1
|
Liang A, Wilson-Barthes M, Galárraga O. Cost-effectiveness of differentiated care models that incorporate economic strengthening for HIV antiretroviral therapy adherence: a systematic review. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2024; 22:46. [PMID: 38790050 PMCID: PMC11127452 DOI: 10.1186/s12962-024-00557-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 05/19/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND There is some evidence that differentiated service delivery (DSD) models, which use a client-centered approach to simplify and increase access to care, improve clinical outcomes among people living with HIV (PLHIV) in high HIV prevalence countries. Integrating economic strengthening tools (e.g., microcredit, cash transfers, food assistance) within DSD models can help address the poverty-related barriers to HIV antiretroviral therapy (ART). Yet there is minimal evidence of the cost-effectiveness of these types of multilevel care delivery models, which potentially prohibits their wider implementation. METHODS Using a qualitative systematic review, this article synthesizes the literature surrounding the cost-effectiveness of differentiated service delivery models that employ economic strengthening initiatives to improve HIV treatment adherence in low- and middle-income countries. We searched three academic databases for randomized controlled trials and observational studies published from January 2000 through March 2024 in Sub-Saharan Africa. The quality of each study was scored using a validated appraisal system. RESULTS Eighty-nine full texts were reviewed and 3 met all eligibility criteria. Two of the three included articles were specific to adolescents living with HIV. Economic strengthening opportunities varied by care model, and included developmental savings accounts, microenterprise workshops, and cash and non-cash conditional incentives. The main drivers of programmatic and per-patient costs were ART medications, CD4 cell count testing, and economic strengthening activities. CONCLUSION All economic evaluations in this review found that including economic strengthening as part of comprehensive differentiated service delivery was cost-effective at a willingness to pay threshold of at least 2 times the national per capita gross domestic product. Two of the three studies in this review focused on adolescents, suggesting that these types of care models may be especially cost-effective for youth entering adulthood. All studies were from the provider perspective, indicating that additional evidence is needed to inform the potential cost-savings of DSD and economic strengthening interventions to patients and society. Randomized trials testing the effectiveness of DSD models that integrate economic strengthening should place greater emphasis on costing these types of programs to inform the potential for bringing these types of multilevel interventions to scale.
Collapse
Affiliation(s)
- Annie Liang
- Brown University School of Public Health, Providence, RI, USA
| | - Marta Wilson-Barthes
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Omar Galárraga
- Department of Health Services, Policy and Practice; and International Health Institute, Brown University School of Public Health, 121 South Main Street, Box G-S121-2, Providence, RI, USA.
| |
Collapse
|
2
|
Bosma CB, Toromo JJ, Ayers MJ, Foster ED, McHenry M, Enane LA. Effects of economic interventions on pediatric and adolescent HIV care outcomes: a systematic review. AIDS Care 2024; 36:1-16. [PMID: 37607246 PMCID: PMC10843852 DOI: 10.1080/09540121.2023.2240071] [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: 02/14/2023] [Accepted: 07/18/2023] [Indexed: 08/24/2023]
Abstract
Economic insecurity and poverty present major barriers to HIV care for young people. We conducted a systematic review of the current evidence for the effect of economic interventions on HIV care outcomes among pediatric populations encompassing young children, adolescents, and youth (ages 0-24). We conducted a search of PubMed MEDLINE, Cochrane, Embase, Scopus, CINAHL, and Global Health databases on October 12, 2022 using a search strategy curated by a medical librarian. Studies included economic interventions targeting participants <25 years in age which measured clinical HIV outcomes. Study characteristics, care outcomes, and quality were independently assessed, and findings were synthesized. Title/abstract screening was performed for 1934 unique records. Thirteen studies met inclusion criteria, reporting on nine distinct interventions. Economic interventions included incentives (n = 5), savings and lending programs (n = 3), and government cash transfers (n = 1). Study designs included three randomized controlled trials, an observational cohort study, a matched retrospective cohort study, and pilot intervention studies. While evidence is very limited, some promising findings were observed supporting retention and viral suppression, particularly for those with suboptimal care engagement or with detectable viral load. There is a need to further study and optimize economic interventions for children and adolescents living with HIV.
Collapse
Affiliation(s)
- Christopher B. Bosma
- Departments of Medicine and Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Judith J. Toromo
- The Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Morgan J. Ayers
- Departments of Medicine and Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Erin D. Foster
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, IN, USA
- Berkeley Library, University of California Berkeley, Berkeley, California, USA
| | - Megan McHenry
- The Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Indiana University Center for Global Health Equity, Indianapolis, IN, USA
| | - Leslie A. Enane
- The Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Indiana University Center for Global Health Equity, Indianapolis, IN, USA
| |
Collapse
|
3
|
Mulawa MI, Knippler ET, Al-Mujtaba M, Wilkinson TH, Ravi VK, Ledbetter LS. Interventions to Improve Adolescent HIV Care Outcomes. Curr HIV/AIDS Rep 2023; 20:218-230. [PMID: 37300592 PMCID: PMC10528099 DOI: 10.1007/s11904-023-00663-z] [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] [Accepted: 05/31/2023] [Indexed: 06/12/2023]
Abstract
PURPOSE OF REVIEW This review of recent studies evaluating interventions to improve HIV care outcomes among adolescents with HIV (AHIV) was conducted to provide a comprehensive overview of the recent evidence, highlight promising approaches, and suggest directions for future research. RECENT FINDINGS Our scoping review revealed 65 studies evaluating a variety of interventions and using a range of study designs at various stages of research. Effective approaches included community-based, integrated service delivery models with case management, trained community adolescent treatment supporters, and consideration of social determinants of health. Recent evidence also supports the feasibility, acceptability, and preliminary efficacy of other innovative approaches, including mental health interventions as well as technology-delivered approaches; however, more research is needed to build the evidence base for these interventions. Our review's findings suggest that interventions providing comprehensive, individualized support are essential to improving HIV care outcomes among adolescents. More research is needed to build the evidence base for such interventions and ensure effective, equitable implementation to support the global target of ending the AIDS epidemic by 2030.
Collapse
Affiliation(s)
- Marta I Mulawa
- School of Nursing, Duke University, DUMC 3322, Durham, NC, 27710, USA.
- Duke Global Health Institute, Duke University, Durham, NC, USA.
| | | | - Maryam Al-Mujtaba
- School of Nursing, Duke University, DUMC 3322, Durham, NC, 27710, USA
| | | | | | - Leila S Ledbetter
- Duke University Medical Center Library and Archives, Durham, NC, USA
| |
Collapse
|
4
|
Ruel T, Mwangwa F, Balzer LB, Ayieko J, Nyabuti M, Mugoma WE, Kabami J, Kamugisha B, Black D, Nzarubara B, Opel F, Schrom J, Agengo G, Nakigudde J, Atuhaire HN, Schwab J, Peng J, Camlin C, Shade SB, Bukusi E, Kapogiannis BG, Charlebois E, Kamya MR, Havlir D. A multilevel health system intervention for virological suppression in adolescents and young adults living with HIV in rural Kenya and Uganda (SEARCH-Youth): a cluster randomised trial. Lancet HIV 2023; 10:e518-e527. [PMID: 37541706 DOI: 10.1016/s2352-3018(23)00118-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 05/11/2023] [Accepted: 05/17/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND Social and cognitive developmental events can disrupt care and medication adherence among adolescents and young adults living with HIV in sub-Saharan Africa. We hypothesised that a dynamic multilevel health system intervention helping adolescents and young adults and their providers navigate life-stage related events would increase virological suppression compared with standard care. METHODS We did a cluster randomised, open-label trial of young individuals aged 15-24 years with HIV and receiving care in eligible clinics (operated by the government and with ≥25 young people receiving care) in rural Kenya and Uganda. After clinic randomisation stratified by region, patient population, and previous participation in the SEARCH trial, participants in intervention clinics received life-stage-based assessment at routine visits, flexible clinic access, and rapid viral load feedback. Providers had a secure mobile platform for interprovider consultation. The control clinics followed standard practice. The primary, prespecified endpoint was virological suppression (HIV RNA <400 copies per mL) at 2 years of follow-up among participants who enrolled before Dec 1, 2019, and received care at the study clinics. This trial is registered with ClinicalTrials.gov, NCT03848728, and is closed to recruitment. FINDINGS 28 clinics were enrolled and randomly assigned (14 control, 14 intervention) in January, 2019. Between March 14, 2019, and Nov 26, 2020, we recruited 1988 participants at the clinics, of whom 1549 were included in the analysis (785 at intervention clinics and 764 at control clinics). The median participant age was 21 years (IQR 19-23) and 1248 (80·6%) of 1549 participants were female. The mean proportion of participants with virological suppression at 2 years was 88% (95% CI 85-92) for participants in intervention clinics and 80% (77-84) for participants in control clinics, equivalent to a 10% beneficial effect of the intervention (risk ratio [RR] 1·10, 95% CI 1·03-1·16; p=0·0019). The intervention resulted in increased virological suppression within all subgroups of sex, age, and care status at baseline, with greatest improvement among those re-engaging in care (RR 1·60, 95% CI 1·00-2·55; p=0·025). INTERPRETATION Routine and systematic life-stage-based assessment, prompt adherence support with rapid viral load testing, and patient-centred, flexible clinic access could help bring adolescents and young adults living with HIV closer towards a goal of universal virological suppression. FUNDING Eunice Kennedy Shriver National Institute of Child Health and Human Development, US National Institutes of Health.
Collapse
Affiliation(s)
- Theodore Ruel
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA.
| | | | - Laura B Balzer
- Division of Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
| | | | | | | | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Douglas Black
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | | | - Fred Opel
- Kenya Medical Research Institute, Kisumu, Kenya
| | - John Schrom
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | | | - Janet Nakigudde
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Josh Schwab
- Division of Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
| | - James Peng
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Carol Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Starley B Shade
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | | | - Bill G Kapogiannis
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Edwin Charlebois
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Moses R Kamya
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane Havlir
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| |
Collapse
|
5
|
Applying Behavioural Insights to HIV Prevention and Management: a Scoping Review. Curr HIV/AIDS Rep 2022; 19:358-374. [PMID: 35930186 PMCID: PMC9508055 DOI: 10.1007/s11904-022-00615-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW This scoping review summarises the literature on HIV prevention and management interventions utilizing behavioural economic principles encapsulated in the MINDSPACE framework. RECENT FINDINGS MINDSPACE is an acronym developed by the UK's behavioural insights team to summarise nine key influences on human behaviour: Messenger, Incentives, Norms, Default, Salience, Priming, Affect, Commitment, and Ego. These effects have been used in various settings to design interventions that encourage positive behaviours. Currently, over 200 institutionalised behavioural insight teams exist internationally, which may draw upon the MINDSPACE framework to inform policy and improve public services. To date, it is not clear how behavioural insights have been applied to HIV prevention and management interventions. After screening 899 studies for eligibility, 124 were included in the final review. We identified examples of interventions that utilised all the MINDSPACE effects in a variety of settings and among various populations. Studies from high-income countries were most common (n = 54) and incentives were the most frequently applied effect (n = 100). The MINDSPACE framework is a useful tool to consider how behavioural science principles can be applied in future HIV prevention and management interventions. Creating nudges to enhance the design of HIV prevention and management interventions can help people make better choices as we strive to end the HIV/AIDS pandemic by 2030.
Collapse
|
6
|
Munyayi FK, van Wyk B, Mayman Y. Interventions to Improve Treatment Outcomes among Adolescents on Antiretroviral Therapy with Unsuppressed Viral Loads: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19073940. [PMID: 35409621 PMCID: PMC8997420 DOI: 10.3390/ijerph19073940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/16/2022] [Accepted: 03/21/2022] [Indexed: 01/02/2023]
Abstract
Adolescents living with HIV (ALHIV) face unique developmental challenges that increase the risk of unsuppressed viral loads. Current reviews present a need for proven interventions to improve viral suppression among ALHIV on ART, who have a history of unsuppressed viral loads. This systematic review aims to synthesize and appraise evidence of the effectiveness of interventions to improve treatment outcomes among ALHIV with unsuppressed viral loads. Six bibliographic databases were searched for published studies and gray literature from 2010 to 2021. The risk of bias and certainty of evidence was assessed using the ROBINS-I tool, CASP checklists and GRADE. A total of 28 studies were eligible for full-text screening; and only three were included in the qualitative synthesis. In addition, two studies were included from website searches. Four types of interventions to improve viral suppression were identified, namely: intensive adherence counselling; community- and facility-based peer-led differentiated service delivery (DSD); family based economic empowerment; and conditional economic incentives and motivational interviewing. We strongly recommend peer-led community-based DSD interventions, intensive adherence counselling, and family-based economic empowerment as potential interventions to improve viral suppression among ALHIV.
Collapse
Affiliation(s)
- Farai Kevin Munyayi
- School of Public Health, University of the Western Cape, Cape Town 7535, South Africa;
- Correspondence:
| | - Brian van Wyk
- School of Public Health, University of the Western Cape, Cape Town 7535, South Africa;
| | - Yolanda Mayman
- Department of Psychology, University of the Western Cape, Cape Town 7535, South Africa;
| |
Collapse
|