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Krebs E, Enns E, Zang X, Mah CS, Quan AM, Behrends CN, Coljin C, Goedel W, Golden M, Marshall BDL, Metsch LR, Pandya A, Shoptaw S, Sullivan P, Tookes HE, Duarte HA, Min JE, Nosyk B. Attributing health benefits to preventing HIV infections versus improving health outcomes among people living with HIV: an analysis in six US cities. AIDS 2021; 35:2169-2179. [PMID: 34148987 PMCID: PMC8490299 DOI: 10.1097/qad.0000000000002993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Combination strategies generate health benefits through improved health outcomes among people living with HIV (PLHIV) and prevention of new infections. We aimed to determine health benefits attributable to improved health among PLHIV versus HIV prevention for a set of combination strategies in six US cities. DESIGN A dynamic HIV transmission model. METHODS Using a model calibrated for Atlanta, Baltimore, Los Angeles, Miami, New York City (NYC) and Seattle, we assessed the health benefits of city-specific optimal combinations of evidence-based interventions implemented at publicly documented levels and at ideal (90% coverage) scale-up (2020-2030 implementation, 20-year study period). We calculated the proportion of health benefit gains (measured as quality-adjusted life-years) resulting from averted and delayed HIV infections; improved health outcomes among PLHIV; and improved health outcomes due to medication for opioid use disorder (MOUD). RESULTS The HIV-specific proportion of total benefits ranged from 68.3% (95% credible interval: 55.3-80.0) in Seattle to 98.5% (97.5-99.3) in Miami, with the rest attributable to MOUD. The majority of HIV-specific health benefits in five of six cities were attributable HIV prevention, and ranged from 33.1% (26.1-41.1) in NYC to 83.1% (79.6-86.6) in Atlanta. Scaling up to ideal service levels resulted in three to seven-fold increases in additional health benefits, mostly from MOUD, with HIV-specific health gains primarily driven by HIV prevention. CONCLUSION Optimal combination strategies generated a larger proportion of health benefits attributable to HIV prevention in five of six cities, underlining the substantial benefits of antiretroviral therapy engagement for the prevention of HIV transmission through viral suppression. Understanding to whom benefits accrue may be important in assessing the equity and impact of HIV investments.
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Affiliation(s)
- Emanuel Krebs
- Faculty of Health Sciences, Simon Fraser University, Burnaby
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Eva Enns
- School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Xiao Zang
- Department of Epidemiology, Brown School of Public Health, Providence, Rhode Island, USA
| | - Cassandra S Mah
- Faculty of Health Sciences, Simon Fraser University, Burnaby
| | - Amanda M Quan
- Faculty of Health Sciences, Simon Fraser University, Burnaby
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Czarina N Behrends
- Department of Population Health Sciences, Weill Cornell Medical College, New York City, New York, USA
| | - Caroline Coljin
- Department of Mathematics, Simon Fraser University, Burnaby, British Columbia, Canada
| | - William Goedel
- Department of Epidemiology, Brown School of Public Health, Providence, Rhode Island, USA
| | - Matthew Golden
- Department of Medicine, Division of Allergy & Infectious Disease, University of Washington, Seattle, Washington
| | - Brandon D L Marshall
- Department of Epidemiology, Brown School of Public Health, Providence, Rhode Island, USA
| | - Lisa R Metsch
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, City, New York
| | - Ankur Pandya
- T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Steven Shoptaw
- Centre for HIV Identification, Prevention and Treatment Services, School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Patrick Sullivan
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Hansel E Tookes
- Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, Coral Gables, Florida
| | - Horacio A Duarte
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Jeong E Min
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- Faculty of Health Sciences, Simon Fraser University, Burnaby
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
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Pérez-Elías MJ, Podzamczer Palter D, Ventayol Bosch P, Jarrín I, Castro A, Rubio-Rodríguez D, Rubio-Terrés C. Clinical and economic benefit of 32 years of antiretroviral treatment for people living with HIV in Spain: Has it been an efficient intervention? ACTA ACUST UNITED AC 2021; 40:550-556. [PMID: 34303633 DOI: 10.1016/j.eimce.2021.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 05/11/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Although antiretroviral therapy (ART) for HIV/AIDS was introduced in 1987, improvement in disease progression and reduction in mortality at a population level was not observed until 1996, with the combination of three or more drugs. The objective was to estimate the clinical and economic benefit of ART in Spain in the 32-year period between 1987 and 2018. METHODS A cost-benefit analysis was performed, using a second-order Monte Carlo simulation, from the societal (base case) and the National Health System (NHS) perspectives. New cases of HIV, AIDS and related deaths were obtained from the SINIVIH and UNAIDS registries, with population projections without ART using triple exponential smoothing. Expenditure on ART was obtained from the National AIDS Plan reports and market studies. RESULTS The NHS invested 6185 million euros in 32 years. In that period, 323,651 AIDS-related deaths, 500,129 AIDS cases and 161,417 HIV cases were averted, with total savings of 41,997 million euros. The net benefit (net savings) is estimated at 35,812 million euros (societal) and 1032 million euros (NHS). For every euro invested in ART, a return on investment of € 6.79 and € 1.16 was obtained, respectively. CONCLUSIONS The use of ART over 32 years prevented a large number of deaths and cases of AIDS and HIV, providing significant economic savings for the NHS. ART is an efficient intervention for the NHS.
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Affiliation(s)
| | | | - Pere Ventayol Bosch
- Servicio de Farmacia, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Inmaculada Jarrín
- Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Madrid, Spain
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Pérez-Elías MJ, Podzamczer Palter D, Ventayol Bosch P, Jarrín I, Castro A, Rubio-Rodríguez D, Rubio-Terrés C. Clinical and economic benefit of 32 years of antiretroviral treatment for people living with HIV in Spain: Has it been an efficient intervention? Enferm Infecc Microbiol Clin 2021; 40:S0213-005X(21)00190-7. [PMID: 34217551 DOI: 10.1016/j.eimc.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/06/2021] [Accepted: 05/11/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Although antiretroviral therapy (ART) for HIV / AIDS was introduced in 1987, improvement in disease progression and reduction in mortality at a population level was not observed until 1996, with the combination of three or more drugs. The objective was to estimate the clinical and economic benefit of ART in Spain in the 32-year period between 1987 and 2018. METHODS A cost-benefit analysis was performed, using a second-order Monte Carlo simulation, from the societal (base case) and the National Health System (NHS) perspectives. New cases of HIV, AIDS and related deaths were obtained from the SINIVIH and UNAIDS registries, with population projections without ART using triple exponential smoothing. Expenditure on ART was obtained from the National AIDS Plan reports and market studies. RESULTS The NHS invested 6,185 million euros in 32 years. In that period, 323,651 AIDS-related deaths, 500,129 AIDS cases and 161,417 HIV cases were averted, with total savings of 41,997 million euros. The net benefit (net savings) is estimated at 35,812 million euros (societal) and 1,032 million euros (NHS). For every euro invested in ART, a return on investment of € 6.79 and € 1.16 was obtained, respectively. CONCLUSION The use of ART over 32 years prevented a large number of deaths and cases of AIDS and HIV, providing significant economic savings for the NHS. ART is an efficient intervention for the NHS.
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Affiliation(s)
| | | | - Pere Ventayol Bosch
- Servicio de Farmacia, Hospital Universitario Son Espases, Palma de Mallorca, España
| | - Inmaculada Jarrín
- Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Madrid, España
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Singleton AL, Marshall BD, Zang X, Nunn AS, Goedel WC. Added Benefits of Pre-Exposure Prophylaxis Use on HIV Incidence with Minimal Changes in Efficiency in the Context of High Treatment Engagement Among Men Who Have Sex with Men. AIDS Patient Care STDS 2020; 34:506-515. [PMID: 33216618 DOI: 10.1089/apc.2020.0151] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Although there is ongoing debate over the need for substantial increases in pre-exposure prophylaxis (PrEP) use when antiretroviral treatment confers the dual benefits of reducing HIV-related morbidity and mortality and the risk of HIV transmission, no studies to date have quantified the potential added benefits of PrEP use and changes in its efficiency in the context of high treatment engagement across multiple US subpopulations. We used a previously published agent-based model to simulate HIV transmission in a dynamic network of Black/African American and White men who have sex with men (MSM) in Atlanta, Georgia (2015-2024) to understand how reductions in HIV incidence attributable to varying levels of PrEP use change when United Nations Joint Programme on HIV/AIDS (UNAIDS) "90-90-90" goals for HIV treatment are achieved and maintained. Even at achievement of "90-90-90" goals, 75% PrEP coverage further reduced incidence by 67.9% and 74.2% to 1.53 [simulation interval (SI): 1.39-1.70] and 0.355 (SI: 0.316-0.391) per 100 person-years for Black/African American and White MSM, respectively, compared with the same scenario with no PrEP use. Increasing PrEP coverage from 15% to 75% under "90-90-90" goals only increased the number of person-years of PrEP use per infection averted by 8.1% and 10.5% to 26.7 (SI: 25.6-28.0) and 73.3 (SI: 70.6-75.7) among Black/African American MSM and White MSM, respectively. Even with high treatment engagement, substantial expansion of PrEP use contributes to meaningful decreases in HIV incidence among MSM with minimal changes in efficiency.
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Affiliation(s)
- Alyson L. Singleton
- Department of Biostatistics, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Brandon D.L. Marshall
- Department of Epidemiology, and School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Xiao Zang
- Department of Epidemiology, and School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Amy S. Nunn
- Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - William C. Goedel
- Department of Epidemiology, and School of Public Health, Brown University, Providence, Rhode Island, USA
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Mustanski B, Moskowitz DA, Moran KO, Newcomb ME, Macapagal K, Rodriguez-Díaz C, Rendina HJ, Laber EB, Li DH, Matson M, Talan AJ, Cabral C. Evaluation of a Stepped-Care eHealth HIV Prevention Program for Diverse Adolescent Men Who Have Sex With Men: Protocol for a Hybrid Type 1 Effectiveness Implementation Trial of SMART. JMIR Res Protoc 2020; 9:e19701. [PMID: 32779573 PMCID: PMC7448177 DOI: 10.2196/19701] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/07/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Adolescent men who have sex with men (AMSM), aged 13 to 18 years, account for more than 80% of teen HIV occurrences. Despite this disproportionate burden, there is a conspicuous lack of evidence-based HIV prevention programs. Implementation issues are critical as traditional HIV prevention delivery channels (eg, community-based organizations, schools) have significant access limitations for AMSM. As such, eHealth interventions, such as our proposed SMART program, represent an excellent modality for delivering AMSM-specific intervention material where youth are. OBJECTIVE This randomized trial aimed to test the effectiveness of the SMART program in reducing condom-less anal sex and increasing condom self-efficacy, condom use intentions, and HIV testing for AMSM. We also plan to test whether SMART has differential effectiveness across important subgroups of AMSM based on race and ethnicity, urban versus rural residence, age, socioeconomic status, and participation in an English versus a Spanish version of SMART. METHODS Using a sequential multiple assignment randomized trial design, we will evaluate the impact of a stepped-care package of increasingly intensive eHealth interventions (ie, the universal, information-based SMART Sex Ed; the more intensive, selective SMART Squad; and a higher cost, indicated SMART Sessions). All intervention content is available in English and Spanish. Participants are recruited primarily from social media sources using paid and unpaid advertisements. RESULTS The trial has enrolled 1285 AMSM aged 13 to 18 years, with a target enrollment of 1878. Recruitment concluded in June 2020. Participants were recruited from 49 US states as well as Puerto Rico and the District of Columbia. Assessments of intervention outcomes at 3, 6, 9, and 12 months are ongoing. CONCLUSIONS SMART is the first web-based program for AMSM to take a stepped-care approach to sexual education and HIV prevention. This design indicates that SMART delivers resources to all adolescents, but more costly treatments (eg, video chat counseling in SMART Sessions) are conserved for individuals who need them the most. SMART has the potential to reach AMSM to provide them with a sex-positive curriculum that empowers them with the information, motivation, and skills to make better health choices. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT03511131; https://clinicaltrials.gov/ct2/show/NCT03511131. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/19701.
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Affiliation(s)
- Brian Mustanski
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, IL, United States
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - David A Moskowitz
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, IL, United States
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Kevin O Moran
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, IL, United States
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Michael E Newcomb
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, IL, United States
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Kathryn Macapagal
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, IL, United States
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Carlos Rodriguez-Díaz
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, United States
- Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico
| | - H Jonathon Rendina
- Department of Psychology, Hunter College of the City University of New York (CUNY), New York, NY, United States
| | - Eric B Laber
- Department of Statistics, North Carolina State University, Raleigh, NC, United States
| | - Dennis H Li
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, IL, United States
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Margaret Matson
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, IL, United States
| | - Ali J Talan
- Department of Psychology, Hunter College of the City University of New York (CUNY), New York, NY, United States
| | - Cynthia Cabral
- Department of Psychology, Hunter College of the City University of New York (CUNY), New York, NY, United States
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