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Solomon SS, McFall AM, Srikrishnan AK, Verma V, Anand S, Khan RT, Kushwaha BS, Vasudevan C, Saravanan S, Paneerselvam N, Kumar MS, Das C, Celentano DD, Mehta SH, Lucas GM. Voucher incentives to improve viral suppression among HIV-positive people who inject drugs and men who have sex with men in India: a cluster randomised trial. Lancet HIV 2024; 11:e309-e320. [PMID: 38583461 PMCID: PMC11177221 DOI: 10.1016/s2352-3018(24)00005-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 12/22/2023] [Accepted: 01/05/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Progress on HIV treatment outcomes for people who inject drugs and men who have sex with men in India has been slow compared with that in other populations. We assessed whether HIV treatment incentives would improve outcomes among these groups. METHODS We did a matched-pair, cluster randomised trial in 16 sites (eight for people who inject drugs and eight for men who have sex with men) across 15 cities in India. We recruited cohorts of HIV-positive people who inject drugs or men who have sex with men who were antiretroviral therapy (ART)-naive or had less than 12 months of ART exposure. We randomised sites to provide incentives or usual care. At intervention sites, we provided incentive vouchers, which could be exchanged for food or household goods, for attending motivational interviewing sessions and timely appointments at government ART clinics. An ART-naive participant meeting all targets could earn the equivalent to 14 days' wages over 12 months. The primary outcome was survival with viral suppression at 12 months. We used an intention-to-treat analytic approach appropriate for matched-pair cluster randomised trials, adjusting for baseline viral suppression. This study was registered with ClinicalTrials.gov, NCT02969915, and is complete. FINDINGS Between Oct 30, 2017, and Oct 12, 2018, we recruited 1200 people who inject drugs and 1114 men who have sex with men living with HIV. Among people who inject drugs, 154 (12·8%) identified as female gender and 1046 (87·2%) as male. The site median percentage of participants earning one or more incentives was 96·1% (IQR 93·7-98·1). At 12 months, HIV viral suppression was 31·9% (n=383) among people who inject drugs and 52·1% (n=580) among men who have sex with men. The incentive intervention was not associated with significantly improved survival with viral suppression compared with usual care (adjusted prevalence difference 9·6 percentage points, 95% CI -4·4 to 23·7). INTERPRETATION Despite high intervention engagement, incentives did not improve survival with viral suppression among people who inject drugs and men who have sex with men living with HIV in India. The poor outcomes overall underscore the need for innovative, multilevel approaches to engage marginalised people living with HIV in low-income and middle-income settings. FUNDING US National Institutes of Health, Elton John AIDS Foundation.
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Affiliation(s)
- Sunil S Solomon
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Allison M McFall
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Vinita Verma
- National AIDS Control Organisation, Ministry of Health and Family Welfare, New Delhi, India
| | - Santhanam Anand
- YR Gaitonde Centre for AIDS Research and Education, Chennai, India
| | - Rifa T Khan
- YR Gaitonde Centre for AIDS Research and Education, Chennai, India
| | - Bhawani Singh Kushwaha
- National AIDS Control Organisation, Ministry of Health and Family Welfare, New Delhi, India
| | | | | | | | | | - Chinmoyee Das
- National AIDS Control Organisation, Ministry of Health and Family Welfare, New Delhi, India
| | - David D Celentano
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shruti H Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Gregory M Lucas
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Kim HY, Inghels M, Mathenjwa T, Shahmanesh M, Seeley J, Matthews P, McGrath N, Adeagbo O, Gareta D, Yapa HM, Zuma T, Dobra A, Bärnighausen T, Tanser F. The impact of a conditional financial incentive on linkage to HIV care: Findings from the HITS cluster randomized clinical trial in rural South Africa. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.15.24304278. [PMID: 38562873 PMCID: PMC10984055 DOI: 10.1101/2024.03.15.24304278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Introduction HIV elimination requires innovative approaches to ensure testing and immediate treatment provision. We investigated the effectiveness of conditional financial incentives on increasing linkage to HIV care in a 2×2 factorial cluster randomized controlled trial-Home-Based Intervention to Test and Start (HITS) - in rural South Africa. Methods Of 45 communities in uMkhanyakude, KwaZulu-Natal, 16 communities were randomly assigned to the arms to receive financial incentives for home-based HIV counseling and testing (HBHCT) and linkage to care within 6 weeks (R50 [US$3] food voucher each) and 29 communities to the arms without financial incentives. We examined linkage to care (i.e., initiation or resumption of antiretroviral therapy after >3 months of care interruption) at local clinics within 6 weeks of a home visit, the eligibility period to receive the second financial incentive. Linkage to care was ascertained from individual clinical records. Intention-to-treat analysis (ITT) was performed using modified Poisson regression with adjustment for receiving another intervention (i.e., male-targeted HIV-specific decision support app) and clustering of standard errors at the community level. Results Among 13,894 eligible men (i.e., ≥15 years and resident in the 45 communities), 20.7% received HBHCT, which resulted in 122 HIV-positive tests. Of these, 27 linked to care within 6 weeks of HBHCT. Additionally, of eligible men who did not receive HBHCT, 66 linked to care. In the ITT analysis, the proportion of linkage to care among men did not differ in the arms which received financial incentives and those without financial incentives (adjusted Risk Ratio [aRR]=0.78, 95% CI: 0.51-1.21). Among 19,884 eligible women, 29.1% received HBHCT, which resulted in 375 HIV-positive tests. Of these, 75 linked to care. Among eligible women who did not receive HBHCT, 121 linked to care within 6 weeks. Women in the financial incentive arms had a significantly higher probability of linkage to care, compared to those in the arms without financial incentives (aRR=1.50; 95% CI: 1.03-2.21). Conclusion While a small once-off financial incentive did not increase linkage to care among men during the eligibility period of 6 weeks, it significantly improved linkage to care among women over the same period. Clinical Trial Number: ClinicalTrials.gov # NCT03757104.
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Tigirigi TO, Sithole GY, Chakara P, Chirombo GZ, Chiweza AR, Mubayiwa TR, Muchemwa S, Chibanda D, Dambi JM. Evaluation of the health-related quality of life and associated factors in Zimbabwean adults living with HIV: a cross-sectional study. BMC Res Notes 2023; 16:251. [PMID: 37794503 PMCID: PMC10548739 DOI: 10.1186/s13104-023-06536-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 09/25/2023] [Indexed: 10/06/2023] Open
Abstract
OBJECTIVE HIV remains a global burden, with the Sub-Saharan Africa (SSA) region reporting the largest number of people living with HIV/AIDS (PLHIV). An exponential improvement in the accessibility and uptake of antiretroviral treatment across SSA has significantly improved outcomes for PLHIV. Hence, HIV care goals have shifted from reducing mortality and morbidity to improving health-related quality of life (HRQoL). This study uses generic and condition-specific HRQoL outcomes to holistically determine the HRQoL of Zimbabwean adult PLHIV and associated factors. HRQoL is a dynamic subject construct that warrants continuous evaluation to provide meaningful feedback to various stakeholders. We enrolled 536 adult PLHIV in Zimbabwe. Collected data were analyzed through descriptive statistics and multivariate binary logistic regression. RESULTS Our study shows a high HRQoL perception by Zimbabwean PLHIV. Anxiety, depression, and poor environmental health were widely reported domains influencing HRQoL. Also, being aware of HIV status for over a year, not experiencing an adverse event, being married, having adequate finances and food security and having higher educational status were associated with higher HRQoL. It is essential to integrate mental health care into routine HIV care to improve treatment outcomes and HRQoL. Last, implementing bespoke multisectoral HRQoL-enhancement interventions is paramount.
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Affiliation(s)
- Tendai Orial Tigirigi
- Rehabilitation Sciences Unit - Faculty of Medicine and Health Sciences, University of Zimbabwe, PO BOX AV 178, Avondale, Harare, Zimbabwe
| | - Grace Yolanda Sithole
- Rehabilitation Sciences Unit - Faculty of Medicine and Health Sciences, University of Zimbabwe, PO BOX AV 178, Avondale, Harare, Zimbabwe
| | - Princess Chakara
- Rehabilitation Sciences Unit - Faculty of Medicine and Health Sciences, University of Zimbabwe, PO BOX AV 178, Avondale, Harare, Zimbabwe
| | - Gracious Z Chirombo
- Rehabilitation Sciences Unit - Faculty of Medicine and Health Sciences, University of Zimbabwe, PO BOX AV 178, Avondale, Harare, Zimbabwe
| | - Annamore Rutendo Chiweza
- Rehabilitation Sciences Unit - Faculty of Medicine and Health Sciences, University of Zimbabwe, PO BOX AV 178, Avondale, Harare, Zimbabwe
| | - Trish R Mubayiwa
- Rehabilitation Sciences Unit - Faculty of Medicine and Health Sciences, University of Zimbabwe, PO BOX AV 178, Avondale, Harare, Zimbabwe
| | - Sidney Muchemwa
- Rehabilitation Sciences Unit - Faculty of Medicine and Health Sciences, University of Zimbabwe, PO BOX AV 178, Avondale, Harare, Zimbabwe.
| | - Dixon Chibanda
- Mental Health Unit - Faculty of Medicine and Health Sciences, University of Zimbabwe, PO Box A178, Avondale, Harare, Zimbabwe
| | - Jermaine M Dambi
- Rehabilitation Sciences Unit - Faculty of Medicine and Health Sciences, University of Zimbabwe, PO BOX AV 178, Avondale, Harare, Zimbabwe
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Schnitzler L, Evers SMAA, Jackson LJ, Paulus ATG, Roberts TE. Are intersectoral costs considered in economic evaluations of interventions relating to sexually transmitted infections (STIs)? A systematic review. BMC Public Health 2022; 22:2180. [PMID: 36434561 PMCID: PMC9701033 DOI: 10.1186/s12889-022-14484-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/29/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND/OBJECTIVE Sexually transmitted infections (STIs) not only have an impact on the health sector but also the private resources of those affected, their families and other sectors of society (i.e. labour, education). This study aimed to i) review and identify economic evaluations of interventions relating to STIs, which aimed to include a societal perspective; ii) analyse the intersectoral costs (i.e. costs broader than healthcare) included; iii) categorise these costs by sector; and iv) assess the impact of intersectoral costs on the overall study results. METHODS Seven databases were searched: MEDLINE (PubMed), EMBASE (Ovid), Web of Science, CINAHL, PsycINFO, EconLit and NHS EED. Key search terms included terms for economic evaluation, STIs and specific infections. This review considered trial- and model-based economic evaluations conducted in an OECD member country. Studies were included that assessed intersectoral costs. Intersectoral costs were extracted and categorised by sector using Drummond's cost classification scheme (i.e. patient/family, productivity, costs in other sectors). A narrative synthesis was performed. RESULTS Twenty-nine studies qualified for data extraction and narrative synthesis. Twenty-eight studies applied a societal perspective of which 8 additionally adopted a healthcare or payer perspective, or both. One study used a modified payer perspective. The following sectors were identified: patient/family, informal care, paid labour (productivity), non-paid opportunity costs, education, and consumption. Patient/family costs were captured in 11 studies and included patient time, travel expenses, out-of-pocket costs and premature burial costs. Informal caregiver support (non-family) and unpaid help by family/friends was captured in three studies. Paid labour losses were assessed in all but three studies. Three studies also captured the costs and inability to perform non-paid work. Educational costs and future non-health consumption costs were each captured in one study. The inclusion of intersectoral costs resulted in more favourable cost estimates. CONCLUSIONS This systematic review suggests that economic evaluations of interventions relating to STIs that adopt a societal perspective tend to be limited in scope. There is an urgent need for economic evaluations to be more comprehensive in order to allow policy/decision-makers to make better-informed decisions.
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Affiliation(s)
- Lena Schnitzler
- grid.6572.60000 0004 1936 7486Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK ,grid.5012.60000 0001 0481 6099Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, The Netherlands
| | - Silvia M. A. A. Evers
- grid.5012.60000 0001 0481 6099Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, The Netherlands ,grid.416017.50000 0001 0835 8259Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
| | - Louise J. Jackson
- grid.6572.60000 0004 1936 7486Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Aggie T. G. Paulus
- grid.5012.60000 0001 0481 6099Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, The Netherlands ,grid.5012.60000 0001 0481 6099School of Health Professions Education (SHE), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, The Netherlands
| | - Tracy E. Roberts
- grid.6572.60000 0004 1936 7486Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Roy Paladhi U, Katz DA, Farquhar C, Thirumurthy H. Using Behavioral Economics to Support PrEP Adherence for HIV Prevention. Curr HIV/AIDS Rep 2022; 19:409-414. [PMID: 36044119 PMCID: PMC9428871 DOI: 10.1007/s11904-022-00624-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2022] [Indexed: 12/01/2022]
Abstract
Purpose of Review We explored different behavioral economics (BE) mechanisms through which pre-exposure prophylaxis (PrEP) initiation and adherence could be impacted and examined recent work using BE principles to further HIV prevention efforts. We also generated new intervention ideas based on existing HIV testing and ART adherence literature. Recent Findings There is limited work that uses BE principles to design interventions to increase PrEP initiation and adherence, mostly involving financial incentives. The recent works highlighted involve financial incentives and demonstrate that key populations are open to accepting monetary incentives to increase PrEP initiation and improve adherence. However, there are mixed results on the long-term impacts of using incentives to modify behavior. Summary While there are a few ongoing studies that utilize BE principles to increase PrEP use, there is need to develop studies that test these concepts, to promote PrEP initiation and adherence. We suggest methods of exploring non-incentives-based ideas to increase PrEP use in key populations.
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Affiliation(s)
- Unmesha Roy Paladhi
- Department of Epidemiology, School of Public Health, University of Washington, UW Box # 351619, Seattle, WA, 98195, USA.
- Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA.
| | - David A Katz
- Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
| | - Carey Farquhar
- Department of Epidemiology, School of Public Health, University of Washington, UW Box # 351619, Seattle, WA, 98195, USA
- Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
- Department of Medicine, School of Medicine, University of Washington, Seattle, USA
| | - Harsha Thirumurthy
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Applying Behavioural Insights to HIV Prevention and Management: a Scoping Review. Curr HIV/AIDS Rep 2022; 19:358-374. [PMID: 35930186 PMCID: PMC9508055 DOI: 10.1007/s11904-022-00615-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW This scoping review summarises the literature on HIV prevention and management interventions utilizing behavioural economic principles encapsulated in the MINDSPACE framework. RECENT FINDINGS MINDSPACE is an acronym developed by the UK's behavioural insights team to summarise nine key influences on human behaviour: Messenger, Incentives, Norms, Default, Salience, Priming, Affect, Commitment, and Ego. These effects have been used in various settings to design interventions that encourage positive behaviours. Currently, over 200 institutionalised behavioural insight teams exist internationally, which may draw upon the MINDSPACE framework to inform policy and improve public services. To date, it is not clear how behavioural insights have been applied to HIV prevention and management interventions. After screening 899 studies for eligibility, 124 were included in the final review. We identified examples of interventions that utilised all the MINDSPACE effects in a variety of settings and among various populations. Studies from high-income countries were most common (n = 54) and incentives were the most frequently applied effect (n = 100). The MINDSPACE framework is a useful tool to consider how behavioural science principles can be applied in future HIV prevention and management interventions. Creating nudges to enhance the design of HIV prevention and management interventions can help people make better choices as we strive to end the HIV/AIDS pandemic by 2030.
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Khazanov GK, Morris PE, Beed A, Jager-Hyman S, Myhre K, McKay JR, Feinn RS, Boland EM, Thase ME. Do financial incentives increase mental health treatment engagement? A meta-analysis. J Consult Clin Psychol 2022; 90:528-544. [PMID: 35771513 PMCID: PMC10603786 DOI: 10.1037/ccp0000737] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Engagement in mental health treatment is low, which can lead to poor outcomes. We evaluated the efficacy of offering patients financial incentives to increase their mental health treatment engagement, also referred to as contingency management. METHOD We meta-analyzed studies offering financial incentives for mental health treatment engagement, including increasing treatment attendance, medication adherence, and treatment goal completion. Analyses were run within a multilevel framework. All study designs were included, and sensitivity analyses were run including only randomized and high-quality studies. RESULTS About 80% of interventions incentivized treatment for substance use disorders. Financial incentives significantly increased treatment attendance (Hedges' g = 0.49, [0.33, 0.64], k = 30, I2 = 83.14), medication adherence (Hedges' g = 0.95, [0.47, 1.44], k = 6, I2 = 87.73), and treatment goal completion (Hedges' g = 0.61, [0.22, 0.99], k = 5, I2 = 60.55), including completing homework, signing treatment plans, and reducing problematic behavior. CONCLUSIONS Financial incentives increase treatment engagement with medium to large effect sizes. We provide strong evidence for their effectiveness in increasing substance use treatment engagement and preliminary evidence for their effectiveness in increasing treatment engagement for other mental health disorders. Future research should prioritize testing the efficacy of incentivizing treatment engagement for mental health disorders aside from substance use. Research must also identify ways to incentivize treatment engagement that improve functioning and long-term outcomes and address ethical and systemic barriers to implementing these interventions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Affiliation(s)
- Gabriela K Khazanov
- Mental Illness Research, Education, and Clinical Center of the Veterans Integrated Service Network 4, Crescenz Veterans Affairs Medical Center
| | | | | | - Shari Jager-Hyman
- Department of Psychiatry, Penn Center for the Prevention of Suicide, University of Pennsylvania
| | - Karoline Myhre
- Department of Psychiatry, Penn Center for the Prevention of Suicide, University of Pennsylvania
| | - James R McKay
- Department of Psychiatry, University of Pennsylvania
| | - Richard S Feinn
- Frank H. Netter MD School of Medicine, Quinnipiac University
| | - Elaine M Boland
- Mental Illness Research, Education, and Clinical Center of the Veterans Integrated Service Network 4, Crescenz Veterans Affairs Medical Center
| | - Michael E Thase
- Mental Illness Research, Education, and Clinical Center of the Veterans Integrated Service Network 4, Crescenz Veterans Affairs Medical Center
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Rua T, Brandão D, Nicolau V, Escoval A. The Utilisation of Payment Models Across the HIV Continuum of Care: Systematic Review of Evidence. AIDS Behav 2021; 25:4193-4208. [PMID: 34184134 PMCID: PMC8602234 DOI: 10.1007/s10461-021-03329-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2021] [Indexed: 10/31/2022]
Abstract
The increasing chronicity and multimorbidities associated with people living with HIV have posed important challenges to health systems across the world. In this context, payment models hold the potential to improve care across a spectrum of clinical conditions. This study aims to systematically review the evidence of HIV performance-based payments models. Literature searches were conducted in March 2020 using multiple databases and manual searches of relevant papers. Papers were limited to any study design that considers the real-world utilisation of performance-based payment models applied to the HIV domain. A total of 23 full-text papers were included. Due to the heterogeneity of study designs, the multiple types of interventions and its implementation across distinct areas of HIV care, direct comparisons between studies were deemed unsuitable. Most evidence focused on healthcare users (83%), seeking to directly affect patients' behaviour based on principles of behavioural economics. Despite the variability between interventions, the implementation of performance-based payment models led to either a neutral or positive impact throughout the HIV care continuum. Moreover, this improvement was likely to be cost-effective or, at least, did not compromise the healthcare system's financial sustainability. However, more research is needed to assess the durability of incentives and its appropriate relative magnitude.
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Dasgupta S, Moore MR, Dimitrov DT, Hughes JP. Bayesian validation framework for dynamic epidemic models. Epidemics 2021; 37:100514. [PMID: 34763161 PMCID: PMC8720263 DOI: 10.1016/j.epidem.2021.100514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/23/2021] [Accepted: 10/21/2021] [Indexed: 11/29/2022] Open
Abstract
Complex models of infectious diseases are used to understand the transmission dynamics of the disease, project the course of an epidemic, predict the effect of interventions and/or provide information for power calculations of community level intervention studies. However, there have been relatively few opportunities to rigorously evaluate the predictions of such models till now. Indeed, while there is a large literature on calibration (fitting model parameters) and validation (comparing model outputs to data) of complex models based on empirical data, the lack of uniformity in accepted criteria for such procedures for models of infectious diseases has led to simple procedures being prevalent for such steps. However, recently, several community level randomized trials of combination HIV intervention have been planned and/or initiated, and in each case, significant epidemic modeling efforts were conducted during trial planning which were integral to the design of these trials. The existence of these models and the (anticipated) availability of results from the related trials, provide a unique opportunity to evaluate the models and their usefulness in trial design. In this project, we outline a framework for evaluating the predictions of complex epidemiological models and describe experiments that can be used to test their predictions.
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Affiliation(s)
- Sayan Dasgupta
- Fred Hutchinson Cancer Research Center, Seattle WA 98122, USA.
| | - Mia R Moore
- Fred Hutchinson Cancer Research Center, Seattle WA 98122, USA
| | | | - James P Hughes
- Fred Hutchinson Cancer Research Center, Seattle WA 98122, USA
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Blackburn NA, Go VF, Bui Q, Hutton H, Tampi RP, Sripaipan T, Ha TV, Latkin CA, Golden S, Golin C, Chander G, Frangakis C, Gottfredson N, Dowdy DW. The Cost-Effectiveness of Adapting and Implementing a Brief Intervention to Target Frequent Alcohol Use Among Persons with HIV in Vietnam. AIDS Behav 2021; 25:2108-2119. [PMID: 33392969 PMCID: PMC8576395 DOI: 10.1007/s10461-020-03139-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2020] [Indexed: 01/21/2023]
Abstract
Brief interventions to reduce frequent alcohol use among persons with HIV (PWH) are evidence-based, but resource-constrained settings must contend with competition for health resources. We evaluated the cost-effectiveness of two intervention arms compared to the standard of care (SOC) in a three-arm randomized control trial targeting frequent alcohol use in PWH through increasing the percent days abstinent from alcohol and viral suppression. We estimated incremental cost per quality-adjusted life year (QALY) gained from a modified societal perspective and a 1-year time horizon using a Markov model of health outcomes. The two-session brief intervention (BI), relative to the six-session combined intervention (CoI), was more effective and less costly; the estimated incremental cost-effectiveness of the BI relative to the SOC, was $525 per QALY gained. The BI may be cost-effective for the HIV treatment setting; the health utility gained from viral suppression requires further exploration.
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Affiliation(s)
- Natalie A Blackburn
- Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Drive, CB #7420, Chapel Hill, NC, 27599-7420, USA.
| | - Vivian F Go
- Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Drive, CB #7420, Chapel Hill, NC, 27599-7420, USA
| | - Quynh Bui
- University of North Carolina Project Vietnam, Hanoi, Vietnam
| | - Heidi Hutton
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Radhika P Tampi
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Teerada Sripaipan
- Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Drive, CB #7420, Chapel Hill, NC, 27599-7420, USA
| | - Tran Viet Ha
- University of North Carolina Project Vietnam, Hanoi, Vietnam
| | - Carl A Latkin
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shelley Golden
- Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Drive, CB #7420, Chapel Hill, NC, 27599-7420, USA
| | - Carol Golin
- Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Drive, CB #7420, Chapel Hill, NC, 27599-7420, USA
| | - Geetanjali Chander
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Constantine Frangakis
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nisha Gottfredson
- Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Drive, CB #7420, Chapel Hill, NC, 27599-7420, USA
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Tozan Y, Capasso A, Sun S, Neilands TB, Damulira C, Namuwonge F, Nakigozi G, Mwebembezi A, Mukasa B, Sensoy Bahar O, Nabunya P, Mellins CA, McKay MM, Ssewamala FM. The efficacy and cost-effectiveness of a family-based economic empowerment intervention (Suubi + Adherence) on suppression of HIV viral loads among adolescents living with HIV: results from a Cluster Randomized Controlled Trial in southern Uganda. J Int AIDS Soc 2021; 24:e25752. [PMID: 34176245 PMCID: PMC8236226 DOI: 10.1002/jia2.25752] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 04/24/2021] [Accepted: 05/05/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Evidence from low-resource settings indicates that economic insecurity is a major barrier to HIV treatment adherence. Economic empowerment (EE) interventions have the potential to improve adherence outcomes among adolescents living with HIV (ALWHIV) by mitigating the effects of poverty. This study aims to assess the efficacy and cost-effectiveness of a savings-led family-based EE intervention, Suubi + Adherence, aimed at improving antiretroviral therapy (ART) adherence outcomes ALWHIV in Uganda. METHODS Adolescents (mean age 12 years at enrolment; 56% female) receiving ART for HIV at 39 health centres were randomized to Suubi + Adherence intervention (n = 358) or bolstered standard of care (BSOC; n = 344). A difference-in-differences analysis was employed to assess the change in the proportion of virally suppressed adolescents (HIV RNA viral load <40 copies/mL) over 24 months. The cost-effectiveness analysis examined how much the intervention cost to virally suppress one additional adolescent relative to BSOC from the healthcare provider perspective. RESULTS At 24 months, the intervention was associated with an 8.85-percentage point [95% confidence interval (CI) 0.80 to 16.90 percentage points] increase in the proportion of virally suppressed adolescents between the study arms (p = 0.032). Per-participant costs were US$177 and US$263 for the BSOC and intervention groups respectively. The incremental cost of virally suppressing one additional adolescent was estimated at US$970 [95% CI, US$508 to 10,725] over two years. CONCLUSIONS Our results support the integration of family-based EE interventions into adherence-support strategies as part of routine HIV care in low-resource settings to address the underlying economic drivers of poor ART adherence among ALWHIV. Moreover, per-participant costs to achieve viral suppression do not seem prohibitive compared to other community-based adherence interventions targeted at ALWHIV in low-resource settings. Further research on combination interventions at the nexus of economic security and HIV treatment and care is needed to inform the development of feasible and scalable HIV policies and programmes.
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Affiliation(s)
- Yesim Tozan
- School of Global Public HealthNew York UniversityNew YorkNYUSA
| | - Ariadna Capasso
- School of Global Public HealthNew York UniversityNew YorkNYUSA
| | - Sicong Sun
- Brown SchoolWashington University in Saint LouisSaint LouisMOUSA
- International Center for Child Health and DevelopmentBrown SchoolWashington University in St. LouisSt. LouisMOUSA
| | - Torsten B Neilands
- Center for AIDS Prevention StudiesSchool of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Christopher Damulira
- International Center for Child Health and DevelopmentWashington University in St. LouisUganda Field OfficeMasakaUganda
| | - Flavia Namuwonge
- International Center for Child Health and DevelopmentWashington University in St. LouisUganda Field OfficeMasakaUganda
| | | | - Abel Mwebembezi
- International Center for Child Health and DevelopmentWashington University in St. LouisUganda Field OfficeMasakaUganda
- Reach the Youth (RTY) UgandaKampalaUganda
| | | | - Ozge Sensoy Bahar
- Brown SchoolWashington University in Saint LouisSaint LouisMOUSA
- International Center for Child Health and DevelopmentBrown SchoolWashington University in St. LouisSt. LouisMOUSA
| | - Proscovia Nabunya
- Brown SchoolWashington University in Saint LouisSaint LouisMOUSA
- International Center for Child Health and DevelopmentBrown SchoolWashington University in St. LouisSt. LouisMOUSA
| | - Claude A Mellins
- HIV Center for Clinical and Behavioral StudiesDepartment of PsychiatryNew York State Psychiatric Institute and Columbia UniversityNew YorkNYUSA
| | - Mary M McKay
- Brown SchoolWashington University in Saint LouisSaint LouisMOUSA
| | - Fred M Ssewamala
- Brown SchoolWashington University in Saint LouisSaint LouisMOUSA
- International Center for Child Health and DevelopmentBrown SchoolWashington University in St. LouisSt. LouisMOUSA
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12
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Tanser FC, Kim HY, Mathenjwa T, Shahmanesh M, Seeley J, Matthews P, Wyke S, McGrath N, Adeagbo O, Sartorius B, Yapa HM, Zuma T, Zeitlin A, Blandford A, Dobra A, Bärnighausen T. Home-Based Intervention to Test and Start (HITS): a community-randomized controlled trial to increase HIV testing uptake among men in rural South Africa. J Int AIDS Soc 2021; 24:e25665. [PMID: 33586911 PMCID: PMC7883477 DOI: 10.1002/jia2.25665] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 11/30/2020] [Accepted: 12/23/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction The uptake of HIV testing and linkage to care remains low among men, contributing to high HIV incidence in women in South Africa. We conducted the “Home‐Based Intervention to Test and Start” (HITS) in a 2x2 factorial cluster randomized controlled trial in one of the World’s largest ongoing HIV cohorts in rural South Africa aimed at enhancing both intrinsic and extrinsic motivations for HIV testing. Methods Between February and December 2018, in the uMkhanyakude district of KwaZulu‐Natal, we randomly assigned 45 communities (clusters) (n = 13,838 residents) to one of the four arms: (i) financial incentives for home‐based HIV testing and linkage to care (R50 [$3] food voucher each); (ii) male‐targeted HIV‐specific decision support application, called EPIC‐HIV; (iii) both financial incentives and male‐targeted HIV‐specific decision support application and (iv) standard of care (SoC). EPIC‐HIV was developed to encourage and serve as an intrinsic motivator for HIV testing and linkage to care, and individually offered to men via a tablet device. Financial incentives were offered to both men and women. Here we report the effect of the interventions on uptake of home‐based HIV testing among men. Intention‐to‐treat (ITT) analysis was performed using modified Poisson regression with adjustment for clustering of standard errors at the cluster levels. Results Among all 13,838 men ≥ 15 years living in the 45 communities, the overall population coverage during a single round of home‐based HIV testing was 20.7%. The uptake of HIV testing was 27.5% (683/2481) in the financial incentives arm, 17.1% (433/2534) in the EPIC‐HIV arm, 26.8% (568/2120) in the arm receiving both interventions and 17.8% in the SoC arm. The probability of HIV testing increased substantially by 55% in the financial incentives arm (risk ratio (RR)=1.55, 95% CI: 1.31 to 1.82, p < 0.001) and 51% in the arm receiving both interventions (RR = 1.51, 95% CI: 1.21 to 1.87 p < 0.001), compared to men in the SoC arm. The probability of HIV testing did not significantly differ in the EPIC‐HIV arm (RR = 0.96, 95% CI: 0.76 to 1.20, p = 0.70). Conclusions The provision of a small financial incentive acted as a powerful extrinsic motivator substantially increasing the uptake of home‐based HIV testing among men in rural South Africa. In contrast, the counselling and testing application which was designed to encourage and serve as an intrinsic motivator to test for HIV did not increase the uptake of home‐based testing.
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Affiliation(s)
- Frank C Tanser
- Africa Health Research Institute, Durban, South Africa.,Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, United Kingdom.,School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Hae-Young Kim
- Africa Health Research Institute, Durban, South Africa.,Department of Population Health, New York University School of Medicine, New York, NY, USA.,KwaZulu-Natal Innovation and Sequencing Platform, KwaZulu-Natal, South Africa
| | | | - Maryam Shahmanesh
- Africa Health Research Institute, Durban, South Africa.,Institute for Global Health, University College London, London, United Kingdom
| | - Janet Seeley
- Africa Health Research Institute, Durban, South Africa.,London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Sally Wyke
- University of Glasgow, Glasgow, United Kingdom
| | - Nuala McGrath
- Africa Health Research Institute, Durban, South Africa.,University of Southampton, Southampton, United Kingdom
| | - Oluwafemi Adeagbo
- Africa Health Research Institute, Durban, South Africa.,Department of Sociology, University of Johannesburg, Johannesburg, South Africa.,Department of Health Promotion, Education and Behaviour, University of South Carolina, Columbia, SC, USA
| | - Benn Sartorius
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Handurugamage Manisha Yapa
- Africa Health Research Institute, Durban, South Africa.,The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | | | - Anya Zeitlin
- Institute for Global Health, University College London, London, United Kingdom
| | - Ann Blandford
- University College London Interaction Centre, University College London, London, United Kingdom
| | | | - Till Bärnighausen
- Africa Health Research Institute, Durban, South Africa.,Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
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13
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Lee C, Kwak S, Kim J. Controlling COVID-19 Outbreaks with Financial Incentives. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18020724. [PMID: 33467714 PMCID: PMC7830108 DOI: 10.3390/ijerph18020724] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 12/23/2022]
Abstract
In this paper, we consider controlling coronavirus disease 2019 (COVID-19) outbreaks with financial incentives. We use the recently developed susceptible-unidentified infected-confirmed (SUC) epidemic model. The unidentified infected population is defined as the infected people who are not yet identified and isolated and can spread the disease to susceptible individuals. It is important to quickly identify and isolate infected people among the unidentified infected population to prevent the infectious disease from spreading. Considering financial incentives as a strategy to control the spread of disease, we predict the effect of the strategy through a mathematical model. Although incentive costs are required, the duration of the disease can be shortened. First, we estimate the unidentified infected cases of COVID-19 in South Korea using the SUC model, and compute two parameters such as the disease transmission rate and the inverse of the average time for confirming infected individuals. We assume that when financial incentives are provided, there are changes in the proportion of confirmed patients out of unidentified infected people in the SUC model. We evaluate the numbers of confirmed and unidentified infected cases with respect to one parameter while fixing the other estimated parameters. We investigate the effect of the incentives on the termination time of the spread of the disease. The larger the incentive budget is, the faster the epidemic will end. Therefore, financial incentives can have the advantage of reducing the total cost required to prevent the spread of the disease, treat confirmed patients, and recover overall economic losses.
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14
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Abstract
PURPOSE OF REVIEW More than half of new HIV diagnoses occur in the Southern United States where the epidemic disproportionately affects persons of color. Although other areas of the country are seeing dramatic declines in the number of new cases, the progress in the South lags behind. This review will examine the reasons for that disparity. Many are unique to the South. RECENT FINDINGS Despite advances in antiretroviral therapy for HIV, many in the South are not benefiting from these medications, at either a personal or public health level. The reasons are complex and include lack of access to healthcare, lower levels of funding than other areas of the country, stigma, structural racism, increased barriers due to social determinants of health, coexisting mental health disorders, substance use disorders and sexually transmitted diseases and insufficient workforce capacity to meet the needs of those living with HIV. SUMMARY These findings should underline the need for investment in the South for a holistic healthcare approach to persons living with HIV including supporting basic needs such as access to food, transportation and housing. Prioritization among politicians for policy and systems changes and approaches to decrease stigma and enhance education about HIV will be key.
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Ghose T, Shubert V, Poitevien V, Choudhuri S, Gross R. Effectiveness of a Viral Load Suppression Intervention for Highly Vulnerable People Living with HIV. AIDS Behav 2019; 23:2443-2452. [PMID: 31098747 DOI: 10.1007/s10461-019-02509-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
We examine the effect of the Undetectables Intervention (UI) on viral loads among socially vulnerable HIV-positive clients. The UI utilized a toolkit that included financial incentives, graphic novels, and community-based case management services. A pre-post repeated measures analysis (n = 502) through 4 years examined longitudinal effects of the intervention. Logistic models regressed social determinants on viral loads. Finally, in-depth qualitative interviews (n = 30) examined how UI shaped adherence. The proportion of virally suppressed time-points increased 15% (from 67 to 82% pre to post-enrollment, p < 0.0001). The proportion of the sample virally suppressed at all time-points increased by 23% (from 39 to 62% pre to post-enrollment, p < 0.0001). African Americans and the homeless were the most likely to be unsuppressed at baseline, but, along with substance users, benefitted the most from UI. The intervention shaped adherence through two pathways, by: (1) establishing worth around adherence, and (2) increasing motivation to become suppressed, and maintain adherence.
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Affiliation(s)
- Toorjo Ghose
- School of Social Policy and Practice, University of Pennsylvania, D17 Caster Building, 3401 Locust Walk, Philadelphia, PA, 19104, USA.
| | | | | | - Sambuddha Choudhuri
- School of Social Policy and Practice, University of Pennsylvania, D17 Caster Building, 3401 Locust Walk, Philadelphia, PA, 19104, USA
| | - Robert Gross
- School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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