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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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Cost implications of HIV retesting for verification in Africa. PLoS One 2019; 14:e0218936. [PMID: 31260467 PMCID: PMC6602186 DOI: 10.1371/journal.pone.0218936] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 06/12/2019] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION HIV misdiagnosis leads to severe individual and public health consequences. Retesting for verification of all HIV-positive cases prior to antiretroviral therapy initiation can reduce HIV misdiagnosis, yet this practice has not been not widely implemented. METHODS We evaluated and compared the cost of retesting for verification of HIV seropositivity (retesting) to the cost of antiretroviral treatment (ART) for misdiagnosed cases in the absence of retesting (no retesting), from the perspective of the health care system. We estimated the number of misdiagnosed cases based on a review of misdiagnosis rates, and the number of positives persons needing ART initiation by 2020. We presented the total and per person costs of retesting as compared to no retesting, over a ten-year horizon, across 50 countries in Africa grouped by income level. We conducted univariate sensitivity analysis on all model input parameters, and threshold analysis to evaluate the parameter values where the total costs of retesting and the costs no retesting are equivalent. Cost data were adjusted to 2017 United States Dollars. RESULTS AND DISCUSSION The estimated number of misdiagnoses, in the absence of retesting was 156,117, 52,720 and 29,884 for lower-income countries (LICs), lower-middle income countries (LMICs), and upper middle-income countries (UMICs), respectively, totaling 240,463 for Africa. Under the retesting scenario, costs per person initially diagnosed were: $40, $21, and $42, for LICs, LMICs, and UMICs, respectively. When retesting for verification is implemented, the savings in unnecessary ART were $125, $43, and $75 per person initially diagnosed, for LICs, LMICs, and UMICs, respectively. Over the ten-year horizon, the total costs under the retesting scenario, over all country income levels, was $475 million, and was $1.192 billion under the no retesting scenario, representing total estimated savings of $717 million in HIV treatment costs averted. CONCLUSIONS Results show that to reduce HIV misdiagnosis, countries in Africa should implement the WHO's recommendation of retesting for verification prior to ART initiation, as part of a comprehensive quality assurance program for HIV testing services.
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Johnson CC, Fonner V, Sands A, Ford N, Obermeyer CM, Tsui S, Wong V, Baggaley R. To err is human, to correct is public health: a systematic review examining poor quality testing and misdiagnosis of HIV status. J Int AIDS Soc 2017; 20:21755. [PMID: 28872271 PMCID: PMC5625583 DOI: 10.7448/ias.20.7.21755] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 03/07/2017] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION In accordance with global testing and treatment targets, many countries are seeking ways to reach the "90-90-90" goals, starting with diagnosing 90% of all people with HIV. Quality HIV testing services are needed to enable people with HIV to be diagnosed and linked to treatment as early as possible. It is essential that opportunities to reach people with undiagnosed HIV are not missed, diagnoses are correct and HIV-negative individuals are not inadvertently initiated on life-long treatment. We conducted this systematic review to assess the magnitude of misdiagnosis and to describe poor HIV testing practices using rapid diagnostic tests. METHODS We systematically searched peer-reviewed articles, abstracts and grey literature published from 1 January 1990 to 19 April 2017. Studies were included if they used at least two rapid diagnostic tests and reported on HIV misdiagnosis, factors related to potential misdiagnosis or described quality issues and errors related to HIV testing. RESULTS Sixty-four studies were included in this review. A small proportion of false positive (median 3.1%, interquartile range (IQR): 0.4-5.2%) and false negative (median: 0.4%, IQR: 0-3.9%) diagnoses were identified. Suboptimal testing strategies were the most common factor in studies reporting misdiagnoses, particularly false positive diagnoses due to using a "tiebreaker" test to resolve discrepant test results. A substantial proportion of false negative diagnoses were related to retesting among people on antiretroviral therapy. Conclusions HIV testing errors and poor practices, particularly those resulting in false positive or false negative diagnoses, do occur but are preventable. Efforts to accelerate HIV diagnosis and linkage to treatment should be complemented by efforts to improve the quality of HIV testing services and strengthen the quality management systems, particularly the use of validated testing algorithms and strategies, retesting people diagnosed with HIV before initiating treatment and providing clear messages to people with HIV on treatment on the risk of a "false negative" test result.
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Affiliation(s)
- Cheryl C. Johnson
- Department of HIV, World Health Organization, Geneva, Switzerland
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Virginia Fonner
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Anita Sands
- Department of Essential Medicines and Health Products, World Health Organization, Geneva, Switzerland
| | - Nathan Ford
- Department of HIV, World Health Organization, Geneva, Switzerland
| | - Carla Mahklouf Obermeyer
- Department of Epidemiology and Population Health, American University of Beirut, Beirut, Lebanon
| | - Sharon Tsui
- Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | - Vincent Wong
- US Agency for International Development, Washington, DC, USA
| | - Rachel Baggaley
- Department of HIV, World Health Organization, Geneva, Switzerland
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Systematic review and meta-analysis of community and facility-based HIV testing to address linkage to care gaps in sub-Saharan Africa. Nature 2015; 528:S77-85. [PMID: 26633769 DOI: 10.1038/nature16044] [Citation(s) in RCA: 366] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
HIV testing and counselling is the first crucial step for linkage to HIV treatment and prevention. However, despite high HIV burden in sub-Saharan Africa, testing coverage is low, particularly among young adults and men. Community-based HIV testing and counselling (testing outside of health facilities) has the potential to reduce coverage gaps, but the relative impact of different modalities is not well assessed. We conducted a systematic review of HIV testing modalities, characterizing community (home, mobile, index, key populations, campaign, workplace and self-testing) and facility approaches by population reached, HIV positivity, CD4 count at diagnosis and linkage. Of 2,520 abstracts screened, 126 met eligibility criteria. Community HIV testing and counselling had high coverage and uptake and identified HIV-positive people at higher CD4 counts than facility testing. Mobile HIV testing reached the highest proportion of men of all modalities examined (50%, 95% confidence interval (CI) = 47-54%) and home with self-testing reached the highest proportion of young adults (66%, 95% CI = 65-67%). Few studies evaluated HIV testing for key populations (commercial sex workers and men who have sex with men), but these interventions yielded high HIV positivity (38%, 95% CI = 19-62%) combined with the highest proportion of first-time testers (78%, 95% CI = 63-88%), indicating service gaps. Community testing with facilitated linkage (for example, counsellor follow-up to support linkage) achieved high linkage to care (95%, 95% CI = 87-98%) and antiretroviral initiation (75%, 95% CI = 68-82%). Expanding home and mobile testing, self-testing and outreach to key populations with facilitated linkage can increase the proportion of men, young adults and high-risk individuals linked to HIV treatment and prevention, and decrease HIV burden.
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