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Endalamaw A, Gilks CF, Assefa Y. Socioeconomic inequality in adults undertaking HIV testing over time in Ethiopia based on data from demographic and health surveys. PLoS One 2024; 19:e0296869. [PMID: 38354195 PMCID: PMC10866500 DOI: 10.1371/journal.pone.0296869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/20/2023] [Indexed: 02/16/2024] Open
Abstract
INTRODUCTION HIV testing is the entry point to HIV prevention, care and treatment and needs continuous evaluation to understand whether all social groups have accessed services equally. Addressing disparities in HIV testing between social groups results in effective and efficient response against HIV prevention. Despite these benefits, there was no previous study on inequality and determinants over time in Ethiopia. Thus, the objective of this research was to examine socioeconomic inequality in individuals undertaking HIV testing over time, allowing for the identification of persistent and emerging determinants. METHODS Data sources for the current study were the 2011 and 2016 Ethiopian Demographic Health Surveys. The 2016 population health survey is the one that Ethiopia used to set national AIDS response strategies; there was no other recent survey with HIV/AIDS-related indicators in Ethiopia. The final sample size for the current study was 28,478 for the year 2011 and 25,542 for the year 2016. The concentration curve and Erreygers' concentration index were used to estimate socioeconomic inequality in HIV testing. Subsequently, decomposition analysis was performed to identify persistent and emerging contributors of socioeconomic inequality. Generalized linear regression model with the logit link function was employed to estimate the marginal effect, elasticity, Erreygers' concentration index (ECI), and absolute and percentage contributions of each covariate. RESULTS The concentration curve was below the line of equality over time, revealing the pro-rich inequality in HIV testing. The inequality was observed in both 2011 (ECI = 0.200) and 2016 (ECI = 0.213). A household wealth rank had the highest percentage contribution (49.2%) for inequality in HIV testing in 2011, which increased to 61.1% in 2016. Additional markers include listening to the radio (13.4% in 2011 and 12.1% in 2016), education status (8.1% in 2011 and 6.8% in 2016), and resident (-2.0% in 2011 and 6.3% in 2016). Persistent determinants of individuals undertaking HIV testing were age 20-34 years, geographic region, education status, marital status, religion, income, media exposure (listening to the radio, reading newspaper, watching television), knowledge about HIV/AIDS, and attitudes towards people living with HIV. Age between 35 and 44 years and urban residence emerged as new associated factors in 2016. CONCLUSIONS The higher HIV testing coverage was among individuals with higher socioeconomic status in Ethiopia. Socioeconomic inequality amongst individuals undertaking HIV testing was diverging over time. Household wealth rank, mass media exposure, education status, and resident took the largest share in explaining the disparity in individuals undertaking HIV testing between the lower and higher income groups. Therefore, interventions to equalise HIV testing coverage should take account of these determinants.
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Affiliation(s)
- Aklilu Endalamaw
- School of Public Health, The University of Queensland, Brisbane, Australia
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Charles F. Gilks
- School of Public Health, The University of Queensland, Brisbane, Australia
| | - Yibeltal Assefa
- School of Public Health, The University of Queensland, Brisbane, Australia
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De Anda JA, Irvine MA, Zhang W, Salway T, Haag D, Gilbert M. Cost-effectiveness of internet-based HIV screening among gay, bisexual and other men who have sex with men (GBMSM) in Metro Vancouver, Canada. PLoS One 2023; 18:e0294628. [PMID: 38011230 PMCID: PMC10681302 DOI: 10.1371/journal.pone.0294628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 11/06/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND GetCheckedOnline is an internet-based screening service aiming to increase HIV testing among gay, bisexual and other men who have sex with men (GBMSM). We assessed the cost-effectiveness of GetCheckedOnline in its first implementation phase at different uptake scenarios compared to clinic-based screening services alone in Metro Vancouver, Canada. METHODS From a healthcare payer's perspective, our cost-utility analysis used an established dynamic GBMSM HIV compartmental model estimating the probability of acquiring HIV, progressing through diagnosis, disease stages and treatment over a 30-year time horizon. The base case scenario assumed 4.7% uptake of GetCheckedOnline in 2016 (remainder using clinic-based services), with 74% of high-risk and 44% of low-risk infrequent testers becoming regular testers in five years. Scenario analyses tested increased GetCheckedOnline uptake to 10% and 15%. RESULTS The cost per test for GetCheckedOnline was $29.40 compared to clinic-based services $56.92. Compared with clinic-based screening services, the projected increase in testing frequency with 4.7% uptake of GetCheckedOnline increased the costs by $329,600 (95% Credible Interval: -$498,200, $571,000) and gained 4.53 (95%CrI: 0, 9.20) quality-adjusted life years (QALYs) in a 30-year time horizon. The probability of GetCheckedOnline being cost-effective was 34% at the threshold of $50,000 per QALY, and increased to 73% at the threshold of $100,000 per QALY. The results were consistent in the other uptake scenarios. The probability of GetCheckedOnline being cost-effective became 80% at the threshold of $50,000 per QALY if assuming 5-year time horizon. CONCLUSIONS GetCheckedOnline is almost half the cost of clinic-based services on a per-test basis. However, increased access to testing should be balanced with risk profiles of patients to ensure the implementation can be a cost-effective strategy for increasing HIV screening among GBMSM in Metro Vancouver. Additional analyses are needed to understand the impact of internet-based screening including screening for other STIs and in other populations.
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Affiliation(s)
- Jose A. De Anda
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael A. Irvine
- Institute of Applied Mathematics, University of British Columbia, Vancouver, British Columbia, Canada
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Wei Zhang
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Advancing Health Outcomes, Vancouver, British Columbia, Canada
| | - Travis Salway
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- Centre for Gender and Sexual Health Equity, Vancouver, British Columbia, Canada
| | - Devon Haag
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Mark Gilbert
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
- Centre for Gender and Sexual Health Equity, Vancouver, British Columbia, Canada
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Jin H, Tappenden P, Ling X, Robinson S, Byford S. A systematic review of whole disease models for informing healthcare resource allocation decisions. PLoS One 2023; 18:e0291366. [PMID: 37708188 PMCID: PMC10501624 DOI: 10.1371/journal.pone.0291366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 08/28/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Whole disease models (WDM) are large-scale, system-level models which can evaluate multiple decision questions across an entire care pathway. Whilst this type of model can offer several advantages as a platform for undertaking economic analyses, the availability and quality of existing WDMs is unknown. OBJECTIVES This systematic review aimed to identify existing WDMs to explore which disease areas they cover, to critically assess the quality of these models and provide recommendations for future research. METHODS An electronic search was performed on multiple databases (MEDLINE, EMBASE, the NHS Economic Evaluation Database and the Health Technology Assessment database) on 23rd July 2023. Two independent reviewers selected studies for inclusion. Study quality was assessed using the National Institute for Health and Care Excellence (NICE) appraisal checklist for economic evaluations. Model characteristics were descriptively summarised. RESULTS Forty-four WDMs were identified, of which thirty-two were developed after 2010. The main disease areas covered by existing WDMs are heart disease, cancer, acquired immune deficiency syndrome and metabolic disease. The quality of included WDMs is generally low. Common limitations included failure to consider the harms and costs of adverse events (AEs) of interventions, lack of probabilistic sensitivity analysis (PSA) and poor reporting. CONCLUSIONS There has been an increase in the number of WDMs since 2010. However, their quality is generally low which means they may require significant modification before they could be re-used, such as modelling AEs of interventions and incorporation of PSA. Sufficient details of the WDMs need to be reported to allow future reuse/adaptation.
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Affiliation(s)
- Huajie Jin
- King’s Health Economics (KHE), Institute of Psychiatry, Psychology & Neuroscience at King’s College London, London, United Kingdom
| | - Paul Tappenden
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Xiaoxiao Ling
- Department of Statistical Science, University College London, London, United Kingdom
| | | | - Sarah Byford
- King’s Health Economics (KHE), Institute of Psychiatry, Psychology & Neuroscience at King’s College London, London, United Kingdom
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Mital S, Kelly D, Hughes C, Nosyk B, Thavorn K, Nguyen HV. Estimated cost-effectiveness of point-of-care testing in community pharmacies vs. self-testing and standard laboratory testing for HIV. AIDS 2023; 37:1125-1135. [PMID: 36928760 DOI: 10.1097/qad.0000000000003526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
OBJECTIVE Point-of-care-testing (POCT) for HIV at community pharmacies can enhance care linkage compared with self-tests and increase testing uptake relative to standard lab testing. While the higher test uptake may increase testing costs, timely diagnosis and treatment can reduce downstream HIV treatment costs and improve health outcomes. This study provides the first evidence on the cost-effectiveness of pharmacist-led POCT vs. HIV self-testing and standard lab testing. DESIGN Dynamic transmission model. METHODS We compared three HIV testing strategies: POCT at community pharmacies; self-testing using HIV self-test kits; and standard lab testing. Analyses were conducted from the Canadian health system perspective over a 30-year time horizon for all individuals aged 15-64 years in Canada. Costs were measured in 2021 Canadian dollars and effectiveness was captured using quality-adjusted life-years (QALYs). RESULTS Compared with standard lab testing, POCT at community pharmacies would save $885 million in testing costs over 30 years. Though antiretroviral treatment costs would increase by $190 million with POCT as more persons living with HIV are identified and treated, these additional costs would be partly offset by their lower downstream healthcare utilization (savings of $150 million). POCT at community pharmacies would also yield over 5000 additional QALYs. Compared with HIV self-testing, POCT at community pharmacies would generate both higher costs and higher QALYs and would be cost-effective with an incremental cost-effectiveness ratio of $47 475 per QALY gained. CONCLUSIONS Offering POCT at community pharmacies can generate substantial cost savings and improve health outcomes compared with standard lab testing. It would also be cost-effective vs. HIV self-testing.
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Affiliation(s)
- Shweta Mital
- College of Pharmacy, University of Manitoba, Winnipeg
| | - Deborah Kelly
- School of Pharmacy, Memorial University of Newfoundland, St. John's
| | - Christine Hughes
- Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta, Edmonton
| | - Bohdan Nosyk
- Faculty of Health Sciences, Simon Fraser University, Burnaby
| | | | - Hai V Nguyen
- School of Pharmacy, Memorial University of Newfoundland, St. John's
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Serag H, Clark I, Naig C, Lakey D, Tiruneh YM. Financing Benefits and Barriers to Routine HIV Screening in Clinical Settings in the United States: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:457. [PMID: 36612775 PMCID: PMC9819288 DOI: 10.3390/ijerph20010457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/16/2022] [Accepted: 12/21/2022] [Indexed: 06/17/2023]
Abstract
The Centers for Disease Control and Prevention recommends everyone between 13-64 years be tested for HIV at least once as a routine procedure. Routine HIV screening is reimbursable by Medicare, Medicaid, expanded Medicaid, and most commercial insurance plans. Yet, scaling-up HIV routine screening remains a challenge. We conducted a scoping review for studies on financial benefits and barriers associated with HIV screening in clinical settings in the U.S. to inform an evidence-based strategy to scale-up routine HIV screening. We searched Ovid MEDLINE®, Cochrane, and Scopus for studies published between 2006-2020 in English. The search identified 383 Citations; we screened 220 and excluded 163 (outside the time limit, irrelevant, or outside the U.S.). Of the 220 screened articles, we included 35 and disqualified 155 (did not meet the eligibility criteria). We organized eligible articles under two themes: financial benefits/barriers of routine HIV screening in healthcare settings (9 articles); and Cost-effectiveness of routine screening in healthcare settings (26 articles). The review concluded drawing recommendations in three areas: (1) Finance: Incentivize healthcare providers/systems for implementing HIV routine screening and/or separate its reimbursement from bundle payments; (2) Personnel: Encourage nurse-initiated HIV screening programs in primary care settings and educate providers on CDC recommendations; and (3) Approach: Use opt-out approach.
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Affiliation(s)
- Hani Serag
- Department of International Medicine, School of Medicine, University of Texas Medical Branch (UTMB), Galveston, TX 77555, USA
| | - Isabel Clark
- HIV/STD Prevention & Care Unit, Texas Department of State Health Services, Austin, TX 78714, USA
| | - Cherith Naig
- MPH Program, School of Public and Population Health, University of Texas Medical Branch (UTMB), Galveston, TX 77555, USA
| | - David Lakey
- Administration Division, University of Texas System, Austin, TX 78701, USA
| | - Yordanos M. Tiruneh
- Department of Preventive Medicine and Population Health, School of Medicine, University of Texas Tyler, Tyler, TX 75799, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
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The Cost-Effectiveness of HIV/STI Prevention in High-Income Countries with Concentrated Epidemic Settings: A Scoping Review. AIDS Behav 2022; 26:2279-2298. [PMID: 35034238 PMCID: PMC9163023 DOI: 10.1007/s10461-022-03583-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2022] [Indexed: 11/27/2022]
Abstract
The purpose of this scoping review is to establish the state of the art on economic evaluations in the field of HIV/STI prevention in high-income countries with concentrated epidemic settings and to assess what we know about the cost-effectiveness of different measures. We reviewed economic evaluations of HIV/STI prevention measures published in the Web of Science and Cost-Effectiveness Registry databases. We included a total of 157 studies focusing on structural, behavioural, and biomedical interventions, covering a variety of contexts, target populations and approaches. The majority of studies are based on mathematical modelling and demonstrate that the preventive measures under scrutiny are cost-effective. Interventions targeted at high-risk populations yield the most favourable results. The generalisability and transferability of the study results are limited due to the heterogeneity of the populations, settings and methods involved. Furthermore, the results depend heavily on modelling assumptions. Since evidence is unequally distributed, we discuss implications for future research.
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Barry M, Ghonem L, Albeeshi N, Alrabiah M, Alsharidi A, Al-Omar HA. Resource Utilization and Caring Cost of People Living with Human Immunodeficiency Virus (PLHIV) in Saudi Arabia: A Tertiary Care University Hospital Experience. Healthcare (Basel) 2022; 10:118. [PMID: 35052282 PMCID: PMC8776132 DOI: 10.3390/healthcare10010118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/02/2022] [Accepted: 01/04/2022] [Indexed: 11/24/2022] Open
Abstract
The human immunodeficiency virus (HIV) is associated with a significant burden of disease, including medical and non-medical costs. Therefore, it is considered to be a priority for all health authorities. The aim of this study is to determine healthcare and treatment costs of caring for PLHIV at one of the tertiary care university hospitals in Riyadh, Saudi Arabia. This was a micro-costing, retrospective, observational study from a tertiary care university hospital and included all confirmed HIV-infected patients who visited infectious disease clinics in the period from 1 January 2015 to 31 December 2018. A total of 42 PLHIV were included in this study. The mean age of the study participants was 38.76 ± 11.47 years with a mean disease duration of 5.27 ± 4.81 years. The majority of patients were male (85.7%) and Saudi (88.1%). More than half of included patients (59.5%) had a CD4 count of more than 500. During the study period, 26 patients (61.9%) were initiated on a single-tablet regimen. Overall, the main cost-driver was antiretroviral medications, which cumulatively represented more than 64% of the total cost. Patients who developed opportunistic infections had a statistically significant (p = 0.033) higher financial impact, both as a total and on a patient level, than those presented without opportunistic infections. On a patient level, the mean and median costs were higher and statistically significant for those with co-morbidities than those without co-morbidities (p = 0.002). The majority of the economic burden of PLHIV is attributable to antiretroviral therapy use. The healthcare costs of PLHIV can vary greatly, depending on the presenting illness, clinical stage, developed opportunistic infection, co-morbidity, and pharmacological therapy.
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Affiliation(s)
- Mazin Barry
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, King Saud University and King Saud University Medical City, Riyadh 11451, Saudi Arabia; (M.B.); (A.A.)
| | - Leen Ghonem
- Department of Pharmacy, King Saud University Medical City, Riyadh 12372, Saudi Arabia;
| | - Nourah Albeeshi
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia;
| | - Maha Alrabiah
- Department of Internal Medicine, College of Medicine, King Saud University and King Saud University Medical City, Riyadh 12372, Saudi Arabia;
| | - Aynaa Alsharidi
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, King Saud University and King Saud University Medical City, Riyadh 11451, Saudi Arabia; (M.B.); (A.A.)
| | - Hussain Abdulrahman Al-Omar
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia
- Health Technology Assessment Unit, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia
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Avau B, Van Remoortel H, Laermans J, Bekkering G, Fergusson D, Georgsen J, Manzini PM, Ozier Y, De Buck E, Compernolle V, Vandekerckhove P. Lack of Cost-Effectiveness of Preoperative Erythropoiesis-Stimulating Agents and/or Iron Therapy in Anaemic, Elective Surgery Patients: A Systematic Review and Updated Analysis. PHARMACOECONOMICS 2021; 39:1123-1139. [PMID: 34235646 PMCID: PMC8476458 DOI: 10.1007/s40273-021-01044-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES For anaemic elective surgery patients, current clinical practice guidelines weakly recommend the routine use of iron, but not erythrocyte-stimulating agents (ESAs), except for short-acting ESAs in major orthopaedic surgery. This recommendation is, however, not based on any cost-effectiveness studies. The aim of this research was to (1) systematically review the literature regarding cost effectiveness of preoperative iron and/or ESAs in anaemic, elective surgery patients and (2) update existing economic evaluations (EEs) with recent data. METHODS Eight databases and registries were searched for EEs and randomized controlled trials (RCTs) reporting cost-effectiveness data on November 11, 2020. Data were extracted, narratively synthesized and critically appraised using the Philips reporting checklist. Pre-existing full EEs were updated with effectiveness data from a recent systematic review and current cost data. Incremental cost-effectiveness ratios were expressed as cost per (quality-adjusted) life-year [(QA)LY] gained. RESULTS Only five studies (4 EEs and 1 RCT) were included, one on intravenous iron and four on ESAs + oral iron. The EE on intravenous iron only had an in-hospital time horizon. Therefore, cost effectiveness of preoperative iron remains uncertain. The three EEs on ESAs had a lifetime time horizon, but reported cost per (QA)LY gained of 20-65 million (GBP or CAD). Updating these analyses with current data confirmed ESAs to have a cost per (QA)LY gained of 3.5-120 million (GBP or CAD). CONCLUSIONS Cost effectiveness of preoperative iron is unproven, whereas routine preoperative ESA therapy cannot be considered cost effective in elective surgery, based on the limited available data. Future guidelines should reflect these findings.
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Affiliation(s)
- Bert Avau
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, 2800, Mechelen, Belgium.
| | - Hans Van Remoortel
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, 2800, Mechelen, Belgium
| | - Jorien Laermans
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, 2800, Mechelen, Belgium
| | - Geertruida Bekkering
- Center for Evidence-Based Medicine, Leuven, Belgium
- Cochrane Belgium, Leuven, Belgium
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
- Canadian Blood Services, Ottawa, Canada
| | - Jørgen Georgsen
- South Danish Transfusion Service, Odense University Hospital, Odense, Denmark
| | - Paola Maria Manzini
- SC Banca del Sangue Servizio di Immunoematologia, University Hospital Città della Salute e della Scienza di Torino, Torino, Italy
| | - Yves Ozier
- University Hospital of Brest, Brest, France
| | - Emmy De Buck
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, 2800, Mechelen, Belgium
- Department of Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Veerle Compernolle
- Blood Services, Belgian Red Cross, Mechelen, Belgium
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Philippe Vandekerckhove
- Department of Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Belgian Red Cross, Mechelen, Belgium
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Leibowitz A, Tan D. Informing California's Plan to Enhance HIV Screening in the Ending the HIV Epidemic Initiative. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2021; 33:377-394. [PMID: 34596426 PMCID: PMC9997719 DOI: 10.1521/aeap.2021.33.5.377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The CDC recommends that everyone have at least one HIV test in their lifetime. However, analyses of California Health Interview Survey data showed that in 2017 only half of Californians had ever received an HIV test. Non-Hispanic Black (64.8%) and Hispanic adults (54.7%) had higher lifetime testing rates than non-Hispanic White adults (48.8%). In multivariable analyses non-Hispanic African American adults had twice and Hispanic adults 1.2 times the odds of lifetime HIV testing as non-Hispanic White adults. The CDC recommends annual HIV testing for higher-risk individuals. Independent of race/ethnicity, heterosexual men with multiple sex partners had lower annual testing rates than other high-risk individuals. Annual testing was unrelated to education level and poverty, but was related to number of doctor visits. HIV screening rates among heterosexual men with multiple partners could be increased by targeting HIV screening to non-medical settings in California's eight Ending the HIV Epidemic counties.
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Affiliation(s)
- Arleen Leibowitz
- Department of Public Policy, Luskin School of Public Affairs, University of California Los Angeles
| | - Diane Tan
- Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles
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Malloy GSP, Goldhaber-Fiebert JD, Enns EA, Brandeau ML. Predicting the Effectiveness of Endemic Infectious Disease Control Interventions: The Impact of Mass Action versus Network Model Structure. Med Decis Making 2021; 41:623-640. [PMID: 33899563 PMCID: PMC8295189 DOI: 10.1177/0272989x211006025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Analyses of the effectiveness of infectious disease control interventions often rely on dynamic transmission models to simulate intervention effects. We aim to understand how the choice of network or compartmental model can influence estimates of intervention effectiveness in the short and long term for an endemic disease with susceptible and infected states in which infection, once contracted, is lifelong. METHODS We consider 4 disease models with different permutations of socially connected network versus unstructured contact (mass-action mixing) model and heterogeneous versus homogeneous disease risk. The models have susceptible and infected populations calibrated to the same long-term equilibrium disease prevalence. We consider a simple intervention with varying levels of coverage and efficacy that reduces transmission probabilities. We measure the rate of prevalence decline over the first 365 d after the intervention, long-term equilibrium prevalence, and long-term effective reproduction ratio at equilibrium. RESULTS Prevalence declined up to 10% faster in homogeneous risk models than heterogeneous risk models. When the disease was not eradicated, the long-term equilibrium disease prevalence was higher in mass-action mixing models than in network models by 40% or more. This difference in long-term equilibrium prevalence between network versus mass-action mixing models was greater than that of heterogeneous versus homogeneous risk models (less than 30%); network models tended to have higher effective reproduction ratios than mass-action mixing models for given combinations of intervention coverage and efficacy. CONCLUSIONS For interventions with high efficacy and coverage, mass-action mixing models could provide a sufficient estimate of effectiveness, whereas for interventions with low efficacy and coverage, or interventions in which outcomes are measured over short time horizons, predictions from network and mass-action models diverge, highlighting the importance of sensitivity analyses on model structure. HIGHLIGHTS • We calibrate 4 models-socially connected network versus unstructured contact (mass-action mixing) model and heterogeneous versus homogeneous disease risk-to 10% preintervention disease prevalence.• We measure the short- and long-term intervention effectiveness of all models using the rate of prevalence decline, long-term equilibrium disease prevalence, and effective reproduction ratio.• Generally, in the short term, prevalence declined faster in the homogeneous risk models than in the heterogeneous risk models.• Generally, in the long term, equilibrium disease prevalence was higher in the mass-action mixing models than in the network models, and the effective reproduction ratio was higher in network models than in the mass-action mixing models.
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Affiliation(s)
- Giovanni S P Malloy
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
| | - Jeremy D Goldhaber-Fiebert
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA
| | - Eva A Enns
- School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Margaret L Brandeau
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
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Xie T, Yan H, Wang G. Translation and Validation: Chinese Version of the HIV-Related Social Support Scale. Int J Gen Med 2021; 14:4025-4030. [PMID: 34349552 PMCID: PMC8326224 DOI: 10.2147/ijgm.s318766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/16/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Social support is increasingly recognized to be important in care of people living with HIV/AIDS (PLWH), we firstly translate and validate the disease-targeted social support instrument in Chinese and to explore the correlation with WHOQOL-HIV. Patients and Methods We established content validity for HIV-related social support scale (HSSS) and administered the resultant questionnaire to 310 PLWH. Descriptive statistics were generated for each of the variables of general characteristics; student t-test was used to compare the different groups. Results The HSSS demonstrated a high level of internal consistency, both within each subscale and with the total score; all Cronbach’s α values exceeded a priori threshold of ≥0.70. The HSSS cores were positively correlated with WHOQOL-HIV total scores (Pearson correlation: 0.39, P < 0.001). We also found that higher educational level, personal income, CD4 cell count, and shorter duration of antiretroviral therapy are significantly associated with a higher level of social support (P < 0.05). Conclusion Social support may improve quality of life for PLWH, Chinese version of HIV-related social support scale can be used in future clinical practice.
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Affiliation(s)
- Tiansheng Xie
- Zhejiang Sino-German Institute of Life science and Healthcare, School of Biological and Chemical Engineering, Zhejiang University of Science and Technology, Hangzhou, Zhejiang, 310023, People's Republic of China.,State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital of Zhejiang University, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310003, People's Republic of China
| | - Haibo Yan
- Center for Disease Prevention and Control, Shaoxing, 312030, People's Republic of China
| | - Guohua Wang
- Center for Disease Prevention and Control, Jiaxing, 314500, People's Republic of China
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Wu H, Yu Q, Ma L, Zhang L, Chen Y, Guo P, Xu P. Health economics modeling of antiretroviral interventions amongst HIV serodiscordant couples. Sci Rep 2021; 11:13967. [PMID: 34234232 PMCID: PMC8263699 DOI: 10.1038/s41598-021-93443-x] [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: 08/24/2020] [Accepted: 06/21/2021] [Indexed: 02/05/2023] Open
Abstract
Antiretroviral treatment (ART) and pre-exposure prophylaxis (PrEP) for HIV-serodiscordant couples, effectively reduce mortality, transmission events and influence quality of life at the expense of increased costs. We aimed to evaluate health economics of antiretroviral-based strategies for HIV-serodiscordant couples in the China context. A deterministic model of HIV evolution and transmission within a cohort of serodiscordant couples was parameterized using the real-world database of Zhoukou city and published literature. We evaluated the mid-ART (a historical strategy, initiating ART with CD4 < 500 cells/mm3), early-ART (the current strategy, offering ART regardless of CD4 cell counts) and a hypothetical strategy (early-ART combined short-term daily PrEP) versus the late-ART (the baseline strategy, initiating ART with CD4 < 350 cells/mm3) offered by 2008 national guidelines. We estimated the incremental cost-effectiveness ratios (ICER) and incremental cost-utility ratios (ICUR) from a societal perspective, derived by clinical benefits and HIV-caused life quality respectively, and portrayed their changes over a 0-30 year's timeframe. The model projections indicated that the antiretroviral-based interventions were more likely to obtain clinical benefits but difficult to improve quality of life, and cumulative ICER and ICUR were generally decreasing without achieving cost-saving. Scale-up access to ART for the HIV-positive among serodiscordant couples was easily fallen within the range of paying for incremental life-years and quality adjusted life years by the societal willingness. The hypothetical strategy had the potential to prevent most seroconversion events within marriages but required enormous upfront costs, thus it took a long time to reach established thresholds. The current strategy of early-ART is the most cost-effective. Clarifying the obstacles of high cost of PrEP and improving life quality for HIV-serodiscordant couples have emerged as an urgent requisition.
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Affiliation(s)
- Haisheng Wu
- Department of Preventive Medicine, Shantou University Medical College, No. 22 Xinling Road, Shantou, 515041, China
| | - Qiuyan Yu
- Department of Preventive Medicine, School of Public Health and Management, Wenzhou Medical University, University Town, Wenzhou, 325035, China
| | - Liping Ma
- Hengrui Pharmaceutical Co., Ltd., No. 7 Kunlun Mountain Road, Lianyungang Economic and Technological Development Zone, Lianyungang, Jiangsu, China
| | - Lin Zhang
- Zhoukou Center for Disease Control and Prevention, No.10 Taihao Road East Section, Zhoukou, Henan, China
| | - Yuliang Chen
- Department of Preventive Medicine, Shantou University Medical College, No. 22 Xinling Road, Shantou, 515041, China
| | - Pi Guo
- Department of Preventive Medicine, Shantou University Medical College, No. 22 Xinling Road, Shantou, 515041, China.
| | - Peng Xu
- National Center for STD/AIDS Prevention and Control, Chinese Center for Disease Control and Prevention, No. 155 Changbai Road, Beijing, 102206, China.
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Nguyen PT, Gilmour S, Le PM, Onishi K, Kato K, Nguyen HV. Progress toward HIV elimination goals: trends in and projections of annual HIV testing and condom use in Africa. AIDS 2021; 35:1253-1262. [PMID: 33730746 DOI: 10.1097/qad.0000000000002870] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To estimate trends in and projections of annual HIV testing and condom use at last higher-risk sex and to calculate the probability of reaching key United Nations Programme on AIDS (UNAIDS)'s target. DESIGN We included 114 nationally-representative datasets in 38 African countries from Demographic and Health Surveys and Multiple Indicator Cluster Surveys with 1 456 224 sexually active adults age 15-49 from 2003 to 2018. METHODS We applied Bayesian mixed effect models to estimate the coverage of annual HIV testing and condom use at last higher-risk sex for every country and year to 2030 and the probability of reaching UNAIDS testing and condom use targets of 95% coverage by 2030. RESULTS Seven countries saw downward trends in annual HIV testing and four saw decreases in condom use at higher-risk sex, whereas most countries have upward trends in both indicators. The highest coverage of testing in 2030 is predicted in Swaziland with 92.6% (95% credible interval: 74.5-98.1%), Uganda with 90.5% (72.2-97.2%), and Lesotho with 90.5% (69.4%-97.6%). Meanwhile, Swaziland, Lesotho, and Namibia will have the highest proportion of condom use in 2030 at 85.0% (57.8-96.1%), 75.6% (42.3-93.6%), and 75.5% (42.4-93.2%). The probabilities of reaching targets were very low for both HIV testing (0-28.5%) and condom use (0-12.1%). CONCLUSIONS We observed limited progress on annual HIV testing and condom use at last higher-risk sex in Africa and little prospect of reaching global targets for HIV/AIDS elimination. Although some funding agencies are considering withdrawal from supporting Africa, more attention to funding and expanding testing and treatment is needed in this region.
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Affiliation(s)
- Phuong T Nguyen
- Graduate School of Public Health, St. Luke's International University, Tokyo
| | - Stuart Gilmour
- Graduate School of Public Health, St. Luke's International University, Tokyo
| | - Phuong M Le
- Graduate School of Public Health, St. Luke's International University, Tokyo
| | - Kazunari Onishi
- Graduate School of Public Health, St. Luke's International University, Tokyo
| | - Kosuke Kato
- Department of Obstetrics and Gynaecology, Kanto Rosai Hospital, Kawasaki, Kanagawa, Japan
| | - Huy V Nguyen
- Graduate School of Public Health, St. Luke's International University, Tokyo
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Gaga S, Mqoqi N, Chimatira R, Moko S, Igumbor JO. Continuous quality improvement in HIV and TB services at selected healthcare facilities in South Africa. South Afr J HIV Med 2021; 22:1202. [PMID: 34192068 PMCID: PMC8182456 DOI: 10.4102/sajhivmed.v22i1.1202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/26/2021] [Indexed: 11/17/2022] Open
Abstract
Background Continuous quality improvement (CQI) is essential for HIV and tuberculosis (TB) services. Similarly, a thorough understanding of the requirements and impact of CQI is critical to its successful institutionalisation. However, this is currently lacking. Objectives The objective of this study is to describe the CQI implementation process and examine its effect on HIV and TB service delivery at selected primary healthcare facilities in two South African districts. Method We used a separate sample, pre- and post-test, quasi-experimental study design based on data collected from the clinical audit of patient cohorts seen in 2014 and 2015 respectively. Quality was measured based on the extent to which prescribed services were provided. Tailored CQI interventions were implemented based on service delivery gaps identified by the 2014 CQI audit. Data were summarised and analysed using a combination of univariate and multivariate analysis. Results The services identified as low quality were related to opportunistic infections management and laboratory practices. Compliance to prescribed service items in antiretroviral treatment initiation and monitoring, pharmacy and laboratory management, exceeded 70% across study sites. Over 80% of low quality service delivery items were optimised in less than six months with targeted quality improvement support. Conclusion The observed improvements signal the effectiveness of the CQI approach, its capacity to rapidly improve under-performance, its high replicability and the need to provide quality maintenance support to sustain or improve healthcare facilities performing well. The study strongly underscores the need to improve the management of opportunistic infections and complications, particularly TB.
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Affiliation(s)
| | | | | | - Singilizwe Moko
- Eastern Cape Provincial Department of Health, Bisho, South Africa
| | - Jude O Igumbor
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Shade SB, Marseille E, Kirby V, Chakravarty D, Steward WT, Koester KK, Cajina A, Myers JJ. Health information technology interventions and engagement in HIV care and achievement of viral suppression in publicly funded settings in the US: A cost-effectiveness analysis. PLoS Med 2021; 18:e1003389. [PMID: 33826617 PMCID: PMC8059802 DOI: 10.1371/journal.pmed.1003389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 04/21/2021] [Accepted: 03/25/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The US National HIV/AIDS Strategy (NHAS) emphasizes the use of technology to facilitate coordination of comprehensive care for people with HIV. We examined cost-effectiveness from the health system perspective of 6 health information technology (HIT) interventions implemented during 2008 to 2012 in a Ryan White HIV/AIDS Program (RWHAP) Special Projects of National Significance (SPNS) Program demonstration project. METHODS/FINDINGS HIT interventions were implemented at 6 sites: Bronx, New York; Durham, North Carolina; Long Beach, California; New Orleans, Louisiana; New York, New York (2 sites); and Paterson, New Jersey. These interventions included: (1) use of HIV surveillance data to identify out-of-care individuals; (2) extension of access to electronic health records (EHRs) to support service providers; (3) use of electronic laboratory ordering and prescribing; and (4) development of a patient portal. We employed standard microcosting techniques to estimate costs (in 2018 US dollars) associated with intervention implementation. Data from a sample of electronic patient records from each demonstration site were analyzed to compare prescription of antiretroviral therapy (ART), CD4 cell counts, and suppression of viral load, before and after implementation of interventions. Markov models were used to estimate additional healthcare costs and quality-adjusted life-years saved as a result of each intervention. Overall, demonstration site interventions cost $3,913,313 (range = $287,682 to $998,201) among 3,110 individuals (range = 258 to 1,181) over 3 years. Changes in the proportion of patients prescribed ART ranged from a decrease from 87.0% to 72.7% at Site 4 to an increase from 74.6% to 94.2% at Site 6; changes in the proportion of patients with 0 to 200 CD4 cells/mm3 ranged from a decrease from 20.2% to 11.0% in Site 6 to an increase from 16.7% to 30.2% in Site 2; and changes in the proportion of patients with undetectable viral load ranged from a decrease from 84.6% to 46.0% in Site 1 to an increase from 67.0% to 69.9% in Site 5. Four of the 6 interventions-including use of HIV surveillance data to identify out-of-care individuals, use of electronic laboratory ordering and prescribing, and development of a patient portal-were not only cost-effective but also cost saving ($6.87 to $14.91 saved per dollar invested). In contrast, the 2 interventions that extended access to EHRs to support service providers were not effective and, therefore, not cost-effective. Most interventions remained either cost-saving or not cost-effective under all sensitivity analysis scenarios. The intervention that used HIV surveillance data to identify out-of-care individuals was no longer cost-saving when the effect of HIV on an individual's health status was reduced and when the natural progression of HIV was increased. The results of this study are limited in that we did not have contemporaneous controls for each intervention; thus, we are only able to assess sites against themselves at baseline and not against standard of care during the same time period. CONCLUSIONS These results provide additional support for the use of HIT as a tool to enhance rapid and effective treatment of HIV to achieve sustained viral suppression. HIT has the potential to increase utilization of services, improve health outcomes, and reduce subsequent transmission of HIV.
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Affiliation(s)
- Starley B. Shade
- Institute for Global Health Sciences, Department of Epidemiology and Biostatistics, University of California, San Francisco, California, United States of America
- Center for AIDS Prevention Studies, University of California, San Francisco, California, United States of America
- * E-mail:
| | | | - Valerie Kirby
- Center for AIDS Prevention Studies, University of California, San Francisco, California, United States of America
| | - Deepalika Chakravarty
- Center for AIDS Prevention Studies, University of California, San Francisco, California, United States of America
| | - Wayne T. Steward
- Center for AIDS Prevention Studies, University of California, San Francisco, California, United States of America
| | - Kimberly K. Koester
- Center for AIDS Prevention Studies, University of California, San Francisco, California, United States of America
| | - Adan Cajina
- Demonstration and Evaluation Branch, HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, Maryland, United States of America
| | - Janet J. Myers
- Center for AIDS Prevention Studies, University of California, San Francisco, California, United States of America
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Singh S, France AM, Chen YH, Farnham PG, Oster AM, Gopalappa C. Progression and transmission of HIV (PATH 4.0)-A new agent-based evolving network simulation for modeling HIV transmission clusters. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2021; 18:2150-2181. [PMID: 33892539 PMCID: PMC8162476 DOI: 10.3934/mbe.2021109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
We present the Progression and Transmission of HIV (PATH 4.0), a simulation tool for analyses of cluster detection and intervention strategies. Molecular clusters are groups of HIV infections that are genetically similar, indicating rapid HIV transmission where HIV prevention resources are needed to improve health outcomes and prevent new infections. PATH 4.0 was constructed using a newly developed agent-based evolving network modeling (ABENM) technique and evolving contact network algorithm (ECNA) for generating scale-free networks. ABENM and ECNA were developed to facilitate simulation of transmission networks for low-prevalence diseases, such as HIV, which creates computational challenges for current network simulation techniques. Simulating transmission networks is essential for studying network dynamics, including clusters. We validated PATH 4.0 by comparing simulated projections of HIV diagnoses with estimates from the National HIV Surveillance System (NHSS) for 2010-2017. We also applied a cluster generation algorithm to PATH 4.0 to estimate cluster features, including the distribution of persons with diagnosed HIV infection by cluster status and size and the size distribution of clusters. Simulated features matched well with NHSS estimates, which used molecular methods to detect clusters among HIV nucleotide sequences of persons with HIV diagnosed during 2015-2017. Cluster detection and response is a component of the U.S. Ending the HIV Epidemic strategy. While surveillance is critical for detecting clusters, a model in conjunction with surveillance can allow us to refine cluster detection methods, understand factors associated with cluster growth, and assess interventions to inform effective response strategies. As surveillance data are only available for cases that are diagnosed and reported, a model is a critical tool to understand the true size of clusters and assess key questions, such as the relative contributions of clusters to onward transmissions. We believe PATH 4.0 is the first modeling tool available to assess cluster detection and response at the national-level and could help inform the national strategic plan.
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Affiliation(s)
- Sonza Singh
- University of Massachusetts Amherst, Amherst, MA, United States
| | - Anne Marie France
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Yao-Hsuan Chen
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Paul G. Farnham
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Alexandra M. Oster
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
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17
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Gupta I, Singh D. Cost-Effectiveness of antiretroviral therapy: A systematic review. Indian J Public Health 2021; 64:S32-S38. [PMID: 32295954 DOI: 10.4103/ijph.ijph_90_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background The mobilization of resources to prevent and treat human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) is unparalleled in the history of public health. The uptake of antiretroviral therapy (ART) has been rapid and unprecedented and made possible by the availability of funding - external and domestic. To justify continuous funding of ART in resource-scarce settings, a spate of cost-effectiveness studies has been undertaken in a number of countries. This paper is based on a systematic review of global studies on cost-effectiveness analysis of ART. Objectives The major objective was to review the existing literature on cost-effectiveness of ART to determine whether ART has been cost-effective (CE) in different settings. Methods We searched PubMed and Google Scholar for articles published between 2008 and 2017. We included studies that measured costs as well as effectiveness of HIV treatment - specifically ART - using incremental cost-effectiveness ratio as one of the outcomes. Results We identified 15 studies that met the search criteria for inclusion in the systematic review. The review confirms that ART programs have been CE across different settings, contexts, and strategies. Conclusion The review would be useful for countries that are straining to raise funds for the health sector, generally, and for AIDS prevention and control program, specifically. This would also be beneficial for carrying out similar studies, if necessary, and as an advocacy tool for garnering additional funding.
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Affiliation(s)
- Indrani Gupta
- Professor, Health Policy Research Unit, Institute of Economic Growth, University of Delhi, Delhi, India
| | - Damini Singh
- Ph.D Fellow, Centre for Economic Studies and Planning, Jawaharlal Nehru University, Delhi, India
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18
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Choi H, Suh J, Lee W, Kim JH, Kim JH, Seong H, Ahn JY, Jeong SJ, Ku NS, Park YS, Yeom JS, Kim C, Kwon HD, Smith DM, Lee J, Choi JY. Cost-effectiveness analysis of pre-exposure prophylaxis for the prevention of HIV in men who have sex with men in South Korea: a mathematical modelling study. Sci Rep 2020; 10:14609. [PMID: 32884082 PMCID: PMC7471951 DOI: 10.1038/s41598-020-71565-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 08/12/2020] [Indexed: 11/10/2022] Open
Abstract
In February 2018, the Ministry of Food and Drug Safety in Korea approved tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) co-formulate for use in pre-exposure prophylaxis (PrEP) for the prevention of human immunodeficiency virus (HIV) infection. This study aimed to estimate the cost-effectiveness of PrEP in men who have sex with men (MSM), a major risk group emerging in Korea. A dynamic compartmental model was developed for HIV transmission and progression in MSM aged 15-64 years. With a combined model including economic analysis, we estimated averted HIV infections, changes in HIV prevalence, discounted costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). PrEP was evaluated in both the general MSM and high-risk MSM populations and was assumed to reduce infection risk by 80%. Implementing PrEP in all MSM would avert 75.2% HIV infections and facilitate a gain of 37,372 QALYs at a cost of $274,822 per QALY gained over 20 years relative to the status quo. Initiating PrEP in high-risk MSM with an average of eight partners per year (around 20% of MSM) would improve the cost-effectiveness, averting 78.0% HIV infections and add 29,242 QALYs at a cost of $51,597 per QALY gained, which is within the willingness-to-pay threshold for Korea of $56,000/QALY gained. This result was highly sensitive to annual PrEP costs, quality-of-life for people who are on PrEP, and initial HIV prevalence. Initiating PrEP in a larger proportion of MSM in Korea would prevent more HIV infections, but at an increasing cost per QALY gained. Focusing PrEP on higher risk MSM and any reduction in PrEP cost would improve cost-effectiveness.
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Affiliation(s)
- Heun Choi
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jiyeon Suh
- Department of Computational Science and Engineering, Yonsei University, Seoul, Republic of Korea
| | - Woonji Lee
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jun Hyoung Kim
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung Ho Kim
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hye Seong
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin Young Ahn
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Su Jin Jeong
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Nam Su Ku
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yoon Soo Park
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joon Sup Yeom
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Changsoo Kim
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hee-Dae Kwon
- Department of Mathematics, Inha University, Incheon, Republic of Korea
| | - Davey M Smith
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
| | - Jeehyun Lee
- Department of Computational Science and Engineering, Yonsei University, Seoul, Republic of Korea
- Department of Mathematics, Yonsei University, Seoul, Republic of Korea
| | - Jun Yong Choi
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Yonsei University Health System, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea.
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19
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The impact of localized implementation: determining the cost-effectiveness of HIV prevention and care interventions across six United States cities. AIDS 2020; 34:447-458. [PMID: 31794521 DOI: 10.1097/qad.0000000000002455] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Effective interventions to reduce the public health burden of HIV/AIDS can vary in their ability to deliver value at different levels of scale and in different epidemiological contexts. Our objective was to determine the cost-effectiveness of HIV treatment and prevention interventions implemented at previously documented scales of delivery in six US cities with diverse HIV microepidemics. DESIGN Dynamic HIV transmission model-based cost-effectiveness analysis. METHODS We identified and estimated previously documented scale of delivery and costs for 16 evidence-based interventions from the US CDC's Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention. Using a model calibrated for Atlanta, Baltimore, Los Angeles, Miami, New York City and Seattle, we estimated averted HIV infections, quality-adjusted life years (QALY) gained and incremental cost-effectiveness ratios (healthcare perspective; 3% discount rate, 2018$US), for each intervention and city (10-year implementation) compared with the status quo over a 20-year time horizon. RESULTS Increased HIV testing was cost-saving or cost-effective across cities. Targeted preexposure prophylaxis for high-risk MSM was cost-saving in Miami and cost-effective in Atlanta ($6123/QALY), Baltimore ($18 333/QALY) and Los Angeles ($86 117/QALY). Interventions designed to improve antiretroviral therapy initiation provided greater value than other treatment engagement interventions. No single intervention was projected to reduce HIV incidence by more than 10.1% in any city. CONCLUSION Combination implementation strategies should be tailored to local epidemiological contexts to provide the most value. Complementary strategies addressing factors hindering access to HIV care will be necessary to meet targets for HIV elimination in the United States.
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Wagner Z, Montoy JCC, Drabo EF, Dow WH. Incentives Versus Defaults: Cost-Effectiveness of Behavioral Approaches for HIV Screening. AIDS Behav 2020; 24:379-386. [PMID: 30953306 DOI: 10.1007/s10461-019-02425-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Many HIV positive individuals are still undiagnosed, which has led health systems to try many approaches to expand HIV testing. In a randomized controlled trial, we found that behavioral economics interventions (opt-out testing and financial incentives) each improved HIV testing rates and these approaches are being implemented by several hospital systems. However, it is unclear if these strategies are cost-effective. We quantified the cost-effectiveness of different behavioral approaches to HIV screening-opt-out testing, financial incentives, and their combination-in terms of cost per new HIV diagnosis and infections averted. We estimated the incremental number of new HIV diagnoses and program costs using a mathematical screening model, and infections averted using and HIV transmission model. We used a 1-year time horizon and a hospital perspective. Switching from opt-into opt-out results in 39 additional diagnoses (56% increase) after 1-year at a cost of $3807 per new diagnosis. Switching from no incentive to a $1, $5, or $10 incentive adds 14, 13, and 28 new diagnoses (20, 19, and 41% increases) at a cost of $11,050, $17,984, and $15,298 per new diagnosis, respectively. Layering on financial incentives to opt-out testing enhances program effectiveness, though at a greater marginal cost per diagnosis. We found a similar pattern for infections averted. This is one of the first cost-effectiveness analyses of behavioral economics interventions in public health. Changing the choice architecture from opt-into opt-out and giving financial incentives for testing are both cost-effective in terms of detecting HIV and reducing transmission. For hospitals interested in increasing HIV screening rates, changing the choice architecture is an efficient strategy and more efficient than incentives.
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Affiliation(s)
- Zachary Wagner
- RAND Corporation, 1776 Main St, Santa Monica, CA, 90401, USA.
| | - Juan Carlos C Montoy
- Department Emergency Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Emmanuel F Drabo
- Department of Health Policy and Management, Johns Hopkins University, Baltimore, MD, USA
| | - William H Dow
- School of Public Health, University of California Berkeley, Berkeley, CA, USA
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Ward T, Sugrue D, Hayward O, McEwan P, Anderson SJ, Lopes S, Punekar Y, Oglesby A. Estimating HIV Management and Comorbidity Costs Among Aging HIV Patients in the United States: A Systematic Review. J Manag Care Spec Pharm 2020; 26:104-116. [PMID: 32011956 PMCID: PMC10391104 DOI: 10.18553/jmcp.2020.26.2.104] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND As life expectancy of patients infected with human immunodeficiency virus (HIV) approaches that of the general population, the composition of HIV management costs is likely to change. OBJECTIVES To (a) review treatment and disease management costs in HIV, including costs of adverse events (AEs) related to antiretroviral therapy (ART) and long-term toxicities, and (b) explore the evolving cost drivers. METHODS A targeted literature review between January 2012 and November 2017 was conducted using PubMed and major conferences. Articles reporting U.S. costs of HIV management, acquired immunodeficiency syndrome (AIDS)-defining events, end of life care, and ART-associated comorbidities such as cardiovascular disease (CVD), chronic kidney disease (CKD), and osteoporosis were included. All costs were inflated to 2017 U.S. dollars. A Markov model-based analysis was conducted to estimate the effect of increased life expectancy on costs associated with HIV treatment and management. RESULTS 22 studies describing HIV costs in the United States were identified, comprising 16 cost-effectiveness analysis studies, 5 retrospective analyses of health care utilization, and 1 cost analysis in a resource-limited setting. Management costs per patient per month, including routine care costs (on/off ART), non-HIV medication, opportunistic infection prophylaxis, inpatient utilization, outpatient utilization, and emergency department utilization were reported as CD4+ cell-based health state costs ranging from $1,192 for patients with CD4 > 500 cells/mm3 to $2,873 for patients with CD4 < 50 cells/mm3. Event costs for AEs ranged from $0 for headache, pain, vomiting, and lipodystrophy to $31,545 for myocardial infarction. The mean monthly per-patient costs for CVD management, CKD management, and osteoporosis were $5,898, $6,108, and $4,365, respectively. Improvements in life expectancy, approaching that of the general population in 2018, are projected to increase ART-related and AE costs by 35.4% and comorbidity costs by 175.8% compared with estimated costs with HIV life expectancy observed in 1996. CONCLUSIONS This study identified and summarized holistic cost estimates appropriate for use within U.S. HIV cost-effectiveness analyses and demonstrates an increasing contribution of comorbidity outcomes, primarily associated with aging in addition to long-term treatment with ART, not typically evaluated in contemporary HIV cost-effectiveness analyses. DISCLOSURES This analysis was sponsored by ViiV Healthcare, which had no role in the analyses and interpretation of study results. Ward, Sugrue, Hayward, and McEwan are employees of HEOR Ltd, which received funding from ViiV Healthcare to conduct this study. Anderson is an employee of GlaxoSmithKline and holds shares in the company. Punekar and Oglesby are employees of ViiV Healthcare and hold shares in GlaxoSmithKline. Lopes was employed by ViiV Healthcare at the time of the study and holds shares in GlaxoSmithKline.
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Affiliation(s)
| | | | | | | | | | - Sara Lopes
- ViiV Healthcare, Brentford, United Kingdom
| | | | - Alan Oglesby
- ViiV Healthcare, Research Triangle, North Carolina
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Ling Murtaugh K, Leibowitz A, Chen X, Pourat N. Missed Opportunities for HIV Screening of New Enrollees in California's Low Income Health Program. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2020; 32:25-35. [PMID: 32073307 PMCID: PMC7654555 DOI: 10.1521/aeap.2020.32.1.25] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The objective of this study was to measure HIV screening rates and variables associated with screening among new enrollees in California's Low Income Health Program (LIHP). A logit model was used to estimate associations between HIV screening and enrollment, claims, and encounter data for enrollees. HIV prevalence among new LIHP enrollees was 1.2%xd. Among 42,550 new LIHP enrollees with no prior HIV diagnosis, only 27% received screening within 12 months of their first medical evaluation. A total of 350 new HIV diagnoses were identified (incidence rate of 0.8%), exceeding the 0.1% level at which the Centers for Disease Control and Prevention (CDC) recommends routine HIV screening. California reduced screening barriers by removing required written informed consent and pretest counseling; the Affordable Care Act (ACA) eliminated cost-sharing and enhanced access. Removing financial and administrative barriers to HIV screening is necessary, but may be insufficient to reach CDC's recommended screening targets.
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Taylor TN, DeHovitz J, Hirshfield S. Intersectional Stigma and Multi-Level Barriers to HIV Testing Among Foreign-Born Black Men From the Caribbean. Front Public Health 2020; 7:373. [PMID: 31998675 PMCID: PMC6965168 DOI: 10.3389/fpubh.2019.00373] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 11/21/2019] [Indexed: 01/08/2023] Open
Abstract
Testing is the entry point into the HIV care continuum that includes linkage to and retention in prevention services, and adherence to prevention strategies, including repeat HIV testing. Despite US policy approaches to expand HIV testing to diverse clinical care and community settings, disparities in HIV testing among Black populations persist. Foreign-born (FB) Black persons from the Caribbean have higher annual rates of HIV diagnosis and a higher percentage of late-stage HIV diagnosis, compared with US-born Black persons; and most HIV infections among FB Blacks are among men. In this article, we provide an overview of HIV testing barriers among FB Black men who engage in HIV risk-taking behaviors (e.g., condomless sex with male and/or female partners of unknown HIV serostatus). Barriers to HIV testing for both FB and US-born Black men, include HIV stigma (anticipated, perceived, internalized), low perceived HIV risk, medical or government mistrust, and perceived low access to testing resources. We examine beliefs about masculinity and gender roles that may perpetuate heteronormative stereotypes associated with perceptions of low HIV risk and barriers to HIV testing. We also discuss the impact of recent immigration policies on accessing HIV testing and treatment services and how intersectional stigmas and structural forms of oppression, such as racism, prejudice against select immigrant groups, and homophobia that may further amplify barriers to HIV testing among FB Black men. Finally, we review comprehensive prevention approaches, and suggest innovative approaches, that may improve the uptake of HIV testing among FB Black men.
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Affiliation(s)
- Tonya N. Taylor
- SUNY Downstate Health Sciences University, Brooklyn, NY, United States
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Zang X, Krebs E, Min JE, Pandya A, Marshall BDL, Schackman BR, Behrends CN, Feaster DJ, Nosyk B. Development and Calibration of a Dynamic HIV Transmission Model for 6 US Cities. Med Decis Making 2019; 40:3-16. [PMID: 31865849 DOI: 10.1177/0272989x19889356] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. Heterogeneity in HIV microepidemics across US cities necessitates locally oriented, combination implementation strategies to prioritize resources. We calibrated and validated a dynamic, compartmental HIV transmission model to establish a status quo treatment scenario, holding constant current levels of care for 6 US cities. Methods. Built off a comprehensive evidence synthesis, we adapted and extended a previously published model to replicate the transmission, progression, and clinical care for each microepidemic. We identified a common set of 17 calibration targets between 2012 and 2015 and used the Morris method to select the most influential parameters for calibration. We then applied the Nelder-Mead algorithm to iteratively calibrate the model to generate 2000 best-fitting parameter sets. Finally, model projections were internally validated with a series of robustness checks and externally validated against published estimates of HIV incidence, while the face validity of 25-year projections was assessed by a Scientific Advisory Committee (SAC). Results. We documented our process for model development, calibration, and validation to maximize its transparency and reproducibility. The projected outcomes demonstrated a good fit to calibration targets, with a mean goodness-of-fit ranging from 0.0174 (New York City [NYC]) to 0.0861 (Atlanta). Most of the incidence predictions were within the uncertainty range for 5 of the 6 cities (ranging from 21% [Miami] to 100% [NYC]), demonstrating good external validity. The face validity of the long-term projections was confirmed by our SAC, showing that the incidence would decrease or remain stable in Atlanta, Los Angeles, NYC, and Seattle while increasing in Baltimore and Miami. Discussion. This exercise provides a basis for assessing the incremental value of further investments in HIV combination implementation strategies tailored to urban HIV microepidemics.
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Affiliation(s)
- Xiao Zang
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Emanuel Krebs
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Jeong E Min
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Brandon D L Marshall
- Department of Epidemiology, School of Public Health, Brown University, Providence, RI, USA
| | - Bruce R Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York City, NY, USA
| | - Czarina N Behrends
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York City, NY, USA
| | - Daniel J Feaster
- Department of Epidemiology and Public Health, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
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Abstract
OBJECTIVES To assess the cost-effectiveness of increased consistent HIV testing among MSM in the Netherlands. METHODS Among MSM testing at sexually transmitted infection clinics in the Netherlands in 2014-2015, approximately 20% tested consistently every 6 months. We examined four scenarios with increased percentage of MSM testing every 6 months: a small and a moderate increase among all MSM; a small and a moderate increase only among MSM with at least 10 partners in the preceding 6 months. We used an agent-based model to calculate numbers of HIV infections and AIDS cases prevented with increased HIV testing. These numbers were used in an economic model to calculate costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) due to increased testing, over 2018-2027, taking a healthcare payer perspective. RESULTS A small increase in the percentage testing every 6 months among all MSM resulted in 490 averted HIV infections and an average ICER of &OV0556;27 900/QALY gained. A moderate increase among all MSM, resulted in 1380 averted HIV infections and an average ICER of &OV0556;36 700/QALY gained. Both were not cost-effective, with a &OV0556;20 000 willingness-to-pay threshold. Increasing the percentage testing every 6 months only among MSM with at least 10 partners in the preceding 6 months resulted in less averted HIV infections than increased testing among all MSM, but was on average cost-saving. CONCLUSION Increased HIV testing can prevent considerable numbers of new HIV infections among MSM, but may be cost-effective only if targeted at high-risk individuals, such as those with many partners.
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Zang X, Krebs E, Wang L, Marshall BDL, Granich R, Schackman BR, Montaner JSG, Nosyk B. Structural Design and Data Requirements for Simulation Modelling in HIV/AIDS: A Narrative Review. PHARMACOECONOMICS 2019; 37:1219-1239. [PMID: 31222521 PMCID: PMC6711792 DOI: 10.1007/s40273-019-00817-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Born out of a necessity for fiscal sustainability, simulation modeling is playing an increasingly prominent role in setting priorities for combination implementation strategies for HIV treatment and prevention globally. The design of a model and the data inputted into it are central factors in ensuring credible inferences. We executed a narrative review of a set of dynamic HIV transmission models to comprehensively synthesize and compare the structural design and the quality of evidence used to support each model. We included 19 models representing both generalized and concentrated epidemics, classified as compartmental, agent-based, individual-based microsimulation or hybrid in our review. We focused on four structural components (population construction; model entry, exit and HIV care engagement; HIV disease progression; and the force of HIV infection), and two analytical components (model calibration/validation; and health economic evaluation, including uncertainty analysis). While the models we reviewed focused on a variety of individual interventions and their combinations, their structural designs were relatively homogenous across three of the four focal components, with key structural elements influenced by model type and epidemiological context. In contrast, model entry, exit and HIV care engagement tended to differ most across models, with some health system interactions-particularly HIV testing-not modeled explicitly in many contexts. The quality of data used in the models and the transparency with which the data was presented differed substantially across model components. Representative and high-quality data on health service delivery were most commonly not accessed or were unavailable. The structure of an HIV model should ideally fit its epidemiological context and be able to capture all efficacious treatment and prevention services relevant to a robust combination implementation strategy. Developing standardized guidelines on evidence syntheses for health economic evaluation would improve transparency and help prioritize data collection to reduce decision uncertainty.
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Affiliation(s)
- Xiao Zang
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Emanuel Krebs
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
| | - Linwei Wang
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
| | | | - Reuben Granich
- Independent Public Health Consultant, Washington, DC, USA
| | | | - Julio S G Montaner
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Bohdan Nosyk
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada.
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.
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Wang L, Krebs E, Min JE, Mathews WC, Nijhawan A, Somboonwit C, Aberg JA, Moore RD, Gebo KA, Nosyk B. Combined estimation of disease progression and retention on antiretroviral therapy among treated individuals with HIV in the USA: a modelling study. Lancet HIV 2019; 6:e531-e539. [PMID: 31303557 DOI: 10.1016/s2352-3018(19)30148-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 04/15/2019] [Accepted: 04/24/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Accurately estimating HIV disease progression and retention on antiretroviral therapy (ART) can help inform interventions to control HIV microepidemics and mathematical models used to inform health-resource allocation decisions. Our objective was to estimate the monthly probabilities of on-ART CD4 T-cell count progression, mortality, ART dropout, and ART reinitiation using a continuous-time multistate Markov model. We also aimed to validate health-state transition probability estimates to ensure they accurately reproduced the regional HIV microepidemics across the USA. METHODS In our modelling study, we considered a cohort of patients from the HIV Research Network, a consortium of 17 adult and paediatric HIV-care providers located in the northeastern (n=8), southern (n=5), and western (n=4) regions of the USA. Individuals aged 15 years or older who were in HIV care (defined as one CD4 test and one HIV-care visit in a calendar year period) with at least one ART prescription between Jan 1, 2010, and Dec 31, 2015, were included in the analysis. We used continuous-time multistate Markov models to estimate transitions between CD4 strata and between on-ART and off-ART states. We examined and adjusted for differences in probability of transition by region, race or ethnicity, sex, HIV risk group, and other baseline clinical indicators. FINDINGS The median age of the 32 242 individuals included in the analysis was 44 years (interquartile range 35-51). Over a median follow-up of 4·9 years (2·6-6·0), 8614 (26·7%) of 32 242 people interrupted ART and 1325 (4·1%) of 32 242 people died. Women, men who have sex with men, and individuals with no previous ART experience had greater increases in CD4 cell counts, whereas black people and people who inject drugs had increased probabilities of ART dropout and faster disease progression. Regardless of CD4 strata, individuals had increased hazard for ART dropout if they were from the south (adjusted hazard ratio [aHR] range from 1·91, 95% CI 1·71-2·13, to 2·45, 2·29-2·62) or the west (aHR range from 1·29, 1·10-1·51, to 1·66, 1·51-1·82) of the USA, compared with individuals from the northeast USA. INTERPRETATION Our results show heterogeneities in disease progression during ART and probability of ART retention across race and ethnicity, HIV risk groups, and regions. These differences should be viewed as targets for intervention and should be incorporated in mathematical models of regional HIV microepidemics in the USA. FUNDING US National Institutes of Health, Agency for Healthcare Research and Quality, and Health Resources and Services Administration.
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Affiliation(s)
- Linwei Wang
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Emanuel Krebs
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Jeong E Min
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | | | - Ank Nijhawan
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Charurut Somboonwit
- Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Judith A Aberg
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Richard D Moore
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelly A Gebo
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bohdan Nosyk
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.
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Ghaderi A, Banafshe HR, Mirhosseini N, Motmaen M, Mehrzad F, Bahmani F, Aghadavod E, Mansournia MA, Reiter RJ, Karimi M, Asemi Z. The effects of melatonin supplementation on mental health, metabolic and genetic profiles in patients under methadone maintenance treatment. Addict Biol 2019; 24:754-764. [PMID: 29949232 DOI: 10.1111/adb.12650] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 04/24/2018] [Accepted: 05/21/2018] [Indexed: 12/11/2022]
Abstract
This investigation was designed to determine the effect of melatonin supplementation on mental health parameters, metabolic and genetic profiles in patients under methadone maintenance treatment (MMT). This randomized, double-blind, placebo-controlled, clinical trial was conducted among 54 patients under MMT. Participants were randomly allocated to receive either 10 mg melatonin (2 melatonin capsules, 5 mg each) (n = 26) or placebo (n = 28) once a day, 1 hour before bedtime for 12 weeks. Melatonin supplementation significantly decreased Pittsburgh Sleep Quality Index (β -4.08; 95 percent CI, -5.51, -2.65; P < 0.001), Beck Depression Inventory index (β -5.46; 95% CI, -8.92, -2.00; P = 0.003) and Beck Anxiety Inventory index (β -3.87; 95% CI, -5.96, -1.77; P = 0.001) and significantly increased International Index of Erectile Functions (β 5.59; 95% CI, 1.76, 9.42; P = 0.005) compared with the placebo. Subjects who received melatonin supplements had significantly lower serum insulin levels (β -2.53; 95% CI, -4.48, -0.59; P = 0.01), homeostasis model of assessment-insulin resistance (β -0.56; 95% CI, -1.03, -0.09; P = 0.01) and higher quantitative insulin sensitivity check index (β 0.01; 95% CI, 0.004, 0.02; P = 0.009) and HDL-cholesterol levels (β 3.71; 95% CI, 1.77, 5.64; P = 0.002) compared to placebo. Additionally, melatonin intake resulted in a significant reduction in serum high sensitivity C-reactive protein (β -0.15; 95% CI, -0.27, -0.02; P = 0.02), malondialdehyde (β -0.31; 95% CI, -0.57, -0.05; P = 0.02) and protein carbonyl (β -0.06; 95% CI, -0.09, -0.04; P < 0.001). This trial indicated that taking melatonin supplements for 12 weeks by patients under MMT had beneficial effects on their mental health metabolic profiles.
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Affiliation(s)
- Amir Ghaderi
- Department of Addiction Studies, School of MedicineKashan University of Medical Sciences Kashan Iran
| | - Hamid Reza Banafshe
- Department of Addiction Studies, School of MedicineKashan University of Medical Sciences Kashan Iran
- Department of Pharmacology, School of MedicineKashan University of Medical Sciences Kashan Iran
| | | | - Maryam Motmaen
- Department of Psychiatry, School of MedicineKashan University of Medical Science Kashan Iran
| | - Fatemeh Mehrzad
- Department of Psychiatry, School of MedicineKashan University of Medical Science Kashan Iran
| | - Fereshteh Bahmani
- Research Center for Biochemistry and Nutrition in Metabolic DiseasesKashan University of Medical Sciences Kashan Iran
| | - Esmat Aghadavod
- Research Center for Biochemistry and Nutrition in Metabolic DiseasesKashan University of Medical Sciences Kashan Iran
| | - Mohammad Ali Mansournia
- Department of Epidemiology and Biostatistics, School of Public HealthTehran University of Medical Sciences Tehran Iran
| | - Russel J. Reiter
- Department of Cellular and Structural BiologyUniversity of Texas Health Science, Center San Antonio TX USA
| | - Mohammad‐Amin Karimi
- Department of Educational Sciences, Science and Research BranchIslamic Azad University Tehran Iran
| | - Zatollah Asemi
- Research Center for Biochemistry and Nutrition in Metabolic DiseasesKashan University of Medical Sciences Kashan Iran
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Talari HR, Azad ZJ, Hamidian Y, Samimi M, Gilasi HR, Ebrahimi Afshar F, Ostadmohammadi V, Asemi Z. Effects of Carnitine Administration on Carotid Intima-media Thickness and Inflammatory Factors in Patients with Polycystic Ovary Syndrome: A Randomized, Double-blind, Placebo-controlled Trial. Int J Prev Med 2019; 10:89. [PMID: 31360336 PMCID: PMC6592103 DOI: 10.4103/ijpvm.ijpvm_2_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 02/26/2018] [Indexed: 12/04/2022] Open
Abstract
Background: This study was performed to evaluate the effects of carnitine administration on carotid intima-media thickness (CIMT) and inflammatory markers in women with polycystic ovary syndrome (PCOS). Methods: This randomized, double-blind, placebo-controlled trial was conducted among 60 women diagnosed with PCOS according to the Rotterdam criteria, aged 18–40 years. Participants were randomly allocated into two groups to intake either 250 mg/day carnitine (n = 30) or placebo (n = 30) for 12 weeks. High-resolution carotid ultrasonography was conducted at baseline and after the 12-week intervention. Results: After the 12-week intervention, compared with the placebo, carnitine supplementation resulted in a significant decrease in maximum levels of the left CIMT (−0.01 ± 0.02 vs. +0.002 mm ± 0.006 mm, P = 0.001), mean levels of the left CIMT (−0.01 ± 0.02 vs. +0.001 mm ± 0.01 mm, P = 0.001), maximum levels of the right CIMT (−0.01 ± 0.02 vs. +0.006 mm ± 0.01 mm, P < 0.001), and mean levels of the right CIMT (−0.01 ± 0.02 vs. +0.002 mm ± 0.01 mm, P = 0.001). Change in plasma nitric oxide (NO) (+2.4 ± 3.6 vs. +0.2 ± 2.3 μmol/L, P = 0.007) was significantly different between the supplemented patients and placebo group. We did not see any significant effect in serum high sensitivity C-reactive protein (hs-CRP) following the supplementation of carnitine compared with the placebo. Conclusions: Overall, carnitine administration for 12 weeks to participants with PCOS had beneficial effects on CIMT and plasma NO, but did not affect serum hs-CRP levels.
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Affiliation(s)
- Hamid Reza Talari
- Department of Radiology, Kashan University of Medical Sciences, Kashan, Iran
| | - Zeinab Jafari Azad
- Department of Radiology, Kashan University of Medical Sciences, Kashan, Iran
| | - Yaser Hamidian
- Department of Radiology, Kashan University of Medical Sciences, Kashan, Iran
| | - Mansooreh Samimi
- Department of Gynecology and Obstetrics, School of Medicine, Kashan University of Medical Sciences, Kashan, Iran
| | - Hamid Reza Gilasi
- Department of Epidemiology and Biostatistics, Faculty of Health, Kashan University of Medical Sciences, Kashan, Iran
| | - Faraneh Ebrahimi Afshar
- Department of Gynecology and Obstetrics, School of Medicine, Kashan University of Medical Sciences, Kashan, Iran
| | - Vahidreza Ostadmohammadi
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran
| | - Zatollah Asemi
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran
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Han S, Shanafelt TD, Sinsky CA, Awad KM, Dyrbye LN, Fiscus LC, Trockel M, Goh J. Estimating the Attributable Cost of Physician Burnout in the United States. Ann Intern Med 2019; 170:784-790. [PMID: 31132791 DOI: 10.7326/m18-1422] [Citation(s) in RCA: 441] [Impact Index Per Article: 88.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Although physician burnout is associated with negative clinical and organizational outcomes, its economic costs are poorly understood. As a result, leaders in health care cannot properly assess the financial benefits of initiatives to remediate physician burnout. OBJECTIVE To estimate burnout-associated costs related to physician turnover and physicians reducing their clinical hours at national (U.S.) and organizational levels. DESIGN Cost-consequence analysis using a mathematical model. SETTING United States. PARTICIPANTS Simulated population of U.S. physicians. MEASUREMENTS Model inputs were estimated by using the results of contemporary published research findings and industry reports. RESULTS On a national scale, the conservative base-case model estimates that approximately $4.6 billion in costs related to physician turnover and reduced clinical hours is attributable to burnout each year in the United States. This estimate ranged from $2.6 billion to $6.3 billion in multivariate probabilistic sensitivity analyses. At an organizational level, the annual economic cost associated with burnout related to turnover and reduced clinical hours is approximately $7600 per employed physician each year. LIMITATIONS Possibility of nonresponse bias and incomplete control of confounders in source data. Some parameters were unavailable from data and had to be extrapolated. CONCLUSION Together with previous evidence that burnout can effectively be reduced with moderate levels of investment, these findings suggest substantial economic value for policy and organizational expenditures for burnout reduction programs for physicians.
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Affiliation(s)
- Shasha Han
- National University of Singapore, Singapore (S.H.)
| | - Tait D Shanafelt
- Stanford University School of Medicine, Palo Alto, California (T.D.S., M.T.)
| | | | | | | | - Lynne C Fiscus
- University of North Carolina Physicians Network, Morrisville, North Carolina (L.C.F.)
| | - Mickey Trockel
- Stanford University School of Medicine, Palo Alto, California (T.D.S., M.T.)
| | - Joel Goh
- National University of Singapore, Singapore, and Harvard Business School, Boston, Massachusetts (J.G.)
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Krebs E, Enns B, Wang L, Zang X, Panagiotoglou D, Del Rio C, Dombrowski J, Feaster DJ, Golden M, Granich R, Marshall B, Mehta SH, Metsch L, Schackman BR, Strathdee SA, Nosyk B. Developing a dynamic HIV transmission model for 6 U.S. cities: An evidence synthesis. PLoS One 2019; 14:e0217559. [PMID: 31145752 PMCID: PMC6542533 DOI: 10.1371/journal.pone.0217559] [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: 12/19/2018] [Accepted: 05/14/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Dynamic HIV transmission models can provide evidence-based guidance on optimal combination implementation strategies to treat and prevent HIV/AIDS. However, these models can be extremely data intensive, and the availability of good-quality data characterizing regional microepidemics varies substantially within and across countries. We aim to provide a comprehensive and transparent description of an evidence synthesis process and reporting framework employed to populate and calibrate a dynamic, compartmental HIV transmission model for six US cities. METHODS We executed a mixed-method evidence synthesis strategy to populate model parameters in six categories: (i) initial HIV-negative and HIV-infected populations; (ii) parameters used to calculate the probability of HIV transmission; (iii) screening, diagnosis, treatment and HIV disease progression; (iv) HIV prevention programs; (v) the costs of medical care; and (vi) health utility weights for each stage of HIV disease progression. We identified parameters that required city-specific data and stratification by gender, risk group and race/ethnicity a priori and sought out databases for primary analysis to augment our evidence synthesis. We ranked the quality of each parameter using context- and domain-specific criteria and verified sources and assumptions with our scientific advisory committee. FINDINGS To inform the 1,667 parameters needed to populate our model, we synthesized evidence from 59 peer-reviewed publications and 24 public health and surveillance reports and executed primary analyses using 11 data sets. Of these 1,667 parameters, 1,517 (91%) were city-specific and 150 (9%) were common for all cities. Notably, 1,074 (64%), 201 (12%) and 312 (19%) parameters corresponded to categories (i), (ii) and (iii), respectively. Parameters ranked as best- to moderate-quality evidence comprised 39% of the common parameters and ranged from 56%-60% across cities for the city-specific parameters. We identified variation in parameter values across cities as well as within cities across risk and race/ethnic groups. CONCLUSIONS Better integration of modelling in decision making can be achieved by systematically reporting on the evidence synthesis process that is used to populate models, and by explicitly assessing the quality of data entered into the model. The effective communication of this process can help prioritize data collection of the most informative components of local HIV prevention and care services in order to reduce decision uncertainty and strengthen model conclusions.
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Affiliation(s)
- Emanuel Krebs
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Benjamin Enns
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Linwei Wang
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Xiao Zang
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Dimitra Panagiotoglou
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Carlos Del Rio
- Hubert Department of Global Health, Emory Center for AIDS Research, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Julia Dombrowski
- Department of Medicine, Division of Allergy & Infectious Disease, adjunct in Epidemiology, University of Washington, Seattle, WA, United States of America
| | - Daniel J. Feaster
- Center for Family Studies, Department of Epidemiology and Public Health, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States of America
| | - Matthew Golden
- Department of Medicine, Division of Allergy & Infectious Disease, adjunct in Epidemiology, University of Washington, Seattle, WA, United States of America
| | - Reuben Granich
- International Association of Providers of AIDS Care, Washington, DC, United States of America
| | - Brandon Marshall
- Department of Epidemiology, Brown School of Public Health, Providence, RI, United States of America
| | - Shruti H. Mehta
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States of America
| | - Lisa Metsch
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - Bruce R. Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, United States of America
| | - Steffanie A. Strathdee
- School of Medicine, University of California San Diego, La Jolla, CA, United States of America
| | - Bohdan Nosyk
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
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Khalatbari-Mohseni A, Banafshe HR, Mirhosseini N, Asemi Z, Ghaderi A, Omidi A. The effects of crocin on psychological parameters in patients under methadone maintenance treatment: a randomized clinical trial. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2019; 14:9. [PMID: 30795785 PMCID: PMC6387551 DOI: 10.1186/s13011-019-0198-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 02/11/2019] [Indexed: 12/31/2022]
Abstract
Background Methadone maintenance treatment (MMT) might be associated with the symptoms of depression and anxiety, sleep disturbances and sexual dysfunctions. This study was designed to determine the effects of crocin on psychological parameters in patients under MMT. Methods Patients under MMT were randomly allocated into two groups to receive either 30 mg/day crocin (2 plus crocin tablet, 15 mg BID) (n = 25) or placebo (2 tablets per day, 15 mg BID) (n = 25), one hour after taking food, for 8 weeks. Psychological parameters were evaluated at baseline and end of the trial to determine related associations between crocin and patients’ mental health status. Results After 8-week intervention, crocin significantly decreased Beck Depression Inventory (b − 6.66; 95% CI, − 9.88, − 3.45; P < 0.0001), Beck Anxiety Inventory (b − 4.35; 95% CI, − 5.94, − 2.75; P < 0.0001), general health questionnaire (b − 4.45; 95% CI, − 7.68, − 1.22; P = 0.008) and Pittsburgh Sleep Quality Index (b − 2.73; 95% CI, − 3.74, − 1.73; P < 0.0001) in patients under MMT, compared with the placebo. Crocin also significantly improved International Index of Erectile Functions (b 4.98; 95% CI, 2.08, 7.88; P = 0.001) rather than placebo. Conclusion Our findings indicated that taking crocin for 8 weeks by patients under MMT had beneficial effects on their mental health status. Crocin can be recommended as an adjunct to methadone in opioid withdrawal protocols because of the ability to improve the quality of life and decrease opioids side effects in these patients. This trial was registered in the Iranian website for clinical trials registry as http://www.irct.ir: IRCT2017110537243N1. Clinical trial registration number www.irct.ir: http://www.irct.ir: IRCT2017110537243N1.
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Affiliation(s)
| | - Hamid Reza Banafshe
- Department of Addiction studies, School of Medical, Kashan University of Medical Sciences, Kashan, Iran.,Department of Pharmacology, School of Medicine, Kashan University of Medical Sciences, Kashan, Iran.,Physiology Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | | | - Zatollah Asemi
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, I.R., Iran
| | - Amir Ghaderi
- Department of Addiction studies, School of Medical, Kashan University of Medical Sciences, Kashan, Iran
| | - Abdollah Omidi
- Department of clinical psychology, School of Medicine, Kashan University of Medical Science, Kashan, Iran.
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Dunn A, Whitmire B, Batch A, Fernando L, Rittmueller L. High Spending Growth Rates For Key Diseases In 2000-14 Were Driven By Technology And Demographic Factors. Health Aff (Millwood) 2019; 37:915-924. [PMID: 29863919 DOI: 10.1377/hlthaff.2017.1688] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We introduce a new source of detailed data on spending by medical condition to analyze US health care spending growth in the period 2000-14. We found that thirty conditions, which represented only 11.5 percent of all conditions studied, accounted for 42 percent of the real growth rate in per capita spending during this period, even though they accounted for only 13 percent of overall spending in 2000. Primary drivers of spending growth included the use of new technologies, a shift toward the provision of preventive-type services, and an aging and more obese population. The health benefits of many new technologies appeared to outweigh the associated expenditures on treatment, which indicates that these are cost-effective and provide a net value to society. However, while these technologies may be of value, new treatments are often more expensive than older ones.
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Affiliation(s)
- Abe Dunn
- Abe Dunn ( ) is an assistant chief economist in the Bureau of Economic Analysis, Department of Commerce, in Washington, D.C
| | - Bryn Whitmire
- Bryn Whitmire is a statistician in the Bureau of Economic Analysis
| | - Andrea Batch
- Andrea Batch is an economist in the Bureau of Economic Analysis, and a PhD student in the College of Information Studies, University of Maryland, in College Park
| | - Lasanthi Fernando
- Lasanthi Fernando is an economist in the Bureau of Economic Analysis
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Evidence for optimal HIV screening and testing intervals in HIV-negative individuals from various risk groups: A systematic review. ACTA ACUST UNITED AC 2018; 44:337-347. [PMID: 31517954 DOI: 10.14745/ccdr.v44i12a05] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Background Human immunodeficiency virus (HIV) testing plays a crucial role in Canada's HIV prevention and treatment efforts and is the first step to achieving the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets; however, how often Canadians, including populations at increased risk of HIV exposure, should be tested is unclear. We conducted a systematic literature review to determine the optimal HIV screening and testing intervals. Objective To examine the current evidence on HIV testing intervals in HIV-negative individuals from various risk groups and to assess the potential harms and patients' values and preferences associated with different testing frequencies. Methods We searched MEDLINE/PubMed, Scopus, Embase, the Cochrane Library, PsychINFO and EconLit for studies on different frequencies of HIV testing published between January 2000 and September 2016. An additional search was conducted for grey literature published between January 2000 and October 2016. Data extraction included study characteristics, participants, exposure, outcomes and economic variables. The quality of the studies was assessed and results summarized. Results Of the 2,702 articles identified from the searches, 27 met the inclusion criteria for review. This included assessments of HIV testing intervals among the general population, men who have sex with men, people who use injection drugs and sex workers. Optimal testing intervals across risk groups ranged from one-time testing to every three months. Data from modelling studies may not be representative of the Canadian context. Few studies identified potential harms of increased screening, specifically an increase in both false positive and false negative results. There were only two studies that addressed patient values and preferences concerning HIV screening, which suggested that the majority of participants were amenable to routine screening through their primary care provider. Conclusion There was insufficient evidence to support optimal HIV screening and testing intervals for different populations. Context-specific factors, such as budget allocation, human resources, local epidemiology, socioeconomic factors and risk behaviours, along with clinical judgement, inform whom and how often to screen, suggesting the need for research specific to Canada. Research on patient preferences as well as the benefits and harms of more frequent screening are also indicated.
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Li J, Peng L, Gilmour S, Gu J, Ruan Y, Zou H, Hao C, Hao Y, Lau JTF. A mathematical model of biomedical interventions for HIV prevention among men who have sex with men in China. BMC Infect Dis 2018; 18:600. [PMID: 30486800 PMCID: PMC6263536 DOI: 10.1186/s12879-018-3516-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 11/15/2018] [Indexed: 12/03/2022] Open
Abstract
Background The new HIV treatment guidelines in China recommend antiretroviral therapy (ART) for all people living with HIV, but significant gaps in implementation still exist. Pre-exposure prophylaxis (PrEP) can effectively reduce the risk of HIV transmission among men who have sex with men (MSM). This study assessed the epidemiological impact and cost effectiveness of PrEP, enhanced biomedical interventions and their combination among MSM in China. Methods A deterministic mathematical model was developed and projected over 20 years to assess the impact of the PrEP, biomedical interventions and their combinations. Incidence and prevalence of HIV were measured, and cost-effectiveness was assessed using incremental cost (international dollars, Int.$) per quality-adjusted life year (QALY) gained. Results A total of 0.78 million new HIV infections were estimated to occur over the next 20 years if no additional interventions are implemented among MSM. The PrEP-only strategy covering 25–75% of HIV-negative high-risk MSM can prevent 0.09–0.20 million (12.1–25.7%) new infections, at a cost of 17,277–18,452 Int.$/QALY. The optimal cost-effectiveness path is from test-and-treat to the combination strategy of test-and-treat and PrEP. Some strategies could almost eliminate new HIV infections over the next 20 years. Conclusions PrEP, test-and-treat, and their combinations among MSM are effective and cost-effective relative to current policy. PrEP is an important and cost-effective addition to current policy in China. Electronic supplementary material The online version of this article (10.1186/s12879-018-3516-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jinghua Li
- Department of Health Policy and Management & Sun Yat-sen Global Health Institute, School of Public Health and Institute of State Governance, Sun Yat-sen University, Guangzhou, China
| | - Liping Peng
- Department of Health Policy and Management, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Stuart Gilmour
- Graduate School of Public Health, St. Luke's International University, Tokyo, Japan.
| | - Jing Gu
- Department of Medical Statistics and Epidemiology & Sun Yat-sen Global Health Institute, School of Public Health and Institute of State Governance, Sun Yat-sen University, Guangzhou, China
| | - Yuhua Ruan
- Division of Virology and Immunology, National Center for AIDS/STD Control and Prevention (NCAIDS), Chinese Center for Disease Control and Prevention, Beijing, China
| | - Huachun Zou
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, China.,Kirby Institute, University of New South Wales, Sydney, Australia
| | - Chun Hao
- Department of Medical Statistics and Epidemiology & Sun Yat-sen Global Health Institute, School of Public Health and Institute of State Governance, Sun Yat-sen University, Guangzhou, China
| | - Yuantao Hao
- Department of Medical Statistics and Epidemiology & Sun Yat-sen Global Health Institute, School of Public Health and Institute of State Governance, Sun Yat-sen University, Guangzhou, China
| | - Joseph Tak-Fai Lau
- The School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
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Kasaie P, Radford M, Kapoor S, Jung Y, Hernandez Novoa B, Dowdy D, Shah M. Economic and epidemiologic impact of guidelines for early ART initiation irrespective of CD4 count in Spain. PLoS One 2018; 13:e0206755. [PMID: 30395635 PMCID: PMC6218062 DOI: 10.1371/journal.pone.0206755] [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] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 10/18/2018] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Emerging data suggest that early antiretroviral therapy (ART) could reduce serious AIDS and non-AIDS events and deaths but could also increase costs. In January 2016, the Spanish guidelines were updated to recommend ART at any CD4 count. However, the epidemiologic and economic impacts of early ART initiation in Spain remain unclear. METHODS The Johns Hopkins HIV Economic-Epidemiologic Mathematical Model (JHEEM) was utilized to estimate costs, transmissions, and outcomes in Spain over 20 years. We compared implementation of guidelines for early ART initiation to a counterfactual scenario deferring ART until CD4-counts fall below 350 cells/mm3. We additionally studied the impact of early ART initiation in combination with improvements to HIV screening, care linkage and engagement. RESULTS Early ART initiation (irrespective of CD4-count) is expected to avert 20,100 [95% Uncertainty Range (UR) 11,100-83,000] new HIV cases over the next two decades compared to delayed ART (28% reduction), at an incremental health system cost of €1.05 billion [€0.66 - €1.63] billion, and an incremental cost-effectiveness ratio (ICER) of €29,700 [€13,700 - €41,200] per QALY gained. Projected ICERs declined further over longer time horizon; e.g., an ICER of €12,691 over 30 years. Furthermore, the impact of early ART initiation was potentiated by improved HIV screening among high-risk individuals, averting an estimated 41,600 [23,200-172,200] HIV infections (a 58% decline) compared to delayed ART. CONCLUSIONS Recommendations for ART initiation irrespective of CD4-counts are cost-effective and could avert > 30% of new cases in Spain. Improving HIV diagnosis can amplify this impact.
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Affiliation(s)
- Parastu Kasaie
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - Sunaina Kapoor
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Younghee Jung
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - David Dowdy
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Maunank Shah
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
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Tang H, Mao Y, Tang W, Han J, Xu J, Li J. "Late for testing, early for antiretroviral therapy, less likely to die": results from a large HIV cohort study in China, 2006-2014. BMC Infect Dis 2018; 18:272. [PMID: 29895275 PMCID: PMC5998580 DOI: 10.1186/s12879-018-3158-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 05/22/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Timely HIV testing and initiation of antiretroviral therapy are two major determinants of survival for HIV-infected individuals. Our study aimed to explore the trend of late HIV/AIDS diagnoses and to assess the factors associated with these late diagnoses in China between 2006 and 2014. METHODS We used data from the Chinese Comprehensive Response Information Management System of HIV/AIDS (CRIMS). All individuals who tested positive for HIV between 2006 and 2014 in China and were at least 15 years of age were included. A late diagnosis was defined as an instance in which an individual was diagnosed as having AIDS or WHO stage 3 or 4 HIV/AIDS, or had a CD4 cell count less than 200 cells/mm3 at the time of diagnosis. RESULTS Among the 528,234 individuals (≥15 years old) newly diagnosed with HIV between 2006 and 2014, 179,700 (34.0%) people were considered to have received late diagnoses. The late diagnosis rate decreased from 33.9% in 2006 to 29.7% in 2014 (P < 0.01). Late diagnoses were more likely to be found among those who were 45-54 years old (adjusted odds ratio [aOR]: 3.25, 95% confidence interval [CI]: 3.17-3.34) or 55+ years old (OR: 2.94, 95% CI: 2.86-3.02), male (aOR: 1.15, 95% CI: 1.13,1.17), employed as a farmer or rural laborer (aOR: 1.13, 95% CI: 1.11-1.14), infected through blood or plasma transfusion (aOR: 4.18, 95% CI: 4.02, 4.35), diagnosed at hospitals (OR: 1.17, 95% CI: 1.15, 1.19), of Han ethnicity (aOR: 1.30, 95% CI: 1.28, 1.32), and married (OR: 1.12, 95% CI: 1.11,1.13). Of those people living with HIV (PLHIV) who received late diagnoses, 7.4%(8637) and 46.1%(28,462) ultimately died with or without receiving antiretroviral therapy within a year of diagnosis, respectively. CONCLUSION A large proportion of individuals with HIV/AIDS receive late diagnoses, and this proportion has witnessed a slight decline in recent years. Expanded testing is needed to increase early HIV diagnosis and antiretroviral therapy should be recommended to all diagnosed individuals as early as possible to reduce AIDS-related death.
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Affiliation(s)
- Houlin Tang
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yurong Mao
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
| | - Weiming Tang
- University of North Carolina at Chapel Hill Project-China, Guangzhou, China.,School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Jing Han
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Juan Xu
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Jian Li
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
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Shen M, Xiao Y, Rong L, Meyers LA, Bellan SE. The cost-effectiveness of oral HIV pre-exposure prophylaxis and early antiretroviral therapy in the presence of drug resistance among men who have sex with men in San Francisco. BMC Med 2018; 16:58. [PMID: 29688862 PMCID: PMC5914040 DOI: 10.1186/s12916-018-1047-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 03/28/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Poor adherence to either antiretroviral treatment (ART) or pre-exposure prophylaxis (PrEP) can promote drug resistance, though this risk is thought to be considerably higher for ART. In the population of men who have sex with men (MSM) in San Francisco, PrEP coverage reached 9.6% in 2014 and has continued to rise. Given the risk of drug resistance and high cost of second-line drugs, the costs and benefits of initiating ART earlier while expanding PrEP coverage remain unclear. METHODS We develop an infection-age-structured mathematical model and fit this model to the annual incidence of AIDS cases and deaths directly, and to resistance and demographic data indirectly. We investigate the impact of six various intervention scenarios (low, medium, or high PrEP coverage, with or without earlier ART) over the next 20 years. RESULTS Low (medium, high) PrEP coverage with earlier ART could prevent 22% (42%, 57%) of a projected 44,508 total new infections and 8% (26%, 41%) of a projected 18,426 new drug-resistant infections, and result in a gain of 43,649 (74,048, 103,270) QALYs over 20 years compared to the status quo, at a cost of $4745 ($78,811, $115,320) per QALY gained, respectively. CONCLUSIONS High PrEP coverage with earlier ART is expected to provide the greatest benefit but also entail the highest costs among the strategies considered. This strategy is cost-effective for the San Francisco MSM population, even considering the acquisition and transmission of ART-mediated drug resistance. However, without a substantial increase to San Francisco's annual HIV budget, the most advisable strategy may be initiating ART earlier, while maintaining current strategies of PrEP enrollment.
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Affiliation(s)
- Mingwang Shen
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, 710061, People's Republic of China.,School of Mathematics and Statistics, Xi'an Jiaotong University, Xi'an, 710049, People's Republic of China.,Department of Integrative Biology, The University of Texas at Austin, Austin, TX, 78712, USA
| | - Yanni Xiao
- School of Mathematics and Statistics, Xi'an Jiaotong University, Xi'an, 710049, People's Republic of China.
| | - Libin Rong
- Department of Mathematics, University of Florida, Gainesville, FL, 32611, USA
| | - Lauren Ancel Meyers
- Department of Integrative Biology, The University of Texas at Austin, Austin, TX, 78712, USA.,The Santa Fe Institute, Santa Fe, NM, 87501, USA
| | - Steven E Bellan
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, 30602, USA.,Center for Ecology of Infectious Diseases, University of Georgia, Athens, GA, 30602, 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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40
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Cost-effectiveness of alternative strategies for provision of HIV preexposure prophylaxis for people who inject drugs. AIDS 2018; 32:663-672. [PMID: 29334549 DOI: 10.1097/qad.0000000000001747] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Oral HIV preexposure prophylaxis (PrEP) has been recommended as a means of HIV prevention among people who inject drugs (PWIDs) but, at current prices, is unlikely to be cost-effective for all PWID. OBJECTIVE To determine the cost-effectiveness of alternative strategies for enrolling PWID in PrEP. DESIGN Dynamic network model that captures HIV transmission and progression among PWID in a representative US urban center. OUTCOME MEASURES HIV infections averted, discounted costs and quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. INTERVENTION We assume 25% PrEP coverage and investigate four strategies: first, random PWID are enrolled (Unselected Enrollment); second, individuals are randomly selected and enrolled together with their partners (Enroll Partners); third, individuals with the highest number of sexual and needle-sharing partnerships are enrolled (Most Partners); fourth, individuals with the greatest number of infected partners are enrolled (Most Positive Partners). RESULTS PrEP can achieve significant health benefits: compared with the status quo of no PrEP, the strategies gain 1114 QALYs (Unselected Enrollment), 2194 QALYs (Enroll Partners), 2481 QALYs (Most Partners), and 3046 QALYs (Most Positive Partners) over 20 years in a population of approximately 8500 people. The incremental cost-effectiveness ratio of each strategy compared with the status quo (cost per QALY gained) is $272 000 (Unselected Enrollment), $158 000 (Enroll Partners), $124 000 (Most Partners), and $101 000 (Most Positive Partners). All strategies except Unselected Enrollment are cost-effective according to WHO criteria. CONCLUSION Selection of high-risk PWID for PrEP can improve the cost-effectiveness of PrEP for PWID.
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Nosyk B, Min JE, Krebs E, Zang X, Compton M, Gustafson R, Barrios R, Montaner JSG. The Cost-Effectiveness of Human Immunodeficiency Virus Testing and Treatment Engagement Initiatives in British Columbia, Canada: 2011-2013. Clin Infect Dis 2018; 66:765-777. [PMID: 29028964 PMCID: PMC5850008 DOI: 10.1093/cid/cix832] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 09/22/2017] [Indexed: 01/03/2023] Open
Abstract
Background Recognition of the secondary preventive benefits of antiretroviral therapy (ART) has mobilized global efforts to "seek, test, treat, and retain" people living with human immunodeficiency virus [HIV]/AIDS (PLHIV) in HIV care. We aimed to determine the cost-effectiveness of a set of HIV testing and treatment engagement interventions initiated in British Columbia, Canada, in 2011-2013. Methods Using a previously validated dynamic HIV transmission model, linked individual-level health administrative data for PLHIV, and aggregate-level HIV testing data, we estimated the cost-effectiveness of primary care testing (hospital, emergency department [ED], outpatient), ART initiation, and ART retention initiatives vs a counterfactual scenario that approximated the status quo. HIV incidence, mortality, costs (in 2015$CDN), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios were estimated. Analyses were executed over 5- to 25-year time horizons from a government-payer perspective. Results ED testing was the best value at $30216 per QALY gained and had the greatest impact on incidence and mortality among PLHIV, while ART initiation provided the greatest QALY gains. The ART retention initiative was not cost-effective. Delivered in combination at the observed scale and sustained throughout the study period, we estimated a 12.8% reduction in cumulative HIV incidence and a 4.7% reduction in deaths among PLHIV at $55258 per QALY gained. Results were most sensitive to uncertainty in the number of undiagnosed PLHIV. Conclusions HIV testing and ART initiation interventions were cost-effective, while the ART retention intervention was not. Developing strategies to reengage PLHIV lost to care is a priority moving forward.
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Affiliation(s)
- Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, Vancouver
- Faculty of Health Sciences, Simon Fraser University, Burnaby
| | - Jeong E Min
- BC Centre for Excellence in HIV/AIDS, Vancouver
| | | | - Xiao Zang
- BC Centre for Excellence in HIV/AIDS, Vancouver
| | - Miranda Compton
- Vancouver Coastal Health Authority, University of British Columbia, Vancouver, British Columbia, Canada
| | - Reka Gustafson
- Vancouver Coastal Health Authority, University of British Columbia, Vancouver, British Columbia, Canada
| | - Rolando Barrios
- BC Centre for Excellence in HIV/AIDS, Vancouver
- Vancouver Coastal Health Authority, University of British Columbia, Vancouver, British Columbia, Canada
| | - Julio S G Montaner
- BC Centre for Excellence in HIV/AIDS, Vancouver
- Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Assoumou SA, Tasillo A, Leff JA, Schackman BR, Drainoni ML, Horsburgh CR, Barry MA, Regis C, Kim AY, Marshall A, Saxena S, Smith PC, Linas BP. Cost-Effectiveness of One-Time Hepatitis C Screening Strategies Among Adolescents and Young Adults in Primary Care Settings. Clin Infect Dis 2018; 66:376-384. [PMID: 29020317 PMCID: PMC5848253 DOI: 10.1093/cid/cix798] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 09/08/2017] [Indexed: 12/15/2022] Open
Abstract
Background High hepatitis C virus (HCV) rates have been reported in young people who inject drugs (PWID). We evaluated the clinical benefit and cost-effectiveness of testing among youth seen in communities with a high overall number of reported HCV cases. Methods We developed a decision analytic model to project quality-adjusted life years (QALYs), costs (2016 US$), and incremental cost-effectiveness ratios (ICERs) of 9 strategies for 1-time testing among 15- to 30-year-olds seen at urban community health centers. Strategies differed in 3 ways: targeted vs routine testing, rapid finger stick vs standard venipuncture, and ordered by physician vs by counselor/tester using standing orders. We performed deterministic and probabilistic sensitivity analyses (PSA) to evaluate uncertainty. Results Compared to targeted risk-based testing (current standard of care), routine testing increased the lifetime medical cost by $80 and discounted QALYs by 0.0013 per person. Across all strategies, rapid testing provided higher QALYs at a lower cost per QALY gained and was always preferred. Counselor-initiated routine rapid testing was associated with an ICER of $71000/QALY gained. Results were sensitive to offer and result receipt rates. Counselor-initiated routine rapid testing was cost-effective (ICER <$100000/QALY) unless the prevalence of PWID was <0.59%, HCV prevalence among PWID was <16%, reinfection rate was >26 cases per 100 person-years, or reflex confirmatory testing followed all reactive venipuncture diagnostics. In PSA, routine rapid testing was the optimal strategy in 90% of simulations. Conclusions Routine rapid HCV testing among 15- to 30-year-olds may be cost-effective when the prevalence of PWID is >0.59%.
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Affiliation(s)
- Sabrina A Assoumou
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Massachusetts
- Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Massachusetts
| | - Abriana Tasillo
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Massachusetts
| | - Jared A Leff
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York
| | - Bruce R Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York
| | - Mari-Lynn Drainoni
- Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Massachusetts
- Department of Health Law, Policy and Management, Boston University School of Public Health
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford
| | - C Robert Horsburgh
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Massachusetts
- Department of Epidemiology, Boston University School of Public Health
| | - M Anita Barry
- Infectious Disease Bureau, Boston Public Health Commission
| | - Craig Regis
- Infectious Disease Bureau, Boston Public Health Commission
| | - Arthur Y Kim
- Division of Infectious Diseases, Massachusetts General Hospital
| | - Alison Marshall
- Boston College Connell School of Nursing
- STD/HIV Prevention Center of New England, Jamaica Plain
- South Boston Community Health Center
| | | | - Peter C Smith
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Massachusetts
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Massachusetts
| | - Benjamin P Linas
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Massachusetts
- Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Massachusetts
- Department of Epidemiology, Boston University School of Public Health
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DiNenno EA, Prejean J, Delaney KP, Bowles K, Martin T, Tailor A, Dumitru G, Mullins MM, Hutchinson A, Lansky A. Evaluating the Evidence for More Frequent Than Annual HIV Screening of Gay, Bisexual, and Other Men Who Have Sex With Men in the United States: Results From a Systematic Review and CDC Expert Consultation. Public Health Rep 2017; 133:3-21. [PMID: 29182894 PMCID: PMC5805092 DOI: 10.1177/0033354917738769] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The Centers for Disease Control and Prevention (CDC) recommended in 2006 that sexually active gay, bisexual, and other men who have sex with men (MSM) be screened for human immunodeficiency virus (HIV) at least annually. A workgroup comprising CDC and external experts conducted a systematic review of the literature, including benefits, harms, acceptability, and feasibility of annual versus more frequent screening among MSM, to determine whether evidence was sufficient to change the current recommendation. Four consultations with managers of public and nonprofit HIV testing programs, clinics, and mathematical modeling experts were conducted to provide input on the programmatic and scientific evidence. Mathematical models predicted that more frequent than annual screening of MSM could prevent some new HIV infections and would be more cost-effective than annual screening, but this evidence was considered insufficient due to study design. Evidence supports CDC's current recommendation that sexually active MSM be screened at least annually. However, some MSM might benefit from more frequent screening. Future research should evaluate which MSM subpopulations would benefit most from more frequent HIV screening.
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Affiliation(s)
- Elizabeth A. DiNenno
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Joseph Prejean
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kevin P. Delaney
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kristina Bowles
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Tricia Martin
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Amrita Tailor
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Gema Dumitru
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mary M. Mullins
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Angela Hutchinson
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Amy Lansky
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Glick M, Greenberg BL. The Role of Oral Health Care Professionals in Providing Medical Services. J Dent Educ 2017; 81:eS180-eS185. [DOI: 10.21815/jde.017.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 02/17/2017] [Indexed: 12/19/2022]
Affiliation(s)
| | - Barbara L. Greenberg
- Department of Epidemiology and Community Health; School of Health Sciences and Practice, New York Medical College
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Nosyk B, Zang X, Min JE, Krebs E, Lima VD, Milloy MJ, Shoveller J, Barrios R, Harrigan PR, Kerr T, Wood E, Montaner JSG. Relative effects of antiretroviral therapy and harm reduction initiatives on HIV incidence in British Columbia, Canada, 1996-2013: a modelling study. Lancet HIV 2017; 4:e303-e310. [PMID: 28366707 PMCID: PMC5494273 DOI: 10.1016/s2352-3018(17)30045-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 01/16/2017] [Accepted: 01/20/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Antiretroviral therapy (ART) and harm reduction services have been cited as key contributors to control of HIV epidemics; however, the specific contribution of ART has been questioned due to uncertainty of its true efficacy on HIV transmission through needle sharing. We aimed to isolate the independent effects of harm reduction services (opioid agonist treatment uptake and needle distribution volumes) and ART on HIV transmission via needle sharing in British Columbia, Canada, from 1996 to 2013. METHODS We used comprehensive linked individual health administrative and registry data for the population of diagnosed people living with HIV in British Columbia to populate a dynamic, compartmental transmission model to simulate the HIV/AIDS epidemic in British Columbia from 1996 to 2013. We estimated HIV incidence, mortality, and quality-adjusted life-years (QALYs). We also estimated scenarios designed to isolate the independent effects of harm reduction services and ART, assuming 50% (10-90%) efficacy, in reducing HIV incidence through needle sharing, and we investigated structural and parameter uncertainty. FINDINGS We estimate that 3204 (upper bound-lower bound 2402-4589) incident HIV cases were averted between 1996 and 2013 as a result of the combined effect of the expansion of harm reduction services and ART coverage on HIV transmission via needle sharing. In a hypothetical scenario assuming ART had zero effect on transmission through needle sharing, we estimated harm reduction services alone would have accounted for 77% (upper bound-lower bound 62-95%) of averted HIV incidence. In a separate hypothetical scenario where harm reduction services remained at 1996 levels, we estimated ART alone would have accounted for 44% (10-67%) of averted HIV incidence. As a result of high distribution volumes, needle distribution predominantly accounted for incidence reductions attributable to harm reduction but opioid agonist treatment provided substantially greater QALY gains. INTERPRETATION If the true efficacy of ART in preventing HIV transmission through needle sharing is closer to its efficacy in sexual transmission, ART's effect on incident cases averted could be greater than that of harm reduction. Nonetheless, harm reduction services had a vital role in reducing HIV incidence in British Columbia, and should be viewed as essential and cost-effective tools in combination implementation strategies to reduce the public health and economic burden of HIV/AIDS. FUNDING BC Ministry of Health; National Institutes of Health (R01DA041747); Genome Canada (142HIV).
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Affiliation(s)
- Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.
| | - Xiao Zang
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Jeong E Min
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada
| | - Emanuel Krebs
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada
| | - Viviane D Lima
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - M-J Milloy
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jean Shoveller
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Rolando Barrios
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - P Richard Harrigan
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Thomas Kerr
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Evan Wood
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Julio S G Montaner
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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Gamble T, Branson B, Donnell D, Hall HI, King G, Cutler B, Hader S, Burns D, Leider J, Wood AF, G Volpp K, Buchacz K, El-Sadr WM. Design of the HPTN 065 (TLC-Plus) study: A study to evaluate the feasibility of an enhanced test, link-to-care, plus treat approach for HIV prevention in the United States. Clin Trials 2017. [PMID: 28627929 PMCID: PMC5639958 DOI: 10.1177/1740774517711682] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background/Aims HIV continues to be a major public health threat in the United States, and mathematical modeling has demonstrated that the universal effective use of antiretroviral therapy among all HIV-positive individuals (i.e. the “test and treat” approach) has the potential to control HIV. However, to accomplish this, all the steps that define the HIV care continuum must be achieved at high levels, including HIV testing and diagnosis, linkage to and retention in clinical care, antiretroviral medication initiation, and adherence to achieve and maintain viral suppression. The HPTN 065 (Test, Link-to-Care Plus Treat [TLC-Plus]) study was designed to determine the feasibility of the “test and treat” approach in the United States. Methods HPTN 065 was conducted in two intervention communities, Bronx, NY, and Washington, DC, along with four non-intervention communities, Chicago, IL; Houston, TX; Miami, FL; and Philadelphia, PA. The study consisted of five components: (1) exploring the feasibility of expanded HIV testing via social mobilization and the universal offer of testing in hospital settings, (2) evaluating the effectiveness of financial incentives to increase linkage to care, (3) evaluating the effectiveness of financial incentives to increase viral suppression, (4) evaluating the effectiveness of a computer-delivered intervention to decrease risk behavior in HIV-positive patients in healthcare settings, and (5) administering provider and patient surveys to assess knowledge and attitudes regarding the use of antiretroviral therapy for prevention and the use of financial incentives to improve health outcomes. The study used observational cohorts, cluster and individual randomization, and made novel use of the existing national HIV surveillance data infrastructure. All components were developed with input from a community advisory board, and pragmatic methods were used to implement and assess the outcomes for each study component. Results A total of 76 sites in Washington, DC, and the Bronx, NY, participated in the study: 37 HIV test sites, including 16 hospitals, and 39 HIV care sites. Between September 2010 and December 2014, all study components were successfully implemented at these sites and resulted in valid outcomes. Our pragmatic approach to the study design, implementation, and the assessment of study outcomes allowed the study to be conducted within established programmatic structures and processes. In addition, it was successfully layered on the ongoing standard of care and existing data infrastructure without disrupting health services. Conclusion The HPTN 065 study demonstrated the feasibility of implementing and evaluating a multi-component “test and treat” trial that included a large number of community sites and involved pragmatic approaches to study implementation and evaluation.
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Affiliation(s)
- Theresa Gamble
- 1 Science Facilitation Department, HPTN Leadership and Operations Center, FHI 360, Durham, NC, USA
| | | | - Deborah Donnell
- 3 Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - H Irene Hall
- 4 Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Georgette King
- 1 Science Facilitation Department, HPTN Leadership and Operations Center, FHI 360, Durham, NC, USA
| | - Blayne Cutler
- 5 Public Health Foundation Enterprises, La Puente, CA, USA
| | - Shannon Hader
- 6 DC Department of Health, HIV/AIDS, Hepatitis, STD and TB Administration, Washington, DC, USA
| | - David Burns
- 7 Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Jason Leider
- 8 Albert Einstein College of Medicine, New York, NY, USA
| | | | - Kevin G Volpp
- 10 Center for Health Incentives and Behavioral Economics; Perelman School of Medicine and the Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Kate Buchacz
- 4 Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Wafaa M El-Sadr
- 11 ICAP at Columbia University, Mailman School of Public Health, New York, NY, USA
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Estimation of the cost-effectiveness of HIV prevention portfolios for people who inject drugs in the United States: A model-based analysis. PLoS Med 2017; 14:e1002312. [PMID: 28542184 PMCID: PMC5443477 DOI: 10.1371/journal.pmed.1002312] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 04/28/2017] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The risks of HIV transmission associated with the opioid epidemic make cost-effective programs for people who inject drugs (PWID) a public health priority. Some of these programs have benefits beyond prevention of HIV-a critical consideration given that injection drug use is increasing across most United States demographic groups. To identify high-value HIV prevention program portfolios for US PWID, we consider combinations of four interventions with demonstrated efficacy: opioid agonist therapy (OAT), needle and syringe programs (NSPs), HIV testing and treatment (Test & Treat), and oral HIV pre-exposure prophylaxis (PrEP). METHODS AND FINDINGS We adapted an empirically calibrated dynamic compartmental model and used it to assess the discounted costs (in 2015 US dollars), health outcomes (HIV infections averted, change in HIV prevalence, and discounted quality-adjusted life years [QALYs]), and incremental cost-effectiveness ratios (ICERs) of the four prevention programs, considered singly and in combination over a 20-y time horizon. We obtained epidemiologic, economic, and health utility parameter estimates from the literature, previously published models, and expert opinion. We estimate that expansions of OAT, NSPs, and Test & Treat implemented singly up to 50% coverage levels can be cost-effective relative to the next highest coverage level (low, medium, and high at 40%, 45%, and 50%, respectively) and that OAT, which we assume to have immediate and direct health benefits for the individual, has the potential to be the highest value investment, even under scenarios where it prevents fewer infections than other programs. Although a model-based analysis can provide only estimates of health outcomes, we project that, over 20 y, 50% coverage with OAT could avert up to 22,000 (95% CI: 5,200, 46,000) infections and cost US$18,000 (95% CI: US$14,000, US$24,000) per QALY gained, 50% NSP coverage could avert up to 35,000 (95% CI: 8,900, 43,000) infections and cost US$25,000 (95% CI: US$7,000, US$76,000) per QALY gained, 50% Test & Treat coverage could avert up to 6,700 (95% CI: 1,200, 16,000) infections and cost US$27,000 (95% CI: US$15,000, US$48,000) per QALY gained, and 50% PrEP coverage could avert up to 37,000 (22,000, 58,000) infections and cost US$300,000 (95% CI: US$162,000, US$667,000) per QALY gained. When coverage expansions are allowed to include combined investment with other programs and are compared to the next best intervention, the model projects that scaling OAT coverage up to 50%, then scaling NSP coverage to 50%, then scaling Test & Treat coverage to 50% can be cost-effective, with each coverage expansion having the potential to cost less than US$50,000 per QALY gained relative to the next best portfolio. In probabilistic sensitivity analyses, 59% of portfolios prioritized the addition of OAT and 41% prioritized the addition of NSPs, while PrEP was not likely to be a priority nor a cost-effective addition. Our findings are intended to be illustrative, as data on achievable coverage are limited and, in practice, the expansion scenarios considered may exceed feasible levels. We assumed independence of interventions and constant returns to scale. Extensive sensitivity analyses allowed us to assess parameter sensitivity, but the use of a dynamic compartmental model limited the exploration of structural sensitivities. CONCLUSIONS We estimate that OAT, NSPs, and Test & Treat, implemented singly or in combination, have the potential to effectively and cost-effectively prevent HIV in US PWID. PrEP is not likely to be cost-effective in this population, based on the scenarios we evaluated. While local budgets or policy may constrain feasible coverage levels for the various interventions, our findings suggest that investments in combined prevention programs can substantially reduce HIV transmission and improve health outcomes among PWID.
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Zang X, Tang H, Min JE, Gu D, Montaner JSG, Wu Z, Nosyk B. Cost-Effectiveness of the 'One4All' HIV Linkage Intervention in Guangxi Zhuang Autonomous Region, China. PLoS One 2016; 11:e0167308. [PMID: 27893864 PMCID: PMC5125690 DOI: 10.1371/journal.pone.0167308] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 11/13/2016] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND In Guangxi Zhuang Autonomous Region, China, an estimated 80% of newly-identified antiretroviral therapy (ART)-eligible patients are not engaged in ART. Delayed ART uptake ultimately translates into high rates of HIV morbidity, mortality, and transmission. To enhance HIV testing receipt and subsequent treatment uptake in Guangxi, the Chinese Center for Disease Control and Prevention (CDC) executed a cluster-randomized trial to assess the effectiveness and cost-effectiveness of a streamlined HIV testing algorithm (the One4All intervention) in 12 county-level hospitals. OBJECTIVE To determine the incremental cost-effectiveness of the One4All intervention delivered at county hospitals in Guangxi, China, compared to the current standard of care (SOC). PERSPECTIVE Health System. TIME HORIZON 1-, 5-and 25-years. METHODS We adapted a dynamic, compartmental HIV transmission model to simulate HIV transmission and progression in Guangxi, China and identify the economic impact and health benefits of implementing the One4All intervention in all Guangxi hospitals. The One4All intervention algorithm entails rapid point-of-care HIV screening, CD4 and viral load testing of individuals presenting for HIV screening, with same-day results and linkage to counselling. We populated the model with data from the One4All trial (CTN-0056), China CDC HIV registry and published reports. Model outcomes were HIV incidence, mortality, costs, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER) of the One4All intervention compared to SOC. RESULTS The One4All testing intervention was more costly than SOC (CNY 2,182 vs. CNY 846), but facilitated earlier ART access, resulting in delayed disease progression and mortality. Over a 25-year time horizon, we estimated that introducing One4All in Guangxi would result in 802 averted HIV cases and 1629 averted deaths at an ICER of CNY 11,678 per QALY gained. Sensitivity analysis revealed that One4All remained cost-effective at even minimal levels of effectiveness. Results were robust to changes to a range of parameters characterizing the HIV epidemic over time. CONCLUSIONS The One4All HIV testing strategy was highly cost-effective by WHO standards, and should be prioritized for widespread implementation in Guangxi, China. Integrating the intervention within a broader combination prevention strategy would enhance the public health response to HIV/AIDS in Guangxi.
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Affiliation(s)
- Xiao Zang
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Houlin Tang
- The National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Jeong Eun Min
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Diane Gu
- The National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Julio S. G. Montaner
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Zunyou Wu
- The National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Bohdan Nosyk
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- * E-mail:
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Drabo EF, Hay JW, Vardavas R, Wagner ZR, Sood N. A Cost-effectiveness Analysis of Preexposure Prophylaxis for the Prevention of HIV Among Los Angeles County Men Who Have Sex With Men. Clin Infect Dis 2016; 63:1495-1504. [PMID: 27558571 DOI: 10.1093/cid/ciw578] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 07/21/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Substantial gaps remain in understanding the trade-offs between the costs and benefits of choosing alternative human immunodeficiency virus (HIV) prevention strategies, including test-and-treat (expanded HIV testing combined with immediate treatment) and PrEP (initiation of preexposure prophylaxis by high-risk uninfected individuals) strategies. METHODS We develop a mathematical epidemiological model to simulate HIV incidence among men residing in Los Angeles County, California, aged 15-65 years, who have sex with men. We combine these incidence data with an economic model to estimate the discounted cost, effectiveness (quality-adjusted life-years [QALYs]), and incremental cost-effectiveness ratios of various HIV prevention strategies using a societal perspective and a lifetime horizon. RESULTS PrEP and test-and-treat yield the largest reductions in HIV incidence, and are highly cost-effective ($27 863/QALY and $19 302/QALY, respectively) relative to status quo and at a US willingness-to-pay threshold of $150 000/QALY saved. Status quo and 12 test-and-treat and PrEP strategies determine the frontier for efficient decisions. More aggressive strategies are costlier, but more effective, albeit with diminishing returns. The relative effectiveness of PrEP is sensitive to the initial HIV prevalence rate, PrEP and antiretroviral therapy (ART) adherence and initiation rates, the probabilities of HIV transmission, and the rates of sexual partner mixing. CONCLUSIONS PrEP and test-and-treat offer cost-effective alternatives to the status quo. The success of these strategies depends on ART and PrEP adherence and initiation rates. The lack of evidence on adherence behaviors toward PrEP, therefore, warrants further studies.
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Affiliation(s)
- Emmanuel F Drabo
- Department of Pharmaceutical and Health Economics, School of Pharmacy
| | - Joel W Hay
- Leonard D. Schaeffer Center for Health Policy, University of Southern California, Los Angeles
| | | | | | - Neeraj Sood
- Leonard D. Schaeffer Center for Health Policy, University of Southern California, Los Angeles
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Impact of early treatment programs on HIV epidemics: An immunity-based mathematical model. Math Biosci 2016; 280:38-49. [PMID: 27474205 DOI: 10.1016/j.mbs.2016.07.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 07/19/2016] [Accepted: 07/20/2016] [Indexed: 11/24/2022]
Abstract
While studies on pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) have demonstrated substantial advantages in controlling HIV transmission, the overall benefits of the programs with early initiation of antiretroviral therapy (ART) have not been fully understood and are still on debate. Here, we develop an immunity-based (CD4+ T cell count based) mathematical model to study the impacts of early treatment programs on HIV epidemics and the overall community-level immunity. The model is parametrized using the HIV prevalence data from South Africa and fully analyzed for stability of equilibria and infection persistence criteria. Using our model, we evaluate the effects of early treatment on the new infection transmission, disease death, basic reproduction number, HIV prevalence, and the community-level immunity. Our model predicts that the programs with early treatments significantly reduce the new infection transmission and increase the community-level immunity, but the treatments alone may not be enough to eliminate HIV epidemics. These findings, including the community-level immunity, might provide helpful information for proper implementation of HIV treatment programs.
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