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Ahmed A, Dujaili JA, Chuah LH, Hashmi FK, Le LKD, Khanal S, Awaisu A, Chaiyakunapruk N. Cost-Effectiveness of Anti-retroviral Adherence Interventions for People Living with HIV: A Systematic Review of Decision Analytical Models. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:731-750. [PMID: 37389788 PMCID: PMC10403422 DOI: 10.1007/s40258-023-00818-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/05/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Although safe and effective anti-retrovirals (ARVs) are readily available, non-adherence to ARVs is highly prevalent among people living with human immunodeficiency virus/acquired immunodeficiency syndrome (PLWHA). Different adherence-improving interventions have been developed and examined through decision analytic model-based health technology assessments. This systematic review aimed to review and appraise the decision analytical economic models developed to assess ARV adherence-improvement interventions. METHODS The review protocol was registered on PROSPERO (CRD42022270039), and reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Relevant studies were identified through searches in six generic and specialized bibliographic databases, i.e. PubMed, Embase, NHS Economic Evaluation Database, PsycINFO, Health Economic Evaluations Database, tufts CEA registry and EconLit, from their inception to 23 October 2022. The cost-effectiveness of adherence interventions is represented by the incremental cost-effectiveness ratio (ICER). The quality of studies was assessed using the quality of the health economics studies (QHES) instrument. Data were narratively synthesized in the form of tables and texts. Due to the heterogeneity of the data, a permutation matrix was used for quantitative data synthesis rather than a meta-analysis. RESULTS Fifteen studies, mostly conducted in North America (8/15 studies), were included in the review. The time horizon ranged from a year to a lifetime. Ten out of 15 studies used a micro-simulation, 4/15 studies employed Markov and 1/15 employed a dynamic model. The most commonly used interventions reported include technology based (5/15), nurse involved (2/15), directly observed therapy (2/15), case manager involved (1/15) and others that involved multi-component interventions (5/15). In 1/15 studies, interventions gained higher quality-adjusted life years (QALYs) with cost savings. The interventions in 14/15 studies were more effective but at a higher cost, and the overall ICER was well below the acceptable threshold mentioned in each study, indicating the interventions could potentially be implemented after careful interpretation. The studies were graded as high quality (13/15) or fair quality (2/15), with some methodological inconsistencies reported. CONCLUSION Counselling and smartphone-based interventions are cost-effective, and they have the potential to reduce the chronic adherence problem significantly. The quality of decision models can be improved by addressing inconsistencies in model selection, data inputs incorporated into models and uncertainty assessment methods.
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Affiliation(s)
- Ali Ahmed
- School of Pharmacy, Monash University, Jalan Lagoon Selatan, Bandar Sunway, 47500, Subang Jaya, Selangor, Malaysia.
| | - Juman Abdulelah Dujaili
- School of Pharmacy, Monash University, Jalan Lagoon Selatan, Bandar Sunway, 47500, Subang Jaya, Selangor, Malaysia
- Swansea University Medical School, Singleton Campus, Swansea University, Wales, UK
| | - Lay Hong Chuah
- School of Pharmacy, Monash University, Jalan Lagoon Selatan, Bandar Sunway, 47500, Subang Jaya, Selangor, Malaysia
| | - Furqan Khurshid Hashmi
- University College of Pharmacy, University of Punjab, Allama Iqbal Campus, Lahore, 54000, Pakistan
| | - Long Khanh-Dao Le
- Monash University Health Economics Group (MUHEG), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Saval Khanal
- Health Economics Consulting, University of East Anglia, Coventry, UK
| | - Ahmed Awaisu
- Department of Clinical Pharmacy and Practice, College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Nathorn Chaiyakunapruk
- College of Pharmacy, University of Utah, Salt Lake City, UT, USA
- IDEAS Center, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT, USA
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Bershteyn A, Jamieson L, Kim HY, Platais I, Milali MP, Mudimu E, Ten Brink D, Martin-Hughes R, Kelly SL, Phillips AN, Bansi-Matharu L, Cambiano V, Revill P, Meyer-Rath G, Nichols BE. Transmission reduction, health benefits, and upper-bound costs of interventions to improve retention on antiretroviral therapy: a combined analysis of three mathematical models. Lancet Glob Health 2022; 10:e1298-e1306. [PMID: 35961353 PMCID: PMC9380252 DOI: 10.1016/s2214-109x(22)00310-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 06/07/2022] [Accepted: 06/24/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND In this so-called treat-all era, antiretroviral therapy (ART) interruptions contribute to an increasing proportion of HIV infections and deaths. Many strategies to improve retention on ART cost more than standard of care. In this study, we aimed to estimate the upper-bound costs at which such interventions should be adopted. METHODS In this combined analysis, we compared the infections averted, disability-adjusted life-years (DALYs) averted, and upper-bound costs of interventions that improve ART retention in three HIV models with diverse structures, assumptions, and baseline settings: EMOD in South Africa, Optima in Malawi, and Synthesis in sub-Saharan African low-income and middle-income countries (LMICs). We modelled estimates over a 40-year time horizon, from a baseline of Jan 1, 2022, when interventions would be implemented, to Jan 1, 2062. We varied increment of ART retention (25%, 50%, 75%, and 100% retention), the extent to which interventions could be targeted towards individuals at risk of interrupting ART, and cost-effectiveness thresholds in each setting. FINDINGS Despite simulating different settings and epidemic trends, all three models produced consistent estimates of health benefit (ie, DALYs averted) and transmission reduction per increment in retention. The range of estimates was 1·35-3·55 DALYs and 0·12-0·20 infections averted over the 40-year time horizon per additional person-year retained on ART. Upper-bound costs varied by setting and intervention effectiveness. Improving retention by 25% among all people receiving ART, regardless of risk of ART interruption, gave an upper-bound cost per person-year of US$2-6 in Optima (Malawi), $43-68 in Synthesis (LMICs in sub-Saharan Africa), and $28-180 in EMOD (South Africa). A maximally targeted and effective retention intervention had an upper-bound cost per person-year of US$93-223 in Optima (Malawi), $871-1389 in Synthesis (LMICs in sub-Saharan Africa), and $1013-6518 in EMOD (South Africa). INTERPRETATION Upper-bound costs that could improve ART retention vary across sub-Saharan African settings and are likely to be similar to or higher than was estimated before the start of the treat-all era. Upper-bound costs could be increased by targeting interventions to those most at risk of interrupting ART. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Anna Bershteyn
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA.
| | - Lise Jamieson
- Health Economics and Epidemiology Research Office (HE2RO), University of the Witwatersrand, Johannesburg, South Africa
| | - Hae-Young Kim
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Ingrida Platais
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Masabho P Milali
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Edinah Mudimu
- Department of Decision Sciences, University of South Africa, Pretoria, South Africa
| | | | | | | | | | | | | | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office (HE2RO), University of the Witwatersrand, Johannesburg, South Africa; Department of Global Health, School of Public Health, Boston University, Boston, MA, USA
| | - Brooke E Nichols
- Health Economics and Epidemiology Research Office (HE2RO), University of the Witwatersrand, Johannesburg, South Africa; Department of Global Health, School of Public Health, Boston University, Boston, MA, USA; Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, Netherlands
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Drabo EF, Moucheraud C, Nguyen A, Garland WH, Holloway IW, Leibowitz A, Suen SC. Using Microsimulation Modeling to Inform EHE Implementation Strategies in Los Angeles County. J Acquir Immune Defic Syndr 2022; 90:S167-S176. [PMID: 35703769 PMCID: PMC9216245 DOI: 10.1097/qai.0000000000002977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Pre-exposure prophylaxis (PrEP) is essential to ending HIV. Yet, uptake remains uneven across racial and ethnic groups. We aimed to estimate the impacts of alternative PrEP implementation strategies in Los Angeles County. SETTING Men who have sex with men, residing in Los Angeles County. METHODS We developed a microsimulation model of HIV transmission, with inputs from key local stakeholders. With this model, we estimated the 15-year (2021-2035) health and racial and ethnic equity impacts of 3 PrEP implementation strategies involving coverage with 9000 additional PrEP units annually, above the Status-quo coverage level. Strategies included PrEP allocation equally (strategy 1), proportionally to HIV prevalence (strategy 2), and proportionally to HIV diagnosis rates (strategy 3), across racial and ethnic groups. We measured the degree of relative equalities in the distribution of the health impacts using the Gini index (G) which ranges from 0 (perfect equality, with all individuals across all groups receiving equal health benefits) to 1 (total inequality). RESULTS HIV prevalence was 21.3% in 2021 [Black (BMSM), 31.1%; Latino (LMSM), 18.3%, and White (WMSM), 20.7%] with relatively equal to reasonable distribution across groups (G, 0.28; 95% confidence interval [CI], 0.26 to 0.34). During 2021-2035, cumulative incident infections were highest under Status-quo (n = 24,584) and lowest under strategy 3 (n = 22,080). Status-quo infection risk declined over time among all groups but remained higher in 2035 for BMSM (incidence rate ratio, 4.76; 95% CI: 4.58 to 4.95), and LMSM (incidence rate ratio, 1.74; 95% CI: 1.69 to 1.80), with the health benefits equally to reasonably distributed across groups (G, 0.32; 95% CI: 0.28 to 0.35). Relative to Status-quo, all other strategies reduced BMSM-WMSM and BMSM-LMSM disparities, but none reduced LMSM-WMSM disparities by 2035. Compared to Status-quo, strategy 3 reduced the most both incident infections (% infections averted: overall, 10.2%; BMSM, 32.4%; LMSM, 3.8%; WMSM, 3.5%) and HIV racial inequalities (G reduction, 0.08; 95% CI: 0.02 to 0.14). CONCLUSIONS Microsimulation models developed with early, continuous stakeholder engagement and inputs yield powerful tools to guide policy implementation.
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Affiliation(s)
- Emmanuel F. Drabo
- Department of Health Policy and Management, John Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Corrina Moucheraud
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, CA
- UCLA Center for HIV Identification, Prevention and Treatment Services, University of Los Angeles, CA
| | - Anthony Nguyen
- Daniel J. Epstein Department of Industrial and Systems Engineering, University of Southern California, Los Angeles, CA
| | - Wendy H. Garland
- Los Angeles County Department of Public Health, Division of HIV and STD Programs, Los Angeles, CA
| | - Ian W. Holloway
- UCLA Center for HIV Identification, Prevention and Treatment Services, University of Los Angeles, CA
- Department of Social Welfare, Luskin School of Public Affairs, University of California, Los Angeles, CA
| | - Arleen Leibowitz
- UCLA Center for HIV Identification, Prevention and Treatment Services, University of Los Angeles, CA
- Department of Public Policy, Luskin School of Public Affairs, University of California, Los Angeles, CA
| | - Sze-chuan Suen
- Daniel J. Epstein Department of Industrial and Systems Engineering, University of Southern California, Los Angeles, CA
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Moraes DCDA, Cabral JDR, Oliveira RCD, Souza VAD. Quality of care and adherence to antiretroviral drugs in specialized HIV services in Pernambuco/Brazil, 2017-2018. SAÚDE EM DEBATE 2021. [DOI: 10.1590/0103-1104202113111i] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT The aim of this study was to evaluate health care quality and medication adherence in people living with human immunodeficiency virus in specialized care services. This is a cross-sectional, evaluative study, with a quantitative approach, carried out in ten services in Pernambuco. Two instruments were validated and analyzed by statistical tests were used and 306 adults and their service managers participated. The quality standard was equivalent for most indicators. Only in the countryside, the indicators referring to the availability of antiretroviral drugs and care in the absence of medication were associated with low adherence (p-value=0.033 and p-value=0.011), the latter being a predictor for low adherence. Services with insufficient quality standards showed a 19% higher occurrence of low medication adherence. 81% of users had low adherence to antiretroviral drugs. There is a deficiency in adherence to antiretroviral drugs, and those assisted in services in the countryside have more complicating factors related to the quality of health care for satisfactory adherence.
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Hazelbag CM, Dushoff J, Dominic EM, Mthombothi ZE, Delva W. Calibration of individual-based models to epidemiological data: A systematic review. PLoS Comput Biol 2020; 16:e1007893. [PMID: 32392252 PMCID: PMC7241852 DOI: 10.1371/journal.pcbi.1007893] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 05/21/2020] [Accepted: 04/21/2020] [Indexed: 01/24/2023] Open
Abstract
Individual-based models (IBMs) informing public health policy should be calibrated to data and provide estimates of uncertainty. Two main components of model-calibration methods are the parameter-search strategy and the goodness-of-fit (GOF) measure; many options exist for each of these. This review provides an overview of calibration methods used in IBMs modelling infectious disease spread. We identified articles on PubMed employing simulation-based methods to calibrate IBMs informing public health policy in HIV, tuberculosis, and malaria epidemiology published between 1 January 2013 and 31 December 2018. Articles were included if models stored individual-specific information, and calibration involved comparing model output to population-level targets. We extracted information on parameter-search strategies, GOF measures, and model validation. The PubMed search identified 653 candidate articles, of which 84 met the review criteria. Of the included articles, 40 (48%) combined a quantitative GOF measure with an algorithmic parameter-search strategy–either an optimisation algorithm (14/40) or a sampling algorithm (26/40). These 40 articles varied widely in their choices of parameter-search strategies and GOF measures. For the remaining 44 (52%) articles, the parameter-search strategy could either not be identified (32/44) or was described as an informal, non-reproducible method (12/44). Of these 44 articles, the majority (25/44) were unclear about the GOF measure used; of the rest, only five quantitatively evaluated GOF. Only a minority of the included articles, 14 (17%) provided a rationale for their choice of model-calibration method. Model validation was reported in 31 (37%) articles. Reporting on calibration methods is far from optimal in epidemiological modelling studies of HIV, malaria and TB transmission dynamics. The adoption of better documented, algorithmic calibration methods could improve both reproducibility and the quality of inference in model-based epidemiology. There is a need for research comparing the performance of calibration methods to inform decisions about the parameter-search strategies and GOF measures. Calibration—that is, “fitting” the model to data—is a crucial part of using mathematical models to better forecast and control the population-level spread of infectious diseases. Evidence that the mathematical model is well-calibrated improves confidence that the model provides a realistic picture of the consequences of health policy decisions. To make informed decisions, Policymakers need information about uncertainty: i.e., what is the range of likely outcomes (rather than just a single prediction). Thus, modellers should also strive to provide accurate measurements of uncertainty, both for their model parameters and for their predictions. This systematic review provides an overview of the methods used to calibrate individual-based models (IBMs) of the spread of HIV, malaria, and tuberculosis. We found that less than half of the reviewed articles used reproducible, non-subjective calibration methods. For the remaining articles, the method could either not be identified or was described as an informal, non-reproducible method. Only one-third of the articles obtained estimates of parameter uncertainty. We conclude that the adoption of better-documented, algorithmic calibration methods could improve both reproducibility and the quality of inference in model-based epidemiology.
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Affiliation(s)
- C. Marijn Hazelbag
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
- * E-mail:
| | - Jonathan Dushoff
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
- Department of Biology, Department of Mathematics and Statistics, Institute for Infectious Disease Research, McMaster University, Hamilton, Ontario, Canada
| | - Emanuel M. Dominic
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Zinhle E. Mthombothi
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Wim Delva
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
- School for Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
- Center for Statistics, I-BioStat, Hasselt University, Diepenbeek, Belgium
- Department of Global Health, Faculty of Medicine and Health, Stellenbosch University, Stellenbosch, South Africa
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium
- Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
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Chirambo L, Valeta M, Banda Kamanga TM, Nyondo-Mipando AL. Factors influencing adherence to antiretroviral treatment among adults accessing care from private health facilities in Malawi. BMC Public Health 2019; 19:1382. [PMID: 31660947 PMCID: PMC6816213 DOI: 10.1186/s12889-019-7768-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 10/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Private health facilities are increasingly being recognized as the neglected partner in the provision of HIV services. The non-adherence rate in the study sites ranged from 19 to 22%. This study explored the factors associated with non-adherence from antiretroviral therapy (ART) among adult patients accessing ART services at two privately owned urban health facilities in Malawi. METHODS We conducted a descriptive qualitative approach employing in-depth interviews among adults who either defaulted or were retained in HIV care in two privately owned facilities in Malawi from March to July 2017. We purposively selected participants and interviewed a total of 6 ART providers and 24 ART clients. Data were analyzed manually using a thematic approach. RESULTS Overall, participants identified four facilitators for retention in care and four broad categories of barriers namely individual, psychological, drug related and human resource related factors. The factors that facilitated retention in care included follow up visits after missing a visit, adequate information education and counseling, and supportive relationships. CONCLUSION The main reason for defaulting from antiretrovirals (ARVs) was fear of disclosing an HIV status to avert potential stigma and discrimination. In implementing ART clinics due consideration and strategies need to be adopted to ensure that privacy and confidentiality is preserved. Although adoption of all the key Malawi Implementing strategies like expert clients and a guardian may optimize retention in care, there is need for prior analysis of how those may lead to unintended disclosure which inadvertently affects adherence. Furthermore, private facilities should orient their clients to the public facilities within the catchment area so that clients have an option for alternative access to HIV care in the event of financial constraints.
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Affiliation(s)
- Lusungu Chirambo
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, Private Bag 360, Blantyre, Malawi
| | - Martha Valeta
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, Private Bag 360, Blantyre, Malawi
| | - Tifiness Mary Banda Kamanga
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, Private Bag 360, Blantyre, Malawi
| | - Alinane Linda Nyondo-Mipando
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
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Fatti G, Jackson D, Goga AE, Shaikh N, Eley B, Nachega JB, Grimwood A. The effectiveness and cost-effectiveness of community-based support for adolescents receiving antiretroviral treatment: an operational research study in South Africa. J Int AIDS Soc 2019; 21 Suppl 1. [PMID: 29485714 PMCID: PMC5978711 DOI: 10.1002/jia2.25041] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 12/11/2017] [Indexed: 12/19/2022] Open
Abstract
Introduction Adolescents and youth receiving antiretroviral treatment (ART) in sub‐Saharan Africa have high attrition and inadequate ART outcomes, and evaluations of interventions improving ART outcomes amongst adolescents are very limited. Sustainable Development Goal (SDG) target 3c is to substantially increase the health workforce in developing countries. We measured the effectiveness and cost‐effectiveness of community‐based support (CBS) provided by lay health workers for adolescents and youth receiving ART in South Africa. Methods A retrospective cohort study including adolescents and youth who initiated ART at 47 facilities. Previously unemployed CBS‐workers provided home‐based ART‐related education, psychosocial support, symptom screening for opportunistic infections and support to access government grants. Outcomes were compared between participants who received CBS plus standard clinic‐based care versus participants who received standard care only. Cumulative incidences of all‐cause mortality and loss to follow‐up (LTFU), adherence measured using medication possession ratios (MPRs), CD4 count slope, and virological suppression were analysed using multivariable Cox, competing‐risks regression, generalized estimating equations and mixed‐effects models over five years of ART. An expenditure approach was used to determine the incremental cost of CBS to usual care from a provider perspective. Incremental cost‐effectiveness ratios were calculated as annual cost per patient‐loss (through death or LTFU) averted. Results Amongst 6706 participants included, 2100 (31.3%) received CBS. Participants who received CBS had reduced mortality, adjusted hazard ratio (aHR) = 0.52 (95% CI: 0.37 to 0.73; p < 0.0001). Cumulative LTFU was 40% lower amongst participants receiving CBS (29.9%) compared to participants without CBS (38.9%), aHR = 0.60 (95% CI: 0.51 to 0.71); p < 0.0001). The effectiveness of CBS in reducing attrition ranged from 42.2% after one year to 35.9% after five years. Virological suppression was similar after three years, but after five years 18.8% CBS participants versus 37.2% non‐CBS participants failed to achieve viral suppression, adjusted odds ratio = 0.24 (95% CI: 0.06 to 1.03). There were no significant differences in MPR or CD4 slope. The cost of CBS was US$49.5/patient/year. The incremental cost per patient‐loss averted was US$600 and US$776 after one and two years, respectively. Conclusions CBS for adolescents and youth receiving ART was associated with substantially reduced patient attrition, and is a low‐cost intervention with reasonable cost‐effectiveness that can aid progress towards several health, economic and equality‐related SDG targets.
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Affiliation(s)
- Geoffrey Fatti
- Kheth'ImpiloCape TownSouth Africa
- The South African Department of Science and Technology/National Research Foundation (DST‐NRF)Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA)Stellenbosch UniversityStellenboschSouth Africa
| | - Debra Jackson
- UNICEFNew YorkNYUSA
- School of Public HealthUniversity of the Western CapeCape TownSouth Africa
| | - Ameena E Goga
- Health Systems Research UnitSouth African Medical Research CouncilPretoriaSouth Africa
- Department of PaediatricsUniversity of PretoriaPretoriaSouth Africa
| | | | - Brian Eley
- Department of Paediatrics and Child HealthRed Cross War Memorial Children's HospitalUniversity of Cape TownCape TownSouth Africa
| | - Jean B Nachega
- Departments of Epidemiology, Infectious Diseases and MicrobiologyUniversity of Pittsburgh Graduate School of Public HealthPittsburghPAUSA
- Department of Medicine and Centre for Infectious DiseasesFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
- Departments of Epidemiology and International HealthJohns Hopkins University Bloomberg School of Public HealthBaltimoreMDUSA
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Rebeiro PF, Bakoyannis G, Musick BS, Braithwaite RS, Wools-Kaloustian KK, Nyandiko W, Some F, Braitstein P, Yiannoutsos CT. Observational Study of the Effect of Patient Outreach on Return to Care: The Earlier the Better. J Acquir Immune Defic Syndr 2017; 76:141-148. [PMID: 28604501 PMCID: PMC5597469 DOI: 10.1097/qai.0000000000001474] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND The burden of HIV remains heaviest in resource-limited settings, where problems of losses to care, silent transfers, gaps in care, and incomplete mortality ascertainment have been recognized. METHODS Patients in care at Academic Model Providing Access to Healthcare (AMPATH) clinics from 2001-2011 were included in this retrospective observational study. Patients missing an appointment were traced by trained staff; those found alive were counseled to return to care (RTC). Relative hazards of RTC were estimated among those having a true gap: missing a clinic appointment and confirmed as neither dead nor receiving care elsewhere. Sample-based multiple imputation accounted for missing vital status. RESULTS Among 34,522 patients lost to clinic, 15,331 (44.4%) had a true gap per outreach, 2754 (8.0%) were deceased, and 837 (2.4%) had documented transfers. Of 15,600 (45.2%) remaining without active ascertainment, 8762 (56.2%) with later RTC were assumed to have a true gap. Adjusted cause-specific hazard ratios (aHRs) showed early outreach (a ≤8-day window, defined by grid-search approach) had twice the hazard for RTC vs. those without (aHR = 2.06; P < 0.001). HRs for RTC were lower the later the outreach effort after disengagement (aHR = 0.86 per unit increase in time; P < 0.001). Older age, female sex (vs. male), antiretroviral therapy use (vs. none), and HIV status disclosure (vs. none) were also associated with greater likelihood of RTC, and higher enrollment CD4 count with lower likelihood of RTC. CONCLUSION Patient outreach efforts have a positive impact on patient RTC, regardless of when undertaken, but particularly soon after the patient misses an appointment.
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Affiliation(s)
| | - Giorgos Bakoyannis
- Indiana University Fairbanks School of Public Health, Indianapolis, IN, USA
| | | | - Ronald S. Braithwaite
- New York University School of Medicine, New York City, NY, USA
- Moi University School of Medicine, Eldoret, Kenya
| | | | | | - Fatma Some
- Moi University School of Medicine, Eldoret, Kenya
| | - Paula Braitstein
- Indiana University Fairbanks School of Public Health, Indianapolis, IN, USA
- Moi University School of Medicine, Eldoret, Kenya
- University of Toronto Dalla Lana School of Public Health, Toronto, ON, Canada
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Uyei J, Li L, Braithwaite RS. Is more research always needed? Estimating optimal sample sizes for trials of retention in care interventions for HIV-positive East Africans. BMJ Glob Health 2017; 2:e000195. [PMID: 29081993 PMCID: PMC5656134 DOI: 10.1136/bmjgh-2016-000195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 04/27/2017] [Accepted: 04/30/2017] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Given the serious health consequences of discontinuing antiretroviral therapy, randomised control trials of interventions to improve retention in care may be warranted. As funding for global HIV research is finite, it may be argued that choices about sample size should be tied to maximising health. METHODS For an East African setting, we calculated expected value of sample information and expected net benefit of sampling to identify the optimal sample size (greatest return on investment) and to quantify net health gains associated with research. Two hypothetical interventions were analysed: (1) one aimed at reducing disengagement from HIV care and (2) another aimed at finding/relinking disengaged patients. RESULTS When the willingness to pay (WTP) threshold was within a plausible range (1-3 × GDP; US$1377-4130/QALY), the optimal sample size was zero for both interventions, meaning that no further research was recommended because the pre-research probability of an intervention's effectiveness and value was sufficient to support a decision on whether to adopt the intervention and any new information gained from additional research would likely not change that decision. In threshold analyses, at a higher WTP of $5200 the optimal sample size for testing a risk reduction intervention was 2750 per arm. For the outreach intervention, the optimal sample size remained zero across a wide range of WTP thresholds and was insensitive to variation. Limitations, including not varying all inputs in the model, may have led to an underestimation of the value of investing in new research. CONCLUSION In summary, more research is not always needed, particularly when there is moderately robust prestudy belief about intervention effectiveness and little uncertainty about the value (cost-effectiveness) of the intervention. Users can test their own assumptions at http://torchresearch.org.
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Affiliation(s)
- Jennifer Uyei
- Division of Comparative Effectiveness and Decision Science, Department of Population Health, New York University School of Medicine, New York City, New York, USA
| | - Lingfeng Li
- Division of Comparative Effectiveness and Decision Science, Department of Population Health, New York University School of Medicine, New York City, New York, USA
| | - R Scott Braithwaite
- Division of Comparative Effectiveness and Decision Science, Department of Population Health, New York University School of Medicine, New York City, New York, USA
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Zürcher K, Mooser A, Anderegg N, Tymejczyk O, Couvillon MJ, Nash D, Egger M. Outcomes of HIV-positive patients lost to follow-up in African treatment programmes. Trop Med Int Health 2017; 22:375-387. [PMID: 28102610 DOI: 10.1111/tmi.12843] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The retention of patients on antiretroviral therapy (ART) is key to achieving global targets in response to the HIV epidemic. Loss to follow-up (LTFU) can be substantial, with unknown outcomes for patients lost to ART programmes. We examined changes in outcomes of patients LTFU over calendar time, assessed associations with other study and programme characteristics and investigated the relative success of different tracing methods. METHODS We performed a systematic review and logistic random-effects meta-regression analysis of studies that traced adults or children who started ART and were LTFU in sub-Saharan African treatment programmes. The primary outcome was mortality, and secondary outcomes were undocumented transfer to another programme, treatment interruption and the success of tracing attempts. RESULTS We included 32 eligible studies from 12 countries in sub-Saharan Africa: 20 365 patients LTFU were traced, and 15 708 patients (77.1%) were found. Compared to telephone calls, tracing that included home visits increased the probability of success: the adjusted odds ratio (aOR) was 9.35 (95% confidence interval [CI] 1.85-47.31). The risk of death declined over calendar time (aOR per 1-year increase 0.86, 95% CI 0.78-0.95), whereas undocumented transfers (aOR 1.13, 95% CI 0.96-1.34) and treatment interruptions (aOR 1.31, 95% CI 1.18-1.45) tended to increase. Mortality was lower in urban than in rural areas (aOR 0.59, 95% CI 0.36-0.98), but there was no difference in mortality between adults and children. The CD4 cell count at the start of ART increased over time. CONCLUSIONS Mortality among HIV-positive patients who started ART in sub-Saharan Africa, were lost to programmes and were successfully traced has declined substantially during the scale-up of ART, probably driven by less severe immunodeficiency at the start of therapy.
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Affiliation(s)
- Kathrin Zürcher
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Anne Mooser
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Nanina Anderegg
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Olga Tymejczyk
- Institute for Implementation Science in Population Health, City University of New York, New York, NY, USA.,Department of Epidemiology and Biostatistics, City University of New York School of Public Health, New York, NY, USA
| | - Margaret J Couvillon
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, NY, USA.,Department of Epidemiology and Biostatistics, City University of New York School of Public Health, New York, NY, USA
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
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11
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Patel AR, Kessler J, Braithwaite RS, Nucifora KA, Thirumurthy H, Zhou Q, Lester RT, Marra CA. Economic evaluation of mobile phone text message interventions to improve adherence to HIV therapy in Kenya. Medicine (Baltimore) 2017; 96:e6078. [PMID: 28207516 PMCID: PMC5319505 DOI: 10.1097/md.0000000000006078] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND A surge in mobile phone availability has fueled low cost short messaging service (SMS) adherence interventions. Multiple systematic reviews have concluded that some SMS-based interventions are effective at improving antiretroviral therapy (ART) adherence, and they are hypothesized to improve retention in care. The objective of this study was to evaluate the cost-effectiveness of SMS-based adherence interventions and explore the added value of retention benefits. METHODS We evaluated the cost-effectiveness of weekly SMS interventions compared to standard care among HIV+ individuals initiating ART for the first time in Kenya. We used an individual level micro-simulation model populated with data from two SMS-intervention trials, an East-African HIV+ cohort and published literature. We estimated average quality adjusted life years (QALY) and lifetime HIV-related costs from a healthcare perspective. We explored a wide range of scenarios and assumptions in one-way and multivariate sensitivity analyses. RESULTS We found that SMS-based adherence interventions were cost-effective by WHO standards, with an incremental cost-effectiveness ratio (ICER) of $1,037/QALY. In the secondary analysis, potential retention benefits improved the cost-effectiveness of SMS intervention (ICER = $864/QALY). In multivariate sensitivity analyses, the interventions remained cost-effective in most analyses, but the ICER was highly sensitive to intervention costs, effectiveness and average cohort CD4 count at ART initiation. SMS interventions remained cost-effective in a test and treat scenario where individuals were assumed to initiate ART upon HIV detection. CONCLUSIONS Effective SMS interventions would likely increase the efficiency of ART programs by improving HIV treatment outcomes at relatively low costs, and they could facilitate achievement of the UNAIDS goal of 90% viral suppression among those on ART by 2020.
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Affiliation(s)
- Anik R. Patel
- University of British Columbia, Vancouver, BC, Canada
- New York University, New York, NY
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12
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Phillips AN, Cambiano V, Nakagawa F, Bansi-Matharu L, Sow PS, Ehrenkranz P, Ford D, Mugurungi O, Apollo T, Murungu J, Bangsberg DR, Revill P. Cost Effectiveness of Potential ART Adherence Monitoring Interventions in Sub-Saharan Africa. PLoS One 2016; 11:e0167654. [PMID: 27977702 PMCID: PMC5157976 DOI: 10.1371/journal.pone.0167654] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 11/17/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Interventions based around objective measurement of adherence to antiretroviral drugs for HIV have potential to improve adherence and to enable differentiation of care such that clinical visits are reduced in those with high adherence. It would be useful to understand the approximate upper limit of cost that could be considered for such interventions of a given effectiveness in order to be cost effective. Such information can guide whether to implement an intervention in the light of a trial showing a certain effectiveness and cost. METHODS An individual-based model, calibrated to Zimbabwe, which incorporates effects of adherence and resistance to antiretroviral therapy, was used to model the potential impact of adherence monitoring-based interventions on viral suppression, death rates, disability adjusted life years and costs. Potential component effects of the intervention were: enhanced average adherence when on ART, reduced risk of ART discontinuation, and reduced risk of resistance acquisition. We considered a situation in which viral load monitoring is not available and one in which it is. In the former case, it was assumed that care would be differentiated based on the adherence level, with fewer clinic visits in those demonstrated to have high adherence. In the latter case, care was assumed to be primarily differentiated according to viral load level. The maximum intervention cost required to be cost effective was calculated based on a cost effectiveness threshold of $500 per DALY averted. FINDINGS In the absence of viral load monitoring, an adherence monitoring-based intervention which results in a durable 6% increase in the proportion of ART experienced people with viral load < 1000 cps/mL was cost effective if it cost up to $50 per person-year on ART, mainly driven by the cost savings of differentiation of care. In the presence of viral load monitoring availability, an intervention with a similar effect on viral load suppression was cost-effective when costing $23-$32 per year, depending on whether the adherence intervention is used to reduce the level of need for viral load measurement. CONCLUSION The cost thresholds identified suggest that there is clear scope for adherence monitoring-based interventions to provide net population health gain, with potential cost-effective use in situations where viral load monitoring is or is not available. Our results guide the implementation of future adherence monitoring interventions found in randomized trials to have health benefit.
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Affiliation(s)
- Andrew N Phillips
- Research Department of Infection & Population Health, UCL, London, United Kingdom
| | - Valentina Cambiano
- Research Department of Infection & Population Health, UCL, London, United Kingdom
| | - Fumiyo Nakagawa
- Research Department of Infection & Population Health, UCL, London, United Kingdom
| | | | - Papa Salif Sow
- Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Peter Ehrenkranz
- Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Deborah Ford
- Institute for Clinical Trials and Methodology, UCL, London, United Kingdom
| | | | | | | | - David R. Bangsberg
- Oregon Health Sciences University-Portland State University School of Public Health, Portland, Oregon, United States of America
| | - Paul Revill
- Centre for Health Economics, University of York, York, United Kingdom
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