RESUMEN
OBJECTIVE: Breakthrough cancer pain (BTCP) represents a considerable economic burden. A decision-analysis model was developed to evaluate the cost-effectiveness of intranasal fentanyl spray (INFS) compared with oral transmucosal fentanyl citrate (OTFC) and fentanyl buccal tablet (FBT) for the treatment of BTCP. METHODS: The model was parameterized for Sweden to estimate the costs and benefits associated with treatments. Expected reductions in pain intensity (PI; measured on a numeric rating scale ranging from 0 to 10) per BTCP episodes were translated into resource use and quality-adjusted life years (QALYs). Relative analgesic efficacy of interventions was derived from a mixed treatment comparison of six randomized controlled trials. The relationship between PI and utility was obtained from a time-trade off study in the general population. Resource use and unit cost data were obtained from the literature and validated by Swedish clinical experts. The base case scenario assumed three BTCP episodes/day, a background PI of 2, and a time horizon of 180 days. Prices of INFS and OTFC were assumed to be equal with FBT â¼14% less. Uncertainty in the source data was incorporated by probabilistic sensitivity analyses and different scenario analyses. RESULTS: With INFS, 55% of BTCP (95% uncertainty interval [UI]: 46-68%) was avoided, which is greater than expected with OTFC (29%; UI 22-38%) or FBT (31%; UI 25-39%). INFS was dominating OTFC (resulting in 0.046 QALY gain and saving 174 Euros with a time horizon of 180 days) and cost-effective versus FBT (incremental cost-effectiveness ratio 12203 Euros/QALY). Despite uncertainty in the source data, there is a >99% probability that INFS is the most cost-effective intervention. CONCLUSION: Given inherent limitations of modelling studies, the greater efficacy of INFS translates to cost and QALY advantages over competing interventions in the treatment for BTCP in Sweden.
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Analgésicos Opioides/economía , Fentanilo/economía , Neoplasias/complicaciones , Neoplasias/economía , Dolor/tratamiento farmacológico , Dolor/economía , Administración Bucal , Administración Intranasal , Analgésicos Opioides/administración & dosificación , Análisis Costo-Beneficio , Árboles de Decisión , Fentanilo/administración & dosificación , Humanos , Modelos Económicos , Neoplasias/tratamiento farmacológico , Dolor/etiología , Años de Vida Ajustados por Calidad de Vida , SueciaRESUMEN
BACKGROUND: Enormous variation exists in HIV prevalence between countries in sub-Saharan Africa. The contribution of migration to the spread of HIV has long been recognized, but its effect at the population level has never been assessed. In this ecological analysis, we explore how much variation in HIV prevalence in urban sub-Saharan Africa is explained by in-migration. METHODS: We performed a linear regression to analyze the association between the proportion of recent in-migrants and HIV prevalence for men and women in urban areas, using 60 data points from 28 sub-Saharan African countries between 1987 and 2005. RESULTS: We found a strong association between recent in-migration and HIV prevalence for women (Pearson R = 57%, P < 0.001) and men (R = 24%, P = 0.016), taking the earliest data point for each country. For women, the association was also strong within east/southern Africa (R = 50%, P = 0.003). For both genders, the association was strongest between 1985 and 1994, slightly weaker between 1995 and 1999, and nonexistent as from 2000. The overall association for both men and women was not confounded by the developmental indicators GNI per capita, income inequalities, or adult literacy. CONCLUSIONS: Migration explains much of the variation in HIV spread in urban areas of sub-Saharan Africa, especially before the year 2000, after which HIV prevalences started to level off in many countries. Our findings suggest that migration is an important factor in the spread of HIV, especially in rapidly increasing epidemics. This may be of relevance to the current HIV epidemics in China and India.
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Brotes de Enfermedades/prevención & control , Emigración e Inmigración/estadística & datos numéricos , Seropositividad para VIH/transmisión , Población Urbana/estadística & datos numéricos , Adolescente , Adulto , África del Sur del Sahara/epidemiología , Análisis de Varianza , Femenino , Humanos , Modelos Lineales , Masculino , Persona de Mediana Edad , Prevalencia , Vigilancia de Guardia , Distribución por Sexo , Factores SocioeconómicosRESUMEN
BACKGROUND: Persons with absent partners may be more vulnerable to risky sexual behavior and therefore HIV. Partner absence can be due to traveling (e.g., family visits or funerals) or to living apart (e.g., work-related or in polygamous marriages). We investigated to what extent partner absence leads to more risky sexual behavior in Tanzanian couples. METHODS: We compared 95 men and 85 women living apart with 283 men and 331 women living together. Only persons who were still married were included, either living apart or cohabiting at the time of the interview. Subjects were classified into 4 groups: coresidents being either nonmobile or mobile, and people living apart either frequently or infrequently seeing each other. RESULTS: Most people living apart were polygamously married. Men living apart did not report more extramarital sex than coresident men. However, among coresident men, extramarital sex was reported by 35% of those being mobile compared with 15% of those nonmobile. Among women, those living apart reported extramarital sex more often than coresidents (14% vs. 7%), and this was mainly due to women living apart who infrequently saw their husbands. CONCLUSIONS: Risky sexual behavior occurs more often in mobile coresident men, and in women living apart infrequently seeing their spouses. These groups are relatively easy to identify and need extra attention in HIV prevention campaigns.
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Infecciones por VIH/epidemiología , Conducta Sexual , Viaje , Adolescente , Adulto , Femenino , Humanos , Masculino , Dinámica Poblacional , Factores de Riesgo , Esposos , Tanzanía/epidemiologíaRESUMEN
BACKGROUND: Pre-exposure prophylaxis (PrEP) is a promising new HIV prevention method, especially for women. An urgent demand for implementation of PrEP is expected at the moment efficacy has been demonstrated in clinical trials. We explored the long-term impact of PrEP on HIV transmission in different HIV epidemics. METHODOLOGY/PRINCIPAL FINDINGS: We used a mathematical model that distinguishes the general population, sex workers and their clients. PrEP scenarios varying in effectiveness, coverage and target group were modeled in the epidemiological settings of Botswana, Nyanza Province in Kenya, and Southern India. We also studied the effect of condom addition or condom substitution during PrEP use. Main outcome was number of HIV infections averted over ten years of PrEP use. PrEP strategies with high effectiveness and high coverage can have a substantial impact in African settings. In Southern India, by contrast, the number of averted HIV infections in different PrEP scenarios would be much lower. The impact of PrEP may be strongly diminished or even reversed by behavioral disinhibition, especially in scenarios with low coverage and low effectiveness. However, additional condom use during low coverage and low effective PrEP doubled the amount of averted HIV infections. CONCLUSIONS/SIGNIFICANCE: The public health impact of PrEP can be substantial. However, this impact may be diminished, or even reversed, by changes in risk behavior. Implementation of PrEP strategies should therefore come on top of current condom campaigns, not as a substitution.
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Infecciones por VIH/epidemiología , Infecciones por VIH/prevención & control , Botswana/epidemiología , Simulación por Computador , Condones , Femenino , Infecciones por VIH/transmisión , Humanos , India/epidemiología , Kenia/epidemiología , Masculino , Prevalencia , Medición de Riesgo , Trabajo SexualRESUMEN
OBJECTIVE: To investigate how mobility is related to sexual risk behavior and HIV infection, with special reference to the partners who stay behind in mobile couples. METHODS: HIV status, sexual behavior and demographic data of 2800 couples were collected in a longitudinal study in Kisesa, rural Tanzania. People were considered short-term mobile if they had slept outside the household at least once on the night before one of the five demographic interviews, and long-term mobile if they were living elsewhere at least once at the time of a demographic round. RESULTS: Overall, whereas long-term mobile men did not report more risk behavior than resident men, short-term mobile men reported having multiple sex partners in the last year significantly more often. In contrast, long-term mobile women reported having multiple sex partners more often than resident women (6.8 versus 2.4%; P = 0.001), and also had a higher HIV prevalence (7.7 versus 2.7%; P = 0.02). In couples, men and women who were resident and had a long-term mobile partner both reported more sexual risk behavior and also showed higher HIV prevalence than people with resident/short-term mobile partners. Remarkably, risk behavior of men increased more when their wives moved than when they were mobile themselves. CONCLUSIONS: More sexual risk behavior and an increased risk of HIV infection were seen not only in mobile persons, but also in partners staying behind. Interventions aiming at reducing risk behavior due to mobility should therefore include partners staying behind.