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When Global ART Budgets Cannot Cover All Patients, Who Should Be Eligible? J Acquir Immune Defic Syndr 2020; 81:134-137. [PMID: 30839381 DOI: 10.1097/qai.0000000000002017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Widely expected cuts to budgets for global HIV/AIDS response force hard prioritization choices. SETTING We examine policies for antiretroviral therapy (ART) eligibility through the lens of the most relevant ethical approaches. METHODS We compare earlier ART eligibility to later ART eligibility in terms of saving the most lives, life-years, and quality-adjusted life-years, special consideration for the sickest, special consideration for those who stand to benefit the most, special consideration for recipients' own health needs, and special consideration to avoid denying ART permanently. RESULTS We argue that, in most low- and middle-income countries with generalized HIV/AIDS epidemic, ethically, ART for sicker patients should come before ART eligibility for healthier ones immediately on diagnosis (namely, before "universal test and treat"). In particular, reserving all ART for sicker patients would usually save more life-years, prioritize the sickest, and display other properties that some central ethical approaches find important, and that concern none-so ethically, it is "cross-theoretically dominant," as we put it. CONCLUSIONS In most circumstances of depressed financing in low- and middle-income countries with generalized HIV/AIDS epidemic, reserving all ART for sicker patients is more ethical than the current international standard.
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The validity of the SF-12 and SF-6D instruments in people living with HIV/AIDS in Kenya. Health Qual Life Outcomes 2017; 15:143. [PMID: 28716065 PMCID: PMC5513113 DOI: 10.1186/s12955-017-0708-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 06/21/2017] [Indexed: 11/24/2022] Open
Abstract
Background Health-related quality of life (HRQoL) and health state utility value (HSUV) measurements are vital components of healthcare clinical and economic evaluations. Accurate measurement of HSUV and HRQoL require validated instruments. The 12-item Short-Form Health Survey (SF-12) is one of few instruments that can evaluate both HRQoL and HSUV, but its validity has not been assessed in people living with HIV/AIDS (PLWHA) in east Africa, where the burden of HIV is high. Methods This cross-sectional study used baseline data from a randomized trial involving PLWHA in Kenya. Data included responses from a translated and adapted SF-12 survey as well as key demographic and clinical data. Construct validity of the survey was examined by testing the SF-12’s ability to distinguish between groups known in advance to have differences in their health based on their disease severity. We classified disease severity based on established definitions from the US Center for Disease Control (CDC) and WHO, as well as a previously studied viral load threshold. T-tests and ANOVA were used to test for differences in HRQoL and HSUV scores. Area under the receive operator curve (AUC) was used to test the discriminative ability of the HRQoL and HSUV instruments. Results Differences in physical component scores met the minimum clinically important difference among participants with more advanced HIV when defined by CD4 count (4.3 units) and WHO criteria (compared to stage 1, stages 2, 3 and 4 were 2.0, 7.2 and 9.8 units lower respectively). Mental score differences met the minimum clinically important difference between WHO stage 1 and stage 4 patients (4.4). Differences in the HSUV were statistically lower in more advanced HIV by all three definitions of severity. The AUC showed poor to weak discriminatory ability in most analyses, but had fair discriminatory ability between WHO clinical stage 1 and clinical stage 4 individuals (AUC = 0.71). Conclusion Our findings suggest that the Kiswahili translated and adapted version of the SF-12 could be used as an assessment tool for physical health, mental health and HSUV for Kiswahili-speaking PLHWA. Trial registration Clinical trials.gov identifier: NCT00830622. Registered 26 January 2009.
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The impact of HCV therapy in a high HIV-HCV prevalence population: A modeling study on people who inject drugs in Ho Chi Minh City, Vietnam. PLoS One 2017; 12:e0177195. [PMID: 28493917 PMCID: PMC5426709 DOI: 10.1371/journal.pone.0177195] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 04/23/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Human Immunodeficiency Virus (HIV) and Hepatitis C Virus (HCV) coinfection is a major global health problem especially among people who inject drugs (PWID), with significant clinical implications. Mathematical models have been used to great effect to shape HIV care, but few have been proposed for HIV/HCV. METHODS We constructed a deterministic compartmental ODE model that incorporated layers for HIV disease progression, HCV disease progression and PWID demography. Antiretroviral therapy (ART) and Methadone Maintenance Therapy (MMT) scale-ups were modeled as from 2016 and projected forward 10 years. HCV treatment roll-out was modeled beginning in 2026, after a variety of MMT scale-up scenarios, and projected forward 10 years. RESULTS Our results indicate that scale-up of ART has a major impact on HIV though not on HCV burden. MMT scale-up has an impact on incidence of both infections. HCV treatment roll-out has a measurable impact on reductions of deaths, increasing multifold the mortality reductions afforded by just ART/MMT scale-ups. CONCLUSION HCV treatment roll-out can have major and long-lasting effects on averting PWID deaths on top of those averted by ART/MMT scale-up. Efficient intervention scale-up of HCV alongside HIV interventions is critical in Vietnam.
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Simultaneous Treatment of Missing Data and Measurement Error in HIV Research Using Multiple Overimputation. Epidemiology 2016. [PMID: 26214336 DOI: 10.1097/ede.0000000000000334] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Both CD4 count and viral load in HIV-infected persons are measured with error. There is no clear guidance on how to deal with this measurement error in the presence of missing data. METHODS We used multiple overimputation, a method recently developed in the political sciences, to account for both measurement error and missing data in CD4 count and viral load measurements from four South African cohorts of a Southern African HIV cohort collaboration. Our knowledge about the measurement error of ln CD4 and log10 viral load is part of an imputation model that imputes both missing and mismeasured data. In an illustrative example, we estimate the association of CD4 count and viral load with the hazard of death among patients on highly active antiretroviral therapy by means of a Cox model. Simulation studies evaluate the extent to which multiple overimputation is able to reduce bias in survival analyses. RESULTS Multiple overimputation emphasizes more strongly the influence of having high baseline CD4 counts compared to both a complete case analysis and multiple imputation (hazard ratio for >200 cells/mm vs. <25 cells/mm: 0.21 [95% confidence interval: 0.18, 0.24] vs. 0.38 [0.29, 0.48], and 0.29 [0.25, 0.34], respectively). Similar results are obtained when varying assumptions about measurement error, when using p-splines, and when evaluating time-updated CD4 count in a longitudinal analysis. The estimates of the association with viral load are slightly more attenuated when using multiple imputation instead of multiple overimputation. Our simulation studies suggest that multiple overimputation is able to reduce bias and mean squared error in survival analyses. CONCLUSIONS Multiple overimputation, which can be used with existing software, offers a convenient approach to account for both missing and mismeasured data in HIV research.
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Su S, Chen X, Mao L, He J, Wei X, Jing J, Zhang L. Superior Effects of Antiretroviral Treatment among Men Who have Sex with Men Compared to Other HIV At-Risk Populations in a Large Cohort Study in Hunan, China. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:ijerph13030283. [PMID: 27005640 PMCID: PMC4808946 DOI: 10.3390/ijerph13030283] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 01/28/2016] [Accepted: 02/19/2016] [Indexed: 02/08/2023]
Abstract
This study assesses association between CD4 level at initiation of antiretroviral treatment (ART) on subsequent treatment outcomes and mortality among people infected with HIV via various routes in Hunan province, China. Over a period of 10 years, a total of 7333 HIV-positive patients, including 553 (7.5%) MSM, 5484 (74.8%) heterosexuals, 1164 (15.9%) injection drug users (IDU) and 132 (1.8%) former plasma donors (FPD), were recruited. MSM substantially demonstrated higher initial CD4 cell level (242, IQR 167-298) than other populations (Heterosexuals: 144 IQR 40-242, IDU: 134 IQR 38-224, FPD: 86 IQR 36-181). During subsequent long-term follow up, the median CD4 level in all participants increased significantly from 151 cells/mm³ (IQR 43-246) to 265 cells/mm³ (IQR 162-380), whereas CD4 level in MSM remained at a high level between 242 and 361 cells/mm³. Consistently, both cumulative immunological and virological failure rates (10.4% and 26.4% in 48 months, respectively) were the lowest in MSM compared with other population groups. Survival analysis indicated that initial CD4 counts ≤ 200 cells/mm³ (AHR = 3.14; CI, 2.43-4.06) significantly contributed to HIV-related mortality during treatment. Timely diagnosis and treatment of HIV patients are vital for improving CD4 level and health outcomes.
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Affiliation(s)
- Shu Su
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC 3004, Australia.
- School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC 3004, Australia.
| | - Xi Chen
- Hunan Provincial Center for Disease Control and Prevention, Changsha 410005, Hunan, China.
| | - Limin Mao
- Center for Social Research in Health, Faculty of Arts and Social Science at the University of New South Wales, Sydney, NSW 2052, Australia.
| | - Jianmei He
- Hunan Provincial Center for Disease Control and Prevention, Changsha 410005, Hunan, China.
| | - Xiuqing Wei
- Hunan Provincial Center for Disease Control and Prevention, Changsha 410005, Hunan, China.
| | - Jun Jing
- Comprehensive AIDS Research Center, Tsinghua University, Beijing 100084, China.
| | - Lei Zhang
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC 3004, Australia.
- School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC 3004, Australia.
- Comprehensive AIDS Research Center, Tsinghua University, Beijing 100084, China.
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC 3004, Australia.
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Naidoo K, Grobler AC, Deghaye N, Reddy T, Gengiah S, Gray A, Karim SA. Cost-Effectiveness of Initiating Antiretroviral Therapy at Different Points in TB Treatment in HIV-TB Coinfected Ambulatory Patients in South Africa. J Acquir Immune Defic Syndr 2015; 69:576-84. [PMID: 26167618 PMCID: PMC4503368 DOI: 10.1097/qai.0000000000000673] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Initiation of antiretroviral therapy (ART) during tuberculosis (TB) treatment improves survival in TB-HIV coinfected patients. In patients with CD4 counts <50 cells per cubic millimeter, there is a substantial clinical and survival benefit of early ART initiation. The purpose of this study was to assess the costs and cost-effectiveness of starting ART at various time points during TB treatment in patients with CD4 counts ≥50 cells per cubic millimeter. METHODS In the SAPiT trial, 642 HIV-TB coinfected patients were randomized to 3 arms: receiving ART within 4 weeks of starting TB treatment (early treatment arm; Arm-1), after the intensive phase of TB treatment (late treatment arm; Arm-2), or after completing TB treatment (sequential arm; Arm-3). Direct health care costs were measured from a provider perspective using a micro-costing approach. The incremental cost per death averted was calculated using the trial outcomes. RESULTS For patients with CD4 count ≥50 cells per cubic millimeter, median monthly variable costs per patient were US $116, US $113, and US $102 in Arm-1, Arm-2 and Arm-3, respectively. There were 12 deaths in 177 patients in Arm-1, 8 deaths in 180 patients in the Arm-2, and 19 deaths in 172 patients in Arm-3. Although the costs were lower in Arm-3, it had a substantially higher mortality rate. The incremental cost per death averted associated with moving from Arm-3 to Arm-2 was US $4199. There was no difference in mortality between Arm-1 and Arm-2, but Arm-1 was slightly more expensive. CONCLUSIONS Initiation of ART after the completion of the intensive phase of TB treatment is cost-effective for patients with CD4 counts ≥50 cells per cubic millimeter.
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Affiliation(s)
- Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, South Africa
| | - Anneke C Grobler
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, South Africa
| | - Nicola Deghaye
- Health Economics and HIV & AIDS Research Division (HEARD), University of KwaZulu-Natal, South Africa
| | - Tarylee Reddy
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, South Africa
- Biostatistics Unit, Medical Research Council, South Africa
| | - Santhanalakshmi Gengiah
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, South Africa
| | - Andrew Gray
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, South Africa
- Discipline of Pharmaceutical Sciences, University of KwaZulu-Natal, South Africa
| | - Salim Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, South Africa
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
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Zhang Q, Tang Z, Sun H, Cheng P, Qin Q, Fan Y, Huang F. Acceptability of early anti-retroviral therapy among HIV-infected people in Anhui province in China. AIDS Care 2014; 27:669-74. [PMID: 25426670 DOI: 10.1080/09540121.2014.983042] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
We investigated the acceptability of early anti-retroviral therapy (ART) among HIV-infected people in Anhui Province, China. A cross-sectional study was conducted in 11 convenience selected cities of Anhui Province from September 2012 to December 2013. Study participants were convenience recruited from local Centers for Disease Control and Prevention when they attended for CD4(+) cell counts testing and HIV counselling. Answers to questionnaires were obtained through face-to-face structured interviews. Factors influencing the acceptability of early ART were identified by multiple logistic regression analysis. A total of 287 HIV-infected people met the criteria and completed the survey. The acceptability of early ART was 65.2%. The results of multiple logistic regression analysis indicated that the acceptability of early ART was associated with the following factors: CD4(+) T cell count (above 750 cells/µL vs. 350 cells/µL to 550 cells/µL: OR = 0.144, P < 0.001), years of HIV diagnosis confirmation (1 year to 5 years vs. <1 year: OR = 0.418, P = 0.005; above 5 years vs. <1 year: OR = 0.160, P < 0.001), whether had sexual behaviour after HIV diagnosis confirmation (yes vs. no: OR = 2.342, P = 0.005) and the awareness of two early ART-related questions (OR = 4.101, P = 0.015; OR = 3.294, P < 0.001). In summary, the present study showed that most HIV-infected people can accept early ART. Early ART interest in Anhui HIV-infected population was high. The awareness of early ART-related knowledge in HIV-infected population was low and should be improved to achieve higher acceptability and keep adherence to early ART for HIV prevention.
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Affiliation(s)
- Qian Zhang
- a Department of Epidemiology and Biostatistics, School of Public Health , Anhui Medical University , Hefei , China
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Cleary S, Mooney G, McIntyre D. Equity and efficiency in HIV-treatment in South Africa: the contribution of mathematical programming to priority setting. HEALTH ECONOMICS 2010; 19:1166-1180. [PMID: 19725025 DOI: 10.1002/hec.1542] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The HIV-epidemic is one of the greatest public health crises to face South Africa. A health care response to the treatment needs of HIV-positive people is a prime example of the desirability of an economic, rational approach to resource allocation in the face of scarcity. Despite this, almost no input based on economic analysis is currently used in national strategic planning. While cost-utility analysis is theoretically able to establish technical efficiency, in practice this is accomplished by comparing an intervention's ICER to a threshold level representing society's maximum willingness to pay to avoid death and improve health-related quality of life. Such an approach has been criticised for a number of reasons, including that it is inconsistent with a fixed budget for health care and that equity is not taken into account. It is also impractical if no national policy on the threshold exists. As an alternative, this paper proposes a mathematical programming approach that is capable of highlighting technical efficiency, equity, the equity/efficiency trade-off and the affordability of alternative HIV-treatment interventions. Government could use this information to plan an HIV-treatment strategy that best meets equity and efficiency objectives within budget constraints.
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Affiliation(s)
- Susan Cleary
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, South Africa.
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Cleary SM, McIntyre D. Affordability--the forgotten criterion in health-care priority setting. HEALTH ECONOMICS 2009; 18:373-375. [PMID: 19267322 DOI: 10.1002/hec.1450] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
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