The number of people living with HIV (PLHIV) with access to effective and life-saving antiretroviral therapy (ART) has grown rapidly in low- and middle-income countries (LMICs) over the past decade.1 Life expectancy has increased,2–8 and the burden of opportunistic infections has decreased.9–12 Data from the United States and Europe demonstrate the increasing burden of noncommunicable diseases (NCDs) among PLHIV in the era of ART.13,14 A similar trend is anticipated in LMICs,11 where NCDs are already on the rise among the general population (see Table A1, Supplemental Appendix, http://links.lww.com/QAI/A545),15,16 with earlier age of onset and higher mortality compared with higher-income countries.17,18 PLHIV in LMICs thus represent a population in whom preventive, screening, and therapeutic strategies for NCDs could offer substantial health benefits.19–21
Existing HIV infrastructure offers an opportunity to address NCDs and their risk factors.2,22–24 To date, integration strategies have focused primarily on tuberculosis (TB), sexually transmitted infections, malaria prevention, and reproductive health,25–28 with some accompanying evaluations of cost-effectiveness.29 To determine the potential value of integrating clinical care for HIV and NCDs, it is critical to first assess the effectiveness of such integrated interventions. Additional questions then follow: Is the integrated approach cost-effective compared with the current nonintegrated care? Is it affordable? How can it best be implemented in a specific setting? Health economics offers useful methodologies to answer these questions and prioritize efforts. Here, we provide an overview of these methodologies and the data needed for such analyses.
Search Strategy and Selection Criteria
We searched the databases of PubMed and Ovid for studies published in English before January 30, 2014. We used the search terms: “HIV,” “tuberculosis,” and “noncommunicable diseases” as the first set of terms, with “cost-effectiveness,” “costs,” “integration,” and “Africa” in subsequent searches. We also searched for specific NCDs such as “cervical cancer,” “depression,” and “hypertension.” We then used the bibliographies of relevant articles to expand the list of eligible articles.
Cost-effectiveness analysis (CEA) and mathematical modeling provide guidance for strategic prioritization of resources by projecting clinical outcomes from specific strategies and examining the comparative value of different strategies. CEA evaluates both effectiveness (eg, in years of life saved) and costs to calculate an incremental cost-effectiveness ratio (ICER; or [INCREMENT] costs/[INCREMENT] effectiveness) that quantifies the value of different strategies of care. Guided by recommendations from World Health Organization CHOosing Interventions that are Cost-Effective (WHO-CHOICE),30 a strategy is often considered “cost-effective” if its ICER is less than 3 times the country-specific per capita gross domestic product and “very cost-effective” if its ICER is less than the per capita gross domestic product. Such analyses can inform policy and allocation of resources for HIV guidelines and care.31–33
For which specific NCDs will integration with HIV services have the greatest impact? As discussed by Petersen et al34 in this supplement, leveraging multi-regional research and programmatic HIV cohorts in LMICs can identify the prevalence and incidence of specific NCDs, including their risk factors and attributable mortality.35–37 The competing risks of different NCDs and HIV infection must be understood to prioritize an expansion of care services for PLHIV.38,39
The value of integration depends on the accuracy and availability of screening and prevention strategies, successful linkage to treatment for those who are eligible, and the effectiveness of the treatment. Necessary data include diagnostic test performance (eg, sensitivity, specificity) in settings with different disease prevalence (eg, yielding different positive and negative predictive values), and the risks associated with screening methods.40 Easily administered, low-cost tests that yield results rapidly—particularly point-of-care diagnostic tests—could be used in integrating NCD screening into HIV care.41 Access to treatment and risk factor modification after screening and diagnosis will also affect the value of integrating services.40 Treatment outcomes include effectiveness, relapse, the frequency and severity of treatment-associated adverse events, and quality of life,42 using either quality-adjusted life years43 or disability-adjusted life years.44
Costs are a major consideration, especially where resources are most limited,45 and include direct medical costs (eg, diagnostic tests, preventive strategies, treatments) and costs for infrastructure, personnel, training, and monitoring and evaluation activities.46,47 Adding costs of NCD screening and treatment to already overstretched health services must be weighed against the burden inflicted by NCDs, including the direct costs associated with management of advanced disease and indirect costs such as time costs (eg, lost wages) for those affected.48 Additionally, integrating NCD services with existing HIV infrastructure could decrease overall costs by taking advantage of efficiencies of scope.
Outcomes of Interest
CEA can use modeling methods to project clinical outcomes and comparative value of interventions for NCD prevention, screening, and management. Although clinical trials largely define outcomes at early time points, models can estimate the clinical impact of interventions in the short and long term. CEA also quantifies the value of one strategy compared with another by projecting the additional clinical benefits attained for resources used.
A related methodology, budget impact analysis (BIA), assesses the costs of a program in specific settings. BIA focuses on program affordability from the perspective of stakeholders, such as ministries of health, nongovernmental organizations, or other payers. These analyses also account for the direct per capita costs of a program and the number of patients treated in a given program over a specified budget period.48 Thus, although a strategy may be cost-effective when measured against an external threshold of willingness to pay,30,40,49 BIA assesses the actual resources needed to implement that strategy in a specific setting.
Integrating clinical services offers an opportunity to improve overall health among PLHIV but also has the potential to undermine HIV care. Further investigation will determine whether outcomes will improve or suffer. After a systematic review of the literature, we describe TB/HIV as 1 example of existing integrated services and describe data needed to assess its cost-effectiveness. We then examine cervical cancer and depression as 2 case examples of the potential for integrated NCD/HIV care.
TB/HIV Integrated Services
TB: Epidemiology, Quality of Life, and Mortality
TB in PLHIV offers a prime opportunity to assess the impact and cost-effectiveness of an integrated approach to care compared with distinct treatment sites. Approximately 1.1 million of the 33.3 million PLHIV in the world were diagnosed with active TB in 2012 alone.50 PLHIV who have TB experience a substantially decreased quality of life51 and increased stigma,52 both of which improve with treatment.53 TB remains the leading cause of death among PLHIV; almost 25% of those with HIV and TB worldwide will die from TB.54
TB/HIV: Screening and Treatment Outcomes
Early detection and treatment of TB are critical to reducing TB mortality and transmission among PLHIV.55–58 Active TB screening results in timely, accurate TB diagnoses for which effective treatment exists.59–63 However, separate clinical sites for TB and HIV can result in reduced TB or HIV case finding and poor (62%) or delayed (32%) linkage to care,64 and low rates of ART initiation (13%–62%).64–67
Integration of TB/HIV services can address these shortcomings.68–71 In Guatemala, TB/HIV integration improved initiation of TB treatment (23% vs. 94%, pre- vs. post-integration) and decreased mortality at 50 weeks (72% vs. 27%).70 In Uganda, integration resulted in modest gains; more patients completed TB treatment (62% vs. 68%, pre- vs. post-) and fewer experienced death or treatment default (33% vs. 25%).71
Integrated TB/HIV care could lead to improvements not only in TB but also in HIV outcomes.72 In the Democratic Republic of Congo, 46% of TB patients preferred HIV counseling/testing by TB nurses rather than referral to a freestanding HIV voluntary counseling/testing site (25%) or a separate, on-site clinic (29%).73 In a Ugandan study, patients were more likely to initiate ART at some point during TB treatment (78% vs. 94%), especially during the earlier intensive treatment phase (23% vs. 60%).71 In an integrated South African site, time to ART initiation decreased from 147 days to 75 days, and patients were 1.6 times more likely to start ART.74
Although the direct costs of TB and HIV care have been reported,75,76 the detailed costs and tradeoffs of integrated TB/HIV care are not yet well described. In addition to diagnostic tests and medications, costs include infrastructure, personnel, and training.77 Integrated TB/HIV care could reduce overall resource utilization by relying on efficiencies of scope to increase the value of existing infrastructure and personnel.
Cost-effectiveness of TB/HIV Integration
Several studies have examined the cost-effectiveness of specific aspects of integrated TB/HIV care. Integrating routine HIV testing into TB treatment clinics in India is “very cost-effective” when compared with selective screening78 and is likely to be even more cost-effective in settings with higher HIV prevalence because more people are likely to be diagnosed with HIV and linked to care.59,79,80 Integrating TB screening methods (eg, Xpert MTB/RIF or urine LAM) when initiating ART for PLHIV can be cost-effective in South Africa as compared with symptom screening and sputum smear or sputum culture.81–83 Point-of-care tests that improve linkage to care could outweigh limitations in test characteristics, such as reduced sensitivity or specificity, when compared with a laboratory-based test.84 Isoniazid preventive therapy among PLHIV offers another example of how integrating an aspect of TB prevention into HIV services can be cost-effective.80,85–87
OPPORTUNITIES TO INTEGRATE HIV AND NCD CARE: USING A COST-EFFECTIVENESS APPROACH
In terms of value, data are limited but promising regarding the impact on NCD outcomes of integrating HIV care into primary care.22,88,89 Screening for NCDs and their risk factors, as well as associated treatments, fall along a wide spectrum regarding continuity of care and costs (see Table A3, Supplemental Appendix, http://links.lww.com/QAI/A545). Interventions are more costly if they require intensive training or the use of new technologies or if they occur at frequent intervals among large numbers of people. Cervical cancer and depression are 2 examples of NCDs that merit further evaluation regarding the potential value of integration.
CERVICAL CANCER/HIV INTEGRATED SERVICES
Cervical Cancer: Epidemiology
As further described by Adebamowo et al in this supplement,90 invasive cervical cancer (ICC) will likely be a major cause of mortality as women living with HIV gain increased access to ART in sub-Saharan Africa (SSA).91,92 The incidence of ICC in SSA is the highest in the world; age-standardized incidence rates in the general population range from 28 to 42.7 cases per 100,000 women.91 HIV-infected women are at even greater risk for ICC,93–96 which often occurs at younger ages97 and presents at more advanced stages when treatment is less likely to be successful.98 Furthermore, ART may not reduce cervical cancer risk, and life-long screening is needed.98,99
Cervical Cancer: Screening and Treatment Outcomes
ICC often manifests with precursor cervical lesions evident with screening and amenable to treatment. Multiple screening methods have demonstrated accuracy in LMICs,91,100 with the ability to incorporate mobile technologies101,102 and well-trained nonphysician clinicians to extend services.97,102,103 Likewise, when precancerous lesions are identified, multiple treatment options demonstrate excellent efficacy in LMICs.102,104–108 Operational aspects of screening and treatment for ICC and its precursor lesions have been demonstrated in Zambia, with more than 65,000 women screened in the first 5 years of a large program109,110 and more than 110,000 women screened over the past 8 years.111
Although screening is available and accurate, only 0.4%–20.2% of African women receive even 1 screening test in their lifetimes.91,102,112,113 Loss to follow-up after initial diagnosis is high, and treatment opportunities are missed.97,114 Integrating ICC screening and treatment with HIV services could offer improved uptake of screening and treatment outcomes.
Cervical Cancer: Costs
Studies have reported on the costs of reagents, technologies, and infrastructure for cervical cancer screening programs in LMICs, including cytology ($2.0–4.4 per specimen), human papillomavirus DNA testing ($7.9–8.6 per test), and visual inspection with acetic acid (<$5 per test).115,116 Costs for staff, training, and quality assurance of procedures have not been reported, and the efficiencies of scope attained with integration of services have not yet been established.
Cost-effectiveness of Cervical Cancer and HIV Integration
Although extensive literature exists on the cost-effectiveness of screening interventions to reduce ICC among the general population in LMICs117–121 and among PLHIV in high-income settings,122 cost-effectiveness literature is limited regarding ICC in PLHIV in LMICs. A study from Brazil suggests that a 2-tiered screening approach (ie, annual human papillomavirus screening followed by cytology, if positive) is very cost-effective in HIV-infected women123; integrating such an approach into routine HIV care could further increase its value if outcomes are maintained and uptake improved. An analysis in SSA suggests that only 262 HIV-infected women receiving ART would need to be screened to prevent 1 cervical cancer death.124 Integration with HIV services and the utilization of existing infrastructure have the potential to facilitate scale-up and decrease barriers to access.114,125
DEPRESSION/HIV INTEGRATED SERVICES
Depression: Epidemiology and Quality of Life
Depression is highly prevalent among PLHIV in SSA, requiring repeated screening and longitudinal treatment, as described by Chibanda et al126 in this supplement. Up to 40% of PLHIV attending ART clinics in LMICs suffer from depression,127–134 and specific subgroups, such as women, are at particularly high risk.135–138
Depression can negatively impact adherence to ART, leading to worse HIV outcomes.130–132,139–143 In a meta-analysis from SSA, ART adherence was 55% lower in patients with depression symptoms.134 Women with HIV who reported symptoms of depression also experienced accelerated HIV disease progression and higher mortality.138 Depression among PLHIV has been correlated with reduced quality of life in the United States,144 and early evidence suggests the same in SSA.145
Depression: Screening and Treatment Outcomes
Simple screening strategies for depression are feasible in LMICs and in HIV-infected populations, offering an opportunity for integration.146,147 Short surveys have been validated in HIV-uninfected populations,148 as have longer surveys149 and visual scales.150 Incorporating screening for substance use, especially alcohol use, could offer particular benefit, given its comorbidity with both HIV and depression.151,152 Integration of depression screening with HIV care could improve case detection and management.153
Treatment options for depression exist in LMICs. Medications, cognitive behavioral therapy, and interpersonal therapy have all been studied in PLHIV in LMICs.147,154–156 Further study is needed on the accessibility and sustainability of these interventions, the quantification of their impact on quality of life and life expectancy, and their integration into routine HIV care.139
Costs of screening for and treating depression include personnel, training, therapy, and associated medications, which could offset other medical costs from utilization of health services and improve economic outcomes in treated patients.157–159 If successful diagnosis and treatment of depression increased ART adherence or retention in care, then costly second-line ART regimens could be deferred or avoided. However, the scale of such benefit is unclear.
Cost-effectiveness of Depression/HIV Integration
In high-income country general populations, CEA has demonstrated that integrating depression screening and treatment with primary care can be cost-effective.157,158 Decreased overall costs of care can be achieved by integrating care for HIV, mental health, and substance use in the United States; longer follow-up for such interventions will provide more data about the sustainability of such an approach.159 This question, to our knowledge, has not yet been studied in LMICs.
TRADEOFFS AND CHALLENGES ASSOCIATED WITH IMPLEMENTATION OF INTEGRATED SERVICES
The optimal implementation of integrated strategies in specific settings remains to be determined,160 and integrated care could have unintended consequences. Wait times increased from 91 to 127 minutes in a Zambian clinic because of staff and patient flow problems after integration of HIV services with primary health care.161 Longer wait times could increase loss to follow-up or exacerbate stigma,162–164 and TB transmissions could even be increased.69,165 Staff training and program quality might be less effective or more costly when multiple interventions are provided together.166 Developing quality indicators for NCD and HIV outcomes will assist in programmatic feedback and assessment of these potential tradeoffs.166–169
The benefits of introducing integrated services and new technologies can be realized only if accompanied by initiatives that strengthen health systems, as emphasized by the Gene Xpert experience in South Africa.170–172 Any value of integrating NCDs or TB with HIV clinical care will only be achieved if health systems are capable of providing high-quality clinical care consistently and rapidly.
Integration of NCD/HIV services could build on innovative approaches from a diversity of tools and experiences. The expanded use of mobile health (mHealth) suggests that information technologies can improve effectiveness and decrease costs for integrated care.101,173,174 Analyses of primary health clinics in LMICs, which face similar challenges in terms of a management of diverse comorbidities, can offer guidance regarding NCD care for PLHIV.175 NCD screening and treatment could be included in decentralized public health clinics, mobile clinics, community-based campaigns, or home-based care, which may offer additional opportunities for accessing those absent from clinics and allow for increased coverage by integrated services.176–180 Although integration and expansion of NCD care within HIV services can be implemented more easily in settings with more established health care infrastructures,181 integration may offer even more clinical benefits in the most resource-limited settings where NCD services are not yet routinely available. Barriers to access and methods to facilitate scale-up need investigation in specific clinical settings.
RESEARCH AND TRAINING AGENDAS
To assess the value of different strategies for screening, prevention, and management of NCDs among PLHIV in LMICs, innovative research at the intersection of NCDs and HIV in LMICs is warranted (Table 1). Data needed include the incidence and prevalence of various NCDs among PLHIV in LMICs, screening and treatment outcomes, effects of NCDs on quality of life in PLHIV, and the costs associated with managing these comorbidities. The specific assessment of integrated services and the implementation of best practices are also critical.
Clinical training of health care workers for NCD screening and treatment is necessary,167,182 as is further training of students and health professionals in epidemiology and implementation science.183 As new programmatic initiatives are developed for NCDs in LMICs, formal training in costing methodology, CEA, and BIA will offer opportunities for capacity building to assist policymakers at local, regional, and national levels.
SUMMARY AND CONCLUSIONS
The remarkable success of ART scale-up in LMICs has established an infrastructure for providing longitudinal medical care to millions of people. PLHIV are living longer and healthier lives but are now at risk for morbidity and mortality from NCDs. The clinical impact and costs of different strategies for NCD prevention, management, and diagnosis in PLHIV is beginning to be quantified. Implementation science can inform the adaptation and expansion of lessons learned from HIV and TB/HIV integrated care to NCDs. Optimal strategies will vary by country, setting, and the underlying burden of different NCDs. Cost-effectiveness and BIA, in addition to observational studies and randomized clinical trials, are complementary tools to assess the value of screening for and treatment of NCDs and can inform health policy in an era marked by very effective HIV therapy, a growing NCD burden, and increasingly limited resources.
2. Bendavid E, Holmes CB, Bhattacharya J, et al.. HIV development assistance and adult mortality in Africa. JAMA. 2012;307:2060–2067.
3. Bor J, Herbst AJ, Newell ML, et al.. Increases in adult life expectancy in rural South Africa: valuing the scale-up of HIV treatment. Science. 2013;339:961–965.
4. Jahn A, Floyd S, Crampin AC, et al.. Population-level effect of HIV on adult mortality and early evidence of reversal after introduction of antiretroviral therapy in Malawi. Lancet. 2008;371:1603–1611.
5. Kilsztajn S, Lopes ES, do Carmo MS, et al.. Improvement in survival among symptomatic AIDS patients by exposure category in Sao Paulo. J Acquir Immune Defic Syndr. 2007;45:342–347.
6. Mills EJ, Bakanda C, Birungi J, et al.. Life expectancy of persons receiving combination antiretroviral therapy in low-income countries: a cohort analysis from Uganda. Ann Intern Med. 2011;155:209–216.
7. Johnson LF, Mossong J, Dorrington RE, et al.. Life expectancies of South African adults starting antiretroviral treatment: collaborative analysis of cohort studies. PLoS Med. 2013;10:e1001418.
8. Herbst AJ, Cooke GS, Barnighausen T, et al.. Adult mortality and antiretroviral treatment roll-out in rural KwaZulu-Natal, South Africa. Bull World Health Organ. 2009;87:754–762.
9. Hoffmann CJ, Fielding KL, Johnston V, et al.. Changing predictors of mortality over time from cART start: implications for care. J Acquir Immune Defic Syndr. 2011;58:269–276.
10. Lim MS, Dowdeswell RJ, Murray J, et al.. The impact of HIV, an antiretroviral programme and tuberculosis
on mortality in South African platinum miners, 1992-2010. PLoS One. 2012;7:e38598.
11. Grinsztejn B, Luz PM, Pacheco AG, et al.. Changing mortality profile among HIV-infected patients in Rio de Janeiro, Brazil: shifting from AIDS to non-AIDS related conditions in the HAART era. PLoS One. 2013;8:e59768.
12. Curtis AJ, Marshall CS, Spelman T, et al.. Incidence of WHO stage 3 and 4 conditions following initiation of anti-retroviral therapy in resource limited settings. PLoS One. 2012;7:e52019.
13. Mocroft A, Brettle R, Kirk O, et al.. Changes in the cause of death among HIV positive subjects across Europe: results from the EuroSIDA study. AIDS. 2002;16:1663–1671.
14. Palella FJ Jr, Baker RK, Moorman AC, et al.. Mortality in the highly active antiretroviral therapy era: changing causes of death and disease in the HIV outpatient study. J Acquir Immune Defic Syndr. 2006;43:27–34.
15. Mendis S, Puska P, Norrving B, eds. Global Atlas on Cardiovascular Disease Prevention and Control. 2011. Available at: http://whqlibdoc.who.int/publications/2011/9789241564373_eng.pdf
. Accessed August 12, 2013.
16. World Health Organization. Global status report on noncommunicable diseases
. 2010. Available at: http://whqlibdoc.who.int/publications/2011/9789240686458_eng.pdf
. Accessed September 20, 2013.
17. Feigin VL, Lawes CM, Bennett DA, et al.. Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review. Lancet Neurol. 2009;8:355–369.
18. Kengne AP, Ntyintyane LM, Mayosi BM. A systematic overview of prospective cohort studies of cardiovascular disease in sub-Saharan Africa. Cardiovasc J Afr. 2012;23:103–112.
19. Wester CW, Koethe JR, Shepherd BE, et al.. Non-AIDS-defining events among HIV-1-infected adults receiving combination antiretroviral therapy in resource-replete versus resource-limited urban setting. AIDS. 2011;25:1471–1479.
20. Geneau R, Hallen G. Toward a systemic research agenda for addressing the joint epidemics of HIV/AIDS
and noncommunicable diseases
. AIDS. 2012;26(suppl 1):S7–S10.
21. Deeks SG, Lewin SR, Havlir DV. The end of AIDS: HIV infection as a chronic disease. Lancet. 2013;382:1525–1533.
22. Walton DA, Farmer PE, Lambert W, et al.. Integrated HIV prevention and care strengthens primary health care: lessons from rural Haiti. J Public Health Policy. 2004;25:137–158.
23. Cohen RL, Li Y, Giese R, et al.. An evaluation of the president's emergency plan for AIDS relief effect on health systems strengthening in sub-Saharan Africa. J Acquir Immune Defic Syndr. 2013;62:471–479.
24. Palen J, El-Sadr W, Phoya A, et al.. PEPFAR, health system strengthening, and promoting sustainability and country ownership. J Acquir Immune Defic Syndr. 2012;60(suppl 3):S113–S119.
25. Colindres P, Mermin J, Ezati E, et al.. Utilization of a basic care and prevention package by HIV-infected persons in Uganda. AIDS Care. 2008;20:139–145.
26. Tolle MA. A package of primary health care services for comprehensive family-centred HIV/AIDS
care and treatment programs in low-income settings. Trop Med Int Health. 2009;14:663–672.
27. Davis S, Patel P, Sheikh A, et al.. Adaptation of a general primary care package for HIV-infected adults to an HIV centre setting in Gaborone, Botswana. Trop Med Int Health. 2013;18:328–343.
28. Grossman D, Onono M, Newmann SJ, et al.. Integration of family planning services into HIV care and treatment in Kenya: a cluster-randomized trial. AIDS. 2013;27(suppl 1):S77–S85.
29. Shade SB, Kevany S, Onono M, et al.. Cost, cost-efficiency and cost-effectiveness
of integrated family planning and HIV services. AIDS. 2013;27(suppl 1):S87–S92.
30. World Health Organization. CHOosing Interventions that are Cost Effective (WHO-CHOICE): cost-effectiveness
thresholds. 2005. Available at: http://www.who.int/choice/costs/CER_thresholds/en/index.html
. Accessed February 28, 2013.
31. Goldie SJ, Yazdanpanah Y, Losina E, et al.. Cost-effectiveness
of HIV treatment in resource-poor settings: the case of Côte d'Ivoire. N Engl J Med. 2006;355:1141–1153.
32. Walensky RP, Wolf LL, Wood R, et al.. When to start antiretroviral therapy in resource-limited settings. Ann Intern Med. 2009;151:157–166.
33. Walensky RP, Wood R, Ciaranello AL, et al.. Scaling up the 2010 World Health Organization HIV treatment guidelines in resource-limited settings: a model-based analysis. PLoS Med. 2010;7:e1000382.
34. Petersen ML, Yiannoutsos CT, Justice AC, et al.. Observational research on NCDs in HIV-positive populations: conceptual and methodological considerations. J Acquir Immune Defic Syndr. 2014;67–S16(suppl 1):S8–S16.
35. Egger M, Ekouevi DK, Williams C, et al.. Cohort profile: the international epidemiological databases to evaluate AIDS (IeDEA) in sub-Saharan Africa. Int J Epidemiol. 2012;41:1256–1264.
36. Hunt PW, Cao HL, Muzoora C, et al.. Impact of CD8+ T-cell activation on CD4+ T-cell recovery and mortality in HIV-infected Ugandans initiating antiretroviral therapy. AIDS. 2011;25:2123–2131.
37. Lahuerta M, Lima J, Elul B, et al.. Patients enrolled in HIV care in Mozambique: baseline characteristics and follow-up outcomes. J Acquir Immune Defic Syndr. 2011;58:e75–e86.
38. Andersen PK, Geskus RB, de Witte T, et al.. Competing risks in epidemiology: possibilities and pitfalls. Int J Epidemiol. 2012;41:861–870.
39. Joint United Nations Programme on HIV/AIDS
(UNAIDS). Chronic care for HIV and noncommunicable diseases
: how to leverage the HIV experience. 2011. Available at: http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2011/20110526_JC2145_Chronic_care_of_HIV.pdf
. Accessed January 6, 2014.
40. Hunink MG, Glasziou P. Decision Making in Health and Medicine: Integrating Evidence and Values. Cambridge, United Kingdom: Cambridge University Press; 2001.
41. Lehe JD, Sitoe NE, Tobaiwa O, et al.. Evaluating operational specifications of point-of-care diagnostic tests: a standardized scorecard. PLoS One. 2012;7:e47459.
42. Weinstein MC, Torrance G, McGuire A. QALYs: the basics. Value Health. 2009;12(suppl 1):S5–S9.
43. Husereau D, Drummond M, Petrou S, et al.. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. Value Health. 2013;16:e1–e5.
44. Murray CJ, Vos T, Lozano R, et al.. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2197–2223.
45. Barnett PG. An improved set of standards for finding cost for cost-effectiveness
analysis. Med Care. 2009;47(suppl 1):S82–S88.
46. Ahonkhai AA, Bassett IV, Ferris TG, et al.. Improving HIV outcomes in resource-limited countries: the importance of quality indicators. BMC Health Serv Res. 2012;12:427.
47. Fund TG. Monitoring and evaluation toolkit, 4th edition: global fund M&E requirements, HIV, tuberculosis
, malaria, and health and community systems strengthening. 2011. Available at: http://www.theglobalfund.org/en/me/documents/toolkit/
. Accessed January 7, 2014.
48. Drummond M, Schulpher M, Torrance G, et al.. Methods for the Economic Evaluation of Health Care Programmes. 3rd ed. Oxford, NY: Oxford University Press; 2005.
49. World Health Organization. Macroeconomics and health: Investing in health for economic development. Report of the Commission on Macroeconomics and Health. 2001. Available at: http://whqlibdoc.who.int/publications/2001/924154550x.pdf
. Accessed November 18, 2009.
50. World Health Organization. Global tuberculosis
report. 2013. Available at: http://apps.who.int/iris/bitstream/10665/75938/1/9789241564502_eng.pdf
. Accessed October 15, 2013.
51. Deribew A, Tesfaye M, Hailmichael Y, et al.. Tuberculosis
and HIV co-infection: its impact on quality of life. Health Qual Life Outcomes. 2009;7:105.
52. Abebe G, Deribew A, Apers L, et al.. Knowledge, health seeking behavior and perceived stigma towards tuberculosis
suspects in a rural community in southwest Ethiopia. PLoS One. 2010;5:e13339.
53. Deribew A, Deribe K, Reda AA, et al.. Change in quality of life: a follow up study among patients with HIV infection with and without TB in Ethiopia. BMC Public Health. 2013;13:408.
54. World Health Organization. Tuberculosis
fact sheet. 2013. Available at: http://www.who.int/mediacentre/factsheets/fs104/en/index.html#
. Accessed August 14, 2013.
55. Bassett IV, Chetty S, Wang B, et al.. Loss to follow-up and mortality among HIV-infected people co-infected with TB at ART initiation in Durban, South Africa. J Acquir Immune Defic Syndr. 2012;59:25–30.
56. World Health Organization. Systematic screening for active tuberculosis
: principles and recommendations. 2013. Available at: http://apps.who.int/iris/bitstream/10665/84971/1/9789241548601_eng.pdf
. Accessed October 20, 2013.
57. World Health Organization. Factsheet: improving early detection of active TB through systematic screening. 2013. Available at: http://www.who.int/tb/publications/tbscreening_factsheet.pdf
. Accessed September 6, 2013.
58. World Health Organization. Guidelines for intensified tuberculosis
case-finding and isoniazid preventive therapy for people living with HIV in resource-constrained settings. 2011. Available at: http://www.who.int/hiv/pub/tb/9789241500708/en/
. Accessed November 24, 2013.
59. Walensky RP, Wood R, Fofana MO, et al.. The clinical impact and cost-effectiveness
of routine, voluntary HIV screening in South Africa. J Acquir Immune Defic Syndr. 2011;56:26–35.
60. Swindells S, Komarow L, Tripathy S, et al.. Screening for pulmonary tuberculosis
in HIV-infected individuals: AIDS Clinical Trials Group protocol A5253. Int J Tuberc Lung Dis. 2013;17:532–539.
61. Kranzer K, Lawn SD, Meyer-Rath G, et al.. Feasibility, yield, and cost of active tuberculosis
case finding linked to a mobile HIV service in Cape Town, South Africa: a cross-sectional study. PLoS Med. 2012;9:e1001281.
62. Kranzer K, Afnan-Holmes H, Tomlin K, et al.. The benefits to communities and individuals of screening for active tuberculosis
disease: a systematic review. Int J Tuberc Lung Dis. 2013;17:432–446.
63. Bassett IV, Wang B, Chetty S, et al.. Intensive tuberculosis
screening for HIV-infected patients starting antiretroviral therapy in Durban, South Africa. Clin Infect Dis. 2010;51:823–829.
64. Voss De Lima Y, Evans D, Page-Shipp L, et al.. Linkage to care and treatment for TB and HIV among people newly diagnosed with TB or HIV-associated TB at a large, inner city South African hospital. PLoS One. 2013;8:e49140.
65. Kranzer K, Zeinecker J, Ginsberg P, et al.. Linkage to HIV care and antiretroviral therapy in Cape Town, South Africa. PLoS One. 2010;5:e13801.
66. Zachariah R, Harries AD, Manzi M, et al.. Acceptance of anti-retroviral therapy among patients infected with HIV and tuberculosis
in rural Malawi is low and associated with cost of transport. PLoS One. 2006;1:e121.
67. Zachariah R, Tayler-Smith K, Manzi M, et al.. Retention and attrition during the preparation phase and after start of antiretroviral treatment in Thyolo, Malawi, and Kibera, Kenya: implications for programmes? Trans R Soc Trop Med Hyg. 2011;105:421–430.
68. Howard AA, Gasana M, Getahun H, et al.. PEPFAR support for the scaling up of collaborative TB/HIV activities. J Acquir Immune Defic Syndr. 2012;60(suppl 3):S136–S144.
69. Schulz SA, Draper HR, Naidoo P. A comparative study of tuberculosis
patients initiated on ART and receiving different models of TB-HIV care. Int J Tuberc Lung Dis. 2013;17:1558–1563.
70. Ikeda JM, Lopez Tellez CA, Hudes ES, et al.. Impact of integrating HIV and TB care and treatment in a regional tuberculosis
hospital in rural Guatemala. AIDS Behav. 2014;18(suppl 1):S96–S103.
71. Hermans SM, Castelnuovo B, Katabira C, et al.. Integration of HIV and TB services results in improved TB treatment outcomes and earlier prioritized ART initiation in a large urban HIV clinic in Uganda. J Acquir Immune Defic Syndr. 2012;60:e29–e35.
72. Uyei J, Coetzee D, Macinko J, et al.. Integrated delivery of HIV and tuberculosis
services in sub-Saharan Africa: a systematic review. Lancet Infect Dis. 2011;11:855–867.
73. Corneli A, Jarrett NM, Sabue M, et al.. Patient and provider perspectives on implementation models of HIV counseling and testing for patients with TB. Int J Tuberc Lung Dis. 2008;12(suppl 1):79–84.
74. Kerschberger B, Hilderbrand K, Boulle AM, et al.. The effect of complete integration of HIV and TB services on time to initiation of antiretroviral therapy: a before-after study. PLoS One. 2012;7:e46988.
75. Menzies NA, Cohen T, Lin HH, et al.. Population health impact and cost-effectiveness
diagnosis with Xpert MTB/RIF: a dynamic simulation and economic evaluation. PLoS Med. 2012;9:e1001347.
76. Vassall A, van Kampen S, Sohn H, et al.. Rapid diagnosis of tuberculosis
with the Xpert MTB/RIF assay in high burden countries: a cost-effectiveness
analysis. PLoS Med. 2011;8:e1001120.
77. Nigatu T. Integration of HIV and noncommunicable diseases
in health care delivery in low- and middle-income countries. Prev Chronic Dis. 2012;9:E93.
78. Uhler LM, Kumarasamy N, Mayer KH, et al.. Cost-effectiveness
of HIV testing referral strategies among tuberculosis
patients in India. PLoS One. 2010;5:pii: e12747.
79. Chi BH, Fusco H, Sinkala M, et al.. Cost and enrollment implications of targeting different source population for an HIV treatment program. J Acquir Immune Defic Syndr. 2005;40:350–355.
80. Hausler HP, Sinanovic E, Kumaranayake L, et al.. Costs of measures to control tuberculosis
/HIV in public primary care facilities in Cape Town, South Africa. Bull World Health Organ. 2006;84:528–536.
81. Abimbola TO, Marston BJ, Date AA, et al.. Cost-effectiveness
diagnostic strategies to reduce early mortality among persons with advanced HIV infection initiating antiretroviral therapy. J Acquir Immune Defic Syndr. 2012;60:e1–e7.
82. Andrews JR, Lawn SD, Rusu C, et al.. The cost-effectiveness
of routine tuberculosis
screening with Xpert MTB/RIF prior to initiation of antiretroviral therapy: a model-based analysis. AIDS. 2012;26:987–995.
83. Sun D, Dorman S, Shah M, et al.. Cost utility of lateral-flow urine lipoarabinomannan for tuberculosis
diagnosis in HIV-infected African adults. Int J Tuberc Lung Dis. 2013;17:552–558.
84. Drain PK, Hyle EP, Noubary F, et al.. Diagnostic point-of-care tests in resource-limited settings. Lancet Infect Dis. 2014;14:239–249.
85. Bell JC, Rose DN, Sacks HS. Tuberculosis
preventive therapy for HIV-infected people in sub-Saharan Africa is cost-effective. AIDS. 1999;13:1549–1556.
86. Foster S, Godfrey-Faussett P, Porter J. Modelling the economic benefits of tuberculosis
preventive therapy for people with HIV: the example of Zambia. AIDS. 1997;11:919–925.
87. Shrestha RK, Mugisha B, Bunnell R, et al.. Cost-effectiveness
of including tuberculin skin testing in an IPT program for HIV-infected persons in Uganda. Int J Tuberc Lung Dis. 2006;10:656–662.
88. Uebel KE, Lombard C, Joubert G, et al.. Integration of HIV care into primary care in South Africa: effect on survival of patients needing antiretroviral treatment. J Acquir Immune Defic Syndr. 2013;63:e94–e100.
89. Flys T, Gonzalez R, Sued O, et al.. A novel educational strategy targeting health care workers in underserved communities in Central America to integrate HIV into primary medical care. PLoS One. 2012;7:e46426.
90. Adebamowo CA, Casper C, Bhatia K, et al.. Challenges in the detection, prevention, and treatment of HIV-associated malignancies in low- and middle-income countries in Africa. J Acquir Immune Defic Syndr. 2014;67(suppl 1):S17–S26.
91. Louie KS, de Sanjose S, Mayaud P. Epidemiology and prevention of human papillomavirus and cervical cancer in sub-Saharan Africa: a comprehensive review. Trop Med Int Health. 2009;14:1287–1302.
92. Franceschi S, Jaffe H. Cervical cancer screening of women living with HIV infection: a must in the era of antiretroviral therapy. Clin Infect Dis. 2007;45:510–513.
93. Mbulaiteye SM, Bhatia K, Adebamowo C, et al.. HIV and cancer in Africa: mutual collaboration between HIV and cancer programs may provide timely research and public health data. Infect Agent Cancer. 2011;6:16.
94. Memiah P, Mbuthia W, Kiiru G, et al.. Prevalence and risk factors associated with precancerous cervical cancer lesions among HIV-infected women in resource-limited settings. AIDS Res Treat. 2012;2012:953743.
95. Jaquet A, Horo A, Charbonneau V, et al.. Cervical human papillomavirus and HIV infection in women of child-bearing age in Abidjan, Côte d'Ivoire, 2010. Br J Cancer. 2012;107:556–563.
96. Horo A, Jaquet A, Ekouevi DK, et al.. Cervical cancer screening by visual inspection in Côte d'Ivoire, operational and clinical aspects according to HIV status. BMC Public Health. 2012;12:237.
97. van Bogaert LJ. Age at diagnosis of preinvasive and invasive cervical neoplasia in South Africa: HIV-positive versus HIV-negative women. Int J Gynecol Cancer. 2011;21:363–366.
98. Chirenje ZM. HIV and cancer of the cervix. Best Pract Res Clin Obstet Gynaecol. 2005;19:269–276.
99. Atashili J, Adimora AA, Ndumbe PM, et al.. High prevalence of cervical squamous intraepithelial lesions in women on antiretroviral therapy in Cameroon: is targeted screening feasible? Cancer Epidemiol. 2012;36:263–269.
100. Mabeya H, Khozaim K, Liu T, et al.. Comparison of conventional cervical cytology versus visual inspection with acetic acid among human immunodeficiency virus-infected women in Western Kenya. J Low Genit Tract Dis. 2012;16:92–97.
101. Quinley KE, Gormley RH, Ratcliffe SJ, et al.. Use of mobile telemedicine for cervical cancer screening. J Telemed Telecare. 2011;17:203–209.
102. Mwanahamuntu MH, Sahasrabuddhe VV, Pfaendler KS, et al.. Implementation of “see-and-treat” cervical cancer prevention services linked to HIV care in Zambia. AIDS. 2009;23:N1–N5.
103. Sahasrabuddhe VV, Bhosale RA, Kavatkar AN, et al.. Comparison of visual inspection with acetic acid and cervical cytology to detect high-grade cervical neoplasia among HIV-infected women in India. Int J Cancer. 2012;130:234–240.
104. Sauvaget C, Muwonge R, Sankaranarayanan R. Meta-analysis of the effectiveness of cryotherapy in the treatment of cervical intraepithelial neoplasia. Int J Gynaecol Obstet. 2013;120:218–223.
105. Wesley RS, Muwonge R, Sauvaget C, et al.. Effectiveness of cryotherapy for histologically confirmed cervical intraepithelial neoplasia grades 1 and 2 in an Indian setting. Int J Gynaecol Obstet. 2013;123:16–20.
106. Sankaranarayanan R, Rajkumar R, Esmy PO, et al.. Effectiveness, safety and acceptability of “see and treat” with cryotherapy by nurses in a cervical screening study in India. Br J Cancer. 2007;96:738–743.
107. Lewis KD, Sellors JW, Dawa A, et al.. Report on a cryotherapy service for women with cervical intraepithelial neoplasia in a district hospital in western Kenya. Afr Health Sci. 2011;11:370–376.
108. Ramogola-Masire D, de Klerk R, Monare B, et al.. Cervical cancer prevention in HIV-infected women using the “see and treat” approach in Botswana. J Acquir Immune Defic Syndr. 2012;59:308–313.
109. Mwanahamuntu MH, Sahasrabuddhe VV, Kapambwe S, et al.. Advancing cervical cancer prevention initiatives in resource-constrained settings: insights from the cervical cancer prevention program in Zambia. PLoS Med. 2011;8:e1001032.
110. Mwanahamuntu MH, Sahasrabuddhe VV, Blevins M, et al.. Utilization of cervical cancer screening services and trends in screening positivity rates in a “screen-and-treat” program integrated with HIV/AIDS
care in Zambia. PLoS One. 2013;8:e74607.
111. Parham G. Personal communication with Vermund S. regarding women screened for ICC in Zambia. 2013.
112. Ezechi OC, Gab-Okafor CV, Ostergren PO, et al.. Willingness and acceptability of cervical cancer screening among HIV positive Nigerian women. BMC Public Health. 2013;13:46.
113. Rabiu KA, Akinbami AA, Adewunmi AA, et al.. The need to incorporate routine cervical cancer counselling and screening in the management of HIV positive women in Nigeria. Asian Pac J Cancer Prev. 2011;12:1211–1214.
114. Khozaim K, Orang'o E, Christoffersen-Deb A, et al.. Successes and challenges of establishing a cervical cancer screening and treatment program in western Kenya. Int J Gynaecol Obstet. 2014;124:12–18.
115. Goldhaber-Fiebert JD, Goldie SJ. Estimating the cost of cervical cancer screening in five developing countries. Cost Eff Resour Alloc. 2006;4:13.
116. Sahasrabuddhe VV, Parham GP, Mwanahamuntu MH, et al.. Cervical cancer prevention in low- and middle-income countries: feasible, affordable, essential. Cancer Prev Res (Phila). 2012;5:11–17.
117. Goldie SJ, Gaffikin L, Goldhaber-Fiebert JD, et al.. Cost-effectiveness
of cervical-cancer screening in five developing countries. N Engl J Med. 2005;353:2158–2168.
118. Goldie SJ, Kuhn L, Denny L, et al.. Policy analysis of cervical cancer screening strategies in low-resource settings: clinical benefits and cost-effectiveness
. JAMA. 2001;285:3107–3115.
119. Campos NG, Kim JJ, Castle PE, et al.. Health and economic impact of HPV 16/18 vaccination and cervical cancer screening in Eastern Africa. Int J Cancer. 2012;130:2672–2684.
120. Ginsberg GM, Lauer JA, Zelle S, et al.. Cost effectiveness of strategies to combat breast, cervical, and colorectal cancer in sub-Saharan Africa and South East Asia: mathematical modelling study. BMJ. 2012;344:e614.
121. Vijayaraghavan A, Efrusy M, Lindeque G, et al.. Cost effectiveness of high-risk HPV DNA testing for cervical cancer screening in South Africa. Gynecol Oncol. 2009;112:377–383.
122. Goldie SJ, Weinstein MC, Kuntz KM, et al.. The costs, clinical benefits, and cost-effectiveness
of screening for cervical cancer in HIV-infected women. Ann Intern Med. 1999;130:97–107.
123. Vanni T, Luz PM, Grinsztejn B, et al.. Cervical cancer screening among HIV-infected women: an economic evaluation in a middle-income country. Int J Cancer. 2012;131:E96–E104.
124. Atashili J, Smith JS, Adimora AA, et al.. Potential impact of antiretroviral therapy and screening on cervical cancer mortality in HIV-positive women in sub-Saharan Africa: a simulation. PLoS One. 2011;6:e18527.
125. Moon TD, Silva-Matos C, Cordoso A, et al.. Implementation of cervical cancer screening using visual inspection with acetic acid in rural Mozambique: successes and challenges using HIV care and treatment programme investments in Zambezia Province. J Int AIDS Soc. 2012;15:17406.
126. Chibanda D, Benjamin L, Weiss HA, et al.. Mental, neurological and substance use disorders (MNS) in people living with HIV/AIDS
in low and middle income countries. J Acquir Immune Defic Syndr. 2014;67(suppl 1):S54–S67.
127. Nakasujja N, Skolasky RL, Musisi S, et al.. Depression symptoms and cognitive function among individuals with advanced HIV infection initiating HAART in Uganda. BMC Psychiatry. 2010;10:44.
128. Joska JA, Fincham DS, Stein DJ, et al.. Clinical correlates of HIV-associated neurocognitive disorders in South Africa. AIDS Behav. 2010;14:371–378.
129. Rabkin JG. HIV and depression: 2008 review and update. Curr HIV/AIDS
130. Nel A, Kagee A. The relationship between depression, anxiety and medication adherence among patients receiving antiretroviral treatment in South Africa. AIDS Care. 2013;25:948–955.
131. Lawler K, Mosepele M, Seloilwe E, et al.. Depression among HIV-positive individuals in Botswana: a behavioral surveillance. AIDS Behav. 2011;15:204–208.
132. Olisah VO, Baiyewu O, Sheikh TL. Adherence to highly active antiretroviral therapy in depressed patients with HIV/AIDS
attending a Nigerian university teaching hospital clinic. Afr J Psychiatry (Johannesbg). 2010;13:275–279.
133. Byakika-Tusiime J, Crane J, Oyugi JH, et al.. Longitudinal antiretroviral adherence in HIV+ Ugandan parents and their children initiating HAART in the MTCT-Plus family treatment model: role of depression in declining adherence over time. AIDS Behav. 2009;13(suppl 1):82–91.
134. Nakimuli-Mpungu E, Bass JK, Alexandre P, et al.. Depression, alcohol use and adherence to antiretroviral therapy in sub-Saharan Africa: a systematic review. AIDS Behav. 2012;16:2101–2118.
135. Brandt R. Putting mental health on the agenda for HIV+ women: a review of evidence from sub-Saharan Africa. Women Health. 2009;49:215–228.
136. Maj M, Janssen R, Starace F, et al.. WHO neuropsychiatric AIDS study, cross-sectional phase I. Study design and psychiatric findings. Arch Gen Psychiatry. 1994;51:39–49.
137. Chikezie UE, Otakpor AN, Kuteyi OB, et al.. Depression among people living with human immunodeficiency virus infection/acquired immunodeficiency syndrome in Benin City, Nigeria: a comparative study. Niger J Clin Pract. 2013;16:238–242.
138. Antelman G, Kaaya S, Wei R, et al.. Depressive symptoms increase risk of HIV disease progression and mortality among women in Tanzania. J Acquir Immune Defic Syndr. 2007;44:470–477.
139. Mayston R, Kinyanda E, Chishinga N, et al.. Mental disorder and the outcome of HIV/AIDS
in low-income and middle-income countries: a systematic review. AIDS. 2012;26(suppl 2):S117–S135.
140. Nakimuli-Mpungu E, Mutamba B, Othengo M, et al.. Psychological distress and adherence to highly active anti-retroviral therapy (HAART) in Uganda: a pilot study. Afr Health Sci. 2009;9(suppl 1):S2–S7.
141. Nakimuli-Mpungu E, Mojtabai R, Alexandre PK, et al.. Lifetime depressive disorders and adherence to anti-retroviral therapy in HIV-infected Ugandan adults: a case-control study. J Affect Disord. 2013;145:221–226.
142. Memiah P, Shumba C, Etienne-Mesubi M, et al.. The effect of depressive symptoms and CD4 count on adherence to highly active antiretroviral therapy in sub-Saharan Africa. J Int Assoc Provid AIDS Care. 2013.
143. Do NT, Phiri K, Bussmann H, et al.. Psychosocial factors affecting medication adherence among HIV-1 infected adults receiving combination antiretroviral therapy (cART) in Botswana. AIDS Res Hum Retroviruses. 2010;26:685–691.
144. Collins PY, Holman AR, Freeman MC, et al.. What is the relevance of mental health to HIV/AIDS
care and treatment programs in developing countries? A systematic review. AIDS. 2006;20:1571–1582.
145. Adewuya AO, Afolabi MO, Ola BA, et al.. Relationship between depression and quality of life in persons with HIV infection in Nigeria. Int J Psychiatry Med. 2008;38:43–51.
146. Akena D, Joska J, Obuku EA, et al.. Comparing the accuracy of brief versus long depression screening instruments which have been validated in low and middle income countries: a systematic review. BMC Psychiatry. 2012;12:187.
147. Patel V, Simon G, Chowdhary N, et al.. Packages of care for depression in low- and middle-income countries. PLoS Med. 2009;6:e1000159.
148. Monahan PO, Shacham E, Reece M, et al.. Validity/reliability of PHQ-9 and PHQ-2 depression scales among adults living with HIV/AIDS
in western Kenya. J Gen Intern Med. 2009;24:189–197.
149. Kaaya SF, Fawzi MC, Mbwambo JK, et al.. Validity of the Hopkins symptom checklist-25 amongst HIV-positive pregnant women in Tanzania. Acta Psychiatr Scand. 2002;106:9–19.
150. Akena D, Joska J, Musisi S, et al.. Sensitivity and specificity of a visual depression screening instrument among HIV-positive individuals in Uganda, an area with low literacy. AIDS Behav. 2012;16:2399–2406.
151. Kaaya S, Eustache E, Lapidos-Salaiz I, et al.. Grand challenges: improving HIV treatment outcomes by integrating interventions for co-morbid mental illness. PLoS Med. 2013;10:e1001447.
152. Farley J, Miller E, Zamani A, et al.. Screening for hazardous alcohol use and depressive symptomatology among HIV-infected patients in Nigeria: prevalence, predictors, and association with adherence. J Int Assoc Physicians AIDS Care (Chic). 2010;9:218–226.
153. Akena D, Stein DJ, Joska J. Does screening HIV-positive individuals in Uganda for major depressive disorder improve case detection rates and antidepressant prescription? AIDS Behav. 2013;17:2802–2807.
154. Futterman D, Shea J, Besser M, et al.. Mamekhaya: a pilot study combining a cognitive-behavioral intervention and mentor mothers with PMTCT services in South Africa. AIDS Care. 2010;22:1093–1100.
155. Chibanda D, Mesu P, Kajawu L, et al.. Problem-solving therapy for depression and common mental disorders in Zimbabwe: piloting a task-shifting primary mental health care intervention in a population with a high prevalence of people living with HIV. BMC Public Health. 2011;11:828.
156. Chibanda D, Shetty AK, Tshimanga M, et al.. Group problem-solving therapy for postnatal depression among HIV positive and HIV negative mothers in Zimbabwe. J Int Assoc Provid AIDS Care. 2013.
157. Donohue JM, Pincus HA. Reducing the societal burden of depression: a review of economic costs, quality of care and effects of treatment. Pharmacoeconomics. 2007;25:7–24.
158. Gilbody S, Bower P, Whitty P. Costs and consequences of enhanced primary care for depression: systematic review of randomised economic evaluations. Br J Psychiatry. 2006;189:297–308.
159. Weaver MR, Conover CJ, Proescholdbell RJ, et al.. Cost-effectiveness
analysis of integrated care
for people with HIV, chronic mental illness and substance abuse disorders. J Ment Health Policy Econ. 2009;12:33–46.
160. Glasgow RE, Eckstein ET, Elzarrad MK. Implementation science perspectives and opportunities for HIV/AIDS
research: integrating science, practice, and policy. J Acquir Immune Defic Syndr. 2013;63(suppl 1):S26–S31.
161. Deo S, Topp SM, Garcia A, et al.. Modeling the impact of integrating HIV and outpatient health services on patient waiting times in an urban health clinic in Zambia. PLoS One. 2012;7:e35479.
162. Lambdin BH, Micek MA, Sherr K, et al.. Integration of HIV care and treatment in primary health care centers and patient retention in central Mozambique: a retrospective cohort study. J Acquir Immune Defic Syndr. 2013;62:e146–152.
163. Church K, Wringe A, Fakudze P, et al.. Are integrated HIV services less stigmatizing than stand-alone models of care? A comparative case study from Swaziland. J Int AIDS Soc. 2013;16:17981.
164. Church K, Wringe A, Fakudze P, et al.. The relationship between service integration and client satisfaction: a mixed methods case study within HIV services in a high prevalence setting in Africa. AIDS Patient Care STDS. 2012;26:662–673.
165. Reid MJ, Saito S, Nash D, et al.. Implementation of tuberculosis
infection control measures at HIV care and treatment sites in sub-Saharan Africa. Int J Tuberc Lung Dis. 2012;16:1605–1612.
166. Scott VE, Sanders D. Evaluation of how integrated HIV and TB programs are implemented in South Africa and the implications for rural-urban equity. Rural Remote Health. 2013;13:2165.
167. Ross DA, South A, Weller I, et al.. HIV treatment and care systems: the way forward. AIDS. 2012;26(suppl 2):S147–S152.
168. Uyei J, Coetzee D, Macinko J, et al.. Measuring the degree of integrated tuberculosis
and HIV service delivery in Cape Town, South Africa. Health Policy Plan. 2014;29:42–55.
169. Uebel KE, Joubert G, Wouters E, et al.. Integrating HIV care into primary care services: quantifying progress of an intervention in South Africa. PLoS One. 2013;8:e54266.
170. Page-Shipp L, Stevens W, Clark D, et al.. Successes, challenges and lessons from a novel deployment of Xpert MTB/RIF at a major South African public event [short communication]. Int J Tuberc Lung Dis. 2014;18:438–440.
171. Creswell J, Codlin AJ, Andre E, et al.. Results from early programmatic implementation of Xpert MTB/RIF testing in nine countries. BMC Infect Dis. 2014;14:2.
172. Clouse K, Page-Shipp L, Dansey H, et al.. Implementation of Xpert MTB/RIF for routine point-of-care diagnosis of tuberculosis
at the primary care level. S Afr Med J. 2012;102:805–807.
173. Chaiyachati KH, Loveday M, Lorenz S, et al.. A pilot study of an mHealth application for healthcare workers: poor uptake despite high reported acceptability at a rural South African community-based MDR-TB treatment program. PLoS One. 2013;8:e64662.
174. Pop-Eleches C, Thirumurthy H, Habyarimana JP, et al.. Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders. AIDS. 2011;25:825–834.
175. Bradley EH, Byam P, Alpern R, et al.. A systems approach to improving rural care in Ethiopia. PLoS One. 2012;7:e35042.
176. Govindasamy D, Kranzer K, van Schaik N, et al.. Linkage to HIV, TB and non-communicable disease care from a mobile testing unit in Cape Town, South Africa. PLoS One. 2013;8:e80017.
177. Chamie G, Kwarisiima D, Clark TD, et al.. Leveraging rapid community-based HIV testing campaigns for non-communicable diseases in rural Uganda. PLoS One. 2012;7:e43400.
178. Rachlis B, Sodhi S, Burciul B, et al.. A taxonomy for community-based care programs focused on HIV/AIDS
prevention, treatment, and care in resource-poor settings. Glob Health Action. 2013;6:1–21.
179. Suthar AB, Klinkenberg E, Ramsay A, et al.. Community-based multi-disease prevention campaigns for controlling human immunodeficiency virus-associated tuberculosis
. Int J Tuberc Lung Dis. 2012;16:430–436.
180. Frasca K, Cohn J. Integration of HIV and tuberculosis
in the community. J Int Assoc Provid AIDS Care. 2013.
181. Vermund SH, Sidat M, Weil LF, et al.. Transitioning HIV care and treatment programs in southern Africa to full local management. AIDS. 2012;26:1303–1310.
182. Munderi P, Grosskurth H, Droti B, et al.. What are the essential components of HIV treatment and care services in low and middle-income countries: an overview by settings and levels of the health system? AIDS. 2012;26(suppl 2):S97–S103.
183. Nachega JB, Uthman OA, Ho YS, et al.. Current status and future prospects of epidemiology and public health training and research in the WHO African region. Int J Epidemiol. 2012;41:1829–1846.