When Global ART Budgets Cannot Cover All Patients, Who Should Be Eligible?

Providing laypeople with results from dynamic infectious disease modelling studies affects their allocation preference for scarce medical resources-a factorial experiment

BACKGROUND

Allocation of scarce medical resources can be based on different principles. It has not yet been investigated which allocation schemes are preferred by medical laypeople in a particular situation of medical scarcity like an emerging infectious disease and how the choices are affected by providing information about expected population-level effects of the allocation scheme based on modelling studies. We investigated the potential benefit of strategic communication of infectious disease modelling results.

METHODS

In a two-way factorial experiment (n = 878 participants), we investigated if prognosis of the disease or information about expected effects on mortality at population-level (based on dynamic infectious disease modelling studies) influenced the choice of preferred allocation schemes for prevention and treatment of an unspecified sexually transmitted infection. A qualitative analysis of the reasons for choosing specific allocation schemes supplements our results.

RESULTS

Presence of the factor "information about the population-level effects of the allocation scheme" substantially increased the probability of choosing a resource allocation system that minimized overall harm among the population, while prognosis did not affect allocation choices. The main reasons for choosing an allocation scheme differed among schemes, but did not differ among those who received additional model-based information on expected population-level effects and those who did not.

CONCLUSIONS

Providing information on the expected population-level effects from dynamic infectious disease modelling studies resulted in a substantially different choice of allocation schemes. This finding supports the importance of incorporating model-based information in decision-making processes and communication strategies.

Interferon-γ-Inducible Protein 10 (IP-10) Kinetics after Antiretroviral Treatment Initiation in Ethiopian Adults with HIV

Interferon-γ-inducible protein 10 (IP-10) has been suggested as a marker for targeted viral load (VL) monitoring during antiretroviral treatment (ART). We aimed to determine the kinetics of IP-10 during the initial year of ART, with particular regard to the impact of tuberculosis (TB) co-infection on IP-10 secretion. Longitudinal plasma IP-10 levels were quantified in 112 treatment-naive HIV-positive adults at Ethiopian health centers, through enzyme-linked immunosorbent assay (ELISA) using samples obtained before and during the initial 12 months of ART. All participants underwent bacteriological TB investigation before starting ART. In virological responders (VRs; defined as VL < 150 copies/ml with no subsequent VL ≥ 1,000 copies/ml), IP-10 kinetics were analyzed using linear regression models. Among 91/112 (81.3%) participants classified as VRs, 17 (18.7%) had concomitant TB. Median baseline IP-10 was 650 pg/ml (interquartile range [IQR], 428-1,002) in VRs. IP-10 decline was more rapid during the first month of ART (median 306 pg/ml/month) compared with later time intervals (median 7-48 pg/ml/month, P < 0.001 in each comparison). Although VRs with TB had higher IP-10 levels at baseline (median 1106 pg/ml [IQR, 627-1,704]), compared with individuals without TB (median 628 pg/ml [IQR, 391-885]; P = 0.003), the rate of IP-10 decline during ART was similar, regardless of TB-status. During the initial year of ART, IP-10 kinetics followed a biphasic pattern in VRs, with a more rapid decline in the first month of ART compared with later time intervals. Baseline IP-10 was higher in individuals with TB versus individuals without TB, but the kinetics during ART were similar. IMPORTANCE To reach the goal of elimination of HIV as public health threat, access to antiretroviral treatment (ART) has to be further scaled up. To ensure viral suppression in individuals receiving ART, novel and robust systems for treatment monitoring are required. Targeting viral load monitoring to identify individuals at increased likelihood of treatment failure, using screening tools, could be an effective use of limited resources for viral load testing. Interferon-γ-inducible protein 10 (IP-10), a host inflammation mediator, has shown potential for this purpose. Here, we have investigated IP-10 kinetics in Ethiopian adults with HIV during the initial year after ART initiation. IP-10 levels decreased in parallel with viral load during ART, and prevalent tuberculosis at ART initiation did not influence IP-10 kinetics. This study shows satisfactory performance for IP-10 as a surrogate marker for viral load in persons starting ART, with no influence of concomitant tuberculosis.

'My Tablets are on Top of the Fridge': The Roles of Relationship Desire and Medical Mistrust in ART Adherence for HIV-Positive MSM and Transgender Women Living in Rural South Africa

Given the high HIV prevalence for men who have sex with men (MSM) and transgender women in South Africa, there is limited understanding of social determinants that influence antiretroviral treatment (ART) adherence. Although universal testing and treatment (UTT) is available, ART adherence remains suboptimal. We conducted focus groups with MSM and transgender women in order to understand factors influencing their ART adherence in Mpumalanga, South Africa. All focus groups were audio-recorded, transcribed and translated for analysis using a constant comparison approach, guided by the concept of Therapeutic Citizenship. We found there is medical mistrust of ART based on differing interpretations of HIV cure that may influence treatment adherence behaviors within social networks, and relationship desire had a significant influence on optimal ART adherence. Our findings suggest that clinics must provide interventions that integrate HIV disclosure and relationship skill-building to support optimal ART adherence for MSM and transgender women under UTT.