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De Anda JA, Irvine MA, Zhang W, Salway T, Haag D, Gilbert M. Cost-effectiveness of internet-based HIV screening among gay, bisexual and other men who have sex with men (GBMSM) in Metro Vancouver, Canada. PLoS One 2023; 18:e0294628. [PMID: 38011230 PMCID: PMC10681302 DOI: 10.1371/journal.pone.0294628] [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: 12/13/2022] [Accepted: 11/06/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND GetCheckedOnline is an internet-based screening service aiming to increase HIV testing among gay, bisexual and other men who have sex with men (GBMSM). We assessed the cost-effectiveness of GetCheckedOnline in its first implementation phase at different uptake scenarios compared to clinic-based screening services alone in Metro Vancouver, Canada. METHODS From a healthcare payer's perspective, our cost-utility analysis used an established dynamic GBMSM HIV compartmental model estimating the probability of acquiring HIV, progressing through diagnosis, disease stages and treatment over a 30-year time horizon. The base case scenario assumed 4.7% uptake of GetCheckedOnline in 2016 (remainder using clinic-based services), with 74% of high-risk and 44% of low-risk infrequent testers becoming regular testers in five years. Scenario analyses tested increased GetCheckedOnline uptake to 10% and 15%. RESULTS The cost per test for GetCheckedOnline was $29.40 compared to clinic-based services $56.92. Compared with clinic-based screening services, the projected increase in testing frequency with 4.7% uptake of GetCheckedOnline increased the costs by $329,600 (95% Credible Interval: -$498,200, $571,000) and gained 4.53 (95%CrI: 0, 9.20) quality-adjusted life years (QALYs) in a 30-year time horizon. The probability of GetCheckedOnline being cost-effective was 34% at the threshold of $50,000 per QALY, and increased to 73% at the threshold of $100,000 per QALY. The results were consistent in the other uptake scenarios. The probability of GetCheckedOnline being cost-effective became 80% at the threshold of $50,000 per QALY if assuming 5-year time horizon. CONCLUSIONS GetCheckedOnline is almost half the cost of clinic-based services on a per-test basis. However, increased access to testing should be balanced with risk profiles of patients to ensure the implementation can be a cost-effective strategy for increasing HIV screening among GBMSM in Metro Vancouver. Additional analyses are needed to understand the impact of internet-based screening including screening for other STIs and in other populations.
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Affiliation(s)
- Jose A. De Anda
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael A. Irvine
- Institute of Applied Mathematics, University of British Columbia, Vancouver, British Columbia, Canada
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Wei Zhang
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Advancing Health Outcomes, Vancouver, British Columbia, Canada
| | - Travis Salway
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- Centre for Gender and Sexual Health Equity, Vancouver, British Columbia, Canada
| | - Devon Haag
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Mark Gilbert
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
- Centre for Gender and Sexual Health Equity, Vancouver, British Columbia, Canada
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Process description of developing HIV prevention monitoring indicators for a province-wide pre-exposure prophylaxis (PrEP) program in British Columbia, Canada. PLoS One 2023; 18:e0283025. [PMID: 36920956 PMCID: PMC10016663 DOI: 10.1371/journal.pone.0283025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 02/28/2023] [Indexed: 03/16/2023] Open
Abstract
In 2018, the pre-exposure prophylaxis (PrEP) program was initiated in British Columbia (BC), Canada, providing PrEP at no cost to qualifying residents. This observational study discussed the steps to develop key evidence-based monitoring indicators and their calculation using real-time data. The indicators were conceptualized, developed, assessed and approved by the Technical Monitoring Committee of representatives from five health authority regions in BC, the BC Ministry of Health, the BC Centre for Disease Control, and the BC Centre for Excellence in HIV/AIDS. Indicator development followed the steps adopted from the United States Centers for Disease Control and Prevention framework for program evaluation in public health. The assessment involved eight selection criteria: data quality, indicator validity, existing scientific evidence, indicator informativeness, indicator computing feasibility, clients' confidentiality maintenance capacity, indicator accuracy, and administrative considerations. Clients' data from the provincial-wide PrEP program (January 2018-December 2020) shows the indicators' calculation. The finalized 14 indicators included gender, age, health authority, new clients enrolled by provider type and by the health authority, new clients dispensed PrEP, clients per provider, key qualifying HIV risk factor(s), client status, PrEP usage type, PrEP quantity dispensed, syphilis and HIV testing and incident cases, and adverse drug reaction events. Cumulative clients' data (n = 6966; 99% cis-gender males) identified an increased new client enrollment and an unexpected drop during the COVID-19 pandemic. About 80% dispensed PrEP from the Vancouver Coastal health authority. The HIV incidence risk index for men who have sex with men score ≥10 was the most common qualifying risk factor. The framework we developed integrating indicators was applied to monitor our PrEP program, which could help reduce the public health impact of HIV.
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Lier AJ, Seval N, Vander Wyk B, Di Paola A, Springer SA. Maintenance on extended-release naltrexone is associated with reduced injection opioid use among justice-involved persons with opioid use disorder. J Subst Abuse Treat 2022; 142:108852. [PMID: 35988513 PMCID: PMC9509444 DOI: 10.1016/j.jsat.2022.108852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/05/2022] [Accepted: 07/26/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Opioid use disorder (OUD) and injection drug use (IDU) place justice-involved individuals at increased risk for acquiring or transmitting HIV or hepatitis C virus (HCV). Methadone and buprenorphine have been associated with reduced opioid IDU; however, the effect of extended-release naltrexone (XR-NTX) on this behavior is incompletely studied. METHODS This study examined injection opioid use and shared injection equipment behavior from a completed double-blind placebo-controlled trial of XR-NTX among 88 justice-involved participants with HIV and OUD. Changes in participants' self-reported daily injection opioid use and shared injection equipment was evaluated pre-incarceration, during incarceration, and monthly post-release for 6 months. The study also assessed differences in time to first opioid injection post-release. The research team performed intention to treat and "as treated" (high treatment versus low treatment) analyses. RESULTS Fifty-eight of 88 participants (69.5 %) endorsed IDU and 26 (29.5 %) reported sharing injection equipment in the 30 days pre-incarceration; 2 participants (2.2 %) reported IDU during incarceration; 19 (21.6 %) reported IDU one month post-release from prison or jail. Fifty-four (61.4 %) participants had an HIV RNA below 200 copies/mL and 62 (70.5 %) were baseline HCV antibody positive. The 6-month follow-up rate was 49.5 % and 50.5 % for those who received XR-NTX and placebo, respectively, which was not significantly different (p = 0.822). Participants in the XR-NTX and placebo groups had similar low mean opioid injection use post-release and time to first injection opioid use in the Intention-to-treat analysis. In the as-treated analysis, participants in the high treatment group had significantly lower mean proportion of days injecting opioids (13.8 % high treatment versus 22.8 % low treatment, p = 0.02) by month 1, which persisted up to 5 months post-release (0 % high treatment vs 24.3 % low treatment, p < 0.001) and experienced a longer time to first opioid injection post-release (143.8 days high treatment vs 67.4 days low treatment, p < 0.001). CONCLUSIONS Injection opioid use was low during incarceration and remained low post-release in this justice-involved population. Retention on XR-NTX was associated with reduced intravenous opioid use, which has important implications for reducing transmission of HIV and HCV.
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Affiliation(s)
- Audun J Lier
- Department of Internal Medicine, Division of Infectious Diseases, Northport VA Medical Center, Northport, NY, USA
| | - Nikhil Seval
- Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, New Haven, CT, USA
| | - Brent Vander Wyk
- Department of Internal Medicine, Section of Geriatrics, Yale School of Medicine, New Haven, CT, USA
| | - Angela Di Paola
- Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, New Haven, CT, USA
| | - Sandra A Springer
- Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, New Haven, CT, USA; Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT, USA.
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The role of depression in secondary HIV transmission among people who inject drugs in Vietnam: A mathematical modeling analysis. PLoS One 2022; 17:e0275995. [PMID: 36240142 PMCID: PMC9565425 DOI: 10.1371/journal.pone.0275995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 09/27/2022] [Indexed: 11/06/2022] Open
Abstract
Background Among people who inject drugs (PWID), depression burden is high and may interfere with HIV prevention efforts. Although depression is known to affect injecting behaviors and HIV treatment, its overall impact on HIV transmission has not been quantified. Using mathematical modeling, we sought to estimate secondary HIV transmissions and identify differences by depression among PWID. Methods We analyzed longitudinal data from 455 PWID living with HIV in Vietnam during 2009–2013. Using a Bernoulli process model with individual-level viral load and behavioral data from baseline and 6-month follow-up visits, we estimated secondary HIV transmission events from participants to their potentially susceptible injecting partners. To evaluate differences by depression, we compared modeled transmissions per 1,000 PWID across depressive symptom categories (severe, mild, or no symptoms) in the three months before each visit. Results We estimated a median of 41.2 (2.5th, 97.5th percentiles: 33.2–49.2) secondary transmissions from all reported acts of sharing injection equipment with 833 injecting partners in the three months before baseline. Nearly half (41%) of modeled transmissions arose from fewer than 5% of participants in that period. Modeled transmissions per 1,000 PWID in that period were highest for severe depressive symptoms (100.4, 80.6–120.2) vs. mild (87.0, 68.2–109.4) or no symptoms (78.9, 63.4–94.1). Transmission estimates fell to near-zero at the 6-month visit. Conclusions Secondary transmissions were predicted to increase with depression severity, although most arose from a small number of participants. Our findings suggest that effective depression interventions could have the important added benefit of reducing HIV transmission among PWID.
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Martel-Laferrière V, Feaster DJ, Metsch LR, Shackman BR, Loignon C, Nosyk B, Tookes H, Behrends CN, Arruda N, Adigun O, Goyer ME, Kolber MA, Mary JF, Rodriguez AE, Yanez IG, Pan Y, Khemiri R, Gooden L, Sako A, Bruneau J. M 2HepPrEP: study protocol for a multi-site multi-setting randomized controlled trial of integrated HIV prevention and HCV care for PWID. Trials 2022; 23:341. [PMID: 35461260 PMCID: PMC9034074 DOI: 10.1186/s13063-022-06085-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 02/05/2022] [Indexed: 12/15/2022] Open
Abstract
Background Opioid use is escalating in North America and comes with a multitude of health consequences, including HIV and hepatitis C virus (HCV) outbreaks among persons who inject drugs (PWID). HIV pre-exposure prophylaxis (PrEP) and HCV treatment regimens have transformative potential to address these co-occurring epidemics. Evaluation of innovative multi-modal approaches, integrating harm reduction, opioid agonist therapy (OAT), PrEP, and HCV treatment is required. The aim of this study is to assess the effectiveness of an on-site integrated care model where delivery of PrEP and HCV treatment for PWID takes places at syringe service programs (SSP) and OAT programs compared with referring PWID to clinical services in the community through a patient navigation model and to examine how structural factors interact with HIV prevention adherence and HCV treatment outcomes. Methods The Miami-Montreal Hepatitis C and Pre-Exposure Prophylaxis trial (M2HepPrEP) is an open-label, multi-site, multi-center, randomized, controlled, superiority trial with two parallel treatment arms. A total of 500 persons who injected drugs in the prior 6 months and are eligible for PrEP will be recruited in OAT clinics and SSP in Miami, FL, and Montréal, Québec. Participants will be randomized to either on-site care, with adherence counseling, or referral to off-site clinics assisted by a patient navigator. PrEP will be offered to all participants and HCV treatment to those HCV-infected. Co-primary endpoints will be (1) adherence to pre-exposure prophylaxis medication at 6 months post-randomization and (2) HCV sustained virological response (SVR) 12 weeks post-treatment completion among participants who were randomized within the HCV stratum. Up to 100 participants will be invited to participate in a semi-structured interview regarding perceptions of adherence barriers and facilitators, after their 6-month assessment. A simulation model-based cost-effectiveness analysis will be performed to determine the comparative value of the strategies being evaluated. Discussion The results of this study have the potential to demonstrate the effectiveness and cost-effectiveness of offering PrEP and HCV treatment in healthcare venues frequently attended by PWID. Testing the intervention in two urban centers with high disease burden among PWID, but with different healthcare system dynamics, will increase generalizability of findings. Trial registration Clinicaltrials.gov NCT03981445. Trial registry name: Integrated HIV Prevention and HCV Care for PWID (M2HepPrEP). Registration date: June 10, 201. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06085-3.
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Affiliation(s)
- Valérie Martel-Laferrière
- Centre hospitalier de l'Université de Montréal, Montreal, Canada. .,Faculté de médecine: Université de Montréal, Montreal, Canada. .,Centre de Recherche du CHUM: Centre hospitalier de l'Université de Montréal Centre de Recherche, Montreal, Canada.
| | | | - Lisa R Metsch
- Columbia University Mailman School of Public Health, New York City, USA
| | - Bruce R Shackman
- Weill Cornell Medical College: Weill Cornell Medicine, New York City, USA
| | | | | | - Hansel Tookes
- University of Miami Miller School of Medicine, Miami, USA
| | - Czarina N Behrends
- Weill Cornell Medical College: Weill Cornell Medicine, New York City, USA
| | - Nelson Arruda
- Direction régionale de la santé publique de Montréal, Montreal, Canada
| | | | - Marie-Eve Goyer
- Faculté de médecine: Université de Montréal, Montreal, Canada
| | | | | | | | - Iveth G Yanez
- Columbia University Mailman School of Public Health, New York City, USA
| | - Yue Pan
- University of Miami Department of Public Health Sciences, Miami, USA
| | - Rania Khemiri
- Centre de Recherche du CHUM: Centre hospitalier de l'Université de Montréal Centre de Recherche, Montreal, Canada
| | - Lauren Gooden
- Columbia University Mailman School of Public Health, New York City, USA
| | - Aïssata Sako
- Centre de Recherche du CHUM: Centre hospitalier de l'Université de Montréal Centre de Recherche, Montreal, Canada
| | - Julie Bruneau
- Centre hospitalier de l'Université de Montréal, Montreal, Canada.,Faculté de médecine: Université de Montréal, Montreal, Canada.,Centre de Recherche du CHUM: Centre hospitalier de l'Université de Montréal Centre de Recherche, Montreal, Canada
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Miller RL, McLaughlin A, Liang RH, Harding J, Wong J, Le AQ, Brumme CJ, Montaner JSG, Joy JB. Phylogenetic prioritization of HIV-1 transmission clusters with viral lineage-level diversification rates. Evol Med Public Health 2022; 10:305-315. [PMID: 35899097 PMCID: PMC9311310 DOI: 10.1093/emph/eoac026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 07/07/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background and objectives
Public health officials faced with a large number of transmission clusters require a rapid, scalable and unbiased way to prioritize distribution of limited resources to maximize benefits. We hypothesize that transmission cluster prioritization based on phylogenetically derived lineage-level diversification rates will perform as well as or better than commonly used growth-based prioritization measures, without need for historical data or subjective interpretation.
Methodology
9822 HIV pol sequences collected during routine drug resistance genotyping were used alongside simulated sequence data to infer sets of phylogenetic transmission clusters via patristic distance threshold. Prioritized clusters inferred from empirical data were compared to those prioritized by the current public health protocols. Prioritization of simulated clusters was evaluated based on correlation of a given prioritization measure with future cluster growth, as well as the number of direct downstream transmissions from cluster members.
Results
Empirical data suggest diversification rate-based measures perform comparably to growth-based measures in recreating public heath prioritization choices. However, unbiased simulated data reveals phylogenetic diversification rate-based measures perform better in predicting future cluster growth relative to growth-based measures, particularly long-term growth. Diversification rate-based measures also display advantages over growth-based measures in highlighting groups with greater future transmission events compared to random groups of the same size. Furthermore, diversification rate measures were notably more robust to effects of decreased sampling proportion.
Conclusions and implications
Our findings indicate diversification rate-based measures frequently outperform growth-based measures in predicting future cluster growth and offer several additional advantages beneficial to optimizing the public health prioritization process.
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Affiliation(s)
- Rachel L Miller
- Molecular Epidemiology and Evolutionary Genetics, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
- Bioinformatics Program, University of British Columbia, Vancouver, Canada
| | - Angela McLaughlin
- Molecular Epidemiology and Evolutionary Genetics, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
- Bioinformatics Program, University of British Columbia, Vancouver, Canada
| | - Richard H Liang
- Laboratory Program, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | | | - Jason Wong
- Clinical Prevention Services, British Columbia Centre for Disease Control, Vancouver, Canada
| | - Anh Q Le
- Laboratory Program, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - Chanson J Brumme
- Laboratory Program, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Julio S G Montaner
- Department of Medicine, University of British Columbia, Vancouver, Canada
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - Jeffrey B Joy
- Corresponding author. Molecular Epidemiology and Evolutionary Genetics, BC Centre for Excellence in HIV/AIDS, 615-1033 Davie St, Vancouver, BC, V6E 1M5, Canada. Tel: +1-(604)-368-5569; E-mail:
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Cerdá M, Jalali MS, Hamilton AD, DiGennaro C, Hyder A, Santaella-Tenorio J, Kaur N, Wang C, Keyes KM. A Systematic Review of Simulation Models to Track and Address the Opioid Crisis. Epidemiol Rev 2021; 43:147-165. [PMID: 34791110 DOI: 10.1093/epirev/mxab013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 10/20/2021] [Accepted: 11/04/2021] [Indexed: 01/04/2023] Open
Abstract
The opioid overdose crisis is driven by an intersecting set of social, structural, and economic forces. Simulation models offer a tool to help us understand and address this complex, dynamic, and nonlinear social phenomenon. We conducted a systematic review of the literature on simulation models of opioid use and overdose up to September 2019. We extracted modeling types, target populations, interventions, and findings. Further, we created a database of model parameters used for model calibration, and evaluated study transparency and reproducibility. Of the 1,398 articles screened, we identified 88 eligible articles. The most frequent types of models were compartmental (36%), Markov (20%), system dynamics (16%), and Agent-Based models (16%). Over a third evaluated intervention cost-effectiveness (40%), and another third (39%) focused on treatment and harm reduction services for people with opioid use disorder (OUD). More than half (61%) discussed calibrating their models to empirical data, and 31% discussed validation approaches used in their modeling process. From the 63 studies that provided model parameters, we extracted the data sources on opioid use, OUD, OUD treatment, cessation/relapse, emergency medical services, and mortality parameters. This database offers a tool that future modelers can use to identify potential model inputs and evaluate comparability of their models to prior work. Future applications of simulation models to this field should actively tackle key methodological challenges, including the potential for bias in the choice of parameter inputs, investment in model calibration and validation, and transparency in the assumptions and mechanics of simulation models to facilitate reproducibility.
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Affiliation(s)
- Magdalena Cerdá
- Center for Opioid Epidemiology and Policy, Division of Epidemiology, Department of Population Health, New York University School of Medicine, New York, New York
| | | | - Ava D Hamilton
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | | | - Ayaz Hyder
- Division of Environmental Health Sciences, College of Public Health, and Translational Data Analytics Institute, The Ohio State University, Columbus, Ohio
| | - Julian Santaella-Tenorio
- Center for Opioid Epidemiology and Policy, Division of Epidemiology, Department of Population Health, New York University School of Medicine, New York, New York
| | - Navdep Kaur
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Christina Wang
- Center for Opioid Epidemiology and Policy, Division of Epidemiology, Department of Population Health, New York University School of Medicine, New York, New York
| | - Katherine M Keyes
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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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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Lima VD, Zhu J, Card KG, Lachowsky NJ, Chowell-Puente G, Wu Z, Montaner JSG. Can the combination of TasP and PrEP eliminate HIV among MSM in British Columbia, Canada? Epidemics 2021; 35:100461. [PMID: 33984688 DOI: 10.1016/j.epidem.2021.100461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/09/2021] [Accepted: 04/05/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION In British Columbia (BC), the HIV epidemic continues to disproportionally affect the gay, bisexual and other men who have sex with men (MSM). In this study, we aimed to evaluate how Treatment as Prevention (TasP) and pre-exposure prophylaxis (PrEP), if used in combination, could lead to HIV elimination in BC among MSM. METHODS Considering the heterogeneity in HIV transmission risk, we developed a compartmental model stratified by age and risk-taking behaviour for the HIV epidemic among MSM in BC, informed by clinical, behavioural and epidemiological data. Key outcome measures included the World Health Organization (WHO) threshold for disease elimination as a public health concern and the effective reproduction number (Re). Model interventions focused on the optimization of different TasP and PrEP components. Sensitivity analysis was done to evaluate the impact of sexual mixing patterns, PrEP effectiveness and increasing risk-taking behaviour. RESULTS The incidence rate was estimated to be 1.2 (0.9-1.9) per 1000 susceptible MSM under the Status Quo scenario by the end of 2029. Optimizing all aspects of TasP and the simultaneous provision of PrEP to high-risk MSM resulted in an HIV incidence rate as low as 0.4 (0.3-0.6) per 1000 susceptible MSM, and an Re as low as 0.7 (0.6-0.9), indicating that disease elimination was possible when TasP and PrEP were combined. Provision of PrEP to younger MSM or high-risk and younger MSM resulted in a similar HIV incidence rate, but an Re with credible intervals that crossed one. CONCLUSION Further optimizing all aspects of TasP and prioritizing PrEP to high-risk MSM can achieve the goal of disease elimination in BC. These results should inform public health policy development and intervention programs that address the HIV epidemic in BC and in other similar settings where MSM are disproportionately affected.
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Affiliation(s)
- Viviane D Lima
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Jielin Zhu
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Kiffer G Card
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; School of Public Health and Social Policy, University of Victoria, Victoria, BC, Canada
| | - Nathan J Lachowsky
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; School of Public Health and Social Policy, University of Victoria, Victoria, BC, Canada
| | - Gerardo Chowell-Puente
- Department of Population Health Sciences, Georgia State University School of Public Health, Atlanta, GA, USA
| | - Zunyou Wu
- Division of HIV Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Julio S G Montaner
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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Krebs E, Zang X, Enns B, Min JE, Behrends CN, Del Rio C, Dombrowski JC, Feaster DJ, Gebo KA, Marshall BDL, Mehta SH, Metsch LR, Pandya A, Schackman BR, Strathdee SA, Nosyk B. Ending the HIV Epidemic Among Persons Who Inject Drugs: A Cost-Effectiveness Analysis in Six US Cities. J Infect Dis 2021; 222:S301-S311. [PMID: 32877548 DOI: 10.1093/infdis/jiaa130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Persons who inject drugs (PWID) are at a disproportionately high risk of HIV infection. We aimed to determine the highest-valued combination implementation strategies to reduce the burden of HIV among PWID in 6 US cities. METHODS Using a dynamic HIV transmission model calibrated for Atlanta, Baltimore, Los Angeles, Miami, New York City, and Seattle, we assessed the value of implementing combinations of evidence-based interventions at optimistic (drawn from best available evidence) or ideal (90% coverage) scale-up. We estimated reduction in HIV incidence among PWID, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) for each city (10-year implementation; 20-year horizon; 2018 $ US). RESULTS Combinations that maximized health benefits contained between 6 (Atlanta and Seattle) and 12 (Miami) interventions with ICER values ranging from $94 069/QALY in Los Angeles to $146 256/QALY in Miami. These strategies reduced HIV incidence by 8.1% (credible interval [CI], 2.8%-13.2%) in Seattle and 54.4% (CI, 37.6%-73.9%) in Miami. Incidence reduction reached 16.1%-75.5% at ideal scale. CONCLUSIONS Evidence-based interventions targeted to PWID can deliver considerable value; however, ending the HIV epidemic among PWID will require innovative implementation strategies and supporting programs to reduce social and structural barriers to care.
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Affiliation(s)
- Emanuel Krebs
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Xiao Zang
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada.,Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Benjamin Enns
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Jeong E Min
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Czarina N Behrends
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York City, New York, USA
| | - Carlos Del Rio
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.,School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Julia C Dombrowski
- Department of Medicine, Division of Allergy and Infectious Disease, University of Washington, Seattle, Washington, USA
| | - Daniel J Feaster
- Department of Public Health Sciences, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Kelly A Gebo
- School of Medicine, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Shruti H Mehta
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Lisa R Metsch
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York City, New York, USA
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Bruce R Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York City, New York, USA
| | | | - Bohdan Nosyk
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada.,Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
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11
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Lima VD, Brumme ZL, Brumme C, Sereda P, Krajden M, Wong J, Guillemi SA, Henry B, Hogg RS, Barrios R, Montaner JSG. The Impact of Treatment as Prevention on the HIV Epidemic in British Columbia, Canada. Curr HIV/AIDS Rep 2020; 17:77-87. [PMID: 32124189 DOI: 10.1007/s11904-020-00482-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE OF REVIEW This study proposes to describe the impact of a publicly funded Treatment as Prevention (TasP) strategy in British Columbia (BC), Canada, in decreasing the individual and public health impact of the HIV/AIDS Epidemic. RECENT FINDINGS In BC, TasP has been associated with a steady decline in HIV-related morbidity and mortality. At the same time, a demographic transition was observed among people living with HIV (PLWH), with the majority of those on antiretroviral treatment (ART) now ≥ 50 years of age, living with at least one comorbidity, and dying from age-associated comorbidities. We also documented a progressive increase in the proportion of viral load suppression as a result of ART expansion. While the pre-ART CD4 T cell count has increased steadily in recent years, there is still a large proportion of PLWH being diagnosed in later stages of HIV infection. New HIV diagnoses have been rapidly declining, however to a lesser extent among men who have sex with men (MSM), and BC is currently experiencing an increase in infectious syphilis cases in this population. These facts reinforce the effectiveness of TasP in decreasing HIV transmission, but at the same time, it highlights the need for further innovation to enhance the control of HIV and syphilis among MSM. This study supports the development of new approaches that address existing gaps in the TasP strategy in BC, and the future health needs of PLWH.
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Affiliation(s)
- Viviane D Lima
- British Columbia Centre for Excellence in HIV/AIDS, Room 667, 1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada.,Department of Medicine, Division of Infectious Diseases, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Zabrina L Brumme
- British Columbia Centre for Excellence in HIV/AIDS, Room 667, 1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Chanson Brumme
- British Columbia Centre for Excellence in HIV/AIDS, Room 667, 1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada.,Department of Medicine, Division of Infectious Diseases, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Paul Sereda
- British Columbia Centre for Excellence in HIV/AIDS, Room 667, 1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada
| | - Mel Krajden
- British Columbia Centre for Disease Control, Vancouver, Canada.,Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Jason Wong
- British Columbia Centre for Disease Control, Vancouver, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Silvia A Guillemi
- British Columbia Centre for Excellence in HIV/AIDS, Room 667, 1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada.,Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Bonnie Henry
- British Columbia Ministry of Health, Victoria, Canada
| | - Robert S Hogg
- British Columbia Centre for Excellence in HIV/AIDS, Room 667, 1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Rolando Barrios
- British Columbia Centre for Excellence in HIV/AIDS, Room 667, 1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada.,Vancouver Coastal Health, Vancouver, Canada
| | - Julio S G Montaner
- British Columbia Centre for Excellence in HIV/AIDS, Room 667, 1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada. .,Department of Medicine, Division of Infectious Diseases, Faculty of Medicine, University of British Columbia, Vancouver, Canada.
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12
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Zang X, Jalal H, Krebs E, Pandya A, Zhou H, Enns B, Nosyk B. Prioritizing Additional Data Collection to Reduce Decision Uncertainty in the HIV/AIDS Response in 6 US Cities: A Value of Information Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:1534-1542. [PMID: 33248508 PMCID: PMC7705607 DOI: 10.1016/j.jval.2020.06.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 06/08/2020] [Accepted: 06/30/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES The ambitious goals of the US Ending the HIV Epidemic initiative will require a targeted, context-specific public health response. Model-based economic evaluation provides useful guidance for decision making while characterizing decision uncertainty. We aim to quantify the value of eliminating uncertainty about different parameters in selecting combination implementation strategies to reduce the public health burden of HIV/AIDS in 6 US cities and identify future data collection priorities. METHODS We used a dynamic compartmental HIV transmission model developed for 6 US cities to evaluate the cost-effectiveness of a range of combination implementation strategies. Using a metamodeling approach with nonparametric and deep learning methods, we calculated the expected value of perfect information, representing the maximum value of further research to eliminate decision uncertainty, and the expected value of partial perfect information for key groups of parameters that would be collected together in practice. RESULTS The population expected value of perfect information ranged from $59 683 (Miami) to $54 108 679 (Los Angeles). The rank ordering of expected value of partial perfect information on key groups of parameters were largely consistent across cities and highest for parameters pertaining to HIV risk behaviors, probability of HIV transmission, health service engagement, HIV-related mortality, health utility weights, and healthcare costs. Los Angeles was an exception, where parameters on retention in pre-exposure prophylaxis ranked highest in contributing to decision uncertainty. CONCLUSIONS Funding additional data collection on HIV/AIDS may be warranted in Baltimore, Los Angeles, and New York City. Value of information analysis should be embedded into decision-making processes on funding future research and public health intervention.
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Affiliation(s)
- Xiao Zang
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Hawre Jalal
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Emanuel Krebs
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Cambridge, MA, USA
| | - Haoxuan Zhou
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Benjamin Enns
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada.
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13
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Preventing HIV outbreaks among people who inject drugs in the United States: plus ça change, plus ça même chose. AIDS 2020; 34:1997-2005. [PMID: 32826391 DOI: 10.1097/qad.0000000000002673] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
: This editorial review covers current trends in the epidemiology of HIV among people who inject drugs (PWID) in the United States, including four recent HIV outbreaks. We discuss gaps in the prevention and treatment cascades for HIV and medications for opioid disorder and propose lessons learned to prevent future HIV outbreaks. Over the last decade, North America has been in the throes of a major opioid epidemic, due in part to over-prescribing of prescription opiates, followed by increasing availability of cheap heroin, synthetic opioids (e.g. fentanyl), and stimulants (e.g. methamphetamine). Historically, HIV infection among PWID in the US had predominantly affected communities who were older, urban and Black. More recently, the majority of these infections are among younger, rural or suburban and Caucasian PWID. All four HIV outbreaks were characterized by a high proportion of women who inject drugs and underlying socioeconomic drivers such as homelessness and poverty. We contend that the US response to the HIV epidemic among PWID has been fractured. A crucial lesson is that when evidence-based responses to HIV prevention are undermined or abandoned because of moral objections, untold humanitarian and financial costs on public health will ensue. Restructuring a path forward requires that evidence-based interventions be integrated and brought to scale while simultaneously addressing underlying structural drivers of HIV and related syndemics. Failing to do so will mean that HIV outbreaks among PWID and the communities they live in will continue to occur in a tragic and relentless cycle.
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14
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Ickowicz S, Dong H, Ti L, Nolan S, Fairbairn N, Barrios R, Milloy MJ. Behavioural, social and structural-level risk factors for developing AIDS among HIV-positive people who use injection drugs in a Canadian setting, 1996-2017. AIDS Care 2020; 32:1262-1267. [PMID: 32476442 DOI: 10.1080/09540121.2020.1772955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
People who use injection drugs (PWID) experience high rates of HIV acquisition and, as a result of lower rates of optimal access and adherence to combination antiretroviral therapy (ART), experience worse HIV treatment outcomes than other key affected populations. However, the incidence and risk factors for the development of AIDS among HIV-positive PWID have not been completely described. We used data from a community-recruited prospective cohort of HIV-positive PWID in Vancouver, Canada, a setting with universal no-cost ART and a comprehensive clinical monitoring registry. We used multivariable extended Cox models to identify factors associated with time to AIDS. Between 1996 and 2017, 396 participants, including 140 (35.4%) women, were followed for a median of 39.0 months (interquartile range: 16.6-76.2), among whom 165 (41.7%) developed AIDS. In a multivariable model, homelessness (Adjusted Hazard Ratio [AHR] = 1.76 (1.18-2.61)) and injection drug use within the preceding six months (AHR = 1.74 (1.17-2.58)) were independently associated with a higher risk of developing AIDS. Despite widespread scale-up of programmes to improve ART utilization, significant risk factors for the development of AIDS remain among HIV-positive PWID in this setting.
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Affiliation(s)
- S Ickowicz
- British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, Canada
| | - H Dong
- British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, Canada
| | - L Ti
- British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, Vancouver, Canada
| | - S Nolan
- British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, Vancouver, Canada
| | - N Fairbairn
- British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, Vancouver, Canada
| | - R Barrios
- BC Centre for Excellence in HIV/AIDS, University of British Columbia, Vancouver, Canada.,Faculty of Medicine, School of Population and Public Health, Vancouver, Canada
| | - M-J Milloy
- British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, Vancouver, Canada
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15
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Nosyk B, Min JE, Zang X, Feaster DJ, Metsch L, Marshall BDL, Rio CD, Granich R, Schackman BR, Montaner JSG. Why Maximizing Quality-Adjusted Life Years, rather than Reducing HIV Incidence, Must Remain Our Objective in Addressing the HIV/AIDS Epidemic. J Int Assoc Provid AIDS Care 2020; 18:2325958218821962. [PMID: 30798657 PMCID: PMC6457342 DOI: 10.1177/2325958218821962] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
With efficacious behavioral, biomedical, and structural interventions available, combination implementation strategies are being implemented to combat HIV/AIDS across settings internationally. However, priority statements from national and international bodies make it unclear whether the objective should be the reduction in HIV incidence or the maximization of health, most commonly measured with quality-adjusted life years (QALYs). Building off a model-based evaluation of HIV care interventions in British Columbia, Canada, we compare the optimal sets of interventions that would be identified using HIV infections averted, and QALYs as the primary outcome in a cost-effectiveness analysis. We found an explicit focus on averting new infections undervalues the health benefits derived from antiretroviral therapy, resulting in suboptimal and potentially harmful funding recommendations.
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Affiliation(s)
- Bohdan Nosyk
- 1 BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada.,2 Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Jeong Eun Min
- 1 BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Xiao Zang
- 1 BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada.,2 Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Daniel J Feaster
- 3 Department of Epidemiology and Public Health, Center for Family Studies, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Lisa Metsch
- 4 Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Brandon D L Marshall
- 5 Department of Epidemiology, Brown School of Public Health, Providence, RI, USA
| | - Carlos Del Rio
- 6 Hubert Department of Global Health, Emory Center for AIDS Research, Rollins School of Public Health of Emory University, Atlanta, GA, USA
| | - Reuben Granich
- 7 Independent Public Health Consultant, Washington, DC, USA
| | | | - Julio S G Montaner
- 1 BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada.,9 Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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16
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El-Akkad SED, Nolan S, Fairbairn N, Ye M, Wu A, Barrios R, Montaner J, Ti L. The impact of high-dose opioid prescription on mortality rates among people living with HIV: A retrospective cohort study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 78:102705. [PMID: 32143186 PMCID: PMC7302960 DOI: 10.1016/j.drugpo.2020.102705] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 12/25/2019] [Accepted: 02/16/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVES High-dose opioid use is associated with increased morbidity, mortality, and healthcare utilization. People living with HIV (PLHIV) are frequently prescribed these medications to manage their pain. However, little is known about the relationship between being prescribed high doses of opioids (> 90 MME/d) and mortality risk among this population. The objective of this study was to examine the trends in mortality and the relationship between high-dose opioid analgesic prescribing and mortality among PLHIV. METHODS Utilizing the STOP HIV/AIDS cohort--a population-level linked database of treatment of PLHIV in British Columbia--we conducted bivariable and multivariable generalized estimating equation (GEE) models with a Poisson distribution to examine the relationship between high-dose opioid prescription and all-cause mortality rates in the study sample. RESULTS Between 1996 and 2015, 9272 PLHIV were included in the study. Age- and sex-adjusted mortality rate (using the 2011 Canadian population as the reference) was 30.99 per 1000 person-years (95% confidence interval [CI]: 28.11-33.88). In a multivariable GEE model with adjustment for various demographic and clinical confounders, there was a positive and independent association between being prescribed high-dose opioids and all-cause mortality rates (adjusted rate ratio [ARR] = 3.01; 95%CI: 2.47-3.66). DISCUSSION We found that mortality rates were significantly higher among PLHIV who were prescribed high-dose opioids compared to those who were prescribed lower doses. Our results highlight the risk associated with the prescribing of high-dose opioids to manage HIV-related pain and emphasize the need to explore non-opioid approaches to pain management.
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Affiliation(s)
- Saif-El-Din El-Akkad
- Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6
| | - Seonaid Nolan
- Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6; Research Scientist & Health Administrative Data Lead, B.C. Centre on Substance Use Assistant Professor, Department of Medicine, University of British Columbia, 400-1045 Howe Street Vancouver, BC, Canada, V6Z 2A9
| | - Nadia Fairbairn
- Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6; Research Scientist & Health Administrative Data Lead, B.C. Centre on Substance Use Assistant Professor, Department of Medicine, University of British Columbia, 400-1045 Howe Street Vancouver, BC, Canada, V6Z 2A9
| | - Monica Ye
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6
| | - Anthony Wu
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6
| | - Rolando Barrios
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6
| | - Julio Montaner
- Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6; British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6
| | - Lianping Ti
- Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6; Research Scientist & Health Administrative Data Lead, B.C. Centre on Substance Use Assistant Professor, Department of Medicine, University of British Columbia, 400-1045 Howe Street Vancouver, BC, Canada, V6Z 2A9.
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17
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The impact of localized implementation: determining the cost-effectiveness of HIV prevention and care interventions across six United States cities. AIDS 2020; 34:447-458. [PMID: 31794521 DOI: 10.1097/qad.0000000000002455] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Effective interventions to reduce the public health burden of HIV/AIDS can vary in their ability to deliver value at different levels of scale and in different epidemiological contexts. Our objective was to determine the cost-effectiveness of HIV treatment and prevention interventions implemented at previously documented scales of delivery in six US cities with diverse HIV microepidemics. DESIGN Dynamic HIV transmission model-based cost-effectiveness analysis. METHODS We identified and estimated previously documented scale of delivery and costs for 16 evidence-based interventions from the US CDC's Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention. Using a model calibrated for Atlanta, Baltimore, Los Angeles, Miami, New York City and Seattle, we estimated averted HIV infections, quality-adjusted life years (QALY) gained and incremental cost-effectiveness ratios (healthcare perspective; 3% discount rate, 2018$US), for each intervention and city (10-year implementation) compared with the status quo over a 20-year time horizon. RESULTS Increased HIV testing was cost-saving or cost-effective across cities. Targeted preexposure prophylaxis for high-risk MSM was cost-saving in Miami and cost-effective in Atlanta ($6123/QALY), Baltimore ($18 333/QALY) and Los Angeles ($86 117/QALY). Interventions designed to improve antiretroviral therapy initiation provided greater value than other treatment engagement interventions. No single intervention was projected to reduce HIV incidence by more than 10.1% in any city. CONCLUSION Combination implementation strategies should be tailored to local epidemiological contexts to provide the most value. Complementary strategies addressing factors hindering access to HIV care will be necessary to meet targets for HIV elimination in the United States.
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18
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Zang X, Krebs E, Min JE, Pandya A, Marshall BDL, Schackman BR, Behrends CN, Feaster DJ, Nosyk B. Development and Calibration of a Dynamic HIV Transmission Model for 6 US Cities. Med Decis Making 2019; 40:3-16. [PMID: 31865849 DOI: 10.1177/0272989x19889356] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. Heterogeneity in HIV microepidemics across US cities necessitates locally oriented, combination implementation strategies to prioritize resources. We calibrated and validated a dynamic, compartmental HIV transmission model to establish a status quo treatment scenario, holding constant current levels of care for 6 US cities. Methods. Built off a comprehensive evidence synthesis, we adapted and extended a previously published model to replicate the transmission, progression, and clinical care for each microepidemic. We identified a common set of 17 calibration targets between 2012 and 2015 and used the Morris method to select the most influential parameters for calibration. We then applied the Nelder-Mead algorithm to iteratively calibrate the model to generate 2000 best-fitting parameter sets. Finally, model projections were internally validated with a series of robustness checks and externally validated against published estimates of HIV incidence, while the face validity of 25-year projections was assessed by a Scientific Advisory Committee (SAC). Results. We documented our process for model development, calibration, and validation to maximize its transparency and reproducibility. The projected outcomes demonstrated a good fit to calibration targets, with a mean goodness-of-fit ranging from 0.0174 (New York City [NYC]) to 0.0861 (Atlanta). Most of the incidence predictions were within the uncertainty range for 5 of the 6 cities (ranging from 21% [Miami] to 100% [NYC]), demonstrating good external validity. The face validity of the long-term projections was confirmed by our SAC, showing that the incidence would decrease or remain stable in Atlanta, Los Angeles, NYC, and Seattle while increasing in Baltimore and Miami. Discussion. This exercise provides a basis for assessing the incremental value of further investments in HIV combination implementation strategies tailored to urban HIV microepidemics.
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Affiliation(s)
- Xiao Zang
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Emanuel Krebs
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Jeong E Min
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Brandon D L Marshall
- Department of Epidemiology, School of Public Health, Brown University, Providence, RI, USA
| | - Bruce R Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York City, NY, USA
| | - Czarina N Behrends
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York City, NY, USA
| | - Daniel J Feaster
- Department of Epidemiology and Public Health, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
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Gali B, Eyawo O, Hull MW, Samji H, Zhang W, Sereda P, Lima VD, McGrail K, Montaner JSG, Hogg RS, Moore D. Incidence of select chronic comorbidities among a population-based cohort of HIV-positive individuals receiving highly active antiretroviral therapy. Curr Med Res Opin 2019; 35:1955-1963. [PMID: 31315470 DOI: 10.1080/03007995.2019.1645999] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Objective: To characterize the incidence of select chronic comorbidities in the era of modern (pre-integrase-inhibitor) highly active antiretroviral therapy (HAART) in British Columbia, Canada. Methods: We used data from the Comparative Outcomes And Service Utilization Trends (COAST) study, a population-based cohort study of people living with HIV (PLWH), to determine incidence rates of six key chronic diseases among PLWH receiving HAART in BC from 2000 to 2012. The selected diseases included cardiovascular disease (CVD), diabetes mellitus (DM), hypertension (HTN), asthma/chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD) and chronic liver disease (CLD) defined using ICD-9 and -10 codes. Disease incidence was determined by number of new cases per year. We used Poisson regression to measure trends in incidence rates. Results: The study sample (n = 10,210) was predominantly male (83%), white (72%) and younger than 50 years of age at HAART initiation (88%). Incidence rates of HTN per 1000 person-years (PY) increased significantly between 2000 and 2012, after adjusting for age, sex, baseline-weighted Charlson Comorbidity Index, CD4 cell count and viral load (p < .001); incidence rates of CKD and CLD decreased significantly over time (p < .001). Unadjusted incidence rates of DM increased over time (p < .01), but remained stable in the adjusted model. Incidence rate patterns for CVD and COPD/asthma were stable over the study period. Conclusions: Population-level increases in incidence rates for HTN, and decreases for CLD and CKD, were observed among PLWH on modern (pre-integrase-inhibitor) HAART from 2000 to 2012. Overall, the increasing incidence of several of these chronic comorbidities in our study suggests that further efforts are needed to maximize the potential for healthy aging among PLWH receiving modern (pre-integrase-inhibitor) HAART.
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Affiliation(s)
- Brent Gali
- British Columbia Centre for Excellence in HIV/AIDS , Vancouver , BC , Canada
- School of Population & Public Health, University of British Columbia , Vancouver , BC , Canada
| | - Oghenowede Eyawo
- British Columbia Centre for Excellence in HIV/AIDS , Vancouver , BC , Canada
- Faculty of Health Sciences, Simon Fraser University , Burnaby , BC , Canada
| | - Mark W Hull
- British Columbia Centre for Excellence in HIV/AIDS , Vancouver , BC , Canada
| | - Hasina Samji
- British Columbia Centre for Disease Control, Provincial Health Services Authority , Vancouver , BC , Canada
| | - Wendy Zhang
- British Columbia Centre for Excellence in HIV/AIDS , Vancouver , BC , Canada
| | - Paul Sereda
- British Columbia Centre for Excellence in HIV/AIDS , Vancouver , BC , Canada
| | - Viviane D Lima
- British Columbia Centre for Excellence in HIV/AIDS , Vancouver , BC , Canada
| | - Kimberlyn McGrail
- School of Population & Public Health, University of British Columbia , Vancouver , BC , Canada
| | - Julio S G Montaner
- British Columbia Centre for Excellence in HIV/AIDS , Vancouver , BC , Canada
- Division of AIDS, Department of Medicine, Faculty of Medicine, University of British Columbia , Vancouver , BC , Canada
| | - Robert S Hogg
- British Columbia Centre for Excellence in HIV/AIDS , Vancouver , BC , Canada
- Faculty of Health Sciences, Simon Fraser University , Burnaby , BC , Canada
| | - David Moore
- British Columbia Centre for Excellence in HIV/AIDS , Vancouver , BC , Canada
- Division of AIDS, Department of Medicine, Faculty of Medicine, University of British Columbia , Vancouver , BC , Canada
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20
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Krebs E, Enns B, Wang L, Zang X, Panagiotoglou D, Del Rio C, Dombrowski J, Feaster DJ, Golden M, Granich R, Marshall B, Mehta SH, Metsch L, Schackman BR, Strathdee SA, Nosyk B. Developing a dynamic HIV transmission model for 6 U.S. cities: An evidence synthesis. PLoS One 2019; 14:e0217559. [PMID: 31145752 PMCID: PMC6542533 DOI: 10.1371/journal.pone.0217559] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 05/14/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Dynamic HIV transmission models can provide evidence-based guidance on optimal combination implementation strategies to treat and prevent HIV/AIDS. However, these models can be extremely data intensive, and the availability of good-quality data characterizing regional microepidemics varies substantially within and across countries. We aim to provide a comprehensive and transparent description of an evidence synthesis process and reporting framework employed to populate and calibrate a dynamic, compartmental HIV transmission model for six US cities. METHODS We executed a mixed-method evidence synthesis strategy to populate model parameters in six categories: (i) initial HIV-negative and HIV-infected populations; (ii) parameters used to calculate the probability of HIV transmission; (iii) screening, diagnosis, treatment and HIV disease progression; (iv) HIV prevention programs; (v) the costs of medical care; and (vi) health utility weights for each stage of HIV disease progression. We identified parameters that required city-specific data and stratification by gender, risk group and race/ethnicity a priori and sought out databases for primary analysis to augment our evidence synthesis. We ranked the quality of each parameter using context- and domain-specific criteria and verified sources and assumptions with our scientific advisory committee. FINDINGS To inform the 1,667 parameters needed to populate our model, we synthesized evidence from 59 peer-reviewed publications and 24 public health and surveillance reports and executed primary analyses using 11 data sets. Of these 1,667 parameters, 1,517 (91%) were city-specific and 150 (9%) were common for all cities. Notably, 1,074 (64%), 201 (12%) and 312 (19%) parameters corresponded to categories (i), (ii) and (iii), respectively. Parameters ranked as best- to moderate-quality evidence comprised 39% of the common parameters and ranged from 56%-60% across cities for the city-specific parameters. We identified variation in parameter values across cities as well as within cities across risk and race/ethnic groups. CONCLUSIONS Better integration of modelling in decision making can be achieved by systematically reporting on the evidence synthesis process that is used to populate models, and by explicitly assessing the quality of data entered into the model. The effective communication of this process can help prioritize data collection of the most informative components of local HIV prevention and care services in order to reduce decision uncertainty and strengthen model conclusions.
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Affiliation(s)
- Emanuel Krebs
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Benjamin Enns
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Linwei Wang
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Xiao Zang
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Dimitra Panagiotoglou
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Carlos Del Rio
- Hubert Department of Global Health, Emory Center for AIDS Research, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Julia Dombrowski
- Department of Medicine, Division of Allergy & Infectious Disease, adjunct in Epidemiology, University of Washington, Seattle, WA, United States of America
| | - Daniel J. Feaster
- Center for Family Studies, Department of Epidemiology and Public Health, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States of America
| | - Matthew Golden
- Department of Medicine, Division of Allergy & Infectious Disease, adjunct in Epidemiology, University of Washington, Seattle, WA, United States of America
| | - Reuben Granich
- International Association of Providers of AIDS Care, Washington, DC, United States of America
| | - Brandon Marshall
- Department of Epidemiology, Brown School of Public Health, Providence, RI, United States of America
| | - Shruti H. Mehta
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States of America
| | - Lisa Metsch
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - Bruce R. Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, United States of America
| | - Steffanie A. Strathdee
- School of Medicine, University of California San Diego, La Jolla, CA, United States of America
| | - Bohdan Nosyk
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
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21
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Gray RT, Wilson DP, Guy RJ, Stoové M, Hellard ME, Prestage GP, Lea T, de Wit J, Holt M. Undiagnosed HIV infections among gay and bisexual men increasingly contribute to new infections in Australia. J Int AIDS Soc 2019; 21:e25104. [PMID: 29638044 PMCID: PMC5894250 DOI: 10.1002/jia2.25104] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 03/09/2018] [Indexed: 01/08/2023] Open
Abstract
Introduction We determined the contribution of undiagnosed HIV to new infections among gay and bisexual men (GBM) over a 12‐year period in Australia where there has been increasing focus on improving testing and HIV treatment coverage. Methods We generated annual estimates for each step of the HIV cascade and the number of new HIV infections for GBM in Australia over 2004 to 2015 using relevant national data. Using Bayesian melding we then fitted a quantitative model to the cascade and incidence estimates to infer relative transmission coefficients associated with being undiagnosed, diagnosed and not on ART, on ART with unsuppressed virus, or on ART with suppressed virus. Results Between 2004 and 2015, we estimated the percentage of GBM with HIV in Australia who were unaware of their status to have decreased from 14.5% to 7.5%. During the same period, there was a substantial increase in the number and proportion of GBM living with HIV on treatment and with suppressed virus, with the number of virally suppressed GBM increasing from around 3900 (30.2% of all GBM living with HIV) in 2004 to around 14,000 (73.7% of all GBM living with HIV) in 2015. Despite the increase in viral suppression, the annual number of new infections rose from around 660 to around 760 over this period. Our results have a wide range due to the uncertainty in the cascade estimates and transmission coefficients. Nevertheless, undiagnosed GBM increasingly appear to contribute to new infections. The proportion of new infections attributable to undiagnosed GBM almost doubled from 33% in 2004 to 59% in 2015. Only a small proportion (<7%) originated from GBM with suppressed virus. Discussion Our study suggests that an increase in HIV treatment coverage in Australia has reduced the overall risk of HIV transmission from people living with HIV. However, the proportion of infections and the rate of transmission from undiagnosed GBM has increased substantially. These findings highlight the importance of HIV testing and intensified prevention for Australian GBM at high risk of HIV.
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Affiliation(s)
- Richard T Gray
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | | | - Rebecca J Guy
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Mark Stoové
- Burnet Institute, Melbourne, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Margaret E Hellard
- Burnet Institute, Melbourne, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of Infectious Diseases, The Alfred Hospital, Melbourne, VIC, Australia
| | | | - Toby Lea
- German Institute for Addiction and Prevention Research (DISuP), Catholic University of Applied Sciences, North Rhine-Westphalia, Germany.,Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, Australia
| | - John de Wit
- Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, Australia
| | - Martin Holt
- Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, Australia
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22
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Duff P, Kestler M, Chamboko P, Braschel M, Ogilvie G, Krüsi A, Montaner J, Money D, Shannon K. Realizing Women Living with HIV's Reproductive Rights in the Era of ART: The Negative Impact of Non-consensual HIV Disclosure on Pregnancy Decisions Amongst Women Living with HIV in a Canadian Setting. AIDS Behav 2018; 22:2906-2915. [PMID: 29627875 DOI: 10.1007/s10461-018-2111-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
To better understand the structural drivers of women living with HIV's (WLWH's) reproductive rights and choices, this study examined the structural correlates, including non-consensual HIV disclosure, on WLWH's pregnancy decisions and describes access to preconception care. Analyses drew on data (2014-present) from SHAWNA, a longitudinal community-based cohort with WLWH across Metro-Vancouver, Canada. Multivariable logistic regression was used to model the effect of non-consensual HIV disclosure on WLWH's pregnancy decisions. Of the 218 WLWH included in our analysis, 24.8% had ever felt discouraged from becoming pregnant and 11.5% reported accessing preconception counseling. In multivariable analyses, non-consensual HIV disclosure was positively associated with feeling discouraged from wanting to become pregnant (AOR 3.76; 95% CI 1.82-7.80). Non-consensual HIV disclosure adversely affects WLWH's pregnancy decisions. Supporting the reproductive rights of WLWH will require further training among general practitioners on the reproductive health of WLWH and improved access to women-centred, trauma-informed care, including non-judgmental preconception counseling.
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Affiliation(s)
- Putu Duff
- Gender and Sexual Health Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081, Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- Faculty of Medicine, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- BC Women's Hospital, 4500 Oak St, Vancouver, BC, V6H 3N1, Canada
| | - Mary Kestler
- Gender and Sexual Health Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081, Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- Faculty of Medicine, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- BC Women's Hospital, 4500 Oak St, Vancouver, BC, V6H 3N1, Canada
| | - Patience Chamboko
- Gender and Sexual Health Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081, Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Melissa Braschel
- Gender and Sexual Health Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081, Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Gina Ogilvie
- BC Women's Hospital, 4500 Oak St, Vancouver, BC, V6H 3N1, Canada
- Department of Obstetrics & Gynecology, University of British Columbia, 1190 Hornby Street, Vancouver, BC, V6Z 2K5, Canada
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Andrea Krüsi
- Gender and Sexual Health Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081, Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Julio Montaner
- Faculty of Medicine, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Deborah Money
- Faculty of Medicine, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- BC Women's Hospital, 4500 Oak St, Vancouver, BC, V6H 3N1, Canada
- Department of Obstetrics & Gynecology, University of British Columbia, 1190 Hornby Street, Vancouver, BC, V6Z 2K5, Canada
| | - Kate Shannon
- Gender and Sexual Health Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081, Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
- Faculty of Medicine, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada.
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23
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Campbell AR, Kinvig K, Côté HC, Lester RT, Qiu AQ, Maan EJ, Alimenti A, Pick N, Murray MC. Health Care Provider Utilization and Cost of an mHealth Intervention in Vulnerable People Living With HIV in Vancouver, Canada: Prospective Study. JMIR Mhealth Uhealth 2018; 6:e152. [PMID: 29986845 PMCID: PMC6056738 DOI: 10.2196/mhealth.9493] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 05/25/2018] [Accepted: 06/08/2018] [Indexed: 11/13/2022] Open
Abstract
Background Improving adherence to combined antiretroviral therapy (cART) can be challenging, especially among vulnerable populations living with HIV. Even where cART is available free of charge, social determinants of health act as barriers to optimal adherence rates. Patient-centered approaches exploiting mobile phone communications (mHealth) have been shown to improve adherence to cART and promote achievement of suppressed HIV plasma viral loads. However, data are scarce on the health care provider (HCP) time commitments and health care costs associated with such interventions. This knowledge is needed to inform policy and programmatic implementation. Objective The purpose of this study was to approximate the resources required and to provide an estimate of the costs associated with running an mHealth intervention program to improve medication adherence in people living with HIV (PLWH). Methods This prospective study of HCP utilization and costs was embedded within a repeated measures effectiveness study of the WelTel short-message service (SMS) mHealth program. The study included 85 vulnerable, nonadherent PLWH in Vancouver, Canada, and resulted in improved medication adherence and HIV plasma viral load among participants. Study participants were provided mobile phones with unlimited texting (where required) and received weekly bidirectional text messages to inquire on their status for one year. A clinic nurse triaged and managed participants' responses, immediately logging all patient interactions by topic, HCP involvement, and time dedicated to addressing issues raised by participants. Interaction costs were determined in Canadian dollars based on HCP type, median salary within our health authority, and their time utilized as part of the intervention. Results Participant-identified problems within text responses included health-related, social, and logistical issues. Taken together, management of problems required a median of 43 minutes (interquartile range, IQR 17-99) of HCP time per participant per year, for a median yearly cost of Can $36.72 (IQR 15.50-81.60) per participant who responded with at least one problem. The clinic nurse who monitored the texts solved or managed 65% of these issues, and the remaining were referred to a variety of other HCPs. The total intervention costs, including mobile phones, plans, and staffing were a median Can $347.74/highly vulnerable participant per year for all participants or Can $383.18/highly vulnerable participant per year for those who responded with at least one problem. Conclusions Bidirectional mHealth programs improve HIV care and treatment outcomes for PLWH. Knowledge about the HCP cost associated, here less than Can $50/year, provides stakeholders and decision makers with information relevant to determining the feasibility and sustainability of mHealth programs in a real-world setting. Trial Registration ClinicalTrials.gov NCT02603536; https://clinicaltrials.gov/ct2/show/NCT02603536 (Archived by WebCite at http://www.webcitation.org/70IYqKUjV).
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Affiliation(s)
- Amber R Campbell
- Division of Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.,Oak Tree Clinic, British Columbia Women's Hospital, Vancouver, BC, Canada.,Women's Health Research Institute, British Columbia Women's Hospital, Vancouver, BC, Canada
| | - Karen Kinvig
- Oak Tree Clinic, British Columbia Women's Hospital, Vancouver, BC, Canada
| | - Hélène Cf Côté
- Women's Health Research Institute, British Columbia Women's Hospital, Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, BC, Canada
| | - Richard T Lester
- Division of Infectious Disease, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Annie Q Qiu
- Oak Tree Clinic, British Columbia Women's Hospital, Vancouver, BC, Canada
| | - Evelyn J Maan
- Oak Tree Clinic, British Columbia Women's Hospital, Vancouver, BC, Canada.,Women's Health Research Institute, British Columbia Women's Hospital, Vancouver, BC, Canada
| | - Ariane Alimenti
- Oak Tree Clinic, British Columbia Women's Hospital, Vancouver, BC, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Neora Pick
- Oak Tree Clinic, British Columbia Women's Hospital, Vancouver, BC, Canada.,Women's Health Research Institute, British Columbia Women's Hospital, Vancouver, BC, Canada.,Division of Infectious Disease, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Melanie Cm Murray
- Oak Tree Clinic, British Columbia Women's Hospital, Vancouver, BC, Canada.,Women's Health Research Institute, British Columbia Women's Hospital, Vancouver, BC, Canada.,Division of Infectious Disease, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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24
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Scheim AI, Bardwell G, Rachlis B, Mitra S, Kerr T. Syringe sharing among people who inject drugs in London, Canada. Canadian Journal of Public Health 2018; 109:174-182. [PMID: 29981046 DOI: 10.17269/s41997-018-0058-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 01/20/2018] [Indexed: 01/20/2023]
Abstract
OBJECTIVES London, Ontario, is facing an outbreak of HIV among people who inject drugs (PWID), as well as persistently high levels of hepatitis C virus (HCV). Syringe sharing is the primary driver of HIV and HCV transmission risks among PWID, however, little is known about factors contributing to syringe sharing in this setting. Therefore, we sought to characterize syringe sharing and its correlates among London PWID. METHODS Between March and April, 2016, PWID participated in a survey administered by peer research associates as part of the Ontario Integrated Supervised Injection Services Feasibility Study. Bivariable and multivariable logistic regression models examined associations with syringe sharing (borrowing or lending previously used syringes) over the previous 6 months. A sub-analysis described patterns of borrowing and lending by self-reported HIV and HCV statuses. RESULTS Of 198 PWID, 44 (22%) reported syringe sharing in the past 6 months. In the multivariable analysis, selling drugs (adjusted odds ratio; AOR = 1.92, 95% CI = 1.20-3.08), daily crystal methamphetamine injection (AOR = 1.66, 95% CI = 1.07-2.59), and identifying as HIV-positive (AOR = 3.11, 95% CI = 1.61-6.01) were independently associated with increased syringe sharing. While not independently associated with syringe sharing, problems accessing syringes were common (13-50%). Self-reported HIV-positive respondents were more likely to report syringe borrowing (p < 0.001), but not lending (p = 0.26). CONCLUSION We observed a high rate of syringe sharing among London PWID, with sharing being associated with high-intensity injection of crystal methamphetamine, as well as with involvement in drug sales. Considering the current HIV outbreak in London, multi-level prevention efforts are urgently needed.
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Affiliation(s)
- Ayden I Scheim
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, N6A 5C1, Canada.,Division of Infectious Diseases and Global Public Health, University of California San Diego School of Medicine, 9500 Gilman Drive, La Jolla, CA, 92093, USA
| | - Geoff Bardwell
- British Columbia Centre on Substance Use, 400-1045 Howe St, Vancouver, BC, V6Z 2A9, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Beth Rachlis
- Ontario HIV Treatment Network, 1300 Yonge Street, Suite 600, Toronto, ON, M4T 1X3, Canada.,Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, 155 College Street West, 6th floor, Toronto, ON, M5T 3M7, Canada
| | - Sanjana Mitra
- British Columbia Centre on Substance Use, 400-1045 Howe St, Vancouver, BC, V6Z 2A9, Canada.,Interdisciplinary Studies, University of British Columbia, 270-2357 Main Mall, Vancouver, British Columbia, V6T 1Z4, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, 400-1045 Howe St, Vancouver, BC, V6Z 2A9, Canada. .,Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
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25
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Nosyk B, Min JE, Krebs E, Zang X, Compton M, Gustafson R, Barrios R, Montaner JSG. The Cost-Effectiveness of Human Immunodeficiency Virus Testing and Treatment Engagement Initiatives in British Columbia, Canada: 2011-2013. Clin Infect Dis 2018; 66:765-777. [PMID: 29028964 PMCID: PMC5850008 DOI: 10.1093/cid/cix832] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 09/22/2017] [Indexed: 01/03/2023] Open
Abstract
Background Recognition of the secondary preventive benefits of antiretroviral therapy (ART) has mobilized global efforts to "seek, test, treat, and retain" people living with human immunodeficiency virus [HIV]/AIDS (PLHIV) in HIV care. We aimed to determine the cost-effectiveness of a set of HIV testing and treatment engagement interventions initiated in British Columbia, Canada, in 2011-2013. Methods Using a previously validated dynamic HIV transmission model, linked individual-level health administrative data for PLHIV, and aggregate-level HIV testing data, we estimated the cost-effectiveness of primary care testing (hospital, emergency department [ED], outpatient), ART initiation, and ART retention initiatives vs a counterfactual scenario that approximated the status quo. HIV incidence, mortality, costs (in 2015$CDN), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios were estimated. Analyses were executed over 5- to 25-year time horizons from a government-payer perspective. Results ED testing was the best value at $30216 per QALY gained and had the greatest impact on incidence and mortality among PLHIV, while ART initiation provided the greatest QALY gains. The ART retention initiative was not cost-effective. Delivered in combination at the observed scale and sustained throughout the study period, we estimated a 12.8% reduction in cumulative HIV incidence and a 4.7% reduction in deaths among PLHIV at $55258 per QALY gained. Results were most sensitive to uncertainty in the number of undiagnosed PLHIV. Conclusions HIV testing and ART initiation interventions were cost-effective, while the ART retention intervention was not. Developing strategies to reengage PLHIV lost to care is a priority moving forward.
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Affiliation(s)
- Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, Vancouver
- Faculty of Health Sciences, Simon Fraser University, Burnaby
| | - Jeong E Min
- BC Centre for Excellence in HIV/AIDS, Vancouver
| | | | - Xiao Zang
- BC Centre for Excellence in HIV/AIDS, Vancouver
| | - Miranda Compton
- Vancouver Coastal Health Authority, University of British Columbia, Vancouver, British Columbia, Canada
| | - Reka Gustafson
- Vancouver Coastal Health Authority, University of British Columbia, Vancouver, British Columbia, Canada
| | - Rolando Barrios
- BC Centre for Excellence in HIV/AIDS, Vancouver
- Vancouver Coastal Health Authority, University of British Columbia, Vancouver, British Columbia, Canada
| | - Julio S G Montaner
- BC Centre for Excellence in HIV/AIDS, Vancouver
- Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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26
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Abstract
Human immunodeficiency virus (HIV) infection continues to disproportionately affect vulnerable populations in Canada; particularly men who have sex with men (MSM). Novel HIV prevention strategies have recently expanded from the use of non-occupational post-exposure prophylaxis (nPEP) after high risk exposures to the use of pre-exposure prophylaxis (PrEP) in which individuals reduce risk of HIV infection through use of combination antiretrovirals taken prior to risk exposure. With approval of tenofovir/emtricitabine (TDF/FTC) for use as PrEP only in early 2016, and with limited public funding to date, uptake in Canada is in its preliminary stages. These biomedical prevention strategies have proven efficacy for MSM, and they may have potential for other at-risk populations. With generic formulations of TDF/FTC now available in Canada, there is an opportunity for widespread implementation. Expanding knowledge of health care providers across Canada on how best to assess, refer for or prescribe and monitor PrEP will contribute to the current efforts to reach the global goal of eliminating new HIV infections.
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Olding M, Enns B, Panagiotoglou D, Shoveller J, Harrigan PR, Barrios R, Kerr T, Montaner JSG, Nosyk B. A historical review of HIV prevention and care initiatives in British Columbia, Canada: 1996-2015. J Int AIDS Soc 2017; 20:21941. [PMID: 28953322 PMCID: PMC5640311 DOI: 10.7448/ias.20.1.21941] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 08/22/2017] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION British Columbia has made significant progress in the treatment and prevention of HIV since 1996, when Highly Active Antiretroviral Therapy (HAART) became available. However, we currently lack a historical summary of HIV prevention and care interventions implemented in the province since the introduction of HAART and how they have shaped the HIV epidemic. Guided by a socio-ecological framework, we present a historical review of biomedical and health services, community and structural interventions implemented in British Columbia from 1996-2015 to prevent HIV transmission or otherwise enhance the cascade of HIV care. METHODS We constructed a historical timeline of HIV interventions implemented in BC between 1996 and 2015 by reviewing publicly available reports, guidelines and other documents from provincial health agencies, community organizations and AIDS service organizations, and by conducting searches of peer-reviewed literature through PubMed and Ovid MEDLINE. We collected further programmatic information by administering a data collection form to representatives from BC's regional health authorities and an umbrella agency representing 45 AIDS Service organizations. Using linked population-level health administrative data, we identified key phases of the HIV epidemic in British Columbia, as characterized by distinct changes in HIV incidence, HAART uptake and the provincial HIV response. RESULTS AND DISCUSSION In total, we identified 175 HIV prevention and care interventions implemented in BC from 1996 to 2015. We identify and describe four phases in BC's response to HIV/AIDS: the early HAART phase (1996-1999); the harm reduction and health service scale-up phase (2000-2005); the early Treatment as Prevention phase (2006-2009); and the STOP HIV/AIDS phase (2010-present). In doing so, we provide an overview of British Columbia's universal and centralized HIV treatment system and detail the role of community-based and provincial stakeholders in advancing innovative prevention and harm reduction approaches, as well as "seek, test, treat and retain" strategies. CONCLUSIONS The review provides valuable insight into British Columbia's HIV response, highlights emerging priorities, and may inform future efforts to evaluate the causal impact of interventions.
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Affiliation(s)
- Michelle Olding
- BC Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC, Canada
| | - Ben Enns
- BC Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC, Canada
| | | | - Jean Shoveller
- BC Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - P Richard Harrigan
- BC Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC, Canada
- Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Rolando Barrios
- BC Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC, Canada
- Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Thomas Kerr
- BC Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC, Canada
- Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Julio S. G. Montaner
- BC Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC, Canada
- Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
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28
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Panagiotoglou D, Krebs E, Min JE, Olding M, Ahamad K, Ti L, Montaner JSG, Nosyk B. Initiating HCV treatment with direct acting agents in opioid agonist treatment: When to start for people co-infected with HIV? THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 47:169-176. [PMID: 28578865 PMCID: PMC5798603 DOI: 10.1016/j.drugpo.2017.05.021] [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: 01/19/2017] [Revised: 04/04/2017] [Accepted: 05/05/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND Direct acting antivirals (DAA) raise the possibility of eliminating Hepatitis C virus (HCV) among people who inject drugs (PWID). However, concerns regarding treatment retention and reinfection challenge implementation efforts. Opioid agonist treatment (OAT) provides an opportunity to engage HCV-positive PWID into DAA-based treatment. Our objective was to identify when OAT adherence sufficiently improved to inform DAA initiation in OAT settings, assuming continuous OAT retention for at least twelve weeks is necessary to complete the DAA treatment course. METHODS This was a retrospective cohort study of HCV/HIV co-infected PWID from a population-level linked administrative database of people diagnosed and living with HIV in British Columbia, Canada between 01/1996 and 12/2013. We used monthly follow-up data after initial OAT entry and considered the effects of demographics, disease severity, and HIV and OAT treatment characteristics over time on the probability of subsequent OAT retention of ≥12 weeks, and ≥8 weeks for sensitivity analysis. We fit a generalized linear mixed model to the overall study population, and on stratified samples of those continuously engaged on combination antiretroviral therapy (≥95% ART adherence). A set of monthly indicator variables (months 1, …, 7, >7) were included to fulfil the study objective. RESULTS Our study included 1427 HCV/HIV co-infected PWID (39.0% female, 68.8% OAT-naïve). The odds of subsequent twelve-week retention in OAT were statistically significantly greater in month 3 versus month 1 (adjusted odds ratio: 1.18; 95% confidence interval: 1.02, 1.37); and the odds of subsequent 8-week retention in OAT were statistically significantly greater in month 2 versus month 1 (1.15, 95% CI: 1.02, 1.31). Among continuously ART-adherent individuals, the odds of subsequent twelve-week retention were not statistically significantly greater than in month 1 (month 2: 1.12 (0.82, 1.51); month 3: 1.08 (0.79, 1.47); month 4: 1.24 (0.91, 1.71)). CONCLUSION We provide evidence that among HCV/HIV co-infected PWID, those retained in OAT for three or more months had higher odds of completing an additional twelve weeks of OAT, compared to no difference in those already receiving ART. These data may have implications for adherence to DAA therapy and further studies are needed to understand the optimal timing of DAA therapy in PWID receiving and not receiving OAT.
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Affiliation(s)
| | - Emanuel Krebs
- BC Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - Jeong Eun Min
- BC Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | | | - Keith Ahamad
- BC Centre for Excellence in HIV/AIDS, Vancouver, Canada; Department of Family Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Lianping Ti
- BC Centre for Excellence in HIV/AIDS, Vancouver, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Julio S G Montaner
- BC Centre for Excellence in HIV/AIDS, Vancouver, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, Vancouver, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
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