Lifetime costs and quality-adjusted life years saved from HIV prevention in the test and treat era

The Relationship between Age at Initiation of Regular Drinking of Alcohol and Viral Suppression Status, and Depression Symptoms Among People Living with HIV in South-Western Uganda

Alcohol use is an important factor in achieving and maintaining viral suppression and optimal mental health among persons with HIV (PWH), however, the effect of age at first regular drinking on viral suppression and depression remains poorly understood. Here, using secondary data from the Alcohol Drinkers' Exposure to Preventive Therapy for Tuberculosis (ADEPT-T) study, we used logistic regression analyses to explore whether there is an association between age at first regular drinking and viral suppression (< 40 copies/ml), or presence of depressive symptoms (Center for Epidemiologic Studies Depression, CES-D ≥ 16) among 262 PWH. The median age at first regular drinking was 20.5 years (IQR: 10), with high proportions starting under age 12 (12.2%) and as teens (13.4%). The majority had an undetectable viral load (91.7%) and 11% had symptoms of probable depression. We found no significant association between age at first regular drinking and viral suppression (i.e., child (aOR = 0.76 95%CI: 0.18, 3.26), adolescent (aOR = 0.74 95%CI: 0.18, 2.97) and young adult (aOR = 1.27 95%CI: 0.40, 3.97)) nor with depressive symptoms (i.e., child (aOR = 0.72 95%CI: 0.19, 2.83), adolescent (aOR = 0.59 95%CI: 0.14, 2.50) and young adult (aOR = 0.57 95%CI: 0.22, 1.53)). Age at first regular drinking among PWH did not appear to be associated with either viral suppression or the presence of depressive symptoms, suggesting interventions may best be focused on the harmful effects of current alcohol use.

Neighborhood characteristics and HIV treatment outcomes: A scoping review

Recognizing challenges faced by people living with HIV is vital for improving their HIV treatment outcomes. While individual-level interventions play a crucial role, community factors can shape the impact of individual interventions on treatment outcomes. Understanding neighborhood characteristics' association with HIV treatment outcomes is crucial for optimizing effectiveness. This review aims to summarize the research scope on the association between neighborhood characteristics and HIV treatment outcomes. The databases PubMed, CINAHL (EBSCOhost), Embase (Elsevier), and PsychINFO (EBSCOhost) were searched from the start of each database to Nov 21, 2022. Screening was performed by three independent reviewers. Full-text publications of all study design meeting inclusion criteria were included in the review. There were no language or geographical limitations. Conference proceedings, abstract only, and opinion reports were excluded from the review. The search yielded 7,822 publications, 35 of which met the criteria for inclusion in the review. Studies assessed the relationship between neighborhood-level disadvantage (n = 24), composition and interaction (n = 17), social-economic status (n = 18), deprivation (n = 16), disorder (n = 8), and rural-urban status (n = 7) and HIV treatment outcomes. The relationship between all neighborhood characteristics and HIV treatment outcomes was not consistent across studies. Only 7 studies found deprivation had a negative association with HIV treatment outcomes; 6 found that areas with specific racial/ethnic densities were associated with poor HIV treatment outcomes, and 5 showed that disorder was associated with poor HIV treatment outcomes. Three studies showed that rural residence was associated with improved HIV treatment outcomes. There were inconsistent findings regarding the association between neighborhood characteristics and HIV treatment outcomes. While the impact of neighborhood characteristics on disease outcomes is highly recognized, there is a paucity of standardized definitions and metrics for community characteristics to support a robust assessment of this hypothesis. Comparative studies that define and assess how specific neighborhood indicators independently or jointly affect HIV treatment outcomes are highly needed.

Lifetime quality-adjusted life years lost due to genital herpes acquired in the United States in 2018: a mathematical modeling study

Background

Genital herpes (GH), caused by herpes simplex virus type 1 and type 2 (HSV-1, HSV-2), is a common sexually transmitted disease associated with adverse health outcomes. Symptoms associated with GH outbreaks can be reduced by antiviral medications, but the infection is incurable and lifelong. In this study, we estimate the long-term health impacts of GH in the United States using quality-adjusted life years (QALYs) lost.

Methods

We used probability trees to model the natural history of GH secondary to infection with HSV-1 and HSV-2 among people aged 18-49 years. We modelled the following outcomes to quantify the major causes of health losses following infection: symptomatic herpes outbreaks, psychosocial impacts associated with diagnosis and recurrences, urinary retention caused by sacral radiculitis, aseptic meningitis, Mollaret's meningitis, and neonatal herpes. The model was parameterized based on published literature on the natural history of GH. We summarized losses of health by computing the lifetime number of QALYs lost per genital HSV-1 and HSV-2 infection, and we combined this information with incidence estimates to compute the total lifetime number of QALYs lost due to infections acquired in 2018 in the United States.

Findings

We estimated 0.05 (95% uncertainty interval (UI) 0.02-0.08) lifetime QALYs lost per incident GH infection acquired in 2018, equivalent to losing 0.05 years or about 18 days of life for one person with perfect health. The average number of QALYs lost per GH infection due to genital HSV-1 and HSV-2 was 0.01 (95% UI 0.01-0.02) and 0.05 (95% UI 0.02-0.09), respectively. The burden of genital HSV-1 is higher among women, while the burden of HSV-2 is higher among men. QALYs lost per neonatal herpes infection was estimated to be 7.93 (95% UI 6.63-9.19). At the population level, the total estimated lifetime QALYs lost as a result of GH infections acquired in 2018 was 33,100 (95% UI 12,600-67,900) due to GH in adults and 3,140 (95% UI 2,260-4,140) due to neonatal herpes. Results were most sensitive to assumptions on the magnitude of the disutility associated with post-diagnosis psychosocial distress and symptomatic recurrences.

Interpretation

GH is associated with substantial health losses in the United States. Results from this study can be used to compare the burden of GH to other diseases, and it provides inputs that may be used in studies on the health impact and cost-effectiveness of interventions that aim to reduce the burden of GH.

Funding

The Center for Disease Control and Prevention.

Estimation of the Lifetime Quality-Adjusted Life Years (QALYs) Lost Due to Syphilis Acquired in the United States in 2018

BACKGROUND

The purpose of this study was to estimate the health impact of syphilis in the United States in terms of the number of quality-adjusted life years (QALYs) lost attributable to infections in 2018.

METHODS

We developed a Markov model that simulates the natural history and management of syphilis. The model was parameterized by sex and sexual orientation (women who have sex with men, men who have sex with women [MSW], and men who have sex with men [MSM]), and by age at primary infection. We developed a separate decision tree model to quantify health losses due to congenital syphilis. We estimated the average lifetime number of QALYs lost per infection, and the total expected lifetime number of QALYs lost due to syphilis acquired in 2018.

RESULTS

We estimated the average number of discounted lifetime QALYs lost per infection as 0.09 (95% uncertainty interval [UI] .03-.19). The total expected number of QALYs lost due to syphilis acquired in 2018 was 13 349 (5071-31 360). Although per-case loss was the lowest among MSM (0.06), MSM accounted for 47.7% of the overall burden. For each case of congenital syphilis, we estimated 1.79 (1.43-2.16) and 0.06 (.01-.14) QALYs lost in the child and the mother, respectively. We projected 2332 (1871-28 250) and 79 (17-177) QALYs lost for children and mothers, respectively, due to congenital syphilis in 2018.

CONCLUSIONS

Syphilis causes substantial health losses in adults and children. Quantifying these health losses in terms of QALYs can inform cost-effectiveness analyses and can facilitate comparisons of the burden of syphilis to that of other diseases.

Assessing the individual benefits of reducing HIV diagnosis delay and increasing adherence to HIV care and treatment

We used an agent-based simulation model (Progression and Transmission of HIV) to follow for 20 years a cohort of persons in the United States infected with HIV in 2015. We assessed the benefits of reducing the delay between HIV infection and diagnosis and increasing adherence to HIV care and treatment on the percent of persons surviving 20 years after infection, average annual HIV transmission rates, and time spent virally suppressed. We examined average diagnosis delays of 1.0-7.0 years, monthly care drop-out rates of 5% to 0.1%, and combinations of these strategies. The percent of the cohort surviving the first 20 years of infection varied from 70.8% to 77.5%, and the annual transmission risk, from 1.5 to 5.2 HIV transmissions per 100 person-years. Thus, individuals can enhance their survival and reduce their risk of transmission to partners by frequent testing for HIV and adhering to care and treatment.

The role of material deprivations in determining ART adherence: Evidence from a conjoint analysis among HIV-positive adults in Uganda

Despite sustained global scale-up of antiretroviral therapy (ART), adherence to ART remains low. Less than half of those in HIV care in Uganda achieve 85% adherence to their ART medication required for clinically meaningful viral suppression, leaving them at higher risk of transmission. Key barriers to ART adherence include poverty-related structural barriers that are inter-connected and occur simultaneously, making it challenging to examine and disentangle them empirically and in turn design effective interventions. Many people living with HIV (PLWH) make tradeoffs between these various barriers (e.g., between expenses for food or transportation) and these can influence long-term health behavior such as adherence to ART. To be able to estimate the distinct influence of key structural barriers related to poverty, we administered a conjoint analysis (CA) to 320 HIV-positive adults currently taking ART at an urban clinic in Uganda between July 2019 and September 2020. We varied the levels of four poverty-related attributes (food security, sleep deprivation, monthly income, and physical pain) that occur simultaneously and asked respondents how they would adhere to their medication under different combinations of attribute levels. This allows us to disentangle the effect of each attribute from one another and to assess their relative importance. We used regression analysis to estimate the effects of each attribute level and found that food security impacts expected adherence the most (treatment effect = 1.3; 95% CI 1.11-1.49, p<0.001), followed by income (treatment effect = 0.99; 95% CI 0.88-1.10, p<0.001. Sleep and pain also impact adherence, although by a smaller magnitude. Sub-group analyses conducted via regression analysis examine heterogeneity in results and suggest that the effects of material deprivations on expected adherence are greater among those with high levels of existing food insecurity. Results from this CA indicate that external factors inherent in the lives of the poor and unrelated to direct ART access can be important barriers to ART adherence. This study applies a CA (typically administered in marketing applications) among PLWH to better understand individual-level perceptions relating to poverty that often occur simultaneously. Policy interventions should address food insecurity and income to improve adherence among HIV-positive adults.

Examining the Implementation of Conditional Financial Incentives Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework to Improve HIV Outcomes among Persons Living with HIV (PLWH) in Louisiana

Economic strengthening interventions are needed to support HIV outcomes among persons living with HIV (PLWH). The Baton Rouge Positive Pathway Study (BRPPS), a mixed method implementation science study, was conducted to assess key RE-AIM components tied to the provision of conditional financial incentives among PLWH in Baton Rouge, Louisiana. Seven hundred and eighty-one (781) PLWH enrolled at four HIV clinic sites were included in the final analyses. Participants completed an initial baseline survey, viral load test, and were contacted at 6 and 12 months (±1 month) post-enrollment for follow-up labs to monitor viral load levels. Participants received up to USD140 in conditional financial incentives. The primary analyses assessed whether participation in the BRPPS was associated with an increase in the proportion of participants who were: (a) engaged in care, (b) retained in care and (c) virally suppressed at baseline to 6 and 12 months post-baseline. We constructed a longitudinal regression model where participant-level outcomes at times t0 (baseline) and t1 (6- or 12-month follow-up) were modeled as a function of time. A secondary analysis was conducted using single-level regression to examine which baseline characteristics were associated with the outcomes of interest at 12-month follow-up. Cost analyses were also conducted with three of the participating clinics. Most participants identified as Black/African American (89%). Fewer than half of participants reported that they were unemployed or made less than USD5000 annually (43%). Over time, the proportion of participants engaged in care and retained in care significantly increased (70% to 93% and 32% to 64%, p < 0.00). However, the proportion of virally suppressed participants decreased over time (59% to 34%, p < 0.00). Implementation costs across the three sites ranged from USD17,198.05 to USD396,910.00 and were associated with between 0.37 and 1.34 HIV transmissions averted at each site. Study findings provide promising evidence to suggest that conditional financial incentives could help support engagement and retention in HIV care for a high need and at risk for falling out of HIV care population.

"The one who doesn't take ART medication has no wealth at all and no purpose on Earth" - a qualitative assessment of how HIV-positive adults in Uganda understand the health and wealth-related benefits of ART

BACKGROUND

Increases in life expectancy from antiretroviral therapy (ART) may influence future health and wealth among people living with HIV (PLWH). What remains unknown is how PLWH in care perceive the benefits of ART adherence, particularly in terms of improving health and wealth in the short and long-term at the individual, household, and structural levels. Understanding future-oriented attitudes towards ART may help policymakers tailor care and treatment programs with both short and long-term-term health benefits in mind, to improve HIV-related outcomes for PLWH.

METHODS

In this qualitative study, we conducted semi-structured interviews among a subsample of 40 PLWH in care at a clinic in Uganda participating in a randomized clinical trial for treatment adherence in Uganda (clinicaltrials.gov: NCT03494777). Interviews were transcribed verbatim and translated from Luganda into English. Two co-authors independently reviewed transcripts, developed a detailed codebook, achieved 93% agreement on double-coded interviews, and analyzed data using inductive and deductive content analysis. Applying the social-ecological framework at the individual, household, and structural levels, we examined how PLWH perceived health and wealth-related benefits to ART.

RESULTS

Our findings revealed several benefits of ART expressed by PLWH, going beyond the short-term health benefits to also include long-term economic benefits. Such benefits largely focused on the ability of PLWH to live longer and be physically and mentally healthy, while also fulfilling responsibilities at the individual level pertaining to themselves (especially in terms of positive long-term habits and motivation to work harder), at the household level pertaining to others (such as improved relations with family and friends), and at the structural level pertaining to society (in terms of reduced stigma, increased comfort in disclosure, and higher levels of civic responsibility).

CONCLUSIONS

PLWH consider short and long-term health benefits of ART. Programming designed to shape ART uptake and increase adherence should emphasize the broader benefits of ART at various levels. Having such benefits directly integrated into the design of clinic-based HIV interventions can be useful especially for PLWH who face competing interests to increase medication adherence. These benefits can ultimately help providers and policymakers better understand PLWH's decision-making as it relates to improving ART-related outcomes.

Cost and Cost-Effectiveness of Incentives for Viral Suppression in People Living with HIV

Only 63% of people living with HIV in the United States are achieving viral suppression. Structural and social barriers limit adherence to antiretroviral therapy which furthers the HIV epidemic while increasing health care costs. This study calculated the cost and cost-effectiveness of a contingency management intervention with cash incentives. People with HIV and detectable viral loads were randomized to usual care or an incentive group. Individuals could earn up to $3650 per year if they achieved and maintained an undetectable viral load. The average 1-year intervention cost, including incentives, was $4105 per patient. The average health care costs were $27,189 per patient in usual care and $35,853 per patient in the incentive group. We estimated a cost of $28,888 per quality-adjusted life-year (QALY) gained, which is well below accepted cost-per-QALY thresholds. Contingency management with cash incentives is a cost-effective intervention for significantly increasing viral suppression.

Progression and transmission of HIV (PATH 4.0)-A new agent-based evolving network simulation for modeling HIV transmission clusters

We present the Progression and Transmission of HIV (PATH 4.0), a simulation tool for analyses of cluster detection and intervention strategies. Molecular clusters are groups of HIV infections that are genetically similar, indicating rapid HIV transmission where HIV prevention resources are needed to improve health outcomes and prevent new infections. PATH 4.0 was constructed using a newly developed agent-based evolving network modeling (ABENM) technique and evolving contact network algorithm (ECNA) for generating scale-free networks. ABENM and ECNA were developed to facilitate simulation of transmission networks for low-prevalence diseases, such as HIV, which creates computational challenges for current network simulation techniques. Simulating transmission networks is essential for studying network dynamics, including clusters. We validated PATH 4.0 by comparing simulated projections of HIV diagnoses with estimates from the National HIV Surveillance System (NHSS) for 2010-2017. We also applied a cluster generation algorithm to PATH 4.0 to estimate cluster features, including the distribution of persons with diagnosed HIV infection by cluster status and size and the size distribution of clusters. Simulated features matched well with NHSS estimates, which used molecular methods to detect clusters among HIV nucleotide sequences of persons with HIV diagnosed during 2015-2017. Cluster detection and response is a component of the U.S. Ending the HIV Epidemic strategy. While surveillance is critical for detecting clusters, a model in conjunction with surveillance can allow us to refine cluster detection methods, understand factors associated with cluster growth, and assess interventions to inform effective response strategies. As surveillance data are only available for cases that are diagnosed and reported, a model is a critical tool to understand the true size of clusters and assess key questions, such as the relative contributions of clusters to onward transmissions. We believe PATH 4.0 is the first modeling tool available to assess cluster detection and response at the national-level and could help inform the national strategic plan.

Adherence and Viral Suppression Among Participants of the Patient-centered Human Immunodeficiency Virus (HIV) Care Model Project: A Collaboration Between Community-based Pharmacists and HIV Clinical Providers

BACKGROUND

Human immunodeficiency virus (HIV) viral suppression (VS) decreases morbidity, mortality, and transmission risk.

METHODS

The Patient-centered HIV Care Model integrated community-based pharmacists with HIV medical providers and required them to share patient clinical information, identify therapy-related problems, and develop therapy-related action plans.Proportions adherent to antiretroviral therapy (proportion of days covered [PDC] ≥90%) and virally suppressed (HIV RNA <200 copies/mL), before and after model implementation, were compared. Factors associated with postimplementation VS were determined using multivariable logistic regression; participant demographics, baseline viral load, and PDC were explanatory variables. PDC was modified to account for time to last viral load in the year postimplementation, and stratified as <50%, 50% to <80%, 80% to <90%, and ≥90%.

RESULTS

The 765 enrolled participants were 43% non-Hispanic black, 73% male, with a median age of 48 years; 421 and 649 were included in the adherence and VS analyses, respectively. Overall, proportions adherent to therapy remained unchanged. However, VS improved a relative 15% (75% to 86%, P < .001). Higher PDC (adjusted odds ratio [AOR], 1.74 per 1-level increase in PDC category [95% confidence interval {CI}, 1.30-2.34]) and baseline VS (AOR, 7.69 [95% CI, 3.96-15.7]) were associated with postimplementation VS. Although non-Hispanic black persons (AOR, 0.29 [95% CI, .12-.62]) had lower odds of suppression, VS improved a relative 23% (63% to 78%, P < .001).

CONCLUSIONS

Integrated care models between community-based pharmacists and primary medical providers may identify and address HIV therapy-related problems and improve VS among persons with HIV.

Estimation of the Incremental Cumulative Cost of HIV Compared with a Non-HIV Population

OBJECTIVE

There are limited real-world data comparing cumulative incremental healthcare costs in people living with HIV (PLWH) and those without HIV. This study evaluated all-cause cumulative and incremental costs in PLWH in the US using a matched-cohort design.

MATERIALS AND METHODS

This retrospective, multi-year, cross-sectional analysis evaluated annual costs from 2013 to 2017, and projected cumulative costs of HIV from age 25 to 69 years. IQVIA's commercial adjudicated claims database was used to identify patients with HIV and match them with patients without HIV (controls). Cumulative all-cause costs were derived from the health plan-allowed costs incurred from ages 25-69 years. Undiscounted, discounted, and incremental costs between PLWH and non-HIV populations were reported in 2017 US dollars (US$), and annual all-cause costs were estimated for each year by 10-year age bands.

RESULTS

A total of 25,261, 24,134, 31,654, 35,374, and 29,039 PLWH and 75,783, 72,402, 94,962, 106,122, and 87,117 matched controls were identified in the years 2013 through 2017, respectively. The mean undiscounted cumulative costs were $1,840,554 for PLWH and $285,065 for controls, an incremental cost difference of $1,555,489, while the mean discounted cumulative cost for PLWH was $983,897 compared with $133,340 for controls, an incremental cost difference of $850,557. Mean all-cause annual and cumulative costs were up to seven times higher for PLWH compared with controls. There was a trend for costs to increase each year with increasing age.

LIMITATIONS AND CONCLUSIONS

While cumulative all-cause cost estimates only approximate total cost burden for any given patient, and the results of this study may not be generalizable to all population subgroups, this is one of the first US studies to examine annual and cumulative costs in a real-world cohort of commercially insured PLWH compared with a population without HIV. In this large, representative sample of commercially insured US adults with HIV, PLWH had substantially higher all-cause cumulative costs than individuals without HIV.

Potential Impact of Targeted HIV Pre-Exposure Prophylaxis Uptake Among Male Sex Workers

Little is known about the potential population-level impact of HIV pre-exposure prophylaxis (PrEP) use among cisgender male sex workers (MSWs), a high-risk subset of cisgender men who have sex with men (MSM). Using an agent-based model, we simulated HIV transmission among cisgender MSM in Rhode Island to determine the impacts of PrEP implementation where cisgender MSWs were equally ("standard expansion") or five times as likely ("focused expansion") to initiate PrEP compared to other cisgender MSM. Without PrEP, the model predicted 920 new HIV infections over a decade, or an average incidence of 0.39 per 100 person-years. In a focused expansion scenario where 15% of at-risk cisgender MSM used PrEP, the total number of new HIV infections was reduced by 58.1% at a cost of $57,180 per quality-adjusted life-year (QALY) gained. Focused expansion of PrEP use among cisgender MSWs may be an efficient and cost-effective strategy for reducing HIV incidence in the broader population of cisgender MSM.

A Cost and Cost-Threshold Analysis of Implementation of an Evidence-Based Intervention for HIV-Serodiscordant Couples

To address gaps in the cost literature by estimating the cost of delivering an evidence-based HIV risk reduction intervention for HIV-serodiscordant, heterosexual, African American couples (Eban II) and calculating the cost-effective thresholds at three participating sites. The cost, cost-saving, and cost-effectiveness thresholds for Eban II were calculated using standard methods. The analytic time period was from July 1 to September 31, 2014. Total costs for 3 months of program implementation were from $13,747 to $25,937, with societal costs ranging from $5632 to $17,008 and program costs ranging from $8115 to $14,122. The costs per participant were from $1621 to $2160; the cost per session (per participant) ranged from $147 to $196. Sites had achievable cost-saving thresholds, which were all less than one for the 3-month costing timeframe.

Heterogeneity in the costs of medical care among people living with HIV/AIDS in the United States

OBJECTIVE

The costs of medical care for people with HIV/AIDS (PWH) vary substantially across demographic groups, stages of disease progression and regionally across the United States. We aimed to estimate medical costs for PWH and examine the heterogeneity in costs within key patient groups typically distinguished in cost-effectiveness analyses.

DESIGN

Retrospective cohort study using health administrative databases for diagnosed PWH in care at 17 HIV Research Network sites across the United States.

METHODS

We estimated mean quarterly costs for key patient groups using multivariable generalized linear mixed effects models. We used quantile regression to highlight differences in the effect of covariates within each patient group (difference between covariate estimates at the mean versus the 90th percentile of quarterly costs), identifying covariates with a larger effect among the highest cost PWH, or generating greater uncertainty in mean cost estimates.

RESULTS

Our sample included 40 022 patients with a median age of 39 years. Mean quarterly costs were highest for people who inject drugs with advanced disease progression and for PWH on antiretroviral treatment (ART). Within patient groups, we found the most heterogeneity at different levels of resource use for PWH on ART and PWH off ART with CD4 cell counts less than 200 cells/μl, people who inject drugs, as well as PWH in the South.

CONCLUSION

The study quantifies heterogeneity in costs both across and within key PWH patient groups. Our results highlight the need for sensitivity analysis on cost estimates and may inform decisions on model structure in cost-effectiveness analyses on HIV/AIDS treatment and prevention strategies.

An Illustration of the Potential Health and Economic Benefits of Combating Antibiotic-Resistant Gonorrhea

Preventing the emergence of ceftriaxone-resistant Neisseria gonorrhoeae can potentially avert hundreds of millions of dollars in direct medical costs of gonorrhea and gonorrhea-attributable HIV infections. In the illustrative scenario we examined, emerging ceftriaxone resistance could lead to 1.2 million additional N. gonorrhoeae infections within 10 years, costing $378.2 million.

Cost-Utility of Access to Care, a National HIV Linkage, Re-engagement and Retention in Care Program

Linkage to HIV medical care and on-going engagement in HIV medical care are vital for ending the HIV epidemic. However, little is known about the cost-utility of HIV linkage, re-engagement and retention (LRC) in care programs. This paper presents the cost-utility analysis of Access to Care, a national HIV LRC program. Using standard methods from the US Panel on Cost-Effectiveness in Health and Medicine, we calculated the cost-utility ratio. Seven Access to Care programs were cost-effective and two were cost-saving. This study adds to a small but growing body of evidence to support the cost-effectiveness of LRC programs.

The Cost and Cost-utility of Three Public Health HIV Case-finding Strategies: Evidence from Rhode Island, 2012-2014

To evaluate three testing strategies to identify new HIV diagnoses in Rhode Island (RI). RI deployed three testing strategies, by using rapid HIV tests at clinical settings, community-based organization (CBO) settings, and the Partner Notification Services (PNS) program from 2012 to 2014. We reviewed the rapid HIV test results and confirmatory test results to identify new diagnoses, and conducted a cost-utility analysis. The average cost per new diagnosis was $33,015 at CBO settings, $5446 at clinical settings, and $33,818 at the PNS program. The cost-utility analysis showed the state-wide program was cost-saving; testing was cost-saving at clinical settings, and cost-effective at CBO settings and the PNS program. Further analyses showed that cost-effectiveness varied widely across CBOs. The HIV testing expansion program in RI was cost-saving overall. The heterogeneity of cost-effectiveness across settings should provide guidance to officials for allocation of future resources to HIV testing.

Methods for Sexually Transmitted Disease Prevention Programs to Estimate the Health and Medical Cost Impact of Changes in Their Budget

BACKGROUND

The purpose of this article was to describe methods that sexually transmitted disease (STD) programs can use to estimate the potential effects of changes in their budgets in terms of disease burden and direct medical costs.

METHODS

We proposed 2 distinct approaches to estimate the potential effect of changes in funding on subsequent STD burden, one based on an analysis of state-level STD prevention funding and gonorrhea case rates and one based on analyses of the effect of Disease Intervention Specialist (DIS) activities on gonorrhea case rates. We also illustrated how programs can estimate the impact of budget changes on intermediate outcomes, such as partner services. Finally, we provided an example of the application of these methods for a hypothetical state STD prevention program.

RESULTS

The methods we proposed can provide general approximations of how a change in STD prevention funding might affect the level of STD prevention services provided, STD incidence rates, and the direct medical cost burden of STDs. In applying these methods to a hypothetical state, a reduction in annual funding of US $200,000 was estimated to lead to subsequent increases in STDs of 1.6% to 3.6%. Over 10 years, the reduction in funding totaled US $2.0 million, whereas the cumulative, additional direct medical costs of the increase in STDs totaled US $3.7 to US $8.4 million.

CONCLUSIONS

The methods we proposed, though subject to important limitations, can allow STD prevention personnel to calculate evidence-based estimates of the effects of changes in their budget.

Clinical and Economic Effects of a Pharmacist-Administered Antiretroviral Therapy Adherence Clinic for Patients Living with HIV

BACKGROUND

Pharmacists have demonstrated the ability to improve patient adherence to antiretroviral therapy (ART).

OBJECTIVE

To determine the clinical and economic effects of a pharmacist-administered ART adherence clinic for patients living with human immunodeficiency virus (HIV).

METHODS

This pilot study with a pretest-posttest design examined the effect of a pharmacy adherence clinic on patient HIV viral load and CD4 count over a 6-month period. Patients with documented adherence problems were referred to the clinic. The pharmacist counseled patients at baseline and met with patients 1-2 weeks, 6 weeks, 3 months, and 6 months after starting ART. A societal perspective net cost analysis of the pharmacy adherence clinic was conducted to assess the economic efficiency of the intervention.

RESULTS

Twenty-eight patients were enrolled in the study, and 16 patients reached completion. Median HIV RNA significantly decreased from 48,000 copies/mL (interquartile range [IQR] = 16,750-139,000) to undetectable (< 20 copies/mL) at 6 months for all study participants who completed the full intervention (P = 0.001). In the 3 months following the intervention, we estimated that it prevented approximately 0.13 secondary HIV infections among the sexual partners of the 16 participants who completed the intervention. The total cost of the intervention was $16,811 ($1,051 per patient), which was less than the future savings in averted HIV-related medical care expenditures ($49,702).

CONCLUSIONS

A pharmacy adherence clinic that focused on early and sustained ART adherence interventions helped patients with documented medication adherence problems achieve an undetectable HIV RNA. The intervention was highly cost saving, with a return of nearly $3 in future medical care savings per dollar spent on the intervention.

DISCLOSURES

This work was supported in part by a research grant to Dilworth, Mercier, and Borrego from the American Society of Health-System Pharmacists Foundation. Klein and Pinkerton were supported in part by grants T32-MH19985 and P30-MH52776, respectively, from the National Institute of Mental Health. No funding bodies had any role in the study design, data collection, analysis, decision to publish, or preparation of the manuscript. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Health Resources and Services Administration. The authors have no conflicts of interest to disclose. Study concept and design were contributed primarily by Dilworth, Mercier, and Borrego, along with the other authors. Dilworth took the lead in data collection, along with Pinkerton, Klein, Mercier, and Jakeman. Data interpretation was performed by Dilworth and Pinkerton, along with the other authors. The manuscript was written by Dilworth, Klein, and Jakeman, with assistance from the other authors, and revised by Dilworth, Jakeman, and Klein, with assistance from the other authors. The results from this study were presented in part at the 2015 United States Conference on AIDS in Washington, DC, on September 10-13, 2015.

Universal Rapid Human Immunodeficiency Virus Screening at Delivery: A Cost-Effectiveness Analysis

Objective

To determine the cost-effectiveness of universal maternal HIV screening at time of delivery to decrease mother-to-child transmission (MTCT), by comparing the cost and quality-adjusted life years (QALYs) of universal rapid HIV screening at time of delivery to two current standards of care for prenatal HIV screening in the United States.

Study Design

We conducted a cost-effectiveness analysis to compare the cost and QALY of universal intrapartum rapid HIV screening with two current standards of care: (I) opt-out rapid HIV testing limited to patients without previous third-trimester screening and (II) opt-out rapid HIV testing limited to patients without any prenatal screening. We developed a decision-tree model and performed sensitivity analyses to estimate the impact of variances in QALY, estimated lifetime medical costs, HIV prevalence, and cumulative incidence.

Results

The incremental cost-effectiveness ratio for universal screening was $7,973.45/QALY. The results remained robust to sensitivity analysis, except for annual cumulative incidence. In areas with an annual cumulative incidence rate of <0.02% for reproductive-age women, the incremental cost-effectiveness ratio for the expanded program would exceed $89,926.94/QALY, approaching the commonly applied cost-effectiveness thresholds ($100,000/QALY).

Conclusions

Intrapartum universal rapid HIV screening to decrease MTCT appears cost-effective in populations with high HIV incidence in the United States.

The Cost-Effectiveness of Syphilis Screening Among Men Who Have Sex With Men: An Exploratory Modeling Analysis

We adapted a published model to estimate the costs and benefits of screening men who have sex with men for syphilis, including the benefits of preventing syphilis-attributable human immunodeficiency virus. The cost per quality-adjusted life year gained by screening was <US $0 (cost-saving) and US $16,100 in the dynamic and static versions of the model, respectively.

Implementation and Operational Research: A Cost-Effective, Clinically Actionable Strategy for Targeting HIV Preexposure Prophylaxis to High-Risk Men Who Have Sex With Men

BACKGROUND

Preexposure prophylaxis (PrEP) is effective at preventing HIV infection among men who have sex with men (MSM), but there is uncertainty about how to identify high-risk MSM who should receive PrEP.

METHODS

We used a mathematical model to assess the cost-effectiveness of using the HIV Incidence Risk Index for MSM (HIRI-MSM) questionnaire to target PrEP to high-risk MSM. We simulated strategies of no PrEP, PrEP available to all MSM, and eligibility thresholds set to HIRI-MSM scores between 5 and 45, in increments of 5 (where a higher score predicts greater HIV risk). Based on the iPrEx, IPERGAY, and PROUD trials, we evaluated PrEP efficacies from 44% to 86% and annual costs from $5900 to 8700. We designate strategies with incremental cost-effectiveness ratio (ICER) ≤$100,000/quality-adjusted life-year (QALY) as "cost-effective."

RESULTS

Over 20 years, making PrEP available to all MSM is projected to prevent 33.5% of new HIV infections, with an ICER of $1,474,000/QALY. Increasing the HIRI-MSM score threshold reduces the prevented infections, but improves cost-effectiveness. A threshold score of 25 is projected to be optimal (most QALYs gained while still being cost-effective) over a wide range of realistic PrEP efficacies and costs. At low cost and high efficacy (IPERGAY), thresholds of 15 or 20 are optimal across a range of other input assumptions; at high cost and low efficacy (iPrEx), 25 or 30 are generally optimal.

CONCLUSIONS

The HIRI-MSM provides a clinically actionable means of guiding PrEP use. Using a score of 25 to determine PrEP eligibility could facilitate cost-effective use of PrEP among high-risk MSM who will benefit from it most.

The Potential Cost-Effectiveness of Pre-Exposure Prophylaxis Combined with HIV Vaccines in the United States

This economic evaluation aims to support policy-making on the combined use of pre-exposure prophylaxis (PrEP) with HIV vaccines in development by evaluating the potential cost-effectiveness of implementation that would support the design of clinical trials for the assessment of combined product safety and efficacy. The target study population is a cohort of men who have sex with men (MSM) in the United States. Policy strategies considered include standard HIV prevention, daily oral PrEP, HIV vaccine, and their combination. We constructed a Markov model based on clinical trial data and the published literature. We used a payer perspective, monthly cycle length, a lifetime horizon, and a 3% discount rate. We assumed a price of $500 per HIV vaccine series in the base case. HIV vaccines dominated standard care and PrEP. At current prices, PrEP was not cost-effective alone or in combination. A combination strategy had the greatest health benefit but was not cost-effective (ICER = $463,448/QALY) as compared to vaccination alone. Sensitivity analyses suggest a combination may be valuable for higher-risk men with good adherence. Vaccine durability and PrEP drug prices were key drivers of cost-effectiveness. The results suggest that boosting potential may be key to HIV vaccine value.

Cost-utility of HIV Testing Programs Among Men Who Have Sex with Men in the United States

Few groups in the United States (US) are as heavily affected by HIV as men who have sex with men (MSM), yet many MSM remain unaware of their infection. HIV diagnosis is important for decreasing onward transmission and promoting effective treatment for HIV, but the cost-effectiveness of testing programs is not well-established. This study reports on the costs and cost-utility of the MSM Testing Initiative (MTI) to newly diagnose HIV among MSM and link them to medical care. Cost and testing data in 15 US cities from January 2013 to March 2014 were prospectively collected and combined to determine the cost-utility of MTI in each city in terms of the cost per Quality Adjusted Life Years (QALY) saved from payer and societal perspectives. The total venue-based HIV testing costs ranged from $18,759 to $564,284 for nine to fifteen months of MTI implementation. The cost-saving threshold for HIV testing of MSM was $20,645 per new HIV diagnosis. Overall, 27,475 men were tested through venue-based MTI, of whom 807 (3 %) were newly diagnosed with HIV. These new diagnoses were associated with approximately 47 averted HIV infections. The cost per QALY saved by implementation of MTI in each city was negative, indicating that MTI venue-based testing was cost-saving in all cities. The cost-utility of social network and couples testing strategies was, however, dependent on whether the programs newly diagnosed MSM. The cost per new HIV diagnosis varied considerably across cities and was influenced by both the local cost of MSM testing implementation and by the seropositivity rate of those reached by the HIV testing program. While the cost-saving threshold for HIV testing is highly achievable, testing programs must successfully reach undiagnosed HIV-positive individuals in order to be cost-effective. This underscores the need for HIV testing programs which target and engage populations such as MSM who are most likely to have undiagnosed HIV to maximize programmatic benefit and cost-utility.

The Cost and Threshold Analysis of Retention in Care (RiC): A Multi-Site National HIV Care Program

Persons diagnosed with HIV but not retained in HIV medical care accounted for the majority of HIV transmissions in 2009 in the United States (US). There is an urgent need to implement and disseminate HIV retention in care programs; however little is known about the costs associated with implementing retention in care programs. We assessed the costs and cost-saving thresholds for seven Retention in Care (RiC) programs implemented in the US using standard methods recommended by the US Panel on Cost-effectiveness in Health and Medicine. Data were gathered from accounting and program implementation records, entered into a standardized RiC economic analysis spreadsheet, and standardized to a 12 month time frame. Total program costs for from the societal perspective ranged from $47,919 to $423,913 per year or $146 to $2,752 per participant. Cost-saving thresholds ranged from 0.13 HIV transmissions averted to 1.18 HIV transmission averted per year. We estimated that these cost-saving thresholds could be achieved through 1 to 16 additional person-years of viral suppression. Across a range of program models, retention in care interventions had highly achievable cost-saving thresholds, suggesting that retention in care programs are a judicious use of resources.

Unmet HIV Service Needs Among Hispanic Men who Have Sex with Men in the United States

The National HIV/AIDS Strategy (NHAS) originally issued in 2010 targets the reduction of HIV-related health disparities. Hispanic men who have sex with men (MSM) have the third highest burden of incident HIV in the US, but there are no estimates of the unmet HIV service needs for Hispanic MSM. We estimate that of approximately 204,800 Hispanic MSM living with HIV, roughly 46,900 were undiagnosed. 157,900 were diagnosed, and of those, 75,700 were not linked to care and 82,200 were linked. Among diagnosed individuals, 48,800 had undetectable viral loads, and 109,100 had detectable viral loads. An estimated 30,000 of diagnosed Hispanic MSM engage in unprotected, serodiscordant risk behaviors. Total cost to meet service needs and achieve NHAS goals is ~$2.511 billion in 2011 US dollars. Transmission rate modeling suggests this investment would avert 3656 new HIV infections at an economically favorable cost of $61,202 per quality-adjusted life year saved.

Assessing Progress, Impact, and Next Steps in Rolling Out Voluntary Medical Male Circumcision for HIV Prevention in 14 Priority Countries in Eastern and Southern Africa through 2014

BACKGROUND

In 2007, the World Health Organization and the Joint United Nations Programme on HIV/AIDS (UNAIDS) identified 14 priority countries across eastern and southern Africa for scaling up voluntary medical male circumcision (VMMC) services. Several years into this effort, we reflect on progress.

METHODS

Using the Decision Makers' Program Planning Tool (DMPPT) 2.1, we assessed age-specific impact, cost-effectiveness, and coverage attributable to circumcisions performed through 2014. We also compared impact of actual progress to that of achieving 80% coverage among men ages 15-49 in 12 VMMC priority countries and Nyanza Province, Kenya. We populated the models with age-disaggregated VMMC service statistics and with population, mortality, and HIV incidence and prevalence projections exported from country-specific Spectrum/Goals files. We assumed each country achieved UNAIDS' 90-90-90 treatment targets.

RESULTS

More than 9 million VMMCs were conducted through 2014: 43% of the estimated 20.9 million VMMCs required to reach 80% coverage by the end of 2015. The model assumed each country reaches the UNAIDS targets, and projected that VMMCs conducted through 2014 will avert 240,000 infections by the end of 2025, compared to 1.1 million if each country had reached 80% coverage by the end of 2015. The median estimated cost per HIV infection averted was $4,400. Nyanza Province in Kenya, the 11 priority regions in Tanzania, and Uganda have reached or are approaching MC coverage targets among males ages 15-24, while coverage in other age groups is lower. Across all countries modeled, more than half of the projected HIV infections averted were attributable to circumcising 10- to 19-year-olds.

CONCLUSIONS

The priority countries have made considerable progress in VMMC scale-up, and VMMC remains a cost-effective strategy for epidemic impact, even assuming near-universal HIV diagnosis, treatment coverage, and viral suppression. Examining circumcision coverage by five-year age groups will inform countries' decisions about next steps.

Return on Investment From Expenditures Incurred to Eliminate Mother-To-Child Transmission Among HIV-Infected Women in New York State: 1998-2013

BACKGROUND

Eliminating mother-to-child transmission (MTCT) of HIV has been one of New York State's public health priorities, and the goal has been virtually accomplished by meeting criteria established by the Centers for Disease Control and Prevention.

METHODS

We use a return on investment (ROI) approach, from the perspective of the state, to compare expenditures incurred to prevent MTCT of HIV in NYS during the period 1998-2013 to benefits realized, as expressed as HIV treatment costs saved from averting an estimated number of HIV infections among newborns. Extrapolating from the 11.5% incidence rate of HIV-infected newborns in 1997, we projected the number of cases of MTCT of HIV that were averted over the 16-year period. A published estimate of lifetime HIV treatment costs was used to estimate HIV treatment costs saved from the averted infections; expenditures for clinical protocols and other services directly associated with preventing MTCT of HIV were also estimated. The ROI was then calculated by dividing program benefits by the expenditures incurred to achieve these benefits.

RESULTS

We estimate that 898 cases of MTCT of HIV were averted between 1998 and 2013, resulting in a savings of $321.03 million in HIV treatment costs. Expenditures to achieve these benefits totaled $81.07 million, yielding an ROI of $3.96.

CONCLUSIONS

Aside from the human suffering from MTCT of HIV that is averted, expenditures for treatment protocols and interventions to prevent MTCT of HIV are relatively inexpensive and can result in almost 4 times their value in HIV treatment cost savings realized.

Cost Effectiveness of HIV Prevention Interventions in the U.S

INTRODUCTION

The purpose of this study was to assess and compare the cost effectiveness of current HIV prevention interventions in the U.S. using a consistent, standardized methodology.

METHODS

The cost effectiveness of common and emerging HIV biomedical and behavioral prevention interventions as delivered to men who have sex with men, injection drug users, and sexually active heterosexuals was estimated. Data on program costs, intervention efficacy, risk behaviors, and per contact transmission probabilities were collected from peer-reviewed papers and health department reports. These data were combined with 2010 national HIV incidence and prevalence surveillance data in a Bernoulli process model to estimate the reduced annual risk of HIV transmission or acquisition associated with these interventions. The cost per prevented case of HIV and the cost per saved quality-adjusted life year were then calculated. Analyses were conducted between 2014 and 2015.

RESULTS

Interventions to diagnose HIV and provide ongoing care and treatment had the lowest cost per prevented case. Among interventions targeted at specific risk groups, interventions for men who have sex with men were the most cost effective. The least cost-effective interventions typically addressed people at risk of acquiring HIV rather than those at risk of transmitting the disease.

CONCLUSIONS

HIV prevention interventions targeted at high-risk populations, those associated with the care continuum, and those that reduce the transmission risk of HIV-infected people are typically the most cost effective. Decision makers can consider these results in planning an efficient allocation of HIV prevention resources.

Cost-Utility Analysis of Three U.S. HIV Linkage and Re-engagement in Care Programs from Positive Charge

Linking and retaining people living with HIV in ongoing, HIV medical care is vital for ending the U.S. HIV epidemic. Yet, 41-44 % of HIV+ individuals are out of care. In response, AIDS United initiated Positive Charge, a series of five HIV linkage and re-engagement projects around the U.S. This paper investigates whether three Positive Charge programs were cost effective and calculates a return on investment for each program. It uses standard methods of cost utility analysis and WHO-CHOICE thresholds. All three projects were found to be cost effective, and two were highly cost effective. Cost utility ratios ranged from $4439 to $137,271. These results suggest that HIV linkage to care programs are a productive and efficient use of public health funds.

Cost and cost threshold analyses for 12 innovative US HIV linkage and retention in care programs

Out of >1,000,000 people living with HIV in the USA, an estimated 60% were not adequately engaged in medical care in 2011. In response, AIDS United spearheaded 12 HIV linkage and retention in care programs. These programs were supported by the Social Innovation Fund, a White House initiative. Each program reflected the needs of its local population living with HIV. Economic analyses of such programs, such as cost and cost threshold analyses, provide important information for policy-makers and others allocating resources or planning programs. Implementation costs were examined from societal and payer perspectives. This paper presents the results of cost threshold analyses, which provide an estimated number of HIV transmissions that would have to be averted for each program to be considered cost-saving and cost-effective. The methods were adapted from the US Panel on Cost-effectiveness in Health and Medicine. Per client program costs ranged from $1109.45 to $7602.54 from a societal perspective. The cost-saving thresholds ranged from 0.32 to 1.19 infections averted, and the cost-effectiveness thresholds ranged from 0.11 to 0.43 infections averted by the programs. These results suggest that such programs are a sound and efficient investment towards supporting goals set by US HIV policy-makers. Cost-utility data are pending.

A SWOT Analysis of the Updated National HIV/AIDS Strategy for the U.S., 2015-2020

In July 2015, President Barack Obama released an updated National HIV/AIDS Strategy (NHAS) for the United States to guide HIV efforts through the year 2020. A federal action plan to accompany the updated NHAS will be released in December 2015. In this editorial, we offer a strengths, weaknesses, opportunities and threats analysis with the aim of increasing discussion of ways to truly fulfill the promise of the updated NHAS and to address barriers that may thwart it from achieving its full potential.

The lifetime medical cost savings from preventing HIV in the United States

OBJECTIVE

Enhanced HIV prevention interventions, such as preexposure prophylaxis for high-risk individuals, require substantial investments. We sought to estimate the medical cost saved by averting 1 HIV infection in the United States.

METHODS

We estimated lifetime medical costs in persons with and without HIV to determine the cost saved by preventing 1 HIV infection. We used a computer simulation model of HIV disease and treatment (CEPAC) to project CD4 cell count, antiretroviral treatment status, and mortality after HIV infection. Annual medical cost estimates for HIV-infected persons, adjusted for age, sex, race/ethnicity, and transmission risk group, were from the HIV Research Network (range, $1854-$4545/mo) and for HIV-uninfected persons were from the Medical Expenditure Panel Survey (range, $73-$628/mo). Results are reported as lifetime medical costs from the US health system perspective discounted at 3% (2012 USD).

RESULTS

The estimated discounted lifetime cost for persons who become HIV infected at age 35 is $326,500 (60% for antiretroviral medications, 15% for other medications, 25% nondrug costs). For individuals who remain uninfected but at high risk for infection, the discounted lifetime cost estimate is $96,700. The medical cost saved by avoiding 1 HIV infection is $229,800. The cost saved would reach $338,400 if all HIV-infected individuals presented early and remained in care. Cost savings are higher taking into account secondary infections avoided and lower if HIV infections are temporarily delayed rather than permanently avoided.

CONCLUSIONS

The economic value of HIV prevention in the United States is substantial given the high cost of HIV disease treatment.

Return on investment: a fuller assessment of the benefits and cost savings of the US publicly funded family planning program

Policy Points: The US publicly supported family planning effort serves millions of women and men each year, and this analysis provides new estimates of its positive impact on a wide range of health outcomes and its net savings to the government. The public investment in family planning programs and providers not only helps women and couples avoid unintended pregnancy and abortion, but also helps many thousands avoid cervical cancer, HIV and other sexually transmitted infections, infertility, and preterm and low birth weight births. This investment resulted in net government savings of $13.6 billion in 2010, or $7.09 for every public dollar spent.

CONTEXT

Each year the United States' publicly supported family planning program serves millions of low-income women. Although the health impact and public-sector savings associated with this program's services extend well beyond preventing unintended pregnancy, they never have been fully quantified.

METHODS

Drawing on an array of survey data and published parameters, we estimated the direct national-level and state-level health benefits that accrued from providing contraceptives, tests for the human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs), Pap tests and tests for human papillomavirus (HPV), and HPV vaccinations at publicly supported family planning settings in 2010. We estimated the public cost savings attributable to these services and compared those with the cost of publicly funded family planning services in 2010 to find the net public-sector savings. We adjusted our estimates of the cost savings for unplanned births to exclude some mistimed births that would remain publicly funded if they had occurred later and to include the medical costs for births through age 5 of the child.

FINDINGS

In 2010, care provided during publicly supported family planning visits averted an estimated 2.2 million unintended pregnancies, including 287,500 closely spaced and 164,190 preterm or low birth weight (LBW) births, 99,100 cases of chlamydia, 16,240 cases of gonorrhea, 410 cases of HIV, and 13,170 cases of pelvic inflammatory disease that would have led to 1,130 ectopic pregnancies and 2,210 cases of infertility. Pap and HPV tests and HPV vaccinations prevented an estimated 3,680 cases of cervical cancer and 2,110 cervical cancer deaths; HPV vaccination also prevented 9,000 cases of abnormal sequelae and precancerous lesions. Services provided at health centers supported by the Title X national family planning program accounted for more than half of these benefits. The gross public savings attributed to these services totaled approximately $15.8 billion-$15.7 billion from preventing unplanned births, $123 million from STI/HIV testing, and $23 million from Pap and HPV testing and vaccines. Subtracting $2.2 billion in program costs from gross savings resulted in net public-sector savings of $13.6 billion.

CONCLUSIONS

Public expenditures for the US family planning program not only prevented unintended pregnancies but also reduced the incidence and impact of preterm and LBW births, STIs, infertility, and cervical cancer. This investment saved the government billions of public dollars, equivalent to an estimated taxpayer savings of $7.09 for every public dollar spent.

Cost-effectiveness of interventions to prevent HIV and STDs among women: a randomized controlled trial

Injection drug use is a leading transmission route of HIV and STDs, and disease prevention among drug users is an important public health concern. This study assesses cost-effectiveness of behavioral interventions for reducing HIV and STDs infections among injection drug-using women. Cost-effectiveness analysis was conducted from societal and provider perspectives for randomized trial data and Bernoullian model estimates of infections averted for three increasingly intensive interventions: (1) NIDA's standard intervention (SI); (2) SI plus a well woman exam (WWE); and (3) SI, WWE, plus four educational sessions (4ES). Trial results indicate that 4ES was cost-effective relative to WWE, which was dominated by SI, for most diseases. Model estimates, however, suggest that WWE was cost-effective relative to SI and dominated 4ES for all diseases. Trial and model results agree that WWE is cost-effective relative to SI per hepatitis C infection averted ($109 308 for in trial, $6 016 in model) and per gonorrhea infection averted ($9 461 in trial, $14 044 in model). In sensitivity analysis, trial results are sensitive to 5 % change in WWE effectiveness relative to SI for hepatitis C and HIV. In the model, WWE remained cost-effective or cost-saving relative to SI for HIV prevention across a range of assumptions. WWE is cost-effective relative to SI for preventing hepatitis C and gonorrhea. WWE may have similar effects as the costlier 4ES.

A user-friendly, open-source tool to project impact and cost of diagnostic tests for tuberculosis

Most models of infectious diseases, including tuberculosis (TB), do not provide results customized to local conditions. We created a dynamic transmission model to project TB incidence, TB mortality, multidrug-resistant (MDR) TB prevalence, and incremental costs over 5 years after scale-up of nine alternative diagnostic strategies. A corresponding web-based interface allows users to specify local costs and epidemiology. In settings with little capacity for up-front investment, same-day microscopy had the greatest impact on TB incidence and became cost-saving within 5 years if delivered at $10/test. With greater initial investment, population-level scale-up of Xpert MTB/RIF or microcolony-based culture often averted 10 times more TB cases than narrowly-targeted strategies, at minimal incremental long-term cost. Xpert for smear-positive TB had reasonable impact on MDR-TB incidence, but at substantial price and little impact on overall TB incidence and mortality. This user-friendly modeling framework improves decision-makers' ability to evaluate the local impact of TB diagnostic strategies.

DOI:http://dx.doi.org/10.7554/eLife.02565.001

Tuberculosis is an infectious bacterial disease caused predominantly by the microorganism Mycobacterium tuberculosis. Although the number of deaths from tuberculosis has been falling in recent years, the disease still kills more than 1 million people every year, mainly in developing countries. Tuberculosis can be treated with antibiotics, but the emergence of bacteria that are resistant to existing drugs is threatening efforts to eradicate the disease.

Preventing the spread of tuberculosis is heavily dependent on accurate diagnosis of individuals with the disease. This is challenging because the initial symptoms are often mild, usually just a cough, which means that someone can spread the disease to many others over a period of several months before the symptoms become worse—fever, night sweats, and weight loss—and they realize that they are sick. Multiple diagnostic strategies are available, from the relatively low-tech—examining sputum samples under a microscope to detect tuberculosis bacteria—to more sophisticated tests that can detect bacterial DNA and determine whether the bacteria are drug-resistant in less than 2 hr.

Choosing which diagnostic strategy to adopt can be challenging because the optimal solution in a region will depend on the specific local conditions. To overcome this problem, Dowdy et al. have developed a computer program that enables decision-makers to input four key parameters that describe the tuberculosis situation in their region, and to obtain 5-year projections of the rate of new infections, mortality, and total costs likely to result from adopting any of nine different diagnostic strategies.

The four parameters are the number of new cases of tuberculosis each year (incidence), the proportion of new cases that are multi-drug resistant, the proportion of the adult population that has HIV, and the local costs of various diagnostic techniques and treatments. Since the entire computer program is written in a freely available open-source programming language (Python), any user can tweak these parameters to provide a more precise fit to their own region. Alternatively, the standard version of the program can be run directly from a website without any need to interact with computer code.

This model is the first to enable local decision-makers to evaluate the impact of different diagnostic strategies for tuberculosis under the conditions specific to their region. The model predicts, for example, that in areas where there is little money available for up-front investment, same-day microscopy analysis of sputum samples and starting patients on treatment is the most cost-effective strategy for reducing the rate of new infections. Given the wide variation in conditions within even small geographical areas, this more flexible approach should lead to the more efficient use of resources and may, ultimately, help to reduce the spread of tuberculosis.

DOI:http://dx.doi.org/10.7554/eLife.02565.002