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Objective To assess the extent to which user fees for antiretroviral therapy (ART) represent a financial barrier to access to ART among HIV-positive patients in Yaounde, Cameroon. Methods Sociodemographic, economic and clinical data were collected from a random sample of 707 HIV-positive patients followed up in six public hospitals of the capital city (Yaounde) and its surroundings through face-to-face interviews carried out by trained interviewers independently from medical staff and medical questionnaires filled out by prescribing physicians. Logistic regression models were used to identify factors associated with self-reported financial difficulties in purchasing ART during the previous 3 months. Findings Of the 532 patients treated with ART at the time of the survey, 20% reported financial difficulty in purchasing their antiretroviral drugs during the previous 3 months. After adjustment for socioeconomic and clinical factors, reports of financial difficulties were significantly associated with lower adherence to ART (odds ratio, OR: 0.24; 95% confidence interval, CI: 0.15-0.40; P< 0.0001) and with lower CD4+ lymphocyte (CD4) counts after 6 months of treatment (OR: 2.14; 95% CI: 1.15-3.96 for CD4 counts < 200 cells/[micro]l; P= 0.04). Conclusion Removing a financial barrier to treatment with ART by eliminating user fees at the point of care delivery, as recommended by WHO, could lead to increased adherence to ART and to improved clinical results. New health financing mechanisms based on the public resources of national governments and international donors are needed to attain universal access to drugs and treatment for HIV infection. Objectif Evaluer dans quelle mesure la participation financiere reglee par les usagers pour beneficier du traitement antiretroviral (ART) represente un obstacle financier a l&apos;acces a ce traitement pour les personnes positives pour le VIH a Yaounde, au Cameroun. Methodes Des donnees sociodemographiques, economiques et cliniques ont ete recueillies parmi un echantillon aleatoire de 707. individus seropositifs pour le VIH, suivis dans six hopitaux publics de la capitale du Cameroun (Yaounde) ou de ses environs, a travers des entretiens face-a-face menes par des enqueteurs formes et independants du personnel medical et a travers des questionnaires medicaux remplis par les medecins prescripteurs. Des modeles de regression logistique ont ete utilises pour identifier les facteurs associes au signalement spontane par les sujets de difficultes financieres pour se procurer les medicaments ART au cours des 3 derniers mois. Resultats Parmi les 532 patients prenant un traitement ART au moment de l&apos;enquete; 20 % ont signale" des difficultes financieres pour se procurer les medicaments antiretroviraux au cours des 3 derniers mois. Apres ajustement pour les facteurs socioeconomiques et cliniques, on a constate une association significative entre le signalement de difficultes financieres et une faible observance du traitement ART (odds ratio, OR: 0,24; intervalle de confiance a 95 %, IC: 0,15-0,40; p < 0,0001) et entre ce signalement et une numeration plus basse des lymphocytes CD4+ (CD4) apres 6 mois de traitement (OR: 2;14, IC a 95 %: 1,15-3,96 pour les numerations des CD4 < 200 cellules/[micro]l; p = 0,04). Conclusion L&apos;elimination de l&apos;obstacle financier au traitement antiretroval que constitue la participation financiere des usagers au point de delivrance des soins, comme le recommande l&apos;OMS, pourrait apporter une amelioration de l&apos;observance du traitement et des resultats cliniques. De nouveaux mecanismes financiers reposant sur les ressources publiques des gouvernements nationaux et sur les apports de donateurs internationaux sont necessaires pour obtenir un acces universel aux medicaments et au traitement contre l&apos;infection par le VIH. Objetivo Evaluar en que medida los honorarios cobrados a los usuarios por el tratamiento antirretroviral (TAR) representan una barrera financiera para acceder a dicha terapia entre los pacientes VIH-positivos en Yaunde, Camerun. Metodos Se reunieron datos sociodemograficos, economicos y clinicos a partir de una muestra aleatoria de 707 pacientes VIH-positivos sometidos a seguimiento en seis hospitales publicos de la capital (Yaunde) y sus alrededores mediante entrevistas personales llevadas a cabo por encuestadores debidamente preparados independientes del personal medico y cuestionarios medicos rellenados por los facultativos que recetaban los medicamentos. Se utilizaron modelos de regresion logistica para determinar los factores asociados a las dificultades financieras declaradas por los propios pacientes para adquirir TAR durante los 3 meses anteriores. Resultados De los 532 pacientes que recibian TAR en el momento de la encuesta, un 20% declararon haber tenido problemas economicos para adquirir la medicacion antirretroviral en los 3 meses anteriores. Tras los ajustes pertinentes en funcion de factores socioeconomicos y clinicos, las referencias a problemas economicos se asociaron de forma significativa a un menor seguimiento dei TAR (razon de posibilidades, OR: 0,24; intervalo de confianza [IC] del 95%: 0,15-0,40; p < 0,0001) y a recuentos mas bajos de los linfocitos CD4+ (CD4) a los 6 meses de tratamiento (OR: 2,14; IC95%: 1,15-3,96 para los recuentos de CD4 < 200 celulas/[micron]l; p = 0,04). Conclusion La supresion de las trabas financieras ai tratamiento con antirretrovirales mediante la eliminacion de los honorarios cobrados a los usuarios en los puntos de atencion sanitaria, de acuerdo con las recomendaciones de la OMS, podria traducirse en un mayor cumplimiento del TAR y unos resultados clinicos mejores. Se necesitan nuevos mecanismos de financiacion sanitaria basados en los recursos publicos de los gobiernos nacionales y los donantes internacionales para garantizar el acceso universal a los medicamentos y el tratamiento que requiere la infeccion por VIH., Introduction After the Bamako Initiative, which was launched at a meeting of African ministers of health in Mali in 1987, many developing countries introduced or expanded cost recovery policies by [...]

Background Socioeconomic disadvantage is a risk factor for dementia, but longitudinal studies suggest that it does not affect the rate of cognitive decline. Our objective is to understand the manner in which socioeconomic disadvantage shapes dementia risk by examining its associations with midlife cognitive performance and cognitive decline from midlife to old age, including cognitive decline trajectories in those with dementia. Methods and findings Data are drawn from the Whitehall II study (N = 10,308 at study recruitment in 1985), with cognitive function assessed at 4 waves (1997, 2002, 2007, and 2012). Sociodemographic, behavioural, and cardiometabolic risk factors from 1985 and chronic conditions until the end of follow-up in 2015 (N dementia/total = 320/9,938) allowed the use of inverse probability weighting to take into account data missing because of loss to follow-up between the study recruitment in 1985 and the introduction of cognitive tests to the study in 1997. Generalized estimating equations and Cox regression were used to assess associations of socioeconomic markers (height, education, and midlife occupation categorized as low, intermediate, and high to represent hierarchy in the socioeconomic marker) with cognitive performance, cognitive decline, and dementia (N dementia/total = 195/7,499). In those with dementia, we examined whether retrospective trajectories of cognitive decline (backward timescale) over 18 years prior to diagnosis differed as a function of socioeconomic markers. Socioeconomic disadvantage was associated with poorer cognitive performance (all p < 0.001). Using point estimates for the effect of age, the differences between the high and low socioeconomic groups corresponded to an age effect of 4, 15, and 26 years, for height, education, and midlife occupation, respectively. There was no evidence of faster cognitive decline in socioeconomically disadvantaged groups. Low occupation, but not height or education, was associated with risk of dementia (hazard ratio [HR] = 2.03 [95% confidence interval (CI) 1.23-3.36]) in an analysis adjusted for sociodemographic factors; the excess risk was unchanged after adjustment for cognitive decline but was completely attenuated after adjustment for cognitive performance. In further analyses restricted to those with dementia, retrospective cognitive trajectories over 18 years prior to dementia diagnosis showed faster cognitive decline in the high education (p = 0.006) and occupation (p = 0.001) groups such that large differences in cognitive performance in midlife were attenuated at dementia diagnosis. A major limitation of our study is the use of electronic health records rather than comprehensive dementia ascertainment. Conclusions Our results support the passive or threshold cognitive reserve hypothesis, in that high cognitive reserve is associated with lower risk for dementia because of its association with cognitive performance, which provides a buffer against clinical expression of dementia., Author(s): Jennifer Rusmaully 1, Aline Dugravot 1, Jean-Paul Moatti 2, Michael G. Marmot 3, Alexis Elbaz 1, Mika Kivimaki 3, Séverine Sabia 1,3, Archana Singh-Manoux 1,3,* Introduction Cognitive reserve refers [...]

Introduction: This study aims to provide a landscape of the global antiretroviral (ARV) market by analyzing the transactional data on donor-funded ARV procurement between 2003 and 2015, and the ARV price determinants. Design: The data were obtained from the Global Price Reporting Mechanism (GPRM) managed by the AIDS Medicines and Diagnostics Service of the WHO, and it consists of information that covers approximately 80% of the total donor-funded adult ARV transactions procurement. Methods: ExWorks prices and procured quantities were standardized according to the guidelines in terms of yearly doses. Descriptive statistics on quantities and prices show the main trends of the ARV market. Ordinary least squares estimation was carried out for the whole sample, then stratified according to the type of supplier (originator and generic) and controlled for time and geographical fixed-effects. Given that analyses were carried out on a public dataset on ARV transactional prices from the GPRM, ethics are respected and consent was not necessary. Results: Originator medicines are on average the least expensive in the sub-Saharan Africa region, where at the same time, generic medicines are on average the most expensive. By contrast, originator medicines are the most expensive in Europe and Central Asia, and generic medicines are the least expensive. In fact, the data suggest mixed strategies by ARV suppliers to exploit opportunities for profit maximization and to adapt to the specific conditions of market competition in each region. Our results also suggest that the expiration of patents is not sufficient to boost additional developments in generic competition (at least in the ARV market) and that formal or informal agreements between generic firms may de facto slow down or even reverse long-term trends towards price decreases. Conclusions: Our findings provide an improved understanding of the ARV market that can help countries strengthen policy measures to increase their bargaining power in price negotiations and the use of TRIPS flexibilities, with a special emphasis on negotiations with generic manufacturers. Keywords: HIV-treatment; price determinants; originator and generic medicines; patents., Introduction The prices of first-line antiretroviral (ARV) medicines fell significantly in recent years, allowing for the scaling up of access to ARV treatment in the developing world. In 2012, nearly [...]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2006.01.029 Byline: Patrick Peretti-Watel (a), Jean-Paul Moatti (b) Keywords: Risk behaviour; Sociology of deviance; Health promotion; Risk denial; Drug-taking Abstract: This paper argues that the sociology of deviance can be used to improve our understanding of some difficulties and unintended effects of health-promotion interventions designed to change risk behaviours, especially drug-taking. Firstly, many people engaged in 'risk behaviours' tend to deny the 'risky' label just as delinquents neutralise the 'deviant' label, and preventive information itself may be used by individuals in shaping risk denial. Secondly, deliberate risk-taking may be an 'innovative deviance',which is related to difficulties of conforming to the dominant 'risk culture'. Health promotion is likely to be quite ineffective if it remains wedded to the dominant risk culture and de facto contributes to the spread of it. Author Affiliation: (a) Health and Medical Research National Institute, French National Cancer Institute, and Regional Centre for Disease Control of South-Eastern France, Marseilles, France (b) University of Provence, Inserm U379, France

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jhealeco.2005.09.006 Byline: Pierre Lasserre (a), Jean-Paul Moatti (b), Antoine Soubeyran (c) Abstract: Criteria for initiation of highly active antiretroviral treatments (HAART) in HIV-infected patients remain a matter of debate world-wide because short-term benefits have to be balanced with costs of these therapies, and restrictions placed on future treatment options if resistant viral strains develop. On the other hand, postponing the introduction of HAART may involve a therapeutic opportunity cost if a patient's health is allowed to deteriorate to such an extent of becoming unable to benefit from new treatments currently under development when they become available. We introduce a two period model where period one treatment adoption is an irreversible act with future, but uncertain, consequences. New information, both endogenous and exogenous, arises over time and shapes the conditions surrounding the second period therapeutic decision. A surprising result is that, under conditions that appear close to those surrounding the HAART debate, the magnitude of the feared resistance effect has no effect on leaves the optimal treatment decision as far as it is high enough. JEL classification: I18; C61 Keywords: Therapeutic decisions; Uncertainty; Information; Irreversibility; Treatment Resume Le bien-fonde d'administrer precocement des traitements antire troviraux a haute activite (HAART) aux personnes infectees par le VIH reste objet de debats dans le monde car leurs bienfaits a court terme peuvent compromettre les traitements futurs si se de veloppent des souches resistantes du virus. Par ailleurs retarder le recours aux HAART comporte un coA't d'opportunite therapeutique si la sante du patient se degrade au point qu'il ne peut plus ben eficier par la suite des traitements encore en cours de de veloppement. Nous formulons un modele a deux periodes oA[sup.1] l'adoption du traitement de premiere periode est irreversible et engage le futur, alors que des informations et connaissances nouvelles, exog enes et endogenes, determinent les conditions entourant la de cision therapeutique de deuxieme periode. Paradoxalement, sous des conditions refletant bien les enjeux du recours aux HAART, il s'av ere que l'effet resistance eventuel a d'autant moins de chance d'importer pour la decision optimale, que sa gravite est elev ee. Author Affiliation: (a) Departement des sciences economiques, Universite du Quebec a Montreal, CIRANO, GREQAM, France (b) Faculte d'economie et gestion, Universite de la Me diterranee, GREQAM, INSERM Research Unit 379, France (c) Departement des sciences economiques, Universite de la Mediterranee, and GREQAM, Rte des Milles, 13290 Les Milles, France Article History: Received 1 January 2001; Revised 1 January 2003; Accepted 1 September 2005

Factors associated with nonadherence during the maintenance phase of highly active antiretroviral therapy (months 12- 60) in the Anti PROtease Cohort (APROCO) cohort after correcting for the bias due to missing outcome data is identified. Psychosocial interventions and the selections of the Best- tolerated regimens are needed to improve long- term adherence of HIV- infected patients to their lifelong treatment.

A study of contingent valuation of user fees for medical care i.e., assessment of the value patients in Palestine are willing to pay to improve medical care is presented.

Despite the acceptance that health gain is the most important attribute of health care, other aspects of health care may affect utility. The aim of this paper is to report an experiment to test the impact of providing different levels of information in the context of the EuroWill study, a joint contingent valuation (CV) of multiple health programmes. Three hundred and three respondents were simultaneously asked for their willingness-to-pay (WTP) for three health care programmes: more HEART operations, a new BREAST CANCER treatment and a HELICOPTER AMBULANCE service. To test for the impact of variation in information, three versions of one of the programmes (HEART) were provided. Results show that WTP for all three programmes tended to be significantly higher for respondents who were provided additional positive information about the HEART programme. Our results show that CV of health care programmes, which only take into account medical outcomes, may lead to the value of such programmes not being adequately estimated, and that the impact of information may even be more decisive in the context of joint evaluation of multiple, rather than single, programmes. Keywords: Contingent valuation; Willingness to pay; Value of information; Health care priorities; Joint evaluation; Europe