Browsing by Person "Walley, J. D."

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Costs and cost-effectiveness of different DOT strategies for the treatment of tuberculosis in Pakistan.
(Oxford University Press, 2002) Khan, M. A.; Walley, J. D.; Witter, Sophie; Imran, Safdar N.
An economic study was conducted alongside a clinical trial at three sites in Pakistan to establish the costs and effectiveness of different strategies for implementing directly observed treatment (DOT) for tuberculosis. Patients were randomly allocated to one of three arms: DOTS with direct observation by health workers (at health centres or by community health workers); DOTS with direct observation by family members; and DOTS without direct observation. The clinical trial found no statistically significant difference in cure rate for the different arms. The economic study collected data on the full range of health service costs and patient costs of the different treatment arms. Data were also disaggregated by gender, rural and urban patients, by treatment site and by economic categories, to investigate the costs of the different strategies, their cost-effectiveness and the impact that they might have on patient compliance with treatment. The study found that direct observation by health centre-based health workers was the least cost-effective of the strategies tested (US$310 per case cured). This is an interesting result, as this is the model recommended by the World Health Organization and International Union against Tuberculosis and Lung Disease. Attending health centres daily during the first 2 months generated high patient costs (direct and in terms of time lost), yet cure rates for this group fell below those of the non-observed group (58%, compared with 62%). One factor suggested by this study is that the high costs of attending may be deterring patients, and in particular, economically active patients who have most to lose from the time taken by direct observation. Without stronger evidence of benefits, it is hard to justify the costs to health services and patients that this type of direct observation imposes. The self-administered group came out as most cost-effective ($164 per case cured). The community health worker sub-group achieved the highest cure rates (67%), with a cost per case only slightly higher than the self-administered group ($172 per case cured). This approach should be investigated further, along with other approaches to improving patient compliance.
Simplified antiviral prophylaxis with or and without artificial feeding to reduce mother-to-child transmission of HIV in low and middle income countries: modelling positive and negative impact on child survival.
(International Scientific Literature, 2001-09) Walley, J. D.; Witter, Sophie; Nicoll, A.
BACKGROUND: Antiviral prophylaxis is recommended for HIV positive mothers to prevent mother-to-child transmission of HIV. To date UNAIDS and WHO policy has been based on a study in Thailand which showed a reduction in transmission by half with short course AZT (Zidovudine) treatment together with artificial feeding. We modelled the possible positive and negative effects on child deaths in low and middle resource developing country settings of two interventions to reduce mother to child transmission (MTCT) of HIV: antenatal testing, short-course antivirals (zidovudine or nevirapine), firstly with and then without artificial feeding. MATERIAL AND METHODS: Estimates are made of child lives likely to be saved by the programme by age ten years, balanced against increases in deaths due to more uninfected mothers choosing to use artificial feeds where these are part of the intervention. Mid-point values for variables affecting the balance of mortality gains and losses are taken from recent published data for low and middle income developing countries and a sensitivity analysis is undertaken. RESULTS: In low income settings the use of antivirals alone would result in an estimated gain in child survival of around 0.36%, representing 360 deaths avoided from a birth cohort of 100,000 by age 10 years. Adding artificial feeding could reduce the gain to 0.03% (30 deaths avoided). In middle income settings the gain from antivirals alone would be 0.26% but as 'spill-over' of artificial feeding to uninfected women was more likely it could result in a net increase of child deaths of up to 1.08% (1,080 additional deaths). A sensitivity analysis emphasised this potential for regimens using artificial feeding if progamme participation was low, and under most circumstances in middle income settings. CONCLUSIONS: HIV testing and use of antivirals by infected mothers, if well implemented, will be effective at a population level in reducing MTCT. However the addition of artificial feeding is potentially be a high risk strategy, especially in middle income countries.
Tuberculosis patient adherence to direct observation: results of a social study in Pakistan.
(Oxford University Press, 2006) Khan, M. A.; Walley, J. D.; Witter, Sophie; Shah, S. K.; Javeed, S.
A randomized controlled trial was carried out in Pakistan in 1999 to establish the effectiveness of the direct observation component of DOTS programmes. It found no significant differences in cure rates for patients directly observed by health facility workers, community health workers or by family members, as compared with the control group who had self-administered treatment. This paper reports on the social studies which were carried out during and after this trial, to explain these results. They consisted of a survey of all patients (64% response rate); in-depth interviews with a smaller sample of different types of patients; and focus group discussions with patients and providers. One finding was that of the 32 in-depth interview patients, 13 (mainly from the health facility observation group) failed to comply with their allocated DOT approach during the trial, citing the inconvenience of the method of observation. Another finding was that while patients found the overall TB care approach efficient and economical in general, they faced numerous barriers to regular attendance for the direct observation of drug-taking (most especially, time, travel costs, ill health and need to pursue their occupation). This may be one of the reasons why there was no overall benefit from direct observation in the trial. Provider attitudes were also poor: health facility workers expressed cynical and uncaring views; community health workers were more positive, but still arranged direct observation to suit their, rather than patients', schedules. The article concludes that direct observation, if used, should be flexible and convenient, whether at a health facility close to the patient's home or in the community. The emphasis should shift in practice from tablet watching towards treatment support, together with education and other adherence measures.