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Hontelez JAC, Bor J, Tanser FC, Pillay D, Moshabela M, Bärnighausen T. HIV Treatment Substantially Decreases Hospitalization Rates: Evidence From Rural South Africa. Health Aff (Millwood) 2019; 37:997-1004. [PMID: 29863928 DOI: 10.1377/hlthaff.2017.0820] [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: 11/05/2022]
Abstract
The effect of HIV treatment on hospitalization rates for HIV-infected people has never been established. We quantified this effect in a rural South African community for the period 2009-13. We linked clinical data on HIV treatment start dates for more than 2,000 patients receiving care in the public-sector treatment program with five years of longitudinal data on self-reported hospitalizations from a community-based population cohort of more than 100,000 adults. Hospitalization rates peaked during the first year of treatment and were about five times higher, compared to hospitalization rates after four years on treatment. Earlier treatment initiation could save more than US$300,000 per 1,000 patients over the first four years of HIV treatment, freeing up scarce resources. Future studies on the cost-effectiveness of HIV treatment should include these effects.
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Affiliation(s)
- Jan A C Hontelez
- Jan A. C. Hontelez ( ) is an assistant professor at Erasmus University Medical Center, in Rotterdam, the Netherlands, and at the Heidelberg Institute of Public Health, Heidelberg University, in Germany
| | - Jacob Bor
- Jacob Bor is an assistant professor in the Departments of Global Health and Epidemiology, Boston University School of Public Health, in Massachusetts
| | - Frank C Tanser
- Frank C. Tanser is a professor of epidemiology at the University of KwaZulu-Natal and senior faculty member of the Africa Health Research Institute. He also holds an honorary professorship in the Research Department of Infection and Population Health, University College London, and is a research associate of the Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal
| | - Deenan Pillay
- Deenan Pillay is director of the Africa Health Research Institute
| | - Mosa Moshabela
- Mosa Moshabela is head of the Department of Rural Health, University of KwaZulu-Natal, and a senior researcher at the Africa Health Research Institute
| | - Till Bärnighausen
- Till Bärnighausen is the Alexander von Humboldt University Professor and director of the Heidelberg Institute of Public Health, Heidelberg University. He is also senior faculty at the Africa Health Research Institute in Somkhele, South Africa, and an adjunct professor of global health at the Harvard T. H. Chan School of Public Health, in Boston
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Level of Alcohol Use Associated with HIV Care Continuum Targets in a National U.S. Sample of Persons Living with HIV Receiving Healthcare. AIDS Behav 2019; 23:140-151. [PMID: 29995206 DOI: 10.1007/s10461-018-2210-6] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We evaluated associations between levels of alcohol use and HIV care continuum components using national Veterans Aging Cohort Study data for all patients with HIV and AUDIT-C screening (2/1/2008-9/30/2014). Poisson regression models evaluated associations between alcohol use levels (non-drinking, low-, medium-, high-, and very high-level drinking) and: (1) engagement with care (documented CD4 cells/µl or viral load copies/ml labs), (2) ART treatment (≥ 1 prescription), and (3) viral suppression (HIV RNA < 500 copies/ml) within one year. Among 33,224 patients, alcohol use level was inversely associated with all care continuum outcomes (all p < 0.001). Adjusted prevalence of care engagement ranged from 77.8% (95% CI 77.1-78.4%) for non-drinking to 69.1% (66.6-71.6%) for high-level drinking. The corresponding range for ART treatment was 74.0% (73.3-74.7%) to 60.1% (57.3-62.9%) and for viral suppression was 57.3% (56.5-58.1%) to 38.3% (35.6-41.1%). Greater alcohol use is associated with suboptimal HIV treatment across the HIV care continuum.
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Brennan AT, Bor J, Davies MA, Wandeler G, Prozesky H, Fatti G, Wood R, Stinson K, Tanser F, Bärnighausen T, Boulle A, Sikazwe I, Zanolini A, Fox MP. Medication Side Effects and Retention in HIV Treatment: A Regression Discontinuity Study of Tenofovir Implementation in South Africa and Zambia. Am J Epidemiol 2018; 187:1990-2001. [PMID: 29767681 DOI: 10.1093/aje/kwy093] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 04/18/2018] [Indexed: 01/05/2023] Open
Abstract
Tenofovir is less toxic than other nucleoside reverse-transcriptase inhibitors used in antiretroviral therapy (ART) and may improve retention of human immunodeficiency virus (HIV)-infected patients on ART. We assessed the impact of national guideline changes in South Africa (2010) and Zambia (2007) recommending tenofovir for first-line ART. We applied regression discontinuity in a prospective cohort study of 52,294 HIV-infected adults initiating first-line ART within 12 months (±12 months) of each guideline change. We compared outcomes in patients presenting just before and after the guideline changes using local linear regression and estimated intention-to-treat effects on initiation of tenofovir, retention in care, and other treatment outcomes at 24 months. We assessed complier causal effects among patients starting tenofovir. The new guidelines increased the percentages of patients initiating tenofovir in South Africa (risk difference (RD) = 81 percentage points, 95% confidence interval (CI): 73, 89) and Zambia (RD = 42 percentage points, 95% CI: 38, 45). With the guideline change, the percentage of single-drug substitutions decreased substantially in South Africa (RD = -15 percentage points, 95% CI: -18, -12). Starting tenofovir also reduced attrition in Zambia (intent-to-treat RD = -1.8% (95% CI: -3.5, -0.1); complier relative risk = 0.74) but not in South Africa (RD = -0.9% (95% CI: -5.9, 4.1); complier relative risk = 0.94). These results highlight the importance of reducing side effects for increasing retention in care, as well as the differences in population impact of policies with heterogeneous treatment effects implemented in different contexts.
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Affiliation(s)
- Alana T Brennan
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts
| | - Jacob Bor
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Gilles Wandeler
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Hans Prozesky
- Division of Infectious Diseases, Department of Medicine, Tygerberg Academic Hospital, University of Stellenbosch, Cape Town, South Africa
| | | | - Robin Wood
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Kathryn Stinson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Frank Tanser
- Africa Health Research Institute, Durban, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Research Department of Infection and Population Health, University College London, London, United Kingdom
| | - Till Bärnighausen
- Africa Health Research Institute, Durban, South Africa
- Institute of Public Health, School of Medicine, Heidelberg University, Heidelberg, Germany
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa
- Division of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Izukanji Sikazwe
- Center for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Arianna Zanolini
- Center for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Matthew P Fox
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts
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Robertson MM, Waldron L, Robbins RS, Chamberlin S, Penrose K, Levin B, Kulkarni S, Braunstein SL, Irvine MK, Nash D. Using Registry Data to Construct a Comparison Group for Programmatic Effectiveness Evaluation: The New York City HIV Care Coordination Program. Am J Epidemiol 2018; 187:1980-1989. [PMID: 29788080 DOI: 10.1093/aje/kwy103] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 05/02/2018] [Indexed: 12/25/2022] Open
Abstract
Many nonrandomized interventions rely upon a pre-post design to evaluate effectiveness. Such designs cannot account for events external to the intervention that may produce the outcome. We describe a method to construct a surveillance registry-based comparison group, which allows for estimating the effectiveness of the intervention while controlling for secular trends in the outcome of interest. Using data from the population-based, human immunodeficiency virus Surveillance Registry in New York City, we created a contemporaneous comparison group for persons enrolled in the New York City human immunodeficiency virus Care Coordination Program (CCP) from December 2009 to March 2013. Inclusion in the Registry-based (non-CCP) comparison group required meeting CCP eligibility criteria. To control for secular trends in the outcome, we randomly assigned persons in the non-CCP, Registry-based comparison group a pseudoenrollment date such that the distribution of pseudoenrollment dates matched the distribution of enrollment dates among CCP enrollees. We then matched CCP to non-CCP persons on propensity for enrollment in the CCP, enrollment dates, and baseline viral load. Registry-based comparison group estimates were attenuated relative to pre-post estimates of program effectiveness. These methods have broad applicability for observational intervention effectiveness studies and programmatic evaluations for conditions with surveillance registries.
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Affiliation(s)
- McKaylee M Robertson
- Institute for Implementation Science in Population Health, Graduate School of Public Health and Health Policy, City University of New York, New York, New York
| | - Levi Waldron
- Institute for Implementation Science in Population Health, Graduate School of Public Health and Health Policy, City University of New York, New York, New York
| | - Rebekkah S Robbins
- Bureau of HIV/AIDS Prevention and Control, New York City Department of Health and Mental Hygiene, New York, New York
| | - Stephanie Chamberlin
- Bureau of HIV/AIDS Prevention and Control, New York City Department of Health and Mental Hygiene, New York, New York
| | - Kate Penrose
- Bureau of HIV/AIDS Prevention and Control, New York City Department of Health and Mental Hygiene, New York, New York
| | - Bruce Levin
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - Sarah Kulkarni
- Institute for Implementation Science in Population Health, Graduate School of Public Health and Health Policy, City University of New York, New York, New York
| | - Sarah L Braunstein
- Bureau of HIV/AIDS Prevention and Control, New York City Department of Health and Mental Hygiene, New York, New York
| | - Mary K Irvine
- Bureau of HIV/AIDS Prevention and Control, New York City Department of Health and Mental Hygiene, New York, New York
| | - Denis Nash
- Institute for Implementation Science in Population Health, Graduate School of Public Health and Health Policy, City University of New York, New York, New York
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Mody A, Sikazwe I, Czaicki NL, Wa Mwanza M, Savory T, Sikombe K, Beres LK, Somwe P, Roy M, Pry JM, Padian N, Bolton-Moore C, Holmes CB, Geng EH. Estimating the real-world effects of expanding antiretroviral treatment eligibility: Evidence from a regression discontinuity analysis in Zambia. PLoS Med 2018; 15:e1002574. [PMID: 29870531 PMCID: PMC5988277 DOI: 10.1371/journal.pmed.1002574] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/27/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Although randomized trials have established the clinical efficacy of treating all persons living with HIV (PLWHs), expanding treatment eligibility in the real world may have additional behavioral effects (e.g., changes in retention) or lead to unintended consequences (e.g., crowding out sicker patients owing to increased patient volume). Using a regression discontinuity design, we sought to assess the effects of a previous change to Zambia's HIV treatment guidelines increasing the threshold for treatment eligibility from 350 to 500 cells/μL to anticipate effects of current global efforts to treat all PLWHs. METHODS AND FINDINGS We analyzed antiretroviral therapy (ART)-naïve adults who newly enrolled in HIV care in a network of 64 clinics operated by the Zambian Ministry of Health and supported by the Centre for Infectious Disease Research in Zambia (CIDRZ). Patients were restricted to those enrolling in a narrow window around the April 1, 2014 change to Zambian HIV treatment guidelines that raised the CD4 threshold for treatment from 350 to 500 cells/μL (i.e., August 1, 2013, to November 1, 2014). Clinical and sociodemographic data were obtained from an electronic medical record system used in routine care. We used a regression discontinuity design to estimate the effects of this change in treatment eligibility on ART initiation within 3 months of enrollment, retention in care at 6 months (defined as clinic attendance between 3 and 9 months after enrollment), and a composite of both ART initiation by 3 months and retention in care at 6 months in all new enrollees. We also performed an instrumental variable (IV) analysis to quantify the effect of actually initiating ART because of this guideline change on retention. Overall, 34,857 ART-naïve patients (39.1% male, median age 34 years [IQR 28-41], median CD4 268 cells/μL [IQR 134-430]) newly enrolled in HIV care during this period; 23,036 were analyzed after excluding patients around the threshold to allow for clinic-to-clinic variations in actual guideline uptake. In all newly enrolling patients, expanding the CD4 threshold for treatment from 350 to 500 cells/μL was associated with a 13.6% absolute increase in ART initiation within 3 months of enrollment (95% CI, 11.1%-16.2%), a 4.1% absolute increase in retention at 6 months (95% CI, 1.6%-6.7%), and a 10.8% absolute increase in the percentage of patients who initiated ART by 3 months and were retained at six months (95% CI, 8.1%-13.5%). These effects were greatest in patients who would have become newly eligible for ART with the change in guidelines: a 43.7% increase in ART initiation by 3 months (95% CI, 37.5%-49.9%), 13.6% increase in retention at six months (95% CI, 7.3%-20.0%), and a 35.5% increase in the percentage of patients on ART at 3 months and still in care at 6 months [95% CI, 29.2%-41.9%). We did not observe decreases in ART initiation or retention in patients not directly targeted by the guideline change. An IV analysis found that initiating ART in response to the guideline change led to a 37.9% (95% CI, 28.8%-46.9%) absolute increase in retention in care. Limitations of this study include uncertain generalizability under newer models of care, lack of laboratory data (e.g., viral load), inability to account for earlier stages in the HIV care cascade (e.g., HIV testing and linkage), and potential for misclassification of eligibility status or outcome. CONCLUSIONS In this study, guidelines raising the CD4 threshold for treatment from 350 to 500 cells/μL were associated with a rapid rise in ART initiation as well as enhanced retention among newly treatment-eligible patients, without negatively impacting patients with lower CD4 levels. These data suggest that health systems in Zambia and other high-prevalence settings could substantially enhance engagement even among those with high CD4 levels (i.e., above 500 cells/μL) by expanding treatment without undermining existing care standards.
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Affiliation(s)
- Aaloke Mody
- Division of HIV, ID and Global Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, United States of America
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Nancy L. Czaicki
- Division of HIV, ID and Global Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, United States of America
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Mwanza Wa Mwanza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Theodora Savory
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | - Laura K. Beres
- Department of International Health, Johns Hopkins University School of Public Health, Baltimore, Maryland, United States of America
| | - Paul Somwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Monika Roy
- Division of HIV, ID and Global Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, United States of America
| | - Jake M. Pry
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Public Health, University of California, Davis, Davis, California, United States of America
| | - Nancy Padian
- Division of Epidemiology, University of California, Berkeley, Berkeley, California, United States of America
| | - Carolyn Bolton-Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, University of Alabama, Birmingham, Alabama, United States of America
| | - Charles B. Holmes
- Department of International Health, Johns Hopkins University School of Public Health, Baltimore, Maryland, United States of America
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Elvin H. Geng
- Division of HIV, ID and Global Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, United States of America
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McGovern ME, Herbst K, Tanser F, Mutevedzi T, Canning D, Gareta D, Pillay D, Bärnighausen T. Do gifts increase consent to home-based HIV testing? A difference-in-differences study in rural KwaZulu-Natal, South Africa. Int J Epidemiol 2018; 45:2100-2109. [PMID: 27940483 PMCID: PMC5841834 DOI: 10.1093/ije/dyw122] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2016] [Indexed: 11/12/2022] Open
Abstract
Background Despite the importance of HIV testing for controlling the HIV epidemic, testing rates remain low. Efforts to scale up testing coverage and frequency in hard-to-reach and at-risk populations commonly focus on home-based HIV testing. This study evaluates the effect of a gift (a US$5 food voucher for families) on consent rates for home-based HIV testing. Methods We use data on 18 478 individuals (6 418 men and 12 060 women) who were successfully contacted to participate in the 2009 and 2010 population-based HIV surveillance carried out by the Wellcome Trust's Africa Health Research Institute in rural KwaZulu-Natal, South Africa. Of 18 478 potential participants contacted in both years, 35% (6 518) consented to test in 2009, and 41% (7 533) consented to test in 2010. Our quasi-experimental difference-in-differences approach controls for unobserved confounding in estimating the causal effect of the intervention on HIV-testing consent rates. Results Allocation of the gift to a family in 2010 increased the probability of family members consenting to test in the same year by 25 percentage points [95% confidence interval (CI) 21-30 percentage points; P < 0.001]. The intervention effect persisted, slightly attenuated, in the year following the intervention (2011). Conclusions In HIV hyperendemic settings, a gift can be highly effective at increasing consent rates for home-based HIV testing. Given the importance of HIV testing for treatment uptake and individual health, as well as for HIV treatment-as-prevention strategies and for monitoring the population impact of the HIV response, gifts should be considered as a supportive intervention for HIV-testing initiatives where consent rates have been low.
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Affiliation(s)
- Mark E McGovern
- CHaRMS - Centre for Health Research at the Management School, Queen's University Belfast, Northern Ireland.,Africa Health Research Institute, Mtubatuba, South Africa
| | - Kobus Herbst
- Africa Health Research Institute, Mtubatuba, South Africa
| | - Frank Tanser
- Africa Health Research Institute, Mtubatuba, South Africa.,School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | | | - David Canning
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston 02115, MA, USA.,Harvard Center for Population and Development Studies, Cambridge 02144, MA, USA
| | - Dickman Gareta
- Africa Health Research Institute, Mtubatuba, South Africa
| | - Deenan Pillay
- Africa Health Research Institute, Mtubatuba, South Africa
| | - Till Bärnighausen
- Africa Health Research Institute, Mtubatuba, South Africa.,Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston 02115, MA, USA.,Harvard Center for Population and Development Studies, Cambridge 02144, MA, USA.,Institute of Public Health, University of Heidelberg, Heidelberg, Germany
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Bor J, Fox MP, Rosen S, Venkataramani A, Tanser F, Pillay D, Bärnighausen T. Treatment eligibility and retention in clinical HIV care: A regression discontinuity study in South Africa. PLoS Med 2017; 14:e1002463. [PMID: 29182641 PMCID: PMC5705070 DOI: 10.1371/journal.pmed.1002463] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 10/25/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Loss to follow-up is high among HIV patients not yet receiving antiretroviral therapy (ART). Clinical trials have demonstrated the clinical efficacy of early ART; however, these trials may miss an important real-world consequence of providing ART at diagnosis: its impact on retention in care. METHODS AND FINDINGS We examined the effect of immediate (versus deferred) ART on retention in care using a regression discontinuity design. The analysis included all patients (N = 11,306) entering clinical HIV care with a first CD4 count between 12 August 2011 and 31 December 2012 in a public-sector HIV care and treatment program in rural South Africa. Patients were assigned to immediate versus deferred ART eligibility, as determined by a CD4 count < 350 cells/μl, per South African national guidelines. Patients referred to pre-ART care were instructed to return every 6 months for CD4 monitoring. Patients initiated on ART were instructed to return at 6 and 12 months post-initiation and annually thereafter for CD4 and viral load monitoring. We assessed retention in HIV care at 12 months, as measured by the presence of a clinic visit, lab test, or ART initiation 6 to 18 months after initial CD4 test. Differences in retention between patients presenting with CD4 counts just above versus just below the 350-cells/μl threshold were estimated using local linear regression models with a data-driven bandwidth and with the algorithm for selecting the bandwidth chosen ex ante. Among patients with CD4 counts close to the 350-cells/μl threshold, having an ART-eligible CD4 count (<350 cells/μl) was associated with higher 12-month retention than not having an ART-eligible CD4 count (50% versus 32%), an intention-to-treat risk difference of 18 percentage points (95% CI 11 to 23; p < 0.001). The decision to start ART was determined by CD4 count for one in four patients (25%) presenting close to the eligibility threshold (95% CI 20% to 31%; p < 0.001). In this subpopulation, having an ART-eligible CD4 count was associated with higher 12-month retention than not having an ART-eligible CD4 count (91% versus 21%), a complier causal risk difference of 70 percentage points (95% CI 42 to 98; p < 0.001). The major limitations of the study are the potential for limited generalizability, the potential for outcome misclassification, and the absence of data on longer-term health outcomes. CONCLUSIONS Patients who were eligible for immediate ART had dramatically higher retention in HIV care than patients who just missed the CD4-count eligibility cutoff. The clinical and population health benefits of offering immediate ART regardless of CD4 count may be larger than suggested by clinical trials.
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Affiliation(s)
- Jacob Bor
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Africa Health Research Institute, Somkhele, South Africa
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Matthew P. Fox
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Atheendar Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Frank Tanser
- Africa Health Research Institute, Somkhele, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, South Africa
- Research Department of Infection & Population Health, University College London, London, United Kingdom
| | - Deenan Pillay
- Africa Health Research Institute, Somkhele, South Africa
- Department of Virology, University College London, London, United Kingdom
| | - Till Bärnighausen
- Africa Health Research Institute, Somkhele, South Africa
- Research Department of Infection & Population Health, University College London, London, United Kingdom
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
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Bärnighausen T, Tugwell P, Røttingen JA, Shemilt I, Rockers P, Geldsetzer P, Lavis J, Grimshaw J, Daniels K, Brown A, Bor J, Tanner J, Rashidian A, Barreto M, Vollmer S, Atun R. Quasi-experimental study designs series—paper 4: uses and value. J Clin Epidemiol 2017; 89:21-29. [DOI: 10.1016/j.jclinepi.2017.03.012] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 03/18/2017] [Accepted: 03/21/2017] [Indexed: 01/20/2023]
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Miller RL, Boyer CB, Chiaramonte D, Lindeman P, Chutuape K, Cooper-Walker B, Kapogiannis BG, Wilson CM, Fortenberry JD. Evaluating Testing Strategies for Identifying Youths With HIV Infection and Linking Youths to Biomedical and Other Prevention Services. JAMA Pediatr 2017; 171:532-537. [PMID: 28418524 PMCID: PMC5540008 DOI: 10.1001/jamapediatrics.2017.0105] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
IMPORTANCE Most human immunodeficiency virus (HIV)-infected youths are unaware of their serostatus (approximately 60%) and therefore not linked to HIV medical or prevention services. The need to identify promising and scalable approaches to promote uptake of HIV testing among youths at risk is critical. OBJECTIVE To evaluate a multisite HIV testing program designed to encourage localized HIV testing programs focused on self-identified sexual minority males and to link youths to appropriate prevention services after receipt of their test results. DESIGN, SETTING, AND PARTICIPANTS Testing strategies were evaluated using an observational design during a 9-month period (June 1, 2015, through February 28, 2016). Testing strategies were implemented by 12 adolescent medicine HIV primary care programs and included targeted testing, universal testing, or a combination. Data were collected from local youth at high risk of HIV infection and, specifically, sexual minority males of color. MAIN OUTCOMES AND MEASURES Proportion of sexual minority males and sexual minority males of color tested, proportion of previously undiagnosed HIV-positive youths identified, and rates of linkage to prevention services. RESULTS A total of 3301 youths underwent HIV testing. Overall, 35 (3.6%) of those who underwent universal testing in primary care clinical settings, such as emergency departments and community health centers, were sexual minority males (35 [3.6%] were males of color) compared with 236 (46.7%) (201 [39.8%] were males of color) who were tested through targeted testing and 693 (37.8%) (503 [27.4%] were males of color) through combination efforts. Identification of new HIV-positive cases varied by strategy: 1 (0.1%) via universal testing, 39 (2.1%) through combination testing, and 16 (3.2%) through targeted testing. However, when targeted tests were separated from universal testing results for sites using a combined strategy, the rate of newly identified HIV-positive cases identified through universal testing decreased to 1 (0.1%). Rates of new HIV-positive cases identified through targeted testing increased to 49 (6.3%). Youths who tested through targeted testing (416 [85.1%]) were more likely to link successfully to local HIV prevention services, including preexposure prophylaxis, compared with those who underwent universal testing (328 [34.1%]). CONCLUSIONS AND RELEVANCE The findings suggest that community-based targeted approaches to HIV testing are more effective than universal screening for reaching young sexual minority males (especially males of color), identifying previously undiagnosed HIV-positive youths, and linking HIV-negative youths to relevant prevention services. Targeted, community-based HIV testing strategies hold promise as a scalable and effective means to identify high-risk youths who are unaware of their HIV status.
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Affiliation(s)
- Robin Lin Miller
- Department of Psychology, Michigan State University, East Lansing
| | - Cherrie B. Boyer
- Department of Pediatrics, University of California, San Francisco
| | | | - Peter Lindeman
- Department of Psychology, Michigan State University, East Lansing
| | - Kate Chutuape
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
| | | | - Bill G. Kapogiannis
- Maternal and Pediatric Infectious Disease, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, Maryland
| | - Craig M. Wilson
- Department of Epidemiology, University of Alabama, Birmingham
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10
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Williams EC, Hahn JA, Saitz R, Bryant K, Lira MC, Samet JH. Alcohol Use and Human Immunodeficiency Virus (HIV) Infection: Current Knowledge, Implications, and Future Directions. Alcohol Clin Exp Res 2016; 40:2056-2072. [PMID: 27696523 PMCID: PMC5119641 DOI: 10.1111/acer.13204] [Citation(s) in RCA: 202] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 07/28/2016] [Indexed: 12/20/2022]
Abstract
Alcohol use is common among people living with human immunodeficiency virus (HIV). In this narrative review, we describe literature regarding alcohol's impact on transmission, care, coinfections, and comorbidities that are common among people living with HIV (PLWH), as well as literature regarding interventions to address alcohol use and its influences among PLWH. This narrative review identifies alcohol use as a risk factor for HIV transmission, as well as a factor impacting the clinical manifestations and management of HIV. Alcohol use appears to have additive and potentially synergistic effects on common HIV-related comorbidities. We find that interventions to modify drinking and improve HIV-related risks and outcomes have had limited success to date, and we recommend research in several areas. Consistent with Office of AIDS Research/National Institutes of Health priorities, we suggest research to better understand how and at what levels alcohol influences comorbid conditions among PLWH, to elucidate the mechanisms by which alcohol use is impacting comorbidities, and to understand whether decreases in alcohol use improve HIV-relevant outcomes. This should include studies regarding whether state-of-the-art medications used to treat common coinfections are safe for PLWH who drink alcohol. We recommend that future research among PLWH include validated self-report measures of alcohol use and/or biological measurements, ideally both. Additionally, subgroup variation in associations should be identified to ensure that the risks of particularly vulnerable populations are understood. This body of research should serve as a foundation for a next generation of intervention studies to address alcohol use from transmission to treatment of HIV. Intervention studies should inform implementation efforts to improve provision of alcohol-related interventions and treatments for PLWH in healthcare settings. By making further progress on understanding how alcohol use affects PLWH in the era of HIV as a chronic condition, this research should inform how we can mitigate transmission, achieve viral suppression, and avoid exacerbating common comorbidities of HIV and alcohol use and make progress toward the 90-90-90 goals for engagement in the HIV treatment cascade.
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Affiliation(s)
- Emily C Williams
- Veterans Health Administration (VA) Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington.,Department of Health Services, University of Washington, Seattle, Washington
| | - Judith A Hahn
- Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Richard Saitz
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts.,Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Kendall Bryant
- Consortiums for HIV/AIDS and Alcohol Research Translation (CHAART) National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland
| | - Marlene C Lira
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Jeffrey H Samet
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts. .,Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts.
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11
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Oldenburg CE, Moscoe E, Bärnighausen T. Regression Discontinuity for Causal Effect Estimation in Epidemiology. CURR EPIDEMIOL REP 2016; 3:233-241. [PMID: 27547695 PMCID: PMC4978750 DOI: 10.1007/s40471-016-0080-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Regression discontinuity analyses can generate estimates of the causal effects of an exposure when a continuously measured variable is used to assign the exposure to individuals based on a threshold rule. Individuals just above the threshold are expected to be similar in their distribution of measured and unmeasured baseline covariates to individuals just below the threshold, resulting in exchangeability. At the threshold exchangeability is guaranteed if there is random variation in the continuous assignment variable, e.g., due to random measurement error. Under exchangeability, causal effects can be identified at the threshold. The regression discontinuity intention-to-treat (RD-ITT) effect on an outcome can be estimated as the difference in the outcome between individuals just above (or below) versus just below (or above) the threshold. This effect is analogous to the ITT effect in a randomized controlled trial. Instrumental variable methods can be used to estimate the effect of exposure itself utilizing the threshold as the instrument. We review the recent epidemiologic literature reporting regression discontinuity studies and find that while regression discontinuity designs are beginning to be utilized in a variety of applications in epidemiology, they are still relatively rare, and analytic and reporting practices vary. Regression discontinuity has the potential to greatly contribute to the evidence base in epidemiology, in particular on the real-life and long-term effects and side-effects of medical treatments that are provided based on threshold rules - such as treatments for low birth weight, hypertension or diabetes.
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Affiliation(s)
- Catherine E. Oldenburg
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA USA
| | - Ellen Moscoe
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA USA
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA USA
- Africa Centre for Population Health, PO Box 198, 3935 Mtubatuba, South Africa
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
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12
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Abstract
Clinical decisions are often driven by decision rules premised around specific thresholds. Specific laboratory measurements, dates, or policy eligibility criteria create cut-offs at which people become eligible for certain treatments or health services. The regression discontinuity design is a statistical approach that utilizes threshold based decision making to derive compelling causal estimates of different interventions. In this review, we argue that regression discontinuity is underutilized in healthcare research despite the ubiquity of threshold based decision making as well as the design’s simplicity and transparency. Moreover, regression discontinuity provides evidence of “real world” therapeutic and policy effects, circumventing a major limitation of randomized controlled trials. We discuss the implementation, strengths, and weaknesses of regression discontinuity and review several examples from clinical medicine, public health, and health policy. We conclude by discussing the wide array of open research questions for which regression discontinuity stands to provide meaningful insights to clinicians and policymakers
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Affiliation(s)
- Atheendar S Venkataramani
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; and Harvard Center for Population and Development Studies, Cambridge, MA, USA
| | - Jacob Bor
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA; Department of Medicine, Massachusetts General Hospital; and National Bureau of Economic Research, Cambridge, MA, USA
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