Cost-effectiveness of increased HIV testing among MSM in The Netherlands

Effects of improved partner notification on the transmission of HIV and N. gonorrhoea among men who have sex with men: a modelling study

Objectives Men who have sex with men (MSM) are disproportionally affected by HIV in the Netherlands. Partner notification (PN) is an important element in controlling the transmission of sexually transmitted infections (STIs) and HIV. We investigated the effects of improving PN on the transmission of HIV and Neisseria gonorrhoeae (NG) among MSM in the Netherlands. Methods We developed an agent-based model that describes the transmission of HIV and NG among MSM. In the baseline scenario, 14.3% and 29.8% of casual and steady partners of the index case get notified and tested for HIV/STI after 3 weeks (percentage notified and tested (PNT)). We examined the following scenarios: (1) increase PNT to 41% for both partner types; (2) decrease the time between the index and the partners tested to 1 week and (3) combine scenarios 1 and 2. Effects are expressed as cumulative change from the baseline simulation over 15 years. Results Increasing PNT could lead to a decrease in gonorrhoea cases of 45% (IQR 39.9% to 49.9%), with an increase in the number of HIV/STI tests of 4.4% (IQR 1.6% to 7.3%), but no change in HIV infections (-5.4%; IQR -21% to 7.9%). Decreasing the time between tests could lead to a change in new NG infections of -14.2% (IQR -17.2% to -10%), no change in HIV infections (8.2%; IQR -1.3% to 20%) or in the number of HIV/STI tests performed (-0.4%; IQR -1.5 to 0.6%). Scenario 3 led to a change in NG infections of -56.8% (IQR -63.8% to -47.4%), no change in HIV infections (11.5%; IQR -11.1% to 33.9%) or in the number of HIV/STI tests (-0.5%; IQR: -4.9% to 4.3%). Conclusions Increasing the percentage of sexual partners notified and tested for HIV/STI may have only a small effect on HIV but could reduce the number of new NG infections substantially. However, it could lead to an increase in the number of HIV/STI tests performed.

Agent based modelling of blood borne viruses: a scoping review

BACKGROUND

The models that historically have been used to model infectious disease outbreaks are equation-based and statistical models. However, these models do not capture the impact of individual and social factors that affect the spread of common blood-borne viruses (BBVs) such as human immunodeficiency virus (HIV), hepatitis C virus (HCV), and hepatitis B virus (HBV). Agent-based modelling (ABM) is an alternative modelling approach that is gaining popularity in public health and epidemiology. As the field expands, it is important to understand how ABMs have been applied. In this context, we completed a scoping review of research that has been done on the ABM of BBVs.

METHOD

The inclusion/exclusion criteria were drafted using the idea of Population, Concept, and Context (PCC). The Preferred Reporting Item for Systematic Reviews and Meta-Analysis, an extension to scoping review (PRISMA-ScR), was employed in retrieving ABM literature that studied BBVs. Three databases (Scopus, Pubmed, and Embase) were systematically searched for article retrieval. 200 articles were retrieved from all the databases, with 10 duplicates. After removing the duplicates, 190 papers were screened for inclusion. After analysing the remaining articles, 70 were excluded during the abstract screening phase, and 32 were excluded during the full-text decision. Eighty-eight were retained for the scoping review analysis. To analyse this corpus of 88 papers, we developed a five-level taxonomy that categorised each paper based first on disease type, then transmission mechanism, then modelled population, then geographic location and finally, model outcome.

RESULTS

The result of this analysis show significant gaps in the ABM of BBV literature, particularly in the modeling of social and individual factors influencing BBV transmission.

CONCLUSION

There is a need for more comprehensive models that address various outcomes across different populations, transmission and intervention mechanisms. Although ABMs are a valuable tool for studying BBVs, further research is needed to address existing gaps and improve our understanding of individual and social factors that influence the spread and control of BBVs. This research can inform researchers, modellers, epidemiologists, and public health practitioners of the ABM research areas that need to be explored to reduce the burden of BBVs globally.

Impact of Varying Pre-exposure Prophylaxis Programs on HIV and Neisseria gonorrhoeae Transmission Among MSM in the Netherlands: A Modeling Study

BACKGROUND

In 2019, a 5-year pre-exposure prophylaxis (PrEP) program started in the Netherlands, in which up to 8500 men who have sex with men (MSM) can obtain PrEP and 3-monthly consultations with HIV/STI testing.

SETTING

We assessed the impact of the PrEP program on transmission of HIV and Neisseria gonorrhea (NG) among MSM in the Netherlands and examined prospective variations of the program after 2024.

METHODS

We used an agent-based model to estimate the effect of the PrEP program. For hypothetical prospective PrEP programs starting in 2024, we varied the capacity (8,500; 12,000; 16,000 participants) and consultation frequency (3-monthly; 6-monthly; 70% 3-monthly and 30% 6-monthly).

RESULTS

At a capacity of 8,500 participants and 3-monthly consultations, the PrEP program could lead to 3,140 [95% credible interval (95% CrI): 1,780-4,780] and 27,930 (95% CrI: 14,560-46,280) averted HIV and NG infections, requiring 316,050 (95% CrI: 314,120-317,580) consultations. At a capacity of 16,000 participants, the programs with 3-monthly consultations and 6-monthly consultations could lead to comparable number of averted HIV [3,940 (95% CrI: 2,420-5,460), and 3,900 (2,320-5,630) respectively] and NG infections [29,970 (95% CrI: 15,490-50,350), and 29,960 (95% CrI: 13,610-50,620) respectively], while requiring substantially different number of consultations: 589,330 (95% CrI: 586,240-591,160) and 272,590 (95% CrI: 271,770-273,290), respectively.

CONCLUSIONS

Continuation of a PrEP program could lead to a substantial reduction in HIV and NG transmission. More infections could be averted if the number of participants is increased. In turn, the consultation frequency could be reduced without reducing the number of averted infections if capacity is increased.

Examining HIV Testing Coverage and Factors Influencing First-Time Testing Among Men Who Have Sex With Men in Zhejiang Province, China: Cross-Sectional Study Based on a Large Internet Survey

BACKGROUND

Men who have sex with men (MSM) constitute a significant population of patients infected with HIV. In recent years, several efforts have been made to promote HIV testing among MSM in China.

OBJECTIVE

This study aimed to assess HIV testing coverage and factors associated with first-time HIV testing among MSM to provide a scientific basis for achieving the goal of diagnosing 95% of patients infected with HIV by 2030.

METHODS

This cross-sectional study was conducted between July 2023 and December 2023. MSM were recruited from the "Sunshine Test," an internet platform that uses location-based services to offer free HIV testing services to MSM by visiting the WeChat official account in Zhejiang Province, China. Participants were required to complete a questionnaire on their demographic characteristics, sexual behaviors, substance use, and HIV testing history. A logistic regression model was used to analyze first-time HIV testing and its associated factors.

RESULTS

A total of 7629 MSM participated in the study, with 87.1% (6647) having undergone HIV testing before and 12.9% (982) undergoing HIV testing for the first time. Multivariate logistic regression analysis revealed that first-time HIV testing was associated with younger age (adjusted odds ratio [aOR] 2.55, 95% CI 1.91-3.42), lower education (aOR 1.39, 95% CI 1.03-1.88), student status (aOR 1.35, 95% CI 1.04-1.75), low income (aOR 1.55, 95% CI 1.16-2.08), insertive anal sex role (aOR 1.28, 95% CI 1.05-1.56), bisexuality (aOR 1.69, 95% CI 1.40-2.03), fewer sex partners (aOR 1.44, 95% CI 1.13-1.83), use of rush poppers (aOR 2.06, 95% CI 1.70-2.49), unknown HIV status of sex partners (aOR 1.40, 95% CI 1.17-1.69), lack of awareness of HIV pre-exposure prophylaxis (aOR 1.39, 95% CI 1.03-1.88), and offline HIV testing uptake (aOR 2.08, 95% CI 1.80-2.41).

CONCLUSIONS

A notable 12.9% (982/7629) of MSM had never undergone HIV testing before this large internet survey. We recommend enhancing HIV intervention and testing through internet-based platforms and gay apps to promote testing among MSM and achieve the target of diagnosing 95% of patients infected with HIV by 2030.

Impact and cost-effectiveness of non-governmental organizations on the HIV epidemic in Ukraine among MSM

OBJECTIVE

Non-governmental organizations (NGOs) in Ukraine have provided HIV testing, treatment, and condom distribution for MSM. HIV prevalence among MSM in Ukraine is 5.6%. We estimated the impact and cost-effectiveness of MSM-targeted NGO activities in Ukraine.

DESIGN

A mathematical model of HIV transmission among MSM was calibrated to data from Ukraine (2011-2018).

METHODS

The model, designed before the 2022 Russian invasion of Ukraine, evaluated the impact of 2018 status quo coverage levels of 28% of MSM being NGO clients over 2016-2020 and 2021-2030 compared with no NGO activities over these time periods. Impact was measured in HIV incidence and infections averted. We compared the costs and disability adjusted life years (DALYs) for the status quo and a counterfactual scenario (no NGOs 2016-2020, but with NGOs thereafter) until 2030 to estimate the mean incremental cost-effectiveness ratio (cost per DALY averted).

RESULTS

Without NGO activity over 2016-2020, the HIV incidence in 2021 would have been 44% (95% credibility interval: 36-59%) higher than with status quo levels of NGO activity, with 25% (21-30%) more incident infections occurring over 2016-2020. Continuing with status quo NGO coverage levels will decrease HIV incidence by 41% over 2021-2030, whereas it will increase by 79% (60-120%) with no NGOs over this period and 37% (30-51%) more HIV infections will occur. Compared with if NGO activities had ceased over 2016-2020 (but continued thereafter), the status quo scenario averts 14 918 DALYs over 2016-2030 with a mean incremental cost-effectiveness ratio of US$600.15 per DALY averted.

CONCLUSION

MSM-targeted NGOs in Ukraine have prevented considerable HIV infections and are highly cost-effective compared with a willingness-to-pay threshold of 50% of Ukraine's 2018 GDP (US$1548).

Cost-effectiveness of implementing HIV and HIV/syphilis dual testing among key populations in Viet Nam: a modelling analysis

OBJECTIVES

Key populations, including sex workers, men who have sex with men, and people who inject drugs, have a high risk of HIV and sexually transmitted infections. We assessed the health and economic impacts of different HIV and syphilis testing strategies among three key populations in Viet Nam using a dual HIV/syphilis rapid diagnostic test (RDT).

SETTING

We used the spectrum AIDS impact model to simulate the HIV epidemic in Viet Nam and evaluated five testing scenarios among key populations. We used a 15-year time horizon and a provider perspective for costs.

PARTICIPANTS

We simulate the entire population of Viet Nam in the model.

INTERVENTIONS

We modelled five testing scenarios among key populations: (1) annual testing with an HIV RDT, (2) annual testing with a dual RDT, (3) biannual testing using dual RDT and HIV RDT, (4) biannual testing using HIV RDT and (5) biannual testing using dual RDT.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome is incremental cost-effectiveness ratios. Secondary outcomes include HIV and syphilis cases.

RESULTS

Annual testing using a dual HIV/syphilis RDT was cost-effective (US$10 per disability-adjusted life year (DALY)) and averted 3206 HIV cases and treated 27 727 syphilis cases compared with baseline over 15 years. Biannual testing using one dual test and one HIV RDT (US$1166 per DALY), or two dual tests (US$5672 per DALY) both averted an additional 875 HIV cases, although only the former scenario was cost-effective. Annual or biannual HIV testing using HIV RDTs and separate syphilis tests were more costly and less effective than using one or two dual RDTs.

CONCLUSIONS

Annual HIV and syphilis testing using dual RDT among key populations is cost-effective in Vietnam and similar settings to reach global reduction goals for HIV and syphilis.

Offering a choice of daily and event-driven preexposure prophylaxis for men who have sex with men in the Netherlands: a cost-effectiveness analysis

OBJECTIVES

To assess the cost-effectiveness of a preexposure prophylaxis (PrEP) programme offering a choice of daily and event-driven PrEP for men who have sex with men (MSM) in the Netherlands.

METHODS

We used an agent-based transmission model and an economic model to simulate a programme offering only daily PrEP and a programme offering daily and event-driven PrEP. Use of PrEP medication and preference for daily versus event-driven PrEP were estimated from the Amsterdam PrEP Demonstration Project (AMPrEP). We calculated costs, quality-adjusted life-years (QALY), and incremental cost-effectiveness ratios (ICER), over 2018-2027. An ICER less than €20 000 per QALY gained was considered cost-effective.

RESULTS

Using AMPrEP data, we estimated that 27% of PrEP users chose event-driven PrEP with a median of 12 pills per month; daily PrEP users used a median of 30 pills per month. With PrEP, 3740 HIV infections were averted and 1482 QALYs were gained over 2018-2027, compared to the scenario without PrEP. The probability of the PrEP programme being cost-effective (compared to not having a PrEP programme) increased from 91% with daily PrEP to 94% with a choice of daily and event-driven PrEP. The probability of being cost-saving increased from 42% with only daily PrEP to 48% with choice of daily and event-driven PrEP.

CONCLUSIONS

A daily PrEP programme for MSM would be cost-effective. Providing a choice of daily and event-driven PrEP can result in savings and is more likely to be cost-effective and cost-saving, compared to a programme offering only daily PrEP.

Preexposure prophylaxis for men who have sex with men in the Netherlands: impact on HIV and Neisseria gonorrhoeae transmission and cost-effectiveness

OBJECTIVES

To assess the impact of a preexposure prophylaxis (PrEP) programme for high-risk men who have sex with men (MSM), which includes gonorrhoea testing and treatment, on the transmission of HIV and Neisseria among MSM in the Netherlands and the cost-effectiveness of such programme with and without risk compensation (in the form of reduced condom use).

METHODS

We developed a stochastic agent-based transmission model of HIV and gonorrhoea. We simulated a capped (max 2.5% of MSM) and uncapped (5.5% of MSM in 2018 declining to 3% in 2027) daily PrEP programme for high-risk MSM, with 3-monthly HIV and gonorrhoea testing, with and without risk compensation. Epidemiological outcomes were calculated from the transmission model and used in an economic model to calculate costs, quality-adjusted life-years (QALY), and incremental cost-effectiveness ratios (ICER), over 2018-2027, taking a healthcare payer perspective.

RESULTS

Without risk compensation, PrEP can lead to a reduction of 61 or 49% in the total number of new HIV infections in 2018-2027, if the programme is uncapped or capped to 2.5% of MSM, respectively. With risk compensation, this reduction can be 63 or 46% in the uncapped and capped programmes, respectively. In all scenarios, gonorrhoea prevalence decreased after introducing PrEP. Without risk compensation, 92% of simulations were cost-effective (of which 52% cost-saving). With risk compensation, 73% of simulations were cost-effective (of which 23% was cost-saving).

CONCLUSION

A nationwide PrEP programme for high-risk MSM can result in substantial reductions in HIV and gonorrhoea transmission and be cost-effective, even with risk compensation.