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Hahn JA, Kevany S, Emenyonu NI, Sanyu N, Katusiime A, Muyindike WR, Fatch R, Shade SB. Costs of a Brief Alcohol Consumption Reduction Intervention for Persons Living with HIV in Southwestern Uganda: Comparisons of Live Versus Automated Cell Phone-Based Booster Components. AIDS Behav 2023:10.1007/s10461-023-04010-6. [PMID: 36807244 PMCID: PMC10386919 DOI: 10.1007/s10461-023-04010-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2023] [Indexed: 02/23/2023]
Abstract
Low-cost interventions are needed to reduce alcohol use among persons with HIV (PWH) in low-income settings. Brief alcohol interventions hold promise, and technology may efficiently deliver brief intervention components with high frequency. We conducted a costing study of the components of a randomized trial that compared a counselling-based intervention with two in-person one-on-one sessions supplemented by booster sessions to reinforce the intervention among PWH with unhealthy alcohol use in southwest Uganda. Booster sessions were delivered twice weekly by two-way short message service (SMS) or Interactive Voice Response (IVR), i.e. via technology, or approximately monthly via live calls from counsellors. We found no significant intervention effects compared to the control, however the cost of the types of booster sessions differed. Start up and recurring costs for the technology-delivered booster sessions were 2.5 to 3 times the cost per participant of the live-call delivered booster intervention for 1000 participants. These results suggest technology-based interventions for PWH are unlikely to be lower cost than person-delivered interventions unless they are at very large scale.
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Affiliation(s)
- Judith A Hahn
- University of California, 550 16th Street, 3rd Floor, San Francisco, 94158, USA.
| | - Sebastian Kevany
- Asia-Pacific Center for Security Studies, Hawaii, USA.,United Nations University, Tokyo, Japan.,University of Leeds, Leeds, United Kingdom
| | - Nneka I Emenyonu
- University of California, 550 16th Street, 3rd Floor, San Francisco, 94158, USA
| | - Naomi Sanyu
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Anita Katusiime
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Robin Fatch
- University of California, 550 16th Street, 3rd Floor, San Francisco, 94158, USA
| | - Starley B Shade
- University of California, 550 16th Street, 3rd Floor, San Francisco, 94158, USA
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Blackburn NA, Go VF, Bui Q, Hutton H, Tampi RP, Sripaipan T, Ha TV, Latkin CA, Golden S, Golin C, Chander G, Frangakis C, Gottfredson N, Dowdy DW. The Cost-Effectiveness of Adapting and Implementing a Brief Intervention to Target Frequent Alcohol Use Among Persons with HIV in Vietnam. AIDS Behav 2021; 25:2108-2119. [PMID: 33392969 PMCID: PMC8576395 DOI: 10.1007/s10461-020-03139-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2020] [Indexed: 01/21/2023]
Abstract
Brief interventions to reduce frequent alcohol use among persons with HIV (PWH) are evidence-based, but resource-constrained settings must contend with competition for health resources. We evaluated the cost-effectiveness of two intervention arms compared to the standard of care (SOC) in a three-arm randomized control trial targeting frequent alcohol use in PWH through increasing the percent days abstinent from alcohol and viral suppression. We estimated incremental cost per quality-adjusted life year (QALY) gained from a modified societal perspective and a 1-year time horizon using a Markov model of health outcomes. The two-session brief intervention (BI), relative to the six-session combined intervention (CoI), was more effective and less costly; the estimated incremental cost-effectiveness of the BI relative to the SOC, was $525 per QALY gained. The BI may be cost-effective for the HIV treatment setting; the health utility gained from viral suppression requires further exploration.
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Affiliation(s)
- Natalie A Blackburn
- Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Drive, CB #7420, Chapel Hill, NC, 27599-7420, USA.
| | - Vivian F Go
- Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Drive, CB #7420, Chapel Hill, NC, 27599-7420, USA
| | - Quynh Bui
- University of North Carolina Project Vietnam, Hanoi, Vietnam
| | - Heidi Hutton
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Radhika P Tampi
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Teerada Sripaipan
- Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Drive, CB #7420, Chapel Hill, NC, 27599-7420, USA
| | - Tran Viet Ha
- University of North Carolina Project Vietnam, Hanoi, Vietnam
| | - Carl A Latkin
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shelley Golden
- Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Drive, CB #7420, Chapel Hill, NC, 27599-7420, USA
| | - Carol Golin
- Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Drive, CB #7420, Chapel Hill, NC, 27599-7420, USA
| | - Geetanjali Chander
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Constantine Frangakis
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nisha Gottfredson
- Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Drive, CB #7420, Chapel Hill, NC, 27599-7420, USA
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Papas RK, Gakinya BN, Mwaniki MM, Lee H, Keter AK, Martino S, Klein DA, Liu T, Loxley MP, Sidle JE, Schlaudt K, Nafula T, Omodi VM, Baliddawa JB, Kinyanjui DW, Maisto SA. A randomized clinical trial of a group cognitive-behavioral therapy to reduce alcohol use among human immunodeficiency virus-infected outpatients in western Kenya. Addiction 2021; 116:305-318. [PMID: 32422685 PMCID: PMC7671944 DOI: 10.1111/add.15112] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/28/2019] [Accepted: 05/11/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS Culturally relevant and feasible interventions are needed to address limited professional resources in sub-Saharan Africa for behaviorally treating the dual epidemics of HIV and alcohol use disorder. This study tested the efficacy of a cognitive-behavioral therapy (CBT) intervention to reduce alcohol use among HIV-infected outpatients in Eldoret, Kenya. DESIGN Randomized clinical trial. SETTING A large HIV outpatient clinic in Eldoret, Kenya, affiliated with the Academic Model Providing Access to Healthcare collaboration. PARTICIPANTS A total of 614 HIV-infected outpatients [312 CBT; 302 healthy life-styles (HL); 48.5% male; mean age: 38.9 years; mean education 7.7 years] who reported a minimum of hazardous or binge drinking. INTERVENTION AND COMPARATOR A culturally adapted six-session gender-stratified group CBT intervention compared with HL education, each delivered by paraprofessionals over six weekly 90-minute sessions with a 9-month follow-up. MEASUREMENTS Primary outcome measures were percentage of drinking days (PDD) and mean drinks per drinking day (DDD) computed from retrospective daily number of drinks data obtained by use of the time-line follow-back from baseline to 9 months post-intervention. Exploratory analyses examined unprotected sex and number of partners. FINDINGS Median attendance was six sessions across condition. Retention at 9 months post-intervention was high and similar by condition: CBT 86% and HL 83%. PDD and DDD marginal means were significantly lower in CBT than HL at all three study phases. Maintenance period, PDD - CBT = 3.64 (0.696), HL = 5.72 (0.71), mean difference 2.08, 95% confidence interval (CI) = 0.13 - 4.04; DDD - CBT = 0.66 (0.96), HL = 0.98 (0.098), mean difference = 0.31, 95% CI = 0.05 - 0.58. Risky sex decreased over time in both conditions, with a temporary effect for CBT at the 1-month follow-up. CONCLUSIONS A cognitive-behavioral therapy intervention was more efficacious than healthy lifestyles education in reducing alcohol use among HIV-infected Kenyan outpatient drinkers.
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Affiliation(s)
| | - Benson N. Gakinya
- Moi University College of Health Sciences, School of Medicine, Eldoret, Kenya
| | | | - Hana Lee
- Brown University School of Public Health, Providence, RI, USA
| | - Alfred K. Keter
- Academic Model providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Steve Martino
- Yale University School of Medicine, New Haven, CT, USA
| | | | - Tao Liu
- Brown University School of Public Health, Providence, RI, USA
| | | | - John E. Sidle
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Tobista Nafula
- Academic Model providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Victor M. Omodi
- Academic Model providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Joyce B. Baliddawa
- Moi University College of Health Sciences, School of Medicine, Eldoret, Kenya
| | - Daniel W. Kinyanjui
- Moi University College of Health Sciences, School of Medicine, Eldoret, Kenya
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Patel AR, Ruggles KV, Nucifora K, Zhou Q, Schensul S, Schensul J, Bryant K, Braithwaite RS. Evaluating Alternative Designs of a Multilevel HIV Intervention in Maharashtra, India: The Impact of Stakeholder Constraints. MDM Policy Pract 2018; 3:2381468318803940. [PMID: 30349875 PMCID: PMC6194934 DOI: 10.1177/2381468318803940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 08/20/2018] [Indexed: 11/16/2022] Open
Abstract
Background. Multilevel interventions combine individual component interventions, and their design can be informed by decision analysis. Our objective was to identify the optimal combination of interventions for alcohol-using HIV+ individuals on antiretroviral drug therapy in Maharashtra, India, explicitly considering stakeholder constraints. Methods. Using an HIV simulation, we evaluated the expected net monetary benefit (ENMB), the probability of lying on the efficiency frontier (PEF), and annual program costs of 5,836 unique combinations of 15 single-focused HIV risk-reduction interventions. We evaluated scenarios of 1) no constraints (i.e., maximize expected value), 2) short-term budget constraints (limits on annual programmatic costs of US$200,000 and $400,000), and 3) a constraint stemming from risk aversion (requiring that the strategy has >50% PEF). Results. With no constraints, the combination including long individual alcohol counseling, text-message adherence support, long group counseling for sex-risk, and long individual counseling for sex-risk (annual cost = $428,886; PEF ∼27%) maximized ENMB and would be the optimal design. With a cost constraint of $400,000, the combination including long individual alcohol counseling, text-message adherence support, brief group counseling for sex-risk, and long individual counseling for sex-risk (annual cost = $374,745; PEF ∼4%) maximized ENMB. With a cost constraint of $200,000, the combination including long individual alcohol counseling, text-message adherence support, and brief group counseling for sex-risk (annual cost = $187,335; PEF ∼54%) maximized ENMB. With the risk aversion constraint, the same configuration (long individual alcohol counseling, text-message support, and brief group counseling for sex-risk) maximized health benefit. Conclusion. Evaluating the costs, risks, and projected benefits of alternatives supports informed decision making prior to initiating study; however, stakeholder constraints should be explicitly included and discussed when using decision analyses to guide study design.
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Affiliation(s)
- Anik R Patel
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kelly V Ruggles
- Department of Population Health, New York University School of Medicine, New York
| | - Kimberly Nucifora
- Department of Population Health, New York University School of Medicine, New York
| | - Qinlian Zhou
- Department of Population Health, New York University School of Medicine, New York
| | - Stephen Schensul
- Department of Community Medicine and Health Care, University of Connecticut, Storrs, Connecticut
| | - Jean Schensul
- Institute of Community Research, Hartford, Connecticut
| | - Kendall Bryant
- National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland
| | - R Scott Braithwaite
- Department of Population Health, New York University School of Medicine, New York
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Parry CDH, Tomlinson M, Bryant K, Rotherham-Borus MJ. Fresh Perspectives on the Alcohol and HIV Nexus: A Call for Action in an Era of Increased Opportunities and Challenges. AIDS Behav 2017; 21:121-125. [PMID: 28956194 PMCID: PMC5839632 DOI: 10.1007/s10461-017-1917-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Charles D H Parry
- Alcohol Tobacco & Other Drug Research Unit, South African Medical Research Council, Tygerberg, South Africa.
- Department of Psychiatry, Stellenbosch University, PO Box 19070, Tygerberg, 7505, South Africa.
| | - Mark Tomlinson
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
| | - Kendall Bryant
- HIV/AIDS and Alcohol Research Program, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Mary Jane Rotherham-Borus
- Global Center for Children and Families, Semel Institute and the Department of Psychiatry, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
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Ruggles KV, Patel AR, Schensul S, Schensul J, Nucifora K, Zhou Q, Bryant K, Braithwaite RS. Betting on the fastest horse: Using computer simulation to design a combination HIV intervention for future projects in Maharashtra, India. PLoS One 2017; 12:e0184179. [PMID: 28873452 PMCID: PMC5584966 DOI: 10.1371/journal.pone.0184179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 08/18/2017] [Indexed: 11/18/2022] Open
Abstract
Objective To inform the design of a combination intervention strategy targeting HIV-infected unhealthy alcohol users in Maharashtra, India, that could be tested in future randomized control trials. Methods Using probabilistic compartmental simulation modeling we compared intervention strategies targeting HIV-infected unhealthy alcohol users on antiretroviral therapy (ART) in Maharashtra, India. We tested interventions targeting four behaviors (unhealthy alcohol consumption, risky sexual behavior, depression and antiretroviral adherence), in three formats (individual, group based, community) and two durations (shorter versus longer). A total of 5,386 possible intervention combinations were tested across the population for a 20-year time horizon and intervention bundles were narrowed down based on incremental cost-effectiveness analysis using a two-step probabilistic uncertainty analysis approach. Results Taking into account uncertainty in transmission variables and intervention cost and effectiveness values, we were able to reduce the number of possible intervention combinations to be used in a randomized control trial from over 5,000 to less than 5. The most robust intervention bundle identified was a combination of three interventions: long individual alcohol counseling; weekly Short Message Service (SMS) adherence counseling; and brief sex risk group counseling. Conclusions In addition to guiding policy design, simulation modeling of HIV transmission can be used as a preparatory step to trial design, offering a method for intervention pre-selection at a reduced cost.
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Affiliation(s)
- Kelly V. Ruggles
- Department of Medicine, New York University School of Medicine, New York, NY, United States of America
- * E-mail:
| | - Anik R. Patel
- Department of Experimental Medicine, University of British Columbia Faculty of Medicine, Vancouver, BC, Canada
| | - Stephen Schensul
- Department of Community Medicine and Health Care, University of Connecticut Health Center, Farmington, CT, United States of America
| | - Jean Schensul
- Institute for Community Research, Hartford, CT, United States of America
| | - Kimberly Nucifora
- Department of Population Health, New York University School of Medicine, New York, NY, United States of America
| | - Qinlian Zhou
- Department of Population Health, New York University School of Medicine, New York, NY, United States of America
| | - Kendall Bryant
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, United States of America
| | - R. Scott Braithwaite
- Department of Population Health, New York University School of Medicine, New York, NY, United States of America
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Kiwanuka N, Ssetaala A, Ssekandi I, Nalutaaya A, Kitandwe PK, Ssempiira J, Bagaya BS, Balyegisawa A, Kaleebu P, Hahn J, Lindan C, Sewankambo NK. Population attributable fraction of incident HIV infections associated with alcohol consumption in fishing communities around Lake Victoria, Uganda. PLoS One 2017; 12:e0171200. [PMID: 28207844 PMCID: PMC5313154 DOI: 10.1371/journal.pone.0171200] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 01/18/2017] [Indexed: 12/16/2022] Open
Abstract
Background Although the association between alcohol consumption and HIV risk is well documented, few studies have examined the magnitude of new HIV infections that could be prevented by controlling alcohol use. We report the population attributable fraction (PAF) of incident HIV infections due to alcohol consumption among the HIV high-risk population of fishing communities along Lake Victoria, Uganda. Methods In a community-based cohort study, 1607 HIV sero-negative participants aged 18–49 years were enrolled from eight fishing communities along Lake Victoria, Uganda. At follow up 12 months later, 1288 (80.1%) were seen and interviewed. At baseline and follow-up visits, participants completed interviewer-administered questionnaires on alcohol consumption, demographics, and sexual risk behavior, and were tested for HIV infection. HIV incidence and adjusted incident rate ratios (adjusted IRRs) were estimated using Poisson regression models; the crude and adjusted PAFs of incident HIV infections associated with alcohol consumption were calculated using the Greenland and Drescher method for cohort studies. Results Among the 1288 participants seen at follow up, 53.5% reported drinking alcohol of whom 24.4% drank occasionally (2 days a week or less) and 29.1% drank regularly (3–7 days a week). Forty eight incident HIV infections occurred giving an incidence rate of 3.39/100 person years at-risk (pyar) (95% CI, 2.55–4.49). Compared to non-drinkers, the adjusted IRR of HIV was 3.09 (1.13–8.46) among occasional drinkers and 5.34 (2.04–13.97) among regular drinkers. The overall adjusted PAF of incident HIV infections due alcohol was 64.1 (95% CI; 23.5–83.1); ranging from 52.3 (11.9–74.2) among Muslims to 71.2 (32.6–87.7) for participants who reported ≥ 2 sexual partners in the past 12 months. Conclusion In fishing communities along Lake Victoria, Uganda, 64% of new HIV infections can be attributed to drinking alcohol. Interventions to reduce alcohol consumption should be integrated in HIV/AIDS prevention activities for populations in whom both HIV and alcohol consumption are highly prevalent.
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Affiliation(s)
- Noah Kiwanuka
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda
- Uganda Virus Research Institute-International AIDS Vaccine Initiative HIV Vaccine Program, Entebbe, Uganda
- * E-mail:
| | - Ali Ssetaala
- Uganda Virus Research Institute-International AIDS Vaccine Initiative HIV Vaccine Program, Entebbe, Uganda
| | - Ismail Ssekandi
- Uganda Virus Research Institute-International AIDS Vaccine Initiative HIV Vaccine Program, Entebbe, Uganda
| | - Annet Nalutaaya
- Uganda Virus Research Institute-International AIDS Vaccine Initiative HIV Vaccine Program, Entebbe, Uganda
| | - Paul Kato Kitandwe
- Uganda Virus Research Institute-International AIDS Vaccine Initiative HIV Vaccine Program, Entebbe, Uganda
| | - Julius Ssempiira
- Uganda Virus Research Institute-International AIDS Vaccine Initiative HIV Vaccine Program, Entebbe, Uganda
| | - Bernard Ssentalo Bagaya
- Uganda Virus Research Institute-International AIDS Vaccine Initiative HIV Vaccine Program, Entebbe, Uganda
- Department of Medical Microbiology, School of Biomedical Sciences, Makerere University, Kampala, Uganda
| | - Apolo Balyegisawa
- International AIDS Vaccine Initiative (IAVI), New York, New York, United States of America
| | - Pontiano Kaleebu
- Medical Research Council/Uganda Virus Research Insitute, Uganda Research Unit on AIDS, Entebbe, Uganda
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Judith Hahn
- Department of Medicine, School of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Christina Lindan
- Department of Medicine, School of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Nelson Kaulukusi Sewankambo
- Makerere University College of Health Sciences, School of Medicine, Clinical Epidemiology Unit, Kampala, Uganda
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Kraemer KL. Can a Behavioral Alcohol Intervention be Delivered Cost-Effectively to Persons Living with HIV/AIDS in Sub-Saharan Africa? Alcohol Clin Exp Res 2016; 40:50-1. [PMID: 26727522 DOI: 10.1111/acer.12934] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 10/16/2015] [Indexed: 01/27/2023]
Affiliation(s)
- Kevin L Kraemer
- Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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