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Pepiot A, Supervie V, Breban R. Impact of voluntary testing on infectious disease epidemiology: A game theoretic approach. PLoS One 2023; 18:e0293968. [PMID: 37934734 PMCID: PMC10629633 DOI: 10.1371/journal.pone.0293968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 10/23/2023] [Indexed: 11/09/2023] Open
Abstract
The World Health Organization recommends test-and-treat interventions to curb and even eliminate epidemics of HIV, viral hepatitis, and sexually transmitted infections (e.g., chlamydia, gonorrhea, syphilis and trichomoniasis). Epidemic models show these goals are achievable, provided the participation of individuals in test-and-treat interventions is sufficiently high. We combine epidemic models and game theoretic models to describe individual's decisions to get tested for infectious diseases within certain epidemiological contexts, and, implicitly, their voluntary participation to test-and-treat interventions. We develop three hybrid models, to discuss interventions against HIV, HCV, and sexually transmitted infections, and the potential behavioral response from the target population. Our findings are similar across diseases. Particularly, individuals use three distinct behavioral patterns relative to testing, based on their perceived costs for testing, besides the payoff for discovering their disease status. Firstly, if the cost of testing is too high, then individuals refrain from voluntary testing and get tested only if they are symptomatic. Secondly, if the cost is moderate, some individuals will test voluntarily, starting treatment if needed. Hence, the spread of the disease declines and the disease epidemiology is mitigated. Thirdly, the most beneficial testing behavior takes place as individuals perceive a per-test payoff that surpasses a certain threshold, every time they get tested. Consequently, individuals achieve high voluntary testing rates, which may result in the elimination of the epidemic, albeit on temporary basis. Trials and studies have attained different levels of participation and testing rates. To increase testing rates, they should provide each eligible individual with a payoff, above a given threshold, each time the individual tests voluntarily.
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Affiliation(s)
- Amandine Pepiot
- Institut Pierre Louis d’Epidémiologie et de Santé Publique (IPLESP), Sorbonne Université, INSERM, Paris, France
| | - Virginie Supervie
- Institut Pierre Louis d’Epidémiologie et de Santé Publique (IPLESP), Sorbonne Université, INSERM, Paris, France
| | - Romulus Breban
- Institut Pasteur, Unité d’Epidémiologie des Maladies Emergentes, Paris, France
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2
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Sahu M, Bayer CJ, Roberts DA, van Rooyen H, van Heerden A, Shahmanesh M, Asiimwe S, Sausi K, Sithole N, Ying R, Rao DW, Krows ML, Shapiro AE, Baeten JM, Celum C, Revill P, Barnabas RV. Population health impact, cost-effectiveness, and affordability of community-based HIV treatment and monitoring in South Africa: A health economics modelling study. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0000610. [PMID: 37669249 PMCID: PMC10479912 DOI: 10.1371/journal.pgph.0000610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 06/06/2023] [Indexed: 09/07/2023]
Abstract
Community-based delivery and monitoring of antiretroviral therapy (ART) for HIV has the potential to increase viral suppression for individual- and population-level health benefits. However, the cost-effectiveness and budget impact are needed for public health policy. We used a mathematical model of HIV transmission in KwaZulu-Natal, South Africa, to estimate population prevalence, incidence, mortality, and disability-adjusted life-years (DALYs) from 2020 to 2060 for two scenarios: 1) standard clinic-based HIV care and 2) five-yearly home testing campaigns with community ART for people not reached by clinic-based care. We parameterised model scenarios using observed community-based ART efficacy. Using a health system perspective, we evaluated incremental cost-effectiveness and net health benefits using a threshold of $750/DALY averted. In a sensitivity analysis, we varied the discount rate; time horizon; costs for clinic and community ART, hospitalisation, and testing; and the proportion of the population receiving community ART. Uncertainty ranges (URs) were estimated across 25 best-fitting parameter sets. By 2060, community ART following home testing averted 27.9% (UR: 24.3-31.5) of incident HIV infections, 27.8% (26.8-28.8) of HIV-related deaths, and 18.7% (17.9-19.7) of DALYs compared to standard of care. Adolescent girls and young women aged 15-24 years experienced the greatest reduction in incident HIV (30.7%, 27.1-34.7). In the first five years (2020-2024), community ART required an additional $44.9 million (35.8-50.1) annually, representing 14.3% (11.4-16.0) of the annual HIV budget. The cost per DALY averted was $102 (85-117) for community ART compared with standard of care. Providing six-monthly refills instead of quarterly refills further increased cost-effectiveness to $78.5 per DALY averted (62.9-92.8). Cost-effectiveness was robust to sensitivity analyses. In a high-prevalence setting, scale-up of decentralised ART dispensing and monitoring can provide large population health benefits and is cost-effective in preventing death and disability due to HIV.
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Affiliation(s)
- Maitreyi Sahu
- Department of Health Metrics Sciences, University of Washington, Seattle, WA, United States of America
| | - Cara J. Bayer
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - D. Allen Roberts
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
| | | | - Alastair van Heerden
- SAMRC/WITS Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
- Center for Community Based Research, Human Sciences Research Council, KwaZulu-Natal, South Africa
| | | | | | - Kombi Sausi
- Human Sciences Research Council, Western Cape, South Africa
| | - Nsika Sithole
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Roger Ying
- School of Medicine, Yale University, New Haven, CT, United States of America
| | - Darcy W. Rao
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
| | - Meighan L. Krows
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Adrienne E. Shapiro
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, United States of America
- Gilead Sciences, Foster City, CA, United States of America
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | | | - Ruanne V. Barnabas
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
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3
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Vasantharoopan A, Simms V, Chan Y, Guinness L, Maheswaran H. Modelling Methods of Economic Evaluations of HIV Testing Strategies in Sub-Saharan Africa: A Systematic Review. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:585-601. [PMID: 36853553 DOI: 10.1007/s40258-022-00782-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/04/2022] [Indexed: 06/01/2023]
Abstract
BACKGROUND AND OBJECTIVE Economic evaluations, a decision-support tool for policy makers, will be crucial in planning and tailoring HIV prevention and treatment strategies especially in the wake of stalled and decreasing funding for the global HIV response. As HIV testing and treatment coverage increase, case identification becomes increasingly difficult and costly. Determining which subset of the population these strategies should be targeted to becomes of vital importance as well. Generating quality economic evidence begins with the validity of the modelling approach and the model structure employed. This study synthesises and critiques the reporting around modelling methodology of economic models in the evaluation of HIV testing strategies in sub-Saharan Africa. METHODS The following databases were searched from January 2000 to September 2020: MEDLINE, Embase, Scopus, EconLit and Global Health. Any model-based economic evaluation of a unique HIV testing strategy conducted in sub-Saharan Africa presenting a cost-effectiveness measure published from 2013 onwards was eligible. Data were extracted around three components: general study characteristics; economic evaluation design; and quality of model reporting using a novel tool developed for the purposes of this study. RESULTS A total of 21 studies were included; 10 cost-effectiveness analyses, 11 cost-utility analyses. All but one study was conducted in Eastern and Southern Africa. Modelling approaches for HIV testing strategies can be broadly characterised as static aggregate models (3/21), static individual models (6/21), dynamic aggregate models (5/21) and dynamic individual models (7/21). Adequate reporting around data handling was the highest of the three categories assessed (74%), and model validation, the lowest (45%). Limitations to model structure, justification of chosen time horizon and cycle length, and description of external model validation process were all adequately reported in less than 40% of studies. The predominant limitation of this review relates to the potential implications of the narrow inclusion criteria. CONCLUSIONS This review is the first to synthesise economic evaluations of HIV testing strategies in sub-Saharan Africa. The majority of models exhibited dynamic, stochastic and individual properties. Model reporting against the 13 criteria in our novel tool was mixed. Future model-based economic evaluations of HIV testing strategies would benefit from transparency around the choice of modelling approach, model structure, data handling procedures and model validation techniques.
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Affiliation(s)
- Arthi Vasantharoopan
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Victoria Simms
- MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Yuyen Chan
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, UK
| | - Lorna Guinness
- London School of Hygiene and Tropical Medicine, London, UK
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Dzinamarira T, Muvunyi CM, Mashamba-Thompson TP. Evaluation of a health education program for improving uptake of HIV self-testing by men in Rwanda: a pilot pragmatic randomized control trial. Pilot Feasibility Stud 2021; 7:202. [PMID: 34772453 PMCID: PMC8588608 DOI: 10.1186/s40814-021-00940-x] [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: 08/10/2020] [Accepted: 10/29/2021] [Indexed: 11/21/2022] Open
Abstract
Background Health education interventions tailored to suit men have the potential to improve health outcomes for this underserved population. HIV self-testing (HIVST) is a promising approach to overcoming challenges associated with low HIV testing rates among men. The primary objective of this study is to assess the feasibility of conducting a definitive trial to determine the effectiveness of a locally adapted and optimized health education program (HEP) on the uptake of HIVST among men in Kigali, Rwanda. Methods This study employs a pilot pragmatic randomized controlled trial to evaluate an HIVST HEP for men. Participants were randomized to the intervention (HEP) arm or to the control arm. In the intervention group, the adapted HEP was administered in addition to routine health education. In the non-intervention group, only routine health education was offered. Participant data was collected first upon recruitment and then after 3 months’ follow-up using interviewer-administered questionnaires. Results There was a 100% response rate at enrollment and no loss to follow-up at exit. There was significant association between the study arm and knowledge of HIVST. Participants in the control arm had a mean knowledge score of 67% compared to 92% among participants in the intervention arm. There was an association between the study arm and HIVST uptake: 67% of the study participants in the intervention arm self-reported HIVST uptake compared to 23% of the participants in the control arm. Discussion This pilot study demonstrates the feasibility of a larger trial to assess the effectiveness of an HEP intervention on uptake of HIVST among men. We found preliminary evidence of increased uptake of HIVST in the intervention group. Trial registration Pan African Clinical Trial Registry PACTR201908758321490. Registered on 8 August 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s40814-021-00940-x.
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Affiliation(s)
- Tafadzwa Dzinamarira
- Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa. .,College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
| | | | - Tivani Phosa Mashamba-Thompson
- Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa.,CIHR Canadian HIV Trials Network, Vancouver, BC, Canada.,Faculty of Health Sciences, University of Pretoria, Pretoria, Pretoria, South Africa
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Abstract
There is growing evidence for the key role of social determinants of health (SDOH) in understanding morbidity and mortality outcomes globally. Factors such as stigma, racism, poverty or access to health and social services represent complex constructs that affect population health via intricate relationships to individual characteristics, behaviors and disease prevention and treatment outcomes. Modeling the role of SDOH is both critically important and inherently complex. Here we describe different modeling approaches and their use in assessing the impact of SDOH on HIV/AIDS. The discussion is thematically divided into mechanistic models and statistical models, while recognizing the overlap between them. To illustrate mechanistic approaches, we use examples of compartmental models and agent-based models; to illustrate statistical approaches, we use regression and statistical causal models. We describe model structure, data sources required, and the scope of possible inferences, highlighting similarities and differences in formulation, implementation, and interpretation of different modeling approaches. We also indicate further needed research on representing and quantifying the effect of SDOH in the context of models for HIV and other health outcomes in recognition of the critical role of SDOH in achieving the goal of ending the HIV epidemic and improving overall population health.
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Thomas R, Probert WJM, Sauter R, Mwenge L, Singh S, Kanema S, Vanqa N, Harper A, Burger R, Cori A, Pickles M, Bell-Mandla N, Yang B, Bwalya J, Phiri M, Shanaube K, Floyd S, Donnell D, Bock P, Ayles H, Fidler S, Hayes RJ, Fraser C, Hauck K. Cost and cost-effectiveness of a universal HIV testing and treatment intervention in Zambia and South Africa: evidence and projections from the HPTN 071 (PopART) trial. Lancet Glob Health 2021; 9:e668-e680. [PMID: 33721566 PMCID: PMC8050197 DOI: 10.1016/s2214-109x(21)00034-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 12/15/2020] [Accepted: 01/21/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND The HPTN 071 (PopART) trial showed that a combination HIV prevention package including universal HIV testing and treatment (UTT) reduced population-level incidence of HIV compared with standard care. However, evidence is scarce on the costs and cost-effectiveness of such an intervention. METHODS Using an individual-based model, we simulated the PopART intervention and standard care with antiretroviral therapy (ART) provided according to national guidelines for the 21 trial communities in Zambia and South Africa (for all individuals aged >14 years), with model parameters and primary cost data collected during the PopART trial and from published sources. Two intervention scenarios were modelled: annual rounds of PopART from 2014 to 2030 (PopART 2014-30; as the UNAIDS Fast-Track target year) and three rounds of PopART throughout the trial intervention period (PopART 2014-17). For each country, we calculated incremental cost-effectiveness ratios (ICERs) as the cost per disability-adjusted life-year (DALY) and cost per HIV infection averted. Cost-effectiveness acceptability curves were used to indicate the probability of PopART being cost-effective compared with standard care at different thresholds of cost per DALY averted. We also assessed budget impact by projecting undiscounted costs of the intervention compared with standard care up to 2030. FINDINGS During 2014-17, the mean cost per person per year of delivering home-based HIV counselling and testing, linkage to care, promotion of ART adherence, and voluntary medical male circumcision via community HIV care providers for the simulated population was US$6·53 (SD 0·29) in Zambia and US$7·93 (0·16) in South Africa. In the PopART 2014-30 scenario, median ICERs for PopART delivered annually until 2030 were $2111 (95% credible interval [CrI] 1827-2462) per HIV infection averted in Zambia and $3248 (2472-3963) per HIV infection averted in South Africa; and $593 (95% CrI 526-674) per DALY averted in Zambia and $645 (538-757) per DALY averted in South Africa. In the PopART 2014-17 scenario, PopART averted one infection at a cost of $1318 (1098-1591) in Zambia and $2236 (1601-2916) in South Africa, and averted one DALY at $258 (225-298) in Zambia and $326 (266-391) in South Africa, when outcomes were projected until 2030. The intervention had almost 100% probability of being cost-effective at thresholds greater than $700 per DALY averted in Zambia, and greater than $800 per DALY averted in South Africa, in the PopART 2014-30 scenario. Incremental programme costs for annual rounds until 2030 were $46·12 million (for a mean of 341 323 people) in Zambia and $30·24 million (for a mean of 165 852 people) in South Africa. INTERPRETATION Combination prevention with universal home-based testing can be delivered at low annual cost per person but accumulates to a considerable amount when scaled for a growing population. Combination prevention including UTT is cost-effective at thresholds greater than $800 per DALY averted and can be an efficient strategy to reduce HIV incidence in high-prevalence settings. FUNDING US National Institutes of Health, President's Emergency Plan for AIDS Relief, International Initiative for Impact Evaluation, Bill & Melinda Gates Foundation.
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Affiliation(s)
- Ranjeeta Thomas
- Department of Health Policy, London School of Economics and Political Science, London, UK.
| | - William J M Probert
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rafael Sauter
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Surya Singh
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Nosivuyile Vanqa
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Abigail Harper
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Ronelle Burger
- Department of Economics, Stellenbosch University, Cape Town, South Africa
| | - Anne Cori
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Michael Pickles
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Nomtha Bell-Mandla
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Blia Yang
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | | | | | | | - Sian Floyd
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Peter Bock
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Helen Ayles
- Zambart, University of Zambia, Lusaka, Zambia; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Sarah Fidler
- Department of Infectious Disease, Imperial College London, London, UK
| | - Richard J Hayes
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Christophe Fraser
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Katharina Hauck
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK; Abdul Latif Jameel Institute for Disease and Emergency Analytics, School of Public Health, Imperial College London, London, UK
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Booton RD, Ong JJ, Lee A, Liu A, Huang W, Wei C, Tang W, Ma W, Vickerman P, Tucker JD, Mitchell KM. Modelling the impact of an HIV testing intervention on HIV transmission among men who have sex with men in China. HIV Med 2021; 22:467-477. [PMID: 33511687 DOI: 10.1111/hiv.13063] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES An intervention developed through participatory crowdsourcing methods increased HIV self-testing among men who have sex with men [MSM; relative risk (RR) = 1.89]. We estimated the long-term impact of this intervention on HIV transmission among MSM in four cities (Guangzhou, Shenzhen, Jinan and Qingdao). METHODS A mathematical model of HIV transmission, testing and treatment among MSM in China was parameterized using city-level demographic and sexual behaviour data and calibrated to HIV prevalence, diagnosis and antiretroviral therapy (ART) coverage data. The model was used to project the HIV infections averted over 20 years (2016-2036) from the intervention to increase self-testing, compared with current testing rates. RESULTS Running the intervention once would avert < 2.2% infections over 20 years. Repeating the intervention (RR = 1.89) annually would avert 6.4-10.7% of new infections, while further increases in the self-testing rate (hypothetical RR = 3) would avert 11.7-20.7% of new infections. CONCLUSIONS Repeated annual interventions would give a three- to seven-fold increase in long-term impact compared with a one-off intervention. Other interventions will be needed to more effectively reduce the HIV burden in this population.
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Affiliation(s)
- Ross D Booton
- University of Bristol, Bristol, UK.,MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Jason J Ong
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Amy Lee
- University of North Carolina Project-China, Guangzhou, China
| | - Aifeng Liu
- University of North Carolina Project-China, Guangzhou, China.,Social Entrepreneurship to Spur Health (SESH) Global, Guangzhou, China
| | - Wenting Huang
- University of North Carolina Project-China, Guangzhou, China.,Social Entrepreneurship to Spur Health (SESH) Global, Guangzhou, China
| | - Chongyi Wei
- Rutgers School of Public Health, Piscataway, NJ, USA
| | - Weiming Tang
- University of North Carolina Project-China, Guangzhou, China.,Social Entrepreneurship to Spur Health (SESH) Global, Guangzhou, China.,University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Wei Ma
- School of Public Health, Shandong University, Jinan, China
| | | | - Joseph D Tucker
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.,University of North Carolina Project-China, Guangzhou, China.,Social Entrepreneurship to Spur Health (SESH) Global, Guangzhou, China.,University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kate M Mitchell
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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Luong Nguyen LB, Yazdanpanah Y, Maman D, Wanjala S, Vandenbulcke A, Price J, Parker RA, Hennequin W, Mendiharat P, Freedberg KA. Voluntary Community Human Immunodeficiency Virus Testing, Linkage, and Retention in Care Interventions in Kenya: Modeling the Clinical Impact and Cost-effectiveness. Clin Infect Dis 2019; 67:719-726. [PMID: 29746619 PMCID: PMC6094004 DOI: 10.1093/cid/ciy173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Accepted: 04/02/2018] [Indexed: 01/30/2023] Open
Abstract
Background In southwest Kenya, the prevalence of human immunodeficiency virus (HIV) infection is about 25%. Médecins Sans Frontières has implemented a voluntary community testing (VCT) program, with linkage to care and retention interventions, to achieve the Joint United Nations Program on HIV and AIDS (UNAIDS) 90-90-90 targets by 2017. We assessed the effectiveness and cost-effectiveness of these interventions. Methods We developed a time-discrete, dynamic microsimulation model to project HIV incidence over time in the adult population in Kenya. We modeled 4 strategies: VCT, VCT-plus-linkage to care, a retention intervention, and all 3 interventions combined. Effectiveness outcomes included HIV incidence, years of life saved (YLS), cost (2014 €), and cost-effectiveness. We performed sensitivity analyses on key model parameters. Results With current care, the projected HIV incidence for 2032 was 1.51/100 person-years (PY); the retention and combined interventions decreased incidence to 1.03/100 PY and 0.75/100 PY, respectively. For 100000 individuals, the retention intervention had an incremental cost-effectiveness ratio (ICER) of €130/YLS compared with current care; the combined intervention incremental cost-effectiveness ratio was €370/YLS compared with the retention intervention. VCT and VCT-plus-linkage interventions cost more and saved fewer life-years than the retention and combined interventions. Baseline HIV prevalence had the greatest impact on the results. Conclusions Interventions targeting VCT, linkage to care, and retention would decrease HIV incidence rate over 15 years in rural Kenya if planned targets are achieved. These interventions together would be more effective and cost-effective than targeting a single stage of the HIV care cascade.
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Affiliation(s)
- Liem B Luong Nguyen
- Infection, Antimicrobials, Modelling, Evolution, UMR 1137, INSERM.,University Pierre and Marie Curie University Paris 06.,Paris Diderot University, Sorbonne Paris Cité
| | - Yazdan Yazdanpanah
- Infection, Antimicrobials, Modelling, Evolution, UMR 1137, INSERM.,University Pierre and Marie Curie University Paris 06.,Paris Diderot University, Sorbonne Paris Cité
| | | | | | | | | | - Robert A Parker
- Medical Practice Evaluation Center and Divisions of General Internal Medicine and Infectious Diseases, Massachusetts General Hospital, and Harvard Medical School
| | | | | | - Kenneth A Freedberg
- Medical Practice Evaluation Center and Divisions of General Internal Medicine and Infectious Diseases, Massachusetts General Hospital, and Harvard Medical School.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Optimal HIV testing strategies for South Africa: a model-based evaluation of population-level impact and cost-effectiveness. Sci Rep 2019; 9:12621. [PMID: 31477764 PMCID: PMC6718403 DOI: 10.1038/s41598-019-49109-w] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 08/19/2019] [Indexed: 11/26/2022] Open
Abstract
Although many African countries have achieved high levels of HIV diagnosis, funding constraints have necessitated greater focus on more efficient testing approaches. We compared the impact and cost-effectiveness of several potential new testing strategies in South Africa, and assessed the prospects of achieving the UNAIDS target of 95% of HIV-positive adults diagnosed by 2030. We developed a mathematical model to evaluate the potential impact of home-based testing, mobile testing, assisted partner notification, testing in schools and workplaces, and testing of female sex workers (FSWs), men who have sex with men (MSM), family planning clinic attenders and partners of pregnant women. In the absence of new testing strategies, the diagnosed fraction is expected to increase from 90.6% in 2020 to 93.8% by 2030. Home-based testing combined with self-testing would have the greatest impact, increasing the fraction diagnosed to 96.5% by 2030, and would be highly cost-effective compared to currently funded HIV interventions, with a cost per life year saved (LYS) of $394. Testing in FSWs and assisted partner notification would be cost-saving; the cost per LYS would also be low in the case of testing MSM ($20/LYS) and self-testing by partners of pregnant women ($130/LYS).
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10
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Sarkar S, Corso P, Ebrahim-Zadeh S, Kim P, Charania S, Wall K. Cost-effectiveness of HIV Prevention Interventions in Sub-Saharan Africa: A Systematic Review. EClinicalMedicine 2019; 10:10-31. [PMID: 31193863 PMCID: PMC6543190 DOI: 10.1016/j.eclinm.2019.04.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 04/04/2019] [Accepted: 04/10/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Sub-Saharan Africa carries the highest HIV burden globally. It is important to understand how interventions cost-effectively fit within guidelines and implementation plans, especially in low- and middle-income settings. We reviewed the evidence from economic evaluations of HIV prevention interventions in sub-Saharan Africa to help inform the allocation of limited resources. METHODS We searched PubMed, Web of Science, Econ-Lit, Embase, and African Index Medicus. We included studies published between January 2009 and December 2018 reporting cost-effectiveness estimates of HIV prevention interventions. We extracted health outcomes and cost-effectiveness ratios (CERs) and evaluated study quality using the CHEERS checklist. FINDINGS 60 studies met the full inclusion criteria. Prevention of mother-to-child transmission interventions had the lowest median CERs ($1144/HIV infection averted and $191/DALY averted), while pre-exposure prophylaxis interventions had the highest ($13,267/HIA and $799/DALY averted). Structural interventions (partner notification, cash transfer programs) have similar CERs ($3576/HIA and $392/DALY averted) to male circumcision ($2965/HIA) and were more favourable to treatment-as-prevention interventions ($7903/HIA and $890/DALY averted). Most interventions showed increased cost-effectiveness when prioritizing specific target groups based on age and risk. INTERPRETATION The presented cost-effectiveness information can aid policy makers and other stakeholders as they develop guidelines and programming for HIV prevention plans in resource-constrained settings.
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Affiliation(s)
- Supriya Sarkar
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | - Phaedra Corso
- Department of Health Policy and Management, Kennesaw State University, Kennesaw, GA, USA
| | | | - Patricia Kim
- Department of Economics, Emory University, Atlanta, GA, USA
| | - Sana Charania
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kristin Wall
- Department of Epidemiology, Emory University, Atlanta, GA, USA
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Barriers to, and emerging strategies for, HIV testing among adolescents in sub-Saharan Africa. Curr Opin HIV AIDS 2019; 13:257-264. [PMID: 29401121 DOI: 10.1097/coh.0000000000000452] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE OF REVIEW HIV/AIDS is one of the leading causes of death among adolescents in sub-Saharan Africa and 40% of new HIV infections worldwide occur in this group. HIV testing and counselling (HTC) is the critical first step to accessing HIV treatment. The prevalence of undiagnosed HIV infection is substantially higher in adolescents compared with adults. We review barriers to HTC for adolescents and emerging HTC strategies appropriate to adolescents in sub-Saharan Africa. RECENT FINDINGS There are substantial individual, health system and legal barriers to HTC among adolescents, and stigma by providers and communities remains an important obstacle. There has been progress made in recent years in developing strategies that address some of these barriers, increase uptake of HTC and yield of HIV. These include targeted approaches focused on provision of HTC among those higher risk of being infected, for example, index-linked HTC and use of screening tools to identify those at risk of HIV. Community-based HIV-testing approaches including HIV self-testing and incentives have also been shown to increase uptake of HTC. SUMMARY In implementing HTC strategies, consideration must be given to scalability and cost-effectiveness. HTC approaches must be coupled with linkage to appropriate care and prevention services.
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Tan N, Sharma M, Winer R, Galloway D, Rees H, Barnabas RV. Model-estimated effectiveness of single dose 9-valent HPV vaccination for HIV-positive and HIV-negative females in South Africa. Vaccine 2018; 36:4830-4836. [PMID: 29891348 PMCID: PMC6508597 DOI: 10.1016/j.vaccine.2018.02.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 01/23/2018] [Accepted: 02/01/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Women in sub-Saharan Africa have high dual burden of HPV and HIV infections, which can interact to increase cervical cancer (CC) risk. The 9-valent HPV (9vHPV) vaccine has high demonstrated effectiveness against HPV types causing 90% of CC. Additionally, one dose of the 9vHPV vaccine has the potential to achieve greater coverage at lower costs than a two-dose schedule. However, the potential impact of single-dose 9vHPV vaccine accounting for HPV-HIV interactions has not been estimated. METHODS We adapted a dynamic HIV transmission model to include HPV acquisition and CC pathogenesis and projected the impact of a single dose 9vHPV preadolescent vaccination in KwaZulu-Natal, South Africa. We report health impacts of HPV vaccination separately for HIV-positive women stratified by HIV treatment and CD4 count and HIV-negative women. RESULTS At 90% coverage of females age 9 years with 80% lifelong vaccine efficacy, single dose HPV vaccination was projected to reduce CC incidence by 74% and mortality by 71% in the general female population at 70 years after the start of the vaccination program. Age-standardized CC incidence and mortality reductions were comparable among HIV-negative women, HIV-positive women, and HIV-positive women on ART. Health benefits were reduced when assuming waning protection at 10, 15 and 20 years after vaccination. DISCUSSION Single dose 9vHPV vaccination is projected to avert substantial CC burden in South Africa and similar high HIV prevalence settings. Health benefits were comparable across all female subpopulations stratified by HIV status, CD4 count, and ART status.
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Affiliation(s)
- Nicholas Tan
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Rachel Winer
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Denise Galloway
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; School of Medicine, University of Washington, Seattle, WA, USA; Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Helen Rees
- Wits Reproductive Health and HIV Institute, University of Witwatersrand, Johannesburg, South Africa
| | - Ruanne V Barnabas
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; School of Medicine, University of Washington, Seattle, WA, USA; Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
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Kumi Smith M, Jewell BL, Hallett TB, Cohen MS. Treatment of HIV for the Prevention of Transmission in Discordant Couples and at the Population Level. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1075:125-162. [PMID: 30030792 DOI: 10.1007/978-981-13-0484-2_6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The scientific breakthrough proving that antiretroviral therapy (ART) can halt heterosexual HIV transmission came in the form of a landmark clinical trial conducted among serodiscordant couples. Study findings immediately informed global recommendations for the use of treatment as prevention in serodiscordant couples. The extent to which these findings are generalizable to other key populations or to groups exposed to HIV through nonsexual transmission routes (i.e., anal intercourse or unsafe injection of drugs) has since driven a large body of research. This review explores the history of HIV research in serodiscordant couples, the implications for management of couples, subsequent research on treatment as prevention in other key populations, and challenges in community implementation of these strategies.
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Affiliation(s)
- M Kumi Smith
- University of North Carolina Chapel Hill, Chapel Hill, NC, USA.
| | | | | | - Myron S Cohen
- University of North Carolina Chapel Hill, Chapel Hill, NC, USA
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Ross JM, Ying R, Celum CL, Baeten JM, Thomas KK, Murnane PM, van Rooyen H, Hughes JP, Barnabas RV. Modeling HIV disease progression and transmission at population-level: The potential impact of modifying disease progression in HIV treatment programs. Epidemics 2017; 23:34-41. [PMID: 29223580 DOI: 10.1016/j.epidem.2017.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 09/15/2017] [Accepted: 12/01/2017] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Mathematical models that incorporate HIV disease progression dynamics can estimate the potential impact of strategies that delay HIV disease progression and reduce infectiousness for persons not on antiretroviral therapy (ART). Suppressive treatment of HIV-positive persons co-infected with herpes simplex virus-2 (HSV-2) with valacyclovir, an HSV-2 antiviral, can lower HIV viral load, but the impact of partially-suppressive valacyclovir relative to fully-suppressive ART on population HIV transmission has not been estimated. METHODS We modeled HIV disease progression as a function of changes in viral load and CD4 count over time among ART naïve persons. The disease progression Markov model was nested within a dynamic model of HIV transmission at population level. We assumed that valacyclovir reduced HIV viral load by 1.23 log copies/μL, and that persons treated with valacyclovir initiated ART more rapidly when their CD4 fell below 500 due to retention in HIV care. We estimated the potential impact of valacyclovir on onward transmission of HIV in three scenarios of different ART and valacyclovir population coverage. RESULTS The average duration of HIV infection was 9.5 years. The duration of disease before reaching CD4 200cells/μL was 2.53 years longer for females than males. Relative to a baseline of ART initiation at CD4≤500cells/μL, the valacyclovir scenario resulted in 167,000 fewer HIV infections over ten years, with an incremental cost-effectiveness ratio (ICER) of $5276 per HIV infection averted. A Test and Treat scenario with 70% ART coverage and no valacyclovir resulted in 350,000 fewer HIV infections at an ICER of $2822 and $812 per HIV infection averted and QALY gained, respectively. CONCLUSION Even when compared with valacyclovir suppression, a drug that reduces HIV viral load, universal treatment for HIV is the optimal strategy for averting new infections and increasing public health benefit. Universal HIV treatment would most effectively and efficiently reduce the HIV burden.
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Affiliation(s)
- Jennifer M Ross
- Department of Medicine, University of Washington, Seattle, WA, USA; Division of Allergy and Infectious Disease, University of Washington, 1959 NE Pacific St., Box 356423, Seattle, WA 98195, USA.
| | - Roger Ying
- Weill Cornell Medical College, Cornell University, 420 E 70th St., 12J-3, New York, NY 10021, USA.
| | - Connie L Celum
- Department of Medicine, University of Washington, Seattle, WA, USA; Department of Global Health, University of Washington, 325 9th Ave., Box 359927, Seattle, WA 98104-2420, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Division of Allergy and Infectious Disease, University of Washington, 1959 NE Pacific St., Box 356423, Seattle, WA 98195, USA.
| | - Jared M Baeten
- Department of Medicine, University of Washington, Seattle, WA, USA; Department of Global Health, University of Washington, 325 9th Ave., Box 359927, Seattle, WA 98104-2420, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Division of Allergy and Infectious Disease, University of Washington, 1959 NE Pacific St., Box 356423, Seattle, WA 98195, USA.
| | - Katherine K Thomas
- Department of Global Health, University of Washington, 325 9th Ave., Box 359927, Seattle, WA 98104-2420, USA.
| | - Pamela M Murnane
- Department of Global Health, University of Washington, 325 9th Ave., Box 359927, Seattle, WA 98104-2420, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco.
| | | | - James P Hughes
- Department of Biostatistics, University of Washington, 1959 NE Pacific St., Box 357232, Seattle, WA 98195, USA; Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
| | - Ruanne V Barnabas
- Department of Medicine, University of Washington, Seattle, WA, USA; Department of Global Health, University of Washington, 325 9th Ave., Box 359927, Seattle, WA 98104-2420, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Division of Allergy and Infectious Disease, University of Washington, 1959 NE Pacific St., Box 356423, Seattle, WA 98195, USA.
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15
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Asiimwe S, Ross JM, Arinaitwe A, Tumusiime O, Turyamureeba B, Roberts DA, O’Malley G, Barnabas RV. Expanding HIV testing and linkage to care in southwestern Uganda with community health extension workers. J Int AIDS Soc 2017; 20:21633. [PMID: 28770598 PMCID: PMC5577731 DOI: 10.7448/ias.20.5.21633] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 04/25/2017] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Achieving the UNAIDS goals of 90-90-90 will require more than doubling the number of people accessing HIV care in Uganda. Community-based programmes for entry into HIV care are effective strategies to expand access to HIV care, but few programmes have been evaluated with a particular focus on scale-up. METHODS Integrated Community Based Initiatives, a Uganda-based non-governmental organization, designed and implemented a programme of community-based HIV counselling and testing and facilitated linkage to care utilizing community health extension workers (CHEWs) in rural Sheema District, Uganda. CHEWs performed programme activities during 1 October 2015 through 31 March 2016. Outcomes for this evaluation were (1) the number of people tested for HIV, and (2) the proportion of those testing positive who were seen at an ART clinic within three months of their positive test, and (3) the cost of the programme per person newly diagnosed with HIV. Microcosting methods were used to calculate the programme costs. Program scalability factors were evaluated using a published framework. RESULTS Sixty-two CHEWs attended a five-day training that introduced the biology of HIV, the conduct of confidential HIV testing, HIV prevention messages, and linkage, referral, and reporting requirements. CHEWs received a $30 monthly stipend and a field testing kit that included a bicycle, field bag, umbrella, gumboots, reporting booklet, pens, and HIV testing materials. Trained CHEWs tested 43,696 persons for HIV infection during the six-month programme period. Nine-hundred seventy-four participants (2.2%) were identified as HIV positive, and 623 participants (64%) were linked to HIV care. An estimated 69% of adult residents received testing as part of this campaign. The programme cost $3.02 per person test, $135.70 per positive person identified, and $212.15 per HIV-positive person linked to care. CONCLUSIONS Lay community health extension workers (CHEWs) can be rapidly trained to scale-up home-based HIV testing and counselling (HTC) and linkage to care in a high-quality and low-cost manner to large numbers of people in a rural, high burden setting. A combination HIV testing approach, such as adding partner testing to community-based testing, could increase the proportion of HIV-positive persons identified.
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Affiliation(s)
| | - Jennifer M. Ross
- Division of Allergy and Infectious Disease, University of Washington, Seattle, WA, USA
| | | | | | | | | | | | - Ruanne V. Barnabas
- Departments of Global Health, Medicine (Allergy and Infectious Disease), and Epidemiology, University of Washington, Seattle, WA, USA
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McCreesh N, Andrianakis I, Nsubuga RN, Strong M, Vernon I, McKinley TJ, Oakley JE, Goldstein M, Hayes R, White RG. Universal test, treat, and keep: improving ART retention is key in cost-effective HIV control in Uganda. BMC Infect Dis 2017; 17:322. [PMID: 28468605 PMCID: PMC5415795 DOI: 10.1186/s12879-017-2420-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 04/25/2017] [Indexed: 12/14/2022] Open
Abstract
Background With ambitious new UNAIDS targets to end AIDS by 2030, and new WHO treatment guidelines, there is increased interest in the best way to scale-up ART coverage. We investigate the cost-effectiveness of various ART scale-up options in Uganda. Methods Individual-based HIV/ART model of Uganda, calibrated using history matching. 22 ART scale-up strategies were simulated from 2016 to 2030, comprising different combinations of six single interventions (1. increased HIV testing rates, 2. no CD4 threshold for ART initiation, 3. improved ART retention, 4. increased ART restart rates, 5. improved linkage to care, 6. improved pre-ART care). The incremental net monetary benefit (NMB) of each intervention was calculated, for a wide range of different willingness/ability to pay (WTP) per DALY averted (health-service perspective, 3% discount rate). Results For all WTP thresholds above $210, interventions including removing the CD4 threshold were likely to be most cost-effective. At a WTP of $715 (1 × per-capita-GDP) interventions to improve linkage to and retention/re-enrolment in HIV care were highly likely to be more cost-effective than interventions to increase rates of HIV testing. At higher WTP (> ~ $1690), the most cost-effective option was ‘Universal Test, Treat, and Keep’ (UTTK), which combines interventions 1–5 detailed above. Conclusions Our results support new WHO guidelines to remove the CD4 threshold for ART initiation in Uganda. With additional resources, this could be supplemented with interventions aimed at improving linkage to and/or retention in HIV care. To achieve the greatest reductions in HIV incidence, a UTTK policy should be implemented. Electronic supplementary material The online version of this article (doi:10.1186/s12879-017-2420-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nicky McCreesh
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Ioannis Andrianakis
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | | | - Mark Strong
- School of Health and Related Research, The University of Sheffield, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Ian Vernon
- Department of Mathematical Sciences, Durham University, Lower Mountjoy, Stockton Road, Durham, DH1 3LE, UK
| | - Trevelyan J McKinley
- College of Engineering, Mathematics and Physical Sciences, University of Exeter, Campusm Penryn, Penryn, TR10 9FE, UK
| | - Jeremy E Oakley
- School of Mathematics and Statistics, University of Sheffield, The Hicks Building, Hounsfield Road, Sheffield, S3 7RH, UK
| | - Michael Goldstein
- Department of Mathematical Sciences, Durham University, Lower Mountjoy, Stockton Road, Durham, DH1 3LE, UK
| | - Richard Hayes
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Richard G White
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Genberg BL, Hogan JW, Braitstein P. Home testing and counselling with linkage to care. Lancet HIV 2016; 3:e244-e246. [PMID: 27240786 PMCID: PMC8573678 DOI: 10.1016/s2352-3018(16)30032-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 04/19/2016] [Accepted: 04/20/2016] [Indexed: 06/05/2023]
Affiliation(s)
- Becky L Genberg
- Department of Health Services, Policy and Practice, Brown University, Providence, RI 02903, USA.
| | - Joseph W Hogan
- Department of Biostatistics, Brown University, Providence, RI 02903, USA; Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; School of Medicine, Moi University, College of Health Sciences, Eldoret, Kenya; Fairbanks School of Public Health, Indiana University, Indianapolis, IN, USA; Regenstrief Institute, Indianapolis, IN, USA
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