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Finocchario-Kessler S, Goggin K, Wexler C, Maloba M, Gautney B, Khamadi S, Lwembe R, Babu S, Sweat M. Incorporating the HIV Infant Tracking System into standard-of-care early infant diagnosis of HIV services in Kenya: a cost-effectiveness analysis of the HITSystem randomised trial. Lancet Glob Health 2023; 11:e1217-e1224. [PMID: 37474229 PMCID: PMC10482001 DOI: 10.1016/s2214-109x(23)00216-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 04/11/2023] [Accepted: 04/27/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND The HITSystem efficacy trial showed significant improvements in early infant diagnosis retention, return and notification of infant test results, and earlier antiretroviral therapy (ART) initiation compared with standard-of-care early infant diagnosis services in Kenya. This study aimed to analyse data from the HITSystem trial to assess the cost-effectiveness of the intervention in Kenya. METHODS In this analysis, we extrapolated results from the HITSystem cluster randomised controlled trial to model early infant diagnosis outcomes and cost-effectiveness if the HITSystem was scaled up nationally in Kenya, compared with standard-of-care outcomes. We used a micro-costing method to collect cost data, which were analysed from a health-system perspective, reflecting the investment required to add HITSystem to existing early infant diagnosis services and infrastructure. The base model used to calculate cost-effectiveness was deterministic and calculated the progression of infants through early infant diagnosis. Differences in progression across study arms were used to establish efficacy outcomes. The number of life-years gained per infant successfully initiating ART were based on the Cost Effectiveness of Preventing AIDS Complications model in east Africa. HITSystem cost data were integrated into the model, and the incremental cost-effectiveness ratio was calculated in terms of cost per life-year gained. Sensitivity analyses were done using the deterministic model with triangular stochastic probability functions for key model parameters added. The number of life-years gained was discounted at 3% and costs were adjusted to 2021 values. FINDINGS The cost per life-year gained from the HITSystem was US$82·72. Total cost for national HITSystem coverage in Kenya was estimated to be around $2·6 million; covering 82 230 infants exposed to HIV at a cost of $31·38 per infant and a yield of 1133 infants receiving timely ART, which would result in 31 189 life-years gained. With sensitivity analyses, the cost per life-year gained varied from $40·13 to $215·05. 90% of model values across iterations ranged between $55·58 (lower 5% threshold) and $132·38 (upper 95% threshold). INTERPRETATION The HITSystem would be very cost-effective in Kenya and can optimise the return on the existing investment in the national early infant diagnosis programme. FUNDING The US National Institute of Child Health and Human Development.
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Affiliation(s)
- Sarah Finocchario-Kessler
- Department of Family Medicine and Community Health, University of Kansas Medical Center, Kansas City, KS, USA.
| | - Kathy Goggin
- Health Services and Outcomes Research, Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, USA
| | - Catherine Wexler
- Department of Family Medicine and Community Health, University of Kansas Medical Center, Kansas City, KS, USA
| | - May Maloba
- Global Health Innovations Kenya, Nairobi, Kenya
| | | | - Samoel Khamadi
- Centre for Virus Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Raphael Lwembe
- Centre for Virus Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Michael Sweat
- Division of Global and Community Health, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
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2
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Elsbernd K, Emmert-Fees KMF, Erbe A, Ottobrino V, Kroidl A, Bärnighausen T, Geisler BP, Kohler S. Costs and cost-effectiveness of HIV early infant diagnosis in low- and middle-income countries: a scoping review. Infect Dis Poverty 2022; 11:82. [PMID: 35841117 PMCID: PMC9284833 DOI: 10.1186/s40249-022-01006-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/01/2022] [Indexed: 11/25/2022] Open
Abstract
Background Continuing progress in the global pediatric human immunodeficiency virus (HIV) response depends on timely identification and care of infants with HIV. As countries scale-out improvements to HIV early infant diagnosis (EID), economic evaluations are needed to inform program design and implementation. This scoping review aimed to summarize the available evidence and discuss practical implications of cost and cost-effectiveness analyses of HIV EID. Methods We systematically searched bibliographic databases (Embase, MEDLINE and EconLit) and grey literature for economic analyses of HIV EID in low- and middle-income countries published between January 2008 and June 2021. We extracted data on unit costs, cost savings, and incremental cost-effectiveness ratios as well as outcomes related to health and the HIV EID care process and summarized results in narrative and tabular formats. We converted unit costs to 2021 USD for easier comparison of costs across studies. Results After title and abstract screening of 1278 records and full-text review of 99 records, we included 29 studies: 17 cost analyses and 12 model-based cost-effectiveness analyses. Unit costs were 21.46–51.80 USD for point-of-care EID tests and 16.21–42.73 USD for laboratory-based EID tests. All cost-effectiveness analyses stated at least one of the interventions evaluated to be cost-effective. Most studies reported costs of EID testing strategies; however, few studies assessed the same intervention or reported costs in the same way, making comparison of costs across studies challenging. Limited data availability of context-appropriate costs and outcomes of children with HIV as well as structural heterogeneity of cost-effectiveness modelling studies limits generalizability of economic analyses of HIV EID. Conclusions The available cost and cost-effectiveness evidence for EID of HIV, while not directly comparable across studies, covers a broad range of interventions and suggests most interventions designed to improve EID are cost-effective or cost-saving. Further studies capturing costs and benefits of EID services as they are delivered in real-world settings are needed. Graphical Abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s40249-022-01006-7.
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Affiliation(s)
- Kira Elsbernd
- Division of Infectious Diseases and Tropical Medicine, Faculty of Medicine, Ludwig Maximilians University, Munich, Germany. .,Institute for Medical Information Processing, Biometry, and Epidemiology (IBE), Faculty of Medicine, Ludwig Maximilian University, Munich, Germany.
| | - Karl M F Emmert-Fees
- Department of Sports and Health Sciences, Technical University of Munich, Munich, Germany.,Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Munich, Germany
| | - Amanda Erbe
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany.,Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Veronica Ottobrino
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany.,Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Arne Kroidl
- Division of Infectious Diseases and Tropical Medicine, Faculty of Medicine, Ludwig Maximilians University, Munich, Germany.,German Center for Infection Research (DZIF), Partner Site, Munich, Germany
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Benjamin P Geisler
- Institute for Medical Information Processing, Biometry, and Epidemiology (IBE), Faculty of Medicine, Ludwig Maximilian University, Munich, Germany.,Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Stefan Kohler
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany.,Institute of Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Mahlakwane KL, Preiser W, Nkosi N, Naidoo N, van Zyl G. Delays in HIV-1 infant polymerase chain reaction testing may leave children without confirmed diagnoses in the Western Cape province, South Africa. Afr J Lab Med 2022; 11:1485. [PMID: 35811753 PMCID: PMC9257942 DOI: 10.4102/ajlm.v11i1.1485] [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: 12/04/2020] [Accepted: 03/24/2022] [Indexed: 11/29/2022] Open
Abstract
Background Early diagnosis and confirmation of HIV infection in newborns is crucial for expedited initiation of antiretroviral therapy. Confirmatory testing must be done for all children with a reactive HIV PCR result. There is no comprehensive data on confirmatory testing and HIV PCR test request rejections at National Health Laboratory Service laboratories in South Africa. Objective This study assessed the metrics of routine infant HIV PCR testing at the Tygerberg Hospital Virology Laboratory, Cape Town, Western Cape, South Africa, including the proportion of rejected test requests, turn-around time (TAT), and rate of confirmatory testing. Methods We retrospectively reviewed laboratory-based data on all HIV PCR tests performed on children ≤ 24 months old (n = 43 346) and data on rejected HIV PCR requests (n = 1479) at the Tygerberg virology laboratory over two years (2017–2019). Data from sample collection to release of results were analysed to assess the TAT and follow-up patterns. Results The proportion of rejected HIV PCR requests was 3.3%; 83.9% of these were rejected for various pre-analytical reasons. Most of the test results (89.2%) met the required 96-h TAT. Of the reactive initial test results, 53.5% had a follow-up sample tested, of which 93.1% were positive. Of the initial indeterminate results, 74.7% were negative on follow-up testing. Conclusion A high proportion of HIV PCR requests were rejected for pre-analytical reasons. The high number of initial reactive tests without evidence of follow-up suggests that a shorter TAT is required to allow confirmatory testing before children are discharged.
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Affiliation(s)
- Kamela L Mahlakwane
- Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Medical Virology, Tygerberg Hospital, National Health Laboratory Service, Cape Town, South Africa
| | - Wolfgang Preiser
- Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Medical Virology, Tygerberg Hospital, National Health Laboratory Service, Cape Town, South Africa
| | - Nokwazi Nkosi
- Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Medical Virology, Tygerberg Hospital, National Health Laboratory Service, Cape Town, South Africa
| | - Nasheen Naidoo
- Division of Clinical Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Clinical Pathology, Tygerberg Hospital, National Health Laboratory Service, Cape Town, South Africa
| | - Gert van Zyl
- Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Medical Virology, Tygerberg Hospital, National Health Laboratory Service, Cape Town, South Africa
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4
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Sutcliffe CG, Moyo N, Schue JL, Mutanga JN, Hamahuwa M, Munachoonga P, Maunga S, Thuma PE, Moss WJ. The NSEBA Demonstration Project: implementation of a point-of-care platform for early infant diagnosis of HIV in rural Zambia. Trop Med Int Health 2021; 26:1036-1046. [PMID: 33999480 PMCID: PMC8416694 DOI: 10.1111/tmi.13627] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To describe the experience and resource requirements of implementing point-of-care testing for early infant diagnosis of HIV in rural Zambia. METHODS A demonstration project was conducted using a hub-and-spoke model in 2018-2019 at five clinics in rural Zambia. Two testing hubs were established, and all HIV-exposed infants were tested with the GeneXpert system. Data on costs, turnaround times and test results were collected. RESULTS Seven hundred and eighty six tests were conducted. At the hubs, results were available a median of 2.4 (IQR: 2.1, 2.8) hours after sample collection and most mothers (84%) received same-day results. At the spoke facilities, results were available a median of 9 days (IQR: 7, 12) after sample collection and provided to the mother a median of 16 days (IQR: 10, 28) after sample collection. Eleven children tested positive, and 9 (82%) started treatment a median of 13 days (IQR: 7, 21) after sample collection and on the day mothers received results. In contrast, results from matching samples sent for routine testing were available a median of 38 days (IQR: 27, 61) after sample collection and provided to the mother a median of 91 days (IQR: 47, 135) after sample collection. CONCLUSIONS Implementing point-of-care testing in a network of rural health centres in Zambia required significant initial and ongoing investment in infrastructure, training and supervision. However, point-of-care testing can rapidly diagnose HIV-infected infants, so they can benefit from early treatment.
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Affiliation(s)
| | | | - Jessica L. Schue
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | | | | | - Philip E. Thuma
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Macha Research Trust, Choma, Zambia
| | - William J. Moss
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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5
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A new highly sensitive single-tube nested real-time PCR assay: Clinical utility in perinatal HIV-1 diagnosis. J Virol Methods 2021; 297:114273. [PMID: 34454987 DOI: 10.1016/j.jviromet.2021.114273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/20/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
Real time PCR is one of the major tools for molecular diagnosis, however not always reaches the required sensitivity, especially in detecting early infectious disease. To overcome this problem, nested PCR is commonly performed, since it is highly sensitive, but it is time-consuming, prone to cross-contamination and difficult to standardize. Therefore, we developed a sensitive and specific single-tube nested real-time PCR (STN-real-time PCR) assay and evaluated its clinical utility on early infant HIV-1 diagnosis (EID). The STN-real-time PCR enables the simultaneous amplification of four HIV-1 specific amplicons by the use of an internal and external pair of primers targeting ltr/gag region, and another one corresponding to human albumin as an internal control. Thermocycling had different annealing temperatures to favor the sequential use of each pair of primers, and included an initial touchdown step to broaden specificity and increase sensitivity. Finally, HIV-1 was detected by melting curve analysis. A total of 234 samples collected retrospectively and prospectively from HIV-1 exposed infants aged <18 months were used to evaluate the performance of the assay and compare it with a routine diagnostic nested-multiplex PCR. The developed assay had a limit of detection of 3 copies of HIV-1 DNA per reaction and had a sensitivity of 31 % more than routine diagnostic nested-multiplex PCR when testing samples near delivery. In conclusion, we developed a new assay by turning a conventional nested-PCR into a faster, more sensitive and feasible STN-real-time PCR assay for EID and potentially useful for detection of pathogens with variable genomes and present in low copy numbers.
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Hans L, von Allmen N, Edelmann A, Hofmann J, Nilsson AY, Simon CO, Seiverth B, Gohl P, Carmona S. Early Diagnosis of HIV-1 and HIV-2 Using Cobas HIV-1/HIV-2 Qualitative Test: A Novel Qualitative Nucleic Acid Amplification Test for Plasma, Serum, and Dried Blood Spot Specimens. J Acquir Immune Defic Syndr 2021; 87:1187-1195. [PMID: 33883470 PMCID: PMC8263138 DOI: 10.1097/qai.0000000000002713] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/25/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Nucleic acid amplification tests (NATs) minimize the time from HIV infection to diagnosis, reducing transmission during acute HIV. NATs are especially useful for diagnosing HIV in children younger than 18 months and discriminating between HIV-1 and HIV-2. METHODS We evaluated the performance of the cobas HIV-1/HIV-2 qualitative (cobas HIV-1/2 Qual) test for use on cobas 6800/8800 Systems. The results of adult plasma and serum samples and pediatric dried blood spots were compared with those of the recomLine HIV-1 & HIV-2 Immunoglobulin G serological test and COBAS AmpliPrep/COBAS TaqMan HIV-1 qualitative test, v2.0. Genotype inclusivity and limits of detection were determined, and sensitivity on seroconversion panels was compared with that in the Bio-Rad Geenius HIV 1/2 Confirmatory Assay, Abbott ARCHITECT HIV Ag/Ab Combo serological test, and cobas TaqScreen MPX, v2.0. RESULTS Concordance of cobas HIV-1/2 Qual test with the comparator serological test and COBAS AmpliPrep/COBAS TaqMan test was ≥99.6% with all sample types. Reactivity with all HIV genotypes was 100%. LOD in plasma samples was 14.8, 12.6, and 27.9 copies/mL for HIV-1 group M, HIV-1 group O, and HIV-2, respectively, with similar results for serum samples. LOD in dried blood spots was 255 copies/mL for HIV-1 and 984 copies/mL for HIV-2. HIV infection was detected 18.9 days and 8.5 days earlier than the confirmatory and serological assays, respectively, and at a similar time to the NAT. CONCLUSIONS The cobas HIV-1/2 Qual test enables early and accurate diagnoses of HIV-1 and HIV-2 in adults and children across sample types. The assay could help avert transmission during acute HIV, simplify HIV diagnostic algorithms, and promote the survival of HIV-infected children.
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Affiliation(s)
- Lucia Hans
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Services, Johannesburg, South Africa;
| | | | - Anke Edelmann
- Department of Virology, Labor Berlin—Charité Vivantes Services GmbH
| | - Jörg Hofmann
- Department of Virology, Labor Berlin—Charité Vivantes Services GmbH
| | - Alex Y. Nilsson
- Global Development, Roche Diagnostics International AG, Rotkreuz, Switzerland;
| | | | - Britta Seiverth
- Global Clinical Operations, Roche Diagnostics International AG, Rotkreuz, Switzerland; and
| | - Peter Gohl
- Bioscientia Institut für Medizinische Diagnostik, Ingelheim, Germany.
| | - Sergio Carmona
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Services, Johannesburg, South Africa;
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7
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Ochodo EA, Guleid F, Deeks JJ, Mallett S. Point-of-care tests detecting HIV nucleic acids for diagnosis of HIV-1 or HIV-2 infection in infants and children aged 18 months or less. Cochrane Database Syst Rev 2021; 8:CD013207. [PMID: 34383961 PMCID: PMC8406580 DOI: 10.1002/14651858.cd013207.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The standard method of diagnosing HIV in infants and children less than 18 months is with a nucleic acid amplification test reverse transcriptase polymerase chain reaction test (NAT RT-PCR) detecting viral ribonucleic acid (RNA). Laboratory testing using the RT-PCR platform for HIV infection is limited by poor access, logistical support, and delays in relaying test results and initiating therapy in low-resource settings. The use of rapid diagnostic tests at or near the point-of-care (POC) can increase access to early diagnosis of HIV infection in infants and children less than 18 months of age and timely initiation of antiretroviral therapy (ART). OBJECTIVES To summarize the diagnostic accuracy of point-of-care nucleic acid-based testing (POC NAT) to detect HIV-1/HIV-2 infection in infants and children aged 18 months or less exposed to HIV infection. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (until 2 February 2021), MEDLINE and Embase (until 1 February 2021), and LILACS and Web of Science (until 2 February 2021) with no language or publication status restriction. We also searched conference websites and clinical trial registries, tracked reference lists of included studies and relevant systematic reviews, and consulted experts for potentially eligible studies. SELECTION CRITERIA We defined POC tests as rapid diagnostic tests conducted at or near the patient site. We included any primary study that compared the results of a POC NAT to a reference standard of laboratory NAT RT-PCR or total nucleic acid testing to detect the presence or absence of HIV infection denoted by HIV viral nucleic acids in infants and children aged 18 months or less who were exposed to HIV-1/HIV-2 infection. We included cross-sectional, prospective, and retrospective study designs and those that provided sufficient data to create the 2 × 2 table to calculate sensitivity and specificity. We excluded diagnostic case control studies with healthy controls. DATA COLLECTION AND ANALYSIS We extracted information on study characteristics using a pretested standardized data extraction form. We used the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies) tool to assess the risk of bias and applicability concerns of the included studies. Two review authors independently selected and assessed the included studies, resolving any disagreements by consensus. The unit of analysis was the participant. We first conducted preliminary exploratory analyses by plotting estimates of sensitivity and specificity from each study on forest plots and in receiver operating characteristic (ROC) space. For the overall meta-analyses, we pooled estimates of sensitivity and specificity using the bivariate meta-analysis model at a common threshold (presence or absence of infection). MAIN RESULTS We identified a total of 12 studies (15 evaluations, 15,120 participants). All studies were conducted in sub-Saharan Africa. The ages of included infants and children in the evaluations were as follows: at birth (n = 6), ≤ 12 months (n = 3), ≤ 18 months (n = 5), and ≤ 24 months (n = 1). Ten evaluations were field evaluations of the POC NAT test at the point of care, and five were laboratory evaluations of the POC NAT tests.The POC NAT tests evaluated included Alere q HIV-1/2 Detect qualitative test (recently renamed m-PIMA q HIV-1/2 Detect qualitative test) (n = 6), Xpert HIV-1 qualitative test (n = 6), and SAMBA HIV-1 qualitative test (n = 3). POC NAT pooled sensitivity and specificity (95% confidence interval (CI)) against laboratory reference standard tests were 98.6% (96.1 to 99.5) (15 evaluations, 1728 participants) and 99.9% (99.7 to 99.9) (15 evaluations, 13,392 participants) in infants and children ≤ 18 months. Risk of bias in the included studies was mostly low or unclear due to poor reporting. Five evaluations had some concerns for applicability for the index test, as they were POC tests evaluated in a laboratory setting, but there was no difference detected between settings in sensitivity (-1.3% (95% CI -4.1 to 1.5)); and specificity results were similar. AUTHORS' CONCLUSIONS For the diagnosis of HIV-1/HIV-2 infection, we found the sensitivity and specificity of POC NAT tests to be high in infants and children aged 18 months or less who were exposed to HIV infection.
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Affiliation(s)
- Eleanor A Ochodo
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
- Centre for Evidence-based Health Care, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Fatuma Guleid
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jonathan J Deeks
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Sue Mallett
- UCL Centre for Medical Imaging, Division of Medicine, Faculty of Medical Sciences, University College London, London, UK
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McCann NC, Cohn J, Flanagan C, Sacks E, Mukherjee S, Walensky RP, Adetunji O, Maeka KK, Panella C, Chadambuka A, Mafaune H, Odhiambo C, Freedberg KA, Ciaranello AL. Strengthening Existing Laboratory-Based Systems vs. Investing in Point-of-Care Assays for Early Infant Diagnosis of HIV: A Model-Based Cost-Effectiveness Analysis. J Acquir Immune Defic Syndr 2021; 84 Suppl 1:S12-S21. [PMID: 32520910 PMCID: PMC7302325 DOI: 10.1097/qai.0000000000002384] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Supplemental Digital Content is Available in the Text. Background: To improve early infant HIV diagnosis (EID) programs, options include replacing laboratory-based tests with point-of-care (POC) assays or investing in strengthened systems for sample transport and result return. Setting: We used the CEPAC-Pediatric model to examine clinical benefits and costs of 3 EID strategies in Zimbabwe for infants 6 weeks of age. Methods: We examined (1) laboratory-based EID (LAB), (2) strengthened laboratory-based EID (S-LAB), and (3) POC EID (POC). LAB/S-LAB and POC assays differed in sensitivity (LAB/S-LAB 100%, POC 96.9%) and specificity (LAB/S-LAB 99.6%, POC 99.9%). LAB/S-LAB/POC algorithms also differed in: probability of result return (79%/91%/98%), time until result return (61/53/1 days), probability of initiating antiretroviral therapy (ART) after positive result (52%/71%/86%), and total cost/test ($18.10/$30.47/$30.71). We projected life expectancy (LE) and average lifetime per-person cost for all HIV-exposed infants. We calculated incremental cost-effectiveness ratios (ICERs) from discounted (3%/year) LE and costs in $/year-of-life saved (YLS), defining cost effective as an ICER <$580/YLS (reflecting programs providing 2 vs. 1 ART regimens). In sensitivity analyses, we varied differences between S-LAB and POC in result return probability, result return time, ART initiation probability, and cost. Results: For infants who acquired HIV, LAB/S-LAB/POC led to projected one-year survival of 67.3%/69.9%/75.6% and undiscounted LE of 21.74/22.71/24.49 years. For all HIV-exposed infants, undiscounted LE was 63.35/63.38/63.43 years, at discounted lifetime costs of $200/220/240 per infant. In cost-effectiveness analysis, S-LAB was an inefficient use of resources; the ICER of POC vs. LAB was $830/YLS. Conclusions: Current EID programs will attain greater benefit from investing in POC EID rather than strengthening laboratory-based systems.
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Affiliation(s)
- Nicole C McCann
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Jennifer Cohn
- Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland.,Division of Infectious Disease, University of Pennsylvania, Philadelphia, PA
| | - Clare Flanagan
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Emma Sacks
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC
| | | | - Rochelle P Walensky
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA.,Harvard University Center for AIDS Research, Boston, MA
| | | | - Kenneth K Maeka
- Early Infant Diagnosis Department, National Microbiology Reference Laboratory, Harare Central Hospital, Harare, Zimbabwe
| | - Christopher Panella
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | | | - Haurovi Mafaune
- Elizabeth Glaser Pediatric AIDS Foundation, Harare, Zimbabwe; and
| | | | - Kenneth A Freedberg
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA.,Harvard University Center for AIDS Research, Boston, MA
| | - Andrea L Ciaranello
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA.,Harvard University Center for AIDS Research, Boston, MA
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9
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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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10
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Terris-Prestholt F, Boeras D, Ong JJ, Torres-Rueda S, Cassim N, Mbengue MAS, Mboup S, Mwau M, Munemo E, Nyegenye W, Odhiambo CO, Dabula P, Sandstrom P, Sarr M, Simbi R, Stevens W, Tucker JD, Vickerman P, Ciaranello A, Peeling RW. The potential for quality assurance systems to save costs and lives: the case of early infant diagnosis of HIV. Trop Med Int Health 2020; 25:1235-1245. [PMID: 32737914 DOI: 10.1111/tmi.13472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Scaling up of point-of-care testing (POCT) for early infant diagnosis of HIV (EID) could reduce the large gap in infant testing. However, suboptimal POCT EID could have limited impact and potentially high avoidable costs. This study models the cost-effectiveness of a quality assurance system to address testing performance and screening interruptions, due to, for example, supply stockouts, in Kenya, Senegal, South Africa, Uganda and Zimbabwe, with varying HIV epidemics and different health systems. METHODS We modelled a quality assurance system-raised EID quality from suboptimal levels: that is, from misdiagnosis rates of 5%, 10% and 20% and EID testing interruptions in months, to uninterrupted optimal performance (98.5% sensitivity, 99.9% specificity). For each country, we estimated the 1-year impact and cost-effectiveness (US$/DALY averted) of improved scenarios in averting missed HIV infections and unneeded HIV treatment costs for false-positive diagnoses. RESULTS The modelled 1-year costs of a national POCT quality assurance system range from US$ 69 359 in South Africa to US$ 334 341 in Zimbabwe. At the country level, quality assurance systems could potentially avert between 36 and 711 missed infections (i.e. false negatives) per year and unneeded treatment costs between US$ 5808 and US$ 739 030. CONCLUSIONS The model estimates adding effective quality assurance systems are cost-saving in four of the five countries within the first year. Starting EQA requires an initial investment but will provide a positive return on investment within five years by averting the costs of misdiagnoses and would be even more efficient if implemented across multiple applications of POCT.
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Affiliation(s)
| | - D Boeras
- London School of Hygiene and Tropical Medicine, London, UK.,Global Health Impact Group, Atlanta, GA, USA
| | - J J Ong
- London School of Hygiene and Tropical Medicine, London, UK.,Central Clinical School, Monash University, Clayton, Vic, Australia
| | - S Torres-Rueda
- London School of Hygiene and Tropical Medicine, London, UK
| | - N Cassim
- National Health Laboratory Service, National Priority Programmes, Johannesburg, South Africa.,Department of Molecular Medicine and Haematology, University of Witwatersrand, Johannesburg, South Africa
| | - M A S Mbengue
- Institut de Recherche en Santé, de Surveillance Epidémiologique et de Formations, Dakar, Sénégal.,Department of Epidemiology and Biostatistics, University of the Witwatersrand, Johannesburg, South Africa
| | - S Mboup
- Institut de Recherche en Santé, de Surveillance Epidémiologique et de Formations, Dakar, Sénégal
| | - M Mwau
- Kenya Medical Research Institute, Nairobi, Kenya
| | - E Munemo
- Ministry of Health and Child Care, National Microbiology Reference Laboratory, Harare Central Hospital, Harare, Zimbabwe
| | - W Nyegenye
- Ministry of Health Uganda, Kampala, Uganda
| | | | - P Dabula
- National Health Laboratory Service, National Priority Programmes, Johannesburg, South Africa
| | - P Sandstrom
- National HIV & Retrovirology Laboratories, Public Health Agency of Canada, Winnipeg, Canada
| | - M Sarr
- Westat, Inc., Rockville, MD, USA
| | - R Simbi
- Ministry of Health and Child Care, National Microbiology Reference Laboratory, Harare Central Hospital, Harare, Zimbabwe
| | - W Stevens
- National Health Laboratory Service, National Priority Programmes, Johannesburg, South Africa
| | - J D Tucker
- London School of Hygiene and Tropical Medicine, London, UK.,University of North Carolina, Chapel Hill, NC, USA
| | - P Vickerman
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - A Ciaranello
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - R W Peeling
- London School of Hygiene and Tropical Medicine, London, UK
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11
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HIV diagnostic algorithm requires confirmatory testing for initial indeterminate or positive screens in the first week of life. AIDS 2020; 34:1029-1035. [PMID: 32287064 DOI: 10.1097/qad.0000000000002532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Risk for nondiagnostic and false-positive HIV testing has not been quantified for neonates. METHODS From April 2015 to July 2018, we screened HIV-exposed infants in Botswana less than 96 h from birth by qualitative DNA PCR. Repeat blood draws for DNA and RNA PCR testing occurred for initial positive and indeterminate results to establish final diagnosis. We compared screening DNA PCR cycle threshold values with final HIV status of the child. RESULTS Of 10 622 HIV-exposed infants, 10 549 (99.3%) had no HIV DNA detected (negative), 42 (0.4%) had HIV DNA detected (positive), and 31 (0.3%) tested indeterminate at first HIV screen. Repeat testing identified 2 (5.0%) of 40 positive screens (2 declined additional testing) as false positives and confirmed 2 (6.5%) of 31 indeterminate screens as infected. Median cycle threshold value at screening was 28.1 (IQR 19.8--34.8) for children with final positive status, and 35.5 (IQR 32.8--41.4) for indeterminates who were ultimately negative. Six (15%) of 40 infants with final positive status had cycle threshold value greater than 33 at first screen, whereas 3 (9.7%) of 31 indeterminates with final negative status had cycle threshold value 33 or less at first screen. This threshold resulted in a negative predictive value of 82% and a positive predictive value of 92% for a single screen. CONCLUSION Although a DNA PCR cycle threshold value of 33 was predictive of the final HIV status in newborns, overlap occurred for true positives, false positives, and initial indeterminates. Testing additional samples should be standard practice for positive and indeterminate HIV DNA PCR tests in the first week of life.
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12
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Use of an Indeterminate Range in HIV Early Infant Diagnosis: A Systematic Review and Meta-Analysis. J Acquir Immune Defic Syndr 2020; 82:281-286. [PMID: 31609927 DOI: 10.1097/qai.0000000000002104] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Expanded access to HIV antiretrovirals has dramatically reduced mother-to-child transmission of HIV. However, there is increasing concern around false-positive HIV test results in perinatally HIV-exposed infants but few insights into the use of indeterminate range to improve infant HIV diagnosis. METHODS A systematic review and meta-analysis was conducted to evaluate the use of an indeterminate range for HIV early infant diagnosis. Published and unpublished studies from 2000 to 2018 were included. Study quality was evaluated using GRADE and QUADAS-2 criteria. A random-effects model compared various indeterminate ranges for identifying true and false positives. RESULTS The review identified 32 studies with data from over 1.3 million infants across 14 countries published from 2000 to 2018. Indeterminate results accounted for 16.5% of initial non-negative test results, and 76% of indeterminate results were negative on repeat testing. Most results were from Roche tests. In the random-effects model, an indeterminate range using a polymerase chain reaction cycle threshold value of ≥33 captured over 93% of false positives while classifying fewer than 9% of true positives as indeterminate. CONCLUSIONS Without the use of an indeterminate range, over 10% of infants could be incorrectly diagnosed as HIV positive if their initial test results are not confirmed. Use of an indeterminate range appears to lead to substantial improvements in the accuracy of early infant diagnosis testing and supports current recommendations to confirm all initial positive tests.
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13
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Clinical Consequences of Using an Indeterminate Range for Early Infant Diagnosis of HIV: A Decision Model. J Acquir Immune Defic Syndr 2020; 82:287-296. [PMID: 31609928 DOI: 10.1097/qai.0000000000002155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To minimize false-positive diagnoses of HIV in exposed infants, the World Health Organization recommends confirmatory testing for all infants initiating antiretroviral therapy (ART). In settings where confirmatory testing is not feasible or intermittently performed, clinical decisions may be aided by semi-quantitative cycle thresholds (Cts) that identify positive results most likely to be false-positive. METHODS We developed a decision analysis model of HIV-exposed infants in sub-Saharan Africa to estimate the clinical consequences of deferring ART for infants with weakly positive ("indeterminate") results. We assessed the degree to which "indeterminate" results may reduce the number of infants starting ART unnecessarily while missing a small number of HIV-infected infants. Our primary outcome was the ratio of averted unnecessary ART regimens to additional HIV-related deaths (due to false-negative diagnosis) at different Ct cutoffs. RESULTS The clinical consequences of adopting an indeterminate range varied with the prevalence of HIV and Ct cutoff. Considering a Ct cutoff ≥33, adopting an indeterminate range could prevent a median of 1.4 infants from receiving ART unnecessarily (95% UR: 1.0-2.0) for each additional HIV-related death. This ratio could be improved by prioritizing infants with indeterminate results for confirmatory testing [median 8.8 (95% UR: 6.0-13.3)] and by adopting a higher cutoff [median 82.3 (95% UR: 49.0-155.8) with Ct ≥36]. CONCLUSIONS When implemented in settings where confirmatory testing is not universal, the benefits of classifying weakly positive results as "indeterminate" may outweigh the risks. Accordingly, the World Health Organization has recommended Ct values ≥33 be considered indeterminate for infant HIV diagnosis.
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14
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Sabi I, Mahiga H, Mgaya J, Geisenberger O, Kastner S, Olomi W, Saathoff E, Njovu L, Lueer C, France J, Maboko L, Ntinginya NE, Hoelscher M, Kroidl A. Accuracy and Operational Characteristics of Xpert Human Immunodeficiency Virus Point-of-Care Testing at Birth and Until Week 6 in Human Immunodeficiency Virus-exposed Neonates in Tanzania. Clin Infect Dis 2020; 68:615-622. [PMID: 29961841 PMCID: PMC6355822 DOI: 10.1093/cid/ciy538] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 06/28/2018] [Indexed: 01/24/2023] Open
Abstract
Background Point-of-care (PoC) systems for early infant diagnosis (EID) may improve timely infant human immunodeficiency virus (HIV) management. Experiences within African public health settings are limited. Methods We evaluated the accuracy and operational feasibility of the Xpert HIV-1 Qual for PoC-EID testing, using fresh blood and dried blood spots (DBS) samples at obstetric health facilities in Tanzania at birth and at postpartum weeks 1, 2, 3, and 6 in HIV-exposed infants. Test results were confirmed using TaqMan DBS HIV-deoxyribonucleic acid and/or plasma HIV-ribonucleic acid (RNA) testing. Results At week 6, 15 (2.5%) out of 614 infants were diagnosed with HIV; 10 (66.7%) of them at birth (median HIV-RNA 4570 copies/mL). At birth, the Xpert-PoC and Xpert-DBS were 100% sensitive (95% confidence intervals: PoC, 69.2–100%; DBS, 66.4–100%) and 100% specific (PoC, 92.1–100%; DBS, 88.4–100%). By week 3, 5 infants with intra/postpartum HIV-infection (median HIV-RNA 1 160 000 copies/mL) were all correctly diagnosed by Xpert. In 2 cases, Xpert-PoC testing correctly identified HIV-infection when DBS tests (Xpert and TaqMan) were negative, suggesting a greater sensitivity. In 2 infants with confirmed HIV at birth, all tests were negative at week 6, possibly because of viral suppression under nevirapine prophylaxis. Problems were reported in 183/2736 (6.7%) of Xpert-PoC tests, mostly related to power cuts (57.9%). Conclusions We demonstrated excellent Xpert HIV-1 Qual performance and good operational feasibility for PoC-EID testing at obstetric health facilities. Week 6 sensitivity issues were possibly related to nevirapine prophylaxis, supporting additional birth PoC-EID testing to avoid underdiagnosis. Clinical Trials Registration NCT02545296
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Affiliation(s)
- Issa Sabi
- National Institute for Medical Research, Mbeya Medical Research Center, Tanzania
| | - Hellen Mahiga
- National Institute for Medical Research, Mbeya Medical Research Center, Tanzania
| | - Jimson Mgaya
- National Institute for Medical Research, Mbeya Medical Research Center, Tanzania
| | - Otto Geisenberger
- Division of Infectious Diseases and Tropical Medicine, University Hospital, LMU Munich.,German Center for Infection Research (DZIF), Munich, Germany
| | - Sabine Kastner
- Division of Infectious Diseases and Tropical Medicine, University Hospital, LMU Munich.,German Center for Infection Research (DZIF), Munich, Germany
| | - Willyhelmina Olomi
- National Institute for Medical Research, Mbeya Medical Research Center, Tanzania
| | - Elmar Saathoff
- Division of Infectious Diseases and Tropical Medicine, University Hospital, LMU Munich.,German Center for Infection Research (DZIF), Munich, Germany
| | - Lilian Njovu
- National Institute for Medical Research, Mbeya Medical Research Center, Tanzania
| | - Cornelia Lueer
- National Institute for Medical Research, Mbeya Medical Research Center, Tanzania.,Division of Infectious Diseases and Tropical Medicine, University Hospital, LMU Munich
| | - John France
- Department of Obstetrics and Gynaecology, Mbeya Zonal Referral Hospital, Tanzania
| | - Leonard Maboko
- National Institute for Medical Research, Mbeya Medical Research Center, Tanzania
| | | | - Michael Hoelscher
- Division of Infectious Diseases and Tropical Medicine, University Hospital, LMU Munich.,German Center for Infection Research (DZIF), Munich, Germany
| | - Arne Kroidl
- Division of Infectious Diseases and Tropical Medicine, University Hospital, LMU Munich.,German Center for Infection Research (DZIF), Munich, Germany
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15
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Soeteman DI, Resch SC, Jalal H, Dugdale CM, Penazzato M, Weinstein MC, Phillips A, Hou T, Abrams EJ, Dunning L, Newell ML, Pei PP, Freedberg KA, Walensky RP, Ciaranello AL. Developing and Validating Metamodels of a Microsimulation Model of Infant HIV Testing and Screening Strategies Used in a Decision Support Tool for Health Policy Makers. MDM Policy Pract 2020; 5:2381468320932894. [PMID: 32587893 PMCID: PMC7294506 DOI: 10.1177/2381468320932894] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 05/08/2020] [Indexed: 11/16/2022] Open
Abstract
Background. Metamodels can simplify complex health policy models and yield instantaneous results to inform policy decisions. We investigated the predictive validity of linear regression metamodels used to support a real-time decision-making tool that compares infant HIV testing/screening strategies. Methods. We developed linear regression metamodels of the Cost-Effectiveness of Preventing AIDS Complications Pediatric (CEPAC-P) microsimulation model used to predict life expectancy and lifetime HIV-related costs/person of two infant HIV testing/screening programs in South Africa. Metamodel performance was assessed with cross-validation and Bland-Altman plots, showing between-method differences in predicted outcomes against their means. Predictive validity was determined by the percentage of simulations in which the metamodels accurately predicted the strategy with the greatest net health benefit (NHB) as projected by the CEPAC-P model. We introduced a zone of indifference and investigated the width needed to produce between-method agreement in 95% of the simulations. We also calculated NHB losses from "wrong" decisions by the metamodel. Results. In cross-validation, linear regression metamodels accurately approximated CEPAC-P-projected outcomes. For life expectancy, Bland-Altman plots showed good agreement between CEPAC-P and the metamodel (within 1.1 life-months difference). For costs, 95% of between-method differences were within $65/person. The metamodels predicted the same optimal strategy as the CEPAC-P model in 87.7% of simulations, increasing to 95% with a zone of indifference of 0.24 life-months ( ∼ 7 days). The losses in health benefits due to "wrong" choices by the metamodel were modest (range: 0.0002-1.1 life-months). Conclusions. For this policy question, linear regression metamodels offered sufficient predictive validity for the optimal testing strategy as compared with the CEPAC-P model. Metamodels can simulate different scenarios in real time, based on sets of input parameters that can be depicted in a widely accessible decision-support tool.
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Affiliation(s)
- Djøra I. Soeteman
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Stephen C. Resch
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Hawre Jalal
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Caitlin M. Dugdale
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Martina Penazzato
- HIV and Hepatitis Department, World Health Organization, Geneva, Switzerland
| | - Milton C. Weinstein
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | - Taige Hou
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Elaine J. Abrams
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York
| | - Lorna Dunning
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Marie-Louise Newell
- Institute for Development Studies, Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
- School of Public Health, Faculty of Health Sciences, WITS, Johannesburg, South Africa
| | - Pamela P. Pei
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kenneth A. Freedberg
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Rochelle P. Walensky
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrea L. Ciaranello
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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16
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Dugdale CM, Phillips TK, Myer L, Hyle EP, Brittain K, Freedberg KA, Cunnama L, Walensky RP, Zerbe A, Weinstein MC, Abrams EJ, Ciaranello AL. Cost-effectiveness of integrating postpartum antiretroviral therapy and infant care into maternal & child health services in South Africa. PLoS One 2019; 14:e0225104. [PMID: 31730630 PMCID: PMC6857940 DOI: 10.1371/journal.pone.0225104] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 10/29/2019] [Indexed: 11/29/2022] Open
Abstract
Background Poor engagement in postpartum maternal HIV care is a challenge worldwide and contributes to adverse maternal outcomes and vertical transmission. Our objective was to project the clinical and economic impact of integrated postpartum maternal antiretroviral therapy (ART) and pediatric care in South Africa. Methods Using the CEPAC computer simulation models, parameterized with data from the Maternal and Child Health–Antiretroviral Therapy (MCH-ART) randomized controlled trial, we evaluated the cost-effectiveness of integrated postpartum care for women initiating ART in pregnancy and their children. We compared two strategies: 1) standard of care (SOC) referral to local clinics after delivery for separate standard ART services for women and pediatric care for infants, and 2) the MCH-ART intervention (MCH-ART) of co-located maternal/pediatric care integrated in Maternal and Child Health (MCH) services throughout breastfeeding. Trial-derived inputs included: 12-month maternal retention in care and virologic suppression (SOC: 49%, MCH-ART: 67%), breastfeeding duration (SOC: 6 months, MCH-ART: 8 months), and postpartum healthcare costs for mother-infant pairs (SOC: $50, MCH-ART: $69). Outcomes included pediatric HIV infections, maternal and infant life expectancy (LE), lifetime HIV-related per-person costs, and incremental cost-effectiveness ratios (ICERs; ICER <US$903/YLS considered “cost-effective”). Results Compared to SOC, MCH-ART increased maternal LE (SOC: 25.26 years, MCH-ART: 26.20 years) and lifetime costs (SOC: $9,912, MCH-ART: $10,207; discounted). Projected pediatric outcomes for all HIV-exposed children were similar between arms, although undiscounted LE for HIV-infected children was shorter in SOC (SOC: 23.13 years, MCH-ART: 23.40 years). Combining discounted maternal and pediatric outcomes, the ICER was $599/YLS. Conclusion Co-located maternal HIV and pediatric care, integrated in MCH services throughout breastfeeding, is a cost-effective strategy to improve maternal and pediatric outcomes and should be implemented in South Africa.
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Affiliation(s)
- Caitlin M. Dugdale
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- * E-mail:
| | - Tamsin K. Phillips
- 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
| | - 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
| | - Emily P. Hyle
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Kirsty Brittain
- 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
| | - Kenneth A. Freedberg
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Lucy Cunnama
- Health Economics Unit, School of Public Health & Family Medicine, University of Cape Town, South Africa
| | - Rochelle P. Walensky
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Allison Zerbe
- ICAP at Columbia and the Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - Milton C. Weinstein
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Elaine J. Abrams
- ICAP at Columbia and the Mailman School of Public Health, Columbia University, New York, NY, United States of America
- College of Physicians & Surgeons, Columbia University, New York, NY, United States of America
| | - Andrea L. Ciaranello
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
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17
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Mwenda R, Fong Y, Magombo T, Saka E, Midiani D, Mwase C, Kandulu J, Wang M, Thomas R, Sherman J, Vojnov L. Significant Patient Impact Observed Upon Implementation of Point-of-Care Early Infant Diagnosis Technologies in an Observational Study in Malawi. Clin Infect Dis 2019; 67:701-707. [PMID: 29490026 PMCID: PMC6093992 DOI: 10.1093/cid/ciy169] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 02/26/2018] [Indexed: 12/25/2022] Open
Abstract
Background In Malawi in 2014, <20% of human immunodeficiency virus (HIV)–exposed infants received an early infant diagnosis (EID) test in the first 2 months of life and only 30% of HIV-infected children were on antiretroviral therapy (ART). We sought to understand the potential patient impact of improving timely infant diagnosis and treatment initiation through implementation of point-of-care (POC) EID technologies in Malawi. Methods In this observational study, POC EID technologies were introduced into routine services at 7 health facilities across Malawi in September 2015. The primary outcome was the proportion of HIV-infected infants initiating ART within 60 days of sample collection in the POC arm compared to the baseline arm with conventional laboratory-based EID testing. Results The time from sample collection to result received by the patient decreased significantly from 56 days (interquartile range [IQR], 30–81 days) in the baseline arm to <1 day in the POC arm (P < .001). Of the HIV-infected infants, the time between sample collection and ART initiation was reduced from 38 days (IQR, 30–54 days) in the baseline arm to <1 day (IQR, 0–1 day) in the POC arm (P = .019). Furthermore, the proportion of HIV-infected infants initiated on ART within 60 days of sample collection increased significantly from 41.9% to 91.1% after the introduction of POC (adjusted risk ratio, 2.28; P < .001). Conclusions ART initiation rates were significantly improved with the implementation of same-day POC EID testing compared with referred, longer-turnaround laboratory-based testing.
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Affiliation(s)
| | - Youyi Fong
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | | | | | | | | | - Melody Wang
- Clinton Health Access Initiative, Lilongwe, Malawi
| | | | | | - Lara Vojnov
- Clinton Health Access Initiative, Lilongwe, Malawi
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18
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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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19
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Strehlau R, Paximadis M, Patel F, Burke M, Technau KG, Shiau S, Abrams EJ, Sherman GG, Hunt G, Ledwaba J, Mazanderani AH, Tiemessen CT, Kuhn L. HIV diagnostic challenges in breast-fed infants of mothers on antiretroviral therapy. AIDS 2019; 33:1751-1756. [PMID: 31149944 PMCID: PMC6663570 DOI: 10.1097/qad.0000000000002276] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Prompt initiation of antiretroviral therapy (ART) for HIV-infected infants is strongly recommended but diagnostic confirmation is important as committing children to life-long ART carries serious health and social implications. METHODS Two HIV-exposed infants in Johannesburg, South Africa were identified presenting with unusual trajectories of diagnostic nucleic acid amplification tests (NAAT) and viral load results. RESULTS Case 1 had repeat indeterminate NAAT results during the first 3 weeks of life; repeat testing thereafter was negative with undetectable viral load including after daily nevirapine prophylaxis ended. ART was not initiated at this time. Case 2 had a single positive NAAT result at 1 month of age that prompted initiation of ART. Subsequent results were negative and ART was discontinued. Repeat negative NAAT with viral load below the limit of quantification or undetectable continued to be obtained. Shortly after and around weaning, positive NAAT results with high viral load (7.1 and 6.03 log10 copies/ml for Cases 1 and 2, respectively) were observed in both children. Both mothers were treated with tenofovir, emtricitabine and efavirenz during breastfeeding. Testing with ultrasensitive assays on early samples conclusively revealed HIV-1 proviral DNA in Case 1. Testing with ultrasensitive assays after the early period but prior to weaning did not detect HIV in either infant. CONCLUSION We hypothesize that breast milk from the mothers of these two rare cases had HIV-specific or nonspecific factors that led to the undetectable results in already infected infants until breastfeeding ended. Our results raise the importance of repeat testing of HIV-exposed breast-fed infants after complete cessation of all breastfeeding.
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Affiliation(s)
- Renate Strehlau
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Maria Paximadis
- Centre for HIV and STIs, National Institute for Communicable Diseases, National Health Laboratory Services, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Faeezah Patel
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Megan Burke
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Karl-Gunter Technau
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Stephanie Shiau
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Gertrude H. Sergievsky Center, College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Elaine J Abrams
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
- Department of Pediatrics, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Gayle G Sherman
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Centre for HIV and STIs, National Institute for Communicable Diseases, National Health Laboratory Services, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gillian Hunt
- Centre for HIV and STIs, National Institute for Communicable Diseases, National Health Laboratory Services, Johannesburg, South Africa
| | - Johanna Ledwaba
- Centre for HIV and STIs, National Institute for Communicable Diseases, National Health Laboratory Services, Johannesburg, South Africa
| | - Ahmad Haeri Mazanderani
- Centre for HIV and STIs, National Institute for Communicable Diseases, National Health Laboratory Services, Johannesburg, South Africa
- Department of Medical Virology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Caroline T Tiemessen
- Centre for HIV and STIs, National Institute for Communicable Diseases, National Health Laboratory Services, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Louise Kuhn
- Gertrude H. Sergievsky Center, College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
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20
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Millar JR, Mvo Z, Bengu N, Fillis R, Sprenger K, Matthews PC, Archary M, Ndung'u T, Adland E, Puertas MC, Martinez-Picado J, Goulder P. Increasing Diagnostic Uncertainties in Children With In Utero HIV Infection. Pediatr Infect Dis J 2019; 38:e166-e168. [PMID: 31033913 PMCID: PMC7612888 DOI: 10.1097/inf.0000000000002315] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We present a case of an in utero HIV-infected child, who on day 1 of life had a positive whole blood total nucleic acid test but viral load <20 RNA copies/mL. Dried blood spot total nucleic acid testing was negative on day 1, 10 and at 3 months, while on ART prophylaxis then positive at 5 months after prophylaxis ended. Retrospective peripheral blood mononuclear cells HIV DNA testing from day 1 of life was positive, confirming in utero infection.
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Affiliation(s)
- Jane R Millar
- Umkhuseli Innovation and Research Management, Pietermaritzburg, South Africa
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Zodumo Mvo
- Umkhuseli Innovation and Research Management, Pietermaritzburg, South Africa
| | - Nomonde Bengu
- Umkhuseli Innovation and Research Management, Pietermaritzburg, South Africa
| | - Rowena Fillis
- Umkhuseli Innovation and Research Management, Pietermaritzburg, South Africa
| | - Ken Sprenger
- Umkhuseli Innovation and Research Management, Pietermaritzburg, South Africa
| | | | - Moherndran Archary
- Department of Paediatrics, University of KwaZulu-Natal, Durban, South Africa
| | - Thumbi Ndung'u
- Ragon Institute of MGH, MIT and Havard, Cambridge, MA, USA
- Africa Health Research Institute, Durban, South Africa
- Max Planck Institute for Infection Biology, Berlin, Germany
| | - Emily Adland
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Maria C Puertas
- AIDS Research Institute IrsiCaixa, Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Spain
| | - Javier Martinez-Picado
- AIDS Research Institute IrsiCaixa, Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Spain
- University of Vic-Central University of Catalonia, Vic, Spain
- Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain
| | - Philip Goulder
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
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21
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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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22
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Mallampati D, MacLean RL, Shapiro R, Dabis F, Engelsmann B, Freedberg KA, Leroy V, Lockman S, Walensky R, Rollins N, Ciaranello A. Optimal breastfeeding durations for HIV-exposed infants: the impact of maternal ART use, infant mortality and replacement feeding risk. J Int AIDS Soc 2019; 21:e25107. [PMID: 29667336 PMCID: PMC5904528 DOI: 10.1002/jia2.25107] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 03/12/2018] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION In 2010, the WHO recommended women living with HIV breastfeed for 12 months while taking antiretroviral therapy (ART) to balance breastfeeding benefits against HIV transmission risks. To inform the 2016 WHO guidelines, we updated prior research on the impact of breastfeeding duration on HIV-free infant survival (HFS) by incorporating maternal ART duration, infant/child mortality and mother-to-child transmission data. METHODS Using the Cost-Effectiveness of Preventing AIDS Complications (CEPAC)-Infant model, we simulated the impact of breastfeeding duration on 24-month HFS among HIV-exposed, uninfected infants. We defined "optimal" breastfeeding durations as those maximizing 24-month HFS. We varied maternal ART duration, mortality rates among breastfed infants/children, and relative risk of mortality associated with replacement feeding ("RRRF"), modelled as a multiplier on all-cause mortality for replacement-fed infants/children (range: 1 [no additional risk] to 6). The base-case simulated RRRF = 3, median infant mortality, and 24-month maternal ART duration. RESULTS In the base-case, HFS ranged from 83.1% (no breastfeeding) to 90.2% (12-months breastfeeding). Optimal breastfeeding durations increased with higher RRRF values and longer maternal ART durations, but did not change substantially with variation in infant mortality rates. Optimal breastfeeding durations often exceeded the previous WHO recommendation of 12 months. CONCLUSIONS In settings with high RRRF and long maternal ART durations, HFS is maximized when mothers breastfeed longer than the previously-recommended 12 months. In settings with low RRRF or short maternal ART durations, shorter breastfeeding durations optimize HFS. If mothers are supported to use ART for longer periods of time, it is possible to reduce transmission risks and gain the benefits of longer breastfeeding durations.
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Affiliation(s)
- Divya Mallampati
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL, USA
| | - Rachel L MacLean
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Divisions of General Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Roger Shapiro
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Immunology and Infectious Diseases, Harvard T.H, Chan School of Public Health, Boston, MA, USA.,The Botswana-Harvard School of Public Health AIDS Institute Partnership for HIV Research and Education, Gaborone, Botswana
| | - Francois Dabis
- Université Bordeaux, Institut de Santé Publique, d'Epidémiologie et de Dévelopement (ISPED), Centre INSERM, U1219-Bordeaux Population Health, Bordeaux, France
| | - Barbara Engelsmann
- Organization for Public Health Interventions and Development, Harare, Zimbabwe
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Divisions of General Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Harvard University Center for AIDS Research Boston, MA, USA
| | | | - Shahin Lockman
- Department of Immunology and Infectious Diseases, Harvard T.H, Chan School of Public Health, Boston, MA, USA.,The Botswana-Harvard School of Public Health AIDS Institute Partnership for HIV Research and Education, Gaborone, Botswana.,Division of Infectious Disease, Brigham and Women's Hospital, Boston, MA, USA
| | - Rochelle Walensky
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Divisions of General Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Harvard University Center for AIDS Research Boston, MA, USA.,Division of Infectious Disease, Brigham and Women's Hospital, Boston, MA, USA.,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Nigel Rollins
- Department of Maternal Newborn, Child and Adolescent Health World Health Organization, Geneva, Switzerland
| | - Andrea Ciaranello
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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23
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Dugdale CM, Ciaranello AL, Bekker LG, Stern ME, Myer L, Wood R, Sax PE, Abrams EJ, Freedberg KA, Walensky RP. Risks and Benefits of Dolutegravir- and Efavirenz-Based Strategies for South African Women With HIV of Child-Bearing Potential: A Modeling Study. Ann Intern Med 2019; 170:614-625. [PMID: 30934067 PMCID: PMC6736740 DOI: 10.7326/m18-3358] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Dolutegravir is superior to efavirenz for HIV antiretroviral therapy (ART) but may be associated with an increased risk for neural tube defects (NTDs) in newborns if used by women at conception. Objective To project clinical outcomes of ART policies for women of child-bearing potential in South Africa. Design Model of 3 strategies: efavirenz for all women of child-bearing potential (EFV), dolutegravir for all women of child-bearing potential (DTG), or World Health Organization (WHO)-recommended efavirenz without contraception or dolutegravir with contraception (WHO approach). Data Sources Published data on NTD risks (efavirenz, 0.05%; dolutegravir, 0.67% [Tsepamo study]), 48-week ART efficacy with initiation (efavirenz, 60% to 91%; dolutegravir, 96%), and age-stratified fertility rates (2 to 139 per 1000 women). Target Population 3.1 million South African women with HIV (aged 15 to 49 years) starting or continuing first-line ART, and their children. Time Horizon 5 years. Perspective Societal. Intervention EFV, DTG, and WHO approach. Outcome Measures Deaths among women and children, sexual and pediatric HIV transmissions, and NTDs. Results of Base-Case Analysis Compared with EFV, DTG averted 13 700 women's deaths (0.44% decrease) and 57 700 sexual HIV transmissions, but increased total pediatric deaths by 4400 because of more NTDs. The WHO approach offered some benefits compared with EFV, averting 4900 women's deaths and 20 500 sexual transmissions while adding 300 pediatric deaths. Overall, combined deaths among women and children were lowest with DTG (358 000 deaths) compared with the WHO approach (362 800 deaths) or EFV (367 300 deaths). Results of Sensitivity Analysis Women's deaths averted with DTG exceeded pediatric deaths added with EFV unless dolutegravir-associated NTD risk was 1.5% or greater. Limitation Uncertainty in NTD risks and dolutegravir efficacy in resource-limited settings, each examined in sensitivity analyses. Conclusion Although NTD risks may be higher with dolutegravir than efavirenz, dolutegravir will lead to many fewer deaths among women, as well as fewer overall HIV transmissions. These results argue against a uniform policy of avoiding dolutegravir in women of child-bearing potential. Primary Funding Source National Institutes of Health, National Institute of Allergy and Infectious Diseases and Eunice Kennedy Shriver National Institute of Child Health and Human Development; Massachusetts General Hospital; and Harvard University Center for AIDS Research.
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Affiliation(s)
- Caitlin M Dugdale
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (C.M.D., A.L.C., K.A.F.)
| | - Andrea L Ciaranello
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (C.M.D., A.L.C., K.A.F.)
| | | | | | - Landon Myer
- University of Cape Town, Cape Town, South Africa (L.B., L.M., R.W.)
| | - Robin Wood
- University of Cape Town, Cape Town, South Africa (L.B., L.M., R.W.)
| | - Paul E Sax
- Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts (P.E.S.)
| | | | - Kenneth A Freedberg
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (C.M.D., A.L.C., K.A.F.)
| | - Rochelle P Walensky
- Massachusetts General Hospital, Harvard Medical School, and Brigham and Women's Hospital, Boston, Massachusetts (R.P.W.)
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24
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Neilan AM, Patel K, Agwu AL, Bassett IV, Amico KR, Crespi CM, Gaur AH, Horvath KJ, Powers KA, Rendina HJ, Hightow-Weidman LB, Li X, Naar S, Nachman S, Parsons JT, Simpson KN, Stanton BF, Freedberg KA, Bangs AC, Hudgens MG, Ciaranello AL. Model-Based Methods to Translate Adolescent Medicine Trials Network for HIV/AIDS Interventions Findings Into Policy Recommendations: Rationale and Protocol for a Modeling Core (ATN 161). JMIR Res Protoc 2019; 8:e9898. [PMID: 30990464 PMCID: PMC6488956 DOI: 10.2196/resprot.9898] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 12/12/2022] Open
Abstract
Background The United States Centers for Disease Control and Prevention estimates that approximately 60,000 US youth are living with HIV. US youth living with HIV (YLWH) have poorer outcomes compared with adults, including lower rates of diagnosis, engagement, retention, and virologic suppression. With Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) support, new trials of youth-centered interventions to improve retention in care and medication adherence among YLWH are underway. Objective This study aimed to use a computer simulation model, the Cost-Effectiveness of Preventing AIDS Complications (CEPAC)-Adolescent Model, to evaluate selected ongoing and forthcoming ATN interventions to improve viral load suppression among YLWH and to define the benchmarks for uptake, effectiveness, durability of effect, and cost that will make these interventions clinically beneficial and cost-effective. Methods This protocol, ATN 161, establishes the ATN Modeling Core. The Modeling Core leverages extensive data—already collected by successfully completed National Institutes of Health–supported studies—to develop novel approaches for modeling critical components of HIV disease and care in YLWH. As new data emerge from ongoing ATN trials during the award period about the effectiveness of novel interventions, the CEPAC-Adolescent simulation model will serve as a flexible tool to project their long-term clinical impact and cost-effectiveness. The Modeling Core will derive model input parameters and create a model structure that reflects key aspects of HIV acquisition, progression, and treatment in YLWH. The ATN Modeling Core Steering Committee, with guidance from ATN leadership and scientific experts, will select and prioritize specific model-based analyses as well as provide feedback on derivation of model input parameters and model assumptions. Project-specific teams will help frame research questions for model-based analyses as well as provide feedback regarding project-specific inputs, results, sensitivity analyses, and policy conclusions. Results This project was funded as of September 2017. Conclusions The ATN Modeling Core will provide critical information to guide the scale-up of ATN interventions and the translation of ATN data into policy recommendations for YLWH in the United States.
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Affiliation(s)
- Anne M Neilan
- Division of General Academic Pediatrics, Massachusetts General Hospital, Boston, MA, United States.,Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, United States
| | - Kunjal Patel
- Department of Epidemiology and Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Allison L Agwu
- Departments of Pediatric and Adult Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Ingrid V Bassett
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, United States.,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - K Rivet Amico
- University of Michigan School of Public Health, Ann Arbor, MI, United States
| | - Catherine M Crespi
- Department of Biostatistics, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, United States
| | - Aditya H Gaur
- St. Jude's Children's Research Hospital, Memphis, TN, United States
| | - Keith J Horvath
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Kimberly A Powers
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - H Jonathon Rendina
- Hunter College of the City University of New York, New York, NY, United States
| | - Lisa B Hightow-Weidman
- Institute for Global Health & Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Xiaoming Li
- Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
| | - Sylvie Naar
- Center for Translational Behavioral Research, Florida State University, Tallahassee, FL, United States
| | - Sharon Nachman
- State University of New York, Stony Brook, NY, United States
| | - Jeffrey T Parsons
- Hunter College of the City University of New York, New York, NY, United States
| | - Kit N Simpson
- Medical University of South Carolina, Charleston, SC, United States
| | - Bonita F Stanton
- Hackensack Meridian School of Medicine at Seton Hall University, Nutley, NJ, United States
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, United States.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Audrey C Bangs
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, United States
| | - Michael G Hudgens
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Andrea L Ciaranello
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, United States.,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
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Rubio-Garrido M, Ndarabu A, Reina G, Barquín D, Fernández-Alonso M, Carlos S, Holguín Á. Utility Of POC Xpert HIV-1 Tests For Detection-Quantification Of Complex HIV Recombinants Using Dried Blood Spots From Kinshasa, D. R. Congo. Sci Rep 2019; 9:5679. [PMID: 30952893 PMCID: PMC6450884 DOI: 10.1038/s41598-019-41963-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 03/18/2019] [Indexed: 01/05/2023] Open
Abstract
Point-of-Care (POC) molecular assays improve HIV infant diagnosis and viral load (VL) quantification in resource-limited settings. We evaluated POC performance in Kinshasa (Democratic Republic of Congo), with high diversity of HIV-1 recombinants. In 2016, 160 dried blood samples (DBS) were collected from 85 children (60 HIV-, 18 HIV+, 7 HIV-exposed) and 75 HIV+ adults (65 treated, 10 naive) at Monkole Hospital (Kinshasa). We compared viraemia with Cepheid-POC-Xpert-HIV-1VL and the non-POC-COBAS®AmpliPrep/COBAS®TaqMan®HIV-1-Testv2 in all HIV+, carrying 72.4%/7.2% HIV-1 unique/complex recombinant forms (URF/CRF). HIV-1 infection was confirmed in 14 HIV+ children by Cepheid-POC-Xpert-HIV-1Qual and in 70 HIV+ adults by both Xpert-VL and Roche-VL, identifying 8 false HIV+ diagnosis performed in DRC (4 adults, 4 children). HIV-1 was detected in 95.2% and 97.6% of 84 HIV+ samples by Xpert-VL and Roche-VL, respectively. Most (92.9%) HIV+ children presented detectable viraemia by both VL assays and 74.3% or 72.8% of 70 HIV+ adults by Xpert or Roche, respectively. Both VL assays presented high correlation (R2 = 0.89), but showing clinical relevant ≥0.5 log VL differences in 15.4% of 78 cases with VL within quantification range by both assays. This is the first study confirming the utility of Xpert HIV-1 tests for detection-quantification of complex recombinants currently circulating in Kinshasa.
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Affiliation(s)
- Marina Rubio-Garrido
- HIV-1 Molecular Epidemiology Laboratory, Microbiology and Parasitology Department, University Hospital Ramón y Cajal-IRYCIS and CIBEREsp-RITIP, Madrid, 28034, Spain
| | - Adolphe Ndarabu
- Monkole Hospital, Kinshasa, Democratic Republic of the Congo
| | - Gabriel Reina
- Microbiology Department, Clínica Universidad de Navarra, Navarra Institute for Health Research (IdiSNA), Institute of Tropical Health, Universidad de Navarra (ISTUN), Pamplona, 31008, Spain.
| | - David Barquín
- Microbiology Department, Clínica Universidad de Navarra, Navarra Institute for Health Research (IdiSNA), Institute of Tropical Health, Universidad de Navarra (ISTUN), Pamplona, 31008, Spain
| | - Mirian Fernández-Alonso
- Microbiology Department, Clínica Universidad de Navarra, Navarra Institute for Health Research (IdiSNA), Institute of Tropical Health, Universidad de Navarra (ISTUN), Pamplona, 31008, Spain
| | - Silvia Carlos
- Department of Preventive Medicine and Public Health, Institute of Culture and Society (ICS), Institute of Tropical Health (ISTUN), Universidad de Navarra, Navarra Institute for Health Research (IdiSNA), Pamplona, 31008, Spain
| | - África Holguín
- HIV-1 Molecular Epidemiology Laboratory, Microbiology and Parasitology Department, University Hospital Ramón y Cajal-IRYCIS and CIBEREsp-RITIP, Madrid, 28034, Spain
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26
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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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27
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Abrams EJ, Ananworanich J, Archary M, Ngongondo M, Brouwers P. Propelling the Pediatric HIV Therapeutic Agenda With Science, Innovation, and Collaboration. J Acquir Immune Defic Syndr 2018; 78 Suppl 1:S32-S39. [PMID: 29994918 PMCID: PMC6044456 DOI: 10.1097/qai.0000000000001747] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND A number of well-described obstacles to the pediatric therapeutic agenda have resulted in substantial delays in the introduction of new medications, formulations, strategies, and approaches to treat infants, children, and adolescents living with HIV. SETTING Global landscape. METHODS The authors will provide a summary of current and emerging initiatives to accelerate the pediatric therapeutic agenda including illustrative case studies of innovations and scientific discovery in diagnosis and treatment of very young children with HIV infection. RESULTS The challenges posed by rapid physiologic and developmental changes that characterize the trajectory of childhood as well as the complex regulatory and fiscal milieu of HIV therapeutics have hampered pediatric HIV therapeutic research. Recent efforts to accelerate this agenda include prioritizing agents and formulations, defining dosing by weight bands, applying innovative study designs, synergizing work across research networks to achieve common goals, and the establishment of a global prioritized research agenda. A case study of initiatives to diagnose and effectively treat newborns and infants will illustrate the critical role of basic science research and novel approaches to study design and implementation that are informing global efforts to end AIDS. CONCLUSIONS A pediatric therapeutic agenda informed by basic science and achieved through innovation and global cooperation is essential to achieve an AIDS-free generation.
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Affiliation(s)
- Elaine J. Abrams
- ICAP at Columbia, Mailman School of Public Health, College of Physicians & Surgeons, Columbia University, New York, NY
| | - Jintanat Ananworanich
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD
- Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD
- Department of Global Health, University of Amsterdam, Amsterdam, the Netherlands
| | - Moherndran Archary
- Paediatric Infectious Diseases Unit, King Edward VIII Hospital, University of KwaZulu Natal, Durban, South Africa
| | | | - Pim Brouwers
- Division of AIDS Research, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
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28
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Abstract
In an Editorial accompanying PLOS Medicine's Special Issue on Advances in Prevention, Treatment and Cure of HIV/AIDS, Guest Editors Steven Deeks, Sharon Lewin, and Linda-Gail Bekker discuss priorities in the field and the content of the issue.
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Affiliation(s)
- Steven G. Deeks
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Sharon R. Lewin
- Peter Doherty Institute of Infection and Immunity, University of Melbourne, and Royal Melbourne Hospital, Melbourne, Australia
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
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