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Shanaube K, Ndubani R, Kelly H, Webb E, Mayaud P, Lamberti O, Fitzpatrick J, Kasese N, Sturt A, Van Lieshout L, Van Dam G, Corstjens PLAM, Kosloff B, Bond V, Hayes R, Terris-Prestholt F, Webster B, Vwalika B, Hansingo I, Ayles H, Bustinduy AL. Zipime-Weka-Schista study protocol: a longitudinal cohort study and economic evaluation of an integrated home-based approach for genital multipathogen screening in women, including female genital schistosomiasis, human papillomavirus, Trichomonas and HIV in Zambia. BMJ Open 2024; 14:e080395. [PMID: 38858160 PMCID: PMC11168163 DOI: 10.1136/bmjopen-2023-080395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 05/27/2024] [Indexed: 06/12/2024] Open
Abstract
INTRODUCTION Multiplathogen home-based self-sampling offers an opportunity to increase access to screening and treatment in endemic settings with high coinfection prevalence of sexually transmitted (HIV, Trichomonas vaginalis (Tv), human papillomavirus (HPV)) and non-sexually transmitted pathogens (Schistosoma haematobium (Sh)). Chronic coinfections may lead to disability (female genital schistosomiasis) and death (cervical cancer). The Zipime-Weka-Schista (Do self-testing sister!) study aims to evaluate the validity, acceptability, uptake, impact and cost-effectiveness of multipathogen self-sampling for genital infections among women in Zambia. METHODS AND ANALYSIS This is a longitudinal cohort study aiming to enrol 2500 non-pregnant, sexually active and non-menstruating women aged 15-50 years from two districts in Zambia with 2-year follow-up. During home visits, community health workers offer HIV and Tv self-testing and cervicovaginal self-swabs for (1) HPV by GeneXpert and, (2) Sh DNA detection by conventional (PCR)and isothermal (recombinase polymerase assay) molecular methods. Schistosoma ova and circulating anodic antigen are detected in urine. At a clinic follow-up, midwives perform the same procedures and obtain hand-held colposcopic images. High-risk HPV positive women are referred for a two-quadrant cervical biopsy according to age and HIV status. A cost-effectiveness analysis is conducted in parallel. ETHICS AND DISSEMINATION The University of Zambia Biomedical Research Ethics Committee (UNZABREC) (reference: 1858-2021), the London School of Hygiene and Tropical Medicine (reference: 25258), Ministry of Health and local superintendents approved the study in September 2021.Written informed consent was obtained from all participants prior to enrolment. Identifiable data collected are stored securely and their confidentiality is protected in accordance with the Data Protection Act 1998.
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Affiliation(s)
| | | | - Helen Kelly
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Emily Webb
- Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Philippe Mayaud
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Olimpia Lamberti
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Amy Sturt
- Department of Infectious Diseases, Veterans Affairs Health Care System, Palo Alto, UK
| | | | - Govert Van Dam
- Leiden University Medical Center, Leiden, The Netherlands
| | - Paul L A M Corstjens
- Department of Cell and Chemical Biology, Leiden University Medical Center, Leiden, The Netherlands
| | - Barry Kosloff
- Zambart, Lusaka, Zambia
- Longhorn Vaccines & Diagnostics, Bethesda, Maryland, USA
| | - Virginia Bond
- Zambart, Lusaka, Zambia
- London School of Hygiene & Tropical Medicine Centre of Global Change and Health, London, UK
| | - Richard Hayes
- Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Bellington Vwalika
- Department of Obstetrics & Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
| | - Isaiah Hansingo
- Gynecology, Livingstone Central Hospital, Livingstone, Zambia
| | - Helen Ayles
- Zambart, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Amaya L Bustinduy
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
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Vanbaelen T, Manoharan-Basil SS, Kenyon C. Four recent insights suggest the need for more refined methods to assess the resistogenicity of doxycycline post exposure prophylaxis. CURRENT RESEARCH IN MICROBIAL SCIENCES 2024; 6:100234. [PMID: 38646593 PMCID: PMC11033152 DOI: 10.1016/j.crmicr.2024.100234] [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] [Indexed: 04/23/2024] Open
Abstract
Two recently published randomized trials of doxycycline post exposure prophylaxis (PEP) have concluded that this intervention is highly effective at reducing the incidence of bacterial sexually transmitted infections (STIs) and has little or no risk of promoting the spread of antimicrobial resistance (AMR). In this perspective piece, we review four types of evidence that suggest that the risk of promoting AMR has been inadequately assessed in these studies. 1) The studies have all used proportion resistant as the outcome measure. This is a less sensitive measure of resistogenicity than MIC distribution. 2) These RCTs have not considered population-level pathways of AMR selection. 3) In populations with very high antimicrobial consumption such as PrEP cohorts, the relationship between antimicrobial consumption and resistance may be saturated. 4) Genetic linkage of AMR means that increased tetracycline use may select for AMR to not only tetracyclines but also other antimicrobials in STIs and other bacterial species. We recommend novel study designs to more adequately assess the AMR-inducing risk of doxycycline PEP.
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Affiliation(s)
- Thibaut Vanbaelen
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, 2000, Belgium
| | | | - Chris Kenyon
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, 2000, Belgium
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, Cape Town, 7700, South Africa
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Bozzani FM, Terris-Prestholt F, Quaife M, Gafos M, Indravudh PP, Giddings R, Medley GF, Malhotra S, Torres-Rueda S. Costs and Cost-Effectiveness of Biomedical, Non-Surgical HIV Prevention Interventions: A Systematic Literature Review. PHARMACOECONOMICS 2023; 41:467-480. [PMID: 36529838 PMCID: PMC10085926 DOI: 10.1007/s40273-022-01223-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/10/2022] [Indexed: 05/10/2023]
Abstract
BACKGROUND Considerable evidence on the costs and cost-effectiveness of biomedical, non-surgical interventions to prevent human immunodeficiency virus (HIV) transmission has been generated over the last decade. This study aims to synthesize findings and identify remaining knowledge gaps to suggest future research priorities. METHODS A systematic literature review was carried out in August 2020 using the MEDLINE, Embase, Global Health and EconLit databases to retrieve economic evaluations and costing studies of oral pre-exposure prophylaxis (PrEP), injectable long-acting PrEP, vaginal microbicide rings and gels, HIV vaccines and broadly neutralizing antibodies. Studies reporting costs from the provider or societal perspective were included in the analysis. Those reporting on behavioural methods of prevention, condoms and surgical approaches (voluntary medical male circumcision) were excluded. The quality of reporting of the included studies was assessed using published checklists. RESULTS We identified 3007 citations, of which 87 studies were retained. Most were set in low- and middle-income countries (LMICs; n = 53) and focused on the costs and/or cost-effectiveness of oral PrEP regimens (n = 70). Model-based economic evaluations were the most frequent study design; only two trial-based cost-effectiveness analyses and nine costing studies were found. Less than half of the studies provided practical details on how the intervention would be delivered by the health system, and only three of these, all in LMICs, explicitly focused on service integration and its implication for delivery costs. 'Real-world' programme delivery mechanisms and costs of intervention delivery were rarely considered. PrEP technologies were generally found to be cost-effective only when targeting high-risk subpopulations. Single-dose HIV vaccines are expected to be cost-effective for all groups despite substantial uncertainty around pricing. CONCLUSIONS A lack of primary, detailed and updated cost data, including above-service level costs, from a variety of settings makes it difficult to evaluate the cost-effectiveness of specific delivery modes at scale, or to evaluate strategies for services integration. Closing this evidence gap around real-world implementation is vital, not least because the strategies targeting high-risk groups that are recommended by PrEP models may incur substantially higher costs and be of limited practical feasibility in some settings.
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Affiliation(s)
- Fiammetta M Bozzani
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | | | - Matthew Quaife
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Mitzy Gafos
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Pitchaya P Indravudh
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | | | - Graham F Medley
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | | | - Sergio Torres-Rueda
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
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Chen S, Wang F, Xue Y, Huo F, Jia J, Dong L, Zhao L, Jiang G, Huang H. Doubled Nontuberculous Mycobacteria Isolation as a Consequence of Changes in the Diagnosis Algorithm. Infect Drug Resist 2022; 15:3347-3355. [PMID: 35782527 PMCID: PMC9249383 DOI: 10.2147/idr.s368671] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/16/2022] [Indexed: 11/23/2022] Open
Abstract
Background Nontuberculous mycobacteria (NTM) and their associated diseases remain neglected. Through minor modifications in our diagnostic algorithm, we observed an unexpected higher number of cultivable NTM isolates. Therefore, a retrospective study was performed thoroughly to investigate the effect of changed laboratory procedures on NTM isolation in a specialized tuberculosis hospital. Methods NTM isolation rates and composition of NTM species were compared for the two diagnostic algorithms: (1) by using traditional p-nitrobenzoic acid (PNB) selective medium as a preliminary test to identify NTM isolates among the positive cultures (procedure I) and (2) by using the MPT64 antigen detection method to distinguish between Mycobacterium tuberculosis complex (MTBC) isolates and possible NTM isolates after a positive MGIT960 liquid culture (procedure II). Results The NTM isolation rate in procedure II was significantly higher than the procedure I (18.08% vs 9.71%; P<0.001). A noticeable increase in the ratio of NTM isolates among the identified mycobacteria was observed over the studied years (ie, from 58.18% in 2019 to 72.93% in 2021), which indicated a more precise prescription of species identification test after prompt information was provided in procedure II. In addition, the consistency of the identified species using multiple specimens from the same patient did not present a significant difference between the procedures. Conclusion According to our study, NTM infection might be far more underestimated than it is. A diagnostic procedure combining MGIT960 culture and MPT64 antigen detection could timely and easily identify clues of NTM isolates and improve the diagnosis of NTM infections.
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Affiliation(s)
- Suting Chen
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, China
| | - Fen Wang
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, China
| | - Yi Xue
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, China
| | - Fengmin Huo
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, China
| | - Junnan Jia
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, China
| | - Lingling Dong
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, China
| | - Liping Zhao
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, China
| | - Guanglu Jiang
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, China
| | - Hairong Huang
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, China
- Correspondence: Hairong Huang, Email ; Guanglu Jiang,
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Sarkar S, Corso P, Ebrahim-Zadeh S, Kim P, Charania S, Wall K. Cost-effectiveness of HIV Prevention Interventions in Sub-Saharan Africa: A Systematic Review. EClinicalMedicine 2019; 10:10-31. [PMID: 31193863 PMCID: PMC6543190 DOI: 10.1016/j.eclinm.2019.04.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 04/04/2019] [Accepted: 04/10/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Sub-Saharan Africa carries the highest HIV burden globally. It is important to understand how interventions cost-effectively fit within guidelines and implementation plans, especially in low- and middle-income settings. We reviewed the evidence from economic evaluations of HIV prevention interventions in sub-Saharan Africa to help inform the allocation of limited resources. METHODS We searched PubMed, Web of Science, Econ-Lit, Embase, and African Index Medicus. We included studies published between January 2009 and December 2018 reporting cost-effectiveness estimates of HIV prevention interventions. We extracted health outcomes and cost-effectiveness ratios (CERs) and evaluated study quality using the CHEERS checklist. FINDINGS 60 studies met the full inclusion criteria. Prevention of mother-to-child transmission interventions had the lowest median CERs ($1144/HIV infection averted and $191/DALY averted), while pre-exposure prophylaxis interventions had the highest ($13,267/HIA and $799/DALY averted). Structural interventions (partner notification, cash transfer programs) have similar CERs ($3576/HIA and $392/DALY averted) to male circumcision ($2965/HIA) and were more favourable to treatment-as-prevention interventions ($7903/HIA and $890/DALY averted). Most interventions showed increased cost-effectiveness when prioritizing specific target groups based on age and risk. INTERPRETATION The presented cost-effectiveness information can aid policy makers and other stakeholders as they develop guidelines and programming for HIV prevention plans in resource-constrained settings.
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Affiliation(s)
- Supriya Sarkar
- Department of Epidemiology, Emory University, Atlanta, GA, USA
- Corresponding author at: Department of Epidemiology, Emory University, Atlanta 30322, USA.
| | - Phaedra Corso
- Department of Health Policy and Management, Kennesaw State University, Kennesaw, GA, USA
| | | | - Patricia Kim
- cDepartment of Economics, Emory University, Atlanta, GA, USA
| | - Sana Charania
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kristin Wall
- Department of Epidemiology, Emory University, Atlanta, GA, USA
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Alam A, Jiang L, Kittleson GA, Steadman KD, Nandi S, Fuqua JL, Palmer KE, Tusé D, McDonald KA. Technoeconomic Modeling of Plant-Based Griffithsin Manufacturing. Front Bioeng Biotechnol 2018; 6:102. [PMID: 30087892 PMCID: PMC6066545 DOI: 10.3389/fbioe.2018.00102] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 07/02/2018] [Indexed: 12/23/2022] Open
Abstract
Griffithsin is a marine algal lectin that exhibits broad-spectrum antiviral activity by binding oligomannose glycans on viral envelope glycoproteins, including those found in HIV-1, HSV-2, SARS, HCV and other enveloped viruses. An efficient, scalable and cost-effective manufacturing process for Griffithsin is essential for the adoption of this drug in human antiviral prophylaxis and therapy, particularly in cost-sensitive indications such as topical microbicides for HIV-1 prevention. The production of certain classes of recombinant biologics in plants can offer scalability, cost and environmental impact advantages over traditional biomanufacturing platforms. Previously, we showed the technical viability of producing recombinant Griffithsin in plants. In this study, we conducted a technoeconomic analysis (TEA) of plant-produced Griffithsin manufactured at commercial launch volumes for use in HIV microbicides. Data derived from multiple non-sequential manufacturing batches conducted at pilot scale and existing facility designs were used to build a technoeconomic model using SuperPro Designer® modeling software. With an assumed commercial launch volume of 20 kg Griffithsin/year for 6.7 million doses of Griffithsin microbicide at 3 mg/dose, a transient vector expression yield of 0.52 g Griffithsin/kg leaf biomass, recovery efficiency of 70%, and purity of >99%, we calculated a manufacturing cost for the drug substance of $0.32/dose and estimated a bulk product cost of $0.38/dose assuming a 20% net fee for a contract manufacturing organization (CMO). This is the first report modeling the manufacturing economics of Griffithsin. The process analyzed is readily scalable and subject to efficiency improvements and could provide the needed market volumes of the lectin within an acceptable range of costs, even for cost-constrained products such as microbicides. The manufacturing process was also assessed for environmental, health and safety impact and found to have a highly favorable environmental output index with negligible risks to health and safety. The results of this study help validate the plant-based manufacturing platform and should assist in selecting preferred indications for Griffithsin as a novel drug.
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Affiliation(s)
- Aatif Alam
- Department of Chemical Engineering, University of California, Davis, Davis, CA, United States
| | - Linda Jiang
- Department of Chemical Engineering, University of California, Davis, Davis, CA, United States
| | - Gregory A. Kittleson
- Department of Chemical Engineering, University of California, Davis, Davis, CA, United States
| | - Kenneth D. Steadman
- Department of Chemical Engineering, University of California, Davis, Davis, CA, United States
| | - Somen Nandi
- Department of Chemical Engineering, University of California, Davis, Davis, CA, United States
- Global HealthShare Initiative, University of California, Davis, Davis, CA, United States
| | - Joshua L. Fuqua
- Center for Predictive Medicine, University of Louisville, Louisville, KY, United States
| | - Kenneth E. Palmer
- Center for Predictive Medicine, University of Louisville, Louisville, KY, United States
| | - Daniel Tusé
- Intrucept Biomedicine, LLC, Sacramento, CA, United States
| | - Karen A. McDonald
- Department of Chemical Engineering, University of California, Davis, Davis, CA, United States
- Global HealthShare Initiative, University of California, Davis, Davis, CA, United States
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Abstract
Sexual intercourse (vaginal and anal) is the predominant mode of human immunodeficiency virus (HIV) transmission. Topical microbicides used in an on-demand format (i.e., immediately before or after sex) can be part of an effective tool kit utilized to prevent sexual transmission of HIV. The effectiveness of prevention products is positively correlated with adherence, which is likely to depend on user acceptability of the product. The development of an efficacious and acceptable product is therefore paramount for the success of an on-demand product. Acceptability of on-demand products (e.g., gels, films, and tablets) and their attributes is influenced by a multitude of user-specific factors that span behavioral, lifestyle, socio-economic, and cultural aspects. In addition, physicochemical properties of the drug, anatomical and physiological aspects of anorectal and vaginal compartments, issues relating to large-scale production, and cost can impact product development. These factors together with user preferences determine the design space of an effective, acceptable, and feasible on-demand product. In this review, we summarize the interacting factors that together determine product choice and its target product profile.
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Affiliation(s)
- Sravan Kumar Patel
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, 15213, USA.,Magee-Womens Research Institute, Pittsburgh, PA, 15213, USA
| | - Lisa Cencia Rohan
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, 15213, USA. .,Magee-Womens Research Institute, Pittsburgh, PA, 15213, USA.
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Notario-Pérez F, Ruiz-Caro R, Veiga-Ochoa MD. Historical development of vaginal microbicides to prevent sexual transmission of HIV in women: from past failures to future hopes. DRUG DESIGN DEVELOPMENT AND THERAPY 2017; 11:1767-1787. [PMID: 28670111 PMCID: PMC5479294 DOI: 10.2147/dddt.s133170] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Infection with human immunodeficiency virus (HIV) remains a global public health concern and is particularly serious in low- and middle-income countries. Widespread sexual violence and poverty, among other factors, increase the risk of infection in women, while currently available prevention methods are outside the control of most. This has driven the study of vaginal microbicides to prevent sexual transmission of HIV from men to women in recent decades. The first microbicides evaluated were formulated as gels for daily use and contained different substances such as surfactants, acidifiers and monoclonal antibodies, which failed to demonstrate efficacy in clinical trials. A gel containing the reverse transcriptase inhibitor tenofovir showed protective efficacy in women. However, the lack of adherence by patients led to the search for dosage forms capable of releasing the active principle for longer periods, and hence to the emergence of the vaginal ring loaded with dapivirine, which requires a monthly application and is able to reduce the sexual transmission of HIV. The future of vaginal microbicides will feature the use of alternative dosage forms, nanosystems for drug release and probiotics, which have emerged as potential microbicides but are still in the early stages of development. Protecting women with vaginal microbicide formulations would, therefore, be a valuable tool for avoiding sexual transmission of HIV.
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Affiliation(s)
- Fernando Notario-Pérez
- Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, Universidad Complutense de Madrid, Madrid, Spain
| | - Roberto Ruiz-Caro
- Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, Universidad Complutense de Madrid, Madrid, Spain
| | - María-Dolores Veiga-Ochoa
- Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, Universidad Complutense de Madrid, Madrid, Spain
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Abstract
With HIV funding plateauing and the number of people living with HIV increasing due to the rollout of life-saving antiretroviral therapy, policy makers are faced with increasingly tighter budgets to manage the ongoing HIV epidemic. Cost-effectiveness and modeling analyses can help determine which HIV interventions may be of best value. Incidence remains remarkably high in certain populations and countries, making prevention key to controlling the spread of HIV. This paper briefly reviews concepts in modeling and cost-effectiveness methodology and then examines results of recently published cost-effectiveness analyses on the following HIV prevention strategies: condoms and circumcision, behavioral- or community-based interventions, prevention of mother-to-child transmission, HIV testing, pre-exposure prophylaxis, and treatment as prevention. We find that the majority of published studies demonstrate cost-effectiveness; however, not all interventions are affordable. We urge continued research on combination strategies and methodologies that take into account willingness to pay and budgetary impact.
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Affiliation(s)
- Margo M Jacobsen
- Medical Practice Evaluation Center (RPW, MMJ), Divisions of Infectious Diseases and General Internal Medicine (RPW), Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA, 02114, USA
| | - Rochelle P Walensky
- Medical Practice Evaluation Center (RPW, MMJ), Divisions of Infectious Diseases and General Internal Medicine (RPW), Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA, 02114, USA. .,Division of Infectious Diseases, Brigham and Women's Hospital (RPW), Boston, MA, USA. .,Harvard University Center for AIDS Research (RPW), Harvard Medical School, Boston, MA, USA.
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Terris-Prestholt F, Quaife M, Vickerman P. Parameterising User Uptake in Economic Evaluations: The role of discrete choice experiments. HEALTH ECONOMICS 2016; 25 Suppl 1:116-23. [PMID: 26773825 PMCID: PMC5066644 DOI: 10.1002/hec.3297] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 05/11/2015] [Accepted: 09/21/2015] [Indexed: 05/16/2023]
Abstract
Model-based economic evaluations of new interventions have shown that user behaviour (uptake) is a critical driver of overall impact achieved. However, early economic evaluations, prior to introduction, often rely on assumed levels of uptake based on expert opinion or uptake of similar interventions. In addition to the likely uncertainty surrounding these uptake assumptions, they also do not allow for uptake to be a function of product, intervention, or user characteristics. This letter proposes using uptake projections from discrete choice experiments (DCE) to better parameterize uptake and substitution in cost-effectiveness models. A simple impact model is developed and illustrated using an example from the HIV prevention field in South Africa. Comparison between the conventional approach and the DCE-based approach shows that, in our example, DCE-based impact predictions varied by up to 50% from conventional estimates and provided far more nuanced projections. In the absence of observed uptake data and to model the effect of variations in intervention characteristics, DCE-based uptake predictions are likely to greatly improve models parameterizing uptake solely based on expert opinion. This is particularly important for global and national level decision making around introducing new and probably more expensive interventions, particularly where resources are most constrained.
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Affiliation(s)
- Fern Terris-Prestholt
- Social and Mathematical Epidemiology (SaME), Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Matthew Quaife
- Social and Mathematical Epidemiology (SaME), Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Peter Vickerman
- Social and Mathematical Epidemiology (SaME), Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Drake TL, Devine A, Yeung S, Day NPJ, White LJ, Lubell Y. Dynamic Transmission Economic Evaluation of Infectious Disease Interventions in Low- and Middle-Income Countries: A Systematic Literature Review. HEALTH ECONOMICS 2016; 25 Suppl 1:124-39. [PMID: 26778620 PMCID: PMC5066646 DOI: 10.1002/hec.3303] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Economic evaluation using dynamic transmission models is important for capturing the indirect effects of infectious disease interventions. We examine the use of these methods in low- and middle-income countries, where infectious diseases constitute a major burden. This review is comprised of two parts: (1) a summary of dynamic transmission economic evaluations across all disease areas published between 2011 and mid-2014 and (2) an in-depth review of mosquito-borne disease studies focusing on health economic methods and reporting. Studies were identified through a systematic search of the MEDLINE database and supplemented by reference list screening. Fifty-seven studies were eligible for inclusion in the all-disease review. The most common subject disease was HIV/AIDS, followed by malaria. A diverse range of modelling methods, outcome metrics and sensitivity analyses were used, indicating little standardisation. Seventeen studies were included in the mosquito-borne disease review. With notable exceptions, most studies did not employ economic evaluation methods beyond calculating a cost-effectiveness ratio or net benefit. Many did not adhere to health care economic evaluations reporting guidelines, particularly with respect to full model reporting and uncertainty analysis. We present a summary of the state-of-the-art and offer recommendations for improved implementation and reporting of health economic methods in this crossover discipline.
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Affiliation(s)
- Tom L Drake
- University of Oxford, Oxford, UK
- Mahidol University, Bangkok, Thailand
| | - Angela Devine
- University of Oxford, Oxford, UK
- Mahidol University, Bangkok, Thailand
| | - Shunmay Yeung
- London School of Hygiene and Tropical Medicine, London, UK
| | - Nicholas P J Day
- University of Oxford, Oxford, UK
- Mahidol University, Bangkok, Thailand
| | - Lisa J White
- University of Oxford, Oxford, UK
- Mahidol University, Bangkok, Thailand
| | - Yoel Lubell
- University of Oxford, Oxford, UK
- Mahidol University, Bangkok, Thailand
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Woodsong C, Holt JDS. Acceptability and preferences for vaginal dosage forms intended for prevention of HIV or HIV and pregnancy. Adv Drug Deliv Rev 2015; 92:146-54. [PMID: 25703190 DOI: 10.1016/j.addr.2015.02.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 01/22/2015] [Accepted: 02/06/2015] [Indexed: 11/28/2022]
Abstract
This paper reviews key issues found to affect acceptability and preferences for vaginal products to prevent HIV infection or HIV and pregnancy. We focus on the interplay between the biological and physico-chemical aspects of formulation and the social and behavioral issues that may affect use. The need for an HIV prevention product that women can use is driven by women's increased biological and social vulnerability to HIV infection, and thus social and behavioral research on microbicide acceptability has been conducted alongside, as well as separate from, the earliest product development efforts. Some acceptability and preference issues are specific to a product's dosage form, use-requirements, and/or use indications, while others pertain to any vaginal product used for prevention of HIV or pregnancy. Although most of the work cited here was published since 2010, it draws on a much longer trajectory of research.
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MESH Headings
- Administration, Intravaginal
- Anti-HIV Agents/administration & dosage
- Anti-HIV Agents/adverse effects
- Anti-HIV Agents/pharmacokinetics
- Contraceptive Agents, Female/administration & dosage
- Contraceptive Agents, Female/adverse effects
- Contraceptive Agents, Female/pharmacokinetics
- Drug Delivery Systems/methods
- Female
- HIV Infections/prevention & control
- Humans
- Patient Preference
- Pregnancy
- Pregnancy, Unplanned
- Vagina/physiology
- Vaginal Absorption
- Vaginal Creams, Foams, and Jellies/administration & dosage
- Vaginal Creams, Foams, and Jellies/adverse effects
- Vaginal Creams, Foams, and Jellies/pharmacokinetics
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Affiliation(s)
- Cynthia Woodsong
- International Partnership for Microbicides, 8401 Colesville Rd., Ste 200, Silver Spring MD 20910, USA.
| | - Jonathon D S Holt
- International Partnership for Microbicides, 8401 Colesville Rd., Ste 200, Silver Spring MD 20910, USA
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Venter WDF, Cowan F, Black V, Rebe K, Bekker LG. Pre-exposure prophylaxis in Southern Africa: feasible or not? J Int AIDS Soc 2015; 18:19979. [PMID: 26198344 PMCID: PMC4509894 DOI: 10.7448/ias.18.4.19979] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 04/06/2015] [Accepted: 04/15/2015] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Southern and Eastern Africa bear the brunt of the AIDS epidemic, and current prevention interventions remain inadequate. Antiretroviral-based pre-exposure prophylaxis (PrEP) is gaining momentum as an effective prevention intervention. DISCUSSION Discussions have been started on how this strategy could be employed in Africa such that the populations most in need can be reached urgently for the greatest impact. This requires the selection of specific risk groups and service environments in which PrEP can be distributed safely and cost effectively while being mindful of any ethical issues. CONCLUSIONS Given the need for an integrated public health approach to this, a number of potential populations and opportunities for PrEP distribution exist and are discussed in this commentary.
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Affiliation(s)
| | - Frances Cowan
- Research Department of Infection and Population Health, University College London, London, UK
| | - Vivian Black
- Wits Reproductive Health and HIV Institute (Wits RHI), University of Witwatersrand, Johannesburg, South Africa
| | - Kevin Rebe
- Health4Men, Anova Health Institute, Cape Town, South Africa
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Cáceres CF, Mayer KH, Baggaley R, O'Reilly KR. PrEP Implementation Science: State-of-the-Art and Research Agenda. J Int AIDS Soc 2015; 18:20527. [PMID: 26198351 PMCID: PMC4581083 DOI: 10.7448/ias.18.4.20527] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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15
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Van Howe RS. Circumcision as a primary HIV preventive: extrapolating from the available data. Glob Public Health 2015; 10:607-25. [PMID: 25760456 DOI: 10.1080/17441692.2015.1016446] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Billions of dollars to circumcise millions of African males as an HIV infection prevention have been sought, yet the effectiveness of circumcision has not been demonstrated. Data from 109 populations comparing HIV prevalence and incidence in men based on circumcision status were evaluated using meta-regression. The impact on the association between circumcision and HIV incidence/prevalence of the HIV risk profile of the population, the circumcision rates within the population and whether the population was in Africa were assessed. No significant difference in the risk of HIV infection based on the circumcision status was seen in general populations. Studies of high-risk populations and populations with a higher prevalence of male circumcision reported significantly greater odds ratios (odds of intact man having HIV) (p < .0001). When adjusted for the impact of a high-risk population and the circumcision rate of the population, the baseline odds ratio was 0.78 (95% CI = 0.56-1.09). No consistent association between presence of HIV infection and circumcision status of adult males in general populations was found. When adjusted for other factors, having a foreskin was not a significant risk factor. This undermines the justification for using circumcision as a primary preventive for HIV infection.
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Affiliation(s)
- Robert S Van Howe
- a College of Medicine, Central Michigan University , Saginaw , MI , USA
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Abstract
Two topical vaginal microbicide candidates for HIV prevention are at an advanced stage of clinical testing, with efficacy results from three clinical trials expected within the next 2 years. Therefore, preparations for introducing and ensuring access to these products in the event that they are proven safe and effective now require increased attention. Microbicides are expected to fill an important global public health need for HIV prevention options for women. They have been developed almost exclusively with public and private funding through academic and nongovernmental institutions and minimal involvement of commercial pharmaceutical partners. Efficient and rapid introduction of a new public health technology requires a broad range of expertise and collaborations, some of which are new to the microbicide field as products are at last completing late-stage pivotal licensure studies. Strong leadership, political commitment, and considerable financial investments will be required to ensure successful distribution as well as uptake and continued access to this new product class. This paper highlights work conducted since 2000 by scientists, advocates, and public health officials to prepare for microbicide introduction, and discusses some of the needed actions to ensure that products will become readily accessible to the women who need them.
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Jewell BL, Cremin I, Pickles M, Celum C, Baeten JM, Delany-Moretlwe S, Hallett TB. Estimating the cost-effectiveness of pre-exposure prophylaxis to reduce HIV-1 and HSV-2 incidence in HIV-serodiscordant couples in South Africa. PLoS One 2015; 10:e0115511. [PMID: 25616135 PMCID: PMC4304839 DOI: 10.1371/journal.pone.0115511] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 11/25/2014] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE To estimate the cost-effectiveness of daily oral tenofovir-based PrEP, with a protective effect against HSV-2 as well as HIV-1, among HIV-1 serodiscordant couples in South Africa. METHODS We incorporated HSV-2 acquisition, transmission, and interaction with HIV-1 into a microsimulation model of heterosexual HIV-1 serodiscordant couples in South Africa, with use of PrEP for the HIV-1 uninfected partner prior to ART initiation for the HIV-1 1infected partner, and for one year thereafter. RESULTS We estimate the cost per disability-adjusted life-year (DALY) averted for two scenarios, one in which PrEP has no effect on reducing HSV-2 acquisition, and one in which there is a 33% reduction. After a twenty-year intervention, the cost per DALY averted is estimated to be $10,383 and $9,757, respectively--a 6% reduction, given the additional benefit of reduced HSV-2 acquisition. If all couples are discordant for both HIV-1 and HSV-2, the cost per DALY averted falls to $1,445, which shows that the impact is limited by HSV-2 concordance in couples. CONCLUSION After a 20-year PrEP intervention, the cost per DALY averted with a reduction in HSV-2 is estimated to be modestly lower than without any effect, providing an increase of health benefits in addition to HIV-1 prevention at no extra cost. The small degree of the effect is in part due to a high prevalence of HSV-2 infection in HIV-1 serodiscordant couples in South Africa.
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Affiliation(s)
- Britta L. Jewell
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Ide Cremin
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Michael Pickles
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Connie Celum
- Departments of Global Health, Medicine and Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Jared M. Baeten
- Departments of Global Health, Medicine and Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Sinead Delany-Moretlwe
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Timothy B. Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
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Nunes R, Sarmento B, das Neves J. Formulation and delivery of anti-HIV rectal microbicides: advances and challenges. J Control Release 2014; 194:278-94. [PMID: 25229988 DOI: 10.1016/j.jconrel.2014.09.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 09/08/2014] [Indexed: 12/24/2022]
Abstract
Men and women engaged in unprotected receptive anal intercourse (RAI) are at higher risk of acquiring HIV from infected partners. The implementation of preventive strategies is urgent and rectal microbicides may be a useful tool in reducing the sexual transmission of HIV. However, pre-clinical and first clinical trials have been able to identify limitations of candidate products, mostly related with safety issues, which can in turn enhance viral infection. Indeed, the development of suitable formulations for the rectal delivery of promising antiretroviral drugs is not an easy task, and has been mostly based on products specifically intended for vaginal delivery, but these have been shown to provide sub-optimal outcomes when administered rectally. Research and development in the rectal microbicide field are now charting their own path and important information is now available. In particular, specific formulation requirements of rectal microbicide products that need to be met have just recently been acknowledged despite additional work being still required. Desirable rectal microbicide product features regarding characteristics such as pH, osmolality, excipients, dosage forms, volume to be administered and the need for applicator use have been studied and defined in recent years, and specific guidance is now possible. This review provides a synopsis of the field of rectal microbicides, namely past and ongoing clinical studies, and details on formulation and drug delivery issues regarding the specific development of rectal microbicide products. Also, future work, as required for the advancement of the field, is discussed.
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Affiliation(s)
- Rute Nunes
- INEB - Instituto de Engenharia Biomédica, University of Porto, Porto, Portugal; CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, Gandra PRD, Portugal
| | - Bruno Sarmento
- INEB - Instituto de Engenharia Biomédica, University of Porto, Porto, Portugal; CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, Gandra PRD, Portugal
| | - José das Neves
- INEB - Instituto de Engenharia Biomédica, University of Porto, Porto, Portugal; CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, Gandra PRD, Portugal.
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