Clinical impact and cost-effectiveness of expanded voluntary HIV testing in India

Recent HIV testing and self-reported HIV prevalence among men who inject drugs in Afghanistan: a nationwide survey in 2019-2020

BACKGROUND

People who inject drugs (PWID) remain at high risk for HIV in many countries, including Afghanistan. Previous reports on HIV testing and prevalence in Afghanistan were published in 2012. This study assessed recent HIV testing and self-reported HIV prevalence among male PWID in Afghanistan from 2019 to 2020.

METHOD

We visited 374 public venues and hotpots where PWID used to gather and meet their peers across 8 cities in Afghanistan to enroll eligible participants in our study. Using interviews and a survey, our trained interviewers collected data on the demographics, types of drugs, HIV testing history, and self-reported HIV status of the participants. We analyzed the data using the venues and hotpots as clusters to report the percentages of recent HIV tests and self-reported HIV prevalence overall and in subgroups defined by demographic characteristics and locations.

RESULTS

Among the 1385 participants, most were from Kabul city (28.9%), spoke Dari (67.4%), were aged 25-34 years (42.1%), and were married (52.4%). Overall, 70.7% (95% CI 67.6-73.6) (ranging from 20.0% in Kandahar to 99.3% in Mazar-i-Sharif) were tested for HIV within the past 12 months. Among those who had ever been tested for HIV, 20.7% (95% CI 17.8-24.0) (ranging from 0% in Zarang to 63.2% in Kabul) reported being positive for HIV.

CONCLUSION

Compared with the results of a similar study in 2012, we found a significant improvement in HIV testing coverage among PWID in Afghanistan. The high self-reported HIV prevalence among this group also highlights the need for targeted screening and treatment programs for PWID in Afghanistan, particularly in the cities of Kabul and Jalalabad.

Current insights and molecular docking studies of HIV-1 reverse transcriptase inhibitors

Human immunodeficiency virus (HIV) causes acquired immunodeficiency syndrome (AIDS), a lethal disease that is prevalent worldwide. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS) data, 38.4 million people worldwide were living with HIV in 2021. Viral reverse transcriptase (RT) is an excellent target for drug intervention. Nucleoside reverse transcriptase inhibitors (NRTIs) were the first class of approved antiretroviral drugs. Later, a new type of non-nucleoside reverse transcriptase inhibitors (NNRTIs) were approved as anti-HIV drugs. Zidovudine, didanosine, and stavudine are FDA-approved NRTIs, while nevirapine, efavirenz, and delavirdine are FDA-approved NNRTIs. Several agents are in clinical trials, including apricitabine, racivir, elvucitabine, doravirine, dapivirine, and elsulfavirine. This review addresses HIV-1 structure, replication cycle, reverse transcription, and HIV drug targets. This study focuses on NRTIs and NNRTIs, their binding sites, mechanisms of action, FDA-approved drugs and drugs in clinical trials, their resistance and adverse effects, their molecular docking studies, and highly active antiretroviral therapy (HAART).

The cost-effectiveness of a resilience-based psychosocial intervention for HIV prevention among MSM in India

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.

The Cost-effectiveness of Human Immunodeficiency Virus (HIV) Preexposure Prophylaxis and HIV Testing Strategies in High-risk Groups in India

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.

A novel method to estimate the indirect community benefit of HIV interventions using a microsimulation model of HIV disease

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.

Trends in Clinical Characteristics and Short-Term Outcome of HIV-Infected Patients at a Tertiary Care Hospital in South India

Background:

Limited information is available on changing trends in HIV positive patients treated with first-line antiretroviral therapy from India.

Methods:

The clinical characteristics and short-term outcome were compared between a retrospective group enrolled between January 2006 and March 2007 (06-07 group—100 patients) and a prospective group enrolled between February 2011 and March 2012 (10-12 group—85 patients).

Results:

Median age was 36 and 38 years in 06-07 and 10-12 groups, respectively. Median baseline CD4 count was 146 cells/mL³ in the 10-12 group, and it was not significantly different from that of 06-07 group. Tuberculosis was diagnosed 3 times more commonly in the 10-12 group. The retention proportion at the end of 10 months was 68% in the 10-12 group when compared to that of 59% in the 06-07 group.

Conclusion:

There was a trend toward improved outcome over the period of time, but the attrition rate remained high.

Cost-effectiveness and budget impact of immediate antiretroviral therapy initiation for treatment of HIV infection in Côte d'Ivoire: A model-based analysis

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.

Scaling Up Human Immunodeficiency Virus Screening and Antiretroviral Therapy Among Men Who Have Sex With Men to Achieve the 90-90-90 Targets in China

INTRODUCTION

The Joint United Nations Programme on human immunodeficiency virus (HIV)/acquired immune deficiency syndrome has proposed the 90-90-90 targets by 2020. Human immunodeficiency virus epidemic is spreading rapidly among men who have sex with men (MSM) in China. This study investigates how the scale-up of HIV testing and treatment in achieving the targets and its cost-effectiveness.

METHODS

We constructed a compartmental model to forecast the HIV epidemic in Chinese MSM based on various "test-and-treat" scale-up scenarios. We assessed their cost effectiveness based on the cost for each HIV infection, death, and disability-adjusted life years (DALYs) prevented by the scale-up.

RESULTS

If the current epidemic continued, HIV prevalence among Chinese MSM would increase from 9.2% in 2016 to 12.6% (9.2-15.6%) in 2020 and 16.2% (11.3-20.0%) in 2025. By 2020, 49.2% of infected MSM would be diagnosed and 40.1% of whom on treatment, falling short of the 90-90-90 targets, so would be even by 2025. To achieve these targets by 2020, additional 850,000 HIV screening tests and 112,500 person-years of antiretroviral treatment (ART) annually are necessary. This spending is US $478 million during 2016 to 2020, which almost tripled the status quo. However, by delaying to 2025, an investment of US $1210 million over 2016 to 2025 corresponding to 52% increase to the status quo, will enable extra 340,000 HIV screening tests and 60,000 person-year on ART annually. In both scenarios, the incremental cost-effectiveness ratio was US $733 to 960 for each DALY prevented, indicating highly cost-effective scenarios.

CONCLUSIONS

Achieving the 90-90-90 targets by 2020 requires steep increase in investment, but delaying the targets to 2025 is practical and cost-effective.

Evidence for optimal HIV screening and testing intervals in HIV-negative individuals from various risk groups: A systematic review

Background

Human immunodeficiency virus (HIV) testing plays a crucial role in Canada's HIV prevention and treatment efforts and is the first step to achieving the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets; however, how often Canadians, including populations at increased risk of HIV exposure, should be tested is unclear. We conducted a systematic literature review to determine the optimal HIV screening and testing intervals.

Objective

To examine the current evidence on HIV testing intervals in HIV-negative individuals from various risk groups and to assess the potential harms and patients' values and preferences associated with different testing frequencies.

Methods

We searched MEDLINE/PubMed, Scopus, Embase, the Cochrane Library, PsychINFO and EconLit for studies on different frequencies of HIV testing published between January 2000 and September 2016. An additional search was conducted for grey literature published between January 2000 and October 2016. Data extraction included study characteristics, participants, exposure, outcomes and economic variables. The quality of the studies was assessed and results summarized.

Results

Of the 2,702 articles identified from the searches, 27 met the inclusion criteria for review. This included assessments of HIV testing intervals among the general population, men who have sex with men, people who use injection drugs and sex workers. Optimal testing intervals across risk groups ranged from one-time testing to every three months. Data from modelling studies may not be representative of the Canadian context. Few studies identified potential harms of increased screening, specifically an increase in both false positive and false negative results. There were only two studies that addressed patient values and preferences concerning HIV screening, which suggested that the majority of participants were amenable to routine screening through their primary care provider.

Conclusion

There was insufficient evidence to support optimal HIV screening and testing intervals for different populations. Context-specific factors, such as budget allocation, human resources, local epidemiology, socioeconomic factors and risk behaviours, along with clinical judgement, inform whom and how often to screen, suggesting the need for research specific to Canada. Research on patient preferences as well as the benefits and harms of more frequent screening are also indicated.

Clinical Benefits and Cost-Effectiveness of Laboratory Monitoring Strategies to Guide Antiretroviral Treatment Switching in India

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.

Respondent-driven sampling for identification of HIV- and HCV-infected people who inject drugs and men who have sex with men in India: A cross-sectional, community-based analysis

BACKGROUND

A major barrier to achieving ambitious targets for global control of HIV and hepatitis C virus (HCV) is low levels of awareness of infection among key populations such as men who have sex with men (MSM) and people who inject drugs (PWID). We explored the potential of a strategy routinely used for surveillance in these groups, respondent-driven sampling (RDS), to be used as an intervention to identify HIV- and HCV-infected PWID and MSM who are unaware of their status and those who are viremic across 26 Indian cities at various epidemic stages.

METHODS AND FINDINGS

Data were collected as part of the baseline assessment of an ongoing cluster-randomized trial. RDS was used to accrue participants at 27 sites (15 PWID sites and 12 MSM sites) selected to reflect varying stages of the HIV epidemic among MSM and PWID in India. A total of 56 seeds recruited a sample of 26,447 persons (approximately 1,000 participants per site) between October 1, 2012, and December 19, 2013. Across MSM sites (n = 11,997), the median age was 25 years and the median number of lifetime male partners was 8. Across PWID sites (n = 14,450), 92.4% were male, the median age was 30 years, and 87.5% reported injection in the prior 6 months. RDS identified 4,051 HIV-infected persons, of whom 2,325 (57.4%) were unaware of their HIV infection and 2,816 (69.5%) were HIV viremic. It also identified 5,777 HCV-infected persons, of whom 5,337 (92.4%) were unaware that they were infected with HCV and 4,728 (81.8%) were viremic. In the overall sample (both MSM and PWID), the prevalence of HIV-infected persons who were unaware of their status increased with sampling depth, from 7.9% in participants recruited in waves 1 through 5 to 12.8% among those recruited in waves 26 and above (p-value for trend < 0.001). The overall detection rate of people unaware of their HIV infection was 0.5 persons per day, and the detection rate of HIV-infected persons with viremia (regardless of their awareness status) was 0.7 per day. The detection rate of HIV viremic individuals was positively associated with underlying HIV prevalence and the prevalence of HIV viremia (linear regression coefficient per 1-percentage-point increase in prevalence: 0.05 and 0.07, respectively). The median detection rate of PWID who were unaware of their HCV infection was 2.5 per day. The cost of identifying 1 unaware HIV-infected individual ranged from US$51 to US$2,072 across PWID sites and from US$189 to US$5,367 across MSM sites. The mean additional cost of identifying 1 unaware HCV-infected PWID was US$13 (site range: US$7-US$140). Limitations of the study include the exclusivity of study sites to India, lack of prior HIV/HCV diagnosis confirmation with clinic records, and lack of cost data from other case-finding approaches commonly used in India.

CONCLUSIONS

In this study, RDS was able to rapidly identify at nominal cost a substantial number of unaware and viremic HIV-infected and HCV-infected individuals who were currently not being reached by existing programs and who were at high risk for transmission. Combining RDS (or other network-driven recruitment approaches) with strategies focused on linkage to care, particularly in high-burden settings, may be a viable option for achieving the 90-90-90 targets in key populations in resource-limited settings.

The impact of antiretroviral therapy in resource-limited settings and current HIV therapeutics

Four million people of the global total of 35 million with HIV infection are from South-East Asia. ART is currently utilized by 15 million people and has led to a dramatic decline in the mortality rate, including those in low- and middle-income countries. A reduction in sexually transmitted HIV and in comorbidities including tuberculosis has also followed. Current recommendations for the initiation of antiretroviral therapy in people who are HIV+ are essentially to initiate ART irrespective of CD4 cell count and clinical stage. The frequency of HIV testing should be culturally specific and based on the HIV incidence in different key populations but phasing in viral load technology in LMIC is an urgent priority and this needs resources and capacity. With the availability of simplified potent ART regimens, persons with HIV now live longer. The recent WHO treatment guidelines recommending routine HIV testing and earlier initiation of treatment should be the stepping stone for ending the AIDS epidemic and to meet the UNAIDS mission of 90*90*90.

Betting on the fastest horse: Using computer simulation to design a combination HIV intervention for future projects in Maharashtra, India

Objective

To inform the design of a combination intervention strategy targeting HIV-infected unhealthy alcohol users in Maharashtra, India, that could be tested in future randomized control trials.

Methods

Using probabilistic compartmental simulation modeling we compared intervention strategies targeting HIV-infected unhealthy alcohol users on antiretroviral therapy (ART) in Maharashtra, India. We tested interventions targeting four behaviors (unhealthy alcohol consumption, risky sexual behavior, depression and antiretroviral adherence), in three formats (individual, group based, community) and two durations (shorter versus longer). A total of 5,386 possible intervention combinations were tested across the population for a 20-year time horizon and intervention bundles were narrowed down based on incremental cost-effectiveness analysis using a two-step probabilistic uncertainty analysis approach.

Results

Taking into account uncertainty in transmission variables and intervention cost and effectiveness values, we were able to reduce the number of possible intervention combinations to be used in a randomized control trial from over 5,000 to less than 5. The most robust intervention bundle identified was a combination of three interventions: long individual alcohol counseling; weekly Short Message Service (SMS) adherence counseling; and brief sex risk group counseling.

Conclusions

In addition to guiding policy design, simulation modeling of HIV transmission can be used as a preparatory step to trial design, offering a method for intervention pre-selection at a reduced cost.

Initiation of antiretroviral therapy based on the 2015 WHO guidelines

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.

Epidemiological impact of achieving UNAIDS 90-90-90 targets for HIV care in India: a modelling study

OBJECTIVE

Recent UNAIDS '90-90-90' targets propose that to end the HIV epidemic by 2030, 90% of persons living with HIV (PLWH) worldwide should know their diagnosis, 90% of diagnosed PLWH should be on antiretroviral therapy (ART) and 90% of PLWH on ART should be virally suppressed by 2020. We sought to quantify the epidemiological impact of achieving these targets in India.

METHODS

We constructed a dynamic-transmission model of the Indian HIV epidemic to project HIV infections and AIDS-related deaths that would occur in India over 15 years. We considered several scenarios: continuation of current care engagement (with early ART initiation), achieving 90-90-90 targets on time and delaying achievement by 5 or 10 years.

RESULTS

In the base case, assuming continuation of current care engagement, we project 794 000 (95% uncertainty range (UR) 571 000-1 104 000) HIV infections and 689 000 (95% UR 468 000-976 000) AIDS-related deaths in India over 15 years. In this scenario, nearly half of PLWH diagnosed would fail to achieve viral suppression by 2030. With achievement of 90-90-90 targets, India could avert 392 000 (95% UR 248 000-559 000) transmissions (48% reduction) and 414 000 (95% UR 260 000-598 000) AIDS-related deaths (59% reduction) compared to the base-case scenario. Furthermore, fewer than 20 000 (95% UR 12 000-30 000) HIV infections would occur in 2030. Delaying achievement of targets resulted in a similar reduction in HIV incidence by 2030 but at the cost of excess overall infections and mortality.

CONCLUSIONS

India can halve the epidemiological burden of HIV over 15 years with achievement of the UNAIDS 90-90-90 targets. Reaching the targets on time will require comprehensive healthcare strengthening, especially in early diagnosis and treatment, expanded access to second-line and third-line ART and long-term retention in care.

Factors associated with HIV testing among male injecting drug users: findings from a cross-sectional behavioural and biological survey in Manipur and Nagaland, India

Background

Although targeted interventions in India require all high-risk groups, including injecting drug users (IDUs), to test for HIV every 6 months, testing uptake among IDUs remains far from universal. Our study estimates the proportion of IDUs who have taken an HIV test and identifies the factors associated with HIV testing uptake in Nagaland and Manipur, two high HIV prevalence states in India where the epidemic is driven by injecting drug use.

Methods

Data are drawn from the cross-sectional Integrated Behavioural and Biological Assessment (2009) of 1650 male IDUs from two districts each of Manipur and Nagaland. Participants were recruited using respondent-driven sampling (RDS). Descriptive data were analysed using RDSAT 7.1. Multivariate logistic regression analysis was undertaken using STATA 11 to examine the association between HIV testing and socio-demographic, behavioural and programme exposure variables.

Results

One third of IDUs reported prior HIV testing, of whom 8 % had tested HIV-positive. Among those without prior testing, 6.2 % tested HIV-positive in the current survey. IDUs aged 25–34 years (adjusted odds ratio (OR) = 1.41; 95 % confidence interval (CI) = 1.03–1.93), married (Adjusted OR = 1.56; 95 % CI = 1.15–2.12), had a paid sexual partner (Adjusted OR = 1.64; 95 % CI = 1.24–2.18), injected drugs for more than 36 months (Adjusted OR = 1.38; 95 % CI = 1.06–1.81), injected frequently (Adjusted OR = 1.49; 95 % CI = 1.12–1.98) and had high-risk perception (Adjusted OR = 1.68; 95 % CI = 1.32–2.14) were more likely than others to test for HIV. Compared to those with no programme exposure, IDUs who received counselling, or counselling and needle/syringe services, were more likely to test for HIV.

Conclusions

HIV testing uptake among IDUs is low in Manipur and Nagaland, and a critical group of HIV-positive IDUs who have never tested for HIV are being missed by current programmes. This study identifies key sub-groups—including early initiators, short duration and less frequent injectors, perceived to be at low risk—for promoting HIV testing. Providing needles/syringes alone is not adequate to increase HIV testing; additionally, interventions must provide counselling services to inform all IDUs about HIV testing benefits, facilitate visits to testing centres and link those testing positive to timely treatment and care.

A Systematic Review of the State of Economic Evaluation for Health Care in India

BACKGROUND AND OBJECTIVE

Economic evaluations are one of the important tools in policy making for rational allocation of resources. Given the very low public investment in the health sector in India, it is critical that resources are used wisely on interventions proven to yield best results. Hence, we undertook this study to assess the extent and quality of evidence for economic evaluation of health-care interventions and programmes in India.

METHODS

A comprehensive search was conducted to search for published full economic evaluations pertaining to India and addressing a health-related intervention or programme. PubMed, Scopus, Embase, ScienceDirect, and York CRD database and websites of important research agencies were identified to search for economic evaluations published from January 1980 to the middle of November 2014. Two researchers independently assessed the quality of the studies based on Drummond and modelling checklist.

RESULTS

Out of a total of 5013 articles enlisted after literature search, a total of 104 met the inclusion criteria for this systematic review. The majority of these papers were cost-effectiveness studies (64%), led by a clinician or public-health professional (77%), using decision analysis-based methods (59%), published in an international journal (80%) and addressing communicable diseases (58%). In addition, 42% were funded by an international funding agency or UN/bilateral aid agency, and 30% focussed on pharmaceuticals. The average quality score of these full economic evaluations was 65.1%. The major limitation was the inability to address uncertainties involved in modelling as only about one-third of the studies assessed modelling structural uncertainties (33%), or ran sub-group analyses to account for heterogeneity (36.5%) or analysed methodological uncertainty (32%).

CONCLUSION

The existing literature on economic evaluations in India is inadequate to feed into sound policy making. There is an urgent need to generate awareness within the government of how economic evaluation can inform and benefit policy making, and at the same time build capacity of health-care professionals in understanding the economic principles of health-care delivery system.

Economic and epidemiological impact of early antiretroviral therapy initiation in India

INTRODUCTION

Recent WHO guidance advocates for early antiretroviral therapy (ART) initiation at higher CD4 counts to improve survival and reduce HIV transmission. We sought to quantify how the cost-effectiveness and epidemiological impact of early ART strategies in India are affected by attrition throughout the HIV care continuum.

METHODS

We constructed a dynamic compartmental model replicating HIV transmission, disease progression and health system engagement among Indian adults. Our model of the Indian HIV epidemic compared implementation of early ART initiation (i.e. initiation above CD4 ≥350 cells/mm(3)) with delayed initiation at CD4 ≤350 cells/mm(3); primary outcomes were incident cases, deaths, quality-adjusted-life-years (QALYs) and costs over 20 years. We assessed how costs and effects of early ART initiation were impacted by suboptimal engagement at each stage in the HIV care continuum.

RESULTS

Assuming "idealistic" engagement in HIV care, early ART initiation is highly cost-effective ($442/QALY-gained) compared to delayed initiation at CD4 ≤350 cells/mm(3) and could reduce new HIV infections to <15,000 per year within 20 years. However, when accounting for realistic gaps in care, early ART initiation loses nearly half of potential epidemiological benefits and is less cost-effective ($530/QALY-gained). We project 1,285,000 new HIV infections and 973,000 AIDS-related deaths with deferred ART initiation with current levels of care-engagement in India. Early ART initiation in this continuum resulted in 1,050,000 new HIV infections and 883,000 AIDS-related deaths, or 18% and 9% reductions (respectively), compared to current guidelines. Strengthening HIV screening increases benefits of earlier treatment modestly (1,001,000 new infections; 22% reduction), while improving retention in care has a larger modulatory impact (676,000 new infections; 47% reduction).

CONCLUSIONS

Early ART initiation is highly cost-effective in India but only has modest epidemiological benefits at current levels of care-engagement. Improved retention in care is needed to realize the full potential of earlier treatment.

Cost-effectiveness of a repeat HIV test in pregnancy in India

OBJECTIVE

To evaluate cost-effectiveness of second HIV test in pregnancy.

BACKGROUND

Current strategy of single HIV test during pregnancy in India can miss new HIV infections acquired after the first test or those HIV infections that were missed in the first test due to a false-negative HIV test.

METHODS

Between August 2011 and April 2013, 9097 pregnant HIV uninfected women were offered a second HIV test near term (34 weeks or beyond) or within 4 weeks of postpartum period. A decision analysis model was used to evaluate cost-effectiveness of a second HIV test in pregnant women near term.

PRIMARY AND SECONDARY OUTCOME

Our key outcome measures include programme cost with addition of second HIV test in pregnant women and quality-adjusted life years (QALYs) gained.

RESULTS

We detected 4 new HIV infections in the second test. Thus HIV incidence among pregnant women was 0.12 (95% 0.032 to 0.297) per 100 person women years (PWY). Current strategy of a single HIV test is 8.2 times costlier for less QALYs gained as compared to proposed repeat HIV testing of pregnant women who test negative during the first test.

CONCLUSIONS

Our results warrant consideration at the national level for including a second HIV test of all pregnant women in the national programme. However prior to allocation of resources for a second HIV test in pregnancy, appropriate strategies will have to be planned for improving compliance for prevention of mother-to-child transmission of HIV and reducing loss-to-follow-up of those women detected with HIV.

TRIAL REGISTRATION NUMBER

CTRI/2013/12/004183.

Modelling the potential population impact and cost-effectiveness of self-testing for HIV: evaluation of data requirements

HIV testing uptake has increased dramatically in recent years in resource limited settings. Nevertheless, over 50 % of the people living with HIV are still unaware of their status. HIV self-testing (HIVST) is a potential new approach to facilitate further uptake of testing which requires consideration, taking into account economic factors. Mathematical models and associated economic analysis can provide useful assistance in decision-making processes, offering insight, in this case, into the potential long-term impact at a population level and the price-point at which free or subsidized HIVST would be cost-effective in a given setting. However, models are based on assumptions, and if the required data are sparse or limited, this uncertainty will be reflected in the results from mathematical models. The aim of this paper is to describe the issues encountered in modeling the cost-effectiveness of introducing HIVST, to indicate the evidence needed to support various modeling assumptions, and thus which data on HIVST would be most beneficial to collect.

Cost analysis and benefits of opt-out HIV testing at a tertiary care centre in northern India

Currently, in India, the National AIDS Control Organization does not recommend HIV screening for all patients attending health care facilities. The objective of study was to evaluate cost and benefits of opt-out HIV testing at a tertiary care hospital from India. This is a retrospective cohort study of patients who had undergone HIV testing. The cost for HIV testing and cost per HIV-infected patient were determined. A total of 6512 patients (66.4% men and 905 patients younger than 14 years) with mean (SD) age of 30.3 (20.7) years were tested for HIV infection during the study period. Overall, 137 (2.1%) patients tested positive for HIV infection. Total cost for performing HIV tests during study period was Indian Rupees (INR) 649,319 (US dollar [USD] 11805.8). The estimated cost per person tested was INR 99.71 (USD1.8) and cost per HIV-infected patient identified and referred to the antiretroviral therapy centre was INR 4739.55 (USD86.2). We determined a 2.1% period prevalence estimate for HIV infection. Based on cost per HIV-infected patient identified and referred to the antiretroviral therapy centre and the burden of HIV infection, it may be cost effective to perform routine opt-out screening for HIV infection in all patients attending health care facilities in developing countries like India.

Spending of HIV resources in Asia and Eastern Europe: systematic review reveals the need to shift funding allocations towards priority populations

INTRODUCTION

It is increasingly important to prioritize the most cost-effective HIV interventions. We sought to summarize the evidence on which types of interventions provide the best value for money in regions with concentrated HIV epidemics.

METHODS

We conducted a systematic review of peer-reviewed and grey literature reporting measurements of cost-effectiveness or cost-benefit for HIV/AIDS interventions in Asia and Eastern Europe. We also collated HIV/AIDS spending assessment data from case-study countries in the region.

RESULTS

We identified 91 studies for inclusion, 47 of which were from peer-reviewed journals. Generally, in concentrated settings, prevention of mother-to-child transmission programmes and prevention programmes targeting people who inject drugs and sex workers had lower incremental cost-effectiveness ratios than programmes aimed at the general population. The few studies evaluating programmes targeting men who have sex with men indicate moderate cost-effectiveness. Collation of prevention programme spending data from 12 countries in the region (none of which had generalized epidemics) indicated that resources for the general population/non-targeted was greater than 30% for eight countries and greater than 50% for five countries.

CONCLUSIONS

There is a misalignment between national spending on HIV/AIDS responses and the most affected populations across the region. In concentrated epidemics, scarce funding should be directed more towards most-at-risk populations. Reaching consensus on general principles of cost-effectiveness of programmes by epidemic settings is difficult due to inconsistent evaluation approaches. Adopting a standard costing, impact evaluation, benefits calculation, analysis and reporting framework would enable cross comparisons and improve HIV resource prioritization and allocation.