Cost effectiveness of human immunodeficiency virus postexposure prophylaxis for healthcare workers

Testing the waters: Ethical considerations for including PrEP in a phase IIb HIV vaccine efficacy trial

BACKGROUND

The field of HIV prevention research has recently experienced some mixed results in efficacy trials of pre-exposure prophylaxis, vaginal microbicides, and HIV vaccines. While there have been positive trial results in some studies, in the near term, no single method will be sufficient to quell the epidemic. Improved HIV prevention methods, choices among methods, and coverage for all at-risk populations will be needed. The emergence of partially effective prevention methods that are not uniformly available raises complex ethical and scientific questions regarding the design of ongoing prevention trials.

METHODS

We present here an ethical analysis regarding inclusion of pre-exposure prophylaxis in an ongoing phase IIb vaccine efficacy trial, HVTN 505. This is the first large vaccine efficacy trial to address the issue of pre-exposure prophylaxis, and the decisions made by the protocol team were informed by extensive stakeholder consultations. The key ethical concerns are analyzed here, and the process of stakeholder engagement and decision-making described.

DISCUSSION

This discussion and analysis will be useful as current and future research teams grapple with ethical and scientific study design questions emerging with the rapidly expanding evidence base for HIV prevention.

Uptake and repeat use of postexposure prophylaxis in a community-based clinic in Los Angeles, California

Postexposure prophylaxis (PEP) has become an important tool for HIV prevention in the men who have sex with men (MSM) communities within Los Angeles County. However, it is unclear as to whether the most sexually at-risk MSM populations are accessing PEP services. Furthermore, it is unclear what behavioral risk factors differentiate individuals who utilize PEP once (single PEP) versus those who utilize it multiple times (re-PEP). Data were collected between May 2011 and December 2012 on all clients enrolled in the Los Angeles LGBT Center's (the Center) PEP-LA program as well as on all sexually transmitted infection (STI) screening clients visiting the Center. Multivariate logistic regression models were used to analyze results. PEP clients had greater odds of having a history of gonorrhea in the past year when compared to high-risk, non-PEP clients (OR: 1.71; CI: 1.25-2.35). Furthermore, they had greater odds of using methamphetamines (OR: 1.71; CI: 1.30-2.24) and inhaled nitrates (OR: 1.62; CI: 1.30-2.01) in the past 12 months when compared to high-risk, non-PEP clients. Re-PEP clients had greater odds of methamphetamine use than single PEP clients (OR: 2.80; CI: 1.65-4.75). There were no significant differences by race/ethnicity between high-risk, non-PEP clients and PEP clients in either the entire cohort or MSM only sample. However, African Americans made up 8.5% of persons accessing PEP services but 16.7% of persons who tested HIV positive. Similar proportions of PEP use by race/ethnicity are problematic considering the disproportionate burden of HIV infections in the African American community. Although uptake among the highest risk populations has been brisk (n=649), inequities based upon race/ethnicity suggest the need for increased outreach.

The value of infectious diseases specialists: non-patient care activities

Recent developments in health care have focused efforts on both the national and local levels to reduce unnecessary health care costs and the number of hospital stays while increasing the quality of care, particularly in the context of hospital-associated infections. Infectious diseases specialists who contract to oversee infection-control and antibiotic-stewardship programs are uniquely positioned to play a pivotal role in helping hospitals to prosper in this new environment. This article will detail the available data supporting the value of infectious diseases specialists in their roles of directing antimicrobial-management and infection-control programs, maintaining health care workers' well-being, and minimizing exposure. The evidence in support of the influence of infectious diseases specialists to achieve cost-savings, decrease the length of hospital stays, and improve outcomes is robust and can be used as the framework for negotiating appropriate compensation from hospital management for these activities. Presenting this information in an amicable but definitive framework may be the linchpin to the overall success of the movement to improve quality of care while minimizing hospital costs and antimicrobial use. Developing this ability is critical to infectious diseases specialists' success as they redefine their role in the quality-of-care and risk-management arenas.

Measuring the value of public health systems: the disconnect between health economists and public health practitioners

We investigated ways of defining and measuring the value of services provided by governmental public health systems. Our data sources included literature syntheses and qualitative interviews of public health professionals. Our examination of the health economic literature revealed growing attempts to measure value of public health services explicitly, but few studies have addressed systems or infrastructure. Interview responses demonstrated no consensus on metrics and no connection to the academic literature. Key challenges for practitioners include developing rigorous, data-driven methods and skilled staff; being politically willing to base allocation decisions on economic evaluation; and developing metrics to capture "intangibles" (e.g., social justice and reassurance value). Academic researchers evaluating the economics of public health investments should increase focus on the working needs of public health professionals.

A Systematic Review of Cost-Utility Analyses in HIV/AIDS: Implications for Public Policy

Objectives . To determine whether gaps exist in published cost-utility analyses as measured by their coverage of topics addressed in current HIV guidelines from the Department of Health and Human Services (DHHS). Design . A systematic review of US-based cost-effectiveness analyses of HIV/AIDS prevention and management strategies, based on original, published research. Methods . Predefined criteria were used to identify all analyses pertaining to prevention and management of HIV/AIDS; information was collected on type of strategy, patient demographics, study perspective, quality of the study, effectiveness measures, costs, and cost-effectiveness ratios. Results . One hundred and six studies were identified; 62 described strategies for averting new HIV infections, and 44 dealt with managing persons who are HIV positive. The quality of studies was generally high, but gaps were found in all studies. Especially common were omissions in reporting data abstraction methodology and discussions of direction and magnitude of potential biases. Among the 22 most highly rated papers (score of 90 or higher), only 1 was cited in the guidelines, and 3 papers reported on interventions that were superseded by newer approaches. Using a $100,000 threshold, the guidelines usually endorsed interventions found to be cost-effective. Exceptions included recommending postexposure prophylaxis (PEP) for populations in which PEP is unlikely to be cost-effective and not recommending primary resistance testing in treatment-naive persons, although the intervention was reported to have a cost-effectiveness ratio of less than $50,000. Conclusions . Despite an abundant literature on the cost-utility of HIV/AIDS-targeted strategies, guidelines cite relatively few of these papers, and gaps exist regarding assessments of some strategies and special populations.

Post-exposure prophylaxis of HIV infection in healthcare workers: recommendations for the European setting

The European Commission funded a project for the standardisation of the management of occupational exposures to HIV/blood-borne infections and antiretroviral post-exposure prophylaxis (PEP) in Europe. Within this project, the following recommendations and rationale were formulated by experts representative of participating countries. Based on assessment of the exposure, material, and source characteristics, PEP should be started as soon as possible with any triple combination of antiretrovirals approved for the treatment of HIV-infected patients; initiation is discouraged after 72 hours Rapid HIV testing of the source could reduce inappropriate PEP. HIV testing should be performed at baseline, 4, 12, and 24 weeks, with additional clinical and laboratory monitoring of adverse reactions and potential toxicity at week 1 and 2. HIV resistance tests in the source and direct virus assays in the exposed HCW are not recommended routinely. These easy-to-use recommendations seek to maximise PEP effect while minimising its toxicity and inappropriate use.