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In the English National Health Service (NHS), patients are now expected to choose the time and place of treatment and even choose the actual treatment. However, the theory on which patient choice is based and the implementation of patient choice are controversial. There is evidence to indicate that attitudes and abilities to make choices are relatively sophisticated and not as straightforward as policy developments suggest. In addition, and surprisingly, there is little research on whether making individual choices about care is regarded as a priority by the largest NHS patient group and the single largest group for most GPs-older people. This conceptual paper examines the theory of patient choice concerning accessing and engaging with healthcare provision and reviews existing evidence on older people and patient choice in primary care.

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AIMS: The aims of this review are to identify and evaluate studies exploring the cost-effectiveness of primary angioplasty (PPCI) vs. thrombolysis (TL) for treating acute myocardial infarction (AMI). METHODS AND RESULTS: A comprehensive free-text searching identified economic evaluation studies that were reviewed with respect to their effectiveness data, identification, measurement and valuation of resource data, measurement and valuation of health outcomes (clinical and QALYs) and uncertainty analysis. A total of 14 studies were included in the review: seven were economic evaluations alongside RCTs, two community-based studies or registries and five decision-analytical models. PPCI was found to be cost-effective when compared with TL in eight studies, cost-saving in three, cost-neutral in one, and not significantly different in terms of both cost and benefits in two studies. CONCLUSIONS: The cost-effective evidence available is mainly derived from RCTs with stringent inclusion criteria using established catheter laboratories for providing PPCI treatment; these two components might restrict the generalisability of their "for managing patients with STEMI in hospital" settings. In order to aid policy makers on the real costs and benefits of the PPCI and TL, it is necessary to conduct more analyses with data from the real world in which there are more strategies evaluated for delivering PPCI than merely those in established catheter laboratories.

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Antiretroviral therapy (ART) improves the quality of life of people living with HIV/AIDS. However, adherence remains a challenge. A total of eight focus group discussions (FGD) were conducted with participants from a randomised controlled trial that monitored strategies for managing ART in African adults: Development of Antiretroviral Therapy. All FGD participants had received ART for at least one year. Perceived benefits of ART were key motivators for adherence. These benefits included improved physical health, restored self-esteem, acceptance in the community and hope for a longer and healthier life and reduced fear of HIV/AIDS-related death. Barriers to adherence included a high pill burden, ART side effects and socio-economic constraints, including lack of food and safe water for taking the pills. Visible ART side effects and involvement in an exclusively HIV/AIDS clinic could expose their HIV status, thus exacerbating stigma. Gender and socio-economic differences were found in the variety of strategies employed to ensure adherence. ART was perceived as improving the overall quality of life of recipients; however, it is crucial for ART programmes to be gender and socio-economic cognizant in order to enhance adherence to a lifelong therapy.

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Informal sources of care may lead to ineffective use of antimalarial drugs. A survey conducted in Malawi estimated the frequency of use of informal and formal services, medications, and household costs. A total of 508 household interviews were conducted. Treatment with an antimalarial was reported in 24% of young children accessing the informal sector and in 91% accessing formal services. Informal care was associated with shorter travel and waiting times, a lower proportion of carers or feverish adults missing work or studies and losing earnings, and a lower proportion of older children missing studies or work. Total out of pocket costs of fever episodes constitutes between 9% and 14% in young children and 18% in adults of their total available resources. Patients may perceive informal services to be associated with opportunity cost advantages; however, these may be associated with health risks of inadequate prescribing, particularly in young children.

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HIV/AIDS has had a devastating impact at individual, household and community levels. This qualitative research investigates the role of HIV voluntary counselling and testing (VCT) and treatment in enabling HIV-positive Ugandans to cope with this disease. Twelve predetermined focus group discussions (FGDs) were conducted; six with men and six with women. Half of the men and women's groups were receiving antiretroviral therapy (ART) and half were not. An FGD was held with the health care providers administering ART. Testing for HIV was perceived as soliciting a death warrant. Participants affirmed that the incentive for testing was the possibility of accessing free ART. They described experiencing gender-variant stigma and depression on confirming their HIV status and commended the role of counselling in supporting them to adopt positive living. For those receiving ART, counselling reinforced treatment adherence. The findings also revealed gender differences in treatment adherence strategies. ART was described to reduce disease symptoms and restore physical health allowing them to resume their daily activities. Additionally, ART was preferred over traditional herbal treatment because it had clear dosages, expiry dates and was scientifically manufactured. Those that were not receiving ART bore myths and misconceptions about the effectiveness and side effects of ART, delaying the decision to seek treatment. Stigma and the attached concern of HIV/AIDS-related swift death, is a major barrier for VCT. Based on this study's findings, ensuring the provision of quality assured and gender conscious VCT and ART delivery services will enhance positive living and enforce compliance to ART programmes.

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OBJECTIVE: To assess the psychometric performance of using standard gamble (SG), time trade-off (TTO) and visual analogue scale (VAS) in the evaluation of three predetermined HIV/AIDS health states in HIV-infected Ugandans, for use in cost-effectiveness analyses. METHODS: We recruited participants with CD4 cells <200/microl from the Development of AntiRetroviral Therapy in Africa (DART) trial cohort [randomized trial evaluating antiretroviral therapy (ART) management strategies] in Uganda, before they initiated ART (n = 276). A comparison group of ART-naive HIV-infected individuals was recruited from the Entebbe Cohort study (n = 159). Participants were interviewed and asked to rate his/her own health state using VAS; rank and evaluate HIV/AIDS predetermined health states using TTO and SG relative to an improved health state. Tools were tested for psychometrical properties. RESULTS: Women constituted 64% and 76% of the DART and Entebbe Cohorts. Mean age was 36.5 and 36.7 years, respectively. Participants could discriminate between predetermined HIV/AIDS health states. Deterioration in health status was associated with a reduction in rating scores (VAS), increased willingness to give up time (TTO) and acceptance of increased risk (SG) to achieve a better health state, independent of the participant's actual health state, as measured by CD4 cell counts. CONCLUSION: VAS, TTO and SG have good psychometric properties, making them good candidates for use in resource-constrained settings. Further research in a wider population is necessary to generate an evidence base with which to inform resource allocation decisions.

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BACKGROUND: Despite policies advocating centralised transfusion services based on voluntary donors, the hospital-based replacement donor system is widespread in sub-Saharan Africa. AIMS: To evaluate the cost of all laboratory resources needed to provide a unit of safe blood in rural Malawi using the family replacement donor system METHODS: Full economic costs of all laboratory tests used to screen potential donors and to perform cross-matching were documented in a prospective, observational study in Ntcheu district hospital laboratory. RESULTS: 1729 potential donors were screened and 11,008 tests were performed to ensure that 1104 units of safe blood were available for transfusion. The annual cost of all transfusion-related tests (in 2005 USdollars) was USdollars 17,976, equivalent to USdollars 16.28 per unit of transfusion-ready blood. Transfusion-related tests used 53% of the laboratory's total annual expenditure of USdollars 33,608. CONCLUSIONS: This is the first study to provide prospective economic costs of all laboratory tests associated with the family replacement donor system in a district hospital in Africa. Results show that despite potential economies of scale, a unit of blood from the centralised system costs about three times as much as one from the hospital-based "replacement" system. Factors affecting these relative costs are complex but are in part due to the cost of donor recruitment in centralised systems. In the replacement system the cost of donor recruitment is entirely borne by families of patients needing a blood transfusion.

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This review summarises a wide range of evidence about environmental and institutional factors that influence vulnerability to malaria, tuberculosis, and HIV infection. By combining this information with that obtained on factors operating at individual, household, and community level, we have identified potential common strategies for improving resilience to all three diseases simultaneously. These strategies depend on collaborations with non-health sectors and include progress in rapid access to funds, provision of education about disease transmission and management, reduction of the burden on carers (predominantly women), and improvement in the quality of health services.

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