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Gandhi AR, Hyle EP, Scott JA, Lee JS, Shebl FM, Joska JA, Andersen LS, O'Cleirigh C, Safren SA, Freedberg KA. The Clinical Impact and Cost-Effectiveness of Clinic-Based Cognitive Behavioral Therapy for People With HIV, Depression, and Virologic Failure in South Africa. J Acquir Immune Defic Syndr 2023; 93:333-342. [PMID: 37079899 PMCID: PMC10287047 DOI: 10.1097/qai.0000000000003205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 03/06/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Depression affects 25%-30% of people with HIV (PWH) in the Republic of South Africa (RSA) and is associated with both antiretroviral therapy (ART) nonadherence and increased mortality. We evaluated the cost-effectiveness of task-shifted, cognitive behavioral therapy (CBT) for PWH with diagnosed depression and virologic failure from a randomized trial in RSA. SETTING RSA. METHODS Using the Cost-Effectiveness of Preventing AIDS Complications model, we simulated both trial strategies: enhanced treatment as usual (ETAU) and ETAU plus CBT for ART adherence and depression (CBT-AD; 8 sessions plus 2 follow-ups). In the trial, viral suppression at 1 year was 20% with ETAU and 32% with CBT-AD. Model inputs included mean initial age (39 years) and CD4 count (214/μL), ART costs ($7.5-22/mo), and CBT costs ($29/session). We projected 5- and 10-year viral suppression, quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs: $/QALY [discounted 3%/yr]; cost-effectiveness threshold: ≤$2545/QALY [0.5× per capita GDP]). In sensitivity analyses, we determined how input parameter variation affected cost-effectiveness. RESULTS Model-projected 5- and 10-year viral suppression were 18.9% and 8.7% with ETAU and 21.2% and 9.7% with CBT-AD, respectively. Compared with ETAU, CBT-AD would increase discounted life expectancy from 4.12 to 4.68 QALYs and costs from $6210/person to $6670/person (incremental cost-effectiveness ratio: $840/QALY). CBT-AD would remain cost-effective unless CBT-AD cost >$70/session and simultaneously improved 1-year viral suppression by ≤4% compared with ETAU. CONCLUSIONS CBT for PWH with depression and virologic failure in RSA could improve life expectancy and be cost-effective. Such targeted mental health interventions should be integrated into HIV care.
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Affiliation(s)
- Aditya R. Gandhi
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Emily P. Hyle
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Center for AIDS Research, Harvard University, Cambridge, MA
| | - Justine A. Scott
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Jasper S. Lee
- Harvard Medical School, Boston, MA
- Department of Psychology, University of Miami, Miami, FL
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Fatma M. Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - John A. Joska
- HIV Mental Health Research Unit, Department of Psychiatry, University of Cape Town, Cape Town, South Africa
| | - Lena S. Andersen
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark; and
| | - Conall O'Cleirigh
- Harvard Medical School, Boston, MA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | | | - Kenneth A. Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Center for AIDS Research, Harvard University, Cambridge, MA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA
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Luz PM, Deshpande V, Kazemian P, Scott JA, Shebl FM, Spaeth H, Pimenta C, Stern M, Pereira G, Struchiner CJ, Grinsztejn B, Veloso VG, Freedberg KA. Impact of pre-exposure prophylaxis uptake among gay, bisexual, and other men who have sex with men in urban centers in Brazil: a modeling study. BMC Public Health 2023; 23:1128. [PMID: 37308858 PMCID: PMC10262537 DOI: 10.1186/s12889-023-15994-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 05/23/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Men who have sex with men (MSM) in Brazil remain disproportionately affected by HIV. We estimated the potential incidence reduction by five years with increased uptake of publicly-funded, daily, oral tenofovir/emtricitabine (TDF/FTC) for HIV pre-exposure prophylaxis (PrEP) among MSM using the Cost Effectiveness of Preventing AIDS Complications microsimulation model. We used national data, local studies, and literature to inform model parameters for three cities: Rio de Janeiro, Salvador, and Manaus. RESULTS In Rio de Janero, a PrEP intervention achieving 10% uptake within 60 months would decrease incidence by 2.3% whereas achieving 60% uptake within 24 months would decrease incidence by 29.7%; results were similar for Salvador and Manaus. In sensitivity analyses, decreasing mean age at PrEP initiation from 33 to 21 years increased incidence reduction by 34%; a discontinuation rate of 25% per year decreased it by 12%. CONCLUSION Targeting PrEP to young MSM and minimizing discontinuation could substantially increase PrEP's impact.
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Affiliation(s)
- Paula M Luz
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Avenida Brasil 4365, Rio de Janeiro, 21040-360, Brazil.
| | - Vijeta Deshpande
- Medical Practice Evaluation Center, Massachusetts General Hospital, 100 Cambridge Street, Suite 1684, Boston, MA, 02114, USA
| | - Pooyan Kazemian
- Department of Operations, Weatherhead School of Management, Case Western Reserve University, 11119 Bellflower Road, Cleveland, OH, 44106, USA
| | - Justine A Scott
- Medical Practice Evaluation Center, Massachusetts General Hospital, 100 Cambridge Street, Suite 1684, Boston, MA, 02114, USA
| | - Fatma M Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, 100 Cambridge Street, Suite 1684, Boston, MA, 02114, USA
| | - Hailey Spaeth
- Medical Practice Evaluation Center, Massachusetts General Hospital, 100 Cambridge Street, Suite 1684, Boston, MA, 02114, USA
| | - Cristina Pimenta
- Ministry of Health of Brazil, SRTVN Quadra 701, Lote D, Edifício PO700, 5º Andar, Brasília/DFBrasilia, 70719-040, Brazil
| | - Madeline Stern
- Medical Practice Evaluation Center, Massachusetts General Hospital, 100 Cambridge Street, Suite 1684, Boston, MA, 02114, USA
| | - Gerson Pereira
- Ministry of Health of Brazil, SRTVN Quadra 701, Lote D, Edifício PO700, 5º Andar, Brasília/DFBrasilia, 70719-040, Brazil
| | | | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Avenida Brasil 4365, Rio de Janeiro, 21040-360, Brazil
| | - Valdilea G Veloso
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Avenida Brasil 4365, Rio de Janeiro, 21040-360, Brazil
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, 100 Cambridge Street, Suite 1684, Boston, MA, 02114, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
- Harvard University Center for AIDS Research, Harvard Medical School, 42 Church Street, Cambridge, MA, 02138, USA
- Division of General Internal Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
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3
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Resch SC, Foote JHA, Wirth KE, Lasry A, Scott JA, Moore J, Shebl FM, Gaolathe T, Feser MK, Lebelonyane R, Hyle EP, Mmalane MO, Bachanas P, Yu L, Makhema JM, Holme MP, Essex M, Alwano MG, Lockman S, Freedberg KA. Health Impact and Cost-Effectiveness of HIV Testing, Linkage, and Early Antiretroviral Treatment in the Botswana Combination Prevention Project. J Acquir Immune Defic Syndr 2022; 90:399-407. [PMID: 35420554 PMCID: PMC9295776 DOI: 10.1097/qai.0000000000002996] [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: 10/19/2021] [Accepted: 03/18/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The Botswana Combination Prevention Project tested the impact of combination prevention (CP) on HIV incidence in a community-randomized trial. Each trial arm had ∼55,000 people, 26% HIV prevalence, and 72% baseline ART coverage. Results showed intensive testing and linkage campaigns, expanded antiretroviral treatment (ART), and voluntary male medical circumcision referrals increased coverage and decreased incidence over ∼29 months of follow-up. We projected lifetime clinical impact and cost-effectiveness of CP in this population. SETTING Rural and periurban communities in Botswana. METHODS We used the Cost-Effectiveness of Preventing AIDS Complications model to estimate lifetime health impact and cost of (1) earlier ART initiation and (2) averting an HIV infection, which we applied to incremental ART initiations and averted infections calculated from trial data. We determined the incremental cost-effectiveness ratio [US$/quality-adjusted life-years (QALY)] for CP vs. standard of care. RESULTS In CP, 1418 additional people with HIV initiated ART and an additional 304 infections were averted. For each additional person started on ART, life expectancy increased 0.90 QALYs and care costs increased by $869. For each infection averted, life expectancy increased 2.43 QALYs with $9200 in care costs saved. With CP, an additional $1.7 million were spent on prevention and $1.2 million on earlier treatment. These costs were mostly offset by decreased care costs from averted infections, resulting in an incremental cost-effectiveness ratio of $79 per QALY. CONCLUSIONS Enhanced HIV testing, linkage, and early ART initiation improve life expectancy, reduce transmission, and can be cost-effective or cost-saving in settings like Botswana.
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Affiliation(s)
- Stephen C. Resch
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Kresge 3 & 4 Floors, Boston, MA 02115, USA
| | - Julia H. A. Foote
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA 02114, USA
| | - Kathleen E. Wirth
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, 651 Huntington Avenue, Boston, MA 02115, USA
| | - Arielle Lasry
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329, USA
| | - Justine A. Scott
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA 02114, USA
| | - Janet Moore
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329, USA
| | - Fatma M. Shebl
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA 02114, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Tendani Gaolathe
- Botswana-Harvard AIDS Institute Partnership, Princess Marina Hospital, Plot No. 1836, Northring Road, Gaborone, Botswana
| | - Mary K. Feser
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA 02114, USA
| | - Refeletswe Lebelonyane
- Botswana Ministry of Health and Wellness, Plot 54609, 24 Amos Street, Government Enclave, Gaborone, Botswana
| | - Emily P. Hyle
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA 02114, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
- Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02144, USA
- Harvard University Center for AIDS Research, 42 Church Street, Cambridge, MA 02138, USA
| | - Mompati O. Mmalane
- Botswana-Harvard AIDS Institute Partnership, Princess Marina Hospital, Plot No. 1836, Northring Road, Gaborone, Botswana
| | - Pamela Bachanas
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329, USA
| | - Liyang Yu
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA 02114, USA
| | - Joseph M. Makhema
- Botswana-Harvard AIDS Institute Partnership, Princess Marina Hospital, Plot No. 1836, Northring Road, Gaborone, Botswana
| | - Molly Pretorius Holme
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, 651 Huntington Avenue, Boston, MA 02115, USA
| | - Max Essex
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, 651 Huntington Avenue, Boston, MA 02115, USA
- Botswana-Harvard AIDS Institute Partnership, Princess Marina Hospital, Plot No. 1836, Northring Road, Gaborone, Botswana
| | | | - Shahin Lockman
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, 651 Huntington Avenue, Boston, MA 02115, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
- Botswana-Harvard AIDS Institute Partnership, Princess Marina Hospital, Plot No. 1836, Northring Road, Gaborone, Botswana
- Division of Infectious Diseases, Brigham and Women’s Hospital, 45 Francis Street, 2 Floor, Boston, MA 02115, USA
| | - Kenneth A. Freedberg
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Kresge 3 & 4 Floors, Boston, MA 02115, USA
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA 02114, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
- Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02144, USA
- Harvard University Center for AIDS Research, 42 Church Street, Cambridge, MA 02138, USA
- Division of General Internal Medicine, Massachusetts General Hospital, 50 Staniford Street, 9 Floor, Boston, MA 02114, USA
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Kazemian P, Ding DD, Scott JA, Feser MK, Biello K, Thomas BE, Dange A, Bedoya CA, Balu V, Rawat S, Kumarasamy N, Mimiaga MJ, O'Cleirigh C, Weinstein MC, Kumar JP, Kumar S, Mayer KH, Safren SA, Freedberg KA. The cost-effectiveness of a resilience-based psychosocial intervention for HIV prevention among MSM in India. AIDS 2022; 36:1223-1232. [PMID: 35471644 PMCID: PMC9283429 DOI: 10.1097/qad.0000000000003231] [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: 11/25/2022]
Abstract
OBJECTIVE MSM in India are at a high risk for HIV infection given psychosocial challenges, sexual orientation stress, and stigma. We examined the cost-effectiveness of a novel resilience-based psychosocial intervention for MSM in India. DESIGN We parameterized a validated microsimulation model (CEPAC) with India-specific data and results from a randomized trial and examined two strategies for MSM: status quo HIV care ( SQ ), and a trial-based psychosocial intervention ( INT ) focused on building resilience to stress, improving mental health, and reducing condomless anal sex (CAS). METHODS We projected lifetime clinical and economic outcomes for MSM without HIV initially. Intervention effectiveness, defined as reduction in self-reported CAS, was estimated at 38%; cost was $49.37/participant. We used a willingness-to-pay threshold of US$2100 (2019 Indian per capita GDP) per year of life saved (YLS) to define cost-effectiveness. We also assessed the 5-year budget impact of offering this intervention to 20% of Indian MSM. RESULTS Model projections showed the intervention would avert 2940 HIV infections among MSM over 10 years. Over a lifetime horizon, the intervention was cost-effective (ICER = $900/YLS). Results were most sensitive to intervention effectiveness and cost; the intervention remained cost-effective under plausible ranges of these parameters. Offering this intervention in the public sector would require an additional US$28 M over 5 years compared with SQ . CONCLUSION A resilience-based psychosocial intervention integrated with HIV risk reduction counseling among MSM in India would reduce HIV infections and be cost-effective. Programs using this approach should be expanded as a part of comprehensive HIV prevention in India.
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Affiliation(s)
- Pooyan Kazemian
- Department of Operations, Weatherhead School of Management, Case Western Reserve University, Cleveland, Ohio
| | - Delaney D Ding
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Justine A Scott
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Mary K Feser
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Katie Biello
- Center for Health Promotion and Health Equity
- Department of Behavioral and Social Sciences
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Beena E Thomas
- National Institute for Research in Tuberculosis, Indian Council of Medical Research, Chennai, Tamil Nadu
| | | | - C Andres Bedoya
- Behavioral Medicine Program, Massachusetts General Hospital
- Harvard Medical School, Boston, Massachusetts, USA
| | - Vinoth Balu
- National Institute for Research in Tuberculosis, Indian Council of Medical Research, Chennai, Tamil Nadu
| | | | - Nagalingeswaran Kumarasamy
- CART Clinical Research Site, Infectious Diseases Medical Centre, Voluntary Health Services, Chennai, Tamil Nadu, India
| | - Matthew J Mimiaga
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
- Department of Epidemiology, UCLA Fielding School of Public Health
- Department of Psychiatry and Biobehavioral Sciences, UCLA Geffen School of Medicine
- UCLA Center for LGBTQ+ Advocacy, Research & Health, Los Angeles, California
| | - Conall O'Cleirigh
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
- Behavioral Medicine Program, Massachusetts General Hospital
- Harvard Medical School, Boston, Massachusetts, USA
| | | | - Jacob Prem Kumar
- National Institute for Research in Tuberculosis, Indian Council of Medical Research, Chennai, Tamil Nadu
| | | | - Kenneth H Mayer
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health
- Harvard University Center for AIDS Research, Harvard University, Boston, Massachusetts
| | - Steven A Safren
- Center for HIV and Research in Mental Health
- Health Promotion and Care Research Program
- Department of Psychology, University of Miami, Miami, Florida
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Health Policy and Management
- Harvard University Center for AIDS Research, Harvard University, Boston, Massachusetts
- Division of General Internal Medicine
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
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Kripke K, Eakle R, Cheng A, Rana S, Torjesen K, Stover J. The case for prevention - Primary HIV prevention in the era of universal test and treat: A mathematical modeling study. EClinicalMedicine 2022; 46:101347. [PMID: 35310517 PMCID: PMC8924323 DOI: 10.1016/j.eclinm.2022.101347] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 02/03/2022] [Accepted: 02/21/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND As antiretroviral therapy (ART) has scaled up and HIV incidence has declined, some have questioned the continued utility of HIV prevention. This study examines the role and cost-effectiveness of HIV prevention in the context of "universal test and treat" (UTT) in three sub-Saharan countries with generalized HIV epidemics. METHODS Scenarios were created in Spectrum/Goals models for Lesotho, Mozambique, and Uganda with various combinations of voluntary medical male circumcision (VMMC); pre-exposure prophylaxis; and a highly effective, durable, hypothetical vaccine layered onto three different ART scenarios. One ART scenario held coverage constant at 2008 levels to replicate prevention modeling studies that were conducted prior to UTT. One scenario assumed scale-up to the UNAIDS treatment goals of 90-90-90 by 2025 and 95-95-95 by 2030. An intermediate scenario held ART constant at 2019 coverage. HIV incidence was visualized over time, and cost per HIV infection averted was assessed over 5-, 15-, and 30-year time frames, with 3% annual discounting. FINDINGS Each prevention intervention reduced HIV incidence beyond what was achieved by ART scale-up alone to the 90-90-90/95-95-95 goals, with near-zero incidence achievable by combinations of interventions covering all segments of the population. Cost-effectiveness of HIV prevention may decrease as HIV incidence decreases, but one-time interventions like VMMC and a durable vaccine may remain cost-effective and even cost-saving as ART is scaled up. INTERPRETATION Primary HIV prevention is still needed in the era of UTT. Combination prevention is more impactful than a single, highly effective intervention. Broad population coverage of primary prevention, regardless of cost-effectiveness, will be required in generalized epidemic countries to eradicate HIV.
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Affiliation(s)
- Katharine Kripke
- Avenir Health, 6930 Carroll Ave., Suite 350, Takoma Park, MD 20912, USA
- Corresponding author: Katharine Kripke, 6930 Carroll Ave., Suite 350, Takoma Park, MD 20912, USA. Telephone: (301) 273-9752.
| | - Robyn Eakle
- U.S. Agency for International Development, Washington, DC, USA
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Alison Cheng
- U.S. Agency for International Development, Washington, DC, USA
| | - Sangeeta Rana
- U.S. Agency for International Development, Washington, DC, USA
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Kazemian P, Costantini S, Kumarasamy N, Paltiel AD, Mayer KH, Chandhiok N, Walensky RP, Freedberg KA. The Cost-effectiveness of Human Immunodeficiency Virus (HIV) Preexposure Prophylaxis and HIV Testing Strategies in High-risk Groups in India. Clin Infect Dis 2021; 70:633-642. [PMID: 30921454 DOI: 10.1093/cid/ciz249] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/21/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The human immunodeficiency virus (HIV) epidemic in India is concentrated among 3.1 million men who have sex with men (MSM) and 1.1 million people who inject drugs (PWID), with a mean incidence of 0.9-1.4 per 100 person-years. We examined the cost-effectiveness of both preexposure prophylaxis (PrEP) and HIV testing strategies for MSM and PWID in India. METHODS We populated an HIV microsimulation model with India-specific data and projected clinical and economic outcomes of 7 strategies for MSM/PWID, including status quo; a 1-time HIV test; routine HIV testing every 3, 6, or 12 months; and PrEP with HIV testing every 3 or 6 months. We used a willingness-to-pay threshold of US$1950, the 2017 Indian per capita gross domestic product, to define cost-effectiveness. RESULTS HIV testing alone increased life expectancy by 0.07-0.30 years in MSM; PrEP added approximately 0.90 life-years to status quo. Results were similar in PWID. PrEP with 6-month testing was cost-effective for both MSM (incremental cost-effectiveness ratio [ICER], $1000/year of life saved [YLS]) and PWID (ICER, $500/YLS). Results were most sensitive to HIV incidence. PrEP with 6-month testing would increase HIV-related expenditures by US$708 million (MSM) and US$218 million (PWID) over 5 years compared to status quo. CONCLUSIONS While the World Health Organization recommends PrEP with quarterly HIV testing, our analysis identifies PrEP with semiannual testing as the cost-effective HIV prevention strategy for Indian MSM and PWID. Since nationwide scale-up would require a substantial fiscal investment, areas of highest HIV incidence may be the appropriate initial targets for PrEP scale-up.
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Affiliation(s)
- Pooyan Kazemian
- Medical Practice Evaluation Center, Boston, Massachusetts.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | | | - Nagalingeswaran Kumarasamy
- CART Clinical Research Site, Infectious Diseases Medical Centre, Voluntary Health Services, Chennai, India
| | - A David Paltiel
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Kenneth H Mayer
- Harvard Medical School, Boston, Massachusetts.,Fenway Institute, Fenway Health, Boston, Massachusetts.,Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Nomita Chandhiok
- Indian Council of Medical Research, Ansari Nagar, New Delhi, India
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Boston, Massachusetts.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts.,Harvard University Center for AIDS Research, Boston, Massachusetts
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Boston, Massachusetts.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts.,Harvard University Center for AIDS Research, Boston, Massachusetts.,Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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7
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Using repeated home-based HIV testing services to reach and diagnose HIV infection among persons who have never tested for HIV, Chókwè health demographic surveillance system, Chókwè district, Mozambique, 2014-2017. PLoS One 2020; 15:e0242281. [PMID: 33216773 PMCID: PMC7678994 DOI: 10.1371/journal.pone.0242281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/29/2020] [Indexed: 11/19/2022] Open
Abstract
Background HIV prevalence in Mozambique (12.6%) is one of the highest in the world, yet ~40% of people living with HIV (PLHIV) do not know their HIV status. Strategies to increase HIV testing uptake and diagnosis among PLHIV are urgently needed. Home-based HIV testing services (HBHTS) have been evaluated primarily as a 1-time campaign strategy. Little is known about the potential of repeating HBHTS to diagnose HIV infection among persons who have never been tested (NTs), nor about factors/reasons associated with never testing in a generalized epidemic setting. Methods During 2014–2017, counselors visited all households annually in the Chókwè Health and Demographic Surveillance System (CHDSS) and offered HBHTS. Cross-sectional surveys were administered to randomly selected 10% or 20% samples of CHDSS households with participants aged 15–59 years before HBHTS were conducted during the visit. Descriptive statistics and logistic regression were used to assess the proportion of NTs, factors/reasons associated with never having been tested, HBHTS acceptance, and HIV-positive diagnosis among NTs. Results The proportion of NTs decreased from 25% (95% confidence interval [CI]:23%–26%) during 2014 to 12% (95% CI:11% –13%), 7% (95% CI:6%–8%), and 7% (95% CI:6%–8%) during 2015, 2016, and 2017, respectively. Adolescent boys and girls and adult men were more likely than adult women to be NTs. In each of the four years, the majority of NTs (87%–90%) accepted HBHTS. HIV-positive yield among NTs subsequently accepting HBHTS was highest (13%, 95% CI:10%–15%) during 2014 and gradually reduced to 11% (95% CI:8%–15%), 9% (95% CI:6%–12%), and 2% (95% CI:0%–4%) during 2015, 2016, and 2017, respectively. Conclusions Repeated HBHTS was helpful in increasing HIV testing coverage and identifying PLHIV in Chókwè. In high HIV-prevalence settings with low testing coverage, repeated HBHTS can be considered to increase HIV testing uptake and diagnosis among NTs.
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Abstract
PURPOSE OF REVIEW The 90-90-90 targets were launched with the aim of reaching specific milestones by 2020. To support these targets, modeling has shown that additional resources are needed. This review examines what is known about current investments for HIV in low and middle-income countries, resource needs, and the potential for additional investment. RECENT FINDINGS Reaching the 90-90-90 targets would place the global community on track to end the AIDS epidemic by 2030, significantly improving health outcomes and reducing future spending needs. Recent analyses indicate, however, that funding has slowed and there is a significant gap in resources needed to reach targets. While some studies have modeled the potential for additional HIV spending based on normative and theoretical benchmarks, there are limitations to such approaches. Others have looked at the potential to increase efficiencies. Even if spending continues at recent rates, there would still be a gap of $6.4 billion in 2020. SUMMARY There is a significant gap in resources needed to reach the 90-90-90 targets by 2020. It may be possible to reduce the gap through more efficient allocation of resources. In addition, there are efforts underway to mobilize more investment. Ultimately, any gap that remains has implications for health outcomes and future spending.
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Kazemian P, Costantini S, Neilan AM, Resch SC, Walensky RP, Weinstein MC, Freedberg KA. A novel method to estimate the indirect community benefit of HIV interventions using a microsimulation model of HIV disease. J Biomed Inform 2020; 107:103475. [PMID: 32526280 PMCID: PMC7374016 DOI: 10.1016/j.jbi.2020.103475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 05/22/2020] [Accepted: 06/02/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Microsimulation models of human immunodeficiency virus (HIV) disease that simulate individual patients one at a time and assess clinical and economic outcomes of HIV interventions often provide key details regarding direct individual clinical benefits ("individual benefit"), but they may lack detail on transmissions, and thus may underestimate an intervention's indirect benefits ("community benefit"). Dynamic transmission models can be used to simulate HIV transmissions, but they may do so at the expense of the clinical detail of microsimulations. We sought to develop, validate, and demonstrate a practical, novel method that can be integrated into existing HIV microsimulation models to capture this community benefit, integrating the effects of reduced transmission while keeping the clinical detail of microsimulations. METHODS We developed a new method to capture the community benefit of HIV interventions by estimating HIV transmissions from the primary cohort of interest. The method captures the benefit of averting infections within the cohort of interest by estimating a corresponding gradual decline in incidence within the cohort. For infections averted outside the cohort of interest, our method estimates transmissions averted based on reductions in HIV viral load within the cohort, and the benefit (life-years gained and cost savings) of averting those infections based on the time they were averted. To assess the validity of our method, we paired it with the Cost-effectiveness of Preventing AIDS Complications (CEPAC) Model - a validated and widely-published microsimulation model of HIV disease. We then compared the consistency of model-estimated outcomes against outcomes of a widely-validated dynamic compartmental transmission model of HIV disease, the HIV Optimization and Prevention Economics (HOPE) model, using the intraclass correlation coefficient (ICC) with a two-way mixed effects model. Replicating an analysis done with HOPE, validation endpoints were number of HIV transmissions averted by offering pre-exposure prophylaxis (PrEP) to men who have sex with men (MSM) and people who inject drugs (PWID) in the US at various uptake and efficacy levels. Finally, we demonstrated an application of our method in a different setting by evaluating the clinical and economic outcomes of a PrEP program for MSM in India, a country currently considering PrEP rollout for this high-risk group. RESULTS The new method paired with CEPAC demonstrated excellent consistency with the HOPE model (ICC = 0.98 for MSM and 0.99 for PWID). With only the individual benefit of the intervention incorporated, a PrEP program for MSM in India averted 43,000 transmissions over a 5-year period and resulted in a lifetime incremental cost-effectiveness ratio (ICER) of US$2,300/year-of-life saved (YLS) compared to the status quo. After applying both the direct (individual) and indirect (community) benefits, PrEP averted 86,000 transmissions over the same period and resulted in an ICER of US$600/YLS. CONCLUSIONS Our method enables HIV microsimulation models that evaluate clinical and economic outcomes of HIV interventions to estimate the community benefit of these interventions (in terms of survival gains and cost savings) efficiently and without sacrificing clinical detail. This method addresses an important methodological gap in health economics microsimulation modeling and allows decision scientists to make more accurate policy recommendations.
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Affiliation(s)
- Pooyan Kazemian
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA.
| | - Sydney Costantini
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Anne M Neilan
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Division of General Academic Pediatrics, Department of Pediatrics, Massachusetts General Hospital, Boston, USA
| | - Stephen C Resch
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Milton C Weinstein
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA; Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
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Hazelbag CM, Dushoff J, Dominic EM, Mthombothi ZE, Delva W. Calibration of individual-based models to epidemiological data: A systematic review. PLoS Comput Biol 2020; 16:e1007893. [PMID: 32392252 PMCID: PMC7241852 DOI: 10.1371/journal.pcbi.1007893] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 05/21/2020] [Accepted: 04/21/2020] [Indexed: 01/24/2023] Open
Abstract
Individual-based models (IBMs) informing public health policy should be calibrated to data and provide estimates of uncertainty. Two main components of model-calibration methods are the parameter-search strategy and the goodness-of-fit (GOF) measure; many options exist for each of these. This review provides an overview of calibration methods used in IBMs modelling infectious disease spread. We identified articles on PubMed employing simulation-based methods to calibrate IBMs informing public health policy in HIV, tuberculosis, and malaria epidemiology published between 1 January 2013 and 31 December 2018. Articles were included if models stored individual-specific information, and calibration involved comparing model output to population-level targets. We extracted information on parameter-search strategies, GOF measures, and model validation. The PubMed search identified 653 candidate articles, of which 84 met the review criteria. Of the included articles, 40 (48%) combined a quantitative GOF measure with an algorithmic parameter-search strategy–either an optimisation algorithm (14/40) or a sampling algorithm (26/40). These 40 articles varied widely in their choices of parameter-search strategies and GOF measures. For the remaining 44 (52%) articles, the parameter-search strategy could either not be identified (32/44) or was described as an informal, non-reproducible method (12/44). Of these 44 articles, the majority (25/44) were unclear about the GOF measure used; of the rest, only five quantitatively evaluated GOF. Only a minority of the included articles, 14 (17%) provided a rationale for their choice of model-calibration method. Model validation was reported in 31 (37%) articles. Reporting on calibration methods is far from optimal in epidemiological modelling studies of HIV, malaria and TB transmission dynamics. The adoption of better documented, algorithmic calibration methods could improve both reproducibility and the quality of inference in model-based epidemiology. There is a need for research comparing the performance of calibration methods to inform decisions about the parameter-search strategies and GOF measures. Calibration—that is, “fitting” the model to data—is a crucial part of using mathematical models to better forecast and control the population-level spread of infectious diseases. Evidence that the mathematical model is well-calibrated improves confidence that the model provides a realistic picture of the consequences of health policy decisions. To make informed decisions, Policymakers need information about uncertainty: i.e., what is the range of likely outcomes (rather than just a single prediction). Thus, modellers should also strive to provide accurate measurements of uncertainty, both for their model parameters and for their predictions. This systematic review provides an overview of the methods used to calibrate individual-based models (IBMs) of the spread of HIV, malaria, and tuberculosis. We found that less than half of the reviewed articles used reproducible, non-subjective calibration methods. For the remaining articles, the method could either not be identified or was described as an informal, non-reproducible method. Only one-third of the articles obtained estimates of parameter uncertainty. We conclude that the adoption of better-documented, algorithmic calibration methods could improve both reproducibility and the quality of inference in model-based epidemiology.
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Affiliation(s)
- C. Marijn Hazelbag
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
- * E-mail:
| | - Jonathan Dushoff
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
- Department of Biology, Department of Mathematics and Statistics, Institute for Infectious Disease Research, McMaster University, Hamilton, Ontario, Canada
| | - Emanuel M. Dominic
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Zinhle E. Mthombothi
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Wim Delva
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
- School for Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
- Center for Statistics, I-BioStat, Hasselt University, Diepenbeek, Belgium
- Department of Global Health, Faculty of Medicine and Health, Stellenbosch University, Stellenbosch, South Africa
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium
- Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
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Okal J, Lango D, Matheka J, Obare F, Ngunu-Gituathi C, Mugambi M, Sarna A. "It is always better for a man to know his HIV status" - A qualitative study exploring the context, barriers and facilitators of HIV testing among men in Nairobi, Kenya. PLoS One 2020; 15:e0231645. [PMID: 32294124 PMCID: PMC7159816 DOI: 10.1371/journal.pone.0231645] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 03/28/2020] [Indexed: 01/20/2023] Open
Abstract
HIV testing services are an important component of HIV program and provide an entry point for clinical care for persons newly diagnosed with HIV. Although uptake of HIV testing has increased in Kenya, men are still less likely than women to get tested and access services. There is, however, limited understanding of the context, barriers and facilitators of HIV testing among men in the country. Data are from in-depth interviews with 30 men living with HIV and 8 HIV testing counsellors that were conducted to gain insights on motivations and drivers for HIV testing among men in the city of Nairobi. Men were identified retroactively by examining clinical CD4 registers on early and late diagnosis (e.g. CD4 of ≥500 cells/mm, early diagnosis and <500 cells/mm, late diagnosis). Analysis involved identifying broad themes and generating descriptive codes and categories. Timing for early testing is linked with strong social support systems and agency to test, while cost of testing, choice of facility to test and weak social support systems (especially poor inter-partner relations) resulted in late testing. Minimal discussions occurred prior to testing and whenever there was dialogue it happened with partners or other close relatives. Interrelated barriers at individual, health-care system, and interpersonal levels hindered access to testing services. Specifically, barriers to testing included perceived providers attitudes, facility location and set up, wait time/inconvenient clinic times, low perception of risk, limited HIV knowled ge, stigma, discrimination and fear of having a test. High risk perception, severe illness, awareness of partner's status, confidentiality, quality of services and supplies, flexible/extended opening hours, and pre-and post-test counselling were facilitators. Experiences between early and late testers overlapped though there were minor differences. In order to achieve the desired impact nationally and to attain the 90-90-90 targets, multiple interventions addressing both barriers and facilitators to testing are needed to increase uptake of testing and to link the positive to care.
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Affiliation(s)
- Jerry Okal
- Population Council, Nairobi, Kenya
- * E-mail:
| | | | | | | | | | - Mary Mugambi
- National HIV and STI Control Programme (NASCOP), Nairobi, Kenya
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Abstract
BACKGROUND Despite Côte d'Ivoire epidemic being labeled as "generalized," key populations (KPs) are important to overall transmission. Using a dynamic model of HIV transmission, we previously estimated the impact of several treatment-as-prevention strategies that reached-or missed-the UNAIDS 90-90-90 targets in different populations groups, including KP and clients of female sex workers (CFSWs). To inform program planning and resources allocation, we assessed the cost-effectiveness of these scenarios. METHODS Costing was performed from the provider's perspective. Unit costs were obtained from the Ivorian Programme national de lutte contre le Sida (USD 2015) and discounted at 3%. Net incremental cost-effectiveness ratios (ICER) per adult HIV infection prevented and per disability-adjusted life-years (DALY) averted were estimated over 2015-2030. RESULTS The 3 most cost-effective and affordable scenarios were the ones that projected current programmatic trends [ICER = $210; 90% uncertainty interval (90% UI): $150-$300], attaining the 90-90-90 objectives among KP and CFSW (ICER = $220; 90% UI: $80-$510), and among KP only (ICER = $290; 90% UI: $90-$660). The least cost-effective scenario was the one that reached the UNAIDS 90-90-90 target accompanied by a 25% point drop in condom use in KP (ICER = $710; 90% UI: $450-$1270). In comparison, the UNAIDS scenario had a net ICER of $570 (90% UI: $390-$900) per DALY averted. CONCLUSIONS According to commonly used thresholds, accelerating the HIV response can be considered very cost-effective for all scenarios. However, when balancing epidemiological impact, cost-effectiveness, and affordability, scenarios that sustain both high condom use and rates of viral suppression among KP and CFSW seem most promising in Côte d'Ivoire.
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Improving the Validity of Mathematical Models for HIV Elimination by Incorporating Empirical Estimates of Progression Through the HIV Treatment Cascade. J Acquir Immune Defic Syndr 2019; 79:596-604. [PMID: 30272631 DOI: 10.1097/qai.0000000000001852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Optimism regarding prospects for eliminating HIV by expanding antiretroviral treatment has been emboldened in part by projections from several mathematical modeling studies. Drawing from a detailed empirical assessment of rates of progression through the entire HIV care cascade, we quantify for the first time the extent to which models may overestimate health benefits from policy changes when they fail to incorporate a realistic understanding of the cascade. SETTING Rural KwaZulu-Natal, South Africa. METHODS We estimated rates of progression through stages of the HIV treatment cascade using data from a longitudinal population-based HIV surveillance system in rural KwaZulu-Natal. Incorporating empirical estimates in a mathematical model of HIV progression, infection transmission, and care, we estimated life expectancy and secondary infections averted under a range of treatment scale-up scenarios reflecting expanding treatment eligibility thresholds. We compared the results with those implied by the conventional assumptions that have been commonly adopted by existing models. RESULTS Survival gains from expanding the treatment eligibility threshold from CD4 350-500 cells/μL and from 500 cells/μL to treating everyone irrespective of their CD4 count may be overestimated by 3.60 and 3.79 times in models that fail to capture realities of the care cascade. HIV infections averted from raising the threshold from CD4 200 to 350, 350 to 500, and 500 cells/μL to treating everyone may be overestimated by 1.10, 2.65, and 1.18 times, respectively. CONCLUSIONS Models using conventional assumptions about cascade progression may substantially overestimate health benefits. As implementation of treatment scale-up proceeds, it is important to assess the effects of required scale-up efforts in a way that incorporates empirical realities of how people move through the HIV cascade.
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Cost-effectiveness and budget impact of immediate antiretroviral therapy initiation for treatment of HIV infection in Côte d'Ivoire: A model-based analysis. PLoS One 2019; 14:e0219068. [PMID: 31247009 PMCID: PMC6597104 DOI: 10.1371/journal.pone.0219068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 06/14/2019] [Indexed: 02/07/2023] Open
Abstract
Introduction The Temprano and START trials provided evidence to support early ART initiation recommendations. We projected long-term clinical and economic outcomes of immediate ART initiation in Côte d’Ivoire. Methods We used a mathematical model to compare three potential ART initiation criteria: 1) CD4 <350/μL (ART<350/μL); 2) CD4 <500/μL (ART<500/μL); and 3) ART at presentation (Immediate ART). Outcomes from the model included life expectancy, 10-year medical resource use, incremental cost-effectiveness ratios (ICERs) in $/year of life saved (YLS), and 5-year budget impact. We simulated people with HIV (PWH) in care (mean CD4: 259/μL, SD 198/μL) and transmitted cases. Key input parameters to the analysis included first-line ART efficacy (80% suppression at 6 months) and ART cost ($90/person-year). We assessed cost-effectiveness relative to Côte d’Ivoire’s 2017 per capita annual gross domestic product ($1,600). Results Immediate ART increased life expectancy by 0.34 years compared to ART<350/μL and 0.17 years compared to ART<500/μL. Immediate ART resulted in 4,500 fewer 10-year transmissions per 170,000 PWH compared to ART<350/μL. In cost-effectiveness analysis, Immediate ART had a 10-year ICER of $680/YLS compared to ART<350/μL, ranging from cost-saving to an ICER of $1,440/YLS as transmission rates varied. ART<500/μL was “dominated” (an inefficient use of resources), compared with Immediate ART. Immediate ART increased the 5-year HIV care budget from $801.9M to $812.6M compared to ART<350/μL. Conclusions In Côte d’Ivoire, immediate compared to later ART initiation will increase life expectancy, decrease HIV transmission, and be cost-effective over the long-term, with modest budget impact. Immediate ART initiation is an appropriate, high-value standard of care in Côte d’Ivoire and similar settings.
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Luz PM, Osher B, Grinsztejn B, Maclean RL, Losina E, Stern ME, Struchiner CJ, Parker RA, Freedberg KA, Mesquita F, Walensky RP, Veloso VG, Paltiel AD. The cost-effectiveness of HIV pre-exposure prophylaxis in men who have sex with men and transgender women at high risk of HIV infection in Brazil. J Int AIDS Soc 2019; 21:e25096. [PMID: 29603888 PMCID: PMC5878414 DOI: 10.1002/jia2.25096] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 03/01/2018] [Indexed: 12/22/2022] Open
Abstract
Introduction Men who have sex with men (MSM) and transgender women (TGW) in Brazil experience high rates of HIV infection. We examined the clinical and economic outcomes of implementing a pre‐exposure prophylaxis (PrEP) programme in these populations. Methods We used the Cost‐Effectiveness of Preventing AIDS Complications (CEPAC)‐International model of HIV prevention and treatment to evaluate two strategies: the current standard of care (SOC) in Brazil, including universal ART access (No PrEP strategy); and the current SOC plus daily tenofovir/emtracitabine PrEP (PrEP strategy) until age 50. Mean age (31 years, SD 8.4 years), age‐stratified annual HIV incidence (age ≤ 40 years: 4.3/100 PY; age > 40 years: 1.0/100 PY), PrEP effectiveness (43% HIV incidence reduction) and PrEP drug costs ($23/month) were from Brazil‐based sources. The analysis focused on direct medical costs of HIV care. We measured the comparative value of PrEP in 2015 United States dollars (USD) per year of life saved (YLS). Willingness‐to‐pay threshold was based on Brazil's annual per capita gross domestic product (GDP; 2015: $8540 USD). Results Lifetime HIV infection risk among high‐risk MSM and TGW was 50.5% with No PrEP and decreased to 40.1% with PrEP. PrEP increased per‐person undiscounted (discounted) life expectancy from 36.8 (20.7) years to 41.0 (22.4) years and lifetime discounted HIV‐related medical costs from $4100 to $8420, which led to an incremental cost‐effectiveness ratio (ICER) of $2530/YLS. PrEP remained cost‐effective (<1x GDP) under plausible variation in key parameters, including PrEP effectiveness and cost, initial cohort age and HIV testing frequency on/off PrEP. Conclusion Daily tenofovir/emtracitabine PrEP among MSM and TGW at high risk of HIV infection in Brazil would increase life expectancy and be highly cost‐effective.
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Affiliation(s)
- Paula M Luz
- The Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Benjamin Osher
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Beatriz Grinsztejn
- The Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Rachel L Maclean
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Elena Losina
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research, Harvard Medical School, Boston, MA, USA.,Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Madeline E Stern
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Claudio J Struchiner
- The Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Robert A Parker
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research, Harvard Medical School, Boston, MA, USA.,Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research, Harvard Medical School, Boston, MA, USA.,Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, USA.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.,Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA
| | - Fabio Mesquita
- The Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research, Harvard Medical School, Boston, MA, USA.,Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Disease, Brigham and Women's Hospital, Boston, MA, USA
| | - Valdilea G Veloso
- The Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
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Dugdale CM, Ciaranello AL, Bekker LG, Stern ME, Myer L, Wood R, Sax PE, Abrams EJ, Freedberg KA, Walensky RP. Risks and Benefits of Dolutegravir- and Efavirenz-Based Strategies for South African Women With HIV of Child-Bearing Potential: A Modeling Study. Ann Intern Med 2019; 170:614-625. [PMID: 30934067 PMCID: PMC6736740 DOI: 10.7326/m18-3358] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Dolutegravir is superior to efavirenz for HIV antiretroviral therapy (ART) but may be associated with an increased risk for neural tube defects (NTDs) in newborns if used by women at conception. Objective To project clinical outcomes of ART policies for women of child-bearing potential in South Africa. Design Model of 3 strategies: efavirenz for all women of child-bearing potential (EFV), dolutegravir for all women of child-bearing potential (DTG), or World Health Organization (WHO)-recommended efavirenz without contraception or dolutegravir with contraception (WHO approach). Data Sources Published data on NTD risks (efavirenz, 0.05%; dolutegravir, 0.67% [Tsepamo study]), 48-week ART efficacy with initiation (efavirenz, 60% to 91%; dolutegravir, 96%), and age-stratified fertility rates (2 to 139 per 1000 women). Target Population 3.1 million South African women with HIV (aged 15 to 49 years) starting or continuing first-line ART, and their children. Time Horizon 5 years. Perspective Societal. Intervention EFV, DTG, and WHO approach. Outcome Measures Deaths among women and children, sexual and pediatric HIV transmissions, and NTDs. Results of Base-Case Analysis Compared with EFV, DTG averted 13 700 women's deaths (0.44% decrease) and 57 700 sexual HIV transmissions, but increased total pediatric deaths by 4400 because of more NTDs. The WHO approach offered some benefits compared with EFV, averting 4900 women's deaths and 20 500 sexual transmissions while adding 300 pediatric deaths. Overall, combined deaths among women and children were lowest with DTG (358 000 deaths) compared with the WHO approach (362 800 deaths) or EFV (367 300 deaths). Results of Sensitivity Analysis Women's deaths averted with DTG exceeded pediatric deaths added with EFV unless dolutegravir-associated NTD risk was 1.5% or greater. Limitation Uncertainty in NTD risks and dolutegravir efficacy in resource-limited settings, each examined in sensitivity analyses. Conclusion Although NTD risks may be higher with dolutegravir than efavirenz, dolutegravir will lead to many fewer deaths among women, as well as fewer overall HIV transmissions. These results argue against a uniform policy of avoiding dolutegravir in women of child-bearing potential. Primary Funding Source National Institutes of Health, National Institute of Allergy and Infectious Diseases and Eunice Kennedy Shriver National Institute of Child Health and Human Development; Massachusetts General Hospital; and Harvard University Center for AIDS Research.
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Affiliation(s)
- Caitlin M Dugdale
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (C.M.D., A.L.C., K.A.F.)
| | - Andrea L Ciaranello
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (C.M.D., A.L.C., K.A.F.)
| | | | | | - Landon Myer
- University of Cape Town, Cape Town, South Africa (L.B., L.M., R.W.)
| | - Robin Wood
- University of Cape Town, Cape Town, South Africa (L.B., L.M., R.W.)
| | - Paul E Sax
- Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts (P.E.S.)
| | | | - Kenneth A Freedberg
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (C.M.D., A.L.C., K.A.F.)
| | - Rochelle P Walensky
- Massachusetts General Hospital, Harvard Medical School, and Brigham and Women's Hospital, Boston, Massachusetts (R.P.W.)
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Glaubius R, Ding Y, Penrose KJ, Hood G, Engquist E, Mellors JW, Parikh UM, Abbas UL. Dapivirine vaginal ring for HIV prevention: modelling health outcomes, drug resistance and cost-effectiveness. J Int AIDS Soc 2019; 22:e25282. [PMID: 31074936 PMCID: PMC6510112 DOI: 10.1002/jia2.25282] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 04/05/2019] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION A vaginal ring containing dapivirine is effective for HIV prevention as pre-exposure prophylaxis (PrEP). We evaluated the potential epidemiological impact and cost-effectiveness of dapivirine vaginal ring PrEP among 22- to 45-year-old women in KwaZulu-Natal, South Africa. METHODS Using mathematical modelling, we studied dapivirine vaginal ring PrEP implementation, either unprioritized, or prioritized based on HIV incidence (≥3% per year), age (22 to 29 years) or female sex worker status, alongside the implementation of voluntary medical male circumcision and antiretroviral therapy scaled-up to UNAIDS Fast-Track targets. Outcomes over the intervention (2019 to 2030) and lifetime horizons included cumulative HIV infections, life-years lived, costs and cost-effectiveness. We assessed the incremental cost-effectiveness ratios against the revealed willingness to pay ($500) and the standard (2017 per capita gross domestic product; $6161) cost-effectiveness thresholds for South Africa. RESULTS Compared to a reference scenario without PrEP, implementation of dapivirine vaginal ring PrEP, assuming 56% effectiveness and covering 50% of 22 to 29-year-old or high-incidence women, prevented 10% or 11% of infections by 2030 respectively. Equivalent, unprioritized coverage (30%) prevented fewer infections (7%), whereas 50% coverage of female sex workers had the least impact (4%). Drug resistance attributable to PrEP was modest (2% to 4% of people living with drug-resistant HIV). Over the lifetime horizon, dapivirine PrEP implementation among female sex workers was cost-saving, whereas incidence-based PrEP cost $1898 per life-year gained, relative to PrEP among female sex workers and $989 versus the reference scenario. In a scenario of 37% PrEP effectiveness, PrEP had less impact, but prioritization to female sex workers remained cost-saving. In uncertainty analysis, female sex worker PrEP was consistently cost-saving; and over the lifetime horizon, PrEP cost less than $6161 per life-year gained in over 99% of simulations, whereas incidence- and age-based PrEP cost below $500 per life-year gained in 61% and 49% of simulations respectively. PrEP adherence and efficacy, and the effectiveness of antiretroviral therapy for HIV prevention, were the principal drivers of uncertainty in the cost-effectiveness of PrEP. CONCLUSIONS Dapivirine vaginal ring PrEP would be cost-saving in KwaZulu-Natal if prioritized to female sex workers. PrEP's impact on HIV prevention would be increased, with potential affordability, if prioritized to women by age or incidence.
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Affiliation(s)
- Robert Glaubius
- Departments of Quantitative Health Sciences and Infectious DiseaseCleveland ClinicClevelandOHUSA
| | - Yajun Ding
- Department of MedicineSection of Infectious Diseases and Department of Molecular Virology and MicrobiologyBaylor College of MedicineHoustonTXUSA
| | - Kerri J Penrose
- Division of Infectious DiseasesSchool of MedicineUniversity of PittsburghPittsburghPAUSA
| | - Greg Hood
- Pittsburgh Supercomputing CenterCarnegie Mellon UniversityPittsburghPAUSA
| | - Erik Engquist
- Center for Research ComputingRice UniversityHoustonTXUSA
| | - John W Mellors
- Division of Infectious DiseasesSchool of MedicineUniversity of PittsburghPittsburghPAUSA
| | - Urvi M Parikh
- Division of Infectious DiseasesSchool of MedicineUniversity of PittsburghPittsburghPAUSA
| | - Ume L Abbas
- Departments of Quantitative Health Sciences and Infectious DiseaseCleveland ClinicClevelandOHUSA
- Department of MedicineSection of Infectious Diseases and Department of Molecular Virology and MicrobiologyBaylor College of MedicineHoustonTXUSA
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18
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Reddy KP, Gupta-Wright A, Fielding KL, Costantini S, Zheng A, Corbett EL, Yu L, van Oosterhout JJ, Resch SC, Wilson DP, Horsburgh CR, Wood R, Alufandika-Moyo M, Peters JA, Freedberg KA, Lawn SD, Walensky RP. Cost-effectiveness of urine-based tuberculosis screening in hospitalised patients with HIV in Africa: a microsimulation modelling study. Lancet Glob Health 2019; 7:e200-e208. [PMID: 30683239 PMCID: PMC6370043 DOI: 10.1016/s2214-109x(18)30436-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 07/23/2018] [Accepted: 09/07/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Testing urine improves the number of tuberculosis diagnoses made among patients in hospital with HIV. In conjunction with the two-country randomised Rapid Urine-based Screening for Tuberculosis to Reduce AIDS-related Mortality in Hospitalised Patients in Africa (STAMP) trial, we used a microsimulation model to estimate the effects on clinical outcomes and the cost-effectiveness of adding urine-based tuberculosis screening to sputum screening for hospitalised patients with HIV. METHODS We compared two tuberculosis screening strategies used irrespective of symptoms among hospitalised patients with HIV in Malawi and South Africa: a GeneXpert assay (Cepheid, Sunnyvale, CA, USA) for Mycobacterium tuberculosis and rifampicin resistance (Xpert) in sputum samples (standard of care) versus sputum Xpert combined with a lateral flow assay for M tuberculosis lipoarabinomannan in urine (Determine TB-LAM Ag test, Abbott, Waltham, MA, USA [formerly Alere]; TB-LAM) and concentrated urine Xpert (intervention). A cohort of simulated patients was modelled using selected characteristics of participants, tuberculosis diagnostic yields, and use of hospital resources in the STAMP trial. We calibrated 2-month model outputs to the STAMP trial results and projected clinical and economic outcomes at 2 years, 5 years, and over a lifetime. We judged the intervention to be cost-effective if the incremental cost-effectiveness ratio (ICER) was less than US$750/year of life saved (YLS) in Malawi and $940/YLS in South Africa. A modified intervention of adding only TB-LAM to the standard of care was also evaluated. We did a budget impact analysis of countrywide implementation of the intervention. FINDINGS The intervention increased life expectancy by 0·5-1·2 years and was cost-effective, with an ICER of $450/YLS in Malawi and $840/YLS in South Africa. The ICERs decreased over time. At lifetime horizon, the intervention remained cost-effective under nearly all modelled assumptions. The modified intervention was at least as cost-effective as the intervention (ICERs $420/YLS in Malawi and $810/YLS in South Africa). Over 5 years, the intervention would save around 51 000 years of life in Malawi and around 171 000 years of life in South Africa. Health-care expenditure for screened individuals was estimated to increase by $37 million (10·8%) and $261 million (2·8%), respectively. INTERPRETATION Urine-based tuberculosis screening of all hospitalised patients with HIV could increase life expectancy and be cost-effective in resource-limited settings. Urine TB-LAM is especially attractive because of high incremental diagnostic yield and low additional cost compared with sputum Xpert, making a compelling case for expanding its use to all hospitalised patients with HIV in areas with high HIV burden and endemic tuberculosis. FUNDING UK Medical Research Council, UK Department for International Development, Wellcome Trust, US National Institutes of Health, Royal College of Physicians, Massachusetts General Hospital.
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Affiliation(s)
- Krishna P Reddy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Ankur Gupta-Wright
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Program, Blantyre, Malawi
| | - Katherine L Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; University of the Witwatersrand, Johannesburg, South Africa
| | - Sydney Costantini
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Amy Zheng
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Elizabeth L Corbett
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Program, Blantyre, Malawi
| | - Liyang Yu
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi; Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi
| | - Stephen C Resch
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Douglas P Wilson
- Department of Internal Medicine, Edendale Hospital, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - C Robert Horsburgh
- Department of Epidemiology, Boston University School of Medicine, Boston, MA, USA; Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Robin Wood
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
| | | | - Jurgens A Peters
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Epidemiology, Boston University School of Medicine, Boston, MA, USA
| | - Stephen D Lawn
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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19
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Krentz HB, Campbell S, Lahl M, Gill MJ. De-simplifying single-tablet antiretroviral treatments: uptake, risks and cost savings. HIV Med 2019; 20:214-221. [PMID: 30632660 DOI: 10.1111/hiv.12701] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES As more HIV-positive individuals receive antiretroviral therapy (ART), payers are seeking options for covering these increased and sustained drug costs. Strategic use of available generic antiretroviral (ARV) formulations may be feasible. De-simplifying a single-tablet co-formulation (STF) into two or more tablets using both brand and generic drugs has been proposed. We determine if voluntary de-simplification of one STF could be utilized as a cost-saving strategy. We report on the challenges, uptake, outcomes and cost savings of this initiative. METHODS Patients stable on the most commonly used STF (Triumeq® ) were offered the option of remaining on Triumeq® or switching to generic abacavir/lamivudine and Tivicay® between 1 January 2015 and 1 January 2018; those starting ART consisting of abacavir/lamivudine/doulutegravir in the same period were offered the option of starting Triumeq® or generic abacavir/laminvudine and Tivicay® . No incentives were provided. We examined the acceptance/decline rates, patient satisfaction, health care outcomes and annual cost savings. RESULTS Of 626 patients receiving Triumeq® , 321 were approached; 177 (55.1%) agreed to de-simplify. Of patients initiating ART, 62.7% chose the generic co-formulation. Patients switching to or starting on the generic co-formulation were more likely to be male, > 45 years old, Caucasian, men who have sex with men (MSM) and more HIV-experienced, and to have more comorbidities (all P < 0.05). Preference for STF was cited for declining de-simplification. No concern about generic ARVs was expressed. The rate of viral load > 500 HIV-1 RNA copies/mL after baseline was 2.7% in switched patients compared with 7.0% in those declining to switch. No de novo resistance occurred. A saving of Cdn$1 319 686 was achieved in the first year. CONCLUSIONS Reliance on altruism, while respecting patient autonomy, achieved de-simplification in > 50% of patients approached, and generated immediate cost savings with no increased risk of adverse events, viral breakthrough or resistance.
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Affiliation(s)
- H B Krentz
- Southern Alberta Clinic, Calgary, AB, Canada.,Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - S Campbell
- Southern Alberta Clinic, Calgary, AB, Canada
| | - M Lahl
- Southern Alberta Clinic, Calgary, AB, Canada
| | - M J Gill
- Southern Alberta Clinic, Calgary, AB, Canada.,Department of Medicine, University of Calgary, Calgary, AB, Canada
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20
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Audet CM, Graves E, Barreto E, De Schacht C, Gong W, Shepherd BE, Aboobacar A, Gonzalez-Calvo L, Alvim MF, Aliyu MH, Kipp AM, Jordan H, Amico KR, Diemer M, Ciaranello A, Dugdale C, Vermund SH, Van Rompaey S. Partners-based HIV treatment for seroconcordant couples attending antenatal and postnatal care in rural Mozambique: A cluster randomized trial protocol. Contemp Clin Trials 2018; 71:63-69. [PMID: 29879469 PMCID: PMC6067957 DOI: 10.1016/j.cct.2018.05.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/26/2018] [Accepted: 05/31/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND In resource-limited rural settings, scale-up of services to eliminate mother-to-child transmission of HIV has not been as effective as in better resourced urban settings. In sub-Saharan Africa, women often require male partner approval to access and remain engaged in HIV care. Our study will evaluate a promising male engagement intervention ("Homens para Saúde Mais" (HoPS+) [Men for Health Plus]) targeting the elimination of mother-to-child transmission in rural Mozambique. DESIGN We will use a cluster randomized clinical trial design to engage 24 health facilities (12 intervention and 12 standard of care), with 45 HIV-infected seroconcordant couples per clinic. The planned intervention will engage male partners to address social-structural and cultural factors influencing eMTCT based on new couple-centered integrated HIV services. CONCLUSIONS The HoPS+ study will evaluate the effectiveness of engaging male partners in antenatal care to improve outcomes among HIV-infected pregnant women, their HIV-infected male partners, and their newborn children. Our objectives are to: (1) Implement and evaluate the impact of male-engaged, couple-centered services on partners' retention in care, adherence to antiretroviral therapy, early infant diagnosis uptake, and mother-to-child transmission throughout pregnancy and breastfeeding; (2) Investigate the impact of HoPS+ intervention on hypothesized mechanisms of change; and (3) Use validated simulation models to evaluate the cost-effectiveness of the HoPS+ intervention with the use of routine clinical data from our trial. We expect the intervention to lead to strategies that can improve outcomes related to partners' retention in care, uptake of services for HIV-exposed infants, and reduced MTCT.
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Affiliation(s)
- Carolyn M Audet
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, 2525 West End Ave, Suite 750, Nashville, TN 37203, USA; Vanderbilt University Medical Center, Department of Health Policy, 2525 West End Ave, Suite 1200, Nashville, TN 37203, USA.
| | - Erin Graves
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, 2525 West End Ave, Suite 750, Nashville, TN 37203, USA
| | - Ezequiel Barreto
- Friends in Global Health, Avenida Maguiguana, 32 R/C, Maputo, CP 604, Mozambique
| | - Caroline De Schacht
- Friends in Global Health, Avenida Maguiguana, 32 R/C, Maputo, CP 604, Mozambique
| | - Wu Gong
- Vanderbilt University School of Medicine, Department of Biostatistics, 2525 West End Ave, Suite 11000, Nashville, TN 37203, USA
| | - Bryan E Shepherd
- Vanderbilt University School of Medicine, Department of Biostatistics, 2525 West End Ave, Suite 11000, Nashville, TN 37203, USA
| | | | - Lazaro Gonzalez-Calvo
- Friends in Global Health, Avenida Maguiguana, 32 R/C, Maputo, CP 604, Mozambique; Vanderbilt University Medical Center, Department of Pediatrics, 2200 Children's Way, Nashville, TN 37232, USA
| | - Maria Fernanda Alvim
- Friends in Global Health, Avenida Maguiguana, 32 R/C, Maputo, CP 604, Mozambique
| | - Muktar H Aliyu
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, 2525 West End Ave, Suite 750, Nashville, TN 37203, USA; Vanderbilt University Medical Center, Department of Health Policy, 2525 West End Ave, Suite 1200, Nashville, TN 37203, USA
| | - Aaron M Kipp
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, 2525 West End Ave, Suite 750, Nashville, TN 37203, USA; Vanderbilt University Medical Center, Division of Epidemiology, Nashville, TN 37203, USA
| | - Heather Jordan
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, 2525 West End Ave, Suite 750, Nashville, TN 37203, USA
| | - K Rivet Amico
- University of Michigan, Department of Health Behavior and Health Education, School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA
| | - Matthew Diemer
- University of Michigan, Combined Program in Education and Psychology & Educational Studies, School of Education, Room 4120, Ann Arbor, MI 48109, USA
| | - Andrea Ciaranello
- Division of Infectious Diseases, 100 Cambridge St, Room 1670, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Harvard University, 25 Shattuck St, Boston 02115, MA, USA
| | - Caitlin Dugdale
- Harvard Medical School, Harvard University, 25 Shattuck St, Boston 02115, MA, USA
| | - Sten H Vermund
- Yale School of Public Health, 60 College St., Suite 212, New Haven, CT, USA
| | - Sara Van Rompaey
- Friends in Global Health, Avenida Maguiguana, 32 R/C, Maputo, CP 604, Mozambique
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21
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Freedberg KA, Kumarasamy N, Borre ED, Ross EL, Mayer KH, Losina E, Swaminathan S, Flanigan TP, Walensky RP. Clinical Benefits and Cost-Effectiveness of Laboratory Monitoring Strategies to Guide Antiretroviral Treatment Switching in India. AIDS Res Hum Retroviruses 2018; 34:486-497. [PMID: 29620932 PMCID: PMC5994680 DOI: 10.1089/aid.2017.0258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Current Indian guidelines recommend twice-annual CD4 testing to monitor first-line antiretroviral therapy (ART), with a plasma HIV RNA test to confirm failure if CD4 declines, which would prompt a switch to second-line ART. We used a mathematical model to assess the clinical benefits and cost-effectiveness of alternative laboratory monitoring strategies in India. We simulated a cohort of HIV-infected patients initiating first-line ART and compared 11 strategies with combinations of CD4 and HIV RNA testing at varying frequencies. We included adaptive strategies that reduce the frequency of tests after 1 year from 6 to 12 months for virologically suppressed patients. We projected life expectancy, time on failed first-line ART, cumulative 10-year HIV transmissions, lifetime cost (2014 US dollars), and incremental cost-effectiveness ratios (ICERs). We defined strategies as cost-effective if their ICER was <1 × the Indian per capita gross domestic product (GDP, $1,600). We found that the current Indian guidelines resulted in a per person life expectancy (from mean age 37) of 150.2 months and a per person cost of $2,680. Adding annual HIV RNA testing increased survival by ∼8 months; adaptive strategies were less expensive than similar nonadaptive strategies with similar life expectancy. The most effective strategy with an ICER <1 × GDP was the adaptive HIV RNA strategy (ICER $840/year). Cumulative 10-year transmissions decreased from 27.2/1,000 person-years with standard-of-care to 20.9/1,000 person-years with adaptive HIV RNA testing. In India, routine HIV RNA monitoring of patients on first-line ART would increase life expectancy, decrease transmissions, be cost-effective, and should be implemented.
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Affiliation(s)
- Kenneth A. Freedberg
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
- Harvard University Center for AIDS Research, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | | | - Ethan D. Borre
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Eric L. Ross
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Kenneth H. Mayer
- Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Fenway Health, Boston, Massachusetts
| | - Elena Losina
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
- Harvard University Center for AIDS Research, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Timothy P. Flanigan
- Division of Infectious Diseases, Miriam Hospital, Brown Medical School, Providence, Rhode Island
| | - Rochelle P. Walensky
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
- Harvard University Center for AIDS Research, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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22
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Wang L, Min JE, Zang X, Sereda P, Harrigan RP, Montaner JSG, Nosyk B. Characterizing Human Immunodeficiency Virus Antiretroviral Therapy Interruption and Resulting Disease Progression Using Population-Level Data in British Columbia, 1996-2015. Clin Infect Dis 2018; 65:1496-1503. [PMID: 29048508 DOI: 10.1093/cid/cix570] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 06/28/2017] [Indexed: 11/12/2022] Open
Abstract
Background Suboptimal retention is among the biggest challenges to realize the full benefits of combination antiretroviral therapy (ART). We aimed to describe ART interruption patterns and identify determinants of disease progression while off ART in British Columbia, Canada. Methods With population-level data on ART utilization and laboratory testing in British Columbia (1996-2015), we described the timing, frequency, and duration of ART interruptions (a gap of ≥90 days in ART dispensation records). A 4-state continuous-time Markov model was implemented to identify determinants of disease progression during individuals' first ART interruption episode. Disease progression was measured according to CD4-based state transitions (cells/μL: ≥500 to 200-499; 200-499 to <200; ≥500 to death; 200-499 to death; and <200 to death). Results Among individuals initiating ART, 3129 (38.6%) interrupted ART over a median 8-year follow-up (interquartile range [IQR], 4.3-13.5 years). Those interrupting ART had a median of 1 interruption (IQR, 1.0-3.0), with the first interruption occurring 12.8 (IQR, 4.0-36.1) months after ART initiation, lasting for 7.5 (IQR, 4.1-20.3) months. The proportion of individuals interrupting ART within the first year of ART initiation decreased over time; however, the absolute number of individuals interrupting ART remained high. In a multivariable analysis, age, historical plasma viral load, and ART regimen changes prior to interruption were associated with increased hazard of CD4 decline and death. Conclusions Our results demonstrate that ART interruptions are common even in a high-resource setting with universal free access to human immunodeficiency virus care. Further efforts are needed to promote ART reengagement and may consider prioritizing individuals with poorer prognostic factors.
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Affiliation(s)
- Linwei Wang
- BC Centre for Excellence in HIV/AIDS, Vancouver
| | | | - Xiao Zang
- BC Centre for Excellence in HIV/AIDS, Vancouver
| | - Paul Sereda
- BC Centre for Excellence in HIV/AIDS, Vancouver
| | - Richard P Harrigan
- BC Centre for Excellence in HIV/AIDS, Vancouver.,Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver
| | - Julio S G Montaner
- BC Centre for Excellence in HIV/AIDS, Vancouver.,Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver
| | - Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, Vancouver.,Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
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23
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Collaborative care for the detection and management of depression among adults receiving antiretroviral therapy in South Africa: study protocol for the CobALT randomised controlled trial. Trials 2018; 19:193. [PMID: 29566739 PMCID: PMC5863840 DOI: 10.1186/s13063-018-2517-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 02/02/2018] [Indexed: 01/15/2023] Open
Abstract
Background The scale-up of antiretroviral treatment (ART) programmes has seen HIV/AIDS transition to a chronic condition characterised by high rates of comorbidity with tuberculosis, non-communicable diseases (NCDs) and mental health disorders. Depression is one such disorder that is associated with higher rates of non-adherence, progression to AIDS and greater mortality. Detection and treatment of comorbid depression is critical to achieve viral load suppression in more than 90% of those on ART and is in line with the recent 90-90-90 Joint United Nations Programme on HIV/AIDS (UNAIDS) targets. The CobALT trial aims to provide evidence on the effectiveness and cost-effectiveness of scalable interventions to reduce the treatment gap posed by the growing burden of depression among adults on lifelong ART. Methods The study design is a pragmatic, parallel group, stratified, cluster randomised trial in 40 clinics across two rural districts of the North West Province of South Africa. The unit of randomisation is the clinic, with outcomes measured among 2000 patients on ART who screen positive for depression using the Patient Health Questionnaire (PHQ-9). Control group clinics are implementing the South African Department of Health’s Integrated Clinical Services Management model, which aims to reduce fragmentation of care in the context of rising multimorbidity, and which includes training in the Primary Care 101 (PC101) guide covering communicable diseases, NCDs, women’s health and mental disorders. In intervention clinics, we supplemented this with training specifically in the mental health components of PC101 and clinical communications skills training to support nurse-led chronic care. We strengthened the referral pathways through the introduction of a clinic-based behavioural health counsellor equipped to provide manualised depression counselling (eight sessions, individual or group), as well as adherence counselling sessions (one session, individual). The co-primary patient outcomes are a reduction in PHQ-9 scores of at least 50% from baseline and viral load suppression rates measured at 6 and 12 months, respectively. Discussion The trial will provide real-world effectiveness of case detection and collaborative care for depression including facility-based counselling on the mental and physical outcomes for people on lifelong ART in resource-constrained settings. Trial registration ClinicalTrials.gov (NCT02407691) registered on 19 March 2015; Pan African Clinical Trials Registry (201504001078347) registered on 19/03/2015; South African National Clinical Trials Register (SANCTR) (DOH-27-0515-5048) NHREC number 4048 issued on 21/04/2015. Electronic supplementary material The online version of this article (10.1186/s13063-018-2517-7) contains supplementary material, which is available to authorized users.
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24
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Clemenzi-Allen A, Geng E, Christopoulos K, Hammer H, Buchbinder S, Havlir D, Gandhi M. Degree of Housing Instability Shows Independent "Dose-Response" With Virologic Suppression Rates Among People Living With Human Immunodeficiency Virus. Open Forum Infect Dis 2018; 5:ofy035. [PMID: 29577059 PMCID: PMC5850870 DOI: 10.1093/ofid/ofy035] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 02/22/2018] [Indexed: 11/20/2022] Open
Abstract
Housing instability negatively impacts outcomes in people living with human immunodeficiency virus (PLHIV), yet the effect of diverse living arrangements has not previously been evaluated. Using 6 dwelling types to measure housing status, we found a strong inverse association between housing instability and viral suppression across a spectrum of unstable housing arrangements.
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Affiliation(s)
- Angelo Clemenzi-Allen
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | - Elvin Geng
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | - Katerina Christopoulos
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | - Hali Hammer
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco.,San Francisco Department of Public Health, California
| | - Susan Buchbinder
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco.,San Francisco Department of Public Health, California
| | - Diane Havlir
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | - Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
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25
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Krentz HB, Campbell S, Gill VC, Gill MJ. Patient perspectives on de-simplifying their single-tablet co-formulated antiretroviral therapy for societal cost savings. HIV Med 2018; 19:290-298. [PMID: 29368401 DOI: 10.1111/hiv.12578] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The incremental costs of expanding antiretroviral (ARV) drug treatment to all HIV-infected patients are substantial, so cost-saving initiatives are important. Our objectives were to determine the acceptability and financial impact of de-simplifying (i.e. switching) more expensive single-tablet formulations (STFs) to less expensive generic-based multi-tablet components. We determined physician and patient perceptions and acceptance of STF de-simplification within the context of a publicly funded ARV budget. METHODS Programme costs were calculated for patients on ARVs followed at the Southern Alberta Clinic, Canada during 2016 (Cdn$). We focused on patients receiving Triumeq® and determined the savings if patients de-simplified to eligible generic co-formulations. We surveyed all prescribing physicians and a convenience sample of patients taking Triumeq® to see if, for budgetary purposes, they felt that de-simplification would be acceptable. RESULTS Of 1780 patients receiving ARVs, 62% (n = 1038) were on STF; 58% (n = 607) of patients on STF were on Triumeq®. The total annual cost of ARVs was $26 222 760. The cost for Triumeq® was $8 292 600. If every patient on Triumeq® switched to generic abacavir/lamivudine and Tivicay® (dolutegravir), total costs would decrease by $4 325 040. All physicians (n = 13) felt that de-simplifying could be safely achieved. Forty-eight per cent of 221 patients surveyed were agreeable to de-simplifying for altruistic reasons, 27% said no, and 25% said maybe. CONCLUSIONS De-simplifying Triumeq® generates large cost savings. Additional savings could be achieved by de-simplifying other STFs. Both physicians and patients agreed that selective de-simplification was acceptable; however, it may not be acceptable to every patient. Monitoring the medical and cost impacts of de-simplification strategies seems warranted.
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Affiliation(s)
- H B Krentz
- Southern Alberta Clinic, Calgary, AB, Canada.,Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - S Campbell
- Southern Alberta Clinic, Calgary, AB, Canada
| | - V C Gill
- Southern Alberta Clinic, Calgary, AB, Canada
| | - M J Gill
- Southern Alberta Clinic, Calgary, AB, Canada.,Department of Medicine, University of Calgary, Calgary, AB, Canada
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26
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Kumi Smith M, Jewell BL, Hallett TB, Cohen MS. Treatment of HIV for the Prevention of Transmission in Discordant Couples and at the Population Level. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1075:125-162. [PMID: 30030792 DOI: 10.1007/978-981-13-0484-2_6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The scientific breakthrough proving that antiretroviral therapy (ART) can halt heterosexual HIV transmission came in the form of a landmark clinical trial conducted among serodiscordant couples. Study findings immediately informed global recommendations for the use of treatment as prevention in serodiscordant couples. The extent to which these findings are generalizable to other key populations or to groups exposed to HIV through nonsexual transmission routes (i.e., anal intercourse or unsafe injection of drugs) has since driven a large body of research. This review explores the history of HIV research in serodiscordant couples, the implications for management of couples, subsequent research on treatment as prevention in other key populations, and challenges in community implementation of these strategies.
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Affiliation(s)
- M Kumi Smith
- University of North Carolina Chapel Hill, Chapel Hill, NC, USA.
| | | | | | - Myron S Cohen
- University of North Carolina Chapel Hill, Chapel Hill, NC, USA
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Walensky RP, Borre ED, Bekker LG, Hyle EP, Gonsalves GS, Wood R, Eholié SP, Weinstein MC, Anglaret X, Freedberg KA, Paltiel AD. Do Less Harm: Evaluating HIV Programmatic Alternatives in Response to Cutbacks in Foreign Aid. Ann Intern Med 2017; 167:618-629. [PMID: 28847013 PMCID: PMC5675810 DOI: 10.7326/m17-1358] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Resource-limited nations must consider their response to potential contractions in international support for HIV programs. OBJECTIVE To evaluate the clinical, epidemiologic, and budgetary consequences of alternative HIV program scale-back strategies in 2 recipient nations, the Republic of South Africa (RSA) and Côte d'Ivoire (CI). DESIGN Model-based comparison between current standard (CD4 count at presentation of 0.260 × 109 cells/L, universal antiretroviral therapy [ART] eligibility, and 5-year retention rate of 84%) and scale-back alternatives, including reduced HIV detection, no ART or delayed initiation (when CD4 count is <0.350 × 109 cells/L), reduced investment in retention, and no viral load monitoring or second-line ART. DATA SOURCES Published RSA- and CI-specific estimates of the HIV care continuum, ART efficacy, and HIV-related costs. TARGET POPULATION HIV-infected persons, including future incident cases. TIME HORIZON 5 and 10 years. PERSPECTIVE Modified societal perspective, excluding time and productivity costs. OUTCOME MEASURES HIV transmissions and deaths, years of life, and budgetary outlays (2015 U.S. dollars). RESULTS OF BASE-CASE ANALYSIS At 10 years, scale-back strategies increase projected HIV transmissions by 0.5% to 19.4% and deaths by 0.6% to 39.1%. Strategies can produce budgetary savings of up to 30% but no more. Compared with the current standard, nearly every scale-back strategy produces proportionally more HIV deaths (and transmissions, in RSA) than savings. When the least harmful and most efficient alternatives for achieving budget cuts of 10% to 20% are applied, every year of life lost will save roughly $900 in HIV-related outlays in RSA and $600 to $900 in CI. RESULTS OF SENSITIVITY ANALYSIS Scale-back programs, when combined, may result in clinical and budgetary synergies and offsets. LIMITATION The magnitude and details of budget cuts are not yet known, nor is the degree to which other international partners might step in to restore budget shortfalls. CONCLUSION Scaling back international aid to HIV programs will have severe adverse clinical consequences; for similar economic savings, certain programmatic scale-back choices result in less harm than others. PRIMARY FUNDING SOURCE National Institutes of Health and Steve and Deborah Gorlin MGH Research Scholars Award.
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Affiliation(s)
- Rochelle P Walensky
- From Massachusetts General Hospital, Brigham and Women's Hospital, Harvard University Center for AIDS Research, Harvard Medical School, Harvard T.H. Chan School of Public Health, and Boston University School of Public Health, Boston, Massachusetts; Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Centre Hospitalier Universitaire de Treichville and Treichville University Hospital, Abidjan, Côte d'Ivoire; University of Bordeaux, Bordeaux, France; and Yale School of Public Health, New Haven, Connecticut
| | - Ethan D Borre
- From Massachusetts General Hospital, Brigham and Women's Hospital, Harvard University Center for AIDS Research, Harvard Medical School, Harvard T.H. Chan School of Public Health, and Boston University School of Public Health, Boston, Massachusetts; Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Centre Hospitalier Universitaire de Treichville and Treichville University Hospital, Abidjan, Côte d'Ivoire; University of Bordeaux, Bordeaux, France; and Yale School of Public Health, New Haven, Connecticut
| | - Linda-Gail Bekker
- From Massachusetts General Hospital, Brigham and Women's Hospital, Harvard University Center for AIDS Research, Harvard Medical School, Harvard T.H. Chan School of Public Health, and Boston University School of Public Health, Boston, Massachusetts; Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Centre Hospitalier Universitaire de Treichville and Treichville University Hospital, Abidjan, Côte d'Ivoire; University of Bordeaux, Bordeaux, France; and Yale School of Public Health, New Haven, Connecticut
| | - Emily P Hyle
- From Massachusetts General Hospital, Brigham and Women's Hospital, Harvard University Center for AIDS Research, Harvard Medical School, Harvard T.H. Chan School of Public Health, and Boston University School of Public Health, Boston, Massachusetts; Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Centre Hospitalier Universitaire de Treichville and Treichville University Hospital, Abidjan, Côte d'Ivoire; University of Bordeaux, Bordeaux, France; and Yale School of Public Health, New Haven, Connecticut
| | - Gregg S Gonsalves
- From Massachusetts General Hospital, Brigham and Women's Hospital, Harvard University Center for AIDS Research, Harvard Medical School, Harvard T.H. Chan School of Public Health, and Boston University School of Public Health, Boston, Massachusetts; Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Centre Hospitalier Universitaire de Treichville and Treichville University Hospital, Abidjan, Côte d'Ivoire; University of Bordeaux, Bordeaux, France; and Yale School of Public Health, New Haven, Connecticut
| | - Robin Wood
- From Massachusetts General Hospital, Brigham and Women's Hospital, Harvard University Center for AIDS Research, Harvard Medical School, Harvard T.H. Chan School of Public Health, and Boston University School of Public Health, Boston, Massachusetts; Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Centre Hospitalier Universitaire de Treichville and Treichville University Hospital, Abidjan, Côte d'Ivoire; University of Bordeaux, Bordeaux, France; and Yale School of Public Health, New Haven, Connecticut
| | - Serge P Eholié
- From Massachusetts General Hospital, Brigham and Women's Hospital, Harvard University Center for AIDS Research, Harvard Medical School, Harvard T.H. Chan School of Public Health, and Boston University School of Public Health, Boston, Massachusetts; Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Centre Hospitalier Universitaire de Treichville and Treichville University Hospital, Abidjan, Côte d'Ivoire; University of Bordeaux, Bordeaux, France; and Yale School of Public Health, New Haven, Connecticut
| | - Milton C Weinstein
- From Massachusetts General Hospital, Brigham and Women's Hospital, Harvard University Center for AIDS Research, Harvard Medical School, Harvard T.H. Chan School of Public Health, and Boston University School of Public Health, Boston, Massachusetts; Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Centre Hospitalier Universitaire de Treichville and Treichville University Hospital, Abidjan, Côte d'Ivoire; University of Bordeaux, Bordeaux, France; and Yale School of Public Health, New Haven, Connecticut
| | - Xavier Anglaret
- From Massachusetts General Hospital, Brigham and Women's Hospital, Harvard University Center for AIDS Research, Harvard Medical School, Harvard T.H. Chan School of Public Health, and Boston University School of Public Health, Boston, Massachusetts; Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Centre Hospitalier Universitaire de Treichville and Treichville University Hospital, Abidjan, Côte d'Ivoire; University of Bordeaux, Bordeaux, France; and Yale School of Public Health, New Haven, Connecticut
| | - Kenneth A Freedberg
- From Massachusetts General Hospital, Brigham and Women's Hospital, Harvard University Center for AIDS Research, Harvard Medical School, Harvard T.H. Chan School of Public Health, and Boston University School of Public Health, Boston, Massachusetts; Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Centre Hospitalier Universitaire de Treichville and Treichville University Hospital, Abidjan, Côte d'Ivoire; University of Bordeaux, Bordeaux, France; and Yale School of Public Health, New Haven, Connecticut
| | - A David Paltiel
- From Massachusetts General Hospital, Brigham and Women's Hospital, Harvard University Center for AIDS Research, Harvard Medical School, Harvard T.H. Chan School of Public Health, and Boston University School of Public Health, Boston, Massachusetts; Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Centre Hospitalier Universitaire de Treichville and Treichville University Hospital, Abidjan, Côte d'Ivoire; University of Bordeaux, Bordeaux, France; and Yale School of Public Health, New Haven, Connecticut
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Petersen M, Balzer L, Kwarsiima D, Sang N, Chamie G, Ayieko J, Kabami J, Owaraganise A, Liegler T, Mwangwa F, Kadede K, Jain V, Plenty A, Brown L, Lavoy G, Schwab J, Black D, van der Laan M, Bukusi EA, Cohen CR, Clark TD, Charlebois E, Kamya M, Havlir D. Association of Implementation of a Universal Testing and Treatment Intervention With HIV Diagnosis, Receipt of Antiretroviral Therapy, and Viral Suppression in East Africa. JAMA 2017; 317:2196-2206. [PMID: 28586888 PMCID: PMC5734234 DOI: 10.1001/jama.2017.5705] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE Antiretroviral treatment (ART) is now recommended for all HIV-positive persons. UNAIDS has set global targets to diagnose 90% of HIV-positive individuals, treat 90% of diagnosed individuals with ART, and suppress viral replication among 90% of treated individuals, for a population-level target of 73% of all HIV-positive persons with HIV viral suppression. OBJECTIVE To describe changes in the proportions of HIV-positive individuals with HIV viral suppression, HIV-positive individuals who had received a diagnosis, diagnosed individuals treated with ART, and treated individuals with HIV viral suppression, following implementation of a community-based testing and treatment program in rural East Africa. DESIGN, SETTING, AND PARTICIPANTS Observational analysis based on interim data from 16 rural Kenyan (n = 6) and Ugandan (n = 10) intervention communities in the SEARCH Study, an ongoing cluster randomized trial. Community residents who were 15 years or older (N = 77 774) were followed up for 2 years (2013-2014 to 2015-2016). HIV serostatus and plasma HIV RNA level were measured annually at multidisease health campaigns followed by home-based testing for nonattendees. All HIV-positive individuals were offered ART using a streamlined delivery model designed to reduce structural barriers, improve patient-clinician relationships, and enhance patient knowledge and attitudes about HIV. MAIN OUTCOMES AND MEASURES Primary outcome was viral suppression (plasma HIV RNA<500 copies/mL) among all HIV-positive individuals, assessed at baseline and after 1 and 2 years. Secondary outcomes included HIV diagnosis, ART among previously diagnosed individuals, and viral suppression among those who had initiated ART. RESULTS Among 77 774 residents (male, 45.3%; age 15-24 years, 35.1%), baseline HIV prevalence was 10.3% (7108 of 69 283 residents). The proportion of HIV-positive individuals with HIV viral suppression at baseline was 44.7% (95% CI, 43.5%-45.9%; 3464 of 7745 residents) and after 2 years of intervention was 80.2% (95% CI, 79.1%-81.2%; 5666 of 7068 residents), an increase of 35.5 percentage points (95% CI, 34.4-36.6). After 2 years, 95.9% of HIV-positive individuals had been previously diagnosed (95% CI, 95.3%-96.5%; 6780 of 7068 residents); 93.4% of those previously diagnosed had received ART (95% CI, 92.8%-94.0%; 6334 of 6780 residents); and 89.5% of those treated had achieved HIV viral suppression (95% CI, 88.6%-90.3%; 5666 of 6334 residents). CONCLUSIONS AND RELEVANCE Among individuals with HIV in rural Kenya and Uganda, implementation of community-based testing and treatment was associated with an increased proportion of HIV-positive adults who achieved viral suppression, along with increased HIV diagnosis and initiation of antiretroviral therapy. In these communities, the UNAIDS population-level viral suppression target was exceeded within 2 years after program implementation. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01864683.
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Affiliation(s)
- Maya Petersen
- School of Public Health, University of California, Berkeley
| | - Laura Balzer
- University of California, San Francisco
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | | | - Norton Sang
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | - James Ayieko
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | | | - Kevin Kadede
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | | | - Geoff Lavoy
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Joshua Schwab
- School of Public Health, University of California, Berkeley
| | | | | | | | | | | | | | - Moses Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Makerere University, Kampala, Uganda
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Williams BG, Gupta S, Wollmers M, Granich R. Progress and prospects for the control of HIV and tuberculosis in South Africa: a dynamical modelling study. LANCET PUBLIC HEALTH 2017; 2:e223-e230. [PMID: 29253488 DOI: 10.1016/s2468-2667(17)30066-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 02/21/2017] [Accepted: 02/23/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND In September, 2016, South Africa adopted a policy of providing antiretroviral treatment to everyone infected with HIV irrespective of their CD4 cell count. Studies of universal treatment and expanded prevention of HIV differ widely in their projections of effects and the associated costs, so we did this analysis to attempt to find a consensus. METHODS We used data on HIV from the Joint UN Programme on HIV and AIDS (UNAIDS) from 1988 to 2013 and from data from WHO on tuberculosis from 1980 to to 2013 to fit a dynamical model to time trends in HIV prevalence, antiretroviral therapy (ART) coverage, and tuberculosis notification rates in South Africa. We then used the model to estimate current trends and project future patterns in HIV prevalence and incidence, AIDS-related mortality, and tuberculosis notification rates, and we used data from the South African National AIDS Council to assess current and future costs under different combinations of treatment and prevention approaches. We considered two treatment strategies: the Constant Effort strategy, in which people infected with HIV continue to start treatment at the rate in 2016, and the Expanded Treatment and Prevention (ETP) strategy, in which testing rates are increased, treatment is started immediately after HIV is detected, and prevention programmes are expanded. FINDINGS Our estimates show that HIV incidence among adults aged 15 years or older fell from 2·3% per year in 1996 to 0·65% per year in 2016, AIDS-related mortality decreased from 1·4% per year in 2006 to 0·37% per year in 2016, and both continue to fall at a relative rate of 17% per year. Our model shows that maintenance of Constant Effort will have a substantial effect on HIV but will not end AIDS, whereas ETP could end AIDS by 2030, with incidence of HIV and AIDs-related mortality rates both at less than one event per 1000 adults per year. Under ETP the annual cost of health care and prevention will increase from US$2·3 billion in 2016 to $2·9 billion in 2018, then decrease to $1·7 billion in 2030 and $0·9 billion in 2050. Over the next 35 years, the expansion of treatment will avert an additional 3·8 million new infections, save 1·1 million lives, and save $3·2 billion compared with continuing Constant Effort up to 2050. Expansion of prevention, including provision of pre-exposure prophylaxis, condom distribution, and male circumcision, could avert a further 150 000 new infections, save 5000 lives, and cost an additional $5·7 billion compared with Constant Effort. INTERPRETATION Our results suggest that South Africa is on track to reduce HIV incidence and AIDS-related mortality substantially by 2030, saving both lives and money. Success will depend on high rates of HIV testing, ART delivery and adherence, good patient monitoring and support, and data to monitor progress. FUNDING None.
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Affiliation(s)
- Brian G Williams
- South African Centre for Epidemiological Modelling and Analysis, University of Stellenbosch, Stellenbosch, South Africa.
| | - Somya Gupta
- International Association of Providers of AIDS Care, Washington, DC, USA
| | | | - Reuben Granich
- International Association of Providers of AIDS Care, Washington, DC, USA
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Essex M. The end of AIDS? LANCET PUBLIC HEALTH 2017; 2:e205-e206. [PMID: 29253481 DOI: 10.1016/s2468-2667(17)30070-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 03/23/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Max Essex
- Harvard T H Chan School of Public Health AIDS Initiative, Harvard University, Boston, MA 02115, USA.
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Effectiveness of UNAIDS targets and HIV vaccination across 127 countries. Proc Natl Acad Sci U S A 2017; 114:4017-4022. [PMID: 28320938 DOI: 10.1073/pnas.1620788114] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The HIV pandemic continues to impose enormous morbidity, mortality, and economic burdens across the globe. Simultaneously, innovations in antiretroviral therapy, diagnostic approaches, and vaccine development are providing novel tools for treatment-as-prevention and prophylaxis. We developed a mathematical model to evaluate the added benefit of an HIV vaccine in the context of goals to increase rates of diagnosis, treatment, and viral suppression in 127 countries. Under status quo interventions, we predict a median of 49 million [first and third quartiles 44M, 58M] incident cases globally from 2015 to 2035. Achieving the Joint United Nations Program on HIV/AIDS 95-95-95 target was estimated to avert 25 million [20M, 33M] of these new infections, and an additional 6.3 million [4.8M, 8.7M] reduction was projected with the 2020 introduction of a 50%-efficacy vaccine gradually scaled up to 70% coverage. This added benefit of prevention through vaccination motivates imminent and ongoing clinical trials of viable candidates to realize the goal of HIV control.
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Abstract
OBJECTIVE In 2015, the WHO recommended initiation of antiretroviral therapy (ART) in all HIV-positive patients regardless of CD4 cell count. We evaluated the cost-effectiveness of immediate versus deferred ART initiation among patients with CD4 cell counts exceeding 500cells/μl in four resource-limited countries (South Africa, Nigeria, Uganda, and India). DESIGN A 5-year Markov model with annual cycles, including patients at CD4 cell counts more than 500 cells/μl initiating ART or deferring therapy until historic ART initiation criteria of CD4 cell counts more than 350 cells/μl were met. METHODS The incidence of opportunistic infections, malignancies, cardiovascular disease, unscheduled hospitalizations, and death, were informed by the START trial results. Risk of HIV transmission was obtained from a systematic review. Disability weights were based on published literature. Cost inputs were inflated to 2014 US dollars and based on local sources. Results were expressed in cost per disability-adjusted life years averted and measured against WHO cost-effectiveness thresholds. RESULTS Immediate initiation of ART is associated with a cost per disability-adjusted life years averted of -$317 [95% confidence interval (CI): -$796-$817] in South Africa; -$507 (95% CI: -$765-$837) in Nigeria; -$136 (-$382-$459) in Uganda; and -$78 (-$256-$374) in India. The results are largely driven by the impact of ART on reducing the risk of new HIV transmissions. CONCLUSIONS In HIV-positive patients with CD4 counts above 500 cells/μl in the four studied countries, immediate initiation of ART versus deferred therapy until historic eligibility criteria are met is cost-effective and likely even cost-saving over time.
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