1
|
Lailulo Y, Kitenge M, Jaffer S, Aluko O, Nyasulu PS. Factors associated with antiretroviral treatment failure among people living with HIV on antiretroviral therapy in resource-poor settings: a systematic review and metaanalysis. Syst Rev 2020; 9:292. [PMID: 33308294 PMCID: PMC7733304 DOI: 10.1186/s13643-020-01524-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 11/08/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Despite the increase in the number of people accessing antiretroviral therapy (ART), there is limited data regarding treatment failure and its related factors among HIV-positive individuals enrolled in HIV care in resource-poor settings. This review aimed to identify factors associated with antiretroviral treatment failure among individuals living with HIV on ART in resource-poor settings. METHODS We conducted a comprehensive search on MEDLINE (PubMed), Excerpta Medica Database (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL), World Health Organization's (WHO's) library database, and Latin American and Caribbean Health Sciences Literature (LILACS). We included observational studies (cohort, case-control, and cross-sectional studies) where adolescents and adults living with HIV were on antiretroviral treatment regardless of the ART regimen. The primary outcomes of interest were immunological, virological, and clinical failure. Some of the secondary outcomes were mm3 opportunistic infections, WHO clinical stage, and socio-demographic factors. We screened titles, abstracts, and the full texts of relevant articles in duplicate. Disagreements were resolved by consensus. We analyzed the data by doing a meta-analysis to pool the results for each outcome of interest. RESULTS Antiretroviral failure was nearly 6 times higher among patients who had poor adherence to treatment as compared to patients with a good treatment adherence (OR = 5.90, 95% CI 3.50, 9.94, moderate strength of evidence). The likelihood of the treatment failure was almost 5 times higher among patients with CD4 < 200 cells/mm3 compared to those with CD4 ≥ 200 CD4 cells/mm3 (OR = 4.82, 95% CI 2.44, 9.52, low strength of evidence). This result shows that poor adherence and CD4 count below < 200 cells/mm3 are significantly associated with treatment failure among HIV-positive patients on ART in a resource-limited setting. CONCLUSION This review highlights that low CD4 counts and poor adherence to ART were associated to ART treatment failure. There is a need for healthcare workers and HIV program implementers to focus on patients who have these characteristics in order to prevent ART treatment failure. SYSTEMATIC REVIEW REGISTRATION The systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO), registration number: 2019 CRD42019136538.
Collapse
Affiliation(s)
- Yishak Lailulo
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Marcel Kitenge
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Médecins Sans Frontières (MSF), Eshowe, KwaZulu Natal South Africa
| | - Shahista Jaffer
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Omololu Aluko
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Peter Suwirakwenda Nyasulu
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
2
|
Point-of-Care HIV Viral Load Testing: an Essential Tool for a Sustainable Global HIV/AIDS Response. Clin Microbiol Rev 2019; 32:32/3/e00097-18. [PMID: 31092508 DOI: 10.1128/cmr.00097-18] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The global public health community has set ambitious treatment targets to end the HIV/AIDS pandemic. With the notable absence of a cure, the goal of HIV treatment is to achieve sustained suppression of an HIV viral load, which allows for immunological recovery and reduces the risk of onward HIV transmission. Monitoring HIV viral load in people living with HIV is therefore central to maintaining effective individual antiretroviral therapy as well as monitoring progress toward achieving population targets for viral suppression. The capacity for laboratory-based HIV viral load testing has increased rapidly in low- and middle-income countries, but implementation of universal viral load monitoring is still hindered by several barriers and delays. New devices for point-of-care HIV viral load testing may be used near patients to improve HIV management by reducing the turnaround time for clinical test results. The implementation of near-patient testing using these new and emerging technologies may be an essential tool for ensuring a sustainable response that will ultimately enable an end to the HIV/AIDS pandemic. In this report, we review the current and emerging technology, the evidence for decentralized viral load monitoring by non-laboratory health care workers, and the additional considerations for expanding point-of-care HIV viral load testing.
Collapse
|
3
|
Sharma A, Prinja S, Sharma A, Gupta A, Arora SK. Cost of antiretroviral treatment for HIV patients in two centres of North India. Int J STD AIDS 2019; 30:769-778. [PMID: 31081489 DOI: 10.1177/0956462419839852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There is paucity of evidence on cost of antiretroviral therapy (ART) delivered through the public sector in India. Moreover, the Government of India is considering changing the criteria for introduction of ART to HIV patients, which is likely to have significant economic implications. In this paper, we assess the health system cost of ART services at two levels of health care delivery. Bottom-up costing was used to collect data on capital and recurrent resources consumed over a period of one year (April 2014–March 2015). Capital costs were annualized and shared costs apportioned to calculate annual and unit costs of providing ART care. Sensitivity analysis was undertaken to measure the extent of uncertainty in input prices. The annual per capita cost of ART therapy was INR 48,975 (USD738) in the Centre of Excellence (COE) and INR 24,954 (USD376) in the ART centre. Drugs contributed around 70% and 65% of total annual cost, followed by human resource (19% each) and capital cost (7%; 12%) in COE and ART centres, respectively. These provide a comprehensive assessment of the cost of ART care in India. The study estimates could be used for planning of services, as well as undertaking further cost-effectiveness studies.
Collapse
Affiliation(s)
- Atul Sharma
- 1 School of Public health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shankar Prinja
- 1 School of Public health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- 2 Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aditi Gupta
- 1 School of Public health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil K Arora
- 3 Department of Immunopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
4
|
Kimmel AD, Bono RS, Keiser O, Sinayobye JD, Estill J, Mujwara D, Tymejczyk O, Nash D. Mathematical modelling to inform 'treat all' implementation in sub-Saharan Africa: a scoping review. J Virus Erad 2018; 4:47-54. [PMID: 30515314 PMCID: PMC6248854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE Despite widespread uptake, only half of sub-Saharan African countries have fully implemented the World Health Organization's 'treat all' policy, hindering achievement of global HIV targets. We examined literature on mathematical modelling studies that sought to inform scale-up and implementation of 'treat all' in sub-Saharan Africa. METHODS We conducted a scoping review, a research synthesis to assess emerging evidence and identify gaps, of peer-reviewed literature, extracting study characteristics on 'treat all' policies and assumptions, setting, key populations, outcomes and findings. Studies were narratively summarised and potential gaps characterised. RESULTS We identified 16 studies examining 'treat all' alone (n=12) or with expanded testing (n=7) and/or care continuum improvements (n=6). Twelve studies examined 'treat all' for Southern African countries, while none did so for Central Africa. Four included the role of resistance; one evaluated any key population. A range of health and economic outcomes were reported, although fewer studies formally assessed budget impact. Fourteen studies involved co-authors with any in-country affiliation; one study also had co-authors with local government affiliation. Overall, 'treat all' improves health outcomes and is cost-effective compared to deferred HIV treatment; 'treat all' with expanded testing or care continuum improvements may provide further health benefits. However, studies generally used optimistic assumptions about the implementation of expanded testing or care continuum improvements. CONCLUSIONS The modelling literature demonstrates improved health and economic benefits of 'treat all'. Using mathematical modelling to inform real-world implementation of 'treat all' requires realistic assumptions about expanded testing and care continuum interventions across a wide range of settings and populations.
Collapse
Affiliation(s)
- April D Kimmel
- Department of Health Behavior and Policy, Virginia Commonwealth University,
Richmond VA,
USA
| | - Rose S Bono
- Department of Health Behavior and Policy, Virginia Commonwealth University,
Richmond VA,
USA
| | - Olivia Keiser
- Institute of Global Health, University of Geneva,
Switzerland
| | - Jean D Sinayobye
- Research and Clinical Education Division, Rwanda Military Hospital,
Kigali,
Rwanda
| | | | - Deo Mujwara
- Department of Health Behavior and Policy, Virginia Commonwealth University,
Richmond VA,
USA
| | | | | |
Collapse
|
5
|
Kimmel AD, Bono RS, Keiser O, Sinayobye JD, Estill J, Mujwara D, Tymejczyk O, Nash D. Mathematical modelling to inform ‘treat all’ implementation in sub-Saharan Africa: a scoping review. J Virus Erad 2018. [DOI: 10.1016/s2055-6640(20)30345-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
|
6
|
Freedberg KA, Kumarasamy N, Borre ED, Ross EL, Mayer KH, Losina E, Swaminathan S, Flanigan TP, Walensky RP. Clinical Benefits and Cost-Effectiveness of Laboratory Monitoring Strategies to Guide Antiretroviral Treatment Switching in India. AIDS Res Hum Retroviruses 2018; 34:486-497. [PMID: 29620932 PMCID: PMC5994680 DOI: 10.1089/aid.2017.0258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Current Indian guidelines recommend twice-annual CD4 testing to monitor first-line antiretroviral therapy (ART), with a plasma HIV RNA test to confirm failure if CD4 declines, which would prompt a switch to second-line ART. We used a mathematical model to assess the clinical benefits and cost-effectiveness of alternative laboratory monitoring strategies in India. We simulated a cohort of HIV-infected patients initiating first-line ART and compared 11 strategies with combinations of CD4 and HIV RNA testing at varying frequencies. We included adaptive strategies that reduce the frequency of tests after 1 year from 6 to 12 months for virologically suppressed patients. We projected life expectancy, time on failed first-line ART, cumulative 10-year HIV transmissions, lifetime cost (2014 US dollars), and incremental cost-effectiveness ratios (ICERs). We defined strategies as cost-effective if their ICER was <1 × the Indian per capita gross domestic product (GDP, $1,600). We found that the current Indian guidelines resulted in a per person life expectancy (from mean age 37) of 150.2 months and a per person cost of $2,680. Adding annual HIV RNA testing increased survival by ∼8 months; adaptive strategies were less expensive than similar nonadaptive strategies with similar life expectancy. The most effective strategy with an ICER <1 × GDP was the adaptive HIV RNA strategy (ICER $840/year). Cumulative 10-year transmissions decreased from 27.2/1,000 person-years with standard-of-care to 20.9/1,000 person-years with adaptive HIV RNA testing. In India, routine HIV RNA monitoring of patients on first-line ART would increase life expectancy, decrease transmissions, be cost-effective, and should be implemented.
Collapse
Affiliation(s)
- Kenneth A. Freedberg
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
- Harvard University Center for AIDS Research, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | | | - Ethan D. Borre
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Eric L. Ross
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Kenneth H. Mayer
- Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Fenway Health, Boston, Massachusetts
| | - Elena Losina
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
- Harvard University Center for AIDS Research, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Timothy P. Flanigan
- Division of Infectious Diseases, Miriam Hospital, Brown Medical School, Providence, Rhode Island
| | - Rochelle P. Walensky
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
- Harvard University Center for AIDS Research, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
7
|
McCreesh N, Andrianakis I, Nsubuga RN, Strong M, Vernon I, McKinley TJ, Oakley JE, Goldstein M, Hayes R, White RG. Choice of time horizon critical in estimating costs and effects of changes to HIV programmes. PLoS One 2018; 13:e0196480. [PMID: 29768457 PMCID: PMC5955498 DOI: 10.1371/journal.pone.0196480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 04/13/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Uganda changed its antiretroviral therapy guidelines in 2014, increasing the CD4 threshold for antiretroviral therapy initiation from 350 cells/μl to 500 cells/μl. We investigate what effect this change in policy is likely to have on HIV incidence, morbidity, and programme costs, and estimate the cost-effectiveness of the change over different time horizons. METHODS We used a complex individual-based model of HIV transmission and antiretroviral therapy scale-up in Uganda. 100 model fits were generated by fitting the model to 51 demographic, sexual behaviour, and epidemiological calibration targets, varying 96 input parameters, using history matching with model emulation. An additional 19 cost and disability weight parameters were varied during the analysis of the model results. For each model fit, the model was run to 2030, with and without the change in threshold to 500 cells/μl. RESULTS The change in threshold led to a 9.7% (90% plausible range: 4.3%-15.0%) reduction in incidence in 2030, and averted 278,944 (118,452-502,790) DALYs, at a total cost of $28M (-$142M to +$195M). The cost per disability adjusted life year (DALY) averted fell over time, from $3238 (-$125 to +$29,969) in 2014 to $100 (-$499 to +$785) in 2030. The change in threshold was cost-effective (cost <3×Uganda's per capita GDP per DALY averted) by 2018, and highly cost-effective (cost CONCLUSIONS Model results suggest that the change in threshold is unlikely to have been cost-effective to date, but is likely to be highly cost-effective in Uganda by 2030. The time horizon needs to be chosen carefully when projecting intervention effects. Large amounts of uncertainty in our results demonstrates the need to comprehensively incorporate uncertainties in model parameterisation.
Collapse
Affiliation(s)
- Nicky McCreesh
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | - Mark Strong
- Sheffield University, Sheffield, United Kingdom
| | - Ian Vernon
- Durham University, Durham, United Kingdom
| | | | | | | | - Richard Hayes
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Richard G. White
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| |
Collapse
|
8
|
Estill J, Kerr CC, Blaser N, Salazar-Vizcaya L, Tenthani L, Wilson DP, Keiser O. The Effect of Monitoring Viral Load and Tracing Patients Lost to Follow-up on the Course of the HIV Epidemic in Malawi: A Mathematical Model. Open Forum Infect Dis 2018; 5:ofy092. [PMID: 29977952 PMCID: PMC6007424 DOI: 10.1093/ofid/ofy092] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 04/24/2018] [Indexed: 12/01/2022] Open
Abstract
Background Antiretroviral therapy (ART) reduces HIV transmission, but treated patients may again become infectious. We used a mathematical model to determine whether ART as prevention is more effective if viral load (VL) is routinely monitored and patients lost to follow-up (LTFU) traced. Methods We simulated ART cohorts to parameterize a deterministic transmission model calibrated to Malawi. We investigated the following strategies for improving treatment and retention: monitoring VL every 12 or 24 months, tracing patients LTFU, or a generic strategy leading to uninterrupted treatment. We tested 3 scenarios, where ART scale-up continues at current (Universal ART), reduced (Failed scale-up), or accelerated speed (Test&Treat). Results In the Universal ART scenario, between 2017 and 2020 (2050), monitoring VL every 24 months prevented 0.5% (0.9%), monitoring every 12 months prevented 0.8% (1.4%), tracing prevented 0.3% (0.5%), and uninterrupted treatment prevented 5.5% (9.9%) of HIV infections. Failed scale-up resulted in 25% more infections than the Universal ART scenarios, whereas Test&Treat resulted in 7%–8% less. Conclusions Test&Treat reduces transmission of HIV, despite individual cases of treatment failure and ART interruption. Whereas viral load monitoring and tracing have only a minor impact on transmission, interventions that aim to minimize treatment interruptions can further increase the preventive effect of ART.
Collapse
Affiliation(s)
- Janne Estill
- Institute of Global Health, University of Geneva, Geneva, Switzerland.,Institute of Mathematical Statistics and Actuarial Science (IMSV).,Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Cliff C Kerr
- Burnet Institute, Melbourne, Australia.,School of Physics, University of Sydney, Sydney, Australia
| | - Nello Blaser
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland.,Department of Mathematics, University of Bergen, Bergen, Norway
| | - Luisa Salazar-Vizcaya
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland.,Department of Infectious Diseases, University Hospital Bern, Bern, Switzerland
| | - Lyson Tenthani
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland.,Supporting Operational AIDS Research (Project SOAR), Population Council, Blantyre, Malawi
| | | | - Olivia Keiser
- Institute of Global Health, University of Geneva, Geneva, Switzerland.,Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| |
Collapse
|
9
|
Lesosky M, Glass T, Mukonda E, Hsiao NY, Abrams EJ, Myer L. Optimal timing of viral load monitoring during pregnancy to predict viraemia at delivery in HIV-infected women initiating ART in South Africa: a simulation study. J Int AIDS Soc 2018; 20 Suppl 7. [PMID: 29171179 PMCID: PMC5978661 DOI: 10.1002/jia2.25000] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 08/21/2017] [Indexed: 01/15/2023] Open
Abstract
Introduction HIV viral load (VL) monitoring is a central tool to evaluate ART effectiveness and transmission risk. There is a global movement to expand VL monitoring following recent recommendations from the World Health Organization (WHO), but there has been little research into VL monitoring in pregnant women. We investigated one important question in this area: when and how frequently VL should be monitored in women initiating ART during pregnancy to predict VL at the time of delivery in a simulated South African population. Methods We developed a mathematical model simulating VL from conception through delivery using VL data from the Maternal and Child Health – Antiretroviral Therapy (MCH‐ART) cohort. VL was modelled based on three major compartments: pre‐ART VL, viral decay immediately after ART initiation and viral maintenance (including viral suppression and viraemic episodes). Using this simulation, we examined the performance of various VL monitoring schema in predicting elevated VL at delivery. Results and discussion If WHO guidelines for non‐pregnant adults were used, the majority of HIV‐infected pregnant women (69%) would not receive a VL test during pregnancy. Most models that based VL monitoring in pregnancy on the time elapsed since ART initiation (regardless of gestation) performed poorly (sensitivity <50%); models that based VL measures in pregnancy on the woman's gestation (regardless of time on ART) appeared to perform better overall (sensitivity >60%). Across all permutations, inclusion of pre‐ART VL values had a negligible impact on predictive performance (improving test sensitivity and specificity <6%). Performance of VL monitoring in predicting VL at delivery generally improved at later gestations, with the best performing option a single VL measure at 36 weeks’ gestation. Conclusions Development and evaluation of a novel simulation model suggests that strategies to measure VL relative to gestational age may be more useful than strategies relative to duration on ART, in women initiating ART during pregnancy, supporting better integration of maternal and HIV health services. Testing turnaround times require careful consideration, and point‐of‐care VL testing may be the best approach for measuring VL at delivery. Broadening the scope of this simulation model in the light of current scale up of VL monitoring in high burden countries is important.
Collapse
Affiliation(s)
- Maia Lesosky
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Tracy Glass
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Elton Mukonda
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nei-Yuan Hsiao
- National Health Laboratory Services, Cape Town, South Africa.,Division of Medical Virology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Elaine J Abrams
- ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA.,College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa.,Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
10
|
Kumi Smith M, Jewell BL, Hallett TB, Cohen MS. Treatment of HIV for the Prevention of Transmission in Discordant Couples and at the Population Level. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1075:125-162. [PMID: 30030792 DOI: 10.1007/978-981-13-0484-2_6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The scientific breakthrough proving that antiretroviral therapy (ART) can halt heterosexual HIV transmission came in the form of a landmark clinical trial conducted among serodiscordant couples. Study findings immediately informed global recommendations for the use of treatment as prevention in serodiscordant couples. The extent to which these findings are generalizable to other key populations or to groups exposed to HIV through nonsexual transmission routes (i.e., anal intercourse or unsafe injection of drugs) has since driven a large body of research. This review explores the history of HIV research in serodiscordant couples, the implications for management of couples, subsequent research on treatment as prevention in other key populations, and challenges in community implementation of these strategies.
Collapse
Affiliation(s)
- M Kumi Smith
- University of North Carolina Chapel Hill, Chapel Hill, NC, USA.
| | | | | | - Myron S Cohen
- University of North Carolina Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
11
|
Barnabas RV, Revill P, Tan N, Phillips A. Cost-effectiveness of routine viral load monitoring in low- and middle-income countries: a systematic review. J Int AIDS Soc 2017; 20 Suppl 7:e25006. [PMID: 29171172 PMCID: PMC5978710 DOI: 10.1002/jia2.25006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 08/21/2017] [Accepted: 08/21/2017] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Routine viral load monitoring for HIV-1 management of persons on antiretroviral therapy (ART) has been recommended by the World Health Organization (WHO) to identify treatment failure. However, viral load testing represents a substantial cost in resource constrained health care systems. The central challenge is whether and how viral load monitoring may be delivered such that it maximizes health gains across the population for the costs incurred. We hypothesized that key features of program design and delivery costs drive the cost-effectiveness of viral load monitoring within programs. METHODS We conducted a systematic review of studies on the cost-effectiveness of viral load monitoring in low- and middle-income countries (LMICs). We followed the Cochrane Collaboration guidelines and the PRISMA reporting guidelines. RESULTS AND DISCUSSION We identified 18 studies that evaluated the cost-effectiveness of viral load monitoring in HIV treatment programs. Overall, we identified three key factors that make it more likely for viral load monitoring to be cost-effective: 1) Use of effective, lower cost approaches to viral load monitoring (e.g. use of dried blood spots); 2) Ensuring the pathway to health improvement is established and that viral load results are acted upon; and 3) Viral load results are used to simplify HIV care in patients with viral suppression (i.e. differentiated care, with fewer clinic visits and longer prescriptions). Within the context of differentiated care, viral load monitoring has the potential to double the health gains and be cost saving compared to the current standard (CD4 monitoring). CONCLUSIONS The cost-effectiveness of viral load monitoring critically depends on how it is delivered and the program context. Viral load monitoring as part of differentiated HIV care is likely to be cost-effective. Viral load monitoring in differentiated care programs provides evidence that reduced clinical engagement, where appropriate, is not impacting health outcomes. Introducing viral load monitoring without differentiated care is unlikely to be cost-effective in most settings and results in lost opportunity for health gains through alternative uses of limited resources. As countries scale up differentiated care programs, data on viral suppression outcomes and costs should be collected to evaluate the on-going cost-effectiveness of viral load monitoring as utilized in practice.
Collapse
Affiliation(s)
- Ruanne V Barnabas
- Global Health, Medicine, and EpidemiologyUniversity of WashingtonSeattleWAUSA
| | - Paul Revill
- Center for Health EconomicsUniversity of YorkYorkUnited Kingdom
| | - Nicholas Tan
- Global Health, Medicine, and EpidemiologyUniversity of WashingtonSeattleWAUSA
| | - Andrew Phillips
- Infection and Population HealthUniversity College LondonLondonUnited Kingdom
| |
Collapse
|
12
|
Gwadz MV, Collins LM, Cleland CM, Leonard NR, Wilton L, Gandhi M, Scott Braithwaite R, Perlman DC, Kutnick A, Ritchie AS. Using the multiphase optimization strategy (MOST) to optimize an HIV care continuum intervention for vulnerable populations: a study protocol. BMC Public Health 2017; 17:383. [PMID: 28472928 PMCID: PMC5418718 DOI: 10.1186/s12889-017-4279-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 04/21/2017] [Indexed: 12/10/2023] Open
Abstract
BACKGROUND More than half of persons living with HIV (PLWH) in the United States are insufficiently engaged in HIV primary care and not taking antiretroviral therapy (ART), mainly African Americans/Blacks and Hispanics. In the proposed project, a potent and innovative research methodology, the multiphase optimization strategy (MOST), will be employed to develop a highly efficacious, efficient, scalable, and cost-effective intervention to increase engagement along the HIV care continuum. Whereas randomized controlled trials are valuable for evaluating the efficacy of multi-component interventions as a package, they are not designed to evaluate which specific components contribute to efficacy. MOST, a pioneering, engineering-inspired framework, addresses this problem through highly efficient randomized experimentation to assess the performance of individual intervention components and their interactions. We propose to use MOST to engineer an intervention to increase engagement along the HIV care continuum for African American/Black and Hispanic PLWH not well engaged in care and not taking ART. Further, the intervention will be optimized for cost-effectiveness. A similar set of multi-level factors impede both HIV care and ART initiation for African American/Black and Hispanic PLWH, primary among them individual- (e.g., substance use, distrust, fear), social- (e.g., stigma), and structural-level barriers (e.g., difficulties accessing ancillary services). Guided by a multi-level social cognitive theory, and using the motivational interviewing approach, the study will evaluate five distinct culturally based intervention components (i.e., counseling sessions, pre-adherence preparation, support groups, peer mentorship, and patient navigation), each designed to address a specific barrier to HIV care and ART initiation. These components are well-grounded in the empirical literature and were found acceptable, feasible, and promising with respect to efficacy in a preliminary study. METHODS/DESIGN Study aims are: 1) using a highly efficient fractional factorial experimental design, identify which of five intervention components contribute meaningfully to improvement in HIV viral suppression, and secondary outcomes of ART adherence and engagement in HIV primary care; 2) identify mediators and moderators of intervention component efficacy; and 3) using a mathematical modeling approach, build the most cost-effective and efficient intervention package from the efficacious components. A heterogeneous sample of African American/Black and Hispanic PLWH (with respect to age, substance use, and sexual minority status) will be recruited with a proven hybrid sampling method using targeted sampling in community settings and peer recruitment (N = 512). DISCUSSION This is the first study to apply the MOST framework in the field of HIV prevention and treatment. This innovative study will produce a culturally based HIV care continuum intervention for the nation's most vulnerable PLWH, optimized for cost-effectiveness, and with exceptional levels of efficacy, efficiency, and scalability. TRIAL REGISTRATION ClinicalTrials.gov, NCT02801747 , Registered June 8, 2016.
Collapse
Affiliation(s)
- Marya Viorst Gwadz
- Center for Drug Use and HIV Research, Rory Meyers College of Nursing, New York University, New York, NY, USA.
| | - Linda M Collins
- The Methodology Center and Department of Human Development and Family Studies, Pennsylvania State University, State College, Pennsylvania, PA, USA
| | - Charles M Cleland
- Center for Drug Use and HIV Research, Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Noelle R Leonard
- Center for Drug Use and HIV Research, Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Leo Wilton
- Department of Human Development, State University of New York at Binghamton, Binghamton, NY, USA
- Faculty of Humanities, University of Johannesburg, Johannesburg, South Africa
| | - Monica Gandhi
- Division of HIV, Infectious Diseases, and Global Medicine, School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - R Scott Braithwaite
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - David C Perlman
- Department of Infectious Diseases, Mount Sinai Beth Israel, New York, NY, USA
| | - Alexandra Kutnick
- Center for Drug Use and HIV Research, Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Amanda S Ritchie
- Center for Drug Use and HIV Research, Rory Meyers College of Nursing, New York University, New York, NY, USA
| |
Collapse
|
13
|
McCreesh N, Andrianakis I, Nsubuga RN, Strong M, Vernon I, McKinley TJ, Oakley JE, Goldstein M, Hayes R, White RG. Universal test, treat, and keep: improving ART retention is key in cost-effective HIV control in Uganda. BMC Infect Dis 2017; 17:322. [PMID: 28468605 PMCID: PMC5415795 DOI: 10.1186/s12879-017-2420-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 04/25/2017] [Indexed: 12/14/2022] Open
Abstract
Background With ambitious new UNAIDS targets to end AIDS by 2030, and new WHO treatment guidelines, there is increased interest in the best way to scale-up ART coverage. We investigate the cost-effectiveness of various ART scale-up options in Uganda. Methods Individual-based HIV/ART model of Uganda, calibrated using history matching. 22 ART scale-up strategies were simulated from 2016 to 2030, comprising different combinations of six single interventions (1. increased HIV testing rates, 2. no CD4 threshold for ART initiation, 3. improved ART retention, 4. increased ART restart rates, 5. improved linkage to care, 6. improved pre-ART care). The incremental net monetary benefit (NMB) of each intervention was calculated, for a wide range of different willingness/ability to pay (WTP) per DALY averted (health-service perspective, 3% discount rate). Results For all WTP thresholds above $210, interventions including removing the CD4 threshold were likely to be most cost-effective. At a WTP of $715 (1 × per-capita-GDP) interventions to improve linkage to and retention/re-enrolment in HIV care were highly likely to be more cost-effective than interventions to increase rates of HIV testing. At higher WTP (> ~ $1690), the most cost-effective option was ‘Universal Test, Treat, and Keep’ (UTTK), which combines interventions 1–5 detailed above. Conclusions Our results support new WHO guidelines to remove the CD4 threshold for ART initiation in Uganda. With additional resources, this could be supplemented with interventions aimed at improving linkage to and/or retention in HIV care. To achieve the greatest reductions in HIV incidence, a UTTK policy should be implemented. Electronic supplementary material The online version of this article (doi:10.1186/s12879-017-2420-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Nicky McCreesh
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Ioannis Andrianakis
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | | | - Mark Strong
- School of Health and Related Research, The University of Sheffield, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Ian Vernon
- Department of Mathematical Sciences, Durham University, Lower Mountjoy, Stockton Road, Durham, DH1 3LE, UK
| | - Trevelyan J McKinley
- College of Engineering, Mathematics and Physical Sciences, University of Exeter, Campusm Penryn, Penryn, TR10 9FE, UK
| | - Jeremy E Oakley
- School of Mathematics and Statistics, University of Sheffield, The Hicks Building, Hounsfield Road, Sheffield, S3 7RH, UK
| | - Michael Goldstein
- Department of Mathematical Sciences, Durham University, Lower Mountjoy, Stockton Road, Durham, DH1 3LE, UK
| | - Richard Hayes
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Richard G White
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| |
Collapse
|
14
|
Ouattara EN, Robine M, Eholié SP, MacLean RL, Moh R, Losina E, Gabillard D, Paltiel AD, Danel C, Walensky RP, Anglaret X, Freedberg KA. Laboratory Monitoring of Antiretroviral Therapy for HIV Infection: Cost-Effectiveness and Budget Impact of Current and Novel Strategies. Clin Infect Dis 2016; 62:1454-1462. [PMID: 26936666 DOI: 10.1093/cid/ciw117] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 02/24/2016] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Optimal laboratory monitoring of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) remains controversial. We evaluated current and novel monitoring strategies in Côte d'Ivoire, West Africa. METHODS We used the Cost-Effectiveness of Preventing AIDS Complications -International model to compare clinical outcomes, cost-effectiveness, and budget impact of 11 ART monitoring strategies varying by type (CD4 and/or viral load [VL]) and frequency. We included "adaptive" strategies (biannual then annual monitoring for patients on ART/suppressed). Mean CD4 count at ART initiation was 154/μL. Laboratory test costs were CD4=$11 and VL=$33. The standard of care (SOC; biannual CD4) was the comparator. We assessed cost-effectiveness relative to Côte d'Ivoire's 2013 per capita GDP ($1500). RESULTS Discounted life expectancy was 16.69 years for SOC, 16.97 years with VL confirmation of immunologic failure, and 17.25 years for adaptive VL. Mean time on failed first-line ART was 3.7 years for SOC and <0.9 years for all routine/adaptive VL strategies. VL failure confirmation was cost-saving compared with SOC. Adaptive VL had an incremental cost-effectiveness ratio (ICER) of $4100/year of life saved compared with VL confirmation and increased the 5-year budget by $310/patient compared with SOC. Adaptive VL achieved an ICER <1× GDP if second-line ART and VL costs simultaneously decreased to $156 and $13, respectively. CONCLUSIONS VL confirmation of immunologic failure is more effective and less costly than CD4 monitoring in Côte d'Ivoire. Adaptive VL monitoring reduces time on failing ART, is cost-effective, and should become standard in Côte d'Ivoire and similar settings.
Collapse
Affiliation(s)
- Eric N Ouattara
- Institut National de la Santé et de la Recherche Médicale Centre 897.,Institut de Santé Publique d'Epidémiologique et de Développement, University of Bordeaux, France.,Programme PACCI/Agence Nationale de Recherche sur le SIDA et les hépatites virales Research Site, Treichville University Hospital Center, Abidjan, Côte d'Ivoire.,Interdepartmental Centre of Tropical Medicine and Clinical International Health, Division of Infectious and Tropical Diseases, Department of Medicine, University Hospital Centre, Bordeaux, France
| | - Marion Robine
- Medical Practice Evaluation Center.,Division of General Internal Medicine, Massachusetts General Hospital, Boston
| | - Serge P Eholié
- Programme PACCI/Agence Nationale de Recherche sur le SIDA et les hépatites virales Research Site, Treichville University Hospital Center, Abidjan, Côte d'Ivoire.,Department of Infectious and Tropical Diseases, Treichville University Hospital, Abidjan, Côte d'Ivoire
| | - Rachel L MacLean
- Medical Practice Evaluation Center.,Division of General Internal Medicine, Massachusetts General Hospital, Boston
| | - Raoul Moh
- Programme PACCI/Agence Nationale de Recherche sur le SIDA et les hépatites virales Research Site, Treichville University Hospital Center, Abidjan, Côte d'Ivoire.,Department of Infectious and Tropical Diseases, Treichville University Hospital, Abidjan, Côte d'Ivoire
| | - Elena Losina
- Medical Practice Evaluation Center.,Division of General Internal Medicine, Massachusetts General Hospital, Boston.,Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Delphine Gabillard
- Institut National de la Santé et de la Recherche Médicale Centre 897.,Institut de Santé Publique d'Epidémiologique et de Développement, University of Bordeaux, France
| | | | - Christine Danel
- Institut National de la Santé et de la Recherche Médicale Centre 897.,Institut de Santé Publique d'Epidémiologique et de Développement, University of Bordeaux, France.,Programme PACCI/Agence Nationale de Recherche sur le SIDA et les hépatites virales Research Site, Treichville University Hospital Center, Abidjan, Côte d'Ivoire
| | - Rochelle P Walensky
- Medical Practice Evaluation Center.,Division of General Internal Medicine, Massachusetts General Hospital, Boston.,Division of Infectious Diseases, Massachusetts General Hospital.,Harvard Medical School.,Division of Infectious Diseases, Brigham and Women's Hospital
| | - Xavier Anglaret
- Institut National de la Santé et de la Recherche Médicale Centre 897.,Institut de Santé Publique d'Epidémiologique et de Développement, University of Bordeaux, France.,Programme PACCI/Agence Nationale de Recherche sur le SIDA et les hépatites virales Research Site, Treichville University Hospital Center, Abidjan, Côte d'Ivoire
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center.,Division of General Internal Medicine, Massachusetts General Hospital, Boston.,Division of Infectious Diseases, Massachusetts General Hospital.,Harvard Medical School.,Department of Epidemiology, Boston University School of Public Health.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| |
Collapse
|
15
|
Drake TL, Devine A, Yeung S, Day NPJ, White LJ, Lubell Y. Dynamic Transmission Economic Evaluation of Infectious Disease Interventions in Low- and Middle-Income Countries: A Systematic Literature Review. HEALTH ECONOMICS 2016; 25 Suppl 1:124-39. [PMID: 26778620 PMCID: PMC5066646 DOI: 10.1002/hec.3303] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Economic evaluation using dynamic transmission models is important for capturing the indirect effects of infectious disease interventions. We examine the use of these methods in low- and middle-income countries, where infectious diseases constitute a major burden. This review is comprised of two parts: (1) a summary of dynamic transmission economic evaluations across all disease areas published between 2011 and mid-2014 and (2) an in-depth review of mosquito-borne disease studies focusing on health economic methods and reporting. Studies were identified through a systematic search of the MEDLINE database and supplemented by reference list screening. Fifty-seven studies were eligible for inclusion in the all-disease review. The most common subject disease was HIV/AIDS, followed by malaria. A diverse range of modelling methods, outcome metrics and sensitivity analyses were used, indicating little standardisation. Seventeen studies were included in the mosquito-borne disease review. With notable exceptions, most studies did not employ economic evaluation methods beyond calculating a cost-effectiveness ratio or net benefit. Many did not adhere to health care economic evaluations reporting guidelines, particularly with respect to full model reporting and uncertainty analysis. We present a summary of the state-of-the-art and offer recommendations for improved implementation and reporting of health economic methods in this crossover discipline.
Collapse
Affiliation(s)
- Tom L Drake
- University of Oxford, Oxford, UK
- Mahidol University, Bangkok, Thailand
| | - Angela Devine
- University of Oxford, Oxford, UK
- Mahidol University, Bangkok, Thailand
| | - Shunmay Yeung
- London School of Hygiene and Tropical Medicine, London, UK
| | - Nicholas P J Day
- University of Oxford, Oxford, UK
- Mahidol University, Bangkok, Thailand
| | - Lisa J White
- University of Oxford, Oxford, UK
- Mahidol University, Bangkok, Thailand
| | - Yoel Lubell
- University of Oxford, Oxford, UK
- Mahidol University, Bangkok, Thailand
| |
Collapse
|
16
|
Abstract
There are inefficiencies in current approaches to monitoring patients on antiretroviral therapy in sub-Saharan Africa. Patients typically attend clinics every 1 to 3 months for clinical assessment. The clinic costs are comparable with the costs of the drugs themselves and CD4 counts are measured every 6 months, but patients are rarely switched to second-line therapies. To ensure sustainability of treatment programmes, a transition to more cost-effective delivery of antiretroviral therapy is needed. In contrast to the CD4 count, measurement of the level of HIV RNA in plasma (the viral load) provides a direct measure of the current treatment effect. Viral-load-informed differentiated care is a means of tailoring care so that those with suppressed viral load visit the clinic less frequently and attention is focussed on those with unsuppressed viral load to promote adherence and timely switching to a second-line regimen. The most feasible approach to measuring viral load in many countries is to collect dried blood spot samples for testing in regional laboratories; however, there have been concerns over the sensitivity and specificity of this approach to define treatment failure and the delay in returning results to the clinic. We use modelling to synthesize evidence and evaluate the cost-effectiveness of viral-load-informed differentiated care, accounting for limitations of dried blood sample testing. We find that viral-load-informed differentiated care using dried blood sample testing is cost-effective and is a recommended strategy for patient monitoring, although further empirical evidence as the approach is rolled out would be of value. We also explore the potential benefits of point-of-care viral load tests that may become available in the future.
Collapse
|
17
|
The HIV Treatment Gap: Estimates of the Financial Resources Needed versus Available for Scale-Up of Antiretroviral Therapy in 97 Countries from 2015 to 2020. PLoS Med 2015; 12:e1001907; discussion e1001907. [PMID: 26599990 PMCID: PMC4658189 DOI: 10.1371/journal.pmed.1001907] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 10/16/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) released revised guidelines in 2015 recommending that all people living with HIV, regardless of CD4 count, initiate antiretroviral therapy (ART) upon diagnosis. However, few studies have projected the global resources needed for rapid scale-up of ART. Under the Health Policy Project, we conducted modeling analyses for 97 countries to estimate eligibility for and numbers on ART from 2015 to 2020, along with the facility-level financial resources required. We compared the estimated financial requirements to estimated funding available. METHODS AND FINDINGS Current coverage levels and future need for treatment were based on country-specific epidemiological and demographic data. Simulated annual numbers of individuals on treatment were derived from three scenarios: (1) continuation of countries' current policies of eligibility for ART, (2) universal adoption of aspects of the WHO 2013 eligibility guidelines, and (3) expanded eligibility as per the WHO 2015 guidelines and meeting the Joint United Nations Programme on HIV/AIDS "90-90-90" ART targets. We modeled uncertainty in the annual resource requirements for antiretroviral drugs, laboratory tests, and facility-level personnel and overhead. We estimate that 25.7 (95% CI 25.5, 26.0) million adults and 1.57 (95% CI 1.55, 1.60) million children could receive ART by 2020 if countries maintain current eligibility plans and increase coverage based on historical rates, which may be ambitious. If countries uniformly adopt aspects of the WHO 2013 guidelines, 26.5 (95% CI 26.0 27.0) million adults and 1.53 (95% CI 1.52, 1.55) million children could be on ART by 2020. Under the 90-90-90 scenario, 30.4 (95% CI 30.1, 30.7) million adults and 1.68 (95% CI 1.63, 1.73) million children could receive treatment by 2020. The facility-level financial resources needed for scaling up ART in these countries from 2015 to 2020 are estimated to be US$45.8 (95% CI 45.4, 46.2) billion under the current scenario, US$48.7 (95% CI 47.8, 49.6) billion under the WHO 2013 scenario, and US$52.5 (95% CI 51.4, 53.6) billion under the 90-90-90 scenario. After projecting recent external and domestic funding trends, the estimated 6-y financing gap ranges from US$19.8 billion to US$25.0 billion, depending on the costing scenario and the U.S. President's Emergency Plan for AIDS Relief contribution level, with the gap for ART commodities alone ranging from US$14.0 to US$16.8 billion. The study is limited by excluding above-facility and other costs essential to ART service delivery and by the availability and quality of country- and region-specific data. CONCLUSIONS The projected number of people receiving ART across three scenarios suggests that countries are unlikely to meet the 90-90-90 treatment target (81% of people living with HIV on ART by 2020) unless they adopt a test-and-offer approach and increase ART coverage. Our results suggest that future resource needs for ART scale-up are smaller than stated elsewhere but still significantly threaten the sustainability of the global HIV response without additional resource mobilization from domestic or innovative financing sources or efficiency gains. As the world moves towards adopting the WHO 2015 guidelines, advances in technology, including the introduction of lower-cost, highly effective antiretroviral regimens, whose value are assessed here, may prove to be "game changers" that allow more people to be on ART with the resources available.
Collapse
|
18
|
Kessler J, Ruggles K, Patel A, Nucifora K, Li L, Roberts MS, Bryant K, Braithwaite RS. Targeting an alcohol intervention cost-effectively to persons living with HIV/AIDS in East Africa. Alcohol Clin Exp Res 2015; 39:2179-88. [PMID: 26463727 PMCID: PMC5651989 DOI: 10.1111/acer.12890] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 08/26/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND In the current report, we ask if targeting a cognitive behavioral therapy (CBT)-based intervention aimed at reducing hazardous alcohol consumption to HIV-infected persons in East Africa would have a favorable value at costs that are feasible for scale-up. METHODS Using a computer simulation to inform HIV prevention decisions in East Africa, we compared 4 different strategies for targeting a CBT intervention-(i) all HIV-infected persons attending clinic; (ii) only those patients in the pre-antiretroviral therapy (ART) stages of care; (iii) only those patients receiving ART; and (iv) only those patients with detectable viral loads (VLs) regardless of disease stage. We define targeting as screening for hazardous alcohol consumption (e.g., using the Alcohol Use Disorders Identification Test and offering the CBT intervention to those who screen positive). We compared these targeting strategies to a null strategy (no intervention) or a hypothetical scenario where an alcohol intervention was delivered to all adults regardless of HIV status. RESULTS An intervention targeted to HIV-infected patients could prevent 18,000 new infections, add 46,000 quality-adjusted life years (QALYs), and yield an incremental cost-effectiveness ratio of $600/QALY compared to the null scenario. Narrowing the prioritized population to only HIV-infected patients in pre-ART phases of care results in 15,000 infections averted, the addition of 21,000 QALYs and would be cost-saving, while prioritizing based on an unsuppressed HIV-1 VL test results in 8,300 new infections averted, adds 6,000 additional QALYs, and would be cost-saving as well. CONCLUSIONS Our results suggest that targeting a cognitive-based treatment aimed at reducing hazardous alcohol consumption to subgroups of HIV-infected patients provides favorable value in comparison with other beneficial strategies for HIV prevention and control in this region. It may even be cost-saving under certain circumstances.
Collapse
Affiliation(s)
- Jason Kessler
- Department of Population Health, NYU School of Medicine, New York, New York
| | - Kelly Ruggles
- Department of Population Health, NYU School of Medicine, New York, New York
| | - Anik Patel
- Department of Population Health, NYU School of Medicine, New York, New York
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kimberly Nucifora
- Department of Population Health, NYU School of Medicine, New York, New York
| | - Lifeng Li
- Department of Population Health, NYU School of Medicine, New York, New York
| | - Mark S Roberts
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Kendall Bryant
- National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland
| | | |
Collapse
|
19
|
Wilson D, Taaffe J, Fraser-Hurt N, Gorgens M. The economics, financing and implementation of HIV treatment as prevention: what will it take to get there? AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2015; 13:109-19. [PMID: 25174628 DOI: 10.2989/16085906.2014.943254] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The 2013 Lancet Commission Report, Global Health 2035, rightly pointed out that we are at a unique place in history where a "grand convergence" of health initiatives to reduce both infectious diseases, and child and maternal mortality--diseases that still plague low income countries--would yield good returns in terms of development and health outcomes. This would also be a good economic investment. Such investments would support achieving health goals of reducing under-five (U5) mortality to 16 per 1000 live births, reducing deaths due to HIV/AIDS to 8 per 100,000 population, and reducing annual TB deaths to 4 per 100,000 population. Treatment as prevention (TasP) holds enormous potential in reducing HIV transmission, and morbidity and mortality associated with HIV/AIDS--and therefore contributing to Global Health 2035 goals. However, TasP requires large financial investments and poses significant implementation challenges. In this review, we discuss the potential effectiveness, financing and implementation of TasP. Overall, we conclude that TasP shows great promise as a cost-effective intervention to address the dual aims of reducing new HIV infections and reducing the global burden of HIV-related disease. Successful implementation will be no easy feat, though. The dramatic increases in the numbers of persons who need antiretroviral therapy (ART) under a TasP approach will pose enormous challenges at all stages of the HIV treatment cascade: HIV diagnosis, antiretroviral (ARV) initiation, ARV adherence and retention, and increased drug resistance with long-term enrolment on ART. Overcoming these implementation challenges will require targeted implementation, not focusing exclusively on TasP, most-at-risk population (MARP)-friendly services for key populations, integrating services, task shifting, more efficient programme management, balancing supply and demand, integration into universal health coverage efforts, demand creation, improved ART retention and adherence strategies, the use of incentives to improve HIV treatment outcomes and reduce unit costs, continued operational research and tapping into technological innovations.
Collapse
|
20
|
How inexpensive does an alcohol intervention in Kenya need to be in order to deliver favorable value by reducing HIV-related morbidity and mortality? J Acquir Immune Defic Syndr 2014; 66:e54-8. [PMID: 24828269 DOI: 10.1097/qai.0000000000000140] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
|
21
|
Keebler D, Revill P, Braithwaite S, Phillips A, Blaser N, Borquez A, Cambiano V, Ciaranello A, Estill J, Gray R, Hill A, Keiser O, Kessler J, Menzies NA, Nucifora KA, Vizcaya LS, Walker S, Welte A, Easterbrook P, Doherty M, Hirnschall G, Hallett TB. Cost-effectiveness of different strategies to monitor adults on antiretroviral treatment: a combined analysis of three mathematical models. LANCET GLOBAL HEALTH 2013; 2:e35-43. [PMID: 25104633 DOI: 10.1016/s2214-109x(13)70048-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND WHO's 2013 revisions to its Consolidated Guidelines on antiretroviral drugs recommend routine viral load monitoring, rather than clinical or immunological monitoring, as the preferred monitoring approach on the basis of clinical evidence. However, HIV programmes in resource-limited settings require guidance on the most cost-effective use of resources in view of other competing priorities such as expansion of antiretroviral therapy coverage. We assessed the cost-effectiveness of alternative patient monitoring strategies. METHODS We evaluated a range of monitoring strategies, including clinical, CD4 cell count, and viral load monitoring, alone and together, at different frequencies and with different criteria for switching to second-line therapies. We used three independently constructed and validated models simultaneously. We estimated costs on the basis of resource use projected in the models and associated unit costs; we quantified impact as disability-adjusted life years (DALYs) averted. We compared alternatives using incremental cost-effectiveness analysis. FINDINGS All models show that clinical monitoring delivers significant benefit compared with a hypothetical baseline scenario with no monitoring or switching. Regular CD4 cell count monitoring confers a benefit over clinical monitoring alone, at an incremental cost that makes it affordable in more settings than viral load monitoring, which is currently more expensive. Viral load monitoring without CD4 cell count every 6-12 months provides the greatest reductions in morbidity and mortality, but incurs a high cost per DALY averted, resulting in lost opportunities to generate health gains if implemented instead of increasing antiretroviral therapy coverage or expanding antiretroviral therapy eligibility. INTERPRETATION The priority for HIV programmes should be to expand antiretroviral therapy coverage, firstly at CD4 cell count lower than 350 cells per μL, and then at a CD4 cell count lower than 500 cells per μL, using lower-cost clinical or CD4 monitoring. At current costs, viral load monitoring should be considered only after high antiretroviral therapy coverage has been achieved. Point-of-care technologies and other factors reducing costs might make viral load monitoring more affordable in future. FUNDING Bill & Melinda Gates Foundation, WHO.
Collapse
Affiliation(s)
- Daniel Keebler
- South African Department of Science and Technology/National Research Foundation Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | | | - Andrew Phillips
- Research Department of Infection and Population Health, University College London, London, UK
| | - Nello Blaser
- Division of International and Environmental Health, Institute of Social and Preventive Medicine (ISPM) University of Bern, Bern, Switzerland
| | - Annick Borquez
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Valentina Cambiano
- Research Department of Infection and Population Health, University College London, London, UK
| | | | - Janne Estill
- Division of International and Environmental Health, Institute of Social and Preventive Medicine (ISPM) University of Bern, Bern, Switzerland
| | - Richard Gray
- The Kirby Institute, The University of New South Wales, Sydney, NSW, Australia
| | | | - Olivia Keiser
- Division of International and Environmental Health, Institute of Social and Preventive Medicine (ISPM) University of Bern, Bern, Switzerland
| | - Jason Kessler
- School of Medicine, New York University, New York, NY, USA
| | - Nicolas A Menzies
- Center for Health Decision Science, Harvard School of Public Health, Boston, MA, USA
| | | | - Luisa Salazar Vizcaya
- Division of International and Environmental Health, Institute of Social and Preventive Medicine (ISPM) University of Bern, Bern, Switzerland
| | - Simon Walker
- Centre for Health Economics, University of York, York, UK
| | - Alex Welte
- South African Department of Science and Technology/National Research Foundation Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | | | | | | | - Timothy B Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK.
| |
Collapse
|