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Mejia E, Lewis AGC, Garcés-Palacio IC, Hernandez DM, Chamberlain RM, Soliman AS. Relationship between universal health insurance benefits and prostate cancer mortality in Colombia. BMC Public Health 2024; 24:2667. [PMID: 39350101 PMCID: PMC11441010 DOI: 10.1186/s12889-024-20117-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Accepted: 09/17/2024] [Indexed: 10/04/2024] Open
Abstract
PURPOSE Prostate cancer is the most common cause for cancer mortality among men in Colombia. Law 100, in 1993, created a contributory regime (private insurance) and subsidized regime (public insurance) in which the subsidized regime had fewer benefits. However, Ruling T760 in July 2012 mandated that both systems must offer equal quality and access to healthcare. This study examines the impact of this change on prostate cancer mortality rates before and after 2012. METHODOLOGY Prostate cancer mortality records from 2006 to 2020 were collected from Colombia's National Administrative Department of Statistics (DANE). Crude mortality was calculated by health insurance for different geographic areas and analyzed for changes between 2006 and 2012 and 2013-2020. Join-Point regressions were used to analyze trends by health insurance. RESULTS Crude mortality rates in the contributory regime had a non-statistically significant decrease from 2006 to 2012 (AAPC= -1.32%, P = 0.14, 95% CI= -3.12, 0.52). In contrast, between 2013 and 2020 there was a non-statistically significant increase in crude mortality (AAPC 1.10%, P = 0.07, 95% CI= -0.09, 2.31). Comparatively, crude mortality in the subsidized regime, from 2006 to 2012, increased with a statistically significant AAPC of 2.51% (P < 0.001, 95% CI = 1.21, 3.83). From 2013 to 2020, mortality continued to increase with statistically significant AAPC of 5.52% (P < 0.001, 95% CI = 4.77, 6.27). Compared to their crude mortality differences from 2006 to 2020, from 2013 to 2020, the departments of Atlántico, Córdoba, Sucre, Arauca, Cesar, and Cauca had the highest rates in prostate cancer mortality in the subsidized regime compared to the contributory regime. CONCLUSION Ruling T760 did not positively impact prostate cancer mortality, particularly of men in the subsidized regime.
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Affiliation(s)
- Emanuel Mejia
- Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy, New York, NY, USA
| | - Almira G C Lewis
- Department of Global Health, School of Public Health, Boston University, Boston, MA, USA
| | - Isabel C Garcés-Palacio
- Epidemiology group, School of Public Health, Universidad de Antioquia UdeA, Calle 70 No. 52-21, Medellín, Colombia.
| | - Diana M Hernandez
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Robert M Chamberlain
- Department of Community Health and Social Medicine, City University of New York School of Medicine, New York, NY, USA
| | - Amr S Soliman
- Department of Community Health and Social Medicine, City University of New York School of Medicine, New York, NY, USA
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Ahmed N, Ong JJ, McGee K, d'Elbée M, Johnson C, Cambiano V, Hatzold K, Corbett EL, Terris-Prestholt F, Maheswaran H. Costs of HIV testing services in sub-Saharan Africa: a systematic literature review. BMC Infect Dis 2024; 22:980. [PMID: 39192180 PMCID: PMC11348535 DOI: 10.1186/s12879-024-09770-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/19/2024] [Indexed: 08/29/2024] Open
Abstract
OBJECTIVE To review HIV testing services (HTS) costs in sub-Saharan Africa. DESIGN A systematic literature review of studies published from January 2006 to October 2020. METHODS We searched ten electronic databases for studies that reported estimates for cost per person tested ($pptested) and cost per HIV-positive person identified ($ppositive) in sub-Saharan Africa. We explored variations in incremental cost estimates by testing modality (health facility-based, home-based, mobile-service, self-testing, campaign-style, and stand-alone), by primary or secondary/index HTS, and by population (general population, people living with HIV, antenatal care male partner, antenatal care/postnatal women and key populations). All costs are presented in 2019US$. RESULTS Sixty-five studies reported 167 cost estimates. Most reported only $pptested (90%), while (10%) reported the $ppositive. Costs were highly skewed. The lowest mean $pptested was self-testing at $12.75 (median = $11.50); primary testing at $16.63 (median = $10.68); in the general population, $14.06 (median = $10.13). The highest costs were in campaign-style at $27.64 (median = $26.70), secondary/index testing at $27.52 (median = $15.85), and antenatal male partner at $47.94 (median = $55.19). Incremental $ppositive was lowest for home-based at $297.09 (median = $246.75); primary testing $352.31 (median = $157.03); in the general population, $262.89 (median: $140.13). CONCLUSION While many studies reported the incremental costs of different HIV testing modalities, few presented full costs. Although the $pptested estimates varied widely, the costs for stand-alone, health facility, home-based, and mobile services were comparable, while substantially higher for campaign-style HTS and the lowest for HIV self-testing. Our review informs policymakers of the affordability of various HTS to ensure universal access to HIV testing.
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Affiliation(s)
- Nurilign Ahmed
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | - Jason J Ong
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Central Clinical School, Monash University, Melbourne, Australia
| | - Kathleen McGee
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Marc d'Elbée
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Cheryl Johnson
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | | | - Karin Hatzold
- Population Services International, Cape Town, South Africa
| | - Elizabeth L Corbett
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Fern Terris-Prestholt
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
- United Nations Joint Programme on HIV AIDS, Geneva, Switzerland
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Thielking AM, Fitzmaurice KP, Sewpaul R, Chrysanthopoulou SA, Dike L, Levy DE, Rigotti NA, Siedner MJ, Wood R, Paltiel AD, Freedberg KA, Hyle EP, Reddy KP. Tobacco smoking, smoking cessation and life expectancy among people with HIV on antiretroviral therapy in South Africa: a simulation modelling study. J Int AIDS Soc 2024; 27:e26315. [PMID: 38924347 PMCID: PMC11197963 DOI: 10.1002/jia2.26315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 06/04/2024] [Indexed: 06/28/2024] Open
Abstract
INTRODUCTION As access to effective antiretroviral therapy (ART) has improved globally, tobacco-related illnesses, including cardiovascular disease, cancer and chronic respiratory conditions, account for a growing proportion of deaths among people with HIV (PWH). We estimated the impact of tobacco smoking and smoking cessation on life expectancy among PWH in South Africa. METHODS In a microsimulation model, we simulated 18 cohorts of PWH with virologic suppression, each homogenous by sex, initial age (35y/45y/55y) and smoking status (current/former/never). Input parameters were from data sources published between 2008 and 2022. We used South African data to estimate age-stratified mortality hazard ratios: 1.2-2.3 (females)/1.1-1.9 (males) for people with current versus never smoking status; and 1.0-1.3 (females)/1.0-1.5 (males) for people with former versus never smoking status, depending on age at cessation. We assumed smoking status remains unchanged during the simulation; people who formerly smoked quit at model start. Simulated PWH face a monthly probability of disengagement from care and virologic non-suppression. In sensitivity analysis, we varied smoking-associated and HIV-associated mortality risks. Additionally, we estimated the total life-years gained if a proportion of all virologically suppressed PWH stopped smoking. RESULTS Forty-five-year-old females/males with HIV with virologic suppression who smoke lose 5.3/3.7 life-years compared to PWH who never smoke. Smoking cessation at age 45y adds 3.4/2.4 life-years. Simulated PWH who continue smoking lose more life-years from smoking than from HIV (females, 5.3 vs. 3.0 life-years; males, 3.7 vs. 2.6 life-years). The impact of smoking and smoking cessation increase as smoking-associated mortality risks increase and HIV-associated mortality risks, including disengagement from care, decrease. Model results are most sensitive to the smoking-associated mortality hazard ratio; varying this parameter results in 1.0-5.1 life-years gained from cessation at age 45y. If 10-25% of virologically suppressed PWH aged 30-59y in South Africa stopped smoking now, 190,000-460,000 life-years would be gained. CONCLUSIONS Among virologically suppressed PWH in South Africa, tobacco smoking decreases life expectancy more than HIV. Integrating tobacco cessation interventions into HIV care, as endorsed by the World Health Organization, could substantially improve life expectancy.
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Affiliation(s)
- Acadia M. Thielking
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMassachusettsUSA
| | - Kieran P. Fitzmaurice
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMassachusettsUSA
| | - Ronel Sewpaul
- Human and Social Capabilities, Human Sciences Research CouncilCape TownSouth Africa
| | | | - Lotanna Dike
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMassachusettsUSA
| | - Douglas E. Levy
- Harvard Medical SchoolBostonMassachusettsUSA
- Tobacco Research and Treatment CenterMassachusetts General HospitalBostonMassachusettsUSA
- Mongan Institute Health Policy Research CenterMassachusetts General HospitalBostonMassachusettsUSA
| | - Nancy A. Rigotti
- Harvard Medical SchoolBostonMassachusettsUSA
- Tobacco Research and Treatment CenterMassachusetts General HospitalBostonMassachusettsUSA
- Mongan Institute Health Policy Research CenterMassachusetts General HospitalBostonMassachusettsUSA
- Division of General Internal MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Mark J. Siedner
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMassachusettsUSA
- Africa Health Research InstituteSomkheleSouth Africa
| | - Robin Wood
- Desmond Tutu Health Foundation, MowbrayCape TownSouth Africa
- Department of MedicineUniversity of Cape TownCape TownSouth Africa
| | - A. David Paltiel
- Public Health Modeling UnitYale School of Public HealthNew HavenConnecticutUSA
| | - Kenneth A. Freedberg
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
- Division of General Internal MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMassachusettsUSA
- Department of Health Policy and ManagementHarvard T. H. Chan School of Public HealthBostonMassachusettsUSA
| | - Emily P. Hyle
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMassachusettsUSA
| | - Krishna P. Reddy
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
- Tobacco Research and Treatment CenterMassachusetts General HospitalBostonMassachusettsUSA
- Division of Pulmonary and Critical Care MedicineMassachusetts General HospitalBostonMassachusettsUSA
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James ND, Tannock I, N'Dow J, Feng F, Gillessen S, Ali SA, Trujillo B, Al-Lazikani B, Attard G, Bray F, Compérat E, Eeles R, Fatiregun O, Grist E, Halabi S, Haran Á, Herchenhorn D, Hofman MS, Jalloh M, Loeb S, MacNair A, Mahal B, Mendes L, Moghul M, Moore C, Morgans A, Morris M, Murphy D, Murthy V, Nguyen PL, Padhani A, Parker C, Rush H, Sculpher M, Soule H, Sydes MR, Tilki D, Tunariu N, Villanti P, Xie LP. The Lancet Commission on prostate cancer: planning for the surge in cases. Lancet 2024; 403:1683-1722. [PMID: 38583453 DOI: 10.1016/s0140-6736(24)00651-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/28/2023] [Accepted: 03/27/2024] [Indexed: 04/09/2024]
Affiliation(s)
- Nicholas D James
- Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK.
| | - Ian Tannock
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | - Felix Feng
- University of California, San Francisco, USA
| | - Silke Gillessen
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Syed Adnan Ali
- University of Manchester, Manchester, UK; The Christie Hospital, Manchester, UK
| | | | | | | | - Freddie Bray
- International Agency for Research on Cancer, Lyon, France
| | - Eva Compérat
- Tenon Hospital, Sorbonne University, Paris; AKH Medical University, Vienna, Austria
| | - Ros Eeles
- Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
| | | | | | | | - Áine Haran
- The Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | | | | | | | - Stacy Loeb
- New York University, New York, NY, USA; Manhattan Veterans Affairs, New York, NY, USA
| | | | | | | | - Masood Moghul
- Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
| | | | | | - Michael Morris
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Declan Murphy
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | | | | | | | | | | | | | - Howard Soule
- Prostate Cancer Foundation, Santa Monica, CA, USA
| | | | - Derya Tilki
- Martini-Klinik Prostate Cancer Center and Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, Koc University Hospital, Istanbul, Türkiye
| | - Nina Tunariu
- Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
| | | | - Li-Ping Xie
- First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Rahim FO, Jain B, Bloomfield GS, Jain P, Rugakingira A, Thielman NM, Sakita F, Hertz JT. A holistic framework to integrate HIV and cardiovascular disease care in sub-Saharan Africa. AIDS 2023; 37:1497-1502. [PMID: 37199570 DOI: 10.1097/qad.0000000000003604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Affiliation(s)
- Faraan O Rahim
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Bhav Jain
- Massachusetts Institute of Technology, Cambridge, Massachusetts
- Stanford University School of Medicine, Stanford, California
| | - Gerald S Bloomfield
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Pankaj Jain
- Highmark Health, Pittsburgh
- Indiana University of Pennsylvania, Indiana, Pennsylvania, USA
| | | | - Nathan M Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Stanford University School of Medicine, Stanford, California
| | - Francis Sakita
- Kilimanjaro Christian Medical Centre
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Moghul M, Cazzaniga W, Croft F, Kinsella N, Cahill D, James ND. Mobile Health Solutions for Prostate Cancer Diagnostics-A Systematic Review. Clin Pract 2023; 13:863-872. [PMID: 37623259 PMCID: PMC10453449 DOI: 10.3390/clinpract13040078] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/10/2023] [Accepted: 07/13/2023] [Indexed: 08/26/2023] Open
Abstract
Prostate cancer, the most common cause of cancer in men in the UK and one of the most common around the world to date, has no consensus on screening. Multiple large-scale trials from around the world have produced conflicting outcomes in cancer-specific and overall mortality. A main part of the issue is the PSA test, which has a high degree of variability, making it challenging to set PSA thresholds, as well as limited specificity. Prostate cancer has a predisposition in men from black backgrounds, and outcomes are worse in men of lower socioeconomic groups. Mobile targeted case finding, focusing on high-risk groups, may be a solution to help those that most need it. The aim of this systematic review was to review the evidence for mobile testing for prostate cancer. A review of all mobile screening studies for prostate cancer was performed in accordance with the Cochrane guidelines and the PRISMA statement. Of the 629 unique studies screened, 6 were found to be eligible for the review. The studies dated from 1973 to 2017 and came from four different continents, with around 30,275 men being screened for prostate cancer. Detection rates varied from 0.6% in the earliest study to 8.2% in the latest study. The challenge of early diagnosis of potentially lethal prostate cancer remains an issue for developed and low- and middle-income countries alike. Although further studies are needed, mobile screening of a targeted population with streamlined investigation and referral pathways combined with raising awareness in those communities may help make the case for screening for prostate cancer.
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Affiliation(s)
- Masood Moghul
- Department of Urology, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London SW3 6JB, UK
| | - Walter Cazzaniga
- Department of Urology, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Fionnuala Croft
- Department of Urology, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Netty Kinsella
- Department of Urology, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Declan Cahill
- Department of Urology, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Nicholas David James
- Department of Urology, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London SW3 6JB, UK
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Vasantharoopan A, Simms V, Chan Y, Guinness L, Maheswaran H. Modelling Methods of Economic Evaluations of HIV Testing Strategies in Sub-Saharan Africa: A Systematic Review. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:585-601. [PMID: 36853553 DOI: 10.1007/s40258-022-00782-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/04/2022] [Indexed: 06/01/2023]
Abstract
BACKGROUND AND OBJECTIVE Economic evaluations, a decision-support tool for policy makers, will be crucial in planning and tailoring HIV prevention and treatment strategies especially in the wake of stalled and decreasing funding for the global HIV response. As HIV testing and treatment coverage increase, case identification becomes increasingly difficult and costly. Determining which subset of the population these strategies should be targeted to becomes of vital importance as well. Generating quality economic evidence begins with the validity of the modelling approach and the model structure employed. This study synthesises and critiques the reporting around modelling methodology of economic models in the evaluation of HIV testing strategies in sub-Saharan Africa. METHODS The following databases were searched from January 2000 to September 2020: MEDLINE, Embase, Scopus, EconLit and Global Health. Any model-based economic evaluation of a unique HIV testing strategy conducted in sub-Saharan Africa presenting a cost-effectiveness measure published from 2013 onwards was eligible. Data were extracted around three components: general study characteristics; economic evaluation design; and quality of model reporting using a novel tool developed for the purposes of this study. RESULTS A total of 21 studies were included; 10 cost-effectiveness analyses, 11 cost-utility analyses. All but one study was conducted in Eastern and Southern Africa. Modelling approaches for HIV testing strategies can be broadly characterised as static aggregate models (3/21), static individual models (6/21), dynamic aggregate models (5/21) and dynamic individual models (7/21). Adequate reporting around data handling was the highest of the three categories assessed (74%), and model validation, the lowest (45%). Limitations to model structure, justification of chosen time horizon and cycle length, and description of external model validation process were all adequately reported in less than 40% of studies. The predominant limitation of this review relates to the potential implications of the narrow inclusion criteria. CONCLUSIONS This review is the first to synthesise economic evaluations of HIV testing strategies in sub-Saharan Africa. The majority of models exhibited dynamic, stochastic and individual properties. Model reporting against the 13 criteria in our novel tool was mixed. Future model-based economic evaluations of HIV testing strategies would benefit from transparency around the choice of modelling approach, model structure, data handling procedures and model validation techniques.
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Affiliation(s)
- Arthi Vasantharoopan
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Victoria Simms
- MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Yuyen Chan
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, UK
| | - Lorna Guinness
- London School of Hygiene and Tropical Medicine, London, UK
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Community Mobilization is Associated with HIV Testing Behaviors and Their Psychosocial Antecedents Among Zambian Adults: Results from a Population-Based Study. AIDS Behav 2022; 27:1682-1693. [PMID: 36307741 PMCID: PMC10140187 DOI: 10.1007/s10461-022-03900-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2022] [Indexed: 12/31/2022]
Abstract
Community mobilization (CM) is a vital yet under-explored avenue for increasing HIV testing in generalized HIV epidemic settings. Using multi-stage cluster sampling, a population-based sample of 3535 Zambian adults (mean age: 28 years, 50% women) were recruited from 14 districts to complete a household survey. Exploratory factor analysis (EFA) was used to re-validate a 23-item, 5-factor CM scale. Multivariable logistic and Poisson regression were then used to identify associations of CM with HIV testing behaviors and their psychosocial antecedents. A 21-item, 3-factor ("Leadership", "Collective Action Capacity", and "Social Cohesion") CM solution emerged from EFA (Cronbach's α 0.88). Among men and in rural settings, higher CM was significantly (p < 0.05) associated with elevated odds of HIV testing and more past-year HIV testing discussion sources, controlling for socio-demographics and sexual behaviors. Results underscore the importance of prioritizing CM to cultivate more favorable environments for HIV testing uptake, especially for men and rural residents.
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Kuo AP, Roche SD, Mugambi ML, Pintye J, Baeten JM, Bukusi E, Ngure K, Stergachis A, Ortblad KF. The effectiveness, feasibility and acceptability of HIV service delivery at private pharmacies in sub-Saharan Africa: a scoping review. J Int AIDS Soc 2022; 25:e26027. [PMID: 36285619 PMCID: PMC9597376 DOI: 10.1002/jia2.26027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 09/28/2022] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Private pharmacies are an understudied setting for differentiated delivery of HIV services that may address barriers to clinic-delivered services, such as stigma and long wait times. To understand the potential for pharmacy-delivered HIV services in sub-Saharan Africa, we conducted a scoping review of the published and grey literature. METHODS Using a modified Cochrane approach, we searched electronic databases through March 2022 and HIV conference abstracts in the past 5 years for studies that: (1) focused on the delivery of HIV testing, antiretroviral therapy (ART) and/or pre-exposure prophylaxis (PrEP) at private pharmacies in sub-Saharan Africa; (2) reported on effectiveness outcomes (e.g. HIV incidence) or implementation outcomes, specifically feasibility and/or acceptability; and (3) were published in English. Two authors identified studies and extracted data on study setting, population, design, outcomes and findings by HIV service type. RESULTS AND DISCUSSION Our search identified 1646 studies. After screening and review, we included 28 studies: seven on HIV testing, nine on ART delivery and 12 on PrEP delivery. Most studies (n = 16) were conducted in East Africa, primarily in Kenya. Only two studies evaluated effectiveness outcomes; the majority (n = 26) reported on feasibility and/or acceptability outcomes. The limited effectiveness data (n = 2 randomized trials) suggest that pharmacy-delivered HIV services can increase demand and result in comparable clinical outcomes (e.g. viral load suppression) to standard-of-care clinic-based models. Studies assessing implementation outcomes found actual and hypothetical models of pharmacy-delivered HIV services to be largely feasible (e.g. high initiation and continuation) and acceptable (e.g. preferable to facility-based models and high willingness to pay/provide) among stakeholders, providers and clients. Potential barriers to implementation included a lack of pharmacy provider training on HIV service delivery, costs to clients and providers, and perceived low quality of care. CONCLUSIONS The current evidence suggests that pharmacy-delivered HIV services may be feasible to implement and acceptable to clients and providers in parts of sub-Saharan Africa. However, limited evidence outside East Africa exists, as does limited evidence on the effectiveness of and costs associated with pharmacy-delivered HIV services. More research of this nature is needed to inform the scale-up of this new differentiated service delivery model throughout the region.
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Affiliation(s)
- Alexandra P. Kuo
- Department of PharmacyUniversity of WashingtonSeattleWashingtonUSA
| | - Stephanie D. Roche
- Public Health Sciences DivisionFred Hutchinson Cancer CenterSeattleWashingtonUSA
| | | | - Jillian Pintye
- School of NursingUniversity of WashingtonSeattleWashingtonUSA
| | - Jared M. Baeten
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- School of NursingUniversity of WashingtonSeattleWashingtonUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
- Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
- Gilead SciencesFoster CityCaliforniaUSA
| | - Elizabeth Bukusi
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Centre for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
- Department of Obstetrics and GynecologyUniversity of WashingtonSeattleWashingtonUSA
| | - Kenneth Ngure
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Department of Community HealthJomo Kenyatta University of Agriculture and TechnologyNairobiKenya
| | - Andy Stergachis
- Department of PharmacyUniversity of WashingtonSeattleWashingtonUSA
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Katrina F. Ortblad
- Public Health Sciences DivisionFred Hutchinson Cancer CenterSeattleWashingtonUSA
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Schaffer DH, Sawczuk LM, Zheng H, Macias-Konstantopoulos WL. Community-Based, Rapid HIV Screening and Pre-Exposure Prophylaxis Initiation: Findings From a Pilot Program. Cureus 2022; 14:e20877. [PMID: 35145784 PMCID: PMC8806132 DOI: 10.7759/cureus.20877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2021] [Indexed: 11/15/2022] Open
Abstract
Objective Many individuals do not have regular access to medical care and preventative health services, suggesting the need for alternative access to HIV testing and pre-exposure prophylaxis (PrEP). The purpose of this study is to describe a novel, community-based HIV screening, a PrEP initiation program, and report preliminary findings. Methods One Tent Health, a 501(c)(3) nonprofit organization, launched a pop-up HIV screening and PrEP initiation program in high-risk areas of Washington, DC in 2017. We describe the unique features of the program and report 25 months of screening, risk assessment, and PrEP education data. Odds ratios were calculated to identify disparities in both HIV risk factors and prior HIV testing. Results Between October 2017 and November 2019, 846 individuals underwent HIV screening. Six individuals (0.709%) screened HIV-positive. Approximately 13% had never been screened for HIV, and another 13% had at least one major risk factor for HIV. Individuals who self-identified as White were more likely to have risk factors (OR 2.19, p = 0.0170) and less likely to have ever been tested (OR 0.50, p = 0.0409). Individuals who self-identified as Black or African American were less likely to have risk factors for HIV (OR 0.57, p = 0.0178). Disparities by sex and gender were also observed. Conclusions This program appears to be the first of its kind within the United States. We found the program to be cost-effective, well-received by the community, and accessible by high-risk and unreached populations while further revealing the role of race and gender in the HIV epidemic.
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Stanic T, McCann N, Penazzato M, Flanagan C, Essajee S, Freedberg KA, Doherty M, Putta N, Myer L, Siberry GK, Collins IJ, Vojnov L, Abrams E, Soeteman DI, Ciaranello AL. Cost-effectiveness of Routine Provider-Initiated Testing and Counseling for Children With Undiagnosed HIV in South Africa. Open Forum Infect Dis 2022; 9:ofab603. [PMID: 35028333 PMCID: PMC8753042 DOI: 10.1093/ofid/ofab603] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 12/03/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND We compared the cost-effectiveness of pediatric provider-initiated HIV testing and counseling (PITC) vs no PITC in a range of clinical care settings in South Africa. METHODS We used the Cost-Effectiveness of Preventing AIDS Complications Pediatric model to simulate a cohort of children, aged 2-10 years, presenting for care in 4 settings (outpatient, malnutrition, inpatient, tuberculosis clinic) with varying prevalence of undiagnosed HIV (1.0%, 15.0%, 17.5%, 50.0%, respectively). We compared "PITC" (routine testing offered to all patients; 97% acceptance and 71% linkage to care after HIV diagnosis) with no PITC. Model outcomes included life expectancy, lifetime costs, and incremental cost-effectiveness ratios (ICERs) from the health care system perspective and the proportion of children with HIV (CWH) diagnosed, on antiretroviral therapy (ART), and virally suppressed. We assumed a threshold of $3200/year of life saved (YLS) to determine cost-effectiveness. Sensitivity analyses varied the age distribution of children seeking care and costs for PITC, HIV care, and ART. RESULTS PITC improved the proportion of CWH diagnosed (45.2% to 83.2%), on ART (40.8% to 80.4%), and virally suppressed (32.6% to 63.7%) at 1 year in all settings. PITC increased life expectancy by 0.1-0.7 years for children seeking care (including those with and without HIV). In all settings, the ICER of PITC vs no PITC was very similar, ranging from $710 to $1240/YLS. PITC remained cost-effective unless undiagnosed HIV prevalence was <0.2%. CONCLUSIONS Routine testing improves HIV clinical outcomes and is cost-effective in South Africa if the prevalence of undiagnosed HIV among children exceeds 0.2%. These findings support current recommendations for PITC in outpatient, inpatient, tuberculosis, and malnutrition clinical settings.
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Affiliation(s)
- Tijana Stanic
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nicole McCann
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Martina Penazzato
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Clare Flanagan
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Meg Doherty
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | | | - Landon Myer
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - George K Siberry
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
| | - Intira Jeannie Collins
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Lara Vojnov
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Elaine Abrams
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, USA.,Department of Pediatrics, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Djøra I Soeteman
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Andrea L Ciaranello
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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12
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Rousseau E, Julies RF, Madubela N, Kassim S. Novel Platforms for Biomedical HIV Prevention Delivery to Key Populations - Community Mobile Clinics, Peer-Supported, Pharmacy-Led PrEP Delivery, and the Use of Telemedicine. Curr HIV/AIDS Rep 2021; 18:500-507. [PMID: 34708316 PMCID: PMC8549812 DOI: 10.1007/s11904-021-00578-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW A gap exists between PrEP interest and PrEP uptake in key populations (KP) for HIV prevention that may be ascribed to PrEP delivery services not being acceptable. This review summarizes novel platforms for HIV prevention outside of the traditional health facilities environment. RECENT FINDINGS Mobile health clinics provide highly acceptable integrated, KP-focused services at convenient locations with the potential of high PrEP uptake. Telemedicine and health apps decongest health systems and allow for personal agency and informed decision-making on personal health. Pharmacy-led PrEP delivery provides de-medicalized, confidential PrEP services at extended hours in community locations, from trusted medical professionals. Peer-supported delivery encourages continued PrEP use. Community-based, differentiated and de-medicalized PrEP delivery can address uptake and continued use barriers in key populations. Future research should assess scalability, cost-effectiveness and sustainability of these PrEP delivery platforms, as well as focus on ways to simplify PrEP provision.
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Affiliation(s)
- E Rousseau
- Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
| | - R F Julies
- Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - N Madubela
- Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - S Kassim
- Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Gonsalves GS, Copple JT, Paltiel AD, Fenichel EP, Bayham J, Abraham M, Kline D, Malloy S, Rayo MF, Zhang N, Faulkner D, Morey DA, Wu F, Thornhill T, Iloglu S, Warren JL. Maximizing the Efficiency of Active Case Finding for SARS-CoV-2 Using Bandit Algorithms. Med Decis Making 2021; 41:970-977. [PMID: 34120510 PMCID: PMC8484027 DOI: 10.1177/0272989x211021603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Even as vaccination for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) expands in the United States, cases will linger among unvaccinated individuals for at least the next year, allowing the spread of the coronavirus to continue in communities across the country. Detecting these infections, particularly asymptomatic ones, is critical to stemming further transmission of the virus in the months ahead. This will require active surveillance efforts in which these undetected cases are proactively sought out rather than waiting for individuals to present to testing sites for diagnosis. However, finding these pockets of asymptomatic cases (i.e., hotspots) is akin to searching for needles in a haystack as choosing where and when to test within communities is hampered by a lack of epidemiological information to guide decision makers' allocation of these resources. Making sequential decisions with partial information is a classic problem in decision science, the explore v. exploit dilemma. Using methods-bandit algorithms-similar to those used to search for other kinds of lost or hidden objects, from downed aircraft or underground oil deposits, we can address the explore v. exploit tradeoff facing active surveillance efforts and optimize the deployment of mobile testing resources to maximize the yield of new SARS-CoV-2 diagnoses. These bandit algorithms can be implemented easily as a guide to active case finding for SARS-CoV-2. A simple Thompson sampling algorithm and an extension of it to integrate spatial correlation in the data are now embedded in a fully functional prototype of a web app to allow policymakers to use either of these algorithms to target SARS-CoV-2 testing. In this instance, potential testing locations were identified by using mobility data from UberMedia to target high-frequency venues in Columbus, Ohio, as part of a planned feasibility study of the algorithms in the field. However, it is easily adaptable to other jurisdictions, requiring only a set of candidate test locations with point-to-point distances between all locations, whether or not mobility data are integrated into decision making in choosing places to test.
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Affiliation(s)
- Gregg S. Gonsalves
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT
- Public Health Modeling Unit, Yale School of Public Health, New Haven, CT
| | - J. Tyler Copple
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT
- Public Health Modeling Unit, Yale School of Public Health, New Haven, CT
| | - A. David Paltiel
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT
- Public Health Modeling Unit, Yale School of Public Health, New Haven, CT
| | | | - Jude Bayham
- Department of Agricultural and Resource Economics, Colorado State University, Fort Collins, CO
| | | | - David Kline
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, OH
| | - Sam Malloy
- Battelle Center for Science, Engineering, and Public Policy, John Glenn College of Public Affairs, The Ohio State University, Columbus, OH
| | - Michael F. Rayo
- Integrated Systems Engineering, The Ohio State University, Columbus, OH
| | - Net Zhang
- Battelle Center for Science, Engineering, and Public Policy, John Glenn College of Public Affairs, The Ohio State University, Columbus, OH
| | - Daria Faulkner
- College of Public Health, The Ohio State University, Columbus, OH
| | - Dane A. Morey
- Integrated Systems Engineering, The Ohio State University, Columbus, OH
| | - Frank Wu
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT
- Public Health Modeling Unit, Yale School of Public Health, New Haven, CT
| | - Thomas Thornhill
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT
- Public Health Modeling Unit, Yale School of Public Health, New Haven, CT
| | - Suzan Iloglu
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT
- Public Health Modeling Unit, Yale School of Public Health, New Haven, CT
| | - Joshua L. Warren
- Department of Biostatistics, Yale School of Public Health, New Haven, CT
- Public Health Modeling Unit, Yale School of Public Health, New Haven, CT
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14
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Mabuto T, Setswe G, Mshweshwe-Pakela N, Clark D, Day S, Molobetsi L, Pienaar J. Findings from a novel and scalable community-based HIV testing approach to reduce the time required to complete point-of-care HIV testing in South Africa. BMC Health Serv Res 2021; 21:1176. [PMID: 34711236 PMCID: PMC8555215 DOI: 10.1186/s12913-021-07173-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 10/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mobile HIV testing approaches are a key to reaching the global targets of halting the HIV epidemic by 2030. Importantly, the number of clients reached through mobile HIV testing approaches, need to remain high to maintain the cost-effectiveness of these approaches. Advances in rapid in-vitro tests such as INSTI® HIV-1/HIV-2 (INSTI) which uses flow-through technologies, offer opportunities to reduce the HIV testing time to about one minute. Using data from a routine mobile HTS programme which piloted the use of the INSTI point-of-care (POC) test, we sought to estimate the effect of using a faster test on client testing volumes and the number of people identified to be living with HIV, in comparison with standard of care HIV rapid tests. METHODS In November 2019, one out of four mobile HTS teams operating in Ekurhuleni District (South Africa) was randomly selected to pilot the field use of INSTI-POC test as an HIV screening test (i.e., the intervention team). We compared the median number of clients tested for HIV and the number of HIV-positive clients by the intervention team with another mobile HTS team (matched on performance and area of operation) which used the standard of care (SOC) HIV screening test (i.e., SOC team). RESULTS From 19 to 20 December 2019, the intervention team tested 7,403 clients, and the SOC team tested 2,426 clients. The intervention team tested a median of 442 (IQR: 288-522) clients/day; SOC team tested a median of 97 (IQR: 40-187) clients/day (p<0.0001). The intervention team tested about 180 more males/day compared to the SOC team, and the median number of adolescents and young adults tested/day by the intervention team were almost four times the number tested by the SOC team. The intervention team identified a higher number of HIV-positive clients compared to the SOC team (142 vs. 88), although the proportion of HIV-positive clients was lower in the intervention team due to the higher number of clients tested. CONCLUSIONS This pilot programme provides evidence of high performance and high reach, for men and young people through the use of faster HIV rapid tests, by trained lay counsellors in mobile HTS units.
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Affiliation(s)
- Tonderai Mabuto
- The Aurum Institute NPC, 29 Queens Road, Parktown, 2193, Johannesburg, South Africa.
| | - Geoffrey Setswe
- The Aurum Institute NPC, 29 Queens Road, Parktown, 2193, Johannesburg, South Africa
- University of South Africa, Preller St, Muckleneuk, Pretoria, South Africa
| | - Nolundi Mshweshwe-Pakela
- The Aurum Institute NPC, 29 Queens Road, Parktown, 2193, Johannesburg, South Africa
- The University of the Witwatersrand School of Public Health, 60 York Rd, Johannesburg, South Africa
| | - Dave Clark
- The Aurum Institute NPC, 29 Queens Road, Parktown, 2193, Johannesburg, South Africa
- Vanderbilt University, 2201 West End Ave, Nashville, TN, USA
| | - Sarah Day
- The Centre for HIV-AIDS Prevention Studies, 25 St Johns Road, Houghton Estate, Johannesburg, South Africa
| | - Lerato Molobetsi
- The Centre for HIV-AIDS Prevention Studies, 25 St Johns Road, Houghton Estate, Johannesburg, South Africa
| | - Jacqueline Pienaar
- The Centre for HIV-AIDS Prevention Studies, 25 St Johns Road, Houghton Estate, Johannesburg, South Africa
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Smith PJ, Davey DJ, Green H, Cornell M, Bekker LG. Reaching underserved South Africans with integrated chronic disease screening and mobile HIV counselling and testing: A retrospective, longitudinal study conducted in Cape Town. PLoS One 2021; 16:e0249600. [PMID: 33945540 PMCID: PMC8096085 DOI: 10.1371/journal.pone.0249600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 03/20/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Community-based, mobile HIV counselling and testing (HCT) and screening for non-communicable diseases (NCDs) may improve early diagnosis and referral for care in underserved populations. We evaluated HCT/NCD data and described population characteristics of those visiting a mobile clinic in high HIV disease burden settings in Cape Town, South Africa, between 2008 and 2016. METHODS Trained counsellors registered patients ≥12 years old at a mobile clinic, which offered HCT and blood pressure, diabetes (glucose testing) and obesity (body mass index) screening. A nurse referred patients who required HIV treatment or NCD care. Using multivariable logistic regression, we estimated correlates of new HIV diagnoses adjusting for gender, age and year. RESULTS Overall, 43,938 individuals (50% male; 29% <25 years; median age = 31 years) tested for HIV at the mobile clinic, where 27% of patients (66% of males, 34% of females) reported being debut HIV testers. Males not previously tested for HIV had higher rates of HIV positivity (11%) than females (7%). Over half (55%, n = 1,343) of those previously diagnosed HIV-positive had not initiated ART. More than one-quarter (26%) of patients screened positive for hypertension (males 28%, females 24%, p<0.001). Females were more likely overweight (25% vs 20%) or obese (43% vs 9%) and presented with more diabetes symptoms than males (8% vs 4%). Females (3%) reported more symptoms of STIs than males (1%). Reporting symptoms of sexually transmitted infections (aOR = 3.45, 95% CI = 2.84, 4.20), diabetes symptoms (aOR = 1.61, 95% 1.35, 1.92), and TB symptoms (aOR = 4.40, 95% CI = 3.85, 5.01) were associated with higher odds of a new HIV diagnosis after adjusting for covariates. CONCLUSION Findings demonstrate that mobile clinics providing integrated HCT and NCD screening may offer the opportunity of early diagnosis and referral for care for those who delay screening, including men living with HIV not previously tested.
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Affiliation(s)
- Philip John Smith
- Faculty of Health Sciences, The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Dvora Joseph Davey
- Faculty of Health Sciences, The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, California, United States of America
- Faculty of Health Sciences, Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Hunter Green
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, California, United States of America
| | - Morna Cornell
- Faculty of Health Sciences, Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Linda-Gail Bekker
- Faculty of Health Sciences, The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Yigezu A, Alemayehu S, Hamusse SD, Ergeta GT, Hailemariam D, Hailu A. Cost-effectiveness of facility-based, stand-alone and mobile-based voluntary counseling and testing for HIV in Addis Ababa, Ethiopia. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2020; 18:34. [PMID: 32944006 PMCID: PMC7488732 DOI: 10.1186/s12962-020-00231-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 09/07/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Globally, there is a consensus to end the HIV/AIDS epidemic by 2030, and one of the strategies to achieve this target is that 90% of people living with HIV should know their HIV status. Even if there is strong evidence of clients' preference for testing in the community, HIV voluntary counseling and testing (VCT) continue to be undertaken predominantly in health facilities. Hence, empirical cost-effectiveness evidence about different HIV counseling and testing models is essential to inform whether such community-based testing are justifiable compared with additional resources required. Therefore, the purpose of this study was to compare the cost-effectiveness of facility-based, stand-alone and mobile-based HIV voluntary counseling and testing methods in Addis Ababa, Ethiopia. METHODS Annual economic costs of counseling and testing methods were collected from the providers' perspective from July 2016 to June 2017. Ingredients based bottom-up costing approach was applied. The effectiveness of the interventions was measured in terms of the number of HIV seropositive clients identified. Decision tree modeling was built using TreeAge Pro 2018 software, and one-way and probabilistic sensitivity analyses were conducted by varying HIV positivity rate, costs, and probabilities. RESULTS The cost of test per client for facility-based, stand-alone and mobile-based VCT was $5.06, $6.55 and $3.35, respectively. The unit costs of test per HIV seropositive client for the corresponding models were $158.82, $150.97 and $135.82, respectively. Of the three models, stand-alone-based VCT was extendedly dominated. Mobile-based VCT costs, an additional cost of USD 239 for every HIV positive client identified when compared to facility-based VCT. CONCLUSION Using a mobile-based VCT approach costs less than both the facility-based and stand-alone approaches, in terms of both unit cost per tested individual and unit cost per HIV seropositive cases identified. The stand-alone VCT approach was not cost-effective compared to facility-based and mobile-based VCT. The incremental cost-effectiveness ratio for mobile-based VCT compared with facility-based VCT was USD 239 per HIV positive case.
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Affiliation(s)
- Amanuel Yigezu
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | | | | | - Getachew Teshome Ergeta
- Bergen Center for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Damen Hailemariam
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alemayehu Hailu
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
- Bergen Center for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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17
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Amoo BA, Dairo DM, Kanmodi KK, Omoleke SA. Utilization rate and factors influencing the use of HIV counseling and testing services among young females: a community-based study from Nigeria. Int J Adolesc Med Health 2020; 33:511-521. [PMID: 32543449 DOI: 10.1515/ijamh-2019-0235] [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] [Received: 11/11/2019] [Accepted: 01/30/2020] [Indexed: 11/15/2022]
Abstract
Objectives This study aims to explore the utilization rate and factors influencing the use of HCT services among young females in Ikorodu, Lagos State, Nigeria. Methods This study was a descriptive cross-sectional survey of 404 females, aged 15-24 years, residing in Ikorodu, Nigeria. Study tool was a questionnaire. Collected data was analyzed using the SPSS version 16 software. Results The mean age (±SD) of the respondents was 19.3 (±2.6) years and 90.1% were single. Only 148 (36.6%) respondents had ever utilized the HCT service, of which only 40.5% of them were adolescents. Amongst those that had ever utilized HCT services (n=148), only 60.1% of them did so within 12 months prior to the study while only 33.8% of them initiated the demand for testing themselves. According to the respondents, the top two barriers to the utilization of HCT services were: fear of discrimination (82.9%); and fear of unavailability of access to treatment (68.0%), while the top two factors that facilitates its use were: the adoption of counseling-before-testing approach in the HCT service centers (85.9%); and peoples' need for HIV status declaration prior to getting a job employment/marriage partner (85.1%). Conclusions The study shows that utilization of HCT service remains low among the respondents. There is an urgent need to encourage the utilization of HCT services among young females in Ikorodu, Nigeria.
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Affiliation(s)
- Babatunde Abiodun Amoo
- Department of Epidemiology and Medical Statistics, Faculty of Public Health, University of Ibadan, Ibadan, Nigeria.,Cephas Health Research Initiative Inc, Ibadan, Nigeria
| | - David Magbagbeola Dairo
- Department of Epidemiology and Medical Statistics, Faculty of Public Health, University of Ibadan, Ibadan, Nigeria
| | - Kehinde Kazeem Kanmodi
- Cephas Health Research Initiative Inc, Ibadan, Nigeria.,Peace Studies & Conflict Resolution Program, Department of Political Science, National Open University of Nigeria, Kebbi Study Centre, Birnin Kebbi, Nigeria.,National Teachers' Institute, Kebbi Study Centre, Birnin Kebbi, Nigeria.,Healthy Mind Program, Mental and Oral Health Development Organization Inc, Birnin Kebbi, Nigeria
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18
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Chukwuma A, Gong E, Latypova M, Fraser-Hurt N. Challenges and opportunities in the continuity of care for hypertension: a mixed-methods study embedded in a primary health care intervention in Tajikistan. BMC Health Serv Res 2019; 19:925. [PMID: 31796016 PMCID: PMC6889695 DOI: 10.1186/s12913-019-4779-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 11/25/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Hypertension, a significant risk factor for ischemic heart disease and other chronic conditions, is the third-highest cause of death and disability in Tajikistan. Thus, ensuring the early detection and appropriate management of hypertension is a core element of strategies to improve population health in Tajikistan. For a strategy to be successful, it should be informed by the causes of gaps in service delivery and feasible solutions to these challenges. The objective of this study was to undertake a systematic assessment of hypertension case detection and retention in care within Tajikistan's primary health care system, and to identify challenges and appropriate solutions. METHODS Our mixed methods study drew on the cascade of care framework to examine patient progression through the recommended stages of hypertension care. We triangulated data from household surveys and facility registries within Tajikistan's Health Services Improvement Project (HSIP) to describe the cascade. Focus group discussions with local HSIP stakeholders identified the barriers to and facilitators for care. Drawing on global empirical evidence on effective interventions and stakeholder judgments on the feasibility of implementation, we developed recommendations to improve hypertension service delivery that were informed by our quantitative and qualitative findings. RESULTS We review the results for the case detection stage of the cascade of care, which had the most significant gaps. Of the half a million people with hypertension in Khatlon and Sogd Oblasts (administrative regions), about 10% have been diagnosed in Khatlon and only 5% in Sogd. Barriers to case detection include misinformation about hypertension, ambiguous protocols, and limited delivery capacity. Solutions identified to these challenges were mobilizing faith-based organizations, scaling up screening through health caravans, task-shifting to increase provider supply, and introducing job aids for providers. CONCLUSIONS Translating findings on discontinuities in care for hypertension and other chronic diseases to actionable policy insights can be facilitated by collaboration with local stakeholders, triangulation of data sources, and identifying the intersection between the feasible and the effective in defining solutions to service delivery challenges.
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Affiliation(s)
- Adanna Chukwuma
- Health, Nutrition, and Population Global Practice, World Bank Group, Washington, DC, 20433, USA.
| | - Estelle Gong
- Mount Sinai Health System, New York, NY, 10019, USA
| | - Mutriba Latypova
- Health, Nutrition, and Population Global Practice, World Bank Group, Washington, DC, 20433, USA
| | - Nicole Fraser-Hurt
- Health, Nutrition, and Population Global Practice, World Bank Group, Washington, DC, 20433, USA
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Optimal HIV testing strategies for South Africa: a model-based evaluation of population-level impact and cost-effectiveness. Sci Rep 2019; 9:12621. [PMID: 31477764 PMCID: PMC6718403 DOI: 10.1038/s41598-019-49109-w] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 08/19/2019] [Indexed: 11/26/2022] Open
Abstract
Although many African countries have achieved high levels of HIV diagnosis, funding constraints have necessitated greater focus on more efficient testing approaches. We compared the impact and cost-effectiveness of several potential new testing strategies in South Africa, and assessed the prospects of achieving the UNAIDS target of 95% of HIV-positive adults diagnosed by 2030. We developed a mathematical model to evaluate the potential impact of home-based testing, mobile testing, assisted partner notification, testing in schools and workplaces, and testing of female sex workers (FSWs), men who have sex with men (MSM), family planning clinic attenders and partners of pregnant women. In the absence of new testing strategies, the diagnosed fraction is expected to increase from 90.6% in 2020 to 93.8% by 2030. Home-based testing combined with self-testing would have the greatest impact, increasing the fraction diagnosed to 96.5% by 2030, and would be highly cost-effective compared to currently funded HIV interventions, with a cost per life year saved (LYS) of $394. Testing in FSWs and assisted partner notification would be cost-saving; the cost per LYS would also be low in the case of testing MSM ($20/LYS) and self-testing by partners of pregnant women ($130/LYS).
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Cost-effectiveness and budget impact of immediate antiretroviral therapy initiation for treatment of HIV infection in Côte d'Ivoire: A model-based analysis. PLoS One 2019; 14:e0219068. [PMID: 31247009 PMCID: PMC6597104 DOI: 10.1371/journal.pone.0219068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 06/14/2019] [Indexed: 02/07/2023] Open
Abstract
Introduction The Temprano and START trials provided evidence to support early ART initiation recommendations. We projected long-term clinical and economic outcomes of immediate ART initiation in Côte d’Ivoire. Methods We used a mathematical model to compare three potential ART initiation criteria: 1) CD4 <350/μL (ART<350/μL); 2) CD4 <500/μL (ART<500/μL); and 3) ART at presentation (Immediate ART). Outcomes from the model included life expectancy, 10-year medical resource use, incremental cost-effectiveness ratios (ICERs) in $/year of life saved (YLS), and 5-year budget impact. We simulated people with HIV (PWH) in care (mean CD4: 259/μL, SD 198/μL) and transmitted cases. Key input parameters to the analysis included first-line ART efficacy (80% suppression at 6 months) and ART cost ($90/person-year). We assessed cost-effectiveness relative to Côte d’Ivoire’s 2017 per capita annual gross domestic product ($1,600). Results Immediate ART increased life expectancy by 0.34 years compared to ART<350/μL and 0.17 years compared to ART<500/μL. Immediate ART resulted in 4,500 fewer 10-year transmissions per 170,000 PWH compared to ART<350/μL. In cost-effectiveness analysis, Immediate ART had a 10-year ICER of $680/YLS compared to ART<350/μL, ranging from cost-saving to an ICER of $1,440/YLS as transmission rates varied. ART<500/μL was “dominated” (an inefficient use of resources), compared with Immediate ART. Immediate ART increased the 5-year HIV care budget from $801.9M to $812.6M compared to ART<350/μL. Conclusions In Côte d’Ivoire, immediate compared to later ART initiation will increase life expectancy, decrease HIV transmission, and be cost-effective over the long-term, with modest budget impact. Immediate ART initiation is an appropriate, high-value standard of care in Côte d’Ivoire and similar settings.
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Meyer-Rath G, van Rensburg C, Chiu C, Leuner R, Jamieson L, Cohen S. The per-patient costs of HIV services in South Africa: Systematic review and application in the South African HIV Investment Case. PLoS One 2019; 14:e0210497. [PMID: 30807573 PMCID: PMC6391029 DOI: 10.1371/journal.pone.0210497] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 12/23/2018] [Indexed: 12/29/2022] Open
Abstract
Background In economic analyses of HIV interventions, South Africa is often used as a case in point, due to the availability of good epidemiological and programme data and the global relevance of its epidemic. Few analyses however use locally relevant cost data. We reviewed available cost data as part of the South African HIV Investment Case, a modelling exercise to inform the optimal use of financial resources for the country’s HIV programme. Methods We systematically reviewed publication databases for published cost data covering a large range of HIV interventions and summarised relevant unit costs (cost per person receiving a service) for each. Where no data was found in the literature, we constructed unit costs either based on available information regarding ingredients and relevant public-sector prices, or based on expenditure records. Results Only 42 (5%) of 1,047 records included in our full-text review reported primary cost data on HIV interventions in South Africa, with 71% of included papers covering ART. Other papers detailed the costs of HCT, MMC, palliative and inpatient care; no papers were found on the costs of PrEP, social and behaviour change communication, and PMTCT. The results informed unit costs for 5 of 11 intervention categories included in the Investment Case, with the remainder costed based on ingredients (35%) and expenditure data (10%). Conclusions A large number of modelled economic analyses of HIV interventions in South Africa use as inputs the same, often outdated, cost analyses, without reference to additional literature review. More primary cost analyses of non-ART interventions are needed.
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Affiliation(s)
- Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Center for Global Health and Development, Boston University, Boston, Massachusetts, United States of America
- * E-mail:
| | - Craig van Rensburg
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Calvin Chiu
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rahma Leuner
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lise Jamieson
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Steve Cohen
- Strategic Development Consultants, Pietermaritzburg, South Africa
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Cherutich P, Farquhar C, Wamuti B, Otieno FA, Ng'ang'a A, Mutiti PM, Macharia P, Sambai B, Bukusi D, Levin C. HIV partner services in Kenya: a cost and budget impact analysis study. BMC Health Serv Res 2018; 18:721. [PMID: 30223833 PMCID: PMC6142360 DOI: 10.1186/s12913-018-3530-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 09/07/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The elicitation of contact information, notification and testing of sex partners of HIV infected patients (aPS), is an effective HIV testing strategy in low-income settings but may not necessarily be affordable. We applied WHO guidelines and the International Society for Pharmaco-economics and Outcomes Research (ISPOR) guidelines to conduct cost and budget impact analyses, respectively, of aPS compared to current practice of HIV testing services (HTS) in Kisumu County, Kenya. METHODS Using study data and time motion studies, we constructed an Excel-based tool to estimate costs and the budget impact of aPS. Cost data were collected from selected facilities in Kisumu County. We report the annual total and unit costs of HTS, incremental total and unit costs for aPS, and the budget impact of scaling up aPS over a 5-year horizon. We also considered a task-shifted scenario that used community health workers (CHWs) rather than facility based health workers and conducted sensitivity analyses assuming different rates of scale up of aPS. RESULTS The average unit costs for HIV testing among HIV-infected index clients was US$ 25.36 per client and US$ 17.86 per client using nurses and CHWs, respectively. The average incremental costs for providing enhanced aPS in Kisumu County were US$ 1,092,161 and US$ 753,547 per year, using nurses and CHWs, respectively. The average incremental cost of scaling up aPS over a five period was 45% higher when using nurses compared to using CHWs (US$ 5,460,837 and US$ 3,767,738 respectively). Over the five years, the upper-bound budget impact of nurse-model was US$ 1,767,863, 63% and 35% of which were accounted for by aPS costs and ART costs, respectively. The CHW model incurred an upper-bound incremental cost of US$ 1,258,854, which was 71.2% lower than the nurse-based model. The budget impact was sensitive to the level of aPS coverage and ranged from US$ 28,547 for 30% coverage using CHWs in 2014 to US$ 1,267,603 for 80% coverage using nurses in 2018. CONCLUSION Scaling aPS using nurses has minimal budget impact but not cost-saving over a five-year period. Targeting aPS to newly-diagnosed index cases and task-shifting to community health workers is recommended.
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Affiliation(s)
- Peter Cherutich
- Ministry of Health, Afya House, Cathedral Road, P.O Box 30016-00100, Nairobi, Kenya.
| | - Carey Farquhar
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Beatrice Wamuti
- Department of Research and Training, Kenyatta National Hospital, Nairobi, Kenya
| | - Felix A Otieno
- Department of Research and Training, Kenyatta National Hospital, Nairobi, Kenya
| | - Ann Ng'ang'a
- Ministry of Health, Afya House, Cathedral Road, P.O Box 30016-00100, Nairobi, Kenya
| | - Peter Maingi Mutiti
- Department of Research and Training, Kenyatta National Hospital, Nairobi, Kenya
| | - Paul Macharia
- Ministry of Health, Afya House, Cathedral Road, P.O Box 30016-00100, Nairobi, Kenya
| | - Betsy Sambai
- Department of Research and Training, Kenyatta National Hospital, Nairobi, Kenya
| | - David Bukusi
- Department of Research and Training, Kenyatta National Hospital, Nairobi, Kenya
| | - Carol Levin
- Department of Global Health, University of Washington, Seattle, WA, USA
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Gonsalves GS, Copple JT, Johnson T, Paltiel AD, Warren JL. Bayesian adaptive algorithms for locating HIV mobile testing services. BMC Med 2018; 16:155. [PMID: 30173667 PMCID: PMC6120098 DOI: 10.1186/s12916-018-1129-0] [Citation(s) in RCA: 8] [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] [Received: 03/30/2018] [Accepted: 07/13/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We have previously conducted computer-based tournaments to compare the yield of alternative approaches to deploying mobile HIV testing services in settings where the prevalence of undetected infection may be characterized by 'hotspots'. We report here on three refinements to our prior assessments and their implications for decision-making. Specifically, (1) enlarging the number of geographic zones; (2) including spatial correlation in the prevalence of undetected infection; and (3) evaluating a prospective search algorithm that accounts for such correlation. METHODS Building on our prior work, we used a simulation model to create a hypothetical city consisting of up to 100 contiguous geographic zones. Each zone was randomly assigned a prevalence of undetected HIV infection. We employed a user-defined weighting scheme to correlate infection levels between adjacent zones. Over 180 days, search algorithms selected a zone in which to conduct a fixed number of HIV tests. Algorithms were permitted to observe the results of their own prior testing activities and to use that information in choosing where to test in subsequent rounds. The algorithms were (1) Thompson sampling (TS), an adaptive Bayesian search strategy; (2) Besag York Mollié (BYM), a Bayesian hierarchical model; and (3) Clairvoyance, a benchmarking strategy with access to perfect information. RESULTS Over 250 tournament runs, BYM detected 65.3% (compared to 55.1% for TS) of the cases identified by Clairvoyance. BYM outperformed TS in all sensitivity analyses, except when there was a small number of zones (i.e., 16 zones in a 4 × 4 grid), wherein there was no significant difference in the yield of the two strategies. Though settings of no, low, medium, and high spatial correlation in the data were examined, differences in these levels did not have a significant effect on the relative performance of BYM versus TS. CONCLUSIONS BYM narrowly outperformed TS in our simulation, suggesting that small improvements in yield can be achieved by accounting for spatial correlation. However, the comparative simplicity with which TS can be implemented makes a field evaluation critical to understanding the practical value of either of these algorithms as an alternative to existing approaches for deploying HIV testing resources.
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Affiliation(s)
- Gregg S. Gonsalves
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, 60 College Street, New Haven, CT USA
| | - J. Tyler Copple
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, 60 College Street, New Haven, CT USA
- Independent Consultant, Yale School of Public Health, 60 College Street, New Haven, CT USA
| | - Tyler Johnson
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, 60 College Street, New Haven, CT USA
| | - A. David Paltiel
- Department of Health Policy and Management, Yale School of Public Health, 60 College Street, New Haven, CT USA
| | - Joshua L. Warren
- Department of Biostatistics, Yale School of Public Health, 60 College Street, New Haven, CT USA
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Cost-effectiveness of health care service delivery interventions in low and middle income countries: a systematic review. Glob Health Res Policy 2018; 3:17. [PMID: 29930989 PMCID: PMC5992822 DOI: 10.1186/s41256-018-0073-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 05/07/2018] [Indexed: 01/17/2023] Open
Abstract
Background Low and middle income countries (LMICs) face severe resource limitations but the highest burden of disease. There is a growing evidence base on effective and cost-effective interventions for these diseases. However, questions remain about the most cost-effective method of delivery for these interventions. We aimed to review the scope, quality, and findings of economic evaluations of service delivery interventions in LMICs. Methods We searched PUBMED, MEDLINE, EconLit, and NHS EED for studies published between 1st January 2000 and 30th October 2016 with no language restrictions. We included all economic evaluations that reported incremental costs and benefits or summary measures of the two such as an incremental cost effectiveness ratio. Studies were grouped by both disease area and outcome measure and permutation plots were completed for similar interventions. Quality was judged by the Drummond checklist. Results Overall, 3818 potentially relevant abstracts were identified of which 101 studies were selected for full text review. Thirty-seven studies were included in the final review. Twenty-three studies reported on interventions we classed as “changing by whom and where care was provided”, specifically interventions that entailed task-shifting from doctors to nurses or community health workers or from facilities into the community. Evidence suggests this type of intervention is likely to be cost-effective or cost-saving. Nine studies reported on quality improvement initiatives, which were generally found to be cost-effective. Quality and methods differed widely limiting comparability of the studies and findings. Conclusions There is significant heterogeneity in the literature, both methodologically and in quality. This renders further comparisons difficult and limits the utility of the available evidence to decision makers.
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de Montigny S, Adamson BJS, Mâsse BR, Garrison LP, Kublin JG, Gilbert PB, Dimitrov DT. Projected effectiveness and added value of HIV vaccination campaigns in South Africa: A modeling study. Sci Rep 2018; 8:6066. [PMID: 29666455 PMCID: PMC5904131 DOI: 10.1038/s41598-018-24268-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 03/26/2018] [Indexed: 01/14/2023] Open
Abstract
Promising multi-dose HIV vaccine regimens are being tested in trials in South Africa. We estimated the potential epidemiological and economic impact of HIV vaccine campaigns compared to continuous vaccination, assuming that vaccine efficacy is transient and dependent on immune response. We used a dynamic economic mathematical model of HIV transmission calibrated to 2012 epidemiological data to simulate vaccination with anticipated antiretroviral treatment scale-up in South Africa. We estimate that biennial vaccination with a 70% efficacious vaccine reaching 20% of the sexually active population could prevent 480,000-650,000 HIV infections (13.8-15.3% of all infections) over 10 years. Assuming a launch price of $15 per dose, vaccination was found to be cost-effective, with an incremental cost-effectiveness ratio of $13,746 per quality-adjusted life-year as compared to no vaccination. Increasing vaccination coverage to 50% will prevent more infections but is less likely to achieve cost-effectiveness. Campaign vaccination is consistently more effective and costs less than continuous vaccination across scenarios. Results suggest that a partially effective HIV vaccine will have substantial impact on the HIV epidemic in South Africa and offer good value if priced less than $105 for a five-dose series. Vaccination campaigns every two years may offer greater value for money than continuous vaccination reaching the same coverage level.
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Affiliation(s)
- Simon de Montigny
- CHU Sainte-Justine Research Centre, Montreal, Canada
- School of Public Health, University of Montreal, Montreal, Canada
| | - Blythe J S Adamson
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Benoît R Mâsse
- CHU Sainte-Justine Research Centre, Montreal, Canada
- School of Public Health, University of Montreal, Montreal, Canada
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Louis P Garrison
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle, WA, USA
| | - James G Kublin
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Peter B Gilbert
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Dobromir T Dimitrov
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, USA.
- Department of Applied Mathematics, University of Washington, Seattle, Washington, USA.
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Cost-effectiveness of HIV screening in high-income countries: A systematic review. Health Policy 2018; 122:533-547. [PMID: 29606287 DOI: 10.1016/j.healthpol.2018.03.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 01/31/2018] [Accepted: 03/09/2018] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Over 2 million people in high-income countries live with HIV. Early diagnosis and treatment present benefits for infected subjects and reduce secondary transmissions. Cost-effectiveness analyses are important to effectively inform policy makers and consequently implement the most cost-effective programmes. Therefore, we conducted a systematic review regarding the cost-effectiveness of HIV screening in high-income countries. METHODS We followed PRISMA statements and included all papers evaluating the cost-effectiveness of HIV screening in the general population or in specific subgroups. RESULTS Thirteen studies considered routine HIV testing in the general population. The most cost-effective option appeared to be associating one-time testing of the general population with annual screening of high-risk groups, such as injecting-drug users. Thirteen studies assessed the cost-effectiveness of HIV screening in specific settings, outlining the attractiveness of similar programmes in emergency departments, primary care, sexually transmitted disease clinics and substance abuse treatment programmes. DISCUSSION Evidence regarding the health benefits and cost-effectiveness of HIV screening is growing, even in low-prevalence countries. One-time screenings offered to the adult population appear to be a valuable choice, associated with repeated testing in high-risk populations. The evidence regarding the benefits of using a rapid test, even in terms of cost-effectiveness, is growing. Finally, HIV screening seems useful in specific settings, such as emergency departments and STD clinics.
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Gonsalves GS, Crawford FW, Cleary PD, Kaplan EH, Paltiel AD. An Adaptive Approach to Locating Mobile HIV Testing Services. Med Decis Making 2018; 38:262-272. [PMID: 28699382 PMCID: PMC5748375 DOI: 10.1177/0272989x17716431] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Public health agencies suggest targeting "hotspots" to identify individuals with undetected HIV infection. However, definitions of hotspots vary. Little is known about how best to target mobile HIV testing resources. METHODS We conducted a computer-based tournament to compare the yield of 4 algorithms for mobile HIV testing. Over 180 rounds of play, the algorithms selected 1 of 3 hypothetical zones, each with unknown prevalence of undiagnosed HIV, in which to conduct a fixed number of HIV tests. The algorithms were: 1) Thompson Sampling, an adaptive Bayesian search strategy; 2) Explore-then-Exploit, a strategy that initially draws comparable samples from all zones and then devotes all remaining rounds of play to HIV testing in whichever zone produced the highest observed yield; 3) Retrospection, a strategy using only base prevalence information; and; 4) Clairvoyance, a benchmarking strategy that employs perfect information about HIV prevalence in each zone. RESULTS Over 250 tournament runs, Thompson Sampling outperformed Explore-then-Exploit 66% of the time, identifying 15% more cases. Thompson Sampling's superiority persisted in a variety of circumstances examined in the sensitivity analysis. Case detection rates using Thompson Sampling were, on average, within 90% of the benchmark established by Clairvoyance. Retrospection was consistently the poorest performer. LIMITATIONS We did not consider either selection bias (i.e., the correlation between infection status and the decision to obtain an HIV test) or the costs of relocation to another zone from one round of play to the next. CONCLUSIONS Adaptive methods like Thompson Sampling for mobile HIV testing are practical and effective, and may have advantages over other commonly used strategies.
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Affiliation(s)
- Gregg S Gonsalves
- Department of the Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA (GSG)
- Yale Law School, New Haven, CT, USA (GSG)
| | - Forrest W Crawford
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA (FWC)
- Department of Ecology & Evolutionary Biology, Yale University, New Haven, CT, USA (FWC)
- Yale School of Management, New Haven, CT, USA (FWC, EHK, ADP)
| | - Paul D Cleary
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA (PDC, EHK, ADP)
| | - Edward H Kaplan
- Yale School of Management, New Haven, CT, USA (FWC, EHK, ADP)
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA (PDC, EHK, ADP)
- School of Engineering & Applied Science, Yale University, New Haven, CT, USA (EHK)
| | - A David Paltiel
- Yale School of Management, New Haven, CT, USA (FWC, EHK, ADP)
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA (PDC, EHK, ADP)
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Meehan SA, Beyers N, Burger R. Cost analysis of two community-based HIV testing service modalities led by a Non-Governmental Organization in Cape Town, South Africa. BMC Health Serv Res 2017; 17:801. [PMID: 29197386 PMCID: PMC5712171 DOI: 10.1186/s12913-017-2760-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 11/23/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In South Africa, the financing and sustainability of HIV services is a priority. Community-based HIV testing services (CB-HTS) play a vital role in diagnosis and linkage to HIV care for those least likely to utilise government health services. With insufficient estimates of the costs associated with CB-HTS provided by NGOs in South Africa, this cost analysis explored the cost to implement and provide services at two NGO-led CB-HTS modalities and calculated the costs associated with realizing key HIV outputs for each CB-HTS modality. METHODS The study took place in a peri-urban area where CB-HTS were provided from a stand-alone centre and mobile service. Using a service provider (NGO) perspective, all inputs were allocated by HTS modality with shared costs apportioned according to client volume or personnel time. We calculated the total cost of each HTS modality and the cost categories (personnel, capital and recurring goods/services) across each HTS modality. Costs were divided into seven pre-determined project components, used to examine cost drivers. HIV outputs were analysed for each HTS modality and the mean cost for each HIV output was calculated per HTS modality. RESULTS The annual cost of the stand-alone and mobile modalities was $96,616 and $77,764 respectively, with personnel costs accounting for 54% of the total costs at the stand-alone. For project components, overheads and service provision made up the majority of the costs. The mean cost per person tested at stand-alone ($51) was higher than at the mobile ($25). Linkage to care cost at the stand-alone ($1039) was lower than the mobile ($2102). CONCLUSIONS This study provides insight into the cost of an NGO led CB-HTS project providing HIV testing and linkage to care through two CB-HIV testing modalities. The study highlights; (1) the importance of including all applicable costs (including overheads) to ensure an accurate cost estimate that is representative of the full service implementation cost, (2) the direct link between test uptake and mean cost per person tested, and (3) the need for effective linkage to care strategies to increase linkage and thereby reduce the mean cost per person linked to HIV care.
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Affiliation(s)
- Sue-Ann Meehan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Ave, Parow, Cape Town, South Africa
| | - Nulda Beyers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Ave, Parow, Cape Town, South Africa
| | - Ronelle Burger
- Department Economics, Stellenbosch University, Cape Town, South Africa
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Eaton JW, Johnson CC, Gregson S. The Cost of Not Retesting: Human Immunodeficiency Virus Misdiagnosis in the Antiretroviral Therapy "Test-and-Offer" Era. Clin Infect Dis 2017; 65:522-525. [PMID: 28444206 PMCID: PMC5850410 DOI: 10.1093/cid/cix341] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 04/20/2017] [Indexed: 11/24/2022] Open
Abstract
We compared estimated costs of retesting human immunodeficiency virus (HIV)-positive persons before antiretroviral therapy (ART) initiation to the costs of ART provision to misdiagnosed HIV-negative persons. Savings from averted unnecessary ART costs were greater than retesting costs within 1 year using assumptions representative of HIV testing performance in programmatic settings. Countries should implement re-testing before ART initiation.
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Affiliation(s)
- Jeffrey W Eaton
- Department of Infectious Disease Epidemiology, Imperial College London, United Kingdom
| | | | - Simon Gregson
- Department of Infectious Disease Epidemiology, Imperial College London, United Kingdom
- Biomedical Research and Training Institute, Harare, Zimbabwe
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Implementation and Operational Research: Cost and Efficiency of a Hybrid Mobile Multidisease Testing Approach With High HIV Testing Coverage in East Africa. J Acquir Immune Defic Syndr 2017; 73:e39-e45. [PMID: 27741031 DOI: 10.1097/qai.0000000000001141] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In 2013-2014, we achieved 89% adult HIV testing coverage using a hybrid testing approach in 32 communities in Uganda and Kenya (SEARCH: NCT01864603). To inform scalability, we sought to determine: (1) overall cost and efficiency of this approach; and (2) costs associated with point-of-care (POC) CD4 testing, multidisease services, and community mobilization. METHODS We applied microcosting methods to estimate costs of population-wide HIV testing in 12 SEARCH trial communities. Main intervention components of the hybrid approach are census, multidisease community health campaigns (CHC), and home-based testing for CHC nonattendees. POC CD4 tests were provided for all HIV-infected participants. Data were extracted from expenditure records, activity registers, staff interviews, and time and motion logs. RESULTS The mean cost per adult tested for HIV was $20.5 (range: $17.1-$32.1) (2014 US$), including a POC CD4 test at $16 per HIV+ person identified. Cost per adult tested for HIV was $13.8 at CHC vs. $31.7 by home-based testing. The cost per HIV+ adult identified was $231 ($87-$1245), with variability due mainly to HIV prevalence among persons tested (ie, HIV positivity rate). The marginal costs of multidisease testing at CHCs were $1.16/person for hypertension and diabetes, and $0.90 for malaria. Community mobilization constituted 15.3% of total costs. CONCLUSIONS The hybrid testing approach achieved very high HIV testing coverage, with POC CD4, at costs similar to previously reported mobile, home-based, or venue-based HIV testing approaches in sub-Saharan Africa. By leveraging HIV infrastructure, multidisease services were offered at low marginal costs.
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Modeling the Cost-Effectiveness of Home-Based HIV Testing and Education (HOPE) for Pregnant Women and Their Male Partners in Nyanza Province, Kenya. J Acquir Immune Defic Syndr 2017; 72 Suppl 2:S174-80. [PMID: 27355506 PMCID: PMC5113236 DOI: 10.1097/qai.0000000000001057] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Supplemental Digital Content is Available in the Text. Introduction: Women in sub-Saharan Africa face a 2-fold higher risk of HIV acquisition during pregnancy and postpartum and the majority do not know the HIV status of their male partner. Home-based couple HIV testing for pregnant women can reduce HIV transmission to women and infants while increasing antiretroviral therapy (ART) coverage in men. However, the cost-effectiveness of this program has not been evaluated. Methods: We modeled the health and economic impact of implementing a home-based partner education and HIV testing (HOPE) intervention for pregnant women and their male partners in a region of Western Kenya (formally Nyanza Province). We used data from the HOPE randomized clinical trial conducted in Kisumu, Kenya, to parameterize a mathematical model of HIV transmission. We conducted an in-country microcosting of the HOPE intervention (payer perspective) to estimate program costs as well as a lower cost scenario of task-shifting to community health workers. Results: The incremental cost of adding the HOPE intervention to standard antenatal care was $31–37 and $14–16 USD per couple tested with program and task-shifting costs, respectively. At 60% coverage of male partners, HOPE was projected to avert 6987 HIV infections and 2603 deaths in Nyanza province over 10 years with an incremental cost-effectiveness ratio (ICER) of $886 and $615 per disability-adjusted life year averted for the program and task-shifting scenario, respectively. ICERs were robust to changes in intervention coverage, effectiveness, and ART initiation and dropout rates. Conclusions: The HOPE intervention can moderately decrease HIV-associated morbidity and mortality by increasing ART coverage in male partners of pregnant women. ICERs fall below Kenya's per capita gross domestic product ($1358) and are therefore considered cost-effective. Task-shifting to community health workers can increase intervention affordability and feasibility.
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Mavegam BO, Pharr JR, Cruz P, Ezeanolue EE. Effective interventions to improve young adults' linkage to HIV care in Sub-Saharan Africa: a systematic review. AIDS Care 2017; 29:1198-1204. [PMID: 28325077 DOI: 10.1080/09540121.2017.1306637] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
HIV/AIDS remains a major public health problem despite the efforts to prevent and decrease its spread. Sub-Saharan Africa (SSA) represents 70% of the global number of people living with HIV and 73% of all HIV/AIDS-related deaths. Young adults age 15-24 years are disproportionately impacted by HIV/AIDS in SSA with 34% of people living with HIV (PLWHIV) and 37% of newly diagnosed individuals being in this age group. It is important that PLWHIV be linked to care to facilitate antiretroviral therapy (ART) initiation and limit the spread of infection. We conducted a systematic literature review to identify effective interventions designed to improve linkage to care among HIV-infected young adults in SSA. One hundred and forty-six titles and abstracts were screened, 28 full-texts were reviewed, and 6 articles met the inclusion and exclusion criteria. Home-based HIV counseling and testing, home-based HIV self-testing, and mobile HIV counseling and testing followed by proper referral of HIV-positive patients to HIV care were effective for improving linkage of young adults to care. Other factors such as referral forms, transportation allowance, home initiation of HIV care, and volunteer escort to the HIV treatment clinic were effective in reducing time to linkage to care. There is a vast need for research and interventions that target HIV-positive young adults in SSA which aim to improve their linkage and access to HIV care. The results of this study illustrate effective interventions in improving linkage to care and reducing time to linkage to care of young adults in SSA.
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Affiliation(s)
| | - Jennifer R Pharr
- a School of Community Health Sciences , University of Nevada , Las Vegas , USA
| | - Patricia Cruz
- a School of Community Health Sciences , University of Nevada , Las Vegas , USA
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Abstract
With HIV funding plateauing and the number of people living with HIV increasing due to the rollout of life-saving antiretroviral therapy, policy makers are faced with increasingly tighter budgets to manage the ongoing HIV epidemic. Cost-effectiveness and modeling analyses can help determine which HIV interventions may be of best value. Incidence remains remarkably high in certain populations and countries, making prevention key to controlling the spread of HIV. This paper briefly reviews concepts in modeling and cost-effectiveness methodology and then examines results of recently published cost-effectiveness analyses on the following HIV prevention strategies: condoms and circumcision, behavioral- or community-based interventions, prevention of mother-to-child transmission, HIV testing, pre-exposure prophylaxis, and treatment as prevention. We find that the majority of published studies demonstrate cost-effectiveness; however, not all interventions are affordable. We urge continued research on combination strategies and methodologies that take into account willingness to pay and budgetary impact.
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Affiliation(s)
- Margo M Jacobsen
- Medical Practice Evaluation Center (RPW, MMJ), Divisions of Infectious Diseases and General Internal Medicine (RPW), Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA, 02114, USA
| | - Rochelle P Walensky
- Medical Practice Evaluation Center (RPW, MMJ), Divisions of Infectious Diseases and General Internal Medicine (RPW), Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA, 02114, USA. .,Division of Infectious Diseases, Brigham and Women's Hospital (RPW), Boston, MA, USA. .,Harvard University Center for AIDS Research (RPW), Harvard Medical School, Boston, MA, USA.
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Gilbert JA, Shenoi SV, Moll AP, Friedland GH, Paltiel AD, Galvani AP. Cost-Effectiveness of Community-Based TB/HIV Screening and Linkage to Care in Rural South Africa. PLoS One 2016; 11:e0165614. [PMID: 27906986 PMCID: PMC5131994 DOI: 10.1371/journal.pone.0165614] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 10/15/2016] [Indexed: 01/08/2023] Open
Abstract
South Africa has one of the highest burdens of TB worldwide, driven by the country's widespread prevalence of HIV, and further complicated by drug resistance. Active case finding within the community, particularly in rural areas where healthcare access is limited, can significantly improve diagnosis and treatment coverage in high-incidence settings. We evaluated the potential health and economic consequences of implementing community-based TB/HIV screening and linkage to care. Using a dynamic model of TB and HIV transmission over a time horizon of 10 years, we compared status quo TB/HIV control to community-based TB/HIV screening at frequencies of once every two years, one year, and six months. We also considered the impact of extending IPT from 36 months for TST positive and 12 months for TST negative or unknown patients (36/12) to lifetime use for all HIV-infected patients. We conducted a probabilistic sensitivity analysis to assess the effect of parameter uncertainty on the cost-effectiveness results. We identified four strategies that saved the most life years for a given outlay: status quo TB/HIV control with 36/12 months of IPT and TB/HIV screening strategies at frequencies of once every two years, one year, and six months with lifetime IPT. All of these strategies were very cost-effective at a threshold of $6,618 per life year saved (the per capita GDP of South Africa). Community-based TB/HIV screening with linkage to care is therefore very cost-effective in rural South Africa.
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Affiliation(s)
- Jennifer A. Gilbert
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
- Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Sheela V. Shenoi
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Anthony P. Moll
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, Connecticut, United States of America
- Church of Scotland Hospital, Tugela Ferry, KwaZulu-Natal, South Africa
| | - Gerald H. Friedland
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - A. David Paltiel
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Alison P. Galvani
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
- Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut, United States of America
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Bigna JJR, Plottel CS, Koulla-Shiro S. Challenges in initiating antiretroviral therapy for all HIV-infected people regardless of CD4 cell count. Infect Dis Poverty 2016; 5:85. [PMID: 27593965 PMCID: PMC5011352 DOI: 10.1186/s40249-016-0179-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 07/29/2016] [Indexed: 11/10/2022] Open
Abstract
Introduction Recently published large randomized controlled trials, START, TEMPRANO and HPTN 052 show the clinical benefit of early initiation of antiretroviral treatment (ART) in HIV-infected persons and in reducing HIV transmission. The trials influenced the World Health Organization (WHO) decision to issue updated recommendations to prescribe ART to all individuals living with HIV, irrespective of age and CD4 cell count. Discussion It is clear that the new 2015 WHO recommendations if followed, will change the face of the HIV epidemic and probably curb its burden over time. Implementation however, requires that health systems, especially those in low and middle-income settings, be ready to face this challenge on a large scale. HIV prevention and treatment are easy in theory yet hard in practice. The new WHO guidelines for initiation of ART regardless of CD4 cell count will lead to upfront increases in the costs of healthcare delivery as the goal is to treat all those now newly eligible for ART. Around 22 million people living with HIV qualify and will therefore require ART. Related challenges immediately follow: firstly, that everyone must be tested for HIV; secondly, that anyone who has had an HIV test should know their result and understand its significance; and, thirdly, that every person identified as HIV-positive should receive and remain on ART. The emergence of HIV drug resistant strains when treatment is started at higher CD4 cell count thresholds is a further concern as persons on HIV treatment for longer periods of time are at increased risk of intermittent medication adherence. Conclusions The new WHO recommendations for ART are welcome, but lacking as they fail to consider meaningful solutions to the challenges inherent to implementation. They fail to incorporate actual strategies on how to disseminate and adopt these far-reaching guidelines, especially in sub-Saharan Africa, an area with weak healthcare infrastructures. Well-designed, high-quality research is needed to assess the feasibility, safety, acceptability, impact, and cost of innovations such as the universal voluntary testing and immediate treatment approaches, and broad consultation must address community, human rights, ethical, and political concerns. Electronic supplementary material The online version of this article (doi:10.1186/s40249-016-0179-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jean Joel R Bigna
- Department of Epidemiology and Public Health, Centre Pasteur of Cameroon, 451, Rue 2005, P.O. Box 1274, Yaounde, Cameroon. .,Bordeaux School of Public Health, University of Bordeaux, Bordeaux, France.
| | - Claudia S Plottel
- Department of Medicine, Division of Translational Medicine, New York University Langone Medical Center, New York, NY, USA
| | - Sinata Koulla-Shiro
- Faculty of Medicine and Biomedical Sciences, University of Yaounde 1, Yaoundé, Cameroon.,Infectious Diseases Unit, Yaounde Central Hospital, Yaounde, Cameroon
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Vojnov L, Markby J, Boeke C, Harris L, Ford N, Peter T. POC CD4 Testing Improves Linkage to HIV Care and Timeliness of ART Initiation in a Public Health Approach: A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0155256. [PMID: 27175484 PMCID: PMC4866695 DOI: 10.1371/journal.pone.0155256] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 04/26/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND CD4 cell count is an important test in HIV programs for baseline risk assessment, monitoring of ART where viral load is not available, and, in many settings, antiretroviral therapy (ART) initiation decisions. However, access to CD4 testing is limited, in part due to the centralized conventional laboratory network. Point of care (POC) CD4 testing has the potential to address some of the challenges of centralized CD4 testing and delays in delivery of timely testing and ART initiation. We conducted a systematic review and meta-analysis to identify the extent to which POC improves linkages to HIV care and timeliness of ART initiation. METHODS We searched two databases and four conference sites between January 2005 and April 2015 for studies reporting test turnaround times, proportion of results returned, and retention associated with the use of point-of-care CD4. Random effects models were used to estimate pooled risk ratios, pooled proportions, and 95% confidence intervals. RESULTS We identified 30 eligible studies, most of which were completed in Africa. Test turnaround times were reduced with the use of POC CD4. The time from HIV diagnosis to CD4 test was reduced from 10.5 days with conventional laboratory-based testing to 0.1 days with POC CD4 testing. Retention along several steps of the treatment initiation cascade was significantly higher with POC CD4 testing, notably from HIV testing to CD4 testing, receipt of results, and pre-CD4 test retention (all p<0.001). Furthermore, retention between CD4 testing and ART initiation increased with POC CD4 testing compared to conventional laboratory-based testing (p = 0.01). We also carried out a non-systematic review of the literature observing that POC CD4 increased the projected life expectancy, was cost-effective, and acceptable. CONCLUSIONS POC CD4 technologies reduce the time and increase patient retention along the testing and treatment cascade compared to conventional laboratory-based testing. POC CD4 is, therefore, a useful tool to perform CD4 testing and expedite result delivery.
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Affiliation(s)
- Lara Vojnov
- Clinton Health Access Initiative, Boston, MA, United States of America
| | | | - Caroline Boeke
- Clinton Health Access Initiative, Boston, MA, United States of America
| | - Lindsay Harris
- Clinton Health Access Initiative, Boston, MA, United States of America
| | - Nathan Ford
- World Health Organization, Geneva, Switzerland
| | - Trevor Peter
- Clinton Health Access Initiative, Boston, MA, United States of America
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Chanda-Kapata P, Kapata N, Klinkenberg E, William N, Mazyanga L, Musukwa K, Kawesha EC, Masiye F, Mwaba P. The adult prevalence of HIV in Zambia: results from a population based mobile testing survey conducted in 2013-2014. AIDS Res Ther 2016; 13:4. [PMID: 26793264 PMCID: PMC4719209 DOI: 10.1186/s12981-015-0088-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 12/30/2015] [Indexed: 11/30/2022] Open
Abstract
Objective To estimate the adult prevalence of HIV among the adult population in Zambia and determine whether demographic characteristics were associated with being HIV positive. Methods A cross sectional population based survey to asses HIV status among participants aged 15 years and above in a national tuberculosis prevalence survey. Counselling was offered to participants who tested for HIV. The prevalence was estimated using a logistic regression model. Univariate and multivariate associations of social demographic characteristics with HIV were determined. Results Of the 46,099 individuals who were eligible to participate in the survey, 44,761 (97.1 %) underwent pre-test counselling for HIV; out of which 30,605 (68.4 %) consented to be tested and 30, 584 (99.9 %) were tested. HIV prevalence was estimated to be 6.6 % (95 % CI 5.8–7.4); with females having a higher prevalence than males 7.7 % (95 % CI 6.8–8.7) versus 5.2 % (95 % CI 4.4–5.9). HIV prevalence was higher among urban (9.8 %; 95 % CI 8.8–10.7) than rural residents (5.0 %; 95 % CI 4.3–5.8). The risk of HIV was double among urban dwellers than among their rural counterparts. Being divorced or widowed was associated with a threefold higher risk of being HIV positive than being never married. The risk of being HIV positive was four times higher among those with tuberculosis than those without tuberculosis. Conclusions HIV prevalence was lower than previously estimated in the country. The burden of HIV showed sociodemographic disparities signifying a need to target key populations or epidemic drivers. Mobile testing for HIV on a national scale in the context of TB prevalence surveys could be explored further in other settings.
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Systematic review and meta-analysis of community and facility-based HIV testing to address linkage to care gaps in sub-Saharan Africa. Nature 2015; 528:S77-85. [PMID: 26633769 DOI: 10.1038/nature16044] [Citation(s) in RCA: 385] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
HIV testing and counselling is the first crucial step for linkage to HIV treatment and prevention. However, despite high HIV burden in sub-Saharan Africa, testing coverage is low, particularly among young adults and men. Community-based HIV testing and counselling (testing outside of health facilities) has the potential to reduce coverage gaps, but the relative impact of different modalities is not well assessed. We conducted a systematic review of HIV testing modalities, characterizing community (home, mobile, index, key populations, campaign, workplace and self-testing) and facility approaches by population reached, HIV positivity, CD4 count at diagnosis and linkage. Of 2,520 abstracts screened, 126 met eligibility criteria. Community HIV testing and counselling had high coverage and uptake and identified HIV-positive people at higher CD4 counts than facility testing. Mobile HIV testing reached the highest proportion of men of all modalities examined (50%, 95% confidence interval (CI) = 47-54%) and home with self-testing reached the highest proportion of young adults (66%, 95% CI = 65-67%). Few studies evaluated HIV testing for key populations (commercial sex workers and men who have sex with men), but these interventions yielded high HIV positivity (38%, 95% CI = 19-62%) combined with the highest proportion of first-time testers (78%, 95% CI = 63-88%), indicating service gaps. Community testing with facilitated linkage (for example, counsellor follow-up to support linkage) achieved high linkage to care (95%, 95% CI = 87-98%) and antiretroviral initiation (75%, 95% CI = 68-82%). Expanding home and mobile testing, self-testing and outreach to key populations with facilitated linkage can increase the proportion of men, young adults and high-risk individuals linked to HIV treatment and prevention, and decrease HIV burden.
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Davids M, Dheda K, Pant Pai N, Cogill D, Pai M, Engel N. A Survey on Use of Rapid Tests and Tuberculosis Diagnostic Practices by Primary Health Care Providers in South Africa: Implications for the Development of New Point-of-Care Tests. PLoS One 2015; 10:e0141453. [PMID: 26509894 PMCID: PMC4624929 DOI: 10.1371/journal.pone.0141453] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 10/08/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Effective infectious disease control requires early diagnosis and treatment initiation. Point-of-care testing offers rapid turn-around-times, facilitating same day clinical management decisions. To maximize the benefits of such POC testing programs, we need to understand how rapid tests are used in everyday clinical practice. METHODS In this cross-sectional survey study, 400 primary healthcare providers in two cities in South Africa were interviewed on their use of rapid tests in general, and tuberculosis diagnostic practices, between September 2012 and June 2013. Public healthcare facilities were selected using probability-sampling techniques and private healthcare providers were randomly selected from the Health Professional Council of South Africa list. To ascertain differences between the two healthcare sectors 2-sample z-tests were used to compare sample proportions. RESULTS The numbers of providers interviewed were equally distributed between the public (n = 200) and private sector (n = 200). The most frequently reported tests in the private sector include blood pressure (99.5%), glucose finger prick (89.5%) and urine dipstick (38.5%); and in the public sector were pregnancy (100%), urine dipstick (100%), blood pressure (100%), glucose finger prick (99%) and HIV rapid test (98%). The majority of TB testing occurs in the public sector, where significantly more providers prefer Xpert MTB/RIF assay, the designated clinical TB diagnostic tool by the national TB program, as compared to the private sector (87% versus 71%, p-value >0.0001). Challenges with regard to TB diagnosis included the long laboratory turn-around-time, difficulty in obtaining sputum samples and lost results. All providers indicated that a new POC test for TB should be rapid and cheap, have good sensitivity and specificity, ease of sample acquisition, detect drug-resistance and work in HIV-infected persons. CONCLUSION/SIGNIFICANCE The existing centralized laboratory services, poor quality assurance, and lack of staff capacity deter the use of more rapid tests at POC. Further research into the practices and choices of these providers is necessary to aid the development of new POC tests.
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Affiliation(s)
- Malika Davids
- Lung Infection and Immunity Unit, Division of pulmonology and UCT lung Institute, Department of Medicine, University of Cape Town, Anzio Road, Cape Town, South Africa
| | - Keertan Dheda
- Lung Infection and Immunity Unit, Division of pulmonology and UCT lung Institute, Department of Medicine, University of Cape Town, Anzio Road, Cape Town, South Africa
| | - Nitika Pant Pai
- Division of Clinical Epidemiology, Department of Medicine, McGill University and McGill University Health Centre, V Building, Royal Victoria Hospital, 687 Pine Avenue West, Montreal, H3A1A1, Canada
| | - Dolphina Cogill
- Lung Infection and Immunity Unit, Division of pulmonology and UCT lung Institute, Department of Medicine, University of Cape Town, Anzio Road, Cape Town, South Africa
| | - Madhukar Pai
- McGill International TB Centre, Department of Epidemiology & Biostatistics, McGill University, 1020 Pine Ave West, Montreal, QC H3A 1A2, Canada
| | - Nora Engel
- Department of Health, Ethics & Society, Research School for Public Health and Primary Care, Maastricht University, Postbus 616, NL - 6200 MD, Maastricht, The Netherlands
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Bassett IV, Regan S, Mbonambi H, Blossom J, Bogan S, Bearnot B, Robine M, Walensky RP, Mhlongo B, Freedberg KA, Thulare H, Losina E. Finding HIV in hard to reach populations: mobile HIV testing and geospatial mapping in Umlazi township, Durban, South Africa. AIDS Behav 2015; 19:1888-95. [PMID: 25874754 PMCID: PMC4531102 DOI: 10.1007/s10461-015-1012-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Mobile, community-based HIV testing may help achieve universal HIV testing in South Africa. We compared the yield, geographic distribution, and demographic characteristics of populations tested by mobile- and clinic-based HIV testing programs deployed by iThembalabantu Clinic in Durban, South Africa. From July to November 2011, 4,701 subjects were tested; HIV prevalence was 35 % among IPHC testers and 10 % among mobile testers (p < 0.001). Mobile testers varied in mean age (22-37 years) and % males (26-67 %). HIV prevalence at mobile sites ranged from 0 to 26 %. Testers traveled further than the clinic closest to their home; mobile testers were more likely to test ≥5 km away from home. Mobile HIV testing can improve testing access and identify testing sites with high HIV prevalence. Individuals often access mobile testing sites farther from home than their nearest clinic. Geospatial techniques can help optimize deployment of mobile units to maximize yield in hard-to-reach populations.
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Affiliation(s)
- Ingrid V Bassett
- Medical Practice Evaluation Center, Massachusetts General Hospital, 50 Staniford Street, Floor 9, Boston, MA, 02114, USA.
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.
- Harvard Center for AIDS Research, Harvard University, Boston, MA, USA.
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Susan Regan
- Medical Practice Evaluation Center, Massachusetts General Hospital, 50 Staniford Street, Floor 9, Boston, MA, 02114, USA
| | - Hlengiwe Mbonambi
- iThembalabantu People's Hope Clinic/AIDS Healthcare Foundation, Durban, South Africa
| | | | - Stacy Bogan
- Harvard Center for Geographic Analysis, Cambridge, MA, USA
| | - Benjamin Bearnot
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Marion Robine
- Medical Practice Evaluation Center, Massachusetts General Hospital, 50 Staniford Street, Floor 9, Boston, MA, 02114, USA
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital, 50 Staniford Street, Floor 9, Boston, MA, 02114, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Harvard Center for AIDS Research, Harvard University, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA
| | - Bright Mhlongo
- iThembalabantu People's Hope Clinic/AIDS Healthcare Foundation, Durban, South Africa
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, 50 Staniford Street, Floor 9, Boston, MA, 02114, USA
- Harvard Center for AIDS Research, Harvard University, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Hilary Thulare
- iThembalabantu People's Hope Clinic/AIDS Healthcare Foundation, Durban, South Africa
| | - Elena Losina
- Medical Practice Evaluation Center, Massachusetts General Hospital, 50 Staniford Street, Floor 9, Boston, MA, 02114, USA
- Harvard Center for AIDS Research, Harvard University, Boston, MA, USA
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
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Cost-effectiveness analysis along the continuum of HIV care: how can we optimize the effect of HIV treatment as prevention programs? Curr HIV/AIDS Rep 2015; 11:468-78. [PMID: 25173799 DOI: 10.1007/s11904-014-0227-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The cascade of HIV care has been proposed as a useful tool to monitor health system performance across the key stages of HIV care delivery to reduce morbidity, mortality, and HIV transmission, the focal points of HIV Treatment as Prevention campaigns. Interventions to improve the cascade at its various stages may vary substantially in their ability to deliver health value per amount expended. In order to meet global antiretroviral treatment access targets, there is an urgent need to maximize the value of health spending by prioritizing cost-effective interventions. We executed a literature review on economic evaluations of interventions to improve specific stages of the cascade of HIV care. In total, 33 articles met the criteria for inclusion in the review, 22 (67 %) of which were published within the last 5 years. Nonetheless, substantial gaps in our knowledge remain, particularly for interventions to improve linkage and retention in HIV care in developed and developing-world settings and generalized and concentrated epidemics. We make the case here that the attention of scientists and policymakers needs to turn to the development, implementation, and rigorous evaluation of interventions to improve the various stages of the cascade of HIV care.
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Abstract
BACKGROUND UNAIDS aims for 90% of HIV-positive individuals to be diagnosed by 2020, but few attempts have been made in developing countries to estimate the fraction of the HIV-positive population that has been diagnosed. METHODS To estimate the rate of HIV diagnosis in South Africa, reported numbers of HIV tests performed in the South African public and private health sectors were aggregated, and estimates of HIV prevalence in individuals tested for HIV were combined. The data were integrated into a mathematical model of the South African HIV epidemic, which was additionally calibrated to estimates of the fraction of the population ever tested for HIV, as reported in three national household surveys. RESULTS The fraction of HIV-positive adults who were undiagnosed declined from more than 80% in the early 2000s to 23.7% [95% confidence interval (95% CI) 23.1-24.3] in 2012. The undiagnosed proportion in 2012 was substantially higher in men (31.9%, 95% CI 29.7-34.3) than in women (19.0%, 95% CI 17.9-19.9). Projected probabilities of experiencing disease progression (CD4 cell count <350 cells/μl) without diagnosis are more than 50% for most HIV-positive adults over the age of 40. The fraction of HIV-positive adults who are undiagnosed is projected to decline to 8.9% by 2020 if current targets (10 million tests per annum) are met. CONCLUSION South Africa has made significant progress in expanding access to HIV testing, and at current testing rates, the target of 90% of HIV-positive adults diagnosed by 2020 is likely to be reached. However, uptake is relatively low in men and older adults.
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An extended cost-effectiveness analysis of publicly financed HPV vaccination to prevent cervical cancer in China. Vaccine 2015; 33:2830-41. [DOI: 10.1016/j.vaccine.2015.02.052] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 02/13/2015] [Accepted: 02/18/2015] [Indexed: 01/31/2023]
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Smith JA, Sharma M, Levin C, Baeten JM, van Rooyen H, Celum C, Hallett TB, Barnabas RV. Cost-effectiveness of community-based strategies to strengthen the continuum of HIV care in rural South Africa: a health economic modelling analysis. Lancet HIV 2015; 2:e159-68. [PMID: 25844394 PMCID: PMC4384819 DOI: 10.1016/s2352-3018(15)00016-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
BACKGROUND Home HIV counselling and testing (HTC) achieves high coverage of testing and linkage to care compared with existing facility-based approaches, particularly among asymptomatic individuals. In a modelling analysis we aimed to assess the effect on population-level health and cost-effectiveness of a community-based package of home HTC in KwaZulu-Natal, South Africa. METHODS We parameterised an individual-based model with data from home HTC and linkage field studies that achieved high coverage (91%) and linkage to antiretroviral therapy (80%) in rural KwaZulu-Natal, South Africa. Costs were derived from a linked microcosting study. The model simulated 10,000 individuals over 10 years and incremental cost-effectiveness ratios were calculated for the intervention relative to the existing status quo of facility-based testing, with costs discounted at 3% annually. FINDINGS The model predicted implementation of home HTC in addition to current practice to decrease HIV-associated morbidity by 10–22% and HIV infections by 9–48% with increasing CD4 cell count thresholds for antiretroviral therapy initiation. Incremental programme costs were US$2·7 million to $4·4 million higher in the intervention scenarios than at baseline, and costs increased with higher CD4 cell count thresholds for antiretroviral therapy initiation; antiretroviral therapy accounted for 48–87% of total costs. Incremental cost-effectiveness ratios per disability-adjusted life-year averted were $1340 at an antiretroviral therapy threshold of CD4 count lower than 200 cells per μL, $1090 at lower than 350 cells per μL, $1150 at lower than 500 cells per μL, and $1360 at universal access to antiretroviral therapy. INTERPRETATION Community-based HTC with enhanced linkage to care can result in increased HIV testing coverage and treatment uptake, decreasing the population burden of HIV-associated morbidity and mortality. The incremental cost-effectiveness ratios are less than 20% of South Africa's gross domestic product per person, and are therefore classed as very cost effective. Home HTC can be a viable means to achieve UNAIDS' ambitious new targets for HIV treatment coverage. FUNDING National Institutes of Health, Bill & Melinda Gates Foundation, Wellcome Trust.
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Affiliation(s)
- Jennifer A Smith
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Monisha Sharma
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Carol Levin
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Jared M Baeten
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Heidi van Rooyen
- HIV/AIDS, STIs and TB, Human Sciences Research Council, Sweetwaters, KwaZulu-Natal, South Africa
| | - Connie Celum
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Timothy B Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Ruanne V Barnabas
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Correspondence to: Dr Ruanne V Barnabas, International Clinical Research Center (ICRC), Department of Global Health, University of Washington, UW Box 359927, Seattle, WA 98104, USA
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45
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Linas BP. Potential Impact and Cost-effectiveness of Self-Testing for HIV in Low-Income Countries. J Infect Dis 2015; 212:513-5. [PMID: 25767215 DOI: 10.1093/infdis/jiv041] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 01/21/2015] [Indexed: 11/12/2022] Open
Affiliation(s)
- Benjamin P Linas
- Boston Medical Center, Boston University Schools of Medicine and Public Health, Massachusetts
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The clinical and economic impact of point-of-care CD4 testing in mozambique and other resource-limited settings: a cost-effectiveness analysis. PLoS Med 2014; 11:e1001725. [PMID: 25225800 PMCID: PMC4165752 DOI: 10.1371/journal.pmed.1001725] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 07/30/2014] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Point-of-care CD4 tests at HIV diagnosis could improve linkage to care in resource-limited settings. Our objective is to evaluate the clinical and economic impact of point-of-care CD4 tests compared to laboratory-based tests in Mozambique. METHODS AND FINDINGS We use a validated model of HIV testing, linkage, and treatment (CEPAC-International) to examine two strategies of immunological staging in Mozambique: (1) laboratory-based CD4 testing (LAB-CD4) and (2) point-of-care CD4 testing (POC-CD4). Model outcomes include 5-y survival, life expectancy, lifetime costs, and incremental cost-effectiveness ratios (ICERs). Input parameters include linkage to care (LAB-CD4, 34%; POC-CD4, 61%), probability of correctly detecting antiretroviral therapy (ART) eligibility (sensitivity: LAB-CD4, 100%; POC-CD4, 90%) or ART ineligibility (specificity: LAB-CD4, 100%; POC-CD4, 85%), and test cost (LAB-CD4, US$10; POC-CD4, US$24). In sensitivity analyses, we vary POC-CD4-specific parameters, as well as cohort and setting parameters to reflect a range of scenarios in sub-Saharan Africa. We consider ICERs less than three times the per capita gross domestic product in Mozambique (US$570) to be cost-effective, and ICERs less than one times the per capita gross domestic product in Mozambique to be very cost-effective. Projected 5-y survival in HIV-infected persons with LAB-CD4 is 60.9% (95% CI, 60.9%-61.0%), increasing to 65.0% (95% CI, 64.9%-65.1%) with POC-CD4. Discounted life expectancy and per person lifetime costs with LAB-CD4 are 9.6 y (95% CI, 9.6-9.6 y) and US$2,440 (95% CI, US$2,440-US$2,450) and increase with POC-CD4 to 10.3 y (95% CI, 10.3-10.3 y) and US$2,800 (95% CI, US$2,790-US$2,800); the ICER of POC-CD4 compared to LAB-CD4 is US$500/year of life saved (YLS) (95% CI, US$480-US$520/YLS). POC-CD4 improves clinical outcomes and remains near the very cost-effective threshold in sensitivity analyses, even if point-of-care CD4 tests have lower sensitivity/specificity and higher cost than published values. In other resource-limited settings with fewer opportunities to access care, POC-CD4 has a greater impact on clinical outcomes and remains cost-effective compared to LAB-CD4. Limitations of the analysis include the uncertainty around input parameters, which is examined in sensitivity analyses. The potential added benefits due to decreased transmission are excluded; their inclusion would likely further increase the value of POC-CD4 compared to LAB-CD4. CONCLUSIONS POC-CD4 at the time of HIV diagnosis could improve survival and be cost-effective compared to LAB-CD4 in Mozambique, if it improves linkage to care. POC-CD4 could have the greatest impact on mortality in settings where resources for HIV testing and linkage are most limited. Please see later in the article for the Editors' Summary.
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47
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Mabuto T, Latka MH, Kuwane B, Churchyard GJ, Charalambous S, Hoffmann CJ. Four models of HIV counseling and testing: utilization and test results in South Africa. PLoS One 2014; 9:e102267. [PMID: 25013938 PMCID: PMC4094499 DOI: 10.1371/journal.pone.0102267] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Accepted: 06/17/2014] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND HIV Counseling and Testing (HCT) is the point-of-entry for pathways of HIV care and prevention. However, HCT is not reaching many who are HIV infected and this may be related to the HCT provision model. We describe HCT utilization and HIV diagnosis using four models of HCT delivery: clinic-based, urban mobile, rural mobile, and stand-alone. METHODS Using cross-sectional data from routine HCT provided in South Africa, we described client characteristics and HIV test results from information collected during service delivery between January 2009 and June 2012. RESULTS 118,358 clients received services at clinic-based units, 18,597; stand-alone, 28,937; urban mobile, 38,840; and rural mobile, 31,984. By unit, clients were similar in terms of median age (range 28-31), but differed in sex distribution, employment status, prior testing, and perceived HIV risk. Urban mobile units had the highest proportion of male clients (52%). Rural mobile units reached the highest proportion of clients with no prior HCT (61%) and reporting no perceived HIV risk (64%). Overall, 10,862 clients (9.3%) tested HIV-positive. CONCLUSIONS Client characteristics varied by HCT model. Importantly, rural and urban mobile units reached more men, first-time testers, and clients who considered themselves to be at low risk for HIV.
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Affiliation(s)
| | - Mary H. Latka
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Gavin J. Churchyard
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Christopher J. Hoffmann
- The Aurum Institute, Johannesburg, South Africa
- Division of Infectious Diseases, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
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