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Casalini C, D’Almeida Y, Nassam MA, Kokoloko E, Wade S, Tchupo JP, Damarly M, Mandala J, Lanham M, Mack N, Akolo C, Pitche VP, Guidigbi H, Dagnra CA. Targeted solutions to increase dolutegravir coverage, viral load testing coverage, and viral suppression among children living with HIV in Togo: An analysis of routine facility data. PLoS One 2023; 18:e0296293. [PMID: 38128036 PMCID: PMC10735014 DOI: 10.1371/journal.pone.0296293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND According to UNAIDS, Togo halved AIDS-related deaths among children ages 0-14 from 2010 to 2020. However, available data show low dolutegravir (DTG)-containing antiretroviral therapy (ART) coverage and low viral load suppression (VLS) among children living with HIV (CLHIV). We analyzed routine facility data before and after implementation of root-cause-based solutions for improving DTG coverage, viral load (VL) testing coverage, and VLS among CLHIV. DESCRIPTION We analyzed routine data for CLHIV ≤14 years from October 2019 through September 2022. We assessed proportion of CLHIV on ART receiving DTG, VL testing coverage (CLHIV on ART with documented VL test result), and VLS (CLHIV with documented VL test result of <1,000 copies among those with test result). From October 2019 to September 2020, 52% were on a DTG-containing regimen, 48% had documented VL test results, and 64% had VLS. Site-level teams conducted a root-cause analysis and designed corresponding solutions implemented beginning October 2020: line listing and contacting eligible CLHIV to start/transition to DTG-containing regimen and collect VL samples; ART adherence support; monthly DTG stock monitoring; tracking pending VL test results through laboratory focal persons; documenting VL test results; and informing caregivers within one week if CLHIV not virally suppressed. Granular data were used to prioritize technical assistance to sites with lowest DTG coverage, VL testing coverage, and VLS. RESULTS From baseline (October 2019-September 2020) to endline (October 2021-September 2022), increases were observed for DTG coverage (52% to 71%), VL testing coverage (48% to 90%), and VLS (64% to 82%). Age-disaggregated data showed positive trends. CONCLUSIONS Root-cause-based solutions and granular data use increased DTG coverage, resulting in increased VL testing and VLS among CLHIV. These interventions should be scaled and become the national standard of care.
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Affiliation(s)
| | | | | | | | | | | | | | - Justin Mandala
- HIV Programs, FHI 360, Durham, NC, United States of America
| | - Michele Lanham
- HIV Programs, FHI 360, Durham, NC, United States of America
| | - Natasha Mack
- HIV Programs, FHI 360, Durham, NC, United States of America
| | - Chris Akolo
- HIV Programs, FHI 360, Durham, NC, United States of America
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Inghels M, Mee P, Diallo OH, Cissé M, Nelson D, Tanser F, Asghar Z, Koita Y, Laborde-Balen G, Breton G. Improving early infant diagnosis for HIV-exposed infants using unmanned aerial vehicles for blood sample transportation in Conakry, Guinea: a comparative cost-effectiveness analysis. BMJ Glob Health 2023; 8:e012522. [PMID: 37984898 PMCID: PMC10660963 DOI: 10.1136/bmjgh-2023-012522] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 08/30/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Early infant diagnosis (EID) for HIV-exposed infants is essential due to high mortality during the first months of their lives. In Conakry (Guinea), timely EID is difficult as traffic congestion prevents the rapid transport of blood samples to the central laboratory. We investigated the cost-effectiveness of transporting EID blood samples by unmanned aerial vehicles (UAV), also known as drones. METHODS AND FINDINGS Using Monte Carlo simulations, we conducted a cost-effectiveness comparative analysis between EID blood samples transportation by on-demand UAV transportation versus the baseline scenario (ie, van with irregular collection schedules) and compared with a hypothetic on-demand motorcycle transportation system. Incremental cost-effectiveness ratio (ICER) per life-year gained was computed. Simulation models included parameters such as consultation timing (eg, time of arrival), motorcycle and UAV characteristics, weather and traffic conditions. Over the 5-year period programme, the UAV and motorcycle strategies were able to save a cumulative additional 834.8 life-years (585.1-1084.5) and 794.7 life-years (550.3-1039.0), respectively, compared with the baseline scenario. The ICER per life-year gained found were US$535 for the UAV strategy versus baseline scenario, US$504 for the motorcycle strategy versus baseline scenario and US$1137 per additional life-year gained for the UAV versus motorcycle strategy. Respectively, those ICERs represented 44.8%, 42.2% and 95.2% of the national gross domestic product (GDP) per capita in Guinea-that is, US$1194. CONCLUSION Compared with the baseline strategy, both transportation of EID blood samples by UAVs or motorcycles had a cost per additional life-year gained below half of the national GDP per capita and could be seen as cost-effective in Conakry. A UAV strategy can save more lives than a motorcycle one although the cost needed per additional life-year gained might need to consider alongside budget impact and feasibility considerations.
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Affiliation(s)
- Maxime Inghels
- Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, UK
- Centre Population et Développement (UMR 196 Paris Descartes - IRD), SageSud (ERL INSERM 1244), Institut de Recherche pour le Développement, Paris, France
| | - Paul Mee
- Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, UK
| | | | - Mohamed Cissé
- Service de Dermatologie, Centre de Traitement Ambulatoire, Laboratoire de Biologie Moléculaire, CHU Donka, Conakry, Guinea
| | - David Nelson
- Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, UK
| | - Frank Tanser
- Centre for Epidemic Response and Innovation, School for Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Zahid Asghar
- School of Health and Social Care, University of Lincoln, Lincoln, UK
| | - Youssouf Koita
- Programme National de Lutte contre le VIH SIDA et les Hépatites (PNLSH), Conakry, Guinea
| | - Gabrièle Laborde-Balen
- TransVIHMI, University of Montpellier, INSERM, Institut de Recherche pour le Développement, Montpellier, France
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Mokua S, Maloba M, Wexler C, Goggin K, Staggs V, Mabachi N, Maosa N, Babu S, Hurley E, Finocchario-Kessler S. Evaluating the efficacy of the HITSystem 2.1 to improve PMTCT retention and maternal viral suppression in Kenya: Study protocol of a cluster-randomized trial. PLoS One 2022; 17:e0263988. [PMID: 35881649 PMCID: PMC9321364 DOI: 10.1371/journal.pone.0263988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 01/28/2022] [Indexed: 11/19/2022] Open
Abstract
Background Gaps in the provision of guideline-adherent prevention of mother-to-child transmission of HIV (PMTCT) services and maternal retention in care contribute to nearly 8000 Kenyan infants becoming infected with HIV annually. Interventions that routinize evidence-based PMTCT service delivery and foster consistent patient engagement are essential to eliminating mother-to-child transmission of HIV. The HITSystem 2.1 is an eHealth intervention that aims to improve retention in PMTCT services and viral load monitoring, using electronic alerts to providers and SMS to patients. This study will evaluate the impact, implementation, and cost-effectiveness of HITSystem 2.1. Method This cluster randomized trial will be conducted at 12 study hospital (6 intervention, 6 control). Pregnant women living with HIV who have initiated PMTCT care ≤36 weeks gestation are eligible. Women enrolled at control hospitals will receive standard-of-care PMTCT services. Women enrolled at intervention hospitals will receive standard-of-care PMTCT services plus enhanced HITSystem 2.1 tracking. Mixed logistic regression models will compare the arms on two primary outcomes: (1) completed guideline-adherence PMTCT services and (2) viral suppression at both delivery and 6 months postpartum. We will assess associations between provider and patient characteristics (disclosure status, partner status, depression, partner support), PMTCT knowledge, and motivation with retention outcomes. Using the RE-AIM model, we will also assess implementation factors to guide sustainable scale-up. Finally, a cost-effectiveness analysis will be conducted. Discussion This study will provide insights regarding the development and adaptation of eHealth strategies to meet the global goal of eliminating new HIV infections in children and optimizing maternal health through PMTCT services. If efficacious, implementation and cost-effectiveness data gathered in this study will guide scale-up across Kenyan health facilities. Trial registration This study was registered at clinicaltrials.gov (NCT04571684) on October 1, 2020.
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Affiliation(s)
- Sharon Mokua
- Kenya Medical Research Institute, Nairobi, Kenya
- * E-mail: ,
| | - May Maloba
- Global Health Innovations–Kenya, Nairobi, Kenya
| | - Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, Missouri, United States of America
| | - Kathy Goggin
- Children’s Mercy Kansas City, Health Services and Outcomes Research, Kansas City, Missouri, United States of America
- University of Missouri-Kansas City, School of Medicine, Kansas City, Missouri, United States of America
| | - Vincent Staggs
- Children’s Mercy Kansas City, Health Services and Outcomes Research, Kansas City, Missouri, United States of America
| | - Natabhona Mabachi
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, Missouri, United States of America
| | | | | | - Emily Hurley
- Children’s Mercy Kansas City, Health Services and Outcomes Research, Kansas City, Missouri, United States of America
| | - Sarah Finocchario-Kessler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, Missouri, United States of America
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Washio Y, Browne FA, Ndirangu J, Kline TL, Wechsberg WM. Antiretroviral Therapy (ART) Adherence and Prenatal Alcohol Use among Women Who Are Pregnant with HIV in South Africa. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:7446. [PMID: 34299897 PMCID: PMC8306976 DOI: 10.3390/ijerph18147446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 07/07/2021] [Accepted: 07/08/2021] [Indexed: 11/17/2022]
Abstract
This brief report emphasizes the need to focus on women with HIV who are pregnant who use alcohol or other drugs. A recently completed implementation science study tested a gender-focused behavioral intervention, the Women's Health CoOp (WHC), to improve antiretroviral therapy (ART) adherence and reduce alcohol use among women with HIV. The study identified 33 participants who had a positive pregnancy test result at the baseline assessment, of whom five participants remained pregnant during the 6-month duration of the study. Of the 33 pregnant participants at the baseline assessment, 55% reported past-month alcohol use, with 27% reporting a history of physical abuse and 12% reporting a history of sexual abuse. The five women who remained pregnant at 6 months showed improved ART adherence and reduced prenatal alcohol use. The gender-focused WHC intervention shows promise as a cost-effective, sustainable, behavioral intervention to address these intersecting syndemic issues. Future research should focus on identifying the needs of women with HIV who are pregnant who use alcohol or other drugs and developing tailored evidence-based behavioral interventions such as the WHC for preventing FASD in addition to improving ART adherence in this key population of women and reducing the economic burden on society.
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Affiliation(s)
- Yukiko Washio
- Substance Use, Gender and Applied Research, RTI International, Research Triangle Park, NC 27709, USA; (F.A.B.); (J.N.); (T.L.K.); (W.M.W.)
- Department of Obstetrics, Gynecology and Reproductive Sciences, Temple University Lewis Katz School of Medicine, Philadelphia, PA 19122, USA
| | - Felicia A. Browne
- Substance Use, Gender and Applied Research, RTI International, Research Triangle Park, NC 27709, USA; (F.A.B.); (J.N.); (T.L.K.); (W.M.W.)
- Gillings School of Global Public Health, University of North Carolina (UNC), Chapel Hill, NC 27599, USA
| | - Jacqueline Ndirangu
- Substance Use, Gender and Applied Research, RTI International, Research Triangle Park, NC 27709, USA; (F.A.B.); (J.N.); (T.L.K.); (W.M.W.)
| | - Tracy L. Kline
- Substance Use, Gender and Applied Research, RTI International, Research Triangle Park, NC 27709, USA; (F.A.B.); (J.N.); (T.L.K.); (W.M.W.)
| | - Wendee M. Wechsberg
- Substance Use, Gender and Applied Research, RTI International, Research Triangle Park, NC 27709, USA; (F.A.B.); (J.N.); (T.L.K.); (W.M.W.)
- Gillings School of Global Public Health, University of North Carolina (UNC), Chapel Hill, NC 27599, USA
- Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC 27708, USA
- Psychology, North Carolina State University, Raleigh, NC 27606, USA
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Dunning L, Gandhi AR, Penazzato M, Soeteman DI, Revill P, Frank S, Phillips A, Dugdale C, Abrams E, Weinstein MC, Newell M, Collins IJ, Doherty M, Vojnov L, Fassinou Ekouévi P, Myer L, Mushavi A, Freedberg KA, Ciaranello AL. Optimizing infant HIV diagnosis with additional screening at immunization clinics in three sub-Saharan African settings: a cost-effectiveness analysis. J Int AIDS Soc 2021; 24:e25651. [PMID: 33474817 PMCID: PMC8992471 DOI: 10.1002/jia2.25651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 10/19/2020] [Accepted: 11/17/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Uptake of early infant HIV diagnosis (EID) varies widely across sub-Saharan African settings. We evaluated the potential clinical impact and cost-effectiveness of universal maternal HIV screening at infant immunization visits, with referral to EID and maternal antiretroviral therapy (ART) initiation. METHODS Using the CEPAC-Pediatric model, we compared two strategies for infants born in 2017 in Côte d'Ivoire (CI), South Africa (SA), and Zimbabwe: (1) existing EID programmes offering six-week nucleic acid testing (NAT) for infants with known HIV exposure (EID), and (2) EID plus universal maternal HIV screening at six-week infant immunization visits, leading to referral for infant NAT and maternal ART initiation (screen-and-test). Model inputs included published Ivoirian/South African/Zimbabwean data: maternal HIV prevalence (4.8/30.8/16.1%), current uptake of EID (40/95/65%) and six-week immunization attendance (99/74/94%). Referral rates for infant NAT and maternal ART initiation after screen-and-test were 80%. Costs included NAT ($24/infant), maternal screening ($10/mother-infant pair), ART ($5 to 31/month) and HIV care ($15 to 190/month). Model outcomes included mother-to-child transmission of HIV (MTCT) among HIV-exposed infants, and life expectancy (LE) and mean lifetime per-person costs for children with HIV (CWH) and all children born in 2017. We calculated incremental cost-effectiveness ratios (ICERs) using discounted (3%/year) lifetime costs and LE for all children. We considered two cost-effectiveness thresholds in each country: (1) the per-capita GDP ($1720/6380/2150) per year-of-life saved (YLS), and (2) the CEPAC-generated ICER of offering 2 versus 1 lifetime ART regimens (e.g. offering second-line ART; $520/500/580/YLS). RESULTS With EID, projected six-week MTCT was 9.3% (CI), 4.2% (SA) and 5.2% (Zimbabwe). Screen-and-test decreased total MTCT by 0.2% to 0.5%, improved LE by 2.0 to 3.5 years for CWH and 0.03 to 0.07 years for all children, and increased discounted costs by $17 to 22/child (all children). The ICER of screen-and-test compared to EID was $1340/YLS (CI), $650/YLS (SA) and $670/YLS (Zimbabwe), below the per-capita GDP but above the ICER of 2 versus 1 lifetime ART regimens in all countries. CONCLUSIONS Universal maternal HIV screening at immunization visits with referral to EID and maternal ART initiation may reduce MTCT, improve paediatric LE, and be of comparable value to current HIV-related interventions in high maternal HIV prevalence settings like SA and Zimbabwe.
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Affiliation(s)
- Lorna Dunning
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
| | - Aditya R Gandhi
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
| | - Martina Penazzato
- Global HIV, Hepatitis, and STIs ProgrammeWorld Health OrganizationGenevaSwitzerland
| | - Djøra I Soeteman
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
- Center for Health Decision ScienceHarvard T.H. Chan School of Public HealthBostonMAUSA
| | - Paul Revill
- Center for Health EconomicsUniversity of YorkYorkUnited Kingdom
| | - Simone Frank
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
| | - Andrew Phillips
- Institute for Global HealthUniversity College LondonLondonUnited Kingdom
| | - Caitlin Dugdale
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Elaine Abrams
- Mailman School of Public HealthICAP at Columbia UniversityNew York CityNYUSA
| | - Milton C Weinstein
- Center for Health Decision ScienceHarvard T.H. Chan School of Public HealthBostonMAUSA
| | - Marie‐Louise Newell
- Institute for Development StudiesHuman Development and HealthFaculty of MedicineUniversity of SouthamptonSouthamptonUnited Kingdom
- School of Public HealthFaculty of Health SciencesUniversity of WitwatersrandJohannesburgSouth Africa
| | - Intira J Collins
- Medical Research Council Clinical Trials UnitUniversity College LondonLondonUnited Kingdom
| | - Meg Doherty
- Global HIV, Hepatitis, and STIs ProgrammeWorld Health OrganizationGenevaSwitzerland
| | - Lara Vojnov
- Global HIV, Hepatitis, and STIs ProgrammeWorld Health OrganizationGenevaSwitzerland
| | | | - Landon Myer
- Division of Epidemiology & BiostatisticsSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | | | - Kenneth A Freedberg
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Andrea L Ciaranello
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
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Jesson J, Desmonde S, Yiannoutsos CT, Patten G, Malateste K, Duda SN, Kumarasamy N, Yotebieng M, Davies MA, Musick B, Leroy V, Ciaranello A. Weight-for-age distributions among children with HIV on antiretroviral therapy in the International epidemiology Databases to Evaluate AIDS (IeDEA) multiregional consortium. BMC Res Notes 2020; 13:249. [PMID: 32448379 PMCID: PMC7245795 DOI: 10.1186/s13104-020-05081-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 05/03/2020] [Indexed: 12/31/2022] Open
Abstract
Objective Pediatric antiretroviral therapy (ART) for children with HIV (CHIV) must be dosed appropriately for children’s changing weights as they grow. To inform accurate estimates of ART formulations and doses needed, we described weight-for-age distributions among CHIV on ART in the IeDEA global pediatric collaboration between 2004 and 2016, using data from six regions (East, West, Central, and Southern Africa, Asia–Pacific, and Central/South America and the Caribbean). Results Overall, 59,862 children contributed to the analysis. Age and weight data were available from 530,080 clinical encounters for girls and 537,894 for boys. For each one-year age stratum from 0 to 15 years, we calculated the proportion of children in each of the weight bands designated by the World Health Organization as relevant to pediatric ART formulations: 0 to < 3 kg, 3 to < 6 kg, 6 to < 10 kg, 10 to < 14 kg, 14 to < 20 kg, 20 to < 25 kg, 25 to < 30 kg, 30 to < 35 kg, 35 to < 40 kg, 40 to < 45 kg, 45 to < 50 kg, 50 to < 55 kg, 55 to < 60 kg, and ≥ 60 kg. Data are reported for the entire cohort, as well as stratified by sex and IeDEA region, calendar year of ART use, and duration on ART at time of assessment (< 12 or ≥ 12 months), provided in data tables. These data are critical to improve the accuracy of forecasting and procurement of pediatric ART formulations as the pediatric HIV epidemic and pediatric HIV treatment strategies evolve.
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Affiliation(s)
- Julie Jesson
- Inserm U1027, Université Paul Sabatier Toulouse 3, Toulouse, France. .,Inserm, UMR 1027 - Epidémiologie et analyses en santé publique: risques, maladies chroniques et handicaps - Université Paul Sabatier Toulouse 3, Equipe 2: Axe santé de l'enfant et de l'adolescent en Afrique, 37 Allées Jules Guesde, 31073 Toulouse Cedex 7, France, Toulouse Cedex 7, France.
| | - Sophie Desmonde
- Inserm U1027, Université Paul Sabatier Toulouse 3, Toulouse, France
| | | | - Gabriela Patten
- School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Karen Malateste
- Inserm U1219, Bordeaux, France.,Bordeaux Population Health Center, Université de Bordeaux, Bordeaux, France
| | | | - Nagalingeswaran Kumarasamy
- Chennai Antiviral Research and Treatment Clinical Research Site (CART CRS), VHS-Infectious Diseases Medical Centre, VHS, Chennai, India
| | - Marcel Yotebieng
- Division of Epidemiology, The Ohio State University, College of Public Health, Columbus, OH, USA
| | - Mary-Ann Davies
- School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Beverly Musick
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Valeriane Leroy
- Inserm U1027, Université Paul Sabatier Toulouse 3, Toulouse, France
| | - Andrea Ciaranello
- The Medical Practice Evaluation Center, Boston, MA, USA.,The Division of General Internal Medicine, Department of Medicine, Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital, Boston, MA, USA
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Simulation Modeling and Metamodeling to Inform National and International HIV Policies for Children and Adolescents. J Acquir Immune Defic Syndr 2019; 78 Suppl 1:S49-S57. [PMID: 29994920 PMCID: PMC6042862 DOI: 10.1097/qai.0000000000001749] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Objective and Approach: Computer-based simulation models serve an important purpose in informing HIV care for children and adolescents. We review current model-based approaches to informing pediatric and adolescent HIV estimates and guidelines. Findings: Clinical disease simulation models and epidemiologic models are used to inform global and regional estimates of numbers of children and adolescents living with HIV and in need of antiretroviral therapy, to develop normative guidelines addressing strategies for diagnosis and treatment of HIV in children, and to forecast future need for pediatric and adolescent antiretroviral therapy formulations and commodities. To improve current model-generated estimates and policy recommendations, better country-level and regional-level data are needed about children living with HIV, as are improved data about survival and treatment outcomes for children with perinatal HIV infection as they age into adolescence and adulthood. In addition, novel metamodeling and value of information methods are being developed to improve the transparency of model methods and results, as well as to allow users to more easily tailor model-based analyses to their own settings. Conclusions: Substantial progress has been made in using models to estimate the size of the pediatric and adolescent HIV epidemic, to inform the development of guidelines for children and adolescents affected by HIV, and to support targeted implementation of policy recommendations to maximize impact. Ongoing work will address key limitations and further improve these model-based projections.
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Gavrilova TV, Shmagel NG, Chereshneva MV, Sergienko AP, Ivanova ES, Chereshnev VA. [Ocular lesions in HIV-infected patients of the ophthalmic hospitals]. Vestn Oftalmol 2019; 134:25-32. [PMID: 30721197 DOI: 10.17116/oftalma201813406125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
PURPOSE To analyze ophthalmic pathologies in HIV-infected patients of the ophthalmic hospitals of Perm city. MATERIAL AND METHODS Medical records of 75 HIV patients registered in Perm Regional Centre for Prevention and Control of AIDS and Infectious Diseases who had received treatment in ophthalmic in-patient clinics of Perm in 2005-2015 years were analyzed retrospectively. Patient examination included traditional ophthalmological methods, as well as immunological (determination of CD4 cells and viral load), serological (detection of antibodies to herpes simplex virus, cytomegalovirus, chlamydia, toxoplasma), general clinical methods, and consultations by allied specialists. RESULTS Ophthalmopathology requiring in-patient care was detected in 75 people (84 eyes). Men comprised 76%, women - 24%; average age was 32.82±8.68 years. The stage of HIV infection was known in 78.66% of patients: stage II - in 5% of cases, stage III - in 32%, stage IV - in 63%. Co-infection (hepatitis B and C, syphilis, tuberculosis) was detected in 81% of patients. HIV-related diseases (cytomegalovirus and herpes infection, candidiasis, toxoplasmosis) were observed in 48% of individuals. The time of emergence of ocular pathology from the time of HIV detection ranged from 1 day to 14 years. Inflammatory ocular diseases occurred in 55% of cases, dystrophic disorders - in 18%, eye traumas - in 24%, and strabismus - in 3% of patients. Reduced level of CD4 (less than 500 cells/mm3) was more prevalent (72.13%) among the study patients. As of the time of the study, only 36.4% of patients were receiving antiretroviral therapy. CONCLUSION Among the studied individuals, eye lesion was mostly severe, inflammatory in nature; it occurred more frequently in stage IV HIV patients with reduced number of CD4 lymphocytes who was not receiving antiretroviral therapy.
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Affiliation(s)
- T V Gavrilova
- Perm State Medical University named after E.A. Wagner, 26 Petropavlovskaya St., Perm, Russian Federation, 614000
| | - N G Shmagel
- Perm Regional Centre for Prevention and Control of AIDS and Infectious Diseases, 21 Sviyazeva St., Perm, Russian Federation, 614088
| | - M V Chereshneva
- Institute of Immunology and Physiology, Ural Branch of the Russian Academy of Sciences, 91 Pervomaiskaya St., Yekaterinburg, Russian Federation, 620041
| | - A P Sergienko
- Perm State Medical University named after E.A. Wagner, 26 Petropavlovskaya St., Perm, Russian Federation, 614000
| | - E S Ivanova
- Perm Regional Centre for Prevention and Control of AIDS and Infectious Diseases, 21 Sviyazeva St., Perm, Russian Federation, 614088
| | - V A Chereshnev
- Perm State Medical University named after E.A. Wagner, 26 Petropavlovskaya St., Perm, Russian Federation, 614000; Institute of Immunology and Physiology, Ural Branch of the Russian Academy of Sciences, 91 Pervomaiskaya St., Yekaterinburg, Russian Federation, 620041
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Desmonde S, Frank SC, Coovadia A, Dahourou DL, Hou T, Abrams EJ, Amorissani-Folquet M, Walensky RP, Strehlau R, Penazzato M, Freedberg KA, Kuhn L, Leroy V, Ciaranello AL. Cost-Effectiveness of Preemptive Switching to Efavirenz-Based Antiretroviral Therapy for Children With Human Immunodeficiency Virus. Open Forum Infect Dis 2019; 6:ofz276. [PMID: 31334298 PMCID: PMC6634435 DOI: 10.1093/ofid/ofz276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 06/05/2019] [Indexed: 11/12/2022] Open
Abstract
Background The NEVEREST-3 (South Africa) and MONOD-ANRS-12206 (Côte d'Ivoire, Burkina Faso) randomized trials found that switching to efavirenz (EFV) in human immunodeficiency virus-infected children >3 years old who were virologically suppressed by ritonavir-boosted lopinavir (LPV/r) was noninferior to continuing o LPV/r. We evaluated the cost-effectiveness of this strategy using the Cost-Effectiveness of Preventing AIDS Complications-Pediatric model. Methods We examined 3 strategies in South African children aged ≥3 years who were virologically suppressed by LPV/r: (1) continued LPV/r, even in case of virologic failure, without second-line regimens; continued on LPV/r with second-line option after observed virologic failure; and preemptive switch to EFV-based antiretroviral therapy (ART), with return to LPV/r after observed virologic failure. We derived data on 24-week suppression (<1000 copies/mL) after a switch to EFV (98.4%) and the subsequent risk of virologic failure (LPV/r, 0.23%/mo; EFV, 0.15%/mo) from NEVEREST-3 data; we obtained ART costs (LPV/r, $6-$20/mo; EFV, $3-$6/mo) from published sources. We projected discounted life expectancy (LE) and lifetime costs per person. A secondary analysis used data from MONOD-ANRS-12206 in Côte d'Ivoire. Results Continued LPV/r led to the shortest LE (18.2 years) and the highest per-person lifetime cost ($19 470). LPV/r with second-line option increased LE (19.9 years) and decreased per-person lifetime costs($16 070). Switching led to the longest LE (20.4 years) and the lowest per-person lifetime cost ($15 240); this strategy was cost saving under plausible variations in key parameters. Using MONOD-ANRS-12206 data in Côte d'Ivoire, the Switch strategy remained cost saving only compared with continued LPV/r, but the LPV/r with second-line option strategy was cost-effective compared with switching. Conclusion For children ≥3 years old and virologically suppressed by LPV/r-based ART, preemptive switching to EFV can improve long-term clinical outcomes and be cost saving. Clinical Trials Registration NCT01127204.
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Affiliation(s)
- Sophie Desmonde
- UMR 1027 Inserm, Université Paul Sabatier, Toulouse.,Bordeaux School of Public Health, France.,Medical Practice Evaluation Center, Boston
| | - Simone C Frank
- Medical Practice Evaluation Center, Boston.,Division of General Internal Medicine, Department of Medicine, Boston
| | - Ashraf Coovadia
- Empilweni Service and Research Unit, Johannesburg, South Africa
| | - Désiré L Dahourou
- Bordeaux School of Public Health, France.,Centre Muraz, Bobo-Dioulasso, Burkina Faso
| | - Taige Hou
- Medical Practice Evaluation Center, Boston.,Division of General Internal Medicine, Department of Medicine, Boston
| | - Elaine J Abrams
- ICAP at Columbia University, Mailman School of Public Health, and Vagelos College of Physicians & Surgeons, Columbia University, New York
| | | | - Rochelle P Walensky
- Medical Practice Evaluation Center, Boston.,Division of General Internal Medicine, Department of Medicine, Boston.,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston.,Center for AIDS Research, Harvard University, Boston
| | - Renate Strehlau
- Empilweni Service and Research Unit, Johannesburg, South Africa
| | | | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Boston.,Division of General Internal Medicine, Department of Medicine, Boston.,Center for AIDS Research, Harvard University, Boston.,Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston
| | - Louise Kuhn
- Gertrude H. Sergievsky Center, College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, New York
| | | | - Andrea L Ciaranello
- Medical Practice Evaluation Center, Boston.,Division of General Internal Medicine, Department of Medicine, Boston.,Harvard Medical School, Boston
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10
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Malati CY, Golin R, O'Brien L, Sugandhi N, Srivastava M, Larson C, Phelps BR. Pursuing use of optimal formulations for paediatric HIV epidemic control - a look at the use of LPV/r oral pellets and oral granules. J Int AIDS Soc 2019; 22:e25267. [PMID: 30983152 PMCID: PMC6462808 DOI: 10.1002/jia2.25267] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 03/05/2019] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Despite a significant reduction in mother-to-child transmission of HIV, an estimated 180,000 children were infected with HIV in 2017, and only 52% of children under 15 years of age living with HIV (CLHIV) are on life-saving antiretroviral therapy (ART). Without effective treatment, half of CLHIV die before the age of two years and only one in five survives to five years of age. DISCUSSION Over the past four years, the United States Food and Drug Administration tentatively approved new formulations of lopinavir/ritonavir (LPV/r) in the form of oral pellets and oral granules. However, the slow uptake of the aforementioned formulations in the low- and middle-income countries with the highest paediatric HIV burden is largely due to three challenges: limited manufacturing capacity; current unit cost of the pellets and granules; and slow uptake of these new formulations by policy makers and health care workers. CONCLUSIONS Solutions to overcome these barriers include ensuring availability of an adequate supply of LPV/r oral pellets and oral granules, considering all programmatic and clinical factors when selecting paediatric ART formulations, and leveraging current resources to decrease paediatric HIV morbidity and mortality.
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Affiliation(s)
| | - Rachel Golin
- United States Agency for International DevelopmentWashingtonDCUSA
| | | | | | - Meena Srivastava
- United States Agency for International DevelopmentWashingtonDCUSA
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11
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Frank SC, Cohn J, Dunning L, Sacks E, Walensky RP, Mukherjee S, Dugdale CM, Turunga E, Freedberg KA, Ciaranello AL. Clinical effect and cost-effectiveness of incorporation of point-of-care assays into early infant HIV diagnosis programmes in Zimbabwe: a modelling study. Lancet HIV 2019; 6:e182-e190. [PMID: 30737187 PMCID: PMC6408227 DOI: 10.1016/s2352-3018(18)30328-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 11/07/2018] [Accepted: 11/08/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND New point-of-care (POC) assays for early infant HIV diagnosis are costlier than conventional total nucleic acid assays, but could increase access to testing, shorten time to results, and expedite initiation of antiretroviral therapy. We aimed to assess the clinical benefits and cost-effectiveness of incorporating these POC assays into early infant diagnosis programmes in Zimbabwe. METHODS We used the Cost Effectiveness of Preventing AIDS Complications (CEPAC)-Pediatric model to examine the clinical benefits, costs, and cost-effectiveness of replacing conventional assays for early infant HIV diagnosis with POC assays at age 6 weeks in Zimbabwe. We simulated two strategies for early infant HIV diagnosis: conventional and POC. Modelled assays differed in sensitivity; specificity; time to, and probability of, return of results; and cost. Model outcomes included survival, life expectancy, and mean lifetime per-person treatment cost, which were reported separately for all HIV-exposed infants and all infants with HIV. We calculated incremental cost-effectiveness ratios with discounted (3% per year) costs and life expectancy from a health-care system perspective for all HIV-exposed infants. We judged incremental cost-effectiveness ratios of $1010 (Zimbabwe's annual gross domestic product per person) or less per year of life saved to be cost-effective. FINDINGS When conventional assays were used for early infant diagnosis, projected undiscounted life expectancy was 22·7 years for infants with HIV and 62·5 years for all HIV-exposed infants, at a cost of $610 per HIV-exposed infant. Use of POC assays for early infant HIV diagnosis improved projected undiscounted life expectancy to 25·5 years among infants with HIV and 62·6 years among HIV-exposed infants at a cost of $690 per HIV-exposed infant. At age 12 weeks, survival among all infants with HIV was 76·1% with the conventional testing strategy and 83·5% with the POC testing strategy. The incremental cost-effectiveness ratio of POC assays versus conventional assays for early infant diagnosis was $680 per year of life saved. When conventional assay characteristics remained constant, this ratio remained under the cost-effectiveness threshold as long as the specificity and sensitivity of the POC assay were greater than 92% and 65%, respectively. Our results were robust to plausible variations in POC assay cost, the probability of ART initiation, and probability of return of the results of POC testing. INTERPRETATION Compared with conventional assays, POC assays for early infant HIV diagnosis in Zimbabwe will improve survival, extend life expectancy, and be cost-effective for HIV-exposed infants. FUNDING Elizabeth Glaser Pediatric AIDS Foundation, US National Institute of Allergy and Infectious Diseases, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Unitaid.
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Affiliation(s)
- Simone C. Frank
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Jennifer Cohn
- Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland
- Division of Infectious Disease, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Lorna Dunning
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Emma Sacks
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States of America
| | - Rochelle P. Walensky
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Sushant Mukherjee
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States of America
| | - Caitlin M. Dugdale
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Esther Turunga
- Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland
| | - Kenneth A. Freedberg
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Andrea L. Ciaranello
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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12
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Dunning L, Francke JA, Mallampati D, MacLean RL, Penazzato M, Hou T, Myer L, Abrams EJ, Walensky RP, Leroy V, Freedberg KA, Ciaranello A. The value of confirmatory testing in early infant HIV diagnosis programmes in South Africa: A cost-effectiveness analysis. PLoS Med 2017; 14:e1002446. [PMID: 29161262 PMCID: PMC5697827 DOI: 10.1371/journal.pmed.1002446] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 10/18/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The specificity of nucleic acid amplification tests (NAATs) used for early infant diagnosis (EID) of HIV infection is <100%, leading some HIV-uninfected infants to be incorrectly identified as HIV-infected. The World Health Organization recommends that infants undergo a second NAAT to confirm any positive test result, but implementation is limited. Our objective was to determine the impact and cost-effectiveness of confirmatory HIV testing for EID programmes in South Africa. METHOD AND FINDINGS Using the Cost-effectiveness of Preventing AIDS Complications (CEPAC)-Pediatric model, we simulated EID testing at age 6 weeks for HIV-exposed infants without and with confirmatory testing. We assumed a NAAT cost of US$25, NAAT specificity of 99.6%, NAAT sensitivity of 100% for infants infected in pregnancy or at least 4 weeks prior to testing, and a mother-to-child transmission (MTCT) rate at 12 months of 4.9%; we simulated guideline-concordant rates of testing uptake, result return, and antiretroviral therapy (ART) initiation (100%). After diagnosis, infants were linked to and retained in care for 10 years (false-positive) or lifelong (true-positive). All parameters were varied widely in sensitivity analyses. Outcomes included number of infants with false-positive diagnoses linked to ART per 1,000 ART initiations, life expectancy (LE, in years) and per-person lifetime HIV-related healthcare costs. Both without and with confirmatory testing, LE was 26.2 years for HIV-infected infants and 61.4 years for all HIV-exposed infants; clinical outcomes for truly infected infants did not differ by strategy. Without confirmatory testing, 128/1,000 ART initiations were false-positive diagnoses; with confirmatory testing, 1/1,000 ART initiations were false-positive diagnoses. Because confirmatory testing averted costly HIV care and ART in truly HIV-uninfected infants, it was cost-saving: total cost US$1,790/infant tested, compared to US$1,830/infant tested without confirmatory testing. Confirmatory testing remained cost-saving unless NAAT cost exceeded US$400 or the HIV-uninfected status of infants incorrectly identified as infected was ascertained and ART stopped within 3 months of starting. Limitations include uncertainty in the data used in the model, which we examined with sensitivity and uncertainty analyses. We also excluded clinical harms to HIV-uninfected infants incorrectly treated with ART after false-positive diagnosis (e.g., medication toxicities); including these outcomes would further increase the value of confirmatory testing. CONCLUSIONS Without confirmatory testing, in settings with MTCT rates similar to that of South Africa, more than 10% of infants who initiate ART may reflect false-positive diagnoses. Confirmatory testing prevents inappropriate HIV diagnosis, is cost-saving, and should be adopted in all EID programmes.
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Affiliation(s)
- Lorna Dunning
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Medical Practice Evaluation Centre, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Jordan A. Francke
- Medical Practice Evaluation Centre, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Divya Mallampati
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois, United States of America
| | - Rachel L. MacLean
- Medical Practice Evaluation Centre, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Martina Penazzato
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Taige Hou
- Medical Practice Evaluation Centre, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Diseases Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Elaine J. Abrams
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, United States of America
- College of Physicians & Surgeons, Columbia University, New York, New York, United States of America
| | - Rochelle P. Walensky
- Medical Practice Evaluation Centre, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Center for AIDS Research, Harvard University, Boston, Massachusetts, United States of America
| | | | - Kenneth A. Freedberg
- Medical Practice Evaluation Centre, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Center for AIDS Research, Harvard University, Boston, Massachusetts, United States of America
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Andrea Ciaranello
- Medical Practice Evaluation Centre, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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13
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Bernays S, Paparini S, Seeley J, Namukwaya Kihika S, Gibb D, Rhodes T. Qualitative study of the BREATHER trial (Short Cycle antiretroviral therapy): is it acceptable to young people living with HIV? BMJ Open 2017; 7:e012934. [PMID: 28213595 PMCID: PMC5318557 DOI: 10.1136/bmjopen-2016-012934] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES A qualitative study of the BREATHER (PENTA 16) randomised clinical trial, which compared virological control of Short Cycle Therapy (SCT) (5 days on: 2 days off) with continuous efavirenz (EFV)-based antiretroviral therapy (CT) in children and young people (aged 8-24) living with HIV with viral load <50 c/mL to examine adaptation, acceptability and experience of SCT to inform intervention development. SETTING Paediatric HIV clinics in the UK (2), Ireland (1), the USA (1) and Uganda (1). PARTICIPANTS All BREATHER trial participants who were over the age of 10 and aware of their HIV diagnosis were invited to participate. 49 young people from both arms of the BREATHER trial (31 females and 18 males; 40% of the total trial population in the respective sites; age range 11-24) gave additional consent to participate in the qualitative study. RESULTS Young people from both trial arms had initial concerns about the impact of SCT on their health and adherence, but these decreased over the early months in the trial. Young people randomised to SCT reported preference for SCT compared with CT pre-trial. Attitudes to SCT did not vary greatly by gender or country. Once short-term adaptation challenges were overcome, SCT was positively described as reducing impact of side effects, easing the pressure to carry and remember medication and enabling more weekend social activities. Young people on both arms reported frequent medication side effects and occasional missed doses that they had rarely voiced to clinical staff. Participants liked SCT by trial end but were concerned that peers who had most problems adhering could find SCT disruptive and difficult to manage. CONCLUSIONS To realise the potential of SCT (and mitigate possible risks of longer interruptions), careful dissemination and communication post-trial is needed. SCT should be provided alongside a package of monitoring, support and education over 3 months to allow adaptation. TRIAL REGISTRATION NUMBER NCT 01641016.
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Affiliation(s)
- Sarah Bernays
- Facultyof Public Health Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Sara Paparini
- Facultyof Public Health Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Janet Seeley
- Facultyof Public Health Policy, London School of Hygiene & Tropical Medicine, London, UK
- MRC/UVRI Uganda Research Unit on AIDS, Social Science Programme, Entebbe, Uganda
| | | | - Diana Gibb
- MRC Clinical Trials Unit at UCL, London, UK
| | - Tim Rhodes
- Facultyof Public Health Policy, London School of Hygiene & Tropical Medicine, London, UK
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14
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Desmonde S, Avit D, Petit J, Amorissani Folquet M, Eboua FT, Amani Bosse C, Dainguy E, Mea V, Timite-Konan M, Ngbeché S, Ciaranello A, Leroy V. Costs of Care of HIV-Infected Children Initiating Lopinavir/Ritonavir-Based Antiretroviral Therapy before the Age of Two in Cote d'Ivoire. PLoS One 2016; 11:e0166466. [PMID: 27935971 PMCID: PMC5147813 DOI: 10.1371/journal.pone.0166466] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 10/28/2016] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES To access the costs of care for Ivoirian children before and after initiating LPV/r-based antiretroviral therapy (ART) before the age of two. METHODS We assessed the direct costs of care for all HIV-infected children over the first 12 months on LPV/r-based ART initiated <2 years of age in Abidjan. We recorded all drug prescriptions, ART and cotrimoxazole prophylaxis delivery, medical analyses/examinations and hospital admissions. We compared these costs to those accrued in the month prior to ART initiation. Costs and 95% confidence intervals (95%CI) were estimated per child-month, according to severe morbidity. RESULTS Of the 114 children screened, 99 initiated LPV/r-based ART at a median age of 13.5 months (IQR: 6.8-18.6); 45% had reached World Health Organization stage 3 or 4. During the first 12 months on ART, 5% died and 3% were lost to follow-up. In the month before ART initiation, the mean cost of care per child-month reached $123.39 (95%CI:$121.02-$125.74). After ART initiation, it was $42.53 (95%CI:$42.15-$42.91); 50% were ART costs. The remaining costs were non-antiretroviral drugs (18%) and medical analyses/examinations (14%). Mean costs were significantly higher within the first three months on ART ($48.76, 95%CI:$47.95-$49.56) and in children experiencing severe morbidity ($49.76, 95%CI:$48.61-50.90). CONCLUSION ART reduces the overall monthly cost of care of HIV-infected children < 2 years. Because children were treated at an advanced HIV disease stage, the additional costs of treating severe morbidity on ART remain substantial. Strategies for treating HIV-infected children as early as possible must remain a priority in Côte d'Ivoire.
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Affiliation(s)
- Sophie Desmonde
- Inserm, U1219, Bordeaux University, Bordeaux, France
- Institut de Sante Publique, d’Epidemiologie et de Developpement, Bordeaux University, Bordeaux, France
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Divine Avit
- Programme PACCI, Site ANRS, Abidjan, Cote d’Ivoire
| | - Junie Petit
- Institut de Sante Publique, d’Epidemiologie et de Developpement, Bordeaux University, Bordeaux, France
| | - Madeleine Amorissani Folquet
- Programme PACCI, Site ANRS, Abidjan, Cote d’Ivoire
- Service de Pediatrie, Centre Hospitalier Universitaire (CHU) de Cocody, Abidjan, Cote d’Ivoire
| | | | | | - Evelyne Dainguy
- Service de Pediatrie, Centre Hospitalier Universitaire (CHU) de Cocody, Abidjan, Cote d’Ivoire
| | | | - Marguerite Timite-Konan
- Programme PACCI, Site ANRS, Abidjan, Cote d’Ivoire
- Service de Pediatrie, Centre Hospitalier Universitaire (CHU) de Yopougon, Abidjan, Cote d’Ivoire
| | - Sylvie Ngbeché
- Centre de Prise en charge, de recherche et de Formation (CePReF), Service Enfant, Yopougon, Abidjan, Cote d’Ivoire
| | - Andrea Ciaranello
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Valeriane Leroy
- Inserm Unit 1027, University of Toulouse 3, Toulouse, France
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15
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Francke JA, Penazzato M, Hou T, Abrams EJ, MacLean RL, Myer L, Walensky RP, Leroy V, Weinstein MC, Parker RA, Freedberg KA, Ciaranello A. Clinical Impact and Cost-effectiveness of Diagnosing HIV Infection During Early Infancy in South Africa: Test Timing and Frequency. J Infect Dis 2016; 214:1319-1328. [PMID: 27540110 PMCID: PMC5079370 DOI: 10.1093/infdis/jiw379] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 07/14/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Diagnosis of human immunodeficiency virus (HIV) infection during early infancy (commonly known as "early infant HIV diagnosis" [EID]) followed by prompt initiation of antiretroviral therapy dramatically reduces mortality. EID testing is recommended at 6 weeks of age, but many infant infections are missed. DESIGN/METHODS We simulated 4 EID testing strategies for HIV-exposed infants in South Africa: no EID (diagnosis only after illness; hereafter, "no EID"), testing once (at birth alone or at 6 weeks of age alone; hereafter, "birth alone" and "6 weeks alone," respectively), and testing twice (at birth and 6 weeks of age; hereafter "birth and 6 weeks"). We calculated incremental cost-effectiveness ratios (ICERs), using discounted costs and life expectancies for all HIV-exposed (infected and uninfected) infants. RESULTS In the base case (guideline-concordant care), the no EID strategy produced a life expectancy of 21.1 years (in the HIV-infected group) and 61.1 years (in the HIV-exposed group); lifetime cost averaged $1430/HIV-exposed infant. The birth and 6 weeks strategy maximized life expectancy (26.5 years in the HIV-infected group and 61.4 years in the HIV-exposed group), costing $1840/infant tested. The ICER of the 6 weeks alone strategy versus the no EID strategy was $1250/year of life saved (19% of South Africa's per capita gross domestic product); the ICER for the birth and 6 weeks strategy versus the 6 weeks alone strategy was $2900/year of life saved (45% of South Africa's per capita gross domestic product). Increasing the proportion of caregivers who receive test results and the linkage of HIV-positive infants to antiretroviral therapy with the 6 weeks alone strategy improved survival more than adding a second test. CONCLUSIONS EID at birth and 6 weeks improves outcomes and is cost-effective, compared with EID at 6 weeks alone. If scale-up costs are comparable, programs should add birth testing after strengthening 6-week testing programs.
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Affiliation(s)
- Jordan A Francke
- Division of General Internal Medicine
- Medical Practice Evaluation Center
| | - Martina Penazzato
- Medical Research Council Clinical Trials Unit London, United Kingdom
- World Health Organization, Geneva, Switzerland
| | - Taige Hou
- Division of General Internal Medicine
- Medical Practice Evaluation Center
| | - Elaine J Abrams
- International Center for AIDS Care and Treatment Program, Mailman School of Public Health
- College of Physicians and Surgeons, Columbia University, New York
| | - Rachel L MacLean
- Division of General Internal Medicine
- Medical Practice Evaluation Center
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Rochelle P Walensky
- Division of General Internal Medicine
- Medical Practice Evaluation Center
- Division of Infectious Diseases, Department of Medicine
- Division of Infectious Diseases, Brigham and Women's Hospital
- Center for AIDS Research, Harvard University
| | | | - Milton C Weinstein
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health
- Harvard Medical School, Boston, Massachusetts
| | - Robert A Parker
- Division of General Internal Medicine
- Medical Practice Evaluation Center
- Biostatistics Center, Massachusetts General Hospital
- Center for AIDS Research, Harvard University
- Harvard Medical School, Boston, Massachusetts
| | - Kenneth A Freedberg
- Division of General Internal Medicine
- Medical Practice Evaluation Center
- Division of Infectious Diseases, Department of Medicine
- Center for AIDS Research, Harvard University
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health
| | - Andrea Ciaranello
- Medical Practice Evaluation Center
- Division of Infectious Diseases, Department of Medicine
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16
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Costing of Paediatric Treatment alongside Clinical Trials under Low Resource Constraint Environments: Cotrimoxazole and Antiretroviral Medications in Children Living with HIV/AIDS. AIDS Res Treat 2016; 2016:9456906. [PMID: 28042479 PMCID: PMC5153543 DOI: 10.1155/2016/9456906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 09/04/2016] [Accepted: 09/06/2016] [Indexed: 11/17/2022] Open
Abstract
Introduction. Costing evidence is essential for policy makers for priority setting and resource allocation. It is in this context that the clinical trials of ARVs and cotrimoxazole provided a costing component to provide evidence for budgeting and resource needs alongside the clinical efficacy studies.Methods. A micro based costing approach was adopted, using case record forms for maintaining patient records. Costs for fixed assets were allocated based on the paediatric space. Medication and other resource costs were costed using the WHO/MSH Drug Price Indicators as well as procurement data where these were available.Results. The costs for cotrimoxazole and ARVs are significantly different. The average costs for human resources were US$22 and US$71 for physician costs and $1.3 and $16 for nursing costs while in-patient costs were $257 and $15 for the cotrimoxazole and ARV cohorts, respectively. Mean or average costs were $870 for the cotrimoxazole cohort and $218 for the ARV. The causal factors for the significant cost differences are attributable to the higher human resource time, higher infections of opportunistic conditions, and longer and higher frequency of hospitalisations, among others.
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The HIV Treatment Gap: Estimates of the Financial Resources Needed versus Available for Scale-Up of Antiretroviral Therapy in 97 Countries from 2015 to 2020. PLoS Med 2015; 12:e1001907; discussion e1001907. [PMID: 26599990 PMCID: PMC4658189 DOI: 10.1371/journal.pmed.1001907] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 10/16/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) released revised guidelines in 2015 recommending that all people living with HIV, regardless of CD4 count, initiate antiretroviral therapy (ART) upon diagnosis. However, few studies have projected the global resources needed for rapid scale-up of ART. Under the Health Policy Project, we conducted modeling analyses for 97 countries to estimate eligibility for and numbers on ART from 2015 to 2020, along with the facility-level financial resources required. We compared the estimated financial requirements to estimated funding available. METHODS AND FINDINGS Current coverage levels and future need for treatment were based on country-specific epidemiological and demographic data. Simulated annual numbers of individuals on treatment were derived from three scenarios: (1) continuation of countries' current policies of eligibility for ART, (2) universal adoption of aspects of the WHO 2013 eligibility guidelines, and (3) expanded eligibility as per the WHO 2015 guidelines and meeting the Joint United Nations Programme on HIV/AIDS "90-90-90" ART targets. We modeled uncertainty in the annual resource requirements for antiretroviral drugs, laboratory tests, and facility-level personnel and overhead. We estimate that 25.7 (95% CI 25.5, 26.0) million adults and 1.57 (95% CI 1.55, 1.60) million children could receive ART by 2020 if countries maintain current eligibility plans and increase coverage based on historical rates, which may be ambitious. If countries uniformly adopt aspects of the WHO 2013 guidelines, 26.5 (95% CI 26.0 27.0) million adults and 1.53 (95% CI 1.52, 1.55) million children could be on ART by 2020. Under the 90-90-90 scenario, 30.4 (95% CI 30.1, 30.7) million adults and 1.68 (95% CI 1.63, 1.73) million children could receive treatment by 2020. The facility-level financial resources needed for scaling up ART in these countries from 2015 to 2020 are estimated to be US$45.8 (95% CI 45.4, 46.2) billion under the current scenario, US$48.7 (95% CI 47.8, 49.6) billion under the WHO 2013 scenario, and US$52.5 (95% CI 51.4, 53.6) billion under the 90-90-90 scenario. After projecting recent external and domestic funding trends, the estimated 6-y financing gap ranges from US$19.8 billion to US$25.0 billion, depending on the costing scenario and the U.S. President's Emergency Plan for AIDS Relief contribution level, with the gap for ART commodities alone ranging from US$14.0 to US$16.8 billion. The study is limited by excluding above-facility and other costs essential to ART service delivery and by the availability and quality of country- and region-specific data. CONCLUSIONS The projected number of people receiving ART across three scenarios suggests that countries are unlikely to meet the 90-90-90 treatment target (81% of people living with HIV on ART by 2020) unless they adopt a test-and-offer approach and increase ART coverage. Our results suggest that future resource needs for ART scale-up are smaller than stated elsewhere but still significantly threaten the sustainability of the global HIV response without additional resource mobilization from domestic or innovative financing sources or efficiency gains. As the world moves towards adopting the WHO 2015 guidelines, advances in technology, including the introduction of lower-cost, highly effective antiretroviral regimens, whose value are assessed here, may prove to be "game changers" that allow more people to be on ART with the resources available.
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Cost-effectiveness of first-line antiretroviral therapy for HIV-infected African children less than 3 years of age. AIDS 2015; 29:1247-59. [PMID: 25870982 PMCID: PMC4536981 DOI: 10.1097/qad.0000000000000672] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background: The International Maternal, Pediatric, and Adolescent Clinical Trials P1060 trial demonstrated superior outcomes for HIV-infected children less than 3 years old initiating antiretroviral therapy (ART) with lopinavir/ritonavir compared to nevirapine, but lopinavir/ritonavir is four-fold costlier. Design/methods: We used the Cost-Effectiveness of Preventing AIDS Complications (CEPAC)-Pediatric model, with published and P1060 data, to project outcomes under three strategies: no ART; first-line nevirapine (with second-line lopinavir/ritonavir); and first-line lopinavir/ritonavir (second-line nevirapine). The base-case examined South African children initiating ART at age 12 months; sensitivity analyses varied all key model parameters. Outcomes included life expectancy, lifetime costs, and incremental cost-effectiveness ratios [ICERs; dollars/year of life saved ($/YLS)]. We considered interventions with ICERs less than 1× per-capita gross domestic product (South Africa: $7500)/YLS as ‘very cost-effective,’ interventions with ICERs below 3× gross domestic product/YLS as ‘cost-effective,’ and interventions leading to longer life expectancy and lower lifetime costs as ‘cost-saving’. Results: Projected life expectancy was 2.8 years with no ART. Both ART regimens markedly improved life expectancy and were very cost-effective, compared to no ART. First-line lopinavir/ritonavir led to longer life expectancy (28.8 years) and lower lifetime costs ($41 350/person, from lower second-line costs) than first-line nevirapine (27.6 years, $44 030). First-line lopinavir/ritonavir remained cost-saving or very cost-effective compared to first-line nevirapine unless: liquid lopinavir/ritonavir led to two-fold higher virologic failure rates or 15-fold greater costs than in the base-case, or second-line ART following first-line lopinavir/ritonavir was very ineffective. Conclusions: On the basis of P1060 data, first-line lopinavir/ritonavir leads to longer life expectancy and is cost-saving or very cost-effective compared to first-line nevirapine. This supports WHO guidelines, but increasing access to pediatric ART is critical regardless of the regimen used.
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