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Korenromp EL, Sabin K, Stover J, Brown T, Johnson LF, Martin-Hughes R, ten Brink D, Teng Y, Stevens O, Silhol R, Arias-Garcia S, Kimani J, Glaubius R, Vickerman P, Mahy M. New HIV Infections Among Key Populations and Their Partners in 2010 and 2022, by World Region: A Multisources Estimation. J Acquir Immune Defic Syndr 2024; 95:e34-e45. [PMID: 38180737 PMCID: PMC10769164 DOI: 10.1097/qai.0000000000003340] [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] [Indexed: 01/06/2024]
Abstract
BACKGROUND Previously, The Joint United Nations Programme on HIV/AIDS estimated proportions of adult new HIV infections among key populations (KPs) in the last calendar year, globally and in 8 regions. We refined and updated these, for 2010 and 2022, using country-level trend models informed by national data. METHODS Infections among 15-49 year olds were estimated for sex workers (SWs), male clients of female SW, men who have sex with men (MSM), people who inject drugs (PWID), transgender women (TGW), and non-KP sex partners of these groups. Transmission models used were Goals (71 countries), AIDS Epidemic Model (13 Asian countries), Optima (9 European and Central Asian countries), and Thembisa (South Africa). Statistical Estimation and Projection Package fits were used for 15 countries. For 40 countries, new infections in 1 or more KPs were approximated from first-time diagnoses by the mode of transmission. Infection proportions among nonclient partners came from Goals, Optima, AIDS Epidemic Model, and Thembisa. For remaining countries and groups not represented in models, median proportions by KP were extrapolated from countries modeled within the same region. RESULTS Across 172 countries, estimated proportions of new adult infections in 2010 and 2022 were both 7.7% for SW, 11% and 20% for MSM, 0.72% and 1.1% for TGW, 6.8% and 8.0% for PWID, 12% and 10% for clients, and 5.3% and 8.2% for nonclient partners. In sub-Saharan Africa, proportions of new HIV infections decreased among SW, clients, and non-KP partners but increased for PWID; elsewhere these groups' 2010-to-2022 differences were opposite. For MSM and TGW, the proportions increased across all regions. CONCLUSIONS KPs continue to have disproportionately high HIV incidence.
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Affiliation(s)
- Eline L. Korenromp
- Data for Impact Department, The Joint United Nations Program on HIV/AIDS (UNAIDS), Geneva, Switzerland
| | - Keith Sabin
- Data for Impact Department, The Joint United Nations Program on HIV/AIDS (UNAIDS), Geneva, Switzerland
| | - John Stover
- Center for Modeling, Planning and Policy Analysis, Avenir Health, Glastonbury, CT
| | - Tim Brown
- Research Program, East-West Center, Honolulu, HI
| | - Leigh F. Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Rowan Martin-Hughes
- Macfarlane Burnet Institute for Medical Research and Public Health, Melbourne, Australia
| | - Debra ten Brink
- Macfarlane Burnet Institute for Medical Research and Public Health, Melbourne, Australia
| | - Yu Teng
- Center for Modeling, Planning and Policy Analysis, Avenir Health, Glastonbury, CT
| | - Oliver Stevens
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Romain Silhol
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
- HIV Prevention Trials Network Modelling Centre, Imperial College London, London, United Kingdom
| | - Sonia Arias-Garcia
- Data for Impact Department, The Joint United Nations Program on HIV/AIDS (UNAIDS), Geneva, Switzerland
| | - Joshua Kimani
- Partners for Health and Development in Africa, Nairobi, Kenya
- University of Nairobi, Nairobi, Kenya; and
| | - Robert Glaubius
- Center for Modeling, Planning and Policy Analysis, Avenir Health, Glastonbury, CT
| | - Peter Vickerman
- Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Mary Mahy
- Data for Impact Department, The Joint United Nations Program on HIV/AIDS (UNAIDS), Geneva, Switzerland
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Silhol R, Anderson RL, Stevens O, Stannah J, Booton RD, Baral S, Dimitrov D, Mitchell KM, Donnell D, Bershteyn A, Brown T, Kelly SL, Kim HY, Johnson LF, Maheu-Giroux M, Martin-Hughes R, Mishra S, Peerapatanapokin W, Stone J, Stover J, Teng Y, Vickerman P, Garcia SA, Korenromp E, Imai-Eaton JW, Boily MC. Measuring HIV Acquisitions Among Partners of Key Populations: Estimates From HIV Transmission Dynamic Models. J Acquir Immune Defic Syndr 2024; 95:e59-e69. [PMID: 38180739 PMCID: PMC10769162 DOI: 10.1097/qai.0000000000003334] [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] [Indexed: 01/06/2024]
Abstract
BACKGROUND Key populations (KPs), including female sex workers (FSWs), gay men and other men who have sex with men (MSM), people who inject drugs (PWID), and transgender women (TGW) experience disproportionate risks of HIV acquisition. The UNAIDS Global AIDS 2022 Update reported that one-quarter of all new HIV infections occurred among their non-KP sexual partners. However, this fraction relied on heuristics regarding the ratio of new infections that KPs transmitted to their non-KP partners to the new infections acquired among KPs (herein referred to as "infection ratios"). We recalculated these ratios using dynamic transmission models. SETTING One hundred seventy-eight settings (106 countries). METHODS Infection ratios for FSW, MSM, PWID, TGW, and clients of FSW were estimated from 12 models for 2020. RESULTS Median model estimates of infection ratios were 0.7 (interquartile range: 0.5-1.0; n = 172 estimates) and 1.2 (0.8-1.8; n = 127) for acquisitions from FSW clients and transmissions from FSW to all their non-KP partners, respectively, which were comparable with the previous UNAIDS assumptions (0.2-1.5 across regions). Model estimates for female partners of MSM were 0.5 (0.2-0.8; n = 20) and 0.3 (0.2-0.4; n = 10) for partners of PWID across settings in Eastern and Southern Africa, lower than the corresponding UNAIDS assumptions (0.9 and 0.8, respectively). The few available model estimates for TGW were higher [5.1 (1.2-7.0; n = 8)] than the UNAIDS assumptions (0.1-0.3). Model estimates for non-FSW partners of FSW clients in Western and Central Africa were high (1.7; 1.0-2.3; n = 29). CONCLUSIONS Ratios of new infections among non-KP partners relative to KP were high, confirming the importance of better addressing prevention and treatment needs among KP as central to reducing overall HIV incidence.
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Affiliation(s)
- Romain Silhol
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
- HIV Prevention Trials Network Modelling Centre, Imperial College London, London, United Kingdom
| | - Rebecca L. Anderson
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Oliver Stevens
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - James Stannah
- Department of Epidemiology and Biostatistics, School of Population and Global Health, Faculty of Medicine and Health Sciences, McGill University, Montréal, Quebec, Canada
| | - Ross D. Booton
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Dobromir Dimitrov
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Kate M. Mitchell
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
- HIV Prevention Trials Network Modelling Centre, Imperial College London, London, United Kingdom
- Department of Nursing and Community Health, Glasgow Caledonian University London, London, United Kindom
| | - Deborah Donnell
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Anna Bershteyn
- Department of Population Health, New York University Grossman School of Medicine, New York, New York
| | - Tim Brown
- Research Program, East-West Center, Honolulu, HI
| | | | - Hae-Young Kim
- Department of Population Health, New York University Grossman School of Medicine, New York, New York
| | - Leigh F. Johnson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Mathieu Maheu-Giroux
- Department of Epidemiology and Biostatistics, School of Population and Global Health, Faculty of Medicine and Health Sciences, McGill University, Montréal, Quebec, Canada
| | | | - Sharmistha Mishra
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Jack Stone
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | | | - Yu Teng
- Avenir Health, Glastonbury, CT
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | | | | | - Jeffrey W. Imai-Eaton
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Marie-Claude Boily
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
- HIV Prevention Trials Network Modelling Centre, Imperial College London, London, United Kingdom
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Stover J, Glaubius R. Methods and Assumptions for Estimating Key HIV Indicators in the UNAIDS Annual Estimates Process. J Acquir Immune Defic Syndr 2024; 95:e5-e12. [PMID: 38180735 PMCID: PMC10769177 DOI: 10.1097/qai.0000000000003316] [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: 04/24/2023] [Accepted: 09/07/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Each year UNAIDS supports national teams to estimate key HIV indicators using their latest data. These estimates are produced using a collection of models and software tools. This paper describes the demographic and HIV projection models used in this process. METHODS The demographic model (DemProj) projects the population by sex and single age for each year of the estimate. This information is fed into the HIV model (AIDS Impact Model) to estimate key HIV indicators. The model uses program, survey and surveillance data along with incidence trends produced through 1 of several separate models, to estimate new HIV infections, HIV-related deaths, and the population living with HIV by sex, age, CD4 category, and treatment status. RESULTS These models allow the annual production of estimates of key HIV indicators including uncertainty intervals. This information is used to track progress toward national and global goals and to develop national strategic plans, Global Fund applications and PEPFAR country operational plans. CONCLUSIONS Under the guidance of the UNAIDS Reference Group on Estimates, Modeling and Projections, these models are updated on a regular basis in response to evolving programmatic needs, new data, and analyses. This process of continuous review and improvement has led to mature models that make the best use of available data to provide estimates of indicators important to monitoring progress and developing future plans.
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Affiliation(s)
- John Stover
- Center for Modeling and Analysis, Avenir Health, Glastonbury, CT
| | - Robert Glaubius
- Center for Modeling and Analysis, Avenir Health, Glastonbury, CT
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Stevens O, Anderson R, Stover J, Teng Y, Stannah J, Silhol R, Jones H, Booton RD, Martin-Hughes R, Johnson L, Maheu-Giroux M, Mishra S, Stone J, Bershteyn A, Kim HY, Sabin K, Mitchell KM, Dimitrov D, Baral S, Donnell D, Korenromp E, Rice B, Hargreaves JR, Vickerman P, Boily MC, Imai-Eaton JW. Comparison of Empirically Derived and Model-Based Estimates of Key Population HIV Incidence and the Distribution of New Infections by Population Group in Sub-Saharan Africa. J Acquir Immune Defic Syndr 2024; 95:e46-e58. [PMID: 38180738 PMCID: PMC10769165 DOI: 10.1097/qai.0000000000003321] [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] [Indexed: 01/06/2024]
Abstract
BACKGROUND The distribution of new HIV infections among key populations, including female sex workers (FSWs), gay men and other men who have sex with men (MSM), and people who inject drugs (PWID) are essential information to guide an HIV response, but data are limited in sub-Saharan Africa (SSA). We analyzed empirically derived and mathematical model-based estimates of HIV incidence among key populations and compared with the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates. METHODS We estimated HIV incidence among FSW and MSM in SSA by combining meta-analyses of empirical key population HIV incidence relative to the total population incidence with key population size estimates (KPSE) and HIV prevalence. Dynamic HIV transmission model estimates of HIV incidence and percentage of new infections among key populations were extracted from 94 country applications of 9 mathematical models. We compared these with UNAIDS-reported distribution of new infections, implied key population HIV incidence and incidence-to-prevalence ratios. RESULTS Across SSA, empirical FSW HIV incidence was 8.6-fold (95% confidence interval: 5.7 to 12.9) higher than total population female 15-39 year incidence, and MSM HIV incidence was 41.8-fold (95% confidence interval: 21.9 to 79.6) male 15-29 year incidence. Combined with KPSE, these implied 12% of new HIV infections in 2021 were among FSW and MSM (5% and 7% respectively). In sensitivity analysis varying KPSE proportions within 95% uncertainty range, the proportion of new infections among FSW and MSM was between 9% and 19%. Insufficient data were available to estimate PWID incidence rate ratios. Across 94 models, median proportion of new infections among FSW, MSM, and PWID was 6.4% (interquartile range 3.2%-11.7%), both much lower than the 25% reported by UNAIDS. CONCLUSION Empirically derived and model-based estimates of HIV incidence confirm dramatically higher HIV risk among key populations in SSA. Estimated proportions of new infections among key populations in 2021 were sensitive to population size assumptions and were substantially lower than estimates reported by UNAIDS.
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Affiliation(s)
- Oliver Stevens
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Rebecca Anderson
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - John Stover
- Center for Modeling, Planning and Policy Analysis, Avenir Health, Glastonbury, CT
| | - Yu Teng
- Center for Modeling, Planning and Policy Analysis, Avenir Health, Glastonbury, CT
| | - James Stannah
- Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montréal, Canada
| | - Romain Silhol
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
- HIV Prevention Trials Network Modelling Centre, Imperial College London, London, United Kingdom
| | - Harriet Jones
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ross D. Booton
- United Kingdom Heath Security Agency, London, United Kingdom
| | - Rowan Martin-Hughes
- Macfarlane Burnet Institute for Medical Research and Public Health, Melbourne, Australia
| | - Leigh Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Mathieu Maheu-Giroux
- Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montréal, Canada
| | - Sharmistha Mishra
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Canada
| | - Jack Stone
- Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Anna Bershteyn
- Department of Population Health, New York University Grossman School of Medicine, New York, NY
| | - Hae-Young Kim
- Department of Population Health, New York University Grossman School of Medicine, New York, NY
| | - Keith Sabin
- Data for Impact, The Joint United Nations Program on HIV/AIDS (UNAIDS), Geneva, Switzerland
| | - Kate M. Mitchell
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
- Department of Nursing and Community Health, Glasgow Caledonian University London, London, United Kingdom
| | - Dobromir Dimitrov
- HIV Prevention Trials Network Modelling Centre, Imperial College London, London, United Kingdom
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Deborah Donnell
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Eline Korenromp
- Data for Impact, The Joint United Nations Program on HIV/AIDS (UNAIDS), Geneva, Switzerland
| | - Brian Rice
- School of Health and Related Research (SchARR), University of Sheffield, Sheffield, United Kingdom; and
| | - James R. Hargreaves
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Peter Vickerman
- Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Marie-Claude Boily
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
- HIV Prevention Trials Network Modelling Centre, Imperial College London, London, United Kingdom
| | - Jeffrey W. Imai-Eaton
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA
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Glaubius R, Stover J, Johnson LF, Mahiane SG, Mahy MI, Eaton JW. Differences in Breastfeeding Duration by Maternal HIV Status: A Pooled Analysis of Nationally Representative Surveys in Sub-Saharan Africa. J Acquir Immune Defic Syndr 2024; 95:e81-e88. [PMID: 38180741 PMCID: PMC10769179 DOI: 10.1097/qai.0000000000003317] [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: 05/01/2023] [Revised: 08/02/2023] [Accepted: 08/04/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Breastfeeding improves child survival but is a source of mother-to-child HIV transmission among women with unsuppressed HIV infection. Estimated HIV incidence in children is sensitive to breastfeeding duration among mothers living with HIV (MLHIV). Breastfeeding duration may vary according to maternal HIV status. SETTING Sub-Saharan Africa. METHODS We analyzed pooled data from nationally representative household surveys conducted during 2003-2019 that included HIV testing and elicited breastfeeding practices. We fitted survival models of breastfeeding duration by country, year, and maternal HIV status for 4 sub-Saharan African regions (Eastern, Central, Southern, and Western). RESULTS Data were obtained from 65 surveys in 31 countries. In 2010, breastfeeding in the first month of life ("initial breastfeeding") among MLHIV ranged from 69.1% (95% credible interval: 68-79.9) in Southern Africa to 93.4% (92.7-98.0) in Western Africa. Median breastfeeding duration among MLHIV was the shortest in Southern Africa at 15.6 (14.2-16.3) months and the longest in Eastern Africa at 22.0 (21.7-22.5) months. By comparison, HIV-negative mothers were more likely to breastfeed initially (91.0%-98.7% across regions) and for longer duration (median 18.3-24.6 months across regions). Initial breastfeeding and median breastfeeding duration decreased during 2005-2015 in most regions and did not increase in any region regardless of maternal HIV status. CONCLUSIONS MLHIV in sub-Saharan Africa are less likely to breastfeed initially and stop breastfeeding sooner than HIV-negative mothers. Since 2020, UNAIDS-supported HIV estimates have accounted for this shorter breastfeeding exposure among HIV-exposed children. MLHIV need support to enable optimal breastfeeding practices and to adhere to antiretroviral therapy for HIV treatment and prevention of postnatal mother-to-child transmission.
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Affiliation(s)
- Robert Glaubius
- Center for Modeling, Planning and Policy Analysis, Avenir Health, Glastonbury, CT
| | - John Stover
- Center for Modeling, Planning and Policy Analysis, Avenir Health, Glastonbury, CT
| | - Leigh F. Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Severin G. Mahiane
- Center for Modeling, Planning and Policy Analysis, Avenir Health, Glastonbury, CT
| | | | - Jeffrey W. Eaton
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA; and
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
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6
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Moolla H, Phillips A, Ten Brink D, Mudimu E, Stover J, Bansi-Matharu L, Martin-Hughes R, Wulan N, Cambiano V, Smith J, Bershteyn A, Meyer-Rath G, Jamieson L, Johnson LF. A quantitative assessment of the consistency of projections from five mathematical models of the HIV epidemic in South Africa: a model comparison study. BMC Public Health 2023; 23:2119. [PMID: 37891514 PMCID: PMC10612295 DOI: 10.1186/s12889-023-16995-9] [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: 03/24/2023] [Accepted: 10/14/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Mathematical models are increasingly used to inform HIV policy and planning. Comparing estimates obtained using different mathematical models can test the robustness of estimates and highlight research gaps. As part of a larger project aiming to determine the optimal allocation of funding for HIV services, in this study we compare projections from five mathematical models of the HIV epidemic in South Africa: EMOD-HIV, Goals, HIV-Synthesis, Optima, and Thembisa. METHODS The five modelling groups produced estimates of the total population, HIV incidence, HIV prevalence, proportion of people living with HIV who are diagnosed, ART coverage, proportion of those on ART who are virally suppressed, AIDS-related deaths, total deaths, and the proportion of adult males who are circumcised. Estimates were made under a "status quo" scenario for the period 1990 to 2040. For each output variable we assessed the consistency of model estimates by calculating the coefficient of variation and examining the trend over time. RESULTS For most outputs there was significant inter-model variability between 1990 and 2005, when limited data was available for calibration, good consistency from 2005 to 2025, and increasing variability towards the end of the projection period. Estimates of HIV incidence, deaths in people living with HIV, and total deaths displayed the largest long-term variability, with standard deviations between 35 and 65% of the cross-model means. Despite this variability, all models predicted a gradual decline in HIV incidence in the long-term. Projections related to the UNAIDS 95-95-95 targets were more consistent, with the coefficients of variation below 0.1 for all groups except children. CONCLUSIONS While models produced consistent estimates for several outputs, there are areas of variability that should be investigated. This is important if projections are to be used in subsequent cost-effectiveness studies.
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Affiliation(s)
- Haroon Moolla
- Centre for Infectious Disease Epidemiology and Research, Faculty of Health Sciences, University of Cape Town, Anzio Road, Cape Town, 7925, Observatory, South Africa.
| | | | | | - Edinah Mudimu
- Department of Decision Sciences, University of South Africa, Pretoria, South Africa
| | | | | | | | | | | | | | - Anna Bershteyn
- Department of Population Health, NYU Grossman School of Medicine, New York, USA
| | - Gesine Meyer-Rath
- Center for Global Health and Development, Boston University, Boston, USA
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
| | - Lise Jamieson
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
- Department of Medical Microbiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Leigh F Johnson
- Centre for Infectious Disease Epidemiology and Research, Faculty of Health Sciences, University of Cape Town, Anzio Road, Cape Town, 7925, Observatory, South Africa
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7
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Chagoma N, Kanyenda T, Pindiwe B, Nyika H, Nyazema L, Stover J, Resar D, Shoko N, Jenkins S, Katanda Y, Xaba S, Mugurungi O. Applying mathematical modelling to estimate the impact of COVID-19-related VMMC service disruptions on new HIV infections in Zimbabwe. BMC Infect Dis 2023; 23:113. [PMID: 36823550 PMCID: PMC9948776 DOI: 10.1186/s12879-023-08081-7] [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: 06/29/2022] [Accepted: 02/13/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic has overwhelmed health systems with knock on effects on diagnosis, treatment, and care. To mitigate the impact, the government of Zimbabwe enforced a strict lockdown beginning 30 March 2020 which ran intermittently until early 2021. In this period, the Ministry of Health and Childcare strategically prioritized delivery of services leading to partial and full suspension of services considered non-essential, including HIV prevention. As a result, Voluntary Medical Male Circumcision (VMMC) services were disrupted leading to an 80% decline in circumcisions conducted in 2020. Given the efficacy of VMMC, we quantified the potential effects of VMMC service disruption on new HIV infections in Zimbabwe. METHODS We applied the GOALS model to evaluate the impact of COVID-19-related disruptions on reducing new HIV infections over 30-years. GOALS is an HIV simulation model that estimates number of new HIV infections based on sexual behaviours of population groups. The model is parameterized based on national surveys and HIV program data. We hypothesized three coverage scenarios by 2030: scenario I - pre-COVID trajectory: 80% VMMC coverage; Scenario II - marginal COVID-19 impact: 60% VMMC coverage, and scenario III - severe COVID-19 impact: 45% VMMC coverage. VMMC coverage between 2020 and 2030 was linearly interpolated to attain the estimated coverage and then held constant from 2030 to 2050, and discounted outcomes at 3%. RESULTS Compared to the baseline scenario I, in scenario II, we estimated that the disruption of VMMC services would generate an average of 200 (176-224) additional new infections per year and 7,200 new HIV infections over the next 30 years. For scenario III, we estimated an average of 413 (389-437) additional new HIV infections per year and 15,000 new HIV infections over the next 30 years. The disruption of VMMC services could generate additional future HIV treatment costs ranging from $27 million to $55 million dollars across scenarios II and III, respectively. CONCLUSION COVID-19 disruptions destabilized delivery of VMMC services which could contribute to an additional 7,200 new infections over the next 30 years. Unless mitigated, these disruptions could derail the national goals of reducing new infections by 2030.
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Affiliation(s)
- Newton Chagoma
- grid.452345.10000 0004 4660 2031Clinton Health Access Initiative, Boston, USA
| | - Tiwonge Kanyenda
- grid.452345.10000 0004 4660 2031Clinton Health Access Initiative, Boston, USA
| | | | - Howard Nyika
- grid.415818.1Ministry of Health and Child Care, Harare, Zimbabwe
| | - Lawrence Nyazema
- grid.415818.1Ministry of Health and Child Care, Harare, Zimbabwe
| | - John Stover
- grid.475068.80000 0004 8349 9627Avenir Health, Glastonbury, USA
| | - Danielle Resar
- grid.452345.10000 0004 4660 2031Clinton Health Access Initiative, Boston, USA
| | - Natsai Shoko
- grid.452345.10000 0004 4660 2031Clinton Health Access Initiative, Boston, USA
| | - Sarah Jenkins
- grid.452345.10000 0004 4660 2031Clinton Health Access Initiative, Boston, USA
| | | | | | - Owen Mugurungi
- grid.415818.1Ministry of Health and Child Care, Harare, Zimbabwe
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8
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Bansi-Matharu L, Mudimu E, Martin-Hughes R, Hamilton M, Johnson L, Ten Brink D, Stover J, Meyer-Rath G, Kelly SL, Jamieson L, Cambiano V, Jahn A, Cowan FM, Mangenah C, Mavhu W, Chidarikire T, Toledo C, Revill P, Sundaram M, Hatzold K, Yansaneh A, Apollo T, Kalua T, Mugurungi O, Kiggundu V, Zhang S, Nyirenda R, Phillips A, Kripke K, Bershteyn A. Cost-effectiveness of voluntary medical male circumcision for HIV prevention across sub-Saharan Africa: results from five independent models. Lancet Glob Health 2023; 11:e244-e255. [PMID: 36563699 PMCID: PMC10005968 DOI: 10.1016/s2214-109x(22)00515-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 10/11/2022] [Accepted: 11/22/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Voluntary medical male circumcision (VMMC) has been a recommended HIV prevention strategy in sub-Saharan Africa since 2007, particularly in countries with high HIV prevalence. However, given the scale-up of antiretroviral therapy programmes, it is not clear whether VMMC still represents a cost-effective use of scarce HIV programme resources. METHODS Using five existing well described HIV mathematical models, we compared continuation of VMMC for 5 years in men aged 15 years and older to no further VMMC in South Africa, Malawi, and Zimbabwe and across a range of setting scenarios in sub-Saharan Africa. Outputs were based on a 50-year time horizon, VMMC cost was assumed to be US$90, and a cost-effectiveness threshold of US$500 was used. FINDINGS In South Africa and Malawi, the continuation of VMMC for 5 years resulted in cost savings and health benefits (infections and disability-adjusted life-years averted) according to all models. Of the two models modelling Zimbabwe, the continuation of VMMC for 5 years resulted in cost savings and health benefits by one model but was not as cost-effective according to the other model. Continuation of VMMC was cost-effective in 68% of setting scenarios across sub-Saharan Africa. VMMC was more likely to be cost-effective in modelled settings with higher HIV incidence; VMMC was cost-effective in 62% of settings with HIV incidence of less than 0·1 per 100 person-years in men aged 15-49 years, increasing to 95% with HIV incidence greater than 1·0 per 100 person-years. INTERPRETATION VMMC remains a cost-effective, often cost-saving, prevention intervention in sub-Saharan Africa for at least the next 5 years. FUNDING Bill & Melinda Gates Foundation for the HIV Modelling Consortium.
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Affiliation(s)
| | - Edinah Mudimu
- Department of Decision Sciences, University of South Africa, Pretoria, South Africa
| | | | | | - Leigh Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | | | | | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | | | - Lise Jamieson
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Andreas Jahn
- Ministry of Health, Lilongwe, Malawi; International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, WA, USA
| | - Frances M Cowan
- Center for Sexual Health and HIV/AIDS Research, Harare, Zimbabwe; Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Collin Mangenah
- Center for Sexual Health and HIV/AIDS Research, Harare, Zimbabwe; Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Webster Mavhu
- Center for Sexual Health and HIV/AIDS Research, Harare, Zimbabwe; Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Carlos Toledo
- Division of Global HIV/AIDS and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | - Maaya Sundaram
- Global Development Program, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Karin Hatzold
- Population Services International, Washington, DC, USA
| | - Aisha Yansaneh
- United States Agency for International Development, Washington, DC, USA
| | - Tsitsi Apollo
- Ministry of Health and Child Welfare, Harare, Zimbabwe
| | - Thoko Kalua
- Department of HIV and AIDS, Ministry of Health Malawi, Lilongwe, Malawi; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | - Valerian Kiggundu
- United States Agency for International Development, Washington, DC, USA
| | - Shufang Zhang
- The Global Fund to Fight AIDS, Tuberculosis, and Malaria, Geneva, Switzerland
| | - Rose Nyirenda
- Department of HIV and AIDS, Ministry of Health Malawi, Lilongwe, Malawi
| | | | | | - Anna Bershteyn
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
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Miller HN, Lindo S, Fish LJ, Roberts J, Stover J, Schwark EH, Eberlein N, Mack D, Falkovic M, Makarushka C, Chatterjee R. Describing current use, barriers, and facilitators of patient portal messaging for research recruitment: Perspectives from study teams and patients at one institution. J Clin Transl Sci 2023; 7:e96. [PMID: 37125060 PMCID: PMC10130833 DOI: 10.1017/cts.2023.522] [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: 11/25/2022] [Revised: 03/28/2023] [Accepted: 03/30/2023] [Indexed: 05/02/2023] Open
Abstract
Introduction The electronic health record (EHR) and patient portal are used increasingly for clinical research, including patient portal recruitment messaging (PPRM). Use of PPRM has grown rapidly; however, best practices are still developing. In this study, we examined the use of PPRM at our institution and conducted qualitative interviews among study teams and patients to understand experiences and preferences for PPRM. Methods We identified study teams that sent PPRMs and patients that received PPRMs in a 60-day period. We characterized these studies and patients, in addition to the patients' interactions with the PPRMs (e.g., viewed, responded). From these groups, we recruited study team members and patients for semi-structured interviews. A pragmatic qualitative inquiry framework was used by interviewers. Interviews were audio-recorded and analyzed using a rapid qualitative analysis exploratory approach. Results Across ten studies, 35,037 PPRMs were sent, 33% were viewed, and 17% were responded to. Interaction rates varied across demographic groups. Six study team members completed interviews and described PPRM as an efficient and helpful recruitment method. Twenty-eight patients completed interviews. They were supportive of receiving PPRMs, particularly when the PPRM was relevant to their health. Patients indicated that providing more information in the PPRM would be helpful, in addition to options to set personalized preferences. Conclusions PPRM is an efficient recruitment method for study teams and is acceptable to patients. Engagement with PPRMs varies across demographic groups, which should be considered during recruitment planning. Additional research is needed to evaluate and implement recommended changes by study teams and patients.
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Affiliation(s)
| | - Sierra Lindo
- Duke Clinical and Translational Science Institute, Recruitment Innovation Center, Duke University, Durham, NC, USA
| | - Laura J. Fish
- Duke Cancer Institute, Behavioral Health and Survey Research Core, Duke University, Durham, NC, USA
- Department of Family Medicine and Community Health, Duke University, Durham, NC, USA
| | | | - John Stover
- Duke University School of Medicine, Durham, NC 27710, USA
| | | | - Nicholas Eberlein
- Duke Clinical and Translational Science Institute, Recruitment Innovation Center, Duke University, Durham, NC, USA
| | - Dalia Mack
- Duke University School of Medicine, Durham, NC 27710, USA
| | - Margaret Falkovic
- Duke Cancer Institute, Behavioral Health and Survey Research Core, Duke University, Durham, NC, USA
| | - Christina Makarushka
- Duke Cancer Institute, Behavioral Health and Survey Research Core, Duke University, Durham, NC, USA
| | - Ranee Chatterjee
- Duke Clinical and Translational Science Institute, Recruitment Innovation Center, Duke University, Durham, NC, USA
- Duke University School of Medicine, Durham, NC 27710, USA
- Address for correspondence: R. Chatterjee, MD, MPH, 710 W. Main Street, 1st floor, Durham, NC 27701, USA.
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10
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Kripke K, Eakle R, Cheng A, Rana S, Torjesen K, Stover J. The case for prevention - Primary HIV prevention in the era of universal test and treat: A mathematical modeling study. EClinicalMedicine 2022; 46:101347. [PMID: 35310517 PMCID: PMC8924323 DOI: 10.1016/j.eclinm.2022.101347] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 02/03/2022] [Accepted: 02/21/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND As antiretroviral therapy (ART) has scaled up and HIV incidence has declined, some have questioned the continued utility of HIV prevention. This study examines the role and cost-effectiveness of HIV prevention in the context of "universal test and treat" (UTT) in three sub-Saharan countries with generalized HIV epidemics. METHODS Scenarios were created in Spectrum/Goals models for Lesotho, Mozambique, and Uganda with various combinations of voluntary medical male circumcision (VMMC); pre-exposure prophylaxis; and a highly effective, durable, hypothetical vaccine layered onto three different ART scenarios. One ART scenario held coverage constant at 2008 levels to replicate prevention modeling studies that were conducted prior to UTT. One scenario assumed scale-up to the UNAIDS treatment goals of 90-90-90 by 2025 and 95-95-95 by 2030. An intermediate scenario held ART constant at 2019 coverage. HIV incidence was visualized over time, and cost per HIV infection averted was assessed over 5-, 15-, and 30-year time frames, with 3% annual discounting. FINDINGS Each prevention intervention reduced HIV incidence beyond what was achieved by ART scale-up alone to the 90-90-90/95-95-95 goals, with near-zero incidence achievable by combinations of interventions covering all segments of the population. Cost-effectiveness of HIV prevention may decrease as HIV incidence decreases, but one-time interventions like VMMC and a durable vaccine may remain cost-effective and even cost-saving as ART is scaled up. INTERPRETATION Primary HIV prevention is still needed in the era of UTT. Combination prevention is more impactful than a single, highly effective intervention. Broad population coverage of primary prevention, regardless of cost-effectiveness, will be required in generalized epidemic countries to eradicate HIV.
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Affiliation(s)
- Katharine Kripke
- Avenir Health, 6930 Carroll Ave., Suite 350, Takoma Park, MD 20912, USA
- Corresponding author: Katharine Kripke, 6930 Carroll Ave., Suite 350, Takoma Park, MD 20912, USA. Telephone: (301) 273-9752.
| | - Robyn Eakle
- U.S. Agency for International Development, Washington, DC, USA
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Alison Cheng
- U.S. Agency for International Development, Washington, DC, USA
| | - Sangeeta Rana
- U.S. Agency for International Development, Washington, DC, USA
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Abstract
Background: Condom promotion and supply was one the earliest interventions to be mobilized to address the HIV pandemic. Condoms are inexpensive and provide protection against transmission of HIV and other sexually transmitted diseases (STIs) as well as against unintended pregnancy. As many as 16 billion condoms may be used annually in all low- and middle-income countries (LMIC). In recent years the focus of HIV programs as been on testing and treatment and new technologies such as PrEP. Rates of condom use have stopped increasing short of UNAIDS targets and funding from donors is declining. Methods: We applied a mathematical HIV transmission model to 77 high HIV burden countries to estimate the number of HIV infections that would have occurred from 1990 to 2019 if condom use had remained at 1990 levels. Results: The results suggest that current levels of HIV would be five times higher without condom use and that the scale-up in condoms use averted about 117 million HIV infections. Conclusions: HIV programs should ensure that affordable condoms are consistently available and that the benefits of condom use are widely understood.
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Affiliation(s)
- John Stover
- Center for Modeling and Analysis, Avenir Health, Glastonbury, CT, 06033, USA
| | - Yu Teng
- Center for Modeling and Analysis, Avenir Health, Glastonbury, CT, 06033, USA
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12
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Abstract
Background: Condom promotion and supply was one the earliest interventions to be mobilized to address the HIV pandemic. Condoms are inexpensive and provide protection against transmission of HIV and other sexually transmitted diseases (STIs) as well as against unintended pregnancy. As many as 16 billion condoms may be used annually in all low- and middle-income countries (LMIC). In recent years the focus of HIV programs as been on testing and treatment and new technologies such as PrEP. Rates of condom use have stopped increasing short of UNAIDS targets and funding from donors is declining. Methods: We applied a mathematical HIV transmission model to 77 high HIV burden countries to estimate the number of HIV infections that would have occurred from 1990 to 2019 if condom use had remained at 1990 levels. Results: The results suggest that current levels of HIV would be five times higher without condom use and that the scale-up in condoms use averted about 117 million HIV infections. Conclusions: HIV programs should ensure that affordable condoms are consistently available and that the benefits of condom use are widely understood.
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Affiliation(s)
- John Stover
- Center for Modeling and Analysis, Avenir Health, Glastonbury, CT, 06033, USA
| | - Yu Teng
- Center for Modeling and Analysis, Avenir Health, Glastonbury, CT, 06033, USA
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13
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Hiebert L, Resch S, Schutte C, Turay M, Zekeng L, Matiku S, Semini I, Stover J, Forsythe S, Hecht R. Tanzania HIV Investment Case (IC) 2.0: Using modeling to explore optimization under severe resource constraints. Journal of Global Health Reports 2022. [DOI: 10.29392/001c.30063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
| | | | | | | | | | | | - Iris Semini
- Joint United Nations Program on HIV/AIDS (UNAIDS)
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Flanagan CF, McCann N, Stover J, Freedberg KA, Ciaranello AL. Do not forget the children: a model‐based analysis on the potential impact of COVID‐19‐associated interruptions in paediatric HIV prevention and care. J Int AIDS Soc 2022; 25:e25864. [PMID: 35048515 PMCID: PMC8771146 DOI: 10.1002/jia2.25864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 12/14/2021] [Indexed: 11/14/2022] Open
Abstract
Introduction The COVID‐19 pandemic has affected women and children globally, disrupting antiretroviral therapy (ART) services and exacerbating pre‐existing barriers to care for both pregnant women and paediatric populations. Methods We used the Spectrum modelling package and the CEPAC‐Pediatric model to project the impact of COVID‐19‐associated care disruptions on three key populations in the 21 Global Plan priority countries in sub‐Saharan Africa: (1) pregnant and breastfeeding women living with HIV and their children, (2) all children (aged 0–14 years) living with HIV (CLWH), regardless of their engagement in care and (3) CLWH who were engaged in care and on ART prior to the start of the pandemic. We projected clinical outcomes over the 12‐month period of 1 March 2020 to 1 March 2021. Results Compared to a scenario with no care disruption, in a 3‐month lockdown with complete service disruption, followed by 3 additional months of partial (50%) service disruption, a projected 755,400 women would have received PMTCT care (a 21% decrease), 187,800 new paediatric HIV infections would have occurred (a 77% increase) and 516,800 children would have received ART (a 35% decrease). For children on ART as of March 2020, we projected 507,200 would have experienced ART failure (an 80% increase). Additionally, a projected 88,400 AIDS‐related deaths would have occurred (a 27% increase) between March 2020 and March 2021, with 51,700 of those deaths occurring among children engaged in care as of March 2020 (a 54% increase). Conclusions While efforts will continue to curb morbidity and mortality stemming directly from COVID‐19 itself, it is critical that providers also consider the immediate and indirect harms of this pandemic, particularly among vulnerable populations. Well‐informed, timely action is critical to meet the health needs of pregnant women and children if the global community is to maintain momentum towards an AIDS‐free generation.
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Affiliation(s)
- Clare F. Flanagan
- Medical Practice Evaluation Center Massachusetts General Hospital Boston Massachusetts USA
| | - Nicole McCann
- Medical Practice Evaluation Center Massachusetts General Hospital Boston Massachusetts USA
| | | | - Kenneth A. Freedberg
- Medical Practice Evaluation Center Massachusetts General Hospital Boston Massachusetts USA
- Harvard Medical School Boston Massachusetts USA
- Division of Infectious Diseases Massachusetts General Hospital Boston Massachusetts USA
- Division of General Internal Medicine Massachusetts General Hospital Boston Massachusetts USA
- Department of Health Policy and Management Harvard T.H. Chan School of Public Health Boston Massachusetts USA
| | - Andrea L. Ciaranello
- Medical Practice Evaluation Center Massachusetts General Hospital Boston Massachusetts USA
- Harvard Medical School Boston Massachusetts USA
- Division of Infectious Diseases Massachusetts General Hospital Boston Massachusetts USA
- Harvard University Center for AIDS Research Cambridge Massachusetts USA
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15
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Stover J, Kelly SL, Mudimu E, Green D, Smith T, Taramusi I, Bansi-Matharu L, Martin-Hughes R, Phillips AN, Bershteyn A. The risks and benefits of providing HIV services during the COVID-19 pandemic. PLoS One 2021; 16:e0260820. [PMID: 34941876 PMCID: PMC8699979 DOI: 10.1371/journal.pone.0260820] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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: 03/31/2021] [Accepted: 11/17/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The COVID-19 pandemic has caused widespread disruptions including to health services. In the early response to the pandemic many countries restricted population movements and some health services were suspended or limited. In late 2020 and early 2021 some countries re-imposed restrictions. Health authorities need to balance the potential harms of additional SARS-CoV-2 transmission due to contacts associated with health services against the benefits of those services, including fewer new HIV infections and deaths. This paper examines these trade-offs for select HIV services. METHODS We used four HIV simulation models (Goals, HIV Synthesis, Optima HIV and EMOD) to estimate the benefits of continuing HIV services in terms of fewer new HIV infections and deaths. We used three COVID-19 transmission models (Covasim, Cooper/Smith and a simple contact model) to estimate the additional deaths due to SARS-CoV-2 transmission among health workers and clients. We examined four HIV services: voluntary medical male circumcision, HIV diagnostic testing, viral load testing and programs to prevent mother-to-child transmission. We compared COVID-19 deaths in 2020 and 2021 with HIV deaths occurring now and over the next 50 years discounted to present value. The models were applied to countries with a range of HIV and COVID-19 epidemics. RESULTS Maintaining these HIV services could lead to additional COVID-19 deaths of 0.002 to 0.15 per 10,000 clients. HIV-related deaths averted are estimated to be much larger, 19-146 discounted deaths per 10,000 clients. DISCUSSION While there is some additional short-term risk of SARS-CoV-2 transmission associated with providing HIV services, the risk of additional COVID-19 deaths is at least 100 times less than the HIV deaths averted by those services. Ministries of Health need to take into account many factors in deciding when and how to offer essential health services during the COVID-19 pandemic. This work shows that the benefits of continuing key HIV services are far larger than the risks of additional SARS-CoV-2 transmission.
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Affiliation(s)
- John Stover
- Avenir Health, Glastonbury, CT, United States of America
- * E-mail:
| | | | - Edinah Mudimu
- Department of Decision Sciences, University of South Africa, Pretoria, South Africa
| | - Dylan Green
- Cooper/Smith, Washington, DC, United States of America
| | - Tyler Smith
- Cooper/Smith, Washington, DC, United States of America
| | | | | | | | - Andrew N. Phillips
- Institute for Global Health, University College London, London, United Kingdom
| | - Anna Bershteyn
- New York University School of Medicine, New York, NY, United States of America
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16
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Jefferis K, Avalos A, Phillips H, Mmelesi M, Ramaabya D, Nkomo B, Muthoga C, Jarvis JN, Ratladi S, Selato R, Stover J. Five years after Treat All implementation: Botswana's HIV response and future directions in the era of COVID-19. South Afr J HIV Med 2021; 22:1275. [PMID: 34853703 PMCID: PMC8602965 DOI: 10.4102/sajhivmed.v22i1.1275] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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] [Received: 06/17/2021] [Accepted: 08/18/2021] [Indexed: 11/01/2022] Open
Abstract
Background As the relentless coronavirus disease-2019 (COVID-19) pandemic continues to spread across Africa, Botswana could face challenges maintaining the pathway towards control of its HIV epidemic. Objective Utilising the Spectrum GOALS module (GOALS-2021), the 5-year outcomes from the implementation of the Treat All strategy were analysed and compared with the original 2016 Investment Case (2016-IC) projections. Future impact of adopting the new Joint United Nations Programme on HIV/AIDS (UNAIDS) Global AIDS Strategy (2021-2026) targets and macroeconomic analysis estimating how the financial constraints from the COVID-19 pandemic could impact the available resources for Botswana's National HIV Response through 2030 were also considered. Method Programmatic costs, population demographics, prevention and treatment outputs were determined. Previous 2016-IC data were uploaded for comparison, and inputs for the GOALS, AIM, DemProj, Resource Needs and Family Planning modules were derived from published reports, strategic plans, programmatic data and expert opinion. The economic projections were recalibrated with consideration of the impact of the COVID-19 pandemic. Results Decreases in HIV infections, incidence and mortality rates were achieved. Increases in laboratory costs were offset by estimated decreases in the population of people living with HIV (PLWH). Moving forward, young women and others at high risk must be targeted in HIV prevention efforts, as Botswana transitions from a generalised to a more concentrated epidemic. Conclusion The Treat All strategy contributed positively to decreases in new HIV infections, mortality and costs. If significant improvements in differentiated service delivery, increases in human resources and HIV prevention can be realised, Botswana could become one of the first countries with a previously high-burdened generalised HIV epidemic to gain epidemic control, despite the demands of the COVID-19 pandemic.
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Affiliation(s)
| | - Ava Avalos
- Careena Centre for Health, Gaborone, Botswana
| | | | | | - Dinah Ramaabya
- Botswana Ministry of Health and Wellness, Gaborone, Botswana
| | - Bornapate Nkomo
- Botswana Ministry of Health and Wellness, Gaborone, Botswana
| | - Charles Muthoga
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Joseph N Jarvis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Robert Selato
- National AIDS and Public Health Agency, Gaborone, Botswana
| | - John Stover
- Avenir Health, Glastonbury, United States of America
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Stover J, Glaubius R, Teng Y, Kelly S, Brown T, Hallett TB, Revill P, Bärnighausen T, Phillips AN, Fontaine C, Frescura L, Izazola-Licea JA, Semini I, Godfrey-Faussett P, De Lay PR, Benzaken AS, Ghys PD. Modeling the epidemiological impact of the UNAIDS 2025 targets to end AIDS as a public health threat by 2030. PLoS Med 2021; 18:e1003831. [PMID: 34662333 PMCID: PMC8559943 DOI: 10.1371/journal.pmed.1003831] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 11/01/2021] [Accepted: 10/01/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND UNAIDS has established new program targets for 2025 to achieve the goal of eliminating AIDS as a public health threat by 2030. This study reports on efforts to use mathematical models to estimate the impact of achieving those targets. METHODS AND FINDINGS We simulated the impact of achieving the targets at country level using the Goals model, a mathematical simulation model of HIV epidemic dynamics that includes the impact of prevention and treatment interventions. For 77 high-burden countries, we fit the model to surveillance and survey data for 1970 to 2020 and then projected the impact of achieving the targets for the period 2019 to 2030. Results from these 77 countries were extrapolated to produce estimates for 96 others. Goals model results were checked by comparing against projections done with the Optima HIV model and the AIDS Epidemic Model (AEM) for selected countries. We included estimates of the impact of societal enablers (access to justice and law reform, stigma and discrimination elimination, and gender equality) and the impact of Coronavirus Disease 2019 (COVID-19). Results show that achieving the 2025 targets would reduce new annual infections by 83% (71% to 86% across regions) and AIDS-related deaths by 78% (67% to 81% across regions) by 2025 compared to 2010. Lack of progress on societal enablers could endanger these achievements and result in as many as 2.6 million (44%) cumulative additional new HIV infections and 440,000 (54%) more AIDS-related deaths between 2020 and 2030 compared to full achievement of all targets. COVID-19-related disruptions could increase new HIV infections and AIDS-related deaths by 10% in the next 2 years, but targets could still be achieved by 2025. Study limitations include the reliance on self-reports for most data on behaviors, the use of intervention effect sizes from published studies that may overstate intervention impacts outside of controlled study settings, and the use of proxy countries to estimate the impact in countries with fewer than 4,000 annual HIV infections. CONCLUSIONS The new targets for 2025 build on the progress made since 2010 and represent ambitious short-term goals. Achieving these targets would bring us close to the goals of reducing new HIV infections and AIDS-related deaths by 90% between 2010 and 2030. By 2025, global new infections and AIDS deaths would drop to 4.4 and 3.9 per 100,000 population, and the number of people living with HIV (PLHIV) would be declining. There would be 32 million people on treatment, and they would need continuing support for their lifetime. Incidence for the total global population would be below 0.15% everywhere. The number of PLHIV would start declining by 2023.
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Affiliation(s)
- John Stover
- Avenir Health, Glastonbury, Connecticut, United States of America
- * E-mail:
| | - Robert Glaubius
- Avenir Health, Glastonbury, Connecticut, United States of America
| | - Yu Teng
- Avenir Health, Glastonbury, Connecticut, United States of America
| | | | - Tim Brown
- East-West Center, Honolulu, Hawaii, United States of America
| | - Timothy B. Hallett
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, United Kingdom
| | - Paul Revill
- Centre for Health Economics, University of York, York, United Kingdom
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Andrew N. Phillips
- Institute for Global Health, University College London, London, United Kingdom
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Glaubius R, Kothegal N, Birhanu S, Jonnalagadda S, Mahiane SG, Johnson LF, Brown T, Stover J, Mangal TD, Pantazis N, Eaton JW. Disease progression and mortality with untreated HIV infection: evidence synthesis of HIV seroconverter cohorts, antiretroviral treatment clinical cohorts and population-based survey data. J Int AIDS Soc 2021; 24 Suppl 5:e25784. [PMID: 34546644 PMCID: PMC8454684 DOI: 10.1002/jia2.25784] [Citation(s) in RCA: 6] [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] [Received: 03/26/2021] [Accepted: 07/19/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Model‐based estimates of key HIV indicators depend on past epidemic trends that are derived based on assumptions about HIV disease progression and mortality in the absence of antiretroviral treatment (ART). Population‐based HIV Impact Assessment (PHIA) household surveys conducted between 2015 and 2018 found substantial numbers of respondents living with untreated HIV infection. CD4 cell counts measured in these individuals provide novel information to estimate HIV disease progression and mortality rates off ART. Methods We used Bayesian multi‐parameter evidence synthesis to combine data on (1) cross‐sectional CD4 cell counts among untreated adults living with HIV from 10 PHIA surveys, (2) survival after HIV seroconversion in East African seroconverter cohorts, (3) post‐seroconversion CD4 counts and (4) mortality rates by CD4 count predominantly from European, North American and Australian seroconverter cohorts. We used incremental mixture importance sampling to estimate HIV natural history and ART uptake parameters used in the Spectrum software. We validated modelled trends in CD4 count at ART initiation against ART initiator cohorts in sub‐Saharan Africa. Results Median untreated HIV survival decreased with increasing age at seroconversion, from 12.5 years [95% credible interval (CrI): 12.1–12.7] at ages 15–24 to 7.2 years (95% CrI: 7.1–7.7) at ages 45–54. Older age was associated with lower initial CD4 counts, faster CD4 count decline and higher HIV‐related mortality rates. Our estimates suggested a weaker association between ART uptake and HIV‐related mortality rates than previously assumed in Spectrum. Modelled CD4 counts in untreated people living with HIV matched recent household survey data well, though some intercountry variation in frequencies of CD4 counts above 500 cells/mm3 was not explained. Trends in CD4 counts at ART initiation were comparable to data from ART initiator cohorts. An alternate model that stratified progression and mortality rates by sex did not improve model fit appreciably. Conclusions Synthesis of multiple data sources results in similar overall survival as previous Spectrum parameter assumptions but implies more rapid progression and longer survival in lower CD4 categories. New natural history parameter values improve consistency of model estimates with recent cross‐sectional CD4 data and trends in CD4 counts at ART initiation.
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Affiliation(s)
- Robert Glaubius
- Center for Modeling, Planning and Policy Analysis, Avenir Health, Glastonbury, Connecticut, USA
| | - Nikhil Kothegal
- Public Health Institute/CDC Global Health Fellow, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sehin Birhanu
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sasi Jonnalagadda
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Severin Guy Mahiane
- Center for Modeling, Planning and Policy Analysis, Avenir Health, Glastonbury, Connecticut, USA
| | - Leigh F Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Tim Brown
- Research Program, East-West Center, Honolulu, Hawaii, USA
| | - John Stover
- Center for Modeling, Planning and Policy Analysis, Avenir Health, Glastonbury, Connecticut, USA
| | - Tara D Mangal
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Nikos Pantazis
- National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Jeffrey W Eaton
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
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Eaton JW, Dwyer‐Lindgren L, Gutreuter S, O'Driscoll M, Stevens O, Bajaj S, Ashton R, Hill A, Russell E, Esra R, Dolan N, Anifowoshe YO, Woodbridge M, Fellows I, Glaubius R, Haeuser E, Okonek T, Stover J, Thomas ML, Wakefield J, Wolock TM, Berry J, Sabala T, Heard N, Delgado S, Jahn A, Kalua T, Chimpandule T, Auld A, Kim E, Payne D, Johnson LF, FitzJohn RG, Wanyeki I, Mahy MI, Shiraishi RW. Naomi: a new modelling tool for estimating HIV epidemic indicators at the district level in sub-Saharan Africa. J Int AIDS Soc 2021; 24 Suppl 5:e25788. [PMID: 34546657 PMCID: PMC8454682 DOI: 10.1002/jia2.25788] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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: 04/28/2021] [Accepted: 07/19/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION HIV planning requires granular estimates for the number of people living with HIV (PLHIV), antiretroviral treatment (ART) coverage and unmet need, and new HIV infections by district, or equivalent subnational administrative level. We developed a Bayesian small-area estimation model, called Naomi, to estimate these quantities stratified by subnational administrative units, sex, and five-year age groups. METHODS Small-area regressions for HIV prevalence, ART coverage and HIV incidence were jointly calibrated using subnational household survey data on all three indicators, routine antenatal service delivery data on HIV prevalence and ART coverage among pregnant women, and service delivery data on the number of PLHIV receiving ART. Incidence was modelled by district-level HIV prevalence and ART coverage. Model outputs of counts and rates for each indicator were aggregated to multiple geographic and demographic stratifications of interest. The model was estimated in an empirical Bayes framework, furnishing probabilistic uncertainty ranges for all output indicators. Example results were presented using data from Malawi during 2016-2018. RESULTS Adult HIV prevalence in September 2018 ranged from 3.2% to 17.1% across Malawi's districts and was higher in southern districts and in metropolitan areas. ART coverage was more homogenous, ranging from 75% to 82%. The largest number of PLHIV was among ages 35 to 39 for both women and men, while the most untreated PLHIV were among ages 25 to 29 for women and 30 to 34 for men. Relative uncertainty was larger for the untreated PLHIV than the number on ART or total PLHIV. Among clients receiving ART at facilities in Lilongwe city, an estimated 71% (95% CI, 61% to 79%) resided in Lilongwe city, 20% (14% to 27%) in Lilongwe district outside the metropolis, and 9% (6% to 12%) in neighbouring Dowa district. Thirty-eight percent (26% to 50%) of Lilongwe rural residents and 39% (27% to 50%) of Dowa residents received treatment at facilities in Lilongwe city. CONCLUSIONS The Naomi model synthesizes multiple subnational data sources to furnish estimates of key indicators for HIV programme planning, resource allocation, and target setting. Further model development to meet evolving HIV policy priorities and programme need should be accompanied by continued strengthening and understanding of routine health system data.
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Stover J, Glaubius R, Kassanjee R, Dugdale CM. Updates to the Spectrum/AIM model for the UNAIDS 2020 HIV estimates. J Int AIDS Soc 2021; 24 Suppl 5:e25778. [PMID: 34546648 PMCID: PMC8454674 DOI: 10.1002/jia2.25778] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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: 01/15/2021] [Accepted: 07/14/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The Spectrum/AIM model is used by national HIV programs and UNAIDS to prepare annual estimates of key HIV indicators. This article describes key updates to paediatric and adult models for the 2021 round of HIV estimates. METHODS Potential updates to Spectrum arise due to newly available data, new analyses of existing data, and the need for new issues to be addressed. Updates are guided by experts through the UNAIDS Reference Group on Estimates, Modelling and Projections. Changes are tested and assessed for impact before being accepted into the final model. RESULTS Spectrum tracks children living with HIV by CD4% for ages 0-4 and CD4 count for ages 5-14. Data from IeDEA treatment sites have been used to map the transition from CD4% to CD4 count at age 5. Breastfeeding patterns in sub-Saharan Africa have been updated with the latest survey data and estimates of continuation on antiretroviral therapy (ART) with breastfeeding have been revised based on recent studies. Model assumptions about the CD4 counts of people who drop out of ART have been revised to account for CD4 count increases while on treatment. If available, monthly data on numbers on ART can now be used to estimate the effects of COVID-19-related disruptions during 2020. CONCLUSIONS These changes are intended to provide more accurate estimates of HIV burden. The effects of these changes on paediatric indicators are small except in countries with new surveys that might have updated patterns of breastfeeding. Changes to the adult model have little effect on total new infections. AIDS-related deaths will be somewhat lower in countries that have data on ART drop out but might be increased by HIV care disruptions due to COVID-19. The updated model uses newly available data to improve the estimation of paediatric and adult HIV indicators.
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Affiliation(s)
- John Stover
- Center for Modeling, Planning and Policy AnalysisAvenir HealthGlastonburyCTUSA
| | - Robert Glaubius
- Center for Modeling, Planning and Policy AnalysisAvenir HealthGlastonburyCTUSA
| | - Reshma Kassanjee
- Centre for Infectious Disease Epidemiology and Research (CIDER)University of Cape TownCape TownSouth Africa
| | - Caitlin M. Dugdale
- Division of Infectious DiseasesMassachusetts General HospitalBostonMAUSA
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Weinberger M, Bellows N, Stover J. Estimating private sector out-of-pocket expenditures on family planning commodities in low-and-middle-income countries. BMJ Glob Health 2021; 6:bmjgh-2020-004635. [PMID: 33846142 PMCID: PMC8048017 DOI: 10.1136/bmjgh-2020-004635] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 12/02/2020] [Revised: 03/06/2021] [Accepted: 03/23/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction The role of the private sector in family planning (FP) is well studied; however, few efforts have been made to quantify the role of private out-of-pocket (OOP) expenditures on FP commodities across low-and-middle-income countries (LMICs). Calculating OOP expenditures is important to illuminate the magnitude of these contributions and to inform discussions on how financial burdens can be reduced. Methods Estimates of FP users and commodities consumed by women getting their FP methods from the private sector were made for 132 LMICs. Next, unit price data were compiled from to estimate the average price of commodities in the private sector at both a commercial and subsidised price point. These unit prices were applied to commodity consumption estimates to calculate total private OOP expenditures. Sensitivity testing was conducted. Results Total estimated private OOP expenditures for FP commodities in 2019 was $2.73 billion across 132 LMICs. Spending on contraceptive pills accounted for 80% of this total, and just over three-quarters of expenditure came from upper-middle-income countries. OOP expenditures on subsidised commodities were small but accounted for 20% of expenditures in low-income countries. Non-subsidised unit prices were found to be between 5 and 20 times higher in upper-middle-income countries compared with low-income countries, although wide variation exists. For low-income and lower-middle-income countries, subsidies appear to be greatest for intrauterine devices (IUDs) and pills. Conclusion Large OOP expenditures across all income levels highlight a need for financing approaches that ensure that a wide range of contraceptives are both accessible and affordable.
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Affiliation(s)
| | | | - John Stover
- Avenir Health, Glastonbury, Connecticut, USA
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22
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Korenromp EL, Bershteyn A, Mudimu E, Weiner R, Bonecwe C, Loykissoonlal D, Manuhwa C, Pretorius C, Teng Y, Stover J, Johnson LF. The impact of the program for medical male circumcision on HIV in South Africa: analysis using three epidemiological models. Gates Open Res 2021; 5:15. [PMID: 33615145 PMCID: PMC7878969 DOI: 10.12688/gatesopenres.13220.1] [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] [Accepted: 01/12/2021] [Indexed: 12/24/2022] Open
Abstract
Background: South Africa began offering medical male circumcision (MMC) in 2010. We evaluated the current and future impact of this program to see if it is effective in preventing new HIV infections. Methods: The Thembisa, Goals and Epidemiological Modeling Software (EMOD) HIV transmission models were calibrated to South Africa's HIV epidemic, fitting to household survey data on HIV prevalence, risk behaviors, and proportions of men circumcised, and to programmatic data on intervention roll-out including program-reported MMCs over 2009-2017. We compared the actual program accomplishments through 2017 and program targets through 2021 with a counterfactual scenario of no MMC program. Results: The MMC program averted 71,000-83,000 new HIV infections from 2010 to 2017. The future benefit of the circumcision already conducted will grow to 496,000-518,000 infections (6-7% of all new infections) by 2030. If program targets are met by 2021 the benefits will increase to 723,000-760,000 infections averted by 2030. The cost would be $1,070-1,220 per infection averted relative to no MMC. The savings from averted treatment needs would become larger than the costs of the MMC program around 2034-2039. In the Thembisa model, when modelling South Africa's 9 provinces individually, the 9-provinces-aggregate results were similar to those of the single national model. Across provinces, projected long-term impacts were largest in Free State, KwaZulu-Natal and Mpumalanga (23-27% reduction over 2017-2030), reflecting these provinces' greater MMC scale-up. Conclusions: MMC has already had a modest impact on HIV incidence in South Africa and can substantially impact South Africa's HIV epidemic in the coming years.
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Affiliation(s)
| | - Anna Bershteyn
- Department of Population and Health, NYU Langone Medical Center, New York, NY, 11016, USA
| | - Edina Mudimu
- Department of Decision Sciences, University of South Africa (UNISA), Pretoria, 0003, South Africa
| | - Renay Weiner
- Research and Training for Health and Development, Johannesburg, 2196, South Africa
| | | | | | - Clarence Manuhwa
- FHI 360, Pretoria, 0083, South Africa
- Independent Consultant, Pretoria, 0083, South Africa
| | - Carel Pretorius
- Center for Modeling and Analysis, Avenir Health, Glastonbury, CT, 06033, USA
| | - Yu Teng
- Center for Modeling and Analysis, Avenir Health, Glastonbury, CT, 06033, USA
| | - John Stover
- Center for Modeling and Analysis, Avenir Health, Glastonbury, CT, 06033, USA
| | - Leigh F. Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
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Jewell BL, Mudimu E, Stover J, Ten Brink D, Phillips AN, Smith JA, Martin-Hughes R, Teng Y, Glaubius R, Mahiane SG, Bansi-Matharu L, Taramusi I, Chagoma N, Morrison M, Doherty M, Marsh K, Bershteyn A, Hallett TB, Kelly SL. Potential effects of disruption to HIV programmes in sub-Saharan Africa caused by COVID-19: results from multiple mathematical models. Lancet HIV 2020; 7:e629-e640. [PMID: 32771089 PMCID: PMC7482434 DOI: 10.1016/s2352-3018(20)30211-3] [Citation(s) in RCA: 253] [Impact Index Per Article: 63.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/25/2020] [Accepted: 06/29/2020] [Indexed: 12/28/2022]
Abstract
Background The COVID-19 pandemic could lead to disruptions to provision of HIV services for people living with HIV and those at risk of acquiring HIV in sub-Saharan Africa, where UNAIDS estimated that more than two-thirds of the approximately 38 million people living with HIV resided in 2018. We aimed to predict the potential effects of such disruptions on HIV-related deaths and new infections in sub-Saharan Africa. Methods In this modelling study, we used five well described models of HIV epidemics (Goals, Optima HIV, HIV Synthesis, an Imperial College London model, and Epidemiological MODeling software [EMOD]) to estimate the effect of various potential disruptions to HIV prevention, testing, and treatment services on HIV-related deaths and new infections in sub-Saharan Africa lasting 6 months over 1 year from April 1, 2020. We considered scenarios in which disruptions affected 20%, 50%, and 100% of the population. Findings A 6-month interruption of supply of antiretroviral therapy (ART) drugs across 50% of the population of people living with HIV who are on treatment would be expected to lead to a 1·63 times (median across models; range 1·39–1·87) increase in HIV-related deaths over a 1-year period compared with no disruption. In sub-Saharan Africa, this increase amounts to a median excess of HIV deaths, across all model estimates, of 296 000 (range 229 023–420 000) if such a high level of disruption occurred. Interruption of ART would increase mother-to-child transmission of HIV by approximately 1·6 times. Although an interruption in the supply of ART drugs would have the largest impact of any potential disruptions, effects of poorer clinical care due to overstretched health facilities, interruptions of supply of other drugs such as co-trimoxazole, and suspension of HIV testing would all have a substantial effect on population-level mortality (up to a 1·06 times increase in HIV-related deaths over a 1-year period due to disruptions affecting 50% of the population compared with no disruption). Interruption to condom supplies and peer education would make populations more susceptible to increases in HIV incidence, although physical distancing measures could lead to reductions in risky sexual behaviour (up to 1·19 times increase in new HIV infections over a 1-year period if 50% of people are affected). Interpretation During the COVID-19 pandemic, the primary priority for governments, donors, suppliers, and communities should focus on maintaining uninterrupted supply of ART drugs for people with HIV to avoid additional HIV-related deaths. The provision of other HIV prevention measures is also important to prevent any increase in HIV incidence. Funding Bill & Melinda Gates Foundation.
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Affiliation(s)
- Britta L Jewell
- Medical Research Council Centre for Global Infectious Disease Analysis, Abdul Latif Jameel Institute for Disease and Emergency Analytics, Imperial College London, London, UK
| | - Edinah Mudimu
- Department of Decision Sciences, University of South Africa, Pretoria, South Africa
| | | | | | | | - Jennifer A Smith
- Medical Research Council Centre for Global Infectious Disease Analysis, Abdul Latif Jameel Institute for Disease and Emergency Analytics, Imperial College London, London, UK
| | | | - Yu Teng
- Avenir Health, Glastonbury, CT, USA
| | | | | | | | | | | | | | | | | | - Anna Bershteyn
- New York University School of Medicine, New York, NY, USA
| | - Timothy B Hallett
- Medical Research Council Centre for Global Infectious Disease Analysis, Abdul Latif Jameel Institute for Disease and Emergency Analytics, Imperial College London, London, UK
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Khalifa A, Stover J, Mahy M, Idele P, Porth T, Lwamba C. Demographic change and HIV epidemic projections to 2050 for adolescents and young people aged 15-24. Glob Health Action 2020; 12:1662685. [PMID: 31510887 PMCID: PMC6746261 DOI: 10.1080/16549716.2019.1662685] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [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: 11/22/2022] Open
Abstract
Background: Ending AIDS as a public health threat by 2030 is a significant
challenge, as new HIV infections among adolescents and young people have not decreased
fast enough to curb the epidemic. The combination of slow HIV response and increasing
youth populations 15–24 could affect progress towards 2030 goals. Objective: This analysis aimed to describe global and regional trends from
2010–2050 in the HIV epidemic among adolescents and young people by accounting for
demographic projections and recent trends in HIV interventions. Methods: 148 national HIV estimates files were used to project the HIV
epidemic to 2050. Numbers of people living with HIV and new HIV infections were projected
by sex and five-year age group. Along with demographic data, projections were based on
three key assumptions: future trends in HIV incidence, antiretroviral treatment coverage,
and coverage of antiretrovirals for prevention of mother-to-child transmission. Results
represent nine geographic regions. Results: While the number of adolescents and young people is projected to
increase by 10% from 2010–2050, those living with HIV is projected to decrease by 61%. In
Eastern and Southern Africa, which hosts the largest HIV epidemic, new HIV infections
among adolescents and young people are projected to decline by 84% from 2010–2050. In West
and Central Africa, which hosts the second-largest HIV epidemic, new infections are
projected to decline by 35%. Conclusions: While adolescents and young people living with HIV are living
longer and ageing into adulthood, if current trends continue, the number of new HIV
infections is not projected to decline fast enough to end AIDS as a health threat in this
age group. Regional variations suggest that while progress in Eastern and Southern Africa
could reduce the size of the epidemic by 2050, other regions exhibit slower rates of
decline among adolescents and young people.
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Affiliation(s)
- Aleya Khalifa
- Division of Data, Research and Policy, United Nations Children's Fund , New York , NY , USA
| | - John Stover
- Center for Modeling, Planning and Policy Analysis, Avenir Health, Avenir Health , Glastonbury , CT , USA
| | - Mary Mahy
- Department of Strategic Information and Evaluation, Joint United Nations Programme for HIV/AIDS , Geneva , Switzerland
| | - Priscilla Idele
- Division of Data, Research and Policy, United Nations Children's Fund , New York , NY , USA
| | - Tyler Porth
- Division of Data, Research and Policy, United Nations Children's Fund , New York , NY , USA
| | - Chibwe Lwamba
- Division of Data, Research and Policy, United Nations Children's Fund , New York , NY , USA
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Slogrove AL, Powis KM, Johnson LF, Stover J, Mahy M. Estimates of the global population of children who are HIV-exposed and uninfected, 2000-18: a modelling study. Lancet Glob Health 2020; 8:e67-e75. [PMID: 31791800 PMCID: PMC6981259 DOI: 10.1016/s2214-109x(19)30448-6] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [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: 06/28/2019] [Revised: 10/01/2019] [Accepted: 10/04/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Children who are HIV-exposed uninfected (HEU) have higher morbidity and mortality than children who are HIV-unexposed and uninfected despite safer breastfeeding and improved maternal health with maternal antiretroviral therapy. We present the first global estimates of the population of children who are HEU (aged 0-14 years) and the geographical and temporal trends in HIV high-burden countries between 2000 and 2018. METHODS The Spectrum AIDS Impact Module developed by Avenir Health, UNAIDS, and partners is used to estimate key HIV epidemic indicators from mathematical models. We used 2019 UNAIDS global estimates of children (aged 0-14 years) who are HEU generated by Spectrum and 2017 UN Population Division estimates of the number of all children in each region or country to estimate the regional or national prevalence of children who were HEU, the regional or national contribution of children who were HEU to the global population of children who were HEU, and the proportion of children who were HEU and exposed to antiretrovirals for six UNAIDS regions and 21 HIV high-burden countries in 2018. We also estimated the percentage change in the global population of children who were HEU between 2000 and 2018. FINDINGS In 2018, there were an estimated 14·8 million (lower estimate 11·1-upper estimate 18·3) children who were HEU, 13·2 million (9·8-16·3; 90%) of whom resided in sub-Saharan Africa and 760 000 (640 000-970 000; 5%) of whom resided in the Asia and Pacific region. Five countries accounted for 50% of all 14·8 million children who were HEU globally: South Africa (3·5 million [23·8%]), Uganda (1·1 million [7·5%]), Mozambique (1·0 million [6·6%]), Tanzania (910 000 [6·1%]); and Nigeria (880 000 [6·0%]). In five southern African countries, the prevalence of children who were HEU exceeded 15% of the general child population: eSwatini (32·4%), Botswana (27·4%), South Africa (21·6%), Lesotho (21·1%), and Namibia (16·4%). INTERPRETATION The global population of children who are HEU is substantial, requiring a coordinated strategy to reduce HIV exposure in children and ensure optimal health and wellbeing of children who are HEU and their families. Future research and programmatic funding investments must be aligned with the geographical distribution of children who are HEU. FUNDING National Institutes of Health, International AIDS Society.
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Affiliation(s)
- Amy L Slogrove
- Department of Paediatrics and Child Health and Ukwanda Centre for Rural Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Worcester, South Africa.
| | - Kathleen M Powis
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA; Departments of Internal Medicine and Pediatrics, Massachusetts General Hospital, Boston, MA, USA; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Leigh F Johnson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | - Mary Mahy
- Strategic Information and Evaluation Department, UNAIDS, Geneva, Switzerland
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Abstract
When designing a family planning (FP) strategy, decision‐makers can choose from a wide range of interventions designed to expand access to and develop demand for FP. However, not all interventions will have the same impact on increasing modern contraceptive prevalence (mCP). Understanding the existing evidence is critical to planning successful and cost‐effective programs. The Impact Matrix is the first comprehensive summary of the impact of a full range of FP interventions on increasing mCP using a single comparable metric. It was developed through an extensive literature review with input from the wider FP community, and includes 138 impact factors highlighting the range of effectiveness observed across categories and subcategories of FP interventions. The Impact Matrix is central to the FP Goals model, used to project scenarios of mCP growth that help decision‐makers set realistic goals and prioritize investments. Development of the Impact Matrix, evidence gaps identified, and the contribution to FP Goals are discussed.
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Beck EJ, Mandalia S, DongmoNguimfack B, Pinheiro E, 't Hoen E, Boulet P, Stover J, Gupta A, Juneja S, Habiyambere V, Ghys P, Nunez C. Does the political will exist to bring quality-assured and affordable drugs to low- and middle-income countries? Glob Health Action 2019; 12:1586317. [PMID: 30983547 PMCID: PMC6484498 DOI: 10.1080/16549716.2019.1586317] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 01/21/2023] Open
Abstract
Background: Increased coverage with antiretroviral therapy for people living with HIV in low- and middle-income countries has increased their life expectancy associated with non-HIV comorbidities and the need for quality-assured and affordable non-communicable diseases drugs . Funders are leaving many middle-income countries that will have to pay and provide quality-assured and affordable HIV and non-HIV drugs, including for non-communicable diseases. Objective: To estimate costs for originator and generic antiretroviral therapy as the number of people living with HIV are projected to increase between 2016 and 2026, and discuss country, regional and global factors associated with increased access to generic drugs. Methods: Based on estimates of annual demand and prices, annual cost estimates were produced for generic and originator antiretroviral drug prices in low- and middle-income countries and projected for 2016–2026. Results: Drug costs varied between US$1.5 billion and US$4.8 billion for generic drugs and US$ 8.2 billion and US$16.5 billion for originator drugs between 2016 and 2026. Discussion: The global HIV response increased access to affordable generic drugs in low- and middle-income countries. Cheaper active pharmaceutical ingredients and market competition were responsible for reduced drug costs. The development and implementation of regulatory changes at country, regional and global levels, covering intellectual property rights and public health, and flexibilities in patent laws enabled prices to be reduced. These changes have not yet been applied in many low- and middle-income countries for HIV, nor for other infectious and non-communicable diseases, that lack the profile and political attention of HIV. Licensing backed up with Trade-Related Aspects of Intellectual Property Rights safeguards should become the norm to provide quality-assured and affordable drugs within competitive generic markets. Conclusion: Does the political will exist among policymakers and other stakeholders to develop and implement these country, regional and global frameworks for non-HIV drugs as they did for antiretroviral drugs?
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Peter Ghys
- a Programme Branch , UNAIDS , Geneva , Switzerland
| | - Cesar Nunez
- a Programme Branch , UNAIDS , Geneva , Switzerland
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von Finck A, Herffurth T, Duparré A, Schröder S, Lequime M, Zerrad M, Liukaityte S, Amra C, Achour S, Chalony M, Kuperman Q, Cornil Y, Bialek A, Goodman T, Greenwell C, Gur B, Brinkers S, Otter G, Vosteen A, Stover J, Vink R, Deep A, Doyle D. International round-robin experiment for angle-resolved light scattering measurement. Appl Opt 2019; 58:6638-6654. [PMID: 31503596 DOI: 10.1364/ao.58.006638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 07/14/2019] [Indexed: 06/10/2023]
Abstract
An international round-robin experiment has been conducted to test procedures and methods for the measurement of angle-resolved light scattering. ASTM E2387-05 has been used as the main guide, while the experience gained should also contribute to the new ISO standard of angle-resolved scattering currently under development (ISO/WD 19986:2016). Seven laboratories from Europe and the United States measured the angle-resolved scattering from Al/SiO2-coated substrates, transparent substrates, volume diffusors, quasi-volume diffusors, white calibration standards, and grating samples at laser wavelengths in the UV, VIS, and NIR spectra. Results were sent to Fraunhofer IOF, which coordinated the experiments and analyzed the data, while ESA-ESTEC, as the project donor, defined conditions and parameters. Depending mainly on the sample type, overall good to reasonable agreements were observed, with largest deviations at scattering angles very close to the specular beam. Volume diffusor characterization unexpectedly turned out to be challenging. Not all participants provided measurement uncertainty ranges according to the Guide to the Expression of Uncertainty in Measurement; often, a single general scatterometer-related measurement uncertainty value was stated. Although relative instrument measurement uncertainties close to 1% are sometimes claimed, the comparison results did not support these claims for specular scattering samples as mirrors, substrates, or gratings.
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Chou VB, Bubb-Humfryes O, Sanders R, Walker N, Stover J, Cochrane T, Stegmuller A, Magalona S, Von Drehle C, Walker DG, Bonilla-Chacin ME, Boer KR. Pushing the envelope through the Global Financing Facility: potential impact of mobilising additional support to scale-up life-saving interventions for women, children and adolescents in 50 high-burden countries. BMJ Glob Health 2018; 3:e001126. [PMID: 30498583 PMCID: PMC6254741 DOI: 10.1136/bmjgh-2018-001126] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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] [Received: 08/18/2018] [Revised: 09/28/2018] [Accepted: 09/28/2018] [Indexed: 11/07/2022] Open
Abstract
Introduction The Global Financing Facility (GFF) was launched to accelerate progress towards the Sustainable Development Goals (SDGs) through scaled and sustainable financing for Reproductive, Maternal, Newborn, Child and Adolescent Health and Nutrition (RMNCAH-N) outcomes. Our objective was to estimate the potential impact of increased resources available to improve RMNCAH-N outcomes, from expanding and scaling up GFF support in 50 high-burden countries. Methods The potential impact of GFF was estimated for the period 2017–2030. First, two scenarios were constructed to reflect conservative and ambitious assumptions around resources that could be mobilised by the GFF model, based on GFF Trust Fund resources of US$2.6 billion. Next, GFF impact was estimated by scaling up coverage of prioritised RMNCAH-N interventions under these resource scenarios. Resource availability was projected using an Excel-based model and health impacts and costs were estimated using the Lives Saved Tool (V.5.69 b9). Results We estimate that the GFF partnership could collectively mobilise US$50–75 billion of additional funds for expanding delivery of life-saving health and nutrition interventions to reach coverage of at least 70% for most interventions by 2030. This could avert 34.7 million deaths—including preventable deaths of mothers, newborns, children and stillbirths—compared with flatlined coverage, or 12.4 million deaths compared with continuation of historic trends. Under-five and neonatal mortality rates are estimated to decrease by 35% and 34%, respectively, and stillbirths by 33%. Conclusion The GFF partnership through country- contextualised prioritisation and innovative financing could go a long way in increasing spending on RMNCAH-N and closing the existing resource gap. Although not all countries will reach the SDGs by relying on gains from the GFF platform alone, the GFF provides countries with an opportunity to significantly improve RMNCAH-N outcomes through achievable, well-directed changes in resource allocation.
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Affiliation(s)
- Victoria B Chou
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | - Neff Walker
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - John Stover
- Avenir Health, Glastonbury, Connecticut, USA
| | - Tom Cochrane
- Cambridge Economic Policy Associates, London, UK
| | - Angela Stegmuller
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Habiyambere V, Dongmo Nguimfack B, Vojnov L, Ford N, Stover J, Hasek L, Maggiore P, Low-Beer D, Pérez Gonzàlez M, Edgil D, Williams J, Kuritsky J, Hargreaves S, NeSmith T. Forecasting the global demand for HIV monitoring and diagnostic tests: A 2016-2021 analysis. PLoS One 2018; 13:e0201341. [PMID: 30231022 PMCID: PMC6145505 DOI: 10.1371/journal.pone.0201341] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [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: 08/02/2017] [Accepted: 07/13/2018] [Indexed: 12/31/2022] Open
Abstract
Introduction Despite considerable progress, just over half of the 37 million people eligible to start antiretroviral therapy (ART) have accessed treatment and millions of HIV-positive people still do not know their status. With demand for ART continuing to grow, meeting the ambitious 90-90-90 HIV treatment targets will depend on improved access to high-quality diagnostics to both diagnose infection and monitor treatment adherence in low and middle-income countries (LMICs). Robust projections of future demand for CD4, viral load (VL), HIV early-infant-diagnosis (EID) tests and HIV rapid diagnostic tests (RDTs) are needed as scale-up continues. Methods We estimate the current coverage for HIV diagnostics and project future demand to 2021 using a consolidated forecast using data on past coverage and current demand from a number of sources, from 130 predominantly LMIC countries. Results We forecast that the overall number of CD4 tests is expected to decline between now and 2021 as more countries adopt test-and-treat and shift to VL testing for patient monitoring. Our consolidated forecast projects a gradual decline in demand for CD4 tests to 16.6 million by 2021. We anticipate that demand for VL tests will increase to 28.5 million by 2021, reflecting the increasing number of people who will receive ART and the adoption of VL testing for patient monitoring. We expect that the demand for EID tests will grow more rapidly than in past years, driven by the implementation of testing at birth in programmes globally, in line with WHO guideline recommendations, doubling to 2.1 million tests by 2021. Demand for rapid diagnostic tests is also likely to increase, reaching 509 million tests by 2021. Discussion In order to achieve the ambitious 90-90-90 targets, it will be essential to maintain and improve access to CD4, VL, EID tests and RDTs. These projections provide insight into the global demand we can expect to see for these HIV monitoring and diagnostic tests, both in relation to historical trends, and the 90-90-90 targets. Our projections will better enable producers to ensure adequate supply, and to support procurement organisations in planning future funding and purchase plans to meet the anticipated demand. The findings highlight the ongoing need for governments and international funding bodies to prioritise improving capacity and access to HIV diagnostic and monitoring technologies in line with demand.
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Affiliation(s)
| | | | - L. Vojnov
- Department of HIV/AIDS, WHO, Geneva, Switzerland
| | - N. Ford
- Department of HIV/AIDS, WHO, Geneva, Switzerland
| | - J. Stover
- Avenir Health, Glastonbury, Connecticut, United States of America
| | - L. Hasek
- CHAI, Boston, Massachusetts, United States of America
| | - P. Maggiore
- CHAI, Boston, Massachusetts, United States of America
| | - D. Low-Beer
- Department of HIV/AIDS, WHO, Geneva, Switzerland
| | | | - D. Edgil
- USAID, Washington DC, United States of America
| | - J. Williams
- US CDC, Atlanta, Georgia, United States of America
| | - J. Kuritsky
- USAID, Washington DC, United States of America
| | - S. Hargreaves
- International Health Unit, Imperial College London, London, United Kingdom
| | - T. NeSmith
- US CDC, Atlanta, Georgia, United States of America
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McGillen JB, Stover J, Klein DJ, Xaba S, Ncube G, Mhangara M, Chipendo GN, Taramusi I, Beacroft L, Hallett TB, Odawo P, Manzou R, Korenromp EL. The emerging health impact of voluntary medical male circumcision in Zimbabwe: An evaluation using three epidemiological models. PLoS One 2018; 13:e0199453. [PMID: 30020940 PMCID: PMC6051576 DOI: 10.1371/journal.pone.0199453] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 06/07/2018] [Indexed: 12/26/2022] Open
Abstract
Background Zimbabwe adopted voluntary medical male circumcision (VMMC) as a priority HIV prevention strategy in 2007 and began implementation in 2009. We evaluated the costs and impact of this VMMC program to date and in future. Methods Three mathematical models describing Zimbabwe’s HIV epidemic and program evolution were calibrated to household survey data on prevalence and risk behaviors, with circumcision coverage calibrated to program-reported VMMCs. We compared trends in new infections and costs to a counterfactual without VMMC. Input assumptions were agreed in workshops with national stakeholders in 2015 and 2017. Results The VMMC program averted 2,600–12,200 infections (among men and women combined) by the end of 2016. This impact will grow as circumcised men are protected lifelong, and onward dynamic transmission effects, which protect women via reduced incidence and prevalence in their male partners, increase over time. If other prevention interventions remain at 2016 coverages, the VMMCs already performed will avert 24,400–69,800 infections (2.3–5% of all new infections) through 2030. If coverage targets are achieved by 2021 and maintained, the program will avert 108,000–171,000 infections (10–13% of all new infections) by 2030, costing $2,100–3,250 per infection averted relative to no VMMC. Annual savings from averted treatment needs will outweigh VMMC maintenance costs once coverage targets are reached. If Zimbabwe also achieves ambitious UNAIDS targets for scaling up treatment and prevention efforts, VMMC will reduce the HIV incidence remaining at 2030 by one-third, critically contributing to the UNAIDS goal of 90% incidence reduction. Conclusions VMMC can substantially impact Zimbabwe’s HIV epidemic in the coming years; this investment will save costs in the longer term.
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Affiliation(s)
- Jessica B. McGillen
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - John Stover
- Avenir Health, Glastonbury, Connecticut, United States of America
| | - Daniel J. Klein
- Institute for Disease Modeling, Seattle, Washington, United States of America
| | | | - Getrude Ncube
- Ministry of Health and Child Welfare, Harare, Zimbabwe
| | | | | | | | - Leo Beacroft
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Timothy B. Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | | | - Rumbidzai Manzou
- Zimbabwe Country Office, Clinton Health Access Initiative, Harare, Zimbabwe
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Pandey A, Dhingra N, Kumar P, Sahu D, Reddy DCS, Narayan P, Raj Y, Sangal B, Chandra N, Nair S, Singh J, Chavan L, Srivastava DJ, Jha UM, Verma V, Kant S, Bhattacharya M, Swain P, Haldar P, Singh L, Bakkali T, Stover J, Ammassari S. Sustained progress, but no room for complacency: Results of 2015 HIV estimations in India. Indian J Med Res 2018; 146:83-96. [PMID: 29168464 PMCID: PMC5719613 DOI: 10.4103/ijmr.ijmr_1658_16] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background & objectives: Evidence-based planning has been the cornerstone of India's response to HIV/AIDS. Here we describe the process, method and tools used for generating the 2015 HIV estimates and provide a summary of the main results. Methods: Spectrum software supported by the UNAIDS was used to produce HIV estimates for India as a whole and its States/Union Territories. This tool takes into consideration the size and HIV prevalence of defined population groups and programme data to estimate HIV prevalence, incidence and mortality over time as well as treatment needs. Results: India's national adult prevalence of HIV was 0.26 per cent in 2015. Of the 2.1 million people living with HIV/AIDS, the largest numbers were in Andhra Pradesh, Maharashtra and Karnataka. New HIV infections were an estimated 86,000 in 2015, reflecting a decline by around 32 per cent from 2007. The declining trend in incidence was mirrored in most States, though an increasing trend was detected in Assam, Chandigarh, Chhattisgarh, Gujarat, Sikkim, Tripura and Uttar Pradesh. AIDS-related deaths were estimated to be 67,600 in 2015, reflecting a 54 per cent decline from 2007. There were variations in the rate and trend of decline across India for this indicator also. Interpretation & conclusions: While key indicators measured through Spectrum modelling confirm success of the National AIDS Control Programme, there is no room for complacency as rising incidence trends in some geographical areas and population pockets remain the cause of concern. Progress achieved so far in responding to HIV/AIDS needs to be sustained to end the HIV epidemic.
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Affiliation(s)
- Arvind Pandey
- ICMR-National Institute of Medical Statistics, New Delhi, India
| | - Neeraj Dhingra
- National AIDS Control Organization (NACO), Ministry of Health & Family Welfare, Government of India, New Delhi, India
| | - Pradeep Kumar
- National AIDS Control Organization (NACO), Ministry of Health & Family Welfare, Government of India, New Delhi, India
| | - Damodar Sahu
- ICMR-National Institute of Medical Statistics, New Delhi, India
| | - D C S Reddy
- Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University (Former Professor), Varanasi, India
| | - Padum Narayan
- ICMR-National Institute of Medical Statistics, New Delhi, India
| | - Yujwal Raj
- Consultant/Former NPO NACO, New Delhi, India
| | - Bhavna Sangal
- National AIDS Control Organization (NACO), Ministry of Health & Family Welfare, Government of India, New Delhi, India
| | - Nalini Chandra
- United Nations Joint Programme on HIV/AIDS (UNAIDS), New Delhi, India
| | - Saritha Nair
- ICMR-National Institute of Medical Statistics, New Delhi, India
| | | | | | | | - Ugra Mohan Jha
- National AIDS Control Organization (NACO), Ministry of Health & Family Welfare, Government of India, New Delhi, India
| | - Vinita Verma
- National AIDS Control Organization (NACO), Ministry of Health & Family Welfare, Government of India, New Delhi, India
| | - Shashi Kant
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Madhulekha Bhattacharya
- Department of Community Health, National Institute of Health & Family Welfare, New Delhi, India
| | - Pushpanjali Swain
- Department of Statistics and Demography, National Institute of Health & Family Welfare, New Delhi, India
| | - Partha Haldar
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Lucky Singh
- ICMR-National Institute of Medical Statistics, New Delhi, India
| | - Taoufik Bakkali
- United Nations Joint Programme on HIV/AIDS (UNAIDS), New Delhi, India
| | | | - Savina Ammassari
- United Nations Joint Programme on HIV/AIDS (UNAIDS), New Delhi, India
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Cahill N, Sonneveldt E, Stover J, Weinberger M, Williamson J, Wei C, Brown W, Alkema L. Modern contraceptive use, unmet need, and demand satisfied among women of reproductive age who are married or in a union in the focus countries of the Family Planning 2020 initiative: a systematic analysis using the Family Planning Estimation Tool. Lancet 2018; 391:870-882. [PMID: 29217374 PMCID: PMC5854461 DOI: 10.1016/s0140-6736(17)33104-5] [Citation(s) in RCA: 114] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 11/14/2017] [Accepted: 11/18/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND The London Summit on Family Planning in 2012 inspired the Family Planning 2020 (FP2020) initiative and the 120×20 goal of having an additional 120 million women and adolescent girls become users of modern contraceptives in 69 of the world's poorest countries by the year 2020. Working towards achieving 120 × 20 is crucial for ultimately achieving the Sustainable Development Goals of universal access and satisfying demand for reproductive health. Thus, a performance assessment is required to determine countries' progress. METHODS An updated version of the Family Planning Estimation Tool (FPET) was used to construct estimates and projections of the modern contraceptive prevalence rate (mCPR), unmet need for, and demand satisfied with modern methods of contraception among women of reproductive age who are married or in a union in the focus countries of the FP2020 initiative. We assessed current levels of family planning indicators and changes between 2012 and 2017. A counterfactual analysis was used to assess if recent levels of mCPR exceeded pre-FP2020 expectations. FINDINGS In 2017, the mCPR among women of reproductive age who are married or in a union in the FP2020 focus countries was 45·7% (95% uncertainty interval [UI] 42·4-49·1), unmet need for modern methods was 21·6% (19·7-23·9), and the demand satisfied with modern methods was 67·9% (64·4-71·1). Between 2012 and 2017 the number of women of reproductive age who are married or in a union who use modern methods increased by 28·8 million (95% UI 5·8-52·5). At the regional level, Asia has seen the mCPR among women of reproductive age who are married or in a union grow from 51·0% (95% UI 48·5-53·4) to 51·8% (47·3-56·5) between 2012 and 2017, which is slow growth, particularly when compared with a change from 23·9% (22·9-25·0) to 28·5% (26·8-30·2) across Africa. At the country level, based on a counterfactual analysis, we found that 61% of the countries that have made a commitment to FP2020 exceeded pre-FP2020 expectations for modern contraceptive use. Country success stories include rapid increases in Kenya, Mozambique, Malawi, Lesotho, Sierra Leone, Liberia, and Chad relative to what was expected in 2012. INTERPRETATION Whereas the estimate of additional users up to 2017 for women of reproductive age who are married or in a union would suggest that the 120 × 20 goal for all women is overly ambitious, the aggregate outcomes mask the diversity in progress at the country level. We identified countries with accelerated progress, that provide inspiration and guidance on how to increase the use of family planning and inform future efforts, especially in countries where progress has been poor. FUNDING The Bill & Melinda Gates Foundation, through grant support to the University of Massachusetts Amherst and Avenir Health.
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Affiliation(s)
- Niamh Cahill
- The Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst, MA, USA; The School of Mathematics and Statistics, University College Dublin, Dublin, Ireland.
| | | | | | | | | | - Chuchu Wei
- The Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst, MA, USA
| | - Win Brown
- The Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Leontine Alkema
- The Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst, MA, USA
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Kofler M, Schiefecker AJ, Beer R, Gaasch M, Rhomberg P, Stover J, Pfausler B, Thomé C, Schmutzhard E, Helbok R. Enteral nutrition increases interstitial brain glucose levels in poor-grade subarachnoid hemorrhage patients. J Cereb Blood Flow Metab 2018; 38:518-527. [PMID: 28322077 PMCID: PMC5851142 DOI: 10.1177/0271678x17700434] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Low brain tissue glucose levels after acute brain injury are associated with poor outcome. Whether enteral nutrition (EN) reliably increases cerebral glucose levels remains unclear. In this retrospective analysis of prospectively collected observational data, we investigate the effect of EN on brain metabolism in 17 poor-grade subarachnoid hemorrhage (SAH) patients undergoing cerebral microdialysis (CMD) monitoring. CMD-values were obtained hourly. A nutritional intervention was defined as the clinical routine administration of EN without supplemental parenteral nutrition. Sixty-three interventions were analyzed. The mean amount of EN per intervention was 472.4 ± 10.7 kcal. CMD-glucose levels significantly increased from 1.59 ± 0.13 mmol/l at baseline to a maximum of 2.03 ± 0.2 mmol/l after 5 h (p < 0.001), independently of insulin-treatment, baseline serum glucose, baseline brain metabolic distress (CMD-lactate-to-pyruvate-ratio (LPR) > 40) and the microdialysis probe location. The increase in CMD-glucose was directly dependent on the magnitude of increase of serum glucose levels (p = 0.007). No change in CMD-lactate, CMD-pyruvate, CMD-LPR, or CMD-glutamate (p > 0.4) was observed. Routine EN also increased CMD-glucose even if baseline concentrations were critically low ( < 0.7 mmol/l, neuroglucopenia; p < 0.001). These results may have treatment implications regarding glucose management of poor-grade aneurysmal SAH patients.
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Affiliation(s)
- Mario Kofler
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Alois J Schiefecker
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Ronny Beer
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Maxime Gaasch
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Paul Rhomberg
- 2 Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - John Stover
- 3 Fresenius Kabi, Bad Homburg vor der Höhe, Germany
| | - Bettina Pfausler
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Claudius Thomé
- 4 Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Erich Schmutzhard
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Raimund Helbok
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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Habiyambere V, Dongmo Nguimfack B, Vojnov L, Ford N, Stover J, Hasek L, Maggiore P, Low-Beer D, Pérez Gonzàlez M, Edgil D, Williams J, Kuritsky J, Hargreaves S, NeSmith T. Forecasting the global demand for HIV monitoring and diagnostic tests: A 2016-2021 analysis. PLoS One 2018. [PMID: 30231022 DOI: 10.1371/journal.pone.020134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION Despite considerable progress, just over half of the 37 million people eligible to start antiretroviral therapy (ART) have accessed treatment and millions of HIV-positive people still do not know their status. With demand for ART continuing to grow, meeting the ambitious 90-90-90 HIV treatment targets will depend on improved access to high-quality diagnostics to both diagnose infection and monitor treatment adherence in low and middle-income countries (LMICs). Robust projections of future demand for CD4, viral load (VL), HIV early-infant-diagnosis (EID) tests and HIV rapid diagnostic tests (RDTs) are needed as scale-up continues. METHODS We estimate the current coverage for HIV diagnostics and project future demand to 2021 using a consolidated forecast using data on past coverage and current demand from a number of sources, from 130 predominantly LMIC countries. RESULTS We forecast that the overall number of CD4 tests is expected to decline between now and 2021 as more countries adopt test-and-treat and shift to VL testing for patient monitoring. Our consolidated forecast projects a gradual decline in demand for CD4 tests to 16.6 million by 2021. We anticipate that demand for VL tests will increase to 28.5 million by 2021, reflecting the increasing number of people who will receive ART and the adoption of VL testing for patient monitoring. We expect that the demand for EID tests will grow more rapidly than in past years, driven by the implementation of testing at birth in programmes globally, in line with WHO guideline recommendations, doubling to 2.1 million tests by 2021. Demand for rapid diagnostic tests is also likely to increase, reaching 509 million tests by 2021. DISCUSSION In order to achieve the ambitious 90-90-90 targets, it will be essential to maintain and improve access to CD4, VL, EID tests and RDTs. These projections provide insight into the global demand we can expect to see for these HIV monitoring and diagnostic tests, both in relation to historical trends, and the 90-90-90 targets. Our projections will better enable producers to ensure adequate supply, and to support procurement organisations in planning future funding and purchase plans to meet the anticipated demand. The findings highlight the ongoing need for governments and international funding bodies to prioritise improving capacity and access to HIV diagnostic and monitoring technologies in line with demand.
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Affiliation(s)
| | | | - L Vojnov
- Department of HIV/AIDS, WHO, Geneva, Switzerland
| | - N Ford
- Department of HIV/AIDS, WHO, Geneva, Switzerland
| | - J Stover
- Avenir Health, Glastonbury, Connecticut, United States of America
| | - L Hasek
- CHAI, Boston, Massachusetts, United States of America
| | - P Maggiore
- CHAI, Boston, Massachusetts, United States of America
| | - D Low-Beer
- Department of HIV/AIDS, WHO, Geneva, Switzerland
| | | | - D Edgil
- USAID, Washington DC, United States of America
| | - J Williams
- US CDC, Atlanta, Georgia, United States of America
| | - J Kuritsky
- USAID, Washington DC, United States of America
| | - S Hargreaves
- International Health Unit, Imperial College London, London, United Kingdom
| | - T NeSmith
- US CDC, Atlanta, Georgia, United States of America
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Askew I, Weinberger M, Dasgupta A, Darroch J, Smith E, Stover J, Yahner M. Harmonizing Methods for Estimating the Impact of Contraceptive Use on Unintended Pregnancy, Abortion, and Maternal Health. Glob Health Sci Pract 2017; 5:658-667. [PMID: 29217695 PMCID: PMC5752611 DOI: 10.9745/ghsp-d-17-00121] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Accepted: 10/17/2017] [Indexed: 11/15/2022]
Abstract
Five models estimate the impact of family planning on health outcomes, but the estimates previously have diverged because the models used different assumptions, inputs, and algorithms. After a collective harmonization process, the models now produce more similar estimates although they retain some minimal differences. These models assist in planning, resource allocation, and evaluation. Estimates of the potential impacts of contraceptive use on averting unintended pregnancies, total and unsafe abortions, maternal deaths, and newborn, infant, and child deaths provide evidence of the value of investments in family planning programs and thus are critically important for policy makers, donors, and advocates alike. Several research teams have independently developed mathematical models that estimate the number of adverse health outcomes averted due to contraceptive use. However, each modeling approach was designed for different purposes, and as such the methodological assumptions, data inputs, and mathematical algorithms initially used in each model differed; consequently, the models did not produce comparable estimates for the same outcome indicators. To address this, a series of expert group meetings took place in which 5 models—Adding it Up, Impact 2, ImpactNow, Reality Check, and FamPlan/Lives Saved Tool (LiST)—were reviewed and harmonized where possible. The group identified the main reasons for the inconsistencies in the estimates generated by the models for each of the adverse health outcome indicators. The group then worked together to align the methodologies for estimating numbers of unintended pregnancies, abortions, and maternal deaths averted due to contraceptive use, and reviewed the challenges with estimating the impact of contraceptive use on newborn, infant, and child deaths, including the lack of a conceptually clear pathway and rigorous evidence. The assumption that most influenced harmonization was the comparison pregnancy rate used by the models to estimate the counterfactual scenario—that is, if women who are currently using contraception were not using a method, how many would become pregnant? All the models now base this on the number of unintended pregnancies among women with unmet contraceptive need, bringing the estimates for unintended pregnancies, total and unsafe abortion, and maternal deaths much closer together. The agreed approaches have already been adopted by the Family Planning 2020 (FP2020) initiative and Track20, a project that supports FP2020. The experts will continue to update their models collaboratively to ensure that the most current estimation methodologies and data available are used. Valid and reliable methodologies for estimating these impacts from family planning are critically important, not only for advocacy to sustain resource allocation commitments but also to enable measurement and tracking of global development indicators. Conflicting estimates can be counterproductive to generating support for family planning programs, and this harmonization process has created a more unified voice for quantifying the benefits of family planning.
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Affiliation(s)
- Ian Askew
- Population Council, New York, NY, USA. Now with the World Health Organization, Geneva, Switzerland.
| | - Michelle Weinberger
- Marie Stopes International, Washington, DC, USA. Now with Avenir Health, Washington, DC, USA
| | - Aisha Dasgupta
- Marie Stopes International, London, UK. Now with the United Nations Population Division, New York, NY, USA
| | | | | | | | - Melanie Yahner
- EngenderHealth, New York, NY, USA. Now with Save the Children, Fairfield, CT, USA
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New JR, Cahill N, Stover J, Gupta YP, Alkema L. Levels and trends in contraceptive prevalence, unmet need, and demand for family planning for 29 states and union territories in India: a modelling study using the Family Planning Estimation Tool. Lancet Glob Health 2017; 5:e350-e358. [PMID: 28193400 DOI: 10.1016/s2214-109x(17)30033-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 11/21/2016] [Accepted: 12/12/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Improving access to reproductive health services and commodities is central to development. Efforts to assess progress on this front have been largely focused on national estimates, but such analyses can mask local disparities. We assessed progress in reproductive health services subnationally in India. METHODS We developed a statistical model to generate estimates and projections of levels and trends in family planning indicators for subpopulations. The model builds onto the UN Population Division's Family Planning Estimation Model and uses data from multiple rounds of the Demographic and Health Survey, the District Level Household & Facility Survey, and the Annual Health Survey. We present annual estimates and projections of levels and trends in the prevalence of modern contraceptive use, and unmet need and demand for family planning for 29 states and union territories in India from 1990 to 2030. We also compared projections of demand satisfied with modern methods with the proposed goal of 75%. FINDINGS There is a large amount of heterogeneity in India, with a difference of up to 55·1 percentage points (95% uncertainty interval 46·4-62·1) in modern contraceptive use in 2015 between subregions. States such as Andhra Pradesh, with 92·7% (90·9-94·2) demand satisfied with modern methods, are performing well above the national average (71·8%, 56·7-83·6), whereas Manipur, with 26·8% (16·7-38·5) of demand satisfied, and Meghalaya, with 45·0% (40·1-50·0), consistently lag behind the rest of the country. Manipur and Meghalaya require the highest percentage increase in modern contraceptive use to achieve 75% demand satisfied with modern methods by 2030. In terms of absolute numbers, Uttar Pradesh requires the greatest increase, needing 9·2 million (5·5-12·6 million) additional users of modern contraception by 2030 to meet the target of 75%. INTERPRETATION The demand for family planning among the states and union territories in India is highly diverse. Greatest attention is needed in Uttar Pradesh, Manipur, and Meghalaya to meet UN targets. The analysis can be generalised to other countries as well as other subpopulations. FUNDING Avenir Health through a grant from the Bill & Melinda Gates Foundation.
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Affiliation(s)
- Jin Rou New
- Department of Statistics and Applied Probability, National University of Singapore, Singapore
| | - Niamh Cahill
- Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst, MA, USA
| | | | | | - Leontine Alkema
- Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst, MA, USA.
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Weinberger M, Sonneveldt E, Stover J. The maximum contraceptive prevalence 'demand curve': guiding discussions on programmatic investments. Gates Open Res 2017; 1:15. [PMID: 29355228 PMCID: PMC5771155 DOI: 10.12688/gatesopenres.12780.1] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2017] [Indexed: 11/25/2022] Open
Abstract
Most frameworks for family planning include both access and demand interventions. Understanding how these two are linked and when each should be prioritized is difficult. The maximum contraceptive prevalence ‘demand curve’ was created based on a relationship between the modern contraceptive prevalence rate (mCPR) and mean ideal number of children to allow for a quantitative assessment of the balance between access and demand interventions. The curve represents the maximum mCPR that is likely to be seen given fertility intentions and related norms and constructs that influence contraceptive use. The gap between a country’s mCPR and this maximum is referred to as the ‘potential use gap.’ This concept can be used by countries to prioritize access investments where the gap is large, and discuss implications for future contraceptive use where the gap is small. It is also used within the FP Goals model to ensure mCPR growth from access interventions does not exceed available demand.
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Abstract
BACKGROUND The Lives Saved Tool (LiST) estimates the effects of maternal and child health interventions on mortality rates and the number of deaths. The family planning module in Spectrum interacts with LiST by providing estimates of the effects of scaling up family planning use on the number of live births, miscarriages, abortions, and stillbirths. METHODS We use the proximate determinants of fertility framework to estimate the effects of changes in contraceptive use, proportion married, postpartum insusceptibility, abortion and sterility on the total fertility rate. We extend this framework to estimate the number of intended and unintended pregnancies and the resulting live births, abortions, stillbirths, and miscarriages. RESULTS We apply the model to four countries (Mali, Kenya, Indonesia, and Ukraine) to demonstrate possible trends with a range of family planning and fertility levels. In high-fertility countries, such as Mali, increases in contraceptive use will partially compensate for the increasing number of women of reproductive age to reduce the annual increases in pregnancies and births. Most unintended pregnancies occur to women defined as having unmet need for contraception. In low-fertility countries, increases in contraceptive use may reduce abortion rates and low levels of unmet need mean that most unintended pregnancies are due to method failure. CONCLUSIONS The family planning module in Spectrum provides a useful framework to incorporate changes in contraceptive practices and pregnancy outcomes in the LiST calculations of mortality rates and deaths.
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Korenromp E, Hamilton M, Sanders R, Mahiané G, Briët OJT, Smith T, Winfrey W, Walker N, Stover J. Impact of malaria interventions on child mortality in endemic African settings: comparison and alignment between LiST and Spectrum-Malaria model. BMC Public Health 2017; 17:781. [PMID: 29143637 PMCID: PMC5688465 DOI: 10.1186/s12889-017-4739-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 12/02/2022] Open
Abstract
Background In malaria-endemic countries, malaria prevention and treatment are critical for child health. In the context of intervention scale-up and rapid changes in endemicity, projections of intervention impact and optimized program scale-up strategies need to take into account the consequent dynamics of transmission and immunity. Methods The new Spectrum-Malaria program planning tool was used to project health impacts of Insecticide-Treated mosquito Nets (ITNs) and effective management of uncomplicated malaria cases (CMU), among other interventions, on malaria infection prevalence, case incidence and mortality in children 0–4 years, 5–14 years of age and adults. Spectrum-Malaria uses statistical models fitted to simulations of the dynamic effects of increasing intervention coverage on these burdens as a function of baseline malaria endemicity, seasonality in transmission and malaria intervention coverage levels (estimated for years 2000 to 2015 by the World Health Organization and Malaria Atlas Project). Spectrum-Malaria projections of proportional reductions in under-five malaria mortality were compared with those of the Lives Saved Tool (LiST) for the Democratic Republic of the Congo and Zambia, for given (standardized) scenarios of ITN and/or CMU scale-up over 2016–2030. Results Proportional mortality reductions over the first two years following scale-up of ITNs from near-zero baselines to moderately higher coverages align well between LiST and Spectrum-Malaria —as expected since both models were fitted to cluster-randomized ITN trials in moderate-to-high-endemic settings with 2-year durations. For further scale-up from moderately high ITN coverage to near-universal coverage (as currently relevant for strategic planning for many countries), Spectrum-Malaria predicts smaller additional ITN impacts than LiST, reflecting progressive saturation. For CMU, especially in the longer term (over 2022–2030) and for lower-endemic settings (like Zambia), Spectrum-Malaria projects larger proportional impacts, reflecting onward dynamic effects not fully captured by LiST. Conclusions Spectrum-Malaria complements LiST by extending the scope of malaria interventions, program packages and health outcomes that can be evaluated for policy making and strategic planning within and beyond the perspective of child survival. Electronic supplementary material The online version of this article (10.1186/s12889-017-4739-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Matthew Hamilton
- Avenir Health, 655 Winding Brook Drive, Glastonbury, CT-06033, USA
| | - Rachel Sanders
- Avenir Health, 655 Winding Brook Drive, Glastonbury, CT-06033, USA
| | - Guy Mahiané
- Avenir Health, 655 Winding Brook Drive, Glastonbury, CT-06033, USA
| | - Olivier J T Briët
- Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051, Basel, Switzerland.,Epidemiology and Public Health, University of Basel, Basel, Switzerland
| | - Thomas Smith
- Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051, Basel, Switzerland.,Epidemiology and Public Health, University of Basel, Basel, Switzerland
| | - William Winfrey
- Avenir Health, 655 Winding Brook Drive, Glastonbury, CT-06033, USA
| | - Neff Walker
- Department of International Health, Institute for International Programs, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD, 21205, USA
| | - John Stover
- Avenir Health, 655 Winding Brook Drive, Glastonbury, CT-06033, USA
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Stenberg K, Hanssen O, Edejer TTT, Bertram M, Brindley C, Meshreky A, Rosen JE, Stover J, Verboom P, Sanders R, Soucat A. Financing transformative health systems towards achievement of the health Sustainable Development Goals: a model for projected resource needs in 67 low-income and middle-income countries. Lancet Glob Health 2017; 5:e875-e887. [PMID: 28728918 PMCID: PMC5554796 DOI: 10.1016/s2214-109x(17)30263-2] [Citation(s) in RCA: 256] [Impact Index Per Article: 36.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 04/11/2017] [Accepted: 06/15/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND The ambitious development agenda of the Sustainable Development Goals (SDGs) requires substantial investments across several sectors, including for SDG 3 (healthy lives and wellbeing). No estimates of the additional resources needed to strengthen comprehensive health service delivery towards the attainment of SDG 3 and universal health coverage in low-income and middle-income countries have been published. METHODS We developed a framework for health systems strengthening, within which population-level and individual-level health service coverage is gradually scaled up over time. We developed projections for 67 low-income and middle-income countries from 2016 to 2030, representing 95% of the total population in low-income and middle-income countries. We considered four service delivery platforms, and modelled two scenarios with differing levels of ambition: a progress scenario, in which countries' advancement towards global targets is constrained by their health system's assumed absorptive capacity, and an ambitious scenario, in which most countries attain the global targets. We estimated the associated costs and health effects, including reduced prevalence of illness, lives saved, and increases in life expectancy. We projected available funding by country and year, taking into account economic growth and anticipated allocation towards the health sector, to allow for an analysis of affordability and financial sustainability. FINDINGS We estimate that an additional $274 billion spending on health is needed per year by 2030 to make progress towards the SDG 3 targets (progress scenario), whereas US$371 billion would be needed to reach health system targets in the ambitious scenario-the equivalent of an additional $41 (range 15-102) or $58 (22-167) per person, respectively, by the final years of scale-up. In the ambitious scenario, total health-care spending would increase to a population-weighted mean of $271 per person (range 74-984) across country contexts, and the share of gross domestic product spent on health would increase to a mean of 7·5% (2·1-20·5). Around 75% of costs are for health systems, with health workforce and infrastructure (including medical equipment) as the main cost drivers. Despite projected increases in health spending, a financing gap of $20-54 billion per year is projected. Should funds be made available and used as planned, the ambitious scenario would save 97 million lives and significantly increase life expectancy by 3·1-8·4 years, depending on the country profile. INTERPRETATION All countries will need to strengthen investments in health systems to expand service provision in order to reach SDG 3 health targets, but even the poorest can reach some level of universality. In view of anticipated resource constraints, each country will need to prioritise equitably, plan strategically, and cost realistically its own path towards SDG 3 and universal health coverage. FUNDING WHO.
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Affiliation(s)
- Karin Stenberg
- Department of Health Systems Governance and Financing, WHO, Geneva, Switzerland.
| | - Odd Hanssen
- Department of Health Systems Governance and Financing, WHO, Geneva, Switzerland
| | | | - Melanie Bertram
- Department of Health Systems Governance and Financing, WHO, Geneva, Switzerland
| | - Callum Brindley
- Department of Health Systems Governance and Financing, WHO, Geneva, Switzerland
| | | | | | | | - Paul Verboom
- 385 Chemin de L'Ovellas, 15 Les Collines de Pitegny, Gex, France
| | | | - Agnès Soucat
- Department of Health Systems Governance and Financing, WHO, Geneva, Switzerland
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Koch C, Dax A, Schug B, Pauly L, Reichart S, Stover J, Pestana E, Lekkos K. MON-P245: New High Protein and High Energy Oral Nutritional Supplement for Compliance and Tolerance in Elderly Care. Clin Nutr 2017. [DOI: 10.1016/s0261-5614(17)30844-0] [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] [Indexed: 10/18/2022]
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Koch C, Dax A, Warnke A, Pauly L, Reichart S, Pestana E, Stover J, Lekkos K. MON-P244: Dispensing a High Caloric, High Protein Oral Nutritional Supplement 3 Times Daily is Well Tolerated and Increase Compliance in Elderly. Clin Nutr 2017. [DOI: 10.1016/s0261-5614(17)30845-2] [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] [Indexed: 10/18/2022]
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Bennani A, El-Kettani A, Hançali A, El-Rhilani H, Alami K, Youbi M, Rowley J, Abu-Raddad L, Smolak A, Taylor M, Mahiané G, Stover J, Korenromp EL. The prevalence and incidence of active syphilis in women in Morocco, 1995-2016: Model-based estimation and implications for STI surveillance. PLoS One 2017; 12:e0181498. [PMID: 28837558 PMCID: PMC5570350 DOI: 10.1371/journal.pone.0181498] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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: 01/10/2017] [Accepted: 07/03/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Evolving health priorities and resource constraints mean that countries require data on trends in sexually transmitted infections (STI) burden, to inform program planning and resource allocation. We applied the Spectrum STI estimation tool to estimate the prevalence and incidence of active syphilis in adult women in Morocco over 1995 to 2016. The results from the analysis are being used to inform Morocco's national HIV/STI strategy, target setting and program evaluation. METHODS Syphilis prevalence levels and trends were fitted through logistic regression to data from surveys in antenatal clinics, women attending family planning clinics and other general adult populations, as available post-1995. Prevalence data were adjusted for diagnostic test performance, and for the contribution of higher-risk populations not sampled in surveys. Incidence was inferred from prevalence by adjusting for the average duration of infection with active syphilis. RESULTS In 2016, active syphilis prevalence was estimated to be 0.56% in women 15 to 49 years of age (95% confidence interval, CI: 0.3%-1.0%), and around 21,675 (10,612-37,198) new syphilis infections have occurred. The analysis shows a steady decline in prevalence from 1995, when the prevalence was estimated to be 1.8% (1.0-3.5%). The decline was consistent with decreasing prevalences observed in TB patients, fishermen and prisoners followed over 2000-2012 through sentinel surveillance, and with a decline since 2003 in national HIV incidence estimated earlier through independent modelling. CONCLUSIONS Periodic population-based surveys allowed Morocco to estimate syphilis prevalence and incidence trends. This first-ever undertaking engaged and focused national stakeholders, and confirmed the still considerable syphilis burden. The latest survey was done in 2012 and so the trends are relatively uncertain after 2012. From 2017 Morocco plans to implement a system to record data from routine antenatal programmatic screening, which should help update and re-calibrate next trend estimations.
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Affiliation(s)
- Aziza Bennani
- Ministry of Health, Directorate of Epidemiology and Disease Control, Rabat, Morocco
| | - Amina El-Kettani
- Ministry of Health, Directorate of Epidemiology and Disease Control, Rabat, Morocco
| | - Amina Hançali
- STIs Laboratory, Department of Bacteriology, National Institute of Hygiene, Rabat, Morocco
| | | | - Kamal Alami
- UNAIDS Morocco country office, Rabat, Morocco
| | - Mohamed Youbi
- Ministry of Health, Directorate of Epidemiology and Disease Control, Rabat, Morocco
| | | | - Laith Abu-Raddad
- Weill Cornell Medical College - Qatar, Cornell University, Doha, Qatar
| | - Alex Smolak
- Weill Cornell Medical College - Qatar, Cornell University, Doha, Qatar
| | - Melanie Taylor
- World Health Organization, Dept. of Reproductive Health and Research, Geneva, Switzerland
- Centers for Disease Control and Prevention, Division of STD Prevention, Atlanta, Georgia, United States of America
| | - Guy Mahiané
- Avenir Health, Glastonbury, Connecticut, United States of America
| | - John Stover
- Avenir Health, Glastonbury, Connecticut, United States of America
| | - Eline L. Korenromp
- Avenir Health, Glastonbury, Connecticut, United States of America
- * E-mail:
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Phillips AN, Stover J, Cambiano V, Nakagawa F, Jordan MR, Pillay D, Doherty M, Revill P, Bertagnolio S. Impact of HIV Drug Resistance on HIV/AIDS-Associated Mortality, New Infections, and Antiretroviral Therapy Program Costs in Sub-Saharan Africa. J Infect Dis 2017; 215:1362-1365. [PMID: 28329236 PMCID: PMC5451603 DOI: 10.1093/infdis/jix089] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 02/15/2017] [Indexed: 01/14/2023] Open
Abstract
To inform the level of attention to be given by antiretroviral therapy (ART) programs to HIV drug resistance (HIVDR), we used an individual-level model to estimate its impact on future AIDS deaths, HIV incidence, and ART program costs in sub–Saharan Africa (SSA) for a range of program situations. We applied this to SSA through the Spectrum-Goals model. In a situation in which current levels of pretreatment HIVDR are over 10% (mean, 15%), 16% of AIDS deaths (890 000 deaths), 9% of new infections (450 000), and 8% ($6.5 billion) of ART program costs in SSA in 2016–2030 will be attributable to HIVDR.
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Affiliation(s)
- Andrew N Phillips
- Institute for Global Health, University College London, United Kingdom
| | | | | | - Fumiyo Nakagawa
- Institute for Global Health, University College London, United Kingdom
| | | | - Deenan Pillay
- African Health Research Institute, KwaZulu-Natal, South Africa and Division of Infection and Immunity, University College London, United Kingdom
| | - Meg Doherty
- World Health Organisation, Geneva, Switzerland
| | - Paul Revill
- Centre for Health Economics, University of York, United Kingdom
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Young PW, Kim AA, Wamicwe J, Nyagah L, Kiama C, Stover J, Oduor J, Rogena EA, Walong E, Zielinski-Gutierrez E, Imbwaga A, Sirengo M, Kellogg TA, De Cock KM. HIV-associated mortality in the era of antiretroviral therapy scale-up - Nairobi, Kenya, 2015. PLoS One 2017; 12:e0181837. [PMID: 28767714 PMCID: PMC5540587 DOI: 10.1371/journal.pone.0181837] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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: 03/03/2017] [Accepted: 07/08/2017] [Indexed: 11/18/2022] Open
Abstract
Background Declines in HIV prevalence and increases in antiretroviral treatment coverage have been documented in Kenya, but population-level mortality associated with HIV has not been directly measured. In urban areas where a majority of deaths pass through mortuaries, mortuary-based studies have the potential to contribute to our understanding of excess mortality among HIV-infected persons. We used results from a cross-sectional mortuary-based HIV surveillance study to estimate the association between HIV and mortality for Nairobi, the capital city of Kenya. Methods and findings HIV seropositivity in cadavers measured at the two largest mortuaries in Nairobi was used to estimate HIV prevalence in adult deaths. Model-based estimates of the HIV-infected and uninfected population for Nairobi were used to calculate a standardized mortality ratio and population-attributable fraction for mortality among the infected versus uninfected population. Monte Carlo simulation was used to assess sensitivity to epidemiological assumptions. When standardized to the age and sex distribution of expected deaths, the estimated HIV positivity among adult deaths aged 15 years and above in Nairobi was 20.9% (95% CI 17.7–24.6%). The standardized mortality ratio of deaths among HIV-infected versus uninfected adults was 4.35 (95% CI 3.67–5.15), while the risk difference was 0.016 (95% CI 0.013–0.019). The HIV population attributable mortality fraction was 0.161 (95% CI 0.131–0.190). Sensitivity analyses demonstrated robustness of results. Conclusions Although 73.6% of adult PLHIV receive antiretrovirals in Nairobi, their risk of death is four-fold greater than in the uninfected, while 16.1% of all adult deaths in the city can be attributed to HIV infection. In order to further reduce HIV-associated mortality, high-burden countries may need to reach very high levels of diagnosis, treatment coverage, retention in care, and viral suppression.
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Affiliation(s)
- Peter W. Young
- Division of Global HIV & Tuberculosis (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
- * E-mail:
| | - Andrea A. Kim
- Division of Global HIV & Tuberculosis (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - Joyce Wamicwe
- National AIDS and STI Control Programme, Ministry of Health, Nairobi, Kenya
| | - Lilly Nyagah
- National AIDS and STI Control Programme, Ministry of Health, Nairobi, Kenya
| | - Catherine Kiama
- Field Epidemiology Training Program, Ministry of Health, Nairobi, Kenya
| | - John Stover
- Avenir Health, Glastonbury, CT, United States of America
| | - Johansen Oduor
- Division of Forensic and Pathology Services, Ministry of Health, Nairobi, Kenya
| | - Emily A. Rogena
- University of Nairobi and Kenyatta National Hospital, Nairobi, Kenya
| | - Edwin Walong
- University of Nairobi and Kenyatta National Hospital, Nairobi, Kenya
| | - Emily Zielinski-Gutierrez
- Division of Global HIV & Tuberculosis (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | | | - Martin Sirengo
- National AIDS and STI Control Programme, Ministry of Health, Nairobi, Kenya
| | | | - Kevin M. De Cock
- Division of Global HIV & Tuberculosis (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
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Stehle P, Ellger B, Kojic D, Feuersenger A, Schneid C, Stover J, Scheiner D, Westphal M. Reply-Letter to the Editor-Glutamine dipeptide-supplemented parenteral nutrition improves the clinical outcomes of critically ill patients: A systematic evaluation of randomised controlled trials. Clin Nutr 2017; 36:1182-1183. [DOI: 10.1016/j.clnu.2017.03.031] [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: 03/31/2017] [Accepted: 03/31/2017] [Indexed: 10/19/2022]
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Silhol R, Gregson S, Nyamukapa C, Mhangara M, Dzangare J, Gonese E, Eaton JW, Case KK, Mahy M, Stover J, Mugurungi O. Empirical validation of the UNAIDS Spectrum model for subnational HIV estimates: case-study of children and adults in Manicaland, Zimbabwe. AIDS 2017; 31 Suppl 1:S41-S50. [PMID: 28296799 PMCID: PMC10660499 DOI: 10.1097/qad.0000000000001418] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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] [Indexed: 11/26/2022]
Abstract
BACKGROUND More cost-effective HIV control may be achieved by targeting geographical areas with high infection rates. The AIDS Impact model of Spectrum - used routinely to produce national HIV estimates - could provide the required subnational estimates but is rarely validated with empirical data, even at a national level. DESIGN The validity of the Spectrum model estimates were compared with empirical estimates. METHODS Antenatal surveillance and population survey data from a population HIV cohort study in Manicaland, East Zimbabwe, were input into Spectrum 5.441 to create a simulation representative of the cohort population. Model and empirical estimates were compared for key demographic and epidemiological outcomes. Alternative scenarios for data availability were examined and sensitivity analyses were conducted for model assumptions considered important for subnational estimates. RESULTS Spectrum estimates generally agreed with observed data but HIV incidence estimates were higher than empirical estimates, whereas estimates of early age all-cause adult mortality were lower. Child HIV prevalence estimates matched well with the survey prevalence among children. Estimated paternal orphanhood was lower than empirical estimates. Including observations from earlier in the epidemic did not improve the HIV incidence model fit. Migration had little effect on observed discrepancies - possibly because the model ignores differences in HIV prevalence between migrants and residents. CONCLUSION The Spectrum model, using subnational surveillance and population data, provided reasonable subnational estimates although some discrepancies were noted. Differences in HIV prevalence between migrants and residents may need to be captured in the model if applied to subnational epidemics.
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Affiliation(s)
- Romain Silhol
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Simon Gregson
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
- Biomedical Research and Training Institute, Avondale, Harare, Zimbabwe
| | - Constance Nyamukapa
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
- Biomedical Research and Training Institute, Avondale, Harare, Zimbabwe
| | - Mutsa Mhangara
- AIDS and TB Unit, Zimbabwe Ministry of Health and Child Welfare, Harare, Zimbabwe
| | - Janet Dzangare
- AIDS and TB Unit, Zimbabwe Ministry of Health and Child Welfare, Harare, Zimbabwe
| | - Elizabeth Gonese
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Harare, Zimbabwe
| | - Jeffrey W. Eaton
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Kelsey K. Case
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Mary Mahy
- Programme Branch, UNAIDS, Geneva, Switzerland
| | - John Stover
- Avenir Health, Glastonbury, Connecticut, USA
| | - Owen Mugurungi
- AIDS and TB Unit, Zimbabwe Ministry of Health and Child Welfare, Harare, Zimbabwe
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Kripke K, Opuni M, Schnure M, Sgaier S, Castor D, Reed J, Njeuhmeli E, Stover J. Correction: Age Targeting of Voluntary Medical Male Circumcision Programs Using the Decision Makers' Program Planning Toolkit (DMPPT) 2.0. PLoS One 2017; 12:e0174466. [PMID: 28301578 PMCID: PMC5354436 DOI: 10.1371/journal.pone.0174466] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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