned hospital which has been providing management to HIV/AIDS patients since 2005. The hospital serves as a referral centre to primary, secondary and other health care centres. It is supported by donor funded United States Agency for International development (USAID) organization. The agency provides the drugs and needed technical supports while the state provides the personnel. The clinic is accessed by patients from within and outside Kano state.
Study Perspective
This comprised both health care providers‘ and the patients‘ perspectives.
Study Design
Retrospective and cross-sectional methods were used to ensure collection of the necessary data.
Study Population
HIV/AIDS patients who were being managed at MMSH, Kano in the categories below formed our study population. They included:
- Adult patients on HAART
- Paediatric patients onHAART
- Adult patients on co-trimoxazole prophylaxisonly
- Paediatric patients on co-trimoxazole prophylaxis only
- All categories of health care workers involved in the management of the patients: doctors, pharmacists, nurses, pharmacy technicians, laboratory scientists and data entry
Study Period
The study was from 1st January 2010 to 31st December 2010 and it comprised of patients who were registered in the clinic on or before 1st January 2010.
Data Source
Data were mainly generated directly from the patients and allied health care workers directly involved in their care (primary data), and also from patient folders and other records (secondary data) kept in the clinic.
CHAPTER FOUR
RESULTS
Clinic Population and Clinic Days
MMSH holds HIV/AIDS clinic at two different sites within the hospital namely the family care centre (FCC) and the adult ART (AART) site. FCC runs its clinic three times a week, on Tuesdays, Wednesdays and Thursdays while the AART site runs four clinics a week on Mondays, Wednesdays, Thursdays and Fridays. Both clinics record an average of 50 patients a day. The total number of patients recorded between 1 January 2010 and 31 December 2010 were 3,333 (328 of whom were less than 14years and 3,005 of whom were 14 years and above) and this yielded a corresponding sample size of 284.
CHAPTER FIVE
DISCUSSION
Generally, the data presented here suggest that the management of HIV/AIDS at the Murtala Mohammed Specialist Hospital, Kano, Nigeria pose a serious economic burden on the health care system and those living with the disease. The study showed that children less than 15 years made up 10.6%, while adults above the age of 50 years account for 1.8%, leaving the economically viable population (15-49 years) with the highest percentage (87.65) of the patients living with this debilitating disease. UNAIDS, WHO (2008) reported that in developing countries most population with HIV/AIDS are within this group. HIV/AIDS is associated with high morbidity and mortality within this group and likely to cause strain on resources as this group is likely to have responsibilities and dependents.
The study also showed that females accounted for 66.2% of HIV/AIDS. This is in accordance with literature which says more than 50% of those infected are women (WHO, 2009). It would also be pertinent to note that the study was carried out in the Northern part of Nigeria where polygamy is widely practiced and could contribute to female infected population. Population Council Inc. (2007) reported that females <15 years of age in northern Nigeria are less likely to receive information on HIV/AIDS and are less likely to continue their education.
The study showed those with tertiary education had the lowest percentage (5.99%) and those with only Islamic education the highest. A study by Hargreaves et al. (2010), in Tanzania showed that changes in HIV prevalence differed by educational attainment level with HIV prevalence stable among those with no education, a small but borderline significant decline among those with primary education, and a larger statistically significant decline among those with secondary education.
CHAPTER SIX
Summary
HIV/AIDS burden to Nigeria and Nigerians cannot be undermined. HIV/AIDS cut across all ages and socio-demographic class. Females are more affected than males and the effect of this can be felt as women are the home keepers and in most cases care givers too.
The burden of HIV/AIDS on healthcare providers as well as on patients is significant. This burden can only increase as the rate of new infection increases at a steady rate and the availability of ARVs increases the life expectancy of the HIV positive individual this will increase the number of PLWHA.
The burden of HIV/AIDS is also increased by the presence of co-morbidities as well as non-medical direct costs and indirect cost.
The study also showed that most HIV/AIDS patients have their resources already strained (as also reported by WHO, 2009) and may never be able to sustain additional costs of paying for the drugs or consultations themselves.
Conclusion
HIV/AIDS management is expensive both to the provider and to the patient. The NGOs have not been able to reach their targets of having all HIV positive eligible patients on therapy and the Government of Nigeria should think of putting in funds to augment the efforts of the donors.
More awareness on prevention may be a cheaper stance for the Government to take so as to decrease overall burden of the disease.
Recommendations
Hastening expansion of HIV/AIDS treatment, prevention and care by decentralization of services and moving them to primary facilities as well as communities may be the key to decreasing overall disease burden in the long run. This will improve awareness on HIV/AIDS in all nook and crannies thereby decreasing incidence of new infections as well as decrease costs such as transport, indirect costs like hospital waiting time, absenteeism from work (because of less patients) and improvement in patient care as the number of patients per clinic day would be decreased. This may also decrease the incidences of OIs and self-medication.
A need for the full documentation of all visits and consultations would ease further studies as well as improve study outcome.
Consolidation of healthcare could be done; this could be by improving on the NHIS or alternative health insurance packages and expanding it to include HIV/AIDS management and redesigning the scheme such that both blue collar and white collar workers benefit from the scheme.
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