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Zhang Y, Johnson CC, Nguyen VTT, Ong JJ. Role of HIV self-testing in strengthening HIV prevention services. Lancet HIV 2024:S2352-3018(24)00187-5. [PMID: 39332440 DOI: 10.1016/s2352-3018(24)00187-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 07/15/2024] [Accepted: 07/17/2024] [Indexed: 09/29/2024]
Abstract
HIV self-testing, which has been increasingly available since 2016, can substantially enhance the uptake of HIV testing, especially for key populations. Clinical trials have explored the application of self-testing in various HIV prevention strategies, including post-exposure prophylaxis (PEP), pre-exposure prophylaxis (PrEP), and voluntary medical male circumcision. Research indicates that self-testing can facilitate PrEP initiation and improve adherence and continuation. However, evidence on the effectiveness of linkage to PrEP post HIV self-testing is mixed, underscoring the need to further understand contextual factors and optimal implementation strategies. Studies on linking voluntary medical male circumcision post HIV self-testing show no statistically significant difference compared with standard voluntary medical male circumcision demand creation strategies. There is a shortage of trials examining the role of self-testing in PrEP reinitiation, PEP initiation, or PEP follow-up. Evidence for the use of HIV prevention models that support self-testing is accumulating, but there is a need for further research in different contexts and among different populations to assess its value when scaled up to contribute to reducing HIV infections globally.
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Affiliation(s)
- Ying Zhang
- School of Translational Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia; Melbourne Sexual Health Centre, Alfred Health, Carlton, VIC, Australia
| | - Cheryl C Johnson
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | | | - Jason J Ong
- School of Translational Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia; Melbourne Sexual Health Centre, Alfred Health, Carlton, VIC, Australia; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.
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2
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Cox SN, Wu L, Wittenauer R, Clark S, Roberts DA, Nwogu IB, Vitruk O, Kuo AP, Johnson C, Jamil MS, Sands A, Schaefer R, Kisia C, Baggaley R, Stekler JD, Akullian A, Sharma M. Impact of HIV self-testing for oral pre-exposure prophylaxis scale-up on drug resistance and HIV outcomes in western Kenya: a modelling study. Lancet HIV 2024; 11:e167-e175. [PMID: 38301668 PMCID: PMC10896737 DOI: 10.1016/s2352-3018(23)00268-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 10/08/2023] [Accepted: 10/13/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND Community-based oral pre-exposure prophylaxis (PrEP) provision has the potential to expand PrEP coverage. HIV self-testing can facilitate PrEP community-based delivery but might have lower sensitivity than facility-based HIV testing, potentially leading to inappropriate PrEP use among people with HIV and subsequent development of drug resistance. We aimed to evaluate the impact of HIV self-testing use for PrEP scale-up. METHODS We parameterised an agent-based network model, EMOD-HIV, to simulate generic tenofovir disoproxil fumarate and emtricitabine PrEP scale-up in western Kenya using four testing scenarios: provider-administered nucleic acid testing, provider-administered rapid diagnostic tests detecting antibodies, blood-based HIV self-testing, or oral fluid HIV self-testing. Scenarios were compared with a no PrEP counterfactual. Individuals aged 18-49 years with one or more heterosexual partners who screened HIV-negative were eligible for PrEP. We assessed the cost and health impact of rapid PrEP scale-up with high coverage over 20 years, and the budget impact over 5 years, using various HIV testing modalities. FINDINGS PrEP coverage of 29% was projected to avert approximately 54% of HIV infections and 17% of HIV-related deaths among adults aged 18-49 years over 20 years; health impacts were similar across HIV testing modalities used to deliver PrEP. The percentage of HIV infections with PrEP-associated nucleoside reverse transcriptase inhibitor (NRTI) drug resistance was 0·6% (95% uncertainty intervals 0·4-0·9) in the blood HIV self-testing scenario and 0·8% (0·6-1·0) in the oral HIV self-testing scenario, compared with 0·3% (0·2-0·3) in the antibody rapid diagnostic testing scenario and 0·2% (0·1-0·2) in the nucleic acid testing scenario. Accounting for background NRTI resistance, we found similarly low proportions of drug resistance across scenarios. The budget impact of implementing PrEP using HIV self-testing and provider-administered rapid diagnostic tests were similar, while nucleic acid testing was approximately 50% more costly. INTERPRETATION Scaling up PrEP using HIV self-testing has similar health impacts, costs, and low risk of drug resistance as provider-administered rapid diagnostic tests. Policy makers should consider leveraging HIV self-testing to expand PrEP access among those at HIV risk. FUNDING The Bill and Melinda Gates Foundation.
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Affiliation(s)
- Sarah N Cox
- Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Global Health, University of Washington, Seattle, WA, USA
| | - Linxuan Wu
- Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Global Health, University of Washington, Seattle, WA, USA
| | - Rachel Wittenauer
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - Samantha Clark
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - D Allen Roberts
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Ifechukwu Benedict Nwogu
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - Olga Vitruk
- Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Global Health, University of Washington, Seattle, WA, USA
| | - Alexandra P Kuo
- Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - Cheryl Johnson
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
| | - Muhammad S Jamil
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
| | - Anita Sands
- Regulation and Prequalification Department, World Health Organization, Geneva, Switzerland
| | - Robin Schaefer
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
| | - Christine Kisia
- World Health Organization - Kenya Country Office, Nairobi, Kenya
| | - Rachel Baggaley
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
| | - Joanne D Stekler
- Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Global Health, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Adam Akullian
- Department of Global Health, University of Washington, Seattle, WA, USA; Institute for Disease Modeling, Bill and Melinda Gates Foundation, Seattle, WA, USA
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA, USA.
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3
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Ochieng W, Suraratdecha C. HIV self-testing, PrEP, and drug resistance: some insights. Lancet HIV 2024; 11:e134-e136. [PMID: 38301669 DOI: 10.1016/s2352-3018(23)00290-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 10/30/2023] [Indexed: 02/03/2024]
Affiliation(s)
- Walter Ochieng
- Office of the Director, Global Health Center, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
| | - Chutima Suraratdecha
- Division of Global HIV and TB, Global Health Center, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
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Sharma I, Hill A. Global HIV Incidence Analysis and Implications for Affordability Using Long-Acting Cabotegravir Versus Continuous and Event-Driven Oral Preexposure Prophylaxis. Clin Infect Dis 2024; 78:386-394. [PMID: 37665213 PMCID: PMC10874262 DOI: 10.1093/cid/ciad537] [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: 07/03/2023] [Revised: 08/24/2023] [Accepted: 08/31/2023] [Indexed: 09/05/2023] Open
Abstract
BACKGROUND The HIV Prevention Trials Network (HPTN) 083/084 trials showed up to 88% increased efficacy of long-acting cabotegravir (CAB-LA) versus continuous oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC). However, CAB-LA's high price limits the number of people who can be treated within fixed prevention budgets. Global human immunodeficiency virus (HIV) prevention budgets are highly limited, with TDF/FTC widely available as a low-cost generic. In randomized clinical trials, event-driven TDF/FTC has shown similar preventive efficacy to continuous TDF/FTC. METHODS A systematic review of global HIV incidence studies was conducted. Weighted incidence was calculated in each at-risk population. HIV infection rates were evaluated for 5 prevention strategies, with additional HIV testing, education, and service access costs assumed for each ($18 per person per year). Assumed efficacies were 90% (continuous CAB-LA), 60% (continuous TDF/FTC), and 60% (event-driven TDF/FTC). Using weighted incidence and an assumed 100 000 target population, annual HIV infection rates by population were calculated for each prevention strategy. RESULTS Ninety-eight studies in 5 230 189 individuals were included. Incidence per 100 person-years ranged from 0.03 (blood donors) to 3.82 (people who inject drugs). Using the number needed to treat to benefit for each strategy, a mean incidence of 2.6 per 100 person-years in at-risk populations, and a 100 000 target population, current-price continuous CAB-LA cost $949 487 per HIV infection successfully prevented, followed by target-price CAB-LA ($11 453), continuous TDF/FTC ($4231), and event-driven TDF/FTC ($1923). CONCLUSIONS High prices of CAB-LA limit numbers treatable within fixed budgets. Low-cost event-driven TDF/FTC consistently prevents the most HIV infections within fixed budgets.
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Affiliation(s)
- Ishani Sharma
- School of Medicine, Imperial College London, London, UK
| | - Andrew Hill
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
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Nagai H, Ankomah A, Fuseini K, Adiibokah E, Semahegn A, Tagoe H. HIV Pre-Exposure Prophylaxis Uptake Among High-Risk Population in Sub-Saharan Africa: A Systematic Review and Meta-Analysis. AIDS Patient Care STDS 2024; 38:70-81. [PMID: 38381951 DOI: 10.1089/apc.2023.0117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024] Open
Abstract
Globally, 38.4 million people are affected by the human immunodeficiency virus (HIV) pandemic, and more than 2.5 million new HIV infections occur yearly. HIV pre-exposure prophylaxis (PrEP) has been widely recognized as a potential way to prevent new infections among risk population. There is a paucity of abridged evidence on the level and barriers to PrEP service uptake in sub-Saharan Africa (SSA). Therefore, we conducted a systematic review to synthesize existing evidence on PrEP uptake in SSA. Relevant studies were searched from major databases (PubMed and PsychInfo) and direct Google Scholar. Data were extracted and recorded using a pilot-tested template. Methodological rigor, heterogeneity and publication bias of studies were assessed to minimize the inclusion of erroneous findings. A random effect model was used for the meta-analysis followed by narrative metasynthesis. The protocol of this systematic review has been by registered PROSPERO (ID: CRD42022308855). A total of 1830 studies were retrieved, and 30 studies met inclusion criteria of the systematic review. People who heard about PrEP ranged from 23% to 98%. The pooled prevalence of willingness to use PrEP was 64.2% (95% confidence interval: 55.5-72.0). Fear of side effect, stigma, nonreceptive attitude, cost of pills, low awareness about PrEP, perceived reason about the effectiveness of PrEP, and lack of friendly services were the common barriers to PrEP uptake in Africa. In conclusion, comprehensive knowledge and willingness to use PrEP were low in SSA. The barriers to low PrEP service uptake are avoidable through comprehensive awareness creation and availing essential services to key population in Africa. Expanding educational messages to key population using friendly approaches and more accessible platforms, engaging stakeholders, and integrating PrEP service with routine health care are important to foster HIV prevention and control in the future.
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Affiliation(s)
- Henry Nagai
- John Snow Research and Training Institute, Inc., Accra, Ghana
| | - Augustine Ankomah
- Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Accra, Ghana
| | | | | | - Agumasie Semahegn
- Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Accra, Ghana
- College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Henry Tagoe
- John Snow Research and Training Institute, Inc., Accra, Ghana
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Moore M, Stansfield S, Donnell DJ, Boily MC, Mitchell KM, Anderson PL, Delany-Moretlwe S, Bekker LG, Mgodi NM, Celum CL, Dimitrov D. Efficacy estimates of oral pre-exposure prophylaxis for HIV prevention in cisgender women with partial adherence. Nat Med 2023; 29:2748-2752. [PMID: 37798438 PMCID: PMC11386520 DOI: 10.1038/s41591-023-02564-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/23/2023] [Indexed: 10/07/2023]
Abstract
Pre-exposure prophylaxis (PrEP) with tenofovir (TFV) disoproxil fumarate and emtricitabine administered orally daily is effective in preventing human immunodeficiency virus (HIV) acquisition in both men and women with sufficient adherence; however, the adherence-efficacy relationship in cisgender women has not been well established. We calculated the adherence-efficacy curve for cisgender women by using HIV incidence and plasma TFV concentration data from three trials (FEM-PrEP, VOICE and Partners PrEP). We imputed TFV diphosphate (TFV-DP) concentrations, a measure of long-term adherence, from TFV quantification by using data from the HIV Prevention Trials Network 082 study, which measured both TFV-DP and TFV concentrations. Two, four and seven pills per week reduced HIV incidence by 59.3% (95% credible interval (CrI) 29.9-95.8%), 83.8% (95% CI 51.7-99.8%) and 95.9% (95% CI 72.6-100%), respectively. Our adherence-efficacy curve can be validated and updated by HIV prevention studies that directly measure TFV-DP concentrations. The curve suggests that high adherence confers high protection in cisgender women. However, the lower efficacy with partial adherence highlights the need for new PrEP products and interventions to increase adherence.
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Affiliation(s)
- Mia Moore
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA.
- HPTN Modelling Centre, Imperial College London, London, UK.
| | - Sarah Stansfield
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- HPTN Modelling Centre, Imperial College London, London, UK
| | - Deborah J Donnell
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Marie-Claude Boily
- HPTN Modelling Centre, Imperial College London, London, UK
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Kate M Mitchell
- HPTN Modelling Centre, Imperial College London, London, UK
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Peter L Anderson
- Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | | | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Nyaradzo M Mgodi
- College of Health Sciences Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Connie L Celum
- Departments of Global Health, Medicine and Epidemiology, University of Washington, Seattle, WA, USA
| | - Dobromir Dimitrov
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- HPTN Modelling Centre, Imperial College London, London, UK
- Department of Applied Mathematics, University of Washington, Seattle, WA, USA
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Phillips AN, Bansi-Matharu L, Shahmanesh M, Hargreaves JR, Smith J, Revill P, Sibanda E, Ehrenkranz P, Sikwese K, Rodger A, Lundgren JD, Gilks CF, Godfrey C, Cowan F, Cambiano V. Potential cost-effectiveness of community availability of tenofovir, lamivudine, and dolutegravir for HIV prevention and treatment in east, central, southern, and west Africa: a modelling analysis. Lancet Glob Health 2023; 11:e1648-e1657. [PMID: 37734807 DOI: 10.1016/s2214-109x(23)00383-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 07/23/2023] [Accepted: 08/04/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Post-exposure prophylaxis (PEP) offers protection from HIV after condomless sex, but is not widely available in a timely manner in east, central, southern, and west Africa. To inform the potential pilot implementation of such an approach, we modelled the effect and cost-effectiveness of making PEP consisting of tenofovir, lamivudine, and dolutegravir (TLD) freely and locally available in communities without prescription, with the aim of enabling PEP use within 24 h of condomless sex. Free community availability of TLD (referred to as community TLD) might also result in some use of TLD as pre-exposure prophylaxis (PrEP) and as antiretroviral therapy for people living with HIV. METHODS Using an existing individual-based model (HIV Synthesis), we explicitly modelled the potential positive and negative effects of community TLD. Through the sampling of parameter values we created 1000 setting-scenarios, reflecting the uncertainty in assumptions and a range of settings similar to those seen in east, central, southern, and west Africa (with a median HIV prevalence of 14·8% in women and 8·1% in men). For each setting scenario, we considered the effects of community TLD. TLD PEP was assumed to have at least 90% efficacy in preventing HIV infection after condomless sex with a person living with HIV. FINDINGS The modelled effects of community TLD availability based on an assumed high uptake of TLD resulted in a mean reduction in incidence of 31% (90% range over setting scenarios, 6% increase to 57% decrease) over 20 years, with an HIV incidence reduction over 50 years in 91% of the 1000 setting scenarios, deaths averted in 55% of scenarios, reduction in costs in 92% of scenarios, and disability-adjusted life-years averted in 64% of scenarios with community TLD. Community TLD was cost-effective in 90% of setting scenarios and cost-saving (with disability-adjusted life-years averted) in 58% of scenarios. When only examining setting scenarios in which there was lower uptake of community TLD, community TLD is cost-effective in 92% of setting scenarios. INTERPRETATION The introduction of community TLD, enabling greater PEP access, is a promising approach to consider further in pilot implementation projects. FUNDING Bill & Melinda Gates Foundation to the HIV Modelling Consortium.
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Affiliation(s)
| | | | - Maryam Shahmanesh
- Institute for Global Health, University College London, London, UK; Africa Health Research Institute, KwaZulu-Natal, South Africa
| | | | - Jennifer Smith
- Institute for Global Health, University College London, London, UK
| | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | - Euphemia Sibanda
- CeSHHAR Zimbabwe, Harare, Zimbabwe; Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Alison Rodger
- Institute for Global Health, University College London, London, UK
| | - Jens D Lundgren
- Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Catherine Godfrey
- Office of the Global AIDS Coordinator, Department of State, Washington, DC, USA
| | - Frances Cowan
- CeSHHAR Zimbabwe, Harare, Zimbabwe; Liverpool School of Tropical Medicine, Liverpool, UK
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Hendrickson C, Hirasen K, Mongwenyana C, Benade M, Bothma R, Smith C, Meyer J, Nichols B, Long L. Costs and outcomes of routine HIV oral pre-exposure prophylaxis implementation across different service delivery models and key populations in South Africa. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.14.23294055. [PMID: 37645864 PMCID: PMC10462215 DOI: 10.1101/2023.08.14.23294055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Background Oral pre-exposure prophylaxis (PrEP) is a highly efficacious biomedical HIV prevention tool, yet despite being recommended by the World Health Organization (WHO) since 2015, uptake and persistence remain limited in much of the world, including sub Saharan Africa (SSA). There is a dearth of evidence-based interventions to improve PrEP uptake and persistence in SSA, and the full costs of PrEP programs implemented in routine care settings remain largely unknown. This study aimed to evaluate the cost of delivery of daily oral PrEP, and associated outcomes, to different key and priority populations across different service delivery models (SDMs) in South Africa. Methods We conducted bottom-up micro-costing of PrEP service delivery from the provider perspective within twelve urban SDMs providing routine PrEP services to various key and propriety populations in Gauteng and KwaZulu-Natal provinces in South Africa. The SDMs included in-facility and outreach models that focused on men who have sex with men (MSM), female sex workers (FSW) and adolescent girls and young women (AGYW). We identified all within- and above-facility activities supporting PrEP delivery, obtained input costs from program budgets, expenditure records and staff interviews, and determined individual resource usage between February 2019 and February 2020 through retrospective medical record review. Our primary outcome was PrEP coverage at six months (defined as having sufficient PrEP drug dispensed at the last visit to be covered at six months post PrEP-initiation). A subset (N=633) of all enrolled subjects had the potential for 12 months of follow-up and were included in a 12-month outcome analysis. We report the cost per client initiated on PrEP in 2021 United States Dollars (USD). Findings We collected medical record data from 1,281 people who initiated PrEP at 12 SDMs between February and August 2019 and had at least six months of potential follow-up. The average number of visits was 2.3 for in-facility models and 1.5 for outreach models and 3,086 months of PrEP was dispensed. PrEP coverage at six months varied greatly across SDMs, from 41.8% at one MSM-focused fixed clinic to 0% in an MSM-focused outreach model. In general, in-facility programs had higher six-month coverage than outreach programs. Across all SDMs with PrEP clients with potential for 12 months of follow-up (n=633), PrEP coverage at 12 months was 13.6%, with variability between SDMs. The average six-month cost per client initiated on PrEP ranged from $29 to $590, with higher average costs generally observed for the in-facility programs ($152 in-facility versus $84 for outreach). The average monthly cost per PrEP client who had six-month PrEP coverage ranged from $18 to $160 dependent on SDM. Interpretation This study is an important addition to the PrEP outcome and cost literature in the SSA region. Results show that costs and outcomes vary considerably across different SDMs and populations in real world PrEP programs and provide crucial information for further scale-up of the oral PrEP program in South Africa and the greater SSA region.
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Castor D, Heck CJ, Quigee D, Telrandhe NV, Kui K, Wu J, Glickson E, Yohannes K, Rueda ST, Bozzani F, Meyers K, Zucker J, Deacon J, Kripke K, Sobieszczyk ME, Terris‐Prestholt F, Malati C, Obermeyer C, Dam A, Schwartz K, Forsythe S. Implementation and resource needs for long-acting PrEP in low- and middle-income countries: a scoping review. J Int AIDS Soc 2023; 26 Suppl 2:e26110. [PMID: 37439063 PMCID: PMC10339010 DOI: 10.1002/jia2.26110] [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: 11/20/2022] [Accepted: 05/05/2023] [Indexed: 07/14/2023] Open
Abstract
INTRODUCTION Several low- and middle-income countries (LMICs) are preparing to introduce long-acting pre-exposure prophylaxis (LAP). Amid multiple pre-exposure prophylaxis (PrEP) options and constrained funding, decision-makers could benefit from systematic implementation planning and aligned costs. We reviewed national costed implementation plans (CIPs) to describe relevant implementation inputs and activities (domains) for informing the costed rollout of LAP. We assessed how primary costing evidence aligned with those domains. METHODS We conducted a rapid review of CIPs for oral PrEP and family planning (FP) to develop a consensus of implementation domains, and a scoping review across nine electronic databases for publications on PrEP costing in LMICs between January 2010 and June 2022. We extracted cost data and assessed alignment with the implementation domains and the Global Health Costing Consortium principles. RESULTS We identified 15 implementation domains from four national PrEP plans and FP-CIP template; only six were in all sources. We included 66 full-text manuscripts, 10 reported LAP, 13 (20%) were primary cost studies-representing seven countries, and none of the 13 included LAP. The 13 primary cost studies included PrEP commodities (n = 12), human resources (n = 11), indirect costs (n = 11), other commodities (n = 10), demand creation (n = 9) and counselling (n = 9). Few studies costed integration into non-HIV services (n = 5), above site costs (n = 3), supply chains and logistics (n = 3) or policy and planning (n = 2), and none included the costs of target setting, health information system adaptations or implementation research. Cost units and outcomes were variable (e.g. average per person-year). DISCUSSION LAP planning will require updating HIV prevention policies, technical assistance for logistical and clinical support, expanding beyond HIV platforms, setting PrEP achievement targets overall and disaggregated by method, extensive supply chain and logistics planning and support, as well as updating health information systems to monitor multiple PrEP methods with different visit schedules. The 15 implementation domains were variable in reviewed studies. PrEP primary cost and budget data are necessary for new product introduction and should match implementation plans with financing. CONCLUSIONS As PrEP services expand to include LAP, decision-makers need a framework, tools and a process to support countries in planning the systematic rollout and costing for LAP.
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Affiliation(s)
- Delivette Castor
- Division of Infectious DiseasesColumbia University Irving Medical CenterNew YorkNew YorkUSA
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
| | - Craig J. Heck
- Division of Infectious DiseasesColumbia University Irving Medical CenterNew YorkNew YorkUSA
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
| | - Daniela Quigee
- Division of Infectious DiseasesColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | | | - Kiran Kui
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
| | - Jiaxin Wu
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
| | | | - Kibret Yohannes
- University of Virginia School of MedicineCharlottesvilleVirginiaUSA
| | | | | | - Kathrine Meyers
- Division of Infectious DiseasesColumbia University Irving Medical CenterNew YorkNew YorkUSA
- The Aaron Diamond AIDS Research CenterColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Jason Zucker
- Division of Infectious DiseasesColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | | | | | | | | | - Christine Malati
- United States Agency for International DevelopmentWashingtonDCUSA
| | - Chris Obermeyer
- The Global Fund to Fight AIDS, Tuberculosis and MalariaGenevaSwitzerland
| | - Anita Dam
- United States Agency for International DevelopmentWashingtonDCUSA
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Luz PM, Deshpande V, Kazemian P, Scott JA, Shebl FM, Spaeth H, Pimenta C, Stern M, Pereira G, Struchiner CJ, Grinsztejn B, Veloso VG, Freedberg KA. Impact of pre-exposure prophylaxis uptake among gay, bisexual, and other men who have sex with men in urban centers in Brazil: a modeling study. BMC Public Health 2023; 23:1128. [PMID: 37308858 PMCID: PMC10262537 DOI: 10.1186/s12889-023-15994-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 05/23/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Men who have sex with men (MSM) in Brazil remain disproportionately affected by HIV. We estimated the potential incidence reduction by five years with increased uptake of publicly-funded, daily, oral tenofovir/emtricitabine (TDF/FTC) for HIV pre-exposure prophylaxis (PrEP) among MSM using the Cost Effectiveness of Preventing AIDS Complications microsimulation model. We used national data, local studies, and literature to inform model parameters for three cities: Rio de Janeiro, Salvador, and Manaus. RESULTS In Rio de Janero, a PrEP intervention achieving 10% uptake within 60 months would decrease incidence by 2.3% whereas achieving 60% uptake within 24 months would decrease incidence by 29.7%; results were similar for Salvador and Manaus. In sensitivity analyses, decreasing mean age at PrEP initiation from 33 to 21 years increased incidence reduction by 34%; a discontinuation rate of 25% per year decreased it by 12%. CONCLUSION Targeting PrEP to young MSM and minimizing discontinuation could substantially increase PrEP's impact.
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Affiliation(s)
- Paula M Luz
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Avenida Brasil 4365, Rio de Janeiro, 21040-360, Brazil.
| | - Vijeta Deshpande
- Medical Practice Evaluation Center, Massachusetts General Hospital, 100 Cambridge Street, Suite 1684, Boston, MA, 02114, USA
| | - Pooyan Kazemian
- Department of Operations, Weatherhead School of Management, Case Western Reserve University, 11119 Bellflower Road, Cleveland, OH, 44106, USA
| | - Justine A Scott
- Medical Practice Evaluation Center, Massachusetts General Hospital, 100 Cambridge Street, Suite 1684, Boston, MA, 02114, USA
| | - Fatma M Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, 100 Cambridge Street, Suite 1684, Boston, MA, 02114, USA
| | - Hailey Spaeth
- Medical Practice Evaluation Center, Massachusetts General Hospital, 100 Cambridge Street, Suite 1684, Boston, MA, 02114, USA
| | - Cristina Pimenta
- Ministry of Health of Brazil, SRTVN Quadra 701, Lote D, Edifício PO700, 5º Andar, Brasília/DFBrasilia, 70719-040, Brazil
| | - Madeline Stern
- Medical Practice Evaluation Center, Massachusetts General Hospital, 100 Cambridge Street, Suite 1684, Boston, MA, 02114, USA
| | - Gerson Pereira
- Ministry of Health of Brazil, SRTVN Quadra 701, Lote D, Edifício PO700, 5º Andar, Brasília/DFBrasilia, 70719-040, Brazil
| | | | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Avenida Brasil 4365, Rio de Janeiro, 21040-360, Brazil
| | - Valdilea G Veloso
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Avenida Brasil 4365, Rio de Janeiro, 21040-360, Brazil
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, 100 Cambridge Street, Suite 1684, Boston, MA, 02114, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
- Harvard University Center for AIDS Research, Harvard Medical School, 42 Church Street, Cambridge, MA, 02138, USA
- Division of General Internal Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
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11
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Bershteyn A, Resar D, Kim HY, Platais I, Mullick S. Optimizing the pipeline of multipurpose prevention technologies: opportunities across women's reproductive lifespans. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1169110. [PMID: 37325241 PMCID: PMC10266103 DOI: 10.3389/frph.2023.1169110] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 05/15/2023] [Indexed: 06/17/2023] Open
Abstract
HIV/AIDS and maternal mortality are the two leading causes of death among women of reproductive age in sub-Saharan Africa. A growing body of research investigates opportunities for multipurpose prevention technologies (MPTs) that prevent unintended pregnancy, HIV, and/or other sexually transmitted infections (STIs) with a single product. More than two dozen MPTs are currently in development, most of them combining contraception with HIV pre-exposure prophylaxis, with or without protection from other STIs. If successful, such MPTs could offer women benefits at multiple levels: greater motivation for effective use; lower product administration burden; accelerated integration of HIV, STI, and reproductive health services; and opportunities to circumvent stigma by using contraception as a "fig leaf" for HIV and/or STI prevention. However, even if women find respite from product burden, lack of motivation, and/or stigma in contraceptive-containing MPTs, their use of MPTs will be interrupted, often multiple times, over the reproductive lifecourse due to desire for pregnancy, pregnancy and breastfeeding, menopause, and changes in risk. Interruptions to the benefits of MPTs could be avoided by combining HIV/STI prevention with other life-stage-appropriate reproductive health products. New product concepts could include combining prenatal supplements with HIV and STI prevention, emergency contraception with HIV post-exposure prophylaxis, or hormone replacement therapies for menopause with HIV and STI prevention. Research is needed to optimize the MPT pipeline based on the populations underserved by available options and the capacity of resource-constrained health systems to deliver novel preventative healthcare products.
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Affiliation(s)
- Anna Bershteyn
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | - Danielle Resar
- Clinton Health Access Initiative, Boston, MA, United States
| | - Hae-Young Kim
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | - Ingrida Platais
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | - Saiqa Mullick
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
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12
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Milali MP, Resar D, Kaftan D, Campbell J, Olowu A, Edwards D, Platais I, Kim HY, Jenkins S, Bershteyn A. Cost-effectiveness of the dual prevention pill for contraception and HIV pre-exposure prophylaxis. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1144217. [PMID: 37266447 PMCID: PMC10230827 DOI: 10.3389/frph.2023.1144217] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 04/24/2023] [Indexed: 06/03/2023] Open
Abstract
Introduction Women in sub-Saharan Africa (SSA) experience the world's highest rates of both HIV infection and unintended pregnancy. The Dual Prevention Pill (DPP) is a novel multipurpose prevention technology (MPT) that co-formulates HIV pre-exposure prophylaxis (PrEP) and combined hormonal oral contraception into a single daily pill. As a dual indication product, the DPP may be preferred by women facing these overlapping health risks. However, most SSA countries face severe healthcare resource constraints. Research is needed to assess whether, in what populations, and in what use cases the DPP would be cost-effective. Methods We augmented an agent-based SSA HIV model with maternal health parameters including unintended pregnancy, abortion, and maternal mortality. Based on a previous market analysis, we assumed a primary DPP user population of current oral contraceptive users ages 25-49, and alternative user populations in different risk groups (age 15-24, sex workers, HIV-serodiscordant couples) and baseline product use profiles (unmet need for contraception, oral PrEP use, condom use). In three geographies (western Kenya, Zimbabwe, South Africa), we estimated HIV infections averted, pregnancies averted, disability-adjusted life-years (DALYs) averted, and the incremental cost-effectiveness ratio (ICER) over a 30-year time horizon, assuming equivalent adherence to the DPP as to oral contraceptives, higher adherence, or lower adherence. Results The DPP is likely to be a cost-effective alternative to oral PrEP among users in need of contraception. Among women not already using PrEP, the DPP is likely to be cost-saving in sex workers and serodiscordant couples. The DPP is unlikely to be cost-effective in oral contraceptive users in the general population. Switching from oral contraception to the DPP could be net harmful in some settings and populations if it were to substantially reduces adherence to oral contraception. Results were robust to a range of time horizons or discount rates. Conclusion The DPP has the potential to be cost-effective and cost-saving in populations at substantial HIV risk. Outcomes are sensitive to adherence, implying that effective counseling and decision-making tools for users considering the DPP will be essential. More research is needed to understand real-life adherence patterns and ensure health benefits achieved from contraception alone are not lost.
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Affiliation(s)
- Masabho P. Milali
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | - Danielle Resar
- Clinton Health Access Initiative, Boston, MA, United States
| | - David Kaftan
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | | | - Adebanjo Olowu
- Clinton Health Access Initiative, Boston, MA, United States
| | - Danny Edwards
- Clinton Health Access Initiative, Boston, MA, United States
| | - Ingrida Platais
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | - Hae-Young Kim
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | - Sarah Jenkins
- Clinton Health Access Initiative, Boston, MA, United States
| | - Anna Bershteyn
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
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13
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Smith J, Bansi-Matharu L, Cambiano V, Dimitrov D, Bershteyn A, van de Vijver D, Kripke K, Revill P, Boily MC, Meyer-Rath G, Taramusi I, Lundgren JD, van Oosterhout JJ, Kuritzkes D, Schaefer R, Siedner MJ, Schapiro J, Delany-Moretlwe S, Landovitz RJ, Flexner C, Jordan M, Venter F, Radebe M, Ripin D, Jenkins S, Resar D, Amole C, Shahmanesh M, Gupta RK, Raizes E, Johnson C, Inzaule S, Shafer R, Warren M, Stansfield S, Paredes R, Phillips AN. Predicted effects of the introduction of long-acting injectable cabotegravir pre-exposure prophylaxis in sub-Saharan Africa: a modelling study. Lancet HIV 2023; 10:e254-e265. [PMID: 36642087 PMCID: PMC10065903 DOI: 10.1016/s2352-3018(22)00365-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/16/2022] [Accepted: 11/22/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Long-acting injectable cabotegravir pre-exposure prophylaxis (PrEP) is recommended by WHO as an additional option for HIV prevention in sub-Saharan Africa, but there is concern that its introduction could lead to an increase in integrase-inhibitor resistance undermining treatment programmes that rely on dolutegravir. We aimed to project the health benefits and risks of cabotegravir-PrEP introduction in settings in sub-Saharan Africa. METHODS With HIV Synthesis, an individual-based HIV model, we simulated 1000 setting-scenarios reflecting both variability and uncertainty about HIV epidemics in sub-Saharan Africa and compared outcomes for each with and without cabotegravir-PrEP introduction. PrEP use is assumed to be risk-informed and to be used only in 3-month periods (the time step for the model) when having condomless sex. We consider three groups at risk of integrase-inhibitor resistance emergence: people who start cabotegravir-PrEP after (unknowingly) being infected with HIV, those who seroconvert while on PrEP, and those with HIV who have residual cabotegravir drugs concentrations during the early tail period after recently stopping PrEP. We projected the outcomes of policies of cabotegravir-PrEP introduction and of no introduction in 2022 across 50 years. In 50% of setting-scenarios we considered that more sensitive nucleic-acid-based HIV diagnostic testing (NAT), rather than regular antibody-based HIV rapid testing, might be used to reduce resistance risk. For cost-effectiveness analysis we assumed in our base case a cost of cabotegravir-PrEP drug to be similar to oral PrEP, resulting in a total annual cost of USD$144 per year ($114 per year and $264 per year considered in sensitivity analyses), a cost-effectiveness threshold of $500 per disability-adjusted life years averted, and a discount rate of 3% per year. FINDINGS Reflecting our assumptions on the appeal of cabotegravir-PrEP, its introduction is predicted to lead to a substantial increase in PrEP use with approximately 2·6% of the adult population (and 46% of those with a current indication for PrEP) receiving PrEP compared with 1·5% (28%) without cabotegravir-PrEP introduction across 20 years. As a result, HIV incidence is expected to be lower by 29% (90% range across setting-scenarios 6-52%) across the same period compared with no introduction of cabotegravir-PrEP. In people initiating antiretroviral therapy, the proportion with integrase-inhibitor resistance after 20 years is projected to be 1·7% (0-6·4%) without cabotegravir-PrEP introduction but 13·1% (4·1-30·9%) with. Cabotegravir-PrEP introduction is predicted to lower the proportion of all people on antiretroviral therapy with viral loads less than 1000 copies per mL by 0·9% (-2·5% to 0·3%) at 20 years. For an adult population of 10 million an overall decrease in number of AIDS deaths of about 4540 per year (-13 000 to -300) across 50 years is predicted, with little discernible benefit with NAT when compared with standard antibody-based rapid testing. AIDS deaths are predicted to be averted with cabotegravir-PrEP introduction in 99% of setting-scenarios. Across the 50-year time horizon, overall HIV programme costs are predicted to be similar regardless of whether cabotegravir-PrEP is introduced (total mean discounted annual HIV programme costs per year across 50 years is $151·3 million vs $150·7 million), assuming the use of standard antibody testing. With antibody-based rapid HIV testing, the introduction of cabotegravir-PrEP is predicted to be cost-effective under an assumed threshold of $500 per disability-adjusted life year averted in 82% of setting-scenarios at the cost of $144 per year, in 52% at $264, and in 87% at $114. INTERPRETATION Despite leading to increases in integrase-inhibitor drug resistance, cabotegravir-PrEP introduction is likely to reduce AIDS deaths in addition to HIV incidence. Long-acting cabotegravir-PrEP is predicted to be cost-effective if delivered at similar cost to oral PrEP with antibody-based rapid HIV testing. FUNDING Bill & Melinda Gates Foundation, National Institute of Allergy and Infectious Diseases of the National Institutes of Health.
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Affiliation(s)
- Jennifer Smith
- Institute for Global Health, University College London, London, UK
| | | | | | - Dobromir Dimitrov
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Anna Bershteyn
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | | | | | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | - Marie-Claude Boily
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Jens D Lundgren
- Department of Clinical Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Joep J van Oosterhout
- Partners in Hope, Lilongwe, Malawi; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Daniel Kuritzkes
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Robin Schaefer
- Global HIV, Hepatitis, and STIs Programmes, WHO, Geneva, Switzerland
| | - Mark J Siedner
- Department of Medicine, Harvard Medical School, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Clinical Research Department, Africa Health Research Institute, Mtubatuba, South Africa
| | | | - Sinead Delany-Moretlwe
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Raphael J Landovitz
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA; Center for Clinical AIDS Research and Education, University of California, Los Angeles, CA, USA
| | - Charles Flexner
- Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Jordan
- Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Francois Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mopo Radebe
- Regional Office for Africa, WHO, Gauteng, South Africa
| | - David Ripin
- Infectious Diseases Program, Clinton Health Access Initiative, New York, NY, USA
| | - Sarah Jenkins
- Infectious Diseases Program, Clinton Health Access Initiative, New York, NY, USA
| | - Danielle Resar
- Infectious Diseases Program, Clinton Health Access Initiative, New York, NY, USA
| | - Carolyn Amole
- Infectious Diseases Program, Clinton Health Access Initiative, New York, NY, USA
| | - Maryam Shahmanesh
- Institute for Global Health, University College London, London, UK; Clinical Research Department, Africa Health Research Institute, Mtubatuba, South Africa
| | - Ravindra K Gupta
- Clinical Research Department, Africa Health Research Institute, Mtubatuba, South Africa; Department of Medicine, University of Cambridge, Cambridge, UK
| | - Elliot Raizes
- US Department of Health and Human Services, Centers for Disease Control, Atlanta, GA, USA
| | - Cheryl Johnson
- Global HIV, Hepatitis, and STIs Programmes, WHO, Geneva, Switzerland
| | - Seth Inzaule
- Global HIV, Hepatitis, and STIs Programmes, WHO, Geneva, Switzerland
| | - Robert Shafer
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| | | | - Sarah Stansfield
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Roger Paredes
- Department of Infectious Diseases, Irsi Caixa Institut de Recerca de la SIDA, Barcelona, Spain
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14
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Godfrey-Faussett P, Frescura L, Abdool Karim Q, Clayton M, Ghys PD. HIV prevention for the next decade: Appropriate, person-centred, prioritised, effective, combination prevention. PLoS Med 2022; 19:e1004102. [PMID: 36156593 PMCID: PMC9550175 DOI: 10.1371/journal.pmed.1004102] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 10/10/2022] [Indexed: 11/18/2022] Open
Abstract
UNAIDS and a broad range of partners have collaborated to establish a new set of HIV prevention targets to be achieved by 2025 as an intermediate step towards the sustainable development target for 2030.The number of new HIV infections in the world continues to decline, in part due to the extraordinary expansion of effective HIV treatment. However, the decline is geographically heterogeneous, with some regions reporting a rise in incidence. The incidence target that was agreed for 2020 has been missed.A range of exciting new HIV prevention technologies have become available or are in the pipeline but will only have an impact if they are accessible and affordable and delivered within systems that take full account of the social and political context in which most infections occur. Most new infections occur in populations that are marginalised or discriminated against due to structural, legal, and cultural barriers.The new targets imply a new approach to HIV prevention that emphasises appropriate, person-centred, prioritised, effective, combination HIV prevention within a framework that reduces existing barriers to services and acknowledges heterogeneity, autonomy, and choice.These targets have consequences for people working in HIV programmes both for delivery and for monitoring and evaluation, for health planners setting local and national priorities, and for funders both domestic and global. Most importantly, they have consequences for people who are at risk of HIV exposure and infection.Achieving these targets will have a huge impact on the future of the HIV epidemic and put us back on track towards ending AIDS as a public health threat by 2030.
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Affiliation(s)
- Peter Godfrey-Faussett
- Data for Impact Practice, UNAIDS, Geneva, Switzerland
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | | | | | | | - Peter D. Ghys
- Data for Impact Practice, UNAIDS, Geneva, Switzerland
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15
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Bershteyn A, Jamieson L, Kim HY, Platais I, Milali MP, Mudimu E, Ten Brink D, Martin-Hughes R, Kelly SL, Phillips AN, Bansi-Matharu L, Cambiano V, Revill P, Meyer-Rath G, Nichols BE. Transmission reduction, health benefits, and upper-bound costs of interventions to improve retention on antiretroviral therapy: a combined analysis of three mathematical models. Lancet Glob Health 2022; 10:e1298-e1306. [PMID: 35961353 PMCID: PMC9380252 DOI: 10.1016/s2214-109x(22)00310-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 06/07/2022] [Accepted: 06/24/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND In this so-called treat-all era, antiretroviral therapy (ART) interruptions contribute to an increasing proportion of HIV infections and deaths. Many strategies to improve retention on ART cost more than standard of care. In this study, we aimed to estimate the upper-bound costs at which such interventions should be adopted. METHODS In this combined analysis, we compared the infections averted, disability-adjusted life-years (DALYs) averted, and upper-bound costs of interventions that improve ART retention in three HIV models with diverse structures, assumptions, and baseline settings: EMOD in South Africa, Optima in Malawi, and Synthesis in sub-Saharan African low-income and middle-income countries (LMICs). We modelled estimates over a 40-year time horizon, from a baseline of Jan 1, 2022, when interventions would be implemented, to Jan 1, 2062. We varied increment of ART retention (25%, 50%, 75%, and 100% retention), the extent to which interventions could be targeted towards individuals at risk of interrupting ART, and cost-effectiveness thresholds in each setting. FINDINGS Despite simulating different settings and epidemic trends, all three models produced consistent estimates of health benefit (ie, DALYs averted) and transmission reduction per increment in retention. The range of estimates was 1·35-3·55 DALYs and 0·12-0·20 infections averted over the 40-year time horizon per additional person-year retained on ART. Upper-bound costs varied by setting and intervention effectiveness. Improving retention by 25% among all people receiving ART, regardless of risk of ART interruption, gave an upper-bound cost per person-year of US$2-6 in Optima (Malawi), $43-68 in Synthesis (LMICs in sub-Saharan Africa), and $28-180 in EMOD (South Africa). A maximally targeted and effective retention intervention had an upper-bound cost per person-year of US$93-223 in Optima (Malawi), $871-1389 in Synthesis (LMICs in sub-Saharan Africa), and $1013-6518 in EMOD (South Africa). INTERPRETATION Upper-bound costs that could improve ART retention vary across sub-Saharan African settings and are likely to be similar to or higher than was estimated before the start of the treat-all era. Upper-bound costs could be increased by targeting interventions to those most at risk of interrupting ART. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Anna Bershteyn
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA.
| | - Lise Jamieson
- Health Economics and Epidemiology Research Office (HE2RO), University of the Witwatersrand, Johannesburg, South Africa
| | - Hae-Young Kim
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Ingrida Platais
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Masabho P Milali
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Edinah Mudimu
- Department of Decision Sciences, University of South Africa, Pretoria, South Africa
| | | | | | | | | | | | | | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office (HE2RO), University of the Witwatersrand, Johannesburg, South Africa; Department of Global Health, School of Public Health, Boston University, Boston, MA, USA
| | - Brooke E Nichols
- Health Economics and Epidemiology Research Office (HE2RO), University of the Witwatersrand, Johannesburg, South Africa; Department of Global Health, School of Public Health, Boston University, Boston, MA, USA; Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, Netherlands
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16
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Phillips AN, Sibanda E, Sikwese K, Bansi-Matharu L, Cambiano V, Rodger A, Lundgren J, Shahmanesh M, Gilks C, Godfrey C, Ehrenkranz P, Hargreaves JR, Revill P, Cowan F. Enabling timely HIV postexposure prophylaxis access in sub-Saharan Africa. AIDS 2022; 36:1473-1475. [PMID: 35876709 DOI: 10.1097/qad.0000000000003258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
| | | | - Kenly Sikwese
- African Community Advisory Board (AfroCAB-HIV), Lusaka, Zambia
| | | | | | | | - Jens Lundgren
- Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Catherine Godfrey
- Office of the Global AIDS Coordinator, Department of State, Washington, DC, USA
| | | | | | - Paul Revill
- Centre for Health Economics, University of York, UK
| | - Frances Cowan
- Liverpool School of Tropical Medicine, UK, and Harare, Zimbabwe
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17
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ten Brink DC, Martin-Hughes R, Minnery ME, Osborne AJ, Schmidt HMA, Dalal S, Green KE, Ramaurtarsing R, Wilson DP, Kelly SL. Cost-effectiveness and impact of pre-exposure prophylaxis to prevent HIV among men who have sex with men in Asia: A modelling study. PLoS One 2022; 17:e0268240. [PMID: 35617169 PMCID: PMC9135227 DOI: 10.1371/journal.pone.0268240] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 04/25/2022] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION More than 70% of new HIV infections in Asia occurred in eight countries in 2020: Cambodia, China, India, Indonesia, Myanmar, Nepal, Thailand, and Vietnam-with a rising incidence among men who have sex with men (MSM). The World Health Organization (WHO) recommends pre-exposure prophylaxis (PrEP) for those at risk of acquiring HIV, yet wide-scale implementation of PrEP, on a daily or event-driven basis, has been limited in Asia. METHODS The Optima HIV model was applied to examine the impact of scaling-up PrEP over five-years to cover an additional 15% of MSM compared with baseline coverage, a target deemed feasible by regional experts. Based on behavioral survey data, we assume that covering 15% of higher-risk MSM will cover 30% of all sexual acts in this group. Scenarios to compare the impact of generic-brand daily dosing of PrEP with generic event-driven dosing (15 days a month) were modelled from the start of 2022 to the end of 2026. Cost-effectiveness of generic versus branded PrEP was also assessed for China, the only country with an active patent for branded, higher cost PrEP. The impact on new HIV infections among the entire population and cost per HIV-related disability-adjusted life year (DALY) averted were estimated from the beginning of 2022 to the end of 2031 and from 2022 to 2051. RESULTS If PrEP were scaled-up to cover an additional 15% of MSM engaging in higher-risk behavior from the beginning of 2022 to the end of 2026 in the eight Asian countries considered, an additional 100,000 (66,000-130,000) HIV infections (17%) and 300,000 (198,000-390,000) HIV-related DALYs (3%) could be averted over the 2022 to 2031 period. The estimated cost per HIV-related DALY averted from 2022 to 2031 ranged from US$600 for event-driven generic PrEP in Indonesia to US$34,400 for daily branded PrEP in Thailand. Over a longer timeframe from 2022 to 2051, the cost per HIV-related DALY averted could be reduced to US$100-US$12,700. CONCLUSION PrEP is a critical tool to further reduce HIV incidence in highly concentrated epidemics. Implementing PrEP in Asia may be cost-effective in settings with increasing HIV prevalence among MSM and if PrEP drug costs can be reduced, PrEP could be more cost-effective over longer timeframes.
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Affiliation(s)
| | | | | | | | - Heather-Marie A. Schmidt
- United Nations Programme on HIV/AIDS, Regional Office for Asia and the Pacific, Bangkok, Thailand
- World Health Organization, Geneva, Switzerland
| | - Shona Dalal
- World Health Organization, Geneva, Switzerland
| | | | | | - David P. Wilson
- Burnet Institute, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
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18
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Schaefer R, Schmidt HMA. Realising the potential of risk-informed PrEP. Lancet HIV 2022; 9:e302-e304. [PMID: 35489374 DOI: 10.1016/s2352-3018(22)00104-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/05/2022] [Indexed: 01/13/2023]
Affiliation(s)
- Robin Schaefer
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland.
| | - Heather-Marie A Schmidt
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland; UNAIDS Regional Office for Asia and the Pacific, Bangkok, Thailand
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