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Luvuno ZPB, Wiafe E, Mpofana N, Urusla MM, Nxumalo CT. Fast-track interventions for HIV and AIDS epidemic control among key populations: A rapid review. Afr J Prim Health Care Fam Med 2024; 16:e1-e12. [PMID: 38708735 DOI: 10.4102/phcfm.v16i1.4088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 05/07/2024] Open
Abstract
BACKGROUND Targeted interventions for key populations remain critical for realisation of epidemic control for human immunodeficiency virus (HIV) infection because of the causal relationship between HIV infection in the general population and among key population groups. AIM To consolidate evidence on the fast-track interventions towards achieving HIV epidemic control among key populations. METHODS A rapid scoping review was conducted using the methodological framework by Arksey and O' Malley. The Population, Intervention, Context and Outcome (PICO) framework was used to identify relevant studies using key words with Boolean operators in electronic data bases, namely CINHAL, Web of Science, Psych Info and Sabinet. Studies were extracted using a modified data extraction tool, and results were presented narratively. RESULTS A total of 19 articles were included in this review. Most articles were primary studies (n = 17), while another involved the review of existing literature and policies (n = 2) and routinely collected data (n = 1). Most studies were conducted in the United States of America (n = 6), while another were conducted in China, Kenya, Botswana, South Africa and Mozambique. All studies revealed findings on tested interventions to achieve HIV epidemic control among key populations. CONCLUSION Effective interventions for HIV epidemic control were stand-alone behavioural preventive interventions, stand-alone biomedical preventive strategies and combination prevention approaches. Furthermore, the findings suggest that effective activities to achieve HIV epidemic control among key populations should be centred around prevention.Contribution: The findings of this study have policy and practice implications for high HIV burden settings such as South Africa in terms of interventions to facilitate realisation of the Joint United Nations Programme on HIV/AIDS (UNAIDS) 95-95-95 targets, thereby contributing to HIV epidemic control.
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Affiliation(s)
- Zamasomi P B Luvuno
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Howard Campus, Durban.
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Forsythe S, Kioko U, Mahiane G, Glaubius R, Musau A, Gichangi A, Reed J, Were D. Estimating the costs and perceived benefits of oral pre-exposure prophylaxis (PrEP) delivery in ten counties of Kenya: a costing and a contingent valuation study. Front Reprod Health 2024; 6:1278764. [PMID: 38463424 PMCID: PMC10920246 DOI: 10.3389/frph.2024.1278764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 01/24/2024] [Indexed: 03/12/2024] Open
Abstract
Background Kenya included oral PrEP in the national guidelines as part of combination HIV prevention, and subsequently began providing PrEP to individuals who are at elevated risk of HIV infection in 2017. However, as scale-up continued, there was a recognized gap in knowledge on the cost of delivering oral PrEP. This gap limited the ability of the Government of Kenya to budget for its PrEP scale-up and to evaluate PrEP relative to other HIV prevention strategies. The following study calculated the actual costs of oral PrEP scale-up as it was being delivered in ten counties in Kenya. This costing also allowed for a comparison of various models of service delivery in different geographic regions from the perspective of service providers in Kenya. In addition, the analysis was also conducted to understand factors that indicate why some individuals place a greater value on PrEP than others, using a contingent valuation technique. Methods Data collection was completed between November 2017 and September 2018. Costing data was collected from 44 Kenyan health facilities, consisting of 23 public facilities, 5 private facilities and 16 drop-in centers (DICEs) through a cross-sectional survey in ten counties. Financial and programmatic data were collected from financial and asset records and through interviewer administered questionnaires. The costs associated with PrEP provision were calculated using an ingredients-based costing approach which involved identification and costing of all the economic inputs (both direct and indirect) used in PrEP service delivery. In addition, a contingent valuation study was conducted at the same 44 facilities to understand factors that reveal why some individuals place a greater value on PrEP than others. Interviews were conducted with 2,258 individuals (1,940 current PrEP clients and 318 non-PrEP clients). A contingent valuation method using a "payment card approach" was used to determine the maximum willingness to pay (WTP) of respondents regarding obtaining access to oral PrEP services. Results The weighted cost of providing PrEP was $253 per person year, ranging from $217 at health centers to $283 at dispensaries. Drop-in centers (DICEs), which served about two-thirds of the client volume at surveyed facilities, had a unit cost of $276. The unit cost was highest for facilities targeting MSM ($355), while it was lowest for those targeting FSW ($248). The unit cost for facilities targeting AGYW was $323 per person year. The largest percentage of costs were attributable to personnel (58.5%), followed by the cost of drugs, which represented 25% of all costs. The median WTP for PrEP was $2 per month (mean was $4.07 per month). This covers only one-third of the monthly cost of the medication (approximately $6 per month) and less than 10% of the full cost of delivering PrEP ($21 per month). A sizable proportion of current clients (27%) were unwilling to pay anything for PrEP. Certain populations put a higher value on PrEP services, including: FSW and MSM, Muslims, individuals with higher education, persons between the ages of 20 and 35, and households with a higher income and expenditures. Discussion This is the most recent and comprehensive study on the cost of PrEP delivery in Kenya. These results will be used in determining resource requirements and for resource mobilization to facilitate sustainable PrEP scale-up in Kenya and beyond. This contingent valuation study does have important implications for Kenya's PrEP program. First, it indicates that some populations are more motivated to adopt oral PrEP, as indicated by their higher WTP for the service. MSM and FSW, for example, placed a higher value on PrEP than AGYW. Higher educated individuals, in turn, put a much higher value on PrEP than those with less education (which may also reflect the higher "ability to pay" among those with more education). This suggests that any attempt to increase demand or improve PrEP continuation should consider these differences in client populations. Cost recovery from existing PrEP clients would have potentially negative consequences for uptake and continuation.
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Affiliation(s)
- Steven Forsythe
- Center for Economics and Costing, Avenir Health, Glastonbury, CT, United States
| | - Urbanus Kioko
- Department of Economics, University of Nairobi, Nairobi, Kenya
| | - Guy Mahiane
- Center for Modeling, Planning and Policy Analysis, Avenir Health, Glastonbury, CT, United States
| | - Robert Glaubius
- Center for Modeling, Planning and Policy Analysis, Avenir Health, Glastonbury, CT, United States
| | | | | | - Jason Reed
- HIV and Infectious Disease Unit, Jhpiego, Baltimore, MD, United States
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Castor D, Heck CJ, Quigee D, Telrandhe NV, Kui K, Wu J, Glickson E, Yohannes K, Rueda ST, Bozzani F, Meyers K, Zucker J, Deacon J, Kripke K, Sobieszczyk ME, Terris‐Prestholt F, Malati C, Obermeyer C, Dam A, Schwartz K, Forsythe S. Implementation and resource needs for long-acting PrEP in low- and middle-income countries: a scoping review. J Int AIDS Soc 2023; 26 Suppl 2:e26110. [PMID: 37439063 PMCID: PMC10339010 DOI: 10.1002/jia2.26110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 05/05/2023] [Indexed: 07/14/2023] Open
Abstract
INTRODUCTION Several low- and middle-income countries (LMICs) are preparing to introduce long-acting pre-exposure prophylaxis (LAP). Amid multiple pre-exposure prophylaxis (PrEP) options and constrained funding, decision-makers could benefit from systematic implementation planning and aligned costs. We reviewed national costed implementation plans (CIPs) to describe relevant implementation inputs and activities (domains) for informing the costed rollout of LAP. We assessed how primary costing evidence aligned with those domains. METHODS We conducted a rapid review of CIPs for oral PrEP and family planning (FP) to develop a consensus of implementation domains, and a scoping review across nine electronic databases for publications on PrEP costing in LMICs between January 2010 and June 2022. We extracted cost data and assessed alignment with the implementation domains and the Global Health Costing Consortium principles. RESULTS We identified 15 implementation domains from four national PrEP plans and FP-CIP template; only six were in all sources. We included 66 full-text manuscripts, 10 reported LAP, 13 (20%) were primary cost studies-representing seven countries, and none of the 13 included LAP. The 13 primary cost studies included PrEP commodities (n = 12), human resources (n = 11), indirect costs (n = 11), other commodities (n = 10), demand creation (n = 9) and counselling (n = 9). Few studies costed integration into non-HIV services (n = 5), above site costs (n = 3), supply chains and logistics (n = 3) or policy and planning (n = 2), and none included the costs of target setting, health information system adaptations or implementation research. Cost units and outcomes were variable (e.g. average per person-year). DISCUSSION LAP planning will require updating HIV prevention policies, technical assistance for logistical and clinical support, expanding beyond HIV platforms, setting PrEP achievement targets overall and disaggregated by method, extensive supply chain and logistics planning and support, as well as updating health information systems to monitor multiple PrEP methods with different visit schedules. The 15 implementation domains were variable in reviewed studies. PrEP primary cost and budget data are necessary for new product introduction and should match implementation plans with financing. CONCLUSIONS As PrEP services expand to include LAP, decision-makers need a framework, tools and a process to support countries in planning the systematic rollout and costing for LAP.
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Affiliation(s)
- Delivette Castor
- Division of Infectious DiseasesColumbia University Irving Medical CenterNew YorkNew YorkUSA
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
| | - Craig J. Heck
- Division of Infectious DiseasesColumbia University Irving Medical CenterNew YorkNew YorkUSA
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
| | - Daniela Quigee
- Division of Infectious DiseasesColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | | | - Kiran Kui
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
| | - Jiaxin Wu
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
| | | | - Kibret Yohannes
- University of Virginia School of MedicineCharlottesvilleVirginiaUSA
| | | | | | - Kathrine Meyers
- Division of Infectious DiseasesColumbia University Irving Medical CenterNew YorkNew YorkUSA
- The Aaron Diamond AIDS Research CenterColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Jason Zucker
- Division of Infectious DiseasesColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | | | | | | | | | - Christine Malati
- United States Agency for International DevelopmentWashingtonDCUSA
| | - Chris Obermeyer
- The Global Fund to Fight AIDS, Tuberculosis and MalariaGenevaSwitzerland
| | - Anita Dam
- United States Agency for International DevelopmentWashingtonDCUSA
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Giddings R, Indravudh P, Medley GF, Bozzani F, Gafos M, Malhotra S, Terris-Prestholt F, Torres-Rueda S, Quaife M. Infectious Disease Modelling of HIV Prevention Interventions: A Systematic Review and Narrative Synthesis of Compartmental Models. Pharmacoeconomics 2023; 41:693-707. [PMID: 36988896 PMCID: PMC10163138 DOI: 10.1007/s40273-023-01260-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/26/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND The HIV epidemic remains a major public health problem. Critical to transmission control are HIV prevention strategies with new interventions continuing to be developed. Mathematical models are important for understanding the potential impact of these interventions and supporting policy decisions. This systematic review aims to answer the following question: when a new HIV prevention intervention is being considered or designed, what information regarding it is necessary to include in a compartmental model to provide useful insights to policy makers? The primary objective of this review is therefore to assess suitability of current compartmental HIV prevention models for informing policy development. METHODS Articles published in EMBASE, Medline, Econlit, and Global Health were screened. Included studies were identified using permutations of (i) HIV, (ii) pre-exposure prophylaxis (PrEP), circumcision (both voluntary male circumcision [VMMC] and early-infant male circumcision [EIMC]), and vaccination, and (iii) modelling. Data extraction focused on study design, model structure, and intervention incorporation into models. Article quality was assessed using the TRACE (TRAnsparent and Comprehensive Ecological modelling documentation) criteria for mathematical models. RESULTS Of 837 articles screened, 48 articles were included in the review, with 32 unique mathematical models identified. The substantial majority of studies included PrEP (83%), whilst fewer modelled circumcision (54%), and only a few focussed on vaccination (10%). Data evaluation, implementation verification, and model output corroboration were identified as areas of poorer model quality. Parameters commonly included in the mathematical models were intervention uptake and effectiveness, with additional intervention-specific common parameters identified. We identified key modelling gaps; critically, models insufficiently incorporate multiple interventions acting simultaneously. Additionally, population subgroups were generally poorly represented-with future models requiring improved incorporation of ethnicity and sexual risk group stratification-and many models contained inappropriate data in parameterisation which will affect output accuracy. CONCLUSIONS This review identified gaps in compartmental models to date and suggests areas of improvement for models focusing on new prevention interventions. Resolution of such gaps within future models will ensure greater robustness and transparency, and enable more accurate assessment of the impact that new interventions may have, thereby providing more meaningful guidance to policy makers.
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Affiliation(s)
| | | | | | | | - Mitzy Gafos
- London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | - Matthew Quaife
- London School of Hygiene & Tropical Medicine, London, UK
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Bozzani FM, Terris-Prestholt F, Quaife M, Gafos M, Indravudh PP, Giddings R, Medley GF, Malhotra S, Torres-Rueda S. Costs and Cost-Effectiveness of Biomedical, Non-Surgical HIV Prevention Interventions: A Systematic Literature Review. Pharmacoeconomics 2023; 41:467-480. [PMID: 36529838 PMCID: PMC10085926 DOI: 10.1007/s40273-022-01223-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/10/2022] [Indexed: 05/10/2023]
Abstract
BACKGROUND Considerable evidence on the costs and cost-effectiveness of biomedical, non-surgical interventions to prevent human immunodeficiency virus (HIV) transmission has been generated over the last decade. This study aims to synthesize findings and identify remaining knowledge gaps to suggest future research priorities. METHODS A systematic literature review was carried out in August 2020 using the MEDLINE, Embase, Global Health and EconLit databases to retrieve economic evaluations and costing studies of oral pre-exposure prophylaxis (PrEP), injectable long-acting PrEP, vaginal microbicide rings and gels, HIV vaccines and broadly neutralizing antibodies. Studies reporting costs from the provider or societal perspective were included in the analysis. Those reporting on behavioural methods of prevention, condoms and surgical approaches (voluntary medical male circumcision) were excluded. The quality of reporting of the included studies was assessed using published checklists. RESULTS We identified 3007 citations, of which 87 studies were retained. Most were set in low- and middle-income countries (LMICs; n = 53) and focused on the costs and/or cost-effectiveness of oral PrEP regimens (n = 70). Model-based economic evaluations were the most frequent study design; only two trial-based cost-effectiveness analyses and nine costing studies were found. Less than half of the studies provided practical details on how the intervention would be delivered by the health system, and only three of these, all in LMICs, explicitly focused on service integration and its implication for delivery costs. 'Real-world' programme delivery mechanisms and costs of intervention delivery were rarely considered. PrEP technologies were generally found to be cost-effective only when targeting high-risk subpopulations. Single-dose HIV vaccines are expected to be cost-effective for all groups despite substantial uncertainty around pricing. CONCLUSIONS A lack of primary, detailed and updated cost data, including above-service level costs, from a variety of settings makes it difficult to evaluate the cost-effectiveness of specific delivery modes at scale, or to evaluate strategies for services integration. Closing this evidence gap around real-world implementation is vital, not least because the strategies targeting high-risk groups that are recommended by PrEP models may incur substantially higher costs and be of limited practical feasibility in some settings.
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Affiliation(s)
- Fiammetta M Bozzani
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | | | - Matthew Quaife
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Mitzy Gafos
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Pitchaya P Indravudh
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | | | - Graham F Medley
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | | | - Sergio Torres-Rueda
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
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Stone J, Bothma R, Gomez GB, Eakle R, Mukandavire C, Subedar H, Fraser H, Boily M, Schwartz S, Coetzee J, Otwombe K, Milovanovic M, Baral S, Johnson LF, Venter WDF, Rees H, Vickerman P. Impact and cost-effectiveness of the national scale-up of HIV pre-exposure prophylaxis among female sex workers in South Africa: a modelling analysis. J Int AIDS Soc 2023; 26:e26063. [PMID: 36807874 PMCID: PMC9939943 DOI: 10.1002/jia2.26063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 01/30/2023] [Indexed: 02/22/2023] Open
Abstract
INTRODUCTION In 2016, South Africa (SA) initiated a national programme to scale-up pre-exposure prophylaxis (PrEP) among female sex workers (FSWs), with ∼20,000 PrEP initiations among FSWs (∼14% of FSW) by 2020. We evaluated the impact and cost-effectiveness of this programme, including future scale-up scenarios and the potential detrimental impact of the COVID-19 pandemic. METHODS A compartmental HIV transmission model for SA was adapted to include PrEP. Using estimates on self-reported PrEP adherence from a national study of FSW (67.7%) and the Treatment and Prevention for FSWs (TAPS) PrEP demonstration study in SA (80.8%), we down-adjusted TAPS estimates for the proportion of FSWs with detectable drug levels (adjusted range: 38.0-70.4%). The model stratified FSW by low (undetectable drug; 0% efficacy) and high adherence (detectable drug; 79.9%; 95% CI: 67.2-87.6% efficacy). FSWs can transition between adherence levels, with lower loss-to-follow-up among highly adherent FSWs (aHR: 0.58; 95% CI: 0.40-0.85; TAPS data). The model was calibrated to monthly data on the national scale-up of PrEP among FSWs over 2016-2020, including reductions in PrEP initiations during 2020. The model projected the impact of the current programme (2016-2020) and the future impact (2021-2040) at current coverage or if initiation and/or retention are doubled. Using published cost data, we assessed the cost-effectiveness (healthcare provider perspective; 3% discount rate; time horizon 2016-2040) of the current PrEP provision. RESULTS Calibrated to national data, model projections suggest that 2.1% of HIV-negative FSWs were currently on PrEP in 2020, with PrEP preventing 0.45% (95% credibility interval, 0.35-0.57%) of HIV infections among FSWs over 2016-2020 or 605 (444-840) infections overall. Reductions in PrEP initiations in 2020 possibly reduced infections averted by 18.57% (13.99-23.29). PrEP is cost-saving, with $1.42 (1.03-1.99) of ART costs saved per dollar spent on PrEP. Going forward, existing coverage of PrEP will avert 5,635 (3,572-9,036) infections by 2040. However, if PrEP initiation and retention doubles, then PrEP coverage increases to 9.9% (8.7-11.6%) and impact increases 4.3 times with 24,114 (15,308-38,107) infections averted by 2040. CONCLUSIONS Our findings advocate for the expansion of PrEP to FSWs throughout SA to maximize its impact. This should include strategies to optimize retention and should target women in contact with FSW services.
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Affiliation(s)
- Jack Stone
- Population Health SciencesUniversity of BristolBristolUK
| | - Rutendo Bothma
- Wits RHIUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Gabriela B. Gomez
- Department of Global Health and DevelopmentLondon School of Hygiene and Tropical MedicineLondonUK
| | - Robyn Eakle
- Wits RHIUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global Health and DevelopmentLondon School of Hygiene and Tropical MedicineLondonUK
- Office of HIV AIDSU.S. Agency for International Development (USAID)WashingtonDCUSA
| | - Christinah Mukandavire
- Population Health SciencesUniversity of BristolBristolUK
- Department of Infectious Disease EpidemiologyImperial College LondonLondonUK
| | | | - Hannah Fraser
- Population Health SciencesUniversity of BristolBristolUK
| | - Marie‐Claude Boily
- Department of Infectious Disease EpidemiologyImperial College LondonLondonUK
| | - Sheree Schwartz
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Jenny Coetzee
- Perinatal HIV Research UnitFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- South African Medical Research CouncilCape TownSouth Africa
- African Potential Management ConsultancyKyalamiSouth Africa
| | - Kennedy Otwombe
- Perinatal HIV Research UnitFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- School of Public HealthFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Minja Milovanovic
- Perinatal HIV Research UnitFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- African Potential Management ConsultancyKyalamiSouth Africa
| | - Stefan Baral
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Leigh F. Johnson
- Centre for Infectious Disease Epidemiology and ResearchUniversity of Cape TownCape TownSouth Africa
| | | | - Helen Rees
- Wits RHIUniversity of the WitwatersrandJohannesburgSouth Africa
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Kaisara T, Nyabadza F. Modelling Botswana's HIV/AIDS response and treatment policy changes: Insights from a cascade of mathematical models. Math Biosci Eng 2023; 20:1122-1147. [PMID: 36650805 DOI: 10.3934/mbe.2023052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
The management of HIV/AIDS has evolved ever since advent of the disease in the past three decades. Many countries have had to revise their policies as new information on the virus, and its transmission dynamics emerged. In this paper, we track the changes in Botswana's HIV/AIDS response and treatment policies using a piece-wise system of differential equations. The policy changes are easily tracked in three epochs. Models for each era are formulated from a "grand model" that can be linked to all the epochs. The grand model's steady states are determined and analysed in terms of the model reproduction number, $ R_{0}. $ The model exhibits a backward bifurcation, where a stable disease-free equilibrium coexists with a stable endemic equilibrium when $ R_{0} < 1. $ The stability of the models for the other epochs can be derived from that of the grand model by setting some parameters to zero. The models are fitted to HIV/AIDS prevalence data from Botswana for the past three decades. The changes in the populations in each compartment are tracked as the response to the disease and treatment policy changed over time. Finally, projections are made to determine the possible trajectory of HIV/AIDS in Botswana. The implications of the policy changes are easily seen, and a discussion on how these changes impacted the epidemic are articulated. The results presented have crucial impact on how policy changes affected and continue to influence the trajectory of the HIV/AIDS epidemic in Botswana.
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Affiliation(s)
- Tefa Kaisara
- University of Johannesburg, Department of Mathematics and Applied Mathematics, P.O. Box 524, Auckland Park, 2006, South Africa
- Botswana International University of Science and Technology, Department of Mathematics and Statistical Sciences, Private Bag 16, Palapye, Botswana
| | - Farai Nyabadza
- University of Johannesburg, Department of Mathematics and Applied Mathematics, P.O. Box 524, Auckland Park, 2006, South Africa
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Rutstein SE, Matoga M, Chen JS, Mathiya E, Ndalema B, Nyirenda N, Bonongwe N, Taoloka S, Chagomerana M, Tegha G, Hosseinipour MC, Herce ME, Jere E, Krysiak R, Hoffman IF. Integrating enhanced HIV pre-exposure prophylaxis into a sexually transmitted infection clinic in Lilongwe (ePrEP STI): A prospective cohort study (Preprint). JMIR Res Protoc 2022; 11:e37395. [DOI: 10.2196/37395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 09/20/2022] [Accepted: 10/11/2022] [Indexed: 11/07/2022] Open
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Nduva GM, Otieno F, Kimani J, Wahome E, McKinnon LR, Cholette F, Majiwa M, Masika M, Mutua G, Anzala O, Graham SM, Gelmon L, Price MA, Smith AD, Bailey RC, Baele G, Lemey P, Hassan AS, Sanders EJ, Esbjörnsson J. Quantifying rates of HIV-1 flow between risk groups and geographic locations in Kenya: A country-wide phylogenetic study. Virus Evol 2022; 8:veac016. [PMID: 35356640 PMCID: PMC8962731 DOI: 10.1093/ve/veac016] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 02/23/2022] [Accepted: 03/01/2022] [Indexed: 12/14/2022] Open
Abstract
In Kenya, HIV-1 key populations including men having sex with men (MSM), people who inject drugs (PWID) and female sex workers (FSW) are thought to significantly contribute to HIV-1 transmission in the wider, mostly heterosexual (HET) HIV-1 transmission network. However, clear data on HIV-1 transmission dynamics within and between these groups are limited. We aimed to empirically quantify rates of HIV-1 flow between key populations and the HET population, as well as between different geographic regions to determine HIV-1 'hotspots' and their contribution to HIV-1 transmission in Kenya. We used maximum-likelihood phylogenetic and Bayesian inference to analyse 4058 HIV-1 pol sequences (representing 0.3 per cent of the epidemic in Kenya) sampled 1986-2019 from individuals of different risk groups and regions in Kenya. We found 89 per cent within-risk group transmission and 11 per cent mixing between risk groups, cyclic HIV-1 exchange between adjoining geographic provinces and strong evidence of HIV-1 dissemination from (i) West-to-East (i.e. higher-to-lower HIV-1 prevalence regions), and (ii) heterosexual-to-key populations. Low HIV-1 prevalence regions and key populations are sinks rather than major sources of HIV-1 transmission in Kenya. Targeting key populations in Kenya needs to occur concurrently with strengthening interventions in the general epidemic.
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Affiliation(s)
- George M Nduva
- Department of Translational Medicine, Lund University, Faculty of Medicine, Lund University, Box 117 SE-221 00 Lund, Sweden
- Kenya Medical Research Institute-Wellcome Trust Research Programme, KEMRI-Center For Geographic Medicine Research, P.O. Box 230-80108, Kilifi, Kenya
| | - Frederick Otieno
- Nyanza Reproductive Health Society, United Mall, P.O. Box 1764, Kisumu, Kenya
| | - Joshua Kimani
- Department of Medical Microbiology, University of Nairobi, P.O. Box 30197-00100, Nairobi, Kenya
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Max Rady College of Medicine, Room 543-745 Bannatyne Avenue, University of Manitoba (Bannatyne campus), Winnipeg MB R3E 0J9, Canada
| | - Elizabeth Wahome
- Kenya Medical Research Institute-Wellcome Trust Research Programme, KEMRI-Center For Geographic Medicine Research, P.O. Box 230-80108, Kilifi, Kenya
| | - Lyle R McKinnon
- Department of Medical Microbiology, University of Nairobi, P.O. Box 30197-00100, Nairobi, Kenya
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Max Rady College of Medicine, Room 543-745 Bannatyne Avenue, University of Manitoba (Bannatyne campus), Winnipeg MB R3E 0J9, Canada
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Private Bag X7, Congella 4013, South Africa
| | - Francois Cholette
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Max Rady College of Medicine, Room 543-745 Bannatyne Avenue, University of Manitoba (Bannatyne campus), Winnipeg MB R3E 0J9, Canada
- National Microbiology Laboratory at the JC Wilt Infectious Diseases Research Centre, Public Health Agency of Canada, 745 Logan Avenue, Winnipeg, Canada
| | - Maxwell Majiwa
- Kenya Medical Research Institute/Center for Global Health Research, KEMRI-CGHR, P.O. Box 20778-00202, Kisumu, Kenya
| | - Moses Masika
- Faculty of Health Sciences 3RD Floor Wing B, KAVI Institute of Clinical Research, University of Nairobi, P.O. Box 19676-00202, Nairobi, Kenya
| | - Gaudensia Mutua
- Faculty of Health Sciences 3RD Floor Wing B, KAVI Institute of Clinical Research, University of Nairobi, P.O. Box 19676-00202, Nairobi, Kenya
| | - Omu Anzala
- Faculty of Health Sciences 3RD Floor Wing B, KAVI Institute of Clinical Research, University of Nairobi, P.O. Box 19676-00202, Nairobi, Kenya
| | - Susan M Graham
- Kenya Medical Research Institute-Wellcome Trust Research Programme, KEMRI-Center For Geographic Medicine Research, P.O. Box 230-80108, Kilifi, Kenya
- Department of Epidemiology, University of Washington, Office of the Chair, UW Box # 351619, Seattle, DC, USA
| | - Larry Gelmon
- Department of Medical Microbiology, University of Nairobi, P.O. Box 30197-00100, Nairobi, Kenya
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Max Rady College of Medicine, Room 543-745 Bannatyne Avenue, University of Manitoba (Bannatyne campus), Winnipeg MB R3E 0J9, Canada
| | - Matt A Price
- IAVI Global Headquarters, 125 Broad Street, 9th Floor, New York, NY 10004, USA
- Department of Epidemiology and Biostatistics, University of California, Mission Hall: Global Health & Clinical Sciences Building, 550 16th Street, 2nd Floor, San Francisco, CA 94158-2549, USA
| | - Adrian D Smith
- Nuffield Department of Medicine, The University of Oxford, Old Road Campus, Headington, Oxford OX3 7BN, UK
| | - Robert C Bailey
- Nyanza Reproductive Health Society, United Mall, P.O. Box 1764, Kisumu, Kenya
- Division of Epidemiology and Biostatistics, University of Illinois at Chicago, 1603 W Taylor St, Chicago, IL 60612, USA
| | - Guy Baele
- KU Leuven Department of Microbiology, Immunology and Transplantation, Rega Institute, Laboratory of Clinical and Evolutionary and Computational Virology, Rega-Herestraat 49-box 1040, Leuven 3000, Belgium
| | - Philippe Lemey
- KU Leuven Department of Microbiology, Immunology and Transplantation, Rega Institute, Laboratory of Clinical and Evolutionary and Computational Virology, Rega-Herestraat 49-box 1040, Leuven 3000, Belgium
| | - Amin S Hassan
- Department of Translational Medicine, Lund University, Faculty of Medicine, Lund University, Box 117 SE-221 00 Lund, Sweden
- Kenya Medical Research Institute-Wellcome Trust Research Programme, KEMRI-Center For Geographic Medicine Research, P.O. Box 230-80108, Kilifi, Kenya
| | - Eduard J Sanders
- Kenya Medical Research Institute-Wellcome Trust Research Programme, KEMRI-Center For Geographic Medicine Research, P.O. Box 230-80108, Kilifi, Kenya
- Nuffield Department of Medicine, The University of Oxford, Old Road Campus, Headington, Oxford OX3 7BN, UK
| | - Joakim Esbjörnsson
- Department of Translational Medicine, Lund University, Faculty of Medicine, Lund University, Box 117 SE-221 00 Lund, Sweden
- Nuffield Department of Medicine, The University of Oxford, Old Road Campus, Headington, Oxford OX3 7BN, UK
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10
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Guure C, Afagbedzi S, Torpey K. Willingness to take and ever use of pre-exposure prophylaxis among female sex workers in Ghana. Medicine (Baltimore) 2022; 101:e28798. [PMID: 35119051 PMCID: PMC8812709 DOI: 10.1097/md.0000000000028798] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 01/19/2022] [Indexed: 01/04/2023] Open
Abstract
Pre-exposure prophylaxis (PrEP) is a drug taken by people who are human immunodeficiency virus (HIV) negative and at increased risk of acquiring HIV. It's an effective intervention for HIV prevention. This study seeks to report on the prevalence and determinants of willingness to take and ever use of PrEP among female sex workers (FSW) in Ghana.The data analyzed was obtained from the Integrated Bio-behavioral Surveillance Survey conducted across the 16 regions of Ghana in 2020. Analysis was only performed on FSW who were tested negative to HIV and were sexually active. All included variables were described using medians, percentages, and graphs. Bayesian adjusted odds ratios and 95% credible intervals were estimated using a Bayesian generalized linear model via the binomial family of distributions under the logit link function.Of the 5107 FSW with complete data on willingness to use PrEP, 2737 (53.59%) reported their willingness to take PrEP. Out of the 998 respondents who have ever heard of PrEP only 64 (6.39%) have ever used PrEP. The median age of the respondents was 25 years. People with no comprehensive knowledge of HIV and acquired immunodeficiency syndrome as well as those who entered into the FSW business at age less than 25 years; 946 (34.56%) and 2181 (79.65%) respectively were more willing to take PrEP. FSW from 6 out of the 16 regions of Ghana have never used PrEP. A statistically significant difference between those who entered the sex work at age less than 25 years and those within 25 to 34 years was observed. About 23% of FSWs who had been screened for Sexually Transmitted Infections were more likely to take PrEP.Respondents with lesser age and no comprehensive knowledge of HIV were more willing to take PrEP. The willingness to accept PrEP among FSWs in Ghana is modest. However, utilization is low. Advocacy or intervention programs are required to improve uptake of PrEP.
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Affiliation(s)
- Chris Guure
- Department of Biostatistics, School of Public Health, University of Ghana, Legon-Accra, Ghana
| | - Seth Afagbedzi
- Department of Biostatistics, School of Public Health, University of Ghana, Legon-Accra, Ghana
| | - Kwasi Torpey
- Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Legon-Accra, Ghana
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11
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Peebles K, Mugwanya KK, Irungu E, Odoyo J, Wamoni E, Morton JF, Ngure K, Bukusi EA, Mugo NR, Masyuko S, Mukui I, Baeten JM, Barnabas RV. Low costs and opportunities for efficiency: a cost analysis of the first year of programmatic PrEP delivery in Kenya's public sector. BMC Health Serv Res 2021; 21:823. [PMID: 34399736 PMCID: PMC8365926 DOI: 10.1186/s12913-021-06832-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/30/2021] [Indexed: 11/10/2022] Open
Abstract
Background In 2017, the Kenyan Ministry of Health integrated provision of pre-exposure prophylaxis (PrEP) into public HIV-1 care clinics as a key component of the national HIV-1 prevention strategy. Estimates of the cost of PrEP provision are needed to inform the affordability and cost-effectiveness of PrEP in Kenya. Methods We conducted activity-based micro-costing from the payer perspective to estimate both the financial and economic costs of all resources and activities required to provide PrEP in Kenya’s public sector. We estimated total and unit costs in 2019 United States dollars from a combination of project expense reports, Ministry of Health training reports, clinic staff interviews, time-and-motion observations, and routinely collected data from PrEP recipient files from 25 high-volume HIV-1 care clinics. Results In the first year of programmatic PrEP delivery in 25 HIV-1 care clinics, 2,567 persons initiated PrEP and accrued 8,847 total months of PrEP coverage, accounting for 2 % of total outpatient clinic visits. The total financial cost to the Ministry of Health was $91,175, translating to an average of $10.31 per person per month. The majority (69 %) of financial costs were attributable to PrEP medication, followed by administrative supplies (17 %) and training (9 %). Economic costs were higher ($188,584 total; $21.32 per person per month) due to the inclusion of the opportunity cost of staff time re-allocated to provide PrEP and a proportional fraction of facility overhead. The vast majority (88 %) of the annual $80,811 economic cost of personnel time was incurred during activities to recruit new clients (e.g., discussion of PrEP within HIV-1 testing and counselling services), while the remaining 12 % was for activities related to both initiation and maintenance of PrEP provision (e.g., client consultations, technical advising, support groups). Conclusions Integration of PrEP provision into existing public health HIV-1 care service delivery platforms resulted in minimal additional staff burden and low incremental costs. Efforts to improve the efficiency of PrEP provision should focus on reductions in the cost of PrEP medication and extra-clinic demand creation and community sensitization to reduce personnel time dedicated to recruitment-related activities. Trial registration ClinicalTrials.gov registration NCT03052010. Retrospectively registered on February 14, 2017. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06832-3.
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Affiliation(s)
- Kathryn Peebles
- Department of Epidemiology, University of Washington, Seattle, WA, USA. .,International Clinical Research Center, HMC # 359927 325 Ave, WA, 98104, Seattle, USA.
| | - Kenneth K Mugwanya
- Division of Disease Control, School of Public Health, Makerere University, Kampala, Uganda.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Elizabeth Irungu
- Department of Global Health, University of Washington, Seattle, WA, USA.,Partners in Health and Research Development, Nairobi, Kenya
| | - Josephine Odoyo
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Jennifer F Morton
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Kenneth Ngure
- Department of Public and Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Nelly R Mugo
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Sarah Masyuko
- National AIDS & Sexually Transmitted Infection Control Programme, Ministry of Health, Nairobi, Kenya
| | - Irene Mukui
- National AIDS & Sexually Transmitted Infection Control Programme, Ministry of Health, Nairobi, Kenya
| | - Jared M Baeten
- Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ruanne V Barnabas
- Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
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12
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Geidelberg L, Mitchell KM, Alary M, Mboup A, Béhanzin L, Guédou F, Geraldo N, Goma-Matsétsé E, Giguère K, Aza-Gnandji M, Kessou L, Diallo M, Kêkê RK, Bachabi M, Dramane K, Lafrance C, Affolabi D, Diabaté S, Gagnon MP, Zannou DM, Gangbo F, Silhol R, Cianci F, Vickerman P, Boily MC. Mathematical Model Impact Analysis of a Real-Life Pre-exposure Prophylaxis and Treatment-As-Prevention Study Among Female Sex Workers in Cotonou, Benin. J Acquir Immune Defic Syndr 2021; 86:e28-e42. [PMID: 33105397 PMCID: PMC7803451 DOI: 10.1097/qai.0000000000002535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 09/28/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Daily pre-exposure prophylaxis (PrEP) and treatment-as-prevention (TasP) reduce HIV acquisition and transmission risk, respectively. A demonstration study (2015-2017) assessed TasP and PrEP feasibility among female sex workers (FSW) in Cotonou, Benin. SETTING Cotonou, Benin. METHODS We developed a compartmental HIV transmission model featuring PrEP and antiretroviral therapy (ART) among the high-risk (FSW and clients) and low-risk populations, calibrated to historical epidemiological and demonstration study data, reflecting observed lower PrEP uptake, adherence and retention compared with TasP. We estimated the population-level impact of the 2-year study and several 20-year intervention scenarios, varying coverage and adherence independently and together. We report the percentage [median, 2.5th-97.5th percentile uncertainty interval (95% UI)] of HIV infections prevented comparing the intervention and counterfactual (2017 coverages: 0% PrEP and 49% ART) scenarios. RESULTS The 2-year study (2017 coverages: 9% PrEP and 83% ART) prevented an estimated 8% (95% UI 6-12) and 6% (3-10) infections among FSW over 2 and 20 years, respectively, compared with 7% (3-11) and 5% (2-9) overall. The PrEP and TasP arms prevented 0.4% (0.2-0.8) and 4.6% (2.2-8.7) infections overall over 20 years, respectively. Twenty-year PrEP and TasP scale-ups (2035 coverages: 47% PrEP and 88% ART) prevented 21% (17-26) and 17% (10-27) infections among FSW, respectively, and 5% (3-10) and 17% (10-27) overall. Compared with TasP scale-up alone, PrEP and TasP combined scale-up prevented 1.9× and 1.2× more infections among FSW and overall, respectively. CONCLUSIONS The demonstration study impact was modest, and mostly from TasP. Increasing PrEP adherence and coverage improves impact substantially among FSW, but little overall. We recommend TasP in prevention packages.
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Affiliation(s)
- Lily Geidelberg
- Medical Research Council Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Kate M. Mitchell
- Medical Research Council Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Michel Alary
- Département de Médecine Sociale et Préventive, Université Laval, Québec, Quebec, Canada
- Axe Santé des Populations et Pratiques Optimales en Santé, Centre de Recherche du CHU de Québec–Université Laval, Québec, Quebec, Canada
- Institut National de Santé Publique du Québec, Québec, Quebec, Canada
| | - Aminata Mboup
- Département de Médecine Sociale et Préventive, Université Laval, Québec, Quebec, Canada
- Axe Santé des Populations et Pratiques Optimales en Santé, Centre de Recherche du CHU de Québec–Université Laval, Québec, Quebec, Canada
| | - Luc Béhanzin
- Axe Santé des Populations et Pratiques Optimales en Santé, Centre de Recherche du CHU de Québec–Université Laval, Québec, Quebec, Canada
- Dispensaire IST, Centre de Santé Communal de Cotonou 1, Cotonou, Bénin
- École Nationale de Formation des Techniciens Supérieurs en Santé Publique et en Surveillance Épidémiologique, Université de Parakou, Parakou, Bénin
| | - Fernand Guédou
- Axe Santé des Populations et Pratiques Optimales en Santé, Centre de Recherche du CHU de Québec–Université Laval, Québec, Quebec, Canada
- Dispensaire IST, Centre de Santé Communal de Cotonou 1, Cotonou, Bénin
| | - Nassirou Geraldo
- Dispensaire IST, Centre de Santé Communal de Cotonou 1, Cotonou, Bénin
| | | | - Katia Giguère
- Département de Médecine Sociale et Préventive, Université Laval, Québec, Quebec, Canada
- Axe Santé des Populations et Pratiques Optimales en Santé, Centre de Recherche du CHU de Québec–Université Laval, Québec, Quebec, Canada
| | | | - Léon Kessou
- Service de Consultance et Expertise Nouvelle en Afrique (SCEN AFRIK), Cotonou, Bénin
| | - Mamadou Diallo
- Département de Médecine Sociale et Préventive, Université Laval, Québec, Quebec, Canada
- Axe Santé des Populations et Pratiques Optimales en Santé, Centre de Recherche du CHU de Québec–Université Laval, Québec, Quebec, Canada
| | - René K. Kêkê
- Programme Santé de Lutte Contre le Sida (PSLS), Cotonou, Bénin
| | - Moussa Bachabi
- Programme Santé de Lutte Contre le Sida (PSLS), Cotonou, Bénin
| | - Kania Dramane
- École Nationale de Formation des Techniciens Supérieurs en Santé Publique et en Surveillance Épidémiologique, Université de Parakou, Parakou, Bénin
| | - Christian Lafrance
- Axe Santé des Populations et Pratiques Optimales en Santé, Centre de Recherche du CHU de Québec–Université Laval, Québec, Quebec, Canada
| | - Dissou Affolabi
- Faculté des Sciences de la Santé, Université d’Abomey-Calavi, Cotonou, Bénin
- Centre National Hospitalier Universitaire HMK de Cotonou, Cotonou, Bénin
| | - Souleymane Diabaté
- Département de Médecine Sociale et Préventive, Université Laval, Québec, Quebec, Canada
- Axe Santé des Populations et Pratiques Optimales en Santé, Centre de Recherche du CHU de Québec–Université Laval, Québec, Quebec, Canada
- Université Alassane Ouattara, Bouake, Côte d'Ivoire
| | - Marie-Pierre Gagnon
- Axe Santé des Populations et Pratiques Optimales en Santé, Centre de Recherche du CHU de Québec–Université Laval, Québec, Quebec, Canada
- Faculté des Sciences Infirmières, Université Laval, Québec, Québec, Canada
| | - Djimon M. Zannou
- Faculté des Sciences de la Santé, Université d’Abomey-Calavi, Cotonou, Bénin
- Centre National Hospitalier Universitaire HMK de Cotonou, Cotonou, Bénin
| | - Flore Gangbo
- Programme Santé de Lutte Contre le Sida (PSLS), Cotonou, Bénin
- Faculté des Sciences de la Santé, Université d’Abomey-Calavi, Cotonou, Bénin
- Centre National Hospitalier Universitaire HMK de Cotonou, Cotonou, Bénin
| | - Romain Silhol
- Medical Research Council Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Fiona Cianci
- Health Protection Surveillance Center, Dublin, Ireland; and
- Population Health Sciences, University of Bristol, Bristol, United Kindom
| | - Peter Vickerman
- Population Health Sciences, University of Bristol, Bristol, United Kindom
| | - Marie-Claude Boily
- Medical Research Council Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
- Axe Santé des Populations et Pratiques Optimales en Santé, Centre de Recherche du CHU de Québec–Université Laval, Québec, Quebec, Canada
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Wahome EW, Graham SM, Thiong'o AN, Mohamed K, Oduor T, Gichuru E, Mwambi J, Prins PM, van der Elst E, Sanders PEJ. PrEP uptake and adherence in relation to HIV-1 incidence among Kenyan men who have sex with men. EClinicalMedicine 2020; 26:100541. [PMID: 33089128 PMCID: PMC7565200 DOI: 10.1016/j.eclinm.2020.100541] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/21/2020] [Accepted: 08/21/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Data on HIV-1 incidence following programmatic pre-exposure prophylaxis (PrEP) uptake by men who have sex with men (MSM) are limited in sub-Saharan Africa. METHODS Since June 2017, MSM participating in an ongoing cohort study in Kenya were offered daily PrEP, assessed for PrEP uptake and adherence, and evaluated for HIV-1 acquisition monthly. We determined tenofovir-diphosphate (TFV-DP) concentrations in dried blood spots 6-12 months after PrEP initiation, and tenofovir (TFV) concentrations and genotypic drug resistance in plasma samples when HIV-1 infection occurred. We assessed HIV-1 incidence by reported PrEP use. FINDINGS Of 172 MSM, 170 (98·8%) were eligible for PrEP, 140 (82·4%) started it, and 64 (57·7%) reported PrEP use at end of study. Of nine MSM who acquired HIV-1 [incidence rate: 3·9 (95% confidence interval (CI), 2·0-7·4) per 100 person-years (PY)], five reported PrEP use at the time of HIV-1 acquisition [incidence rate: 3·6 (95% CI, 1·5-8·6) per 100 PY)] and four had stopped or had never started PrEP [incidence rate: 4·3 (95% CI, 1·6-11·3) per 100 PY]. Among 76 MSM who reported PrEP use, 11 (14·5%) had protective TFV-DP concentrations of ≥700 fmol/punch (≥4 tablets a week). Among the five MSM who acquired HIV-1 while reporting PrEP use, only one had detectable but low TFV concentrations in plasma and none had genotypic HIV-1 resistance. INTERPRETATION HIV-1 incidence among MSM with access to programmatic PrEP was high and did not differ by reported PrEP use. Only one in seven MSM taking PrEP had protective tenofovir concentrations and four out of five MSM who acquired HIV-1 while reporting PrEP use had not taken it. Strengthened PrEP adherence support is required among MSM in Kenya. FUNDING This work was supported by the International AIDS Vaccine Initiative (IAVI).
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Affiliation(s)
- Elizabeth W. Wahome
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research–Coast, P.O. Box 230-80108, Kilifi, Kenya
- Corresponding author.
| | - Susan M. Graham
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research–Coast, P.O. Box 230-80108, Kilifi, Kenya
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, Wash, USA
| | - Alexander N. Thiong'o
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research–Coast, P.O. Box 230-80108, Kilifi, Kenya
| | - Khamisi Mohamed
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research–Coast, P.O. Box 230-80108, Kilifi, Kenya
| | - Tony Oduor
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research–Coast, P.O. Box 230-80108, Kilifi, Kenya
| | - Evans Gichuru
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research–Coast, P.O. Box 230-80108, Kilifi, Kenya
| | - John Mwambi
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research–Coast, P.O. Box 230-80108, Kilifi, Kenya
| | - Prof. Maria Prins
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
- Department of Infectious Diseases, Amsterdam Infection & Immunity Institute (AI&II), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Elise van der Elst
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research–Coast, P.O. Box 230-80108, Kilifi, Kenya
- Department of Global Health, University of Amsterdam, Amsterdam, the Netherlands
| | - Prof. Eduard J. Sanders
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research–Coast, P.O. Box 230-80108, Kilifi, Kenya
- Department of Global Health, University of Amsterdam, Amsterdam, the Netherlands
- Nuffield Department of Medicine, University of Oxford, Headington, UK
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Abstract
Purpose of review To explore the comparative importance of HIV infections among key populations and their intimate partners as HIV epidemics evolve, and to review implications for guiding responses. Recent findings Even as concentrated epidemics evolve, new infections among current and former key population members and their intimate partners dominate new infections. Prevalent infections in the general population grow primarily because of key population turnover and infections among their intimate partners. In generalized epidemic settings, data and analysis on key populations are often inadequate to assess the impact of key population-focused responses, so they remain limited in coverage and under resourced. Models must incorporate downstream infections in comparing impacts of alternative responses. Summary Recognize that every epidemic is unique, moving beyond the overly simplistic concentrated/generalized epidemic paradigm that can misdirect resources. Guide HIV responses by gathering and using locally relevant data, understanding risk heterogeneity, and applying modeling at both national and sub-national levels to optimize resource allocations among different populations for greatest impact. Translate this improved understanding into clear, unequivocal advice for policymakers on where to focus for impact, breaking them free of the generalized/concentrated paradigm limiting their thinking and affecting their decisions.
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Stewart J, Bukusi E, Celum C, Delany-Moretlwe S, Baeten JM. Sexually transmitted infections among African women: an opportunity for combination sexually transmitted infection/HIV prevention. AIDS 2020; 34:651-8. [PMID: 32167988 DOI: 10.1097/QAD.0000000000002472] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Khanna AS, Schneider JA, Collier N, Ozik J, Issema R, di Paola A, Skwara A, Ramachandran A, Webb J, Brewer R, Cunningham W, Hilliard C, Ramani S, Fujimoto K, Harawa N. A modeling framework to inform preexposure prophylaxis initiation and retention scale-up in the context of 'Getting to Zero' initiatives. AIDS 2019; 33:1911-1922. [PMID: 31490212 PMCID: PMC6760326 DOI: 10.1097/qad.0000000000002290] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE(S) 'Getting to Zero' (GTZ) initiatives aim to eliminate new HIV infections over a projected time frame. Increased preexposure prophylaxis (PrEP) uptake among populations with the highest HIV incidence, such as young Black MSM, is necessary to accomplish this aim. Agent-based network models (ABNMs) can help guide policymakers on strategies to increase PrEP uptake. DESIGN Effective PrEP implementation requires a model that incorporates the dynamics of interventions and dynamic feedbacks across multiple levels including virus, host, behavior, networks, and population. ABNMs are a powerful tool to incorporate these processes. METHODS An ABNM, designed for and parameterized using data for young Black MSM in Illinois, was used to compare the impact of PrEP initiation and retention interventions on HIV incidence after 10 years, consistent with GTZ timelines. Initiation interventions selected individuals in serodiscordant partnerships, or in critical sexual network positions, and compared with a controlled setting where PrEP initiators were randomly selected. Retention interventions increased the mean duration of PrEP use. A combination intervention modeled concurrent increases in PrEP initiation and retention. RESULTS Selecting HIV-negative individuals for PrEP initiation in serodiscordant partnerships resulted in the largest HIV incidence declines, relative to other interventions. For a given PrEP uptake level, distributing effort between increasing PrEP initiation and retention in combination was approximately as effective as increasing only one exclusively. CONCLUSION Simulation results indicate that expanded PrEP interventions alone may not accomplish GTZ goals within a decade, and integrated scale-up of PrEP, antiretroviral therapy, and other interventions might be necessary.
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Affiliation(s)
| | | | - Nicholson Collier
- Consortium for Advanced Science and Engineering, The University of Chicago, Chicago, Illinois
| | - Jonathan Ozik
- Consortium for Advanced Science and Engineering, The University of Chicago, Chicago, Illinois
| | - Rodal Issema
- Chicago Center for HIV Elimination
- Department of Medicine
| | - Angela di Paola
- Center for Health Promotion and Prevention Research, The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
| | - Abigail Skwara
- Chicago Center for HIV Elimination
- Department of Medicine
| | | | - Jeannette Webb
- Chicago Center for HIV Elimination
- Department of Medicine
| | - Russell Brewer
- Chicago Center for HIV Elimination
- Department of Medicine
| | - William Cunningham
- Department of Health Policy and Management, University of California, Los Angeles
| | - Charles Hilliard
- Department of Psychiatry and Human Behavior, Charles R. Drew University
| | | | - Kayo Fujimoto
- Center for Health Promotion and Prevention Research, The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
| | - Nina Harawa
- Department of Psychiatry and Human Behavior, Charles R. Drew University
- Department of Epidemiology, University of California, Los Angeles, Los Angeles, California, USA
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Shea J, Bula A, Dunda W, Hosseinipour MC, Golin CE, Hoffman IF, Miller WC, Go VF, Lungu T, Lancaster KE. "The Drug Will Help Protect My Tomorrow": Perceptions of Integrating PrEP into HIV Prevention Behaviors Among Female Sex Workers in Lilongwe, Malawi. AIDS Educ Prev 2019; 31:421-432. [PMID: 31550194 PMCID: PMC6793990 DOI: 10.1521/aeap.2019.31.5.421] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Female sex workers (FSW) are disproportionately at risk for HIV. Pre-exposure prophylaxis (PrEP) is an effective HIV prevention method, yet approaches for incorporating PrEP within prevention strategies used by FSW are lacking. Semistructured focus group discussions were conducted with 44 HIV-negative FSW in Lilongwe, Malawi to explore perceptions of PrEP: acceptability, integration within HIV prevention behaviors, and barriers to use. Acceptability of PrEP was high. Motivation to use PrEP was rooted in love for one's life, anticipated negative economic effects associated with HIV acquisition. PrEP was viewed as complementary to existing norms for engaging in healthy sexual behaviors. Many felt PrEP may provide extra protection from HIV, along with condoms and frequent STI testing. Unpredictable daily lives, stigma, and side effects were barriers that could affect PrEP use. Leveraging existing HIV prevention strategies and social norms surrounding HIV prevention behaviors may positively impact PrEP uptake among FSW in Malawi and sub-Saharan Africa.
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Affiliation(s)
- Jaclyn Shea
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina (UNC) at Chapel Hill, Chapel Hill, North Carolina
| | | | | | - Mina C Hosseinipour
- UNC Project Malawi, Lilongwe, Malawi
- Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill
| | - Carol E Golin
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina (UNC) at Chapel Hill, Chapel Hill, North Carolina
- UNC Center for AIDS Research, Lineberger Cancer Center, University of North Carolina at Chapel Hill
| | - Irving F Hoffman
- Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill
| | - William C Miller
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio
| | - Vivian F Go
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina (UNC) at Chapel Hill, Chapel Hill, North Carolina
| | | | - Kathryn E Lancaster
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio
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Abstract
Controlling the spread of HIV among hidden, high-risk populations such as survival sex workers and their clients is becoming increasingly important in the ongoing fight against HIV/AIDS. Several sociological and structural factors render general control strategies ineffective in these settings; instead, focused prevention, testing and treatment strategies which take into account the nature of survival sex work are required. Using a dynamic bipartite network model of sexual contacts, we investigate the optimal distribution of treatment and preventative resources among sex workers and their clients; specifically, we consider control strategies that randomly allocate antiretroviral therapy and pre-exposure prophylaxis within each subpopulation separately. Motivated by historical data from a South African mining community, three main asymmetries between sex workers and clients are considered in our model: relative population sizes, migration rates and partner distributions. We find that preventative interventions targeted at female sex workers are the lowest cost strategies for reducing HIV prevalence, since the sex workers form a smaller population and have, on average, more sexual contacts. However, the high migration rate among survival sex workers limits the extent to which prevalence can be reduced using this strategy. To achieve a further reduction in HIV prevalence, testing and treatment in the client population cannot be ignored.
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Affiliation(s)
- Nicola Mulberry
- Department of Mathematics, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Alexander R Rutherford
- Department of Mathematics and SFU Big Data, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Ralf W Wittenberg
- Department of Mathematics, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Brian G Williams
- South African Centre for Epidemiological Modelling and Analysis, University of Stellenbosch, Stellenbosch, South Africa
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Case KK, Gomez GB, Hallett TB. The impact, cost and cost-effectiveness of oral pre-exposure prophylaxis in sub-Saharan Africa: a scoping review of modelling contributions and way forward. J Int AIDS Soc 2019; 22:e25390. [PMID: 31538407 PMCID: PMC6753289 DOI: 10.1002/jia2.25390] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 08/06/2019] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Oral pre-exposure prophylaxis (PrEP) is a new form of HIV prevention being considered for inclusion in national prevention portfolios. Many mathematical modelling studies have been undertaken that speak to the impact, cost and cost-effectiveness of PrEP programmes. We assess the available evidence from mathematical modelling studies to inform programme planning and policy decision making for PrEP and further research directions. METHODS We conducted a scoping review of the published modelling literature. Articles published in English which modelled oral PrEP in sub-Saharan Africa, or non-specific settings with relevance to generalized HIV epidemic settings, were included. Data were extracted for the strategies of PrEP use modelled, and the impact, cost and cost-effectiveness of PrEP for each strategy. We define an algorithm to assess the quality and relevance of studies included, summarize the available evidence and identify the current gaps in modelling. Recommendations are generated for future modelling applications and data collection. RESULTS AND DISCUSSION We reviewed 1924 abstracts and included 44 studies spanning 2007 to 2017. Modelling has reported that PrEP can be a cost-effective addition to HIV prevention portfolios for some use cases, but also that it would not be cost-effective to fund PrEP before other prevention interventions are expanded. However, our assessment of the quality of the modelling indicates cost-effectiveness analyses failed to comply with standards of reporting for economic evaluations and the assessment of relevance highlighted that both key parameters and scenarios are now outdated. Current evidence gaps include modelling to inform service development using updated programmatic information and ex post modelling to evaluate and inform efficient deployment of resources in support of PrEP, especially among key populations, using direct evidence of cost, adherence and uptake patterns. CONCLUSIONS Updated modelling which more appropriately captures PrEP programme delivery, uses current intervention scenarios, and is parameterized with data from demonstration and implementation projects is needed in support of more conclusive findings and actionable recommendations for programmes and policy. Future analyses should address these issues, aligning with countries to support the needs of programme planners and decision makers for models to more directly inform programme planning and policy.
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Affiliation(s)
- Kelsey K Case
- Department of Infectious Disease EpidemiologyImperial College LondonLondonUK
| | - Gabriela B Gomez
- Department of Global Health and DevelopmentLondon School of Hygiene and Tropical MedicineLondonUK
| | - Timothy B Hallett
- Department of Infectious Disease EpidemiologyImperial College LondonLondonUK
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Roberts DA, Barnabas RV, Abuna F, Lagat H, Kinuthia J, Pintye J, Bochner AF, Forsythe S, Gomez GB, Baeten JM, John‐Stewart G, Levin C. The role of costing in the introduction and scale-up of HIV pre-exposure prophylaxis: evidence from integrating PrEP into routine maternal and child health and family planning clinics in western Kenya. J Int AIDS Soc 2019; 22 Suppl 4:e25296. [PMID: 31328443 PMCID: PMC6643078 DOI: 10.1002/jia2.25296] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 05/08/2019] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Understanding the cost of strategies to reach and deliver pre-exposure prophylaxis (PrEP) to priority populations is essential to assess the cost-effectiveness and budget impact of HIV prevention programmes. Providing PrEP through maternal and child health and family planning clinics offers a promising strategy to reach women in high HIV burden settings. We estimated incremental costs and explored the cost drivers of integrating PrEP delivery into routine maternal and child health and family planning services in Kenya. METHODS We conducted a costing study from the provider perspective within the PrEP Implementation for Young Women and Adolescents programme in western Kenya. We identified all within- and above-facility activities supporting PrEP delivery and measured clinical service time using time-and-motion studies. We obtained input costs from programme budgets, expenditure records and staff interviews. We estimated changes in costs if creatinine testing were postponed from initiation to first follow-up visit and if PrEP were prioritized to clients at high HIV risk using a behavioural risk assessment tool. We also projected costs under Ministry of Health (MOH) implementation assuming MOH salaries and programme supervision. We estimated annual numbers of PrEP visits from programme data abstracted from 16 facilities between November 2017 and June 2018. We report the cost per client-month of PrEP dispensed in 2017 USD. RESULTS For an annual programme output of 24,005 screenings, 4198 PrEP initiations and 4427 follow-up visits, the average cost per client-month of PrEP dispensed in the study was $26.52. Personnel, drugs and laboratory tests comprised 43%, 25% and 14% of programme costs respectively. Postponing creatinine testing and prioritizing PrEP delivery to clients at high HIV risk reduced total programme costs by 8% and 14% respectively. In the MOH scenario assuming no changes in outputs, the projected cost per client-month of PrEP dispensed decreased to $16.54 and total programme costs decreased by 38%. CONCLUSIONS Incremental PrEP costs are sensitive to the service delivery strategy used to engage priority populations. Postponing creatinine testing and prioritizing PrEP delivery to clients at high HIV risk may reduce costs. Context-specific cost data are crucial to assess the cost-effectiveness and affordability of PrEP delivery models.
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Affiliation(s)
- D Allen Roberts
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
| | - Ruanne V Barnabas
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of MedicineUniversity of WashingtonSeattleWAUSA
| | - Felix Abuna
- University of Washington in KenyaNairobiKenya
| | | | | | - Jillian Pintye
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Aaron F Bochner
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | | | - Gabriela B Gomez
- Department of Global Health and DevelopmentLondon School of Tropical Hygiene and MedicineLondonUnited Kingdom
| | - Jared M Baeten
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of MedicineUniversity of WashingtonSeattleWAUSA
| | - Grace John‐Stewart
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of MedicineUniversity of WashingtonSeattleWAUSA
| | - Carol Levin
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
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Eakle R, Weatherburn P, Bourne A. Understanding user perspectives of and preferences for oral PrEP for HIV prevention in the context of intervention scale-up: a synthesis of evidence from sub-Saharan Africa. J Int AIDS Soc 2019; 22 Suppl 4:e25306. [PMID: 31328429 PMCID: PMC6643067 DOI: 10.1002/jia2.25306] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 05/10/2019] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Oral pre-exposure prophylaxis (PrEP) for HIV prevention has been proven to significantly reduce new HIV infections yet scale-up has been slow. As contexts continue to adjust to make space for PrEP, it is crucial to understand the perspectives and experiences of potential end-users. In order to inform PrEP and demand creation interventions, this paper examines personal perspectives on adopting and using PrEP among HIV at-risk populations in sub-Saharan Africa. METHODS Using the principles of a scoping review in July 2018, we explored the extent, range, and nature of published literature regarding PrEP uptake and use among; men who have sex with men, HIV serodiscordant couples, adolescent girls and young women, pregnant and breastfeeding women, women partners of migrant workers; and people who use drugs. Steps included: identification of the research question; identification of relevant studies; study selection; charting the data; and collation - summarizing and reporting results. PubMed and PsycInfo were searched for papers relating to PrEP uptake and use in sub-Saharan Africa. Resulting papers were reviewed with data extracted and compiled in Excel for analysis. A broad content analysis was conducted and organized into high-level themes. RESULTS AND DISCUSSION Thirty-five papers were included in this review. There was little opposition in general to oral PrEP; however, there were significant nuances in its broader acceptability, applicability, and usability. We identified five themes within which these are discussed. These relate to balancing complexities of personal empowerment and stigma; navigating complex risk environments; influences of relationships and partners; efficacy and side effects; and practicalities of use. This body of research suggests that while product attributes and the logistics of PrEP delivery and use are important topics, it is vital to consider stigma, the interactions of PrEP use with relationships, and the need for broader understanding of ARVs for prevention versus treatment. CONCLUSIONS Planning for, programming and promoting the adoption of oral PrEP necessitates a deeper understanding of end-user priorities in order to ensure successful interventions. This review illustrates the nuances facilitating or deterring PrEP use that may affect the larger effort of PrEP scale-up.
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Affiliation(s)
- Robyn Eakle
- Department of Global Health and DevelopmentLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Peter Weatherburn
- Sigma ResearchDepartment of Public Health, Environments and SocietyLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Adam Bourne
- Australian Research Centre in Sex, Health & SocietyLa Trobe UniversityMelbourneAustralia
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Sarkar S, Corso P, Ebrahim-Zadeh S, Kim P, Charania S, Wall K. Cost-effectiveness of HIV Prevention Interventions in Sub-Saharan Africa: A Systematic Review. EClinicalMedicine 2019; 10:10-31. [PMID: 31193863 PMCID: PMC6543190 DOI: 10.1016/j.eclinm.2019.04.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 04/04/2019] [Accepted: 04/10/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Sub-Saharan Africa carries the highest HIV burden globally. It is important to understand how interventions cost-effectively fit within guidelines and implementation plans, especially in low- and middle-income settings. We reviewed the evidence from economic evaluations of HIV prevention interventions in sub-Saharan Africa to help inform the allocation of limited resources. METHODS We searched PubMed, Web of Science, Econ-Lit, Embase, and African Index Medicus. We included studies published between January 2009 and December 2018 reporting cost-effectiveness estimates of HIV prevention interventions. We extracted health outcomes and cost-effectiveness ratios (CERs) and evaluated study quality using the CHEERS checklist. FINDINGS 60 studies met the full inclusion criteria. Prevention of mother-to-child transmission interventions had the lowest median CERs ($1144/HIV infection averted and $191/DALY averted), while pre-exposure prophylaxis interventions had the highest ($13,267/HIA and $799/DALY averted). Structural interventions (partner notification, cash transfer programs) have similar CERs ($3576/HIA and $392/DALY averted) to male circumcision ($2965/HIA) and were more favourable to treatment-as-prevention interventions ($7903/HIA and $890/DALY averted). Most interventions showed increased cost-effectiveness when prioritizing specific target groups based on age and risk. INTERPRETATION The presented cost-effectiveness information can aid policy makers and other stakeholders as they develop guidelines and programming for HIV prevention plans in resource-constrained settings.
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Affiliation(s)
- Supriya Sarkar
- Department of Epidemiology, Emory University, Atlanta, GA, USA
- Corresponding author at: Department of Epidemiology, Emory University, Atlanta 30322, USA.
| | - Phaedra Corso
- Department of Health Policy and Management, Kennesaw State University, Kennesaw, GA, USA
| | | | - Patricia Kim
- cDepartment of Economics, Emory University, Atlanta, GA, USA
| | - Sana Charania
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kristin Wall
- Department of Epidemiology, Emory University, Atlanta, GA, USA
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Zhang L, Peng P, Wu Y, Ma X, Soe NN, Huang X, Wu H, Markowitz M, Meyers K. Modelling the Epidemiological Impact and Cost-Effectiveness of PrEP for HIV Transmission in MSM in China. AIDS Behav 2019; 23:523-33. [PMID: 29971734 DOI: 10.1007/s10461-018-2205-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Risk of HIV infection is high in Chinese MSM, with an annual HIV incidence ranging from 3.41 to 13.7/100 person-years. Tenofovir-based PrEP is effective in preventing HIV transmission in MSM. This study evaluates the epidemiological impact and cost-effectiveness of implementing PrEP in Chinese MSM over the next two decades. A compartmental model for HIV was used to forecast the impact of PrEP on number of infections, deaths, and disability-adjusted life years (DALY) averted. We also provide an estimate of the incremental cost-effectiveness ratio (ICER) and the cost per DALY averted of the intervention. Without PrEP, there will be 1.1-3.0 million new infections and 0.7-2.3 million HIV-related deaths in the next two decades. Moderate PrEP coverage (50%) would prevent 0.17-0.32 million new HIV infections. At Truvada's current price in China, daily oral PrEP costs $46,813-52,008 per DALY averted and is not cost-effective; on-demand Truvada reduces ICER to $25,057-27,838 per DALY averted, marginally cost-effective; daily generic tenofovir-based regimens further reduce ICER to $3675-8963, wholly cost-effective. The cost of daily oral Truvada PrEP regimen would need to be reduced by half to achieve cost-effectiveness and realize the public health good of preventing hundreds of thousands of HIV infections among MSM in China.
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Gomez A, Loar R, England Kramer A. The impact of market segmentation and social marketing on uptake of preventive programmes: the example of voluntary medical male circumcision. A literature review. Gates Open Res 2018; 2:68. [PMID: 31131368 PMCID: PMC6480503 DOI: 10.12688/gatesopenres.12888.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2018] [Indexed: 11/20/2022] Open
Abstract
Background: The business world has long recognized the power of defining discrete audiences within a target population. However, market segmentation's full potential has not been applied to the public health context. While some broad elements of market segmentation (e.g., age, geography) are considered, a nuanced look at behavioural and psychographic segmentation, which could greatly enhance the possibility of lasting behaviour change, is often missing. Segmentation, and the associated mindset which acknowledges the multi-dimensional differences between people, allows service providers, implementers, policymakers, and government officials to target initiatives and lead to a greater likelihood of lasting behavioural change. This paper investigates what segmentation is, how it has been applied to voluntary medical male circumcision (VMMC), how it can be applied in development, and the challenges in both measuring and adopting segmentation as part of program design. Methods: We performed a detailed search of peer-reviewed literature using PubMed, ProQuest, ScienceDirect, Google Scholar, and the abstract directories of the International AIDS Society (IAS) published between January 2015 and September 2018. We also accessed articles from business databases such as the Harvard Business Review. Results: Results from a VMMC-focused intervention that successfully designed and delivered segmentation-based programs in two countries demonstrated that it is possible to adapt private sector approaches. However, within the sector of global development that is most familiar with segmentation, these efforts rarely go beyond basic demographic segments. Conclusions: Existing published material tends not to measure the impact of segmentation itself, but the impact of the intervention to which segmentation was applied, which makes it challenging for the development sector to invest in the approach without evidence that it works. Nonetheless, the experiences of segmentation and demand creation for VMMC do highlight the opportunity for better integrating this approach in HIV prevention and in global development and measurement initiatives.
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Affiliation(s)
| | - Rebecca Loar
- Independent Consultant, Independent Consultant, Austin, Texas, USA
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25
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Reed JB, Patel RR, Baggaley R. Lessons from a decade of voluntary medical male circumcision implementation and their application to HIV pre-exposure prophylaxis scale up. Int J STD AIDS 2018; 29:1432-1443. [PMID: 30114997 PMCID: PMC6287252 DOI: 10.1177/0956462418787896] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Oral pre-exposure prophylaxis (PrEP) has the ability to curb HIV incidence worldwide and bring us closer to ending the HIV epidemic. Scale up of PrEP service delivery has many similar challenges to those faced by voluntary medical male circumcision (VMMC) services roll-out. This article outlines ten important lessons learned during the scale up of VMMC services in sub-Saharan Africa and their application to current oral PrEP implementation efforts to promote faster expansion for public health impact.
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Affiliation(s)
- Jason B Reed
- HIV-Malaria-Infectious Diseases, Jhpiego, Baltimore, MD, USA
| | - Rupa R Patel
- Division of Infectious Diseases, Washington University in St. Louis, St Louis, MO, USA
| | - Rachel Baggaley
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
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Suraratdecha C, Stuart RM, Manopaiboon C, Green D, Lertpiriyasuwat C, Wilson DP, Pavaputanon P, Visavakum P, Monkongdee P, Khawcharoenporn T, Tharee P, Kittinunvorakoon C, Martin M. Cost and cost-effectiveness analysis of pre-exposure prophylaxis among men who have sex with men in two hospitals in Thailand. J Int AIDS Soc 2018; 21 Suppl 5:e25129. [PMID: 30033559 PMCID: PMC6055129 DOI: 10.1002/jia2.25129] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 05/17/2018] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION In 2014, the Government of Thailand recommended pre-exposure prophylaxis (PrEP) as an additional HIV prevention programme within Thailand's National Guidelines on HIV/AIDS Treatment Prevention. However, to date implementation and uptake of PrEP programmes have been limited, and evidence on the costs and the epidemiological and economic impact is not available. METHODS We estimated the costs associated with PrEP provision among men having sex with men (MSM) participating in a facility-based, prospective observational cohort study: the Test, Treat and Prevent HIV Programme in Thailand. We created a suite of scenarios to estimate the cost-effectiveness of PrEP and sensitivity of the results to the model input parameters, including PrEP programme effectiveness, PrEP uptake among high-risk and low-risk MSM, baseline and future antiretroviral therapy (ART) coverage, condom use, unit cost of delivering PrEP, and the discount rate. RESULTS Drug costs accounted for 82.5% of the total cost of providing PrEP, followed by lab testing (8.2%) and personnel costs (7.8%). The estimated costs of providing the PrEP package in accordance with the national recommendation ranges from US$223 to US$311 per person per year. Based on our modelling results, we estimate that PrEP would be cost-effective when provided to either high-risk or all MSM. However, we found that the programme would be approximately 32% more cost-effective if offered to high-risk MSM than it would be if offered to all MSM, with an incremental cost-effectiveness ratio of US$4,836 per disability-adjusted life years (DALY) averted and US$7,089 per DALY averted respectively. Cost-effectiveness acceptability curves demonstrate that 80% of scenarios would be cost-effective when PrEP is provided solely to higher-risk MSM. CONCLUSION We provide the first estimates on cost and cost-effectiveness of PrEP in the Asia-Pacific region, and offer insights on how to deliver PrEP in combination with ART. While the high drug cost poses a budgeting challenge, incorporating PrEP delivery into an existing ART programme could be a cost-effective strategy to prevent HIV infections among MSM in Thailand.
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Affiliation(s)
- Chutima Suraratdecha
- Division of Global HIV and TBCenters for Disease Control and PreventionAtlantaGAUSA
| | - Robyn M Stuart
- Burnet InstituteMelbourneVictoriaAustralia
- Department of Mathematical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Chomnad Manopaiboon
- Division of Global HV and TBThailand Ministry of Public Health‐U.S. CDC CollaborationNonthaburiThailand
| | - Dylan Green
- Division of Global HIV and TBCenters for Disease Control and PreventionAtlantaGAUSA
| | | | | | | | - Prin Visavakum
- Division of Global HV and TBThailand Ministry of Public Health‐U.S. CDC CollaborationNonthaburiThailand
| | - Patama Monkongdee
- Division of Global HV and TBThailand Ministry of Public Health‐U.S. CDC CollaborationNonthaburiThailand
| | - Thana Khawcharoenporn
- Division of Infectious DiseasesFaculty of MedicineThammasat UniversityPathumthaniThailand
| | | | | | - Michael Martin
- Division of Global HIV and TBCenters for Disease Control and PreventionAtlantaGAUSA
- Division of Global HV and TBThailand Ministry of Public Health‐U.S. CDC CollaborationNonthaburiThailand
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Abstract
Pre-exposure prophylaxis (PrEP) for HIV prevention has evolved significantly over the years where clinical trials have now demonstrated the efficacy of oral PrEP, and the field is scaling-up implementation. The WHO and UNAIDS have made PrEP implementation a priority for populations at highest risk, and several countries have developed guidelines and national plans accordingly, largely based on evidence generated by demonstration projects. PrEP presents the opportunity to change the face of HIV prevention by offering a new option for protection against HIV and disrupting current HIV prevention systems. Nevertheless, as with all new technologies, both practical and social requirements for implementation must be taken into account if there is to be sustained and widespread adoption, which will also apply to forthcoming prevention technologies. Defining and building success for PrEP within the scope of scale-up requires careful consideration. This review summarises where the PrEP field is today, lessons learned from the past, the philosophy and practicalities of how successful programming may be defined, and provides perspectives of costs and affordability. We argue that a successful PrEP programme is about effective intervention integration and ultimately keeping people HIV negative.
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Affiliation(s)
- Robyn Eakle
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Hillbrow Health Precinct, 22 Esselen Street, Hillbrow, Johannesburg, 2001 South Africa
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Francois Venter
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Hillbrow Health Precinct, 22 Esselen Street, Hillbrow, Johannesburg, 2001 South Africa
| | - Helen Rees
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Hillbrow Health Precinct, 22 Esselen Street, Hillbrow, Johannesburg, 2001 South Africa
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Affiliation(s)
- R Scott Braithwaite
- Department of Population Health, New York University School of Medicine, New York, NY 10016, USA.
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Robineau O, Velter A, Barin F, Boelle PY. HIV transmission and pre-exposure prophylaxis in a high risk MSM population: A simulation study of location-based selection of sexual partners. PLoS One 2017; 12:e0189002. [PMID: 29190784 PMCID: PMC5708822 DOI: 10.1371/journal.pone.0189002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 11/16/2017] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE In France, indications for pre-exposure prophylaxis (PrEP) for HIV prevention are based on individual-level risk factors for HIV infection. However, the risk of HIV infection may also depend on characteristics of sexual partnerships. Here we study how place-based selection of partners change transmission and the overall efficiency of PrEP. METHODS We used the PREVAGAY survey of sexual behavior and HIV serostatus in men who have sex with men (MSM) in a Parisian district to look for associations between sexual network characteristics and HIV infection. We then simulated HIV transmission in a high-risk MSM population. We used information about venues visited to meet casual sexual partners (clubs, backrooms or saunas) to define sexual networks. We then simulated HIV transmission in these networks and assessed the impact of PrEP in this population. RESULTS In the PREVAGAY study, we found that HIV serostatus changed with the type of venues visited, in addition to other individual risk factors. In simulations, we found similar differences in HIV incidence when the choice of venues visited was not random. The use of PrEP allowed reducing incidence, irrespective of the venues visited by PrEP users. However, with the same amount of PrEP, the number of infections adverted could almost double depending on network structure and venues visited by PrEP users. CONCLUSION This study shows that characteristics of the sexual network structure can strongly impact the effectiveness of PrEP interventions. These should be considered further to refine individual risk assessment and maximize the effect of individual-based prevention policies.
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Affiliation(s)
- Olivier Robineau
- Sorbonne Universités - Univ Paris 06, INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique, INSERM U1136, Paris, France
- Service Universitaire des Maladies Infectieuses et du Voyageur, Centre Hospitalier Gustave Dron, Tourcoing, France
- Département des maladies infectieuses, Univ Lille 2, Lille, France
| | | | - Francis Barin
- Université François-Rabelais, INSERM UMR966, Tours, France
- Centre Hospitalier Régional Universitaire, Centre National de Référence du VIH, Tours, France
| | - Pierre-Yves Boelle
- Sorbonne Universités - Univ Paris 06, INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique, INSERM U1136, Paris, France
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Gaist P, Stirratt MJ. The Roles of Behavioral and Social Science Research in the Fight Against HIV/AIDS: A Functional Framework. J Acquir Immune Defic Syndr 2017; 75:371-81. [DOI: 10.1097/qai.0000000000001399] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Affiliation(s)
- April D Kimmel
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA 23298-0430, USA.
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York (CUNY), NY, USA
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