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Gupta S, Abimbola T, Date A, Suthar AB, Bennett R, Sangrujee N, Granich R. Cost-effectiveness of the Three I's for HIV/TB and ART to prevent TB among people living with HIV. Int J Tuberc Lung Dis 2015; 18:1159-65. [PMID: 25216828 DOI: 10.5588/ijtld.13.0571] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To evaluate the cost-effectiveness of the Three I's for HIV/TB (human immunodeficiency virus/tuberculosis): antiretroviral therapy (ART), intensified TB case finding (ICF), isoniazid preventive treatment (IPT), and TB infection control (IC). METHODS Using a 3-year decision-analytic model, we estimated the cost-effectiveness of a base scenario (55% ART coverage at CD4 count ⩿350 cells/mm(3)) and 19 strategies that included one or more of the following: 1) 90% ART coverage, 2) IC and 3) ICF using four-symptom screening and 6- or 36-month IPT. The TB diagnostic algorithm included 1) sputum smear microscopy with chest X-ray, and 2) Xpert® MTB/RIF. RESULTS In resource-constrained settings with a high burden of HIV and TB, the most cost-effective strategies under both diagnostic algorithms included 1) 55% ART coverage and IC, 2) 55% ART coverage, IC and 36-month IPT, and 3) expanded ART at 90% coverage with IC and 36-month IPT. The latter averted more TB cases than other scenarios with increased ART coverage, IC, 6-month IPT and/or IPT for tuberculin skin test positive individuals. The cost-effectiveness results did not change significantly under the sensitivity analyses. CONCLUSION Expanded ART to 90% coverage, IC and a 36-month IPT strategy averted most TB cases and is among the cost-effective strategies.
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Affiliation(s)
- S Gupta
- Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
| | - T Abimbola
- US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - A Date
- US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - A B Suthar
- South African Centre for Epidemiological Modelling and Analysis, University of Stellenbosch, Cape Town, South Africa
| | - R Bennett
- Independent Consultant, Huntingdon, UK
| | - N Sangrujee
- US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - R Granich
- Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
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O'Brien L, Shaffer N, Sangrujee N, Abimbola TO. The incremental cost of switching from Option B to Option B+ for the prevention of mother-to-child transmission of HIV. Bull World Health Organ 2014; 92:162-70. [PMID: 24700975 DOI: 10.2471/blt.13.122523] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 10/07/2013] [Accepted: 10/09/2013] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To estimate the incremental cost over 5 years of a policy switch from the Option B to the Option B+ protocol for the prevention of mother-to-child transmission (PMTCT) of the human immunodeficiency virus (HIV). METHODS Data from cost studies and other published sources were used to determine the cost, per woman and per cohort (1000 breastfeeding and 1000 non-breastfeeding women), of switching from Option B (maternal triple antiretroviral [ARV] regimen during pregnancy and breastfeeding plus daily nevirapine for the infant for 6 weeks) to Option B+ (maternal triple ARV regimen initiated during pregnancy and continued for life). The variables used to model the different scenarios were maternal CD4+ T lymphocyte (CD4+ cell) count (350-500 versus > 500 cells/µl), rate of decline in CD4+ cells (average, rapid, slow), breastfeeding status (yes, no) and breastfeeding duration (12, 18 or 24 months). FINDINGS For women with CD4+ cell counts of 350-500 cells/µl, the incremental cost per 1000 women was 157,345 United States dollars (US$) for breastfeeding women and US$ 92,813 for non-breastfeeding women. For women with CD4+ cell counts > 500 cells/µl, the incremental cost per 1000 women ranged from US$ 363,443 to US$ 484,591 for breastfeeding women and was US$ 605,739 for non-breastfeeding women. CONCLUSION From a cost perspective, a policy switch from Option B to Option B+ is feasible in PMTCT programme settings where resources are currently being allocated to Option B.
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Affiliation(s)
- Lisa O'Brien
- Health Economics, Systems and Integration Branch, Division of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention, MS-E30, 1600 Clifton Rd, Atlanta GA 30333, United States of America
| | - Nathan Shaffer
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Nalinee Sangrujee
- Health Economics, Systems and Integration Branch, Division of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention, MS-E30, 1600 Clifton Rd, Atlanta GA 30333, United States of America
| | - Taiwo O Abimbola
- Health Economics, Systems and Integration Branch, Division of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention, MS-E30, 1600 Clifton Rd, Atlanta GA 30333, United States of America
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Eaton JW, Menzies NA, Stover J, Cambiano V, Chindelevitch L, Cori A, Hontelez JAC, Humair S, Kerr CC, Klein DJ, Mishra S, Mitchell KM, Nichols BE, Vickerman P, Bakker R, Bärnighausen T, Bershteyn A, Bloom DE, Boily MC, Chang ST, Cohen T, Dodd PJ, Fraser C, Gopalappa C, Lundgren J, Martin NK, Mikkelsen E, Mountain E, Pham QD, Pickles M, Phillips A, Platt L, Pretorius C, Prudden HJ, Salomon JA, van de Vijver DAMC, de Vlas SJ, Wagner BG, White RG, Wilson DP, Zhang L, Blandford J, Meyer-Rath G, Remme M, Revill P, Sangrujee N, Terris-Prestholt F, Doherty M, Shaffer N, Easterbrook PJ, Hirnschall G, Hallett TB. Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models. Lancet Glob Health 2013; 2:23-34. [PMID: 25083415 PMCID: PMC4114402 DOI: 10.1016/s2214-109x(13)70172-4] [Citation(s) in RCA: 177] [Impact Index Per Article: 16.1] [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] [Indexed: 12/18/2022]
Abstract
BACKGROUND New WHO guidelines recommend ART initiation for HIV-positive persons with CD4 cell counts ≤500 cells/µL, a higher threshold than was previously recommended. Country decision makers must consider whether to further expand ART eligibility accordingly. METHODS We used multiple independent mathematical models in four settings-South Africa, Zambia, India, and Vietnam-to evaluate the potential health impact, costs, and cost-effectiveness of different adult ART eligibility criteria under scenarios of current and expanded treatment coverage, with results projected over 20 years. Analyses considered extending eligibility to include individuals with CD4 ≤500 cells/µL or all HIV-positive adults, compared to the previous recommendation of initiation with CD4 ≤350 cells/µL. We assessed costs from a health system perspective, and calculated the incremental cost per DALY averted ($/DALY) to compare competing strategies. Strategies were considered 'very cost-effective' if the $/DALY was less than the country's per capita gross domestic product (GDP; South Africa: $8040, Zambia: $1425, India: $1489, Vietnam: $1407) and 'cost-effective' if $/DALY was less than three times per capita GDP. FINDINGS In South Africa, the cost per DALY averted of extending ART eligibility to CD4 ≤500 cells/µL ranged from $237 to $1691/DALY compared to 2010 guidelines; in Zambia, expanded eligibility ranged from improving health outcomes while reducing costs (i.e. dominating current guidelines) to $749/DALY. Results were similar in scenarios with substantially expanded treatment access and for expanding eligibility to all HIV-positive adults. Expanding treatment coverage in the general population was therefore found to be cost-effective. In India, eligibility for all HIV-positive persons ranged from $131 to $241/DALY and in Vietnam eligibility for CD4 ≤500 cells/µL cost $290/DALY. In concentrated epidemics, expanded access among key populations was also cost-effective. INTERPRETATION Earlier ART eligibility is estimated to be very cost-effective in low- and middle-income settings, although these questions should be revisited as further information becomes available. Scaling-up ART should be considered among other high-priority health interventions competing for health budgets. FUNDING The Bill and Melinda Gates Foundation and World Health Organization.
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Affiliation(s)
- Jeffrey W Eaton
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Nicolas A Menzies
- Center for Health Decision Science, Harvard School of Public Health, Boston, MA, USA
| | | | - Valentina Cambiano
- Research Department of Infection and Population Health, University College London, London, UK
| | - Leonid Chindelevitch
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA
| | - Anne Cori
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Jan A C Hontelez
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa
- Nijmegen International Center for Health System Analysis and Education (NICHE), Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Salal Humair
- Harvard School of Public Health, Boston, MA, USA
| | - Cliff C Kerr
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Daniel J Klein
- Epidemiological Modeling Group, Intellectual Ventures Laboratory, Bellevue, WA, USA
| | - Sharmistha Mishra
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
- Division of Infectious Diseases, St. Michael’s Hospital, University of Toronto, Canada
| | - Kate M Mitchell
- Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Brooke E Nichols
- Department of Virology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Peter Vickerman
- Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Roel Bakker
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Till Bärnighausen
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa
- Harvard School of Public Health, Boston, MA, USA
| | - Anna Bershteyn
- Epidemiological Modeling Group, Intellectual Ventures Laboratory, Bellevue, WA, USA
| | | | - Marie-Claude Boily
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Stewart T Chang
- Epidemiological Modeling Group, Intellectual Ventures Laboratory, Bellevue, WA, USA
| | - Ted Cohen
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
| | - Peter J Dodd
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Christophe Fraser
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | | | - Jens Lundgren
- Copenhagen University Hospital/Rigshospitalet, Copenhagen, Denmark
- University of Copenhagen, Copenhagen, Denmark
| | - Natasha K Martin
- Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Evelinn Mikkelsen
- Nijmegen International Center for Health System Analysis and Education (NICHE), Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Elisa Mountain
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Quang D Pham
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Michael Pickles
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Andrew Phillips
- Research Department of Infection and Population Health, University College London, London, UK
| | - Lucy Platt
- Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Holly J Prudden
- Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Joshua A Salomon
- Center for Health Decision Science, Harvard School of Public Health, Boston, MA, USA
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA
| | | | - Sake J de Vlas
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Bradley G Wagner
- Epidemiological Modeling Group, Intellectual Ventures Laboratory, Bellevue, WA, USA
| | - Richard G White
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - David P Wilson
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Lei Zhang
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - John Blandford
- U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Gesine Meyer-Rath
- Center for Global Health and Development, Boston University, Boston, MA, USA
- Health Economics and Epidemiology Research Office, Department of Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Michelle Remme
- Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | | | - Fern Terris-Prestholt
- Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Meg Doherty
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Nathan Shaffer
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | | | | | - Timothy B Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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