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Filip I. Changing costs of preexposure prophylaxis may undermine efforts to curb HIV infection rates. AIDS 2024; 38:N11-N12. [PMID: 38489576 DOI: 10.1097/qad.0000000000003883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Affiliation(s)
- Iulia Filip
- MedEd Medical Communications, LLC, Bluffton, South Carolina, USA
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Gergen M, Hewitt A, Sanger CB, Striker R. Monitoring immune recovery on HIV therapy: critical, helpful, or waste of money in the current era? AIDS 2024; 38:937-943. [PMID: 38310348 PMCID: PMC11064897 DOI: 10.1097/qad.0000000000003850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 01/11/2024] [Accepted: 01/18/2024] [Indexed: 02/05/2024]
Affiliation(s)
| | | | - Cristina B. Sanger
- Department of Surgery
- Department of Surgery, W. S. Middleton Memorial Veterans’ Hospital, Madison, WI, USA
| | - Rob Striker
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine and Public Health
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Marinosci A, Sculier D, Wandeler G, Yerly S, Stoeckle M, Bernasconi E, Braun DL, Vernazza P, Cavassini M, Buzzi M, Metzner KJ, Decosterd L, Günthard HF, Schmid P, Limacher A, Branca M, Calmy A. Costs and acceptability of simplified monitoring in HIV-suppressed patients switching to dual therapy: the SIMPL'HIV open-label, factorial randomised controlled trial. Swiss Med Wkly 2024; 154:3762. [PMID: 38754068 DOI: 10.57187/s.3762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Clinical and laboratory monitoring of patients on antiretroviral therapy is an integral part of HIV care and determines whether treatment needs enhanced adherence or modification of the drug regimen. However, different monitoring and treatment strategies carry different costs and health consequences. MATERIALS AND METHODS The SIMPL'HIV study was a randomised trial that assessed the non-inferiority of dual maintenance therapy. The co-primary outcome was a comparison of costs over 48 weeks of dual therapy with standard antiretroviral therapy and the costs associated with a simplified HIV care approach (patient-centred monitoring [PCM]) versus standard, tri-monthly routine monitoring. Costs included outpatient medical consultations (HIV/non-HIV consultations), non-medical consultations, antiretroviral therapy, laboratory tests and hospitalisation costs. PCM participants had restricted immunological and blood safety monitoring at weeks 0 and 48, and they were offered the choice to complete their remaining study visits via a telephone call, have medications delivered to a specified address, and to have blood tests performed at a location of their choice. We analysed the costs of both strategies using invoices for medical consultations issued by the hospital where the patient was followed, as well as those obtained from health insurance companies. Secondary outcomes included differences between monitoring arms for renal function, lipids and glucose values, and weight over 48 weeks. Patient satisfaction with treatment and monitoring was also assessed using visual analogue scales. RESULTS Of 93 participants randomised to dolutegravir plus emtricitabine and 94 individuals to combination antiretroviral therapy (median nadir CD4 count, 246 cells/mm3; median age, 48 years; female, 17%),patient-centred monitoring generated no substantial reductions or increases in total costs (US$ -421 per year [95% CI -2292 to 1451]; p = 0.658). However, dual therapy was significantly less expensive (US$ -2620.4 [95% CI -2864.3 to -2331.4]) compared to standard triple-drug antiretroviral therapy costs. Approximately 50% of participants selected one monitoring option, one-third chose two, and a few opted for three. The preferred option was telephone calls, followed by drug delivery. The number of additional visits outside the study schedule did not differ by type of monitoring. Patient satisfaction related to treatment and monitoring was high at baseline, with no significant increase at week 48. CONCLUSIONS Patient-centred monitoring did not reduce costs compared to standard monitoring in individuals switching to dual therapy or those continuing combined antiretroviral therapy. In this representative sample of patients with suppressed HIV, antiretroviral therapy was the primary factor driving costs, which may be reduced by using generic drugs to mitigate the high cost of lifelong HIV treatment. TRIAL REGISTRATION ClinicalTrials.gov NCT03160105.
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Affiliation(s)
- Annalisa Marinosci
- HIV/AIDS Unit, Department of Infectious Diseases, Geneva University Hospitals, and the University of Geneva Faculty of Medicine, Geneva, Switzerland
| | - Delphine Sculier
- HIV/AIDS Unit, Department of Infectious Diseases, Geneva University Hospitals, and the University of Geneva Faculty of Medicine, Geneva, Switzerland
- Private Practice Office, Geneva, Switzerland
| | - Gilles Wandeler
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Sabine Yerly
- Laboratory of Virology, Geneva University Hospitals, Geneva, Switzerland
| | - Marcel Stoeckle
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Enos Bernasconi
- Service of Infectious Diseases, Lugano Regional Hospital, Lugano, Switzerland
| | - Dominique L Braun
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Pietro Vernazza
- Division of Infectious Diseases and Hospital Epidemiology, Kantonspital St.Gallen, St. Gall, Switzerland
| | - Matthias Cavassini
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
- Department of Infectious Diseases, University Hospital of Lausanne, Lausanne, Switzerland
| | - Marta Buzzi
- HIV/AIDS Unit, Department of Infectious Diseases, Geneva University Hospitals, and the University of Geneva Faculty of Medicine, Geneva, Switzerland
| | - Karin J Metzner
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Laurent Decosterd
- Pharmacology Laboratory, Clinical Pharmacology Department, University of Lausanne, Lausanne, Switzerland
| | - Huldrych F Günthard
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Patrick Schmid
- Division of Infectious Diseases and Hospital Epidemiology, Kantonspital St.Gallen, St. Gall, Switzerland
| | | | | | - Alexandra Calmy
- HIV/AIDS Unit, Department of Infectious Diseases, Geneva University Hospitals, and the University of Geneva Faculty of Medicine, Geneva, Switzerland
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Chingombe I, Mapingure MP, Balachandra S, Chipango TN, Gambanga F, Mushavi A, Apollo T, Suraratdecha C, Rogers JH, Ruangtragool L, Gonese E, Musuka GN, Mugurungi OM, Harris TG. Patient costs for prevention of mother-to-child HIV transmission and antiretroviral therapy services in public health facilities in Zimbabwe. PLoS One 2021; 16:e0256291. [PMID: 34407129 PMCID: PMC8372940 DOI: 10.1371/journal.pone.0256291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 08/03/2021] [Indexed: 11/18/2022] Open
Abstract
Zimbabwe has made large strides in addressing HIV. To ensure a continued robust response, a clear understanding of costs associated with its HIV program is critical. We conducted a cross-sectional evaluation in 2017 to estimate the annual average patient cost for accessing Prevention of Mother-To-Child Transmission (PMTCT) services (through antenatal care) and Antiretroviral Treatment (ART) services in Zimbabwe. Twenty sites representing different types of public health facilities in Zimbabwe were included. Data on patient costs were collected through in-person interviews with 414 ART and 424 PMTCT adult patients and through telephone interviews with 38 ART and 47 PMTCT adult patients who had missed their last appointment. The mean and median annual patient costs were examined overall and by service type for all participants and for those who paid any cost. Potential patient costs related to time lost were calculated by multiplying the total time to access services (travel time, waiting time, and clinic visit duration) by potential earnings (US$75 per month assuming 8 hours per day and 5 days per week). Mean annual patient costs for accessing services for the participants was US$20.00 [standard deviation (SD) = US$80.42, median = US$6.00, range = US$0.00-US$12,18.00] for PMTCT and US$18.73 (SD = US$58.54, median = US$8.00, range = US$0.00-US$ 908.00) for ART patients. The mean annual direct medical costs for PMTCT and ART were US$9.78 (SD = US$78.58, median = US$0.00, range = US$0.00-US$ 90) and US$7.49 (SD = US$60.00, median = US$0.00) while mean annual direct non-medical cost for US$10.23 (SD = US$17.35, median = US$4.00) and US$11.23 (SD = US$25.22, median = US$6.00, range = US$0.00-US$ 360.00). The PMTCT and ART costs per visit based on time lost were US$3.53 (US$1.13 to US$8.69) and US$3.43 (US$1.14 to US$8.53), respectively. The mean annual patient costs per person for PMTCT and ART in this evaluation will impact household income since PMTCT and ART services in Zimbabwe are supposed to be free.
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Affiliation(s)
- Innocent Chingombe
- ICAP at Columbia University, New York, NY, United States of America
- * E-mail:
| | | | | | | | - Fiona Gambanga
- ICAP at Columbia University, New York, NY, United States of America
| | | | | | - Chutima Suraratdecha
- U.S. Centers for Disease Control and Prevention, Atlanta, Georgia United States of America
| | - John H. Rogers
- U.S. Centers for Disease Control and Prevention, Harare, Zimbabwe
| | - Leala Ruangtragool
- PHI/CDC Global HIV Surveillance Fellow, U.S. Centers for Disease Control and Prevention, Harare, Zimbabwe
| | - Elizabeth Gonese
- U.S. Centers for Disease Control and Prevention, Harare, Zimbabwe
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Phillips AN, Cambiano V, Johnson L, Nakagawa F, Homan R, Meyer-Rath G, Rehle T, Tanser F, Moyo S, Shahmanesh M, Castor D, Russell E, Jamieson L, Bansi-Matharu L, Shroufi A, Barnabas RV, Parikh UM, Mellors JW, Revill P. Potential Impact and Cost-Effectiveness of Condomless-Sex-Concentrated PrEP in KwaZulu-Natal Accounting for Drug Resistance. J Infect Dis 2021; 223:1345-1355. [PMID: 31851759 PMCID: PMC8064039 DOI: 10.1093/infdis/jiz667] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 10/08/2019] [Accepted: 12/17/2019] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Oral preexposure prophylaxis (PrEP) in the form of tenofovir-disoproxil-fumarate/emtricitabine is being implemented in selected sites in South Africa. Addressing outstanding questions on PrEP cost-effectiveness can inform further implementation. METHODS We calibrated an individual-based model to KwaZulu-Natal to predict the impact and cost-effectiveness of PrEP, with use concentrated in periods of condomless sex, accounting for effects on drug resistance. We consider (1) PrEP availability for adolescent girls and young women aged 15-24 years and female sex workers, and (2) availability for everyone aged 15-64 years. Our primary analysis represents a level of PrEP use hypothesized to be attainable by future PrEP programs. RESULTS In the context of PrEP use in adults aged 15-64 years, there was a predicted 33% reduction in incidence and 36% reduction in women aged 15-24 years. PrEP was cost-effective, including in a range of sensitivity analyses, although with substantially reduced (cost) effectiveness under a policy of ART initiation with efavirenz- rather than dolutegravir-based regimens due to PrEP undermining ART effectiveness by increasing HIV drug resistance. CONCLUSIONS PrEP use concentrated during time periods of condomless sex has the potential to substantively impact HIV incidence and be cost-effective.
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Affiliation(s)
- Andrew N Phillips
- Institute for Global Health, University College London, London, UK
- Correspondence: Andrew Phillips, PhD, UCL, Royal Free Campus, Rowland Hill Street, London NW3, UK ()
| | | | - Leigh Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Fumiyo Nakagawa
- Institute for Global Health, University College London, London, UK
| | | | - Gesine Meyer-Rath
- Departmentof Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Thomas Rehle
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Frank Tanser
- Lincoln Institute for Health, University of Lincoln, Lincoln, UK
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Sizulu Moyo
- Human Sciences Research Council, Pretoria, South Africa
| | - Maryam Shahmanesh
- Institute for Global Health, University College London, London, UK
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
| | - Delivette Castor
- United States Agency for International Development, Washington, District of Columbia, USA
| | - Elizabeth Russell
- United States Agency for International Development, Washington, District of Columbia, USA
| | - Lise Jamieson
- Departmentof Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Amir Shroufi
- Medécins Sans Frontières, Cape Town, South Africa
| | | | - Urvi M Parikh
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Wanga V, Peebles K, Obiero A, Mogaka F, Omollo V, Odoyo JB, Morton JF, Bukusi EA, Celum C, Baeten JM, Barnabas RV. Cost of pre-exposure prophylaxis delivery in family planning clinics to prevent HIV acquisition among adolescent girls and young women in Kisumu, Kenya. PLoS One 2021; 16:e0249625. [PMID: 33857195 PMCID: PMC8049260 DOI: 10.1371/journal.pone.0249625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 05/07/2020] [Accepted: 03/22/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Oral pre-exposure prophylaxis (PrEP) is increasingly being implemented in sub-Saharan Africa. Adolescent girls and young women (AGYW) in Kenya contribute more than half of all new infections among young people aged 15-24 years, highlighting the need for evidence on the cost of PrEP in real-world implementation to inform the budget impact, cost-effectiveness, and financial sustainability of PrEP programs. METHODS We estimated the cost of delivering PrEP to AGYW enrolled in a PrEP implementation study in two family planning clinics in Kisumu county, located in western Kenya. We derived total annual costs and the average cost per client-month of PrEP by input type (variable or fixed) and visit type (initiation or follow-up). We estimated all costs as implemented in the study, and under implementation by the Kenyan Ministry of Health (MoH), both at the program volume observed and if the facilities were delivering PrEP at full capacity (scaled-MoH). RESULTS For the costing period between March 2018 and March 2019, 615 HIV-negative women contributed 1,128 (502 initiation and 626 follow-up) visits. The average cost per client-month of PrEP dispensed per study protocol and per the MoH scenario was $28.92 and $14.52, respectively. If the MoH scaled the program so that facilities could see PrEP clients at capacity, the average cost per client-month of PrEP was $10.88. Medication costs accounted for the largest proportion of the total annual costs (48% in MoH scenario and 65% in the scaled-MoH scenario). CONCLUSIONS Using data from a PrEP implementation program, we found that the cost per client-month of PrEP dispensed is reduced by 62% if PrEP delivery at the two clinics is scaled up by the MoH. Our findings are valuable for informing local resource allocation and budgetary cost projections for scale-up of PrEP delivery to AGYW. Additionally, previous cost-effectiveness studies have been limited by the use of fixed assumptions of the cost of PrEP per person-month. Our study provides cost estimates from practical data which will better inform cost-effectiveness and budget impact analyses.
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Affiliation(s)
- Valentine Wanga
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- * E-mail:
| | - Kathryn Peebles
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Alfred Obiero
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Felix Mogaka
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Victor Omollo
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Josephine B. Odoyo
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Jennifer F. Morton
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Elizabeth A. Bukusi
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Departments of Obstetrics and Gynecology, University of Washington, Seattle, WA, United States of America
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Jared M. Baeten
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Ruanne V. Barnabas
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Medicine, University of Washington, Seattle, WA, United States of America
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Lujintanon S, Amatavete S, Sungsing T, Seekaew P, Peelay J, Mingkwanrungruang P, Chinbunchorn T, Teeratakulpisarn S, Methajittiphan P, Leenasirima P, Norchaiwong A, Nilmanat A, Phanuphak P, Ramautarsing RA, Phanuphak N. Client and provider preferences for HIV care: Implications for implementing differentiated service delivery in Thailand. J Int AIDS Soc 2021; 24:e25693. [PMID: 33792192 PMCID: PMC8013790 DOI: 10.1002/jia2.25693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 02/14/2021] [Accepted: 02/23/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Differentiated service delivery (DSD) for antiretroviral therapy (ART) maintenance embodies the client-centred approach to tailor services to support people living with HIV in adhering to treatment and achieving viral suppression. We aimed to assess the preferences for HIV care and attitudes towards DSD for ART maintenance among ART clients and providers at healthcare facilities in Thailand. METHODS A cross-sectional study using self-administered questionnaires was conducted in September-November 2018 at five healthcare facilities in four high HIV burden provinces in Thailand. Eligible participants who were ART clients aged ≥18 years and ART providers were recruited by consecutive sampling. Descriptive statistics were used to summarize demographic characteristics, preferences for HIV services and expectations and concerns towards DSD for ART maintenance. RESULTS Five hundred clients and 52 providers completed the questionnaires. Their median ages (interquartile range; IQR) were 38.6 (29.8 to 45.5) and 37.3 (27.3 to 45.1); 48.5% and 78.9% were females, 16.8% and 1.9% were men who have sex with men, and 2.4% and 7.7% were transgender women, respectively. Most clients and providers agreed that ART maintenance tasks, including ART refill, viral load testing, HIV/sexually transmitted infection monitoring, and psychosocial support should be provided at ART clinics (85.2% to 90.8% vs. 76.9% to 84.6%), by physicians (77.0% to 94.6% vs. 71.2% to 100.0%), every three months (26.7% to 40.8% vs. 17.3% to 55.8%) or six months (33.0% to 56.7% vs. 28.9% to 80.8%). Clients agreed that DSD would encourage their autonomy (84.9%) and empower responsibility for their health (87.7%). Some clients and providers disagreed that DSD would lead to poor ART retention (54.0% vs. 40.4%), increased loss to follow-up (52.5% vs. 42.3%), and delayed detection of treatment failure (48.3% vs. 44.2%), whereas 31.4% to 50.0% of providers were unsure about these expectations and concerns. CONCLUSIONS Physician-led, facility-based clinical consultation visit spacing in combination with multi-month ART refill was identified as one promising DSD model in Thailand. However, low preference for decentralization and task shifting may prove challenging to implement other models, especially since many providers were unsure about DSD benefits. This calls for local implementation studies to prove feasibility and governmental and social support to legitimize and normalize DSD in order to gain acceptance among clients and providers.
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Affiliation(s)
| | | | | | - Pich Seekaew
- Institute of HIV Research and InnovationBangkokThailand
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNYUSA
| | | | | | | | | | | | | | | | | | | | | | - Nittaya Phanuphak
- Institute of HIV Research and InnovationBangkokThailand
- Center of Excellence in Transgender HealthChulalongkorn UniversityBangkokThailand
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Parker B, Ward T, Hayward O, Jacob I, Arthurs E, Becker D, Anderson SJ, Chounta V, Van de Velde N. Cost-effectiveness of the long-acting regimen cabotegravir plus rilpivirine for the treatment of HIV-1 and its potential impact on adherence and viral transmission: A modelling study. PLoS One 2021; 16:e0245955. [PMID: 33529201 PMCID: PMC7853524 DOI: 10.1371/journal.pone.0245955] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 01/11/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Combination antiretroviral therapy (cART) improves outcomes for people living with HIV (PLWH) but requires adherence to daily dosing. Suboptimal adherence results in reduced treatment effectiveness, increased costs, and greater risk of resistance and onwards transmission. Treatment with long-acting (LA), injection-based ART administered by healthcare professionals (directly observed therapy (DOT)) eliminates the need for adherence to daily dosing and may improve clinical outcomes. This study reports the cost-effectiveness of the cabotegravir plus rilpivirine LA regimen (CAB+RPV LA) and models the potential impact of LA DOT therapies. Methods Parameterisation was performed using pooled data from recent CAB+RPV LA Phase III trials. The analysis was conducted using a cohort-level hybrid decision-tree and state-transition model, with states defined by viral load and CD4 cell count. The efficacy of oral cART was adjusted to reflect adherence to daily regimens from published data. A Canadian health service perspective was adopted. Results CAB+RPV LA is predicted to be the dominant intervention when compared to oral cART, generating, per 1,000 patients treated, lifetime cost-savings of $1.5 million, QALY and life-year gains of 107 and 138 respectively with three new HIV cases averted. Conclusions Economic evaluations of LA DOTs need to account for the impact of adherence and HIV transmission. This study adds to the existing literature by incorporating transmission and using clinical data from the first LA DOT regimen. Providing PLWH and healthcare providers with novel modes of ART administration, enhancing individualisation of treatment, may facilitate the achievement of UNAIDS 95-95-95 objectives.
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Affiliation(s)
- Ben Parker
- Health Economics and Outcomes Research Ltd, Pontprennau, Cardiff, United Kingdom
| | - Tom Ward
- Health Economics and Outcomes Research Ltd, Pontprennau, Cardiff, United Kingdom
| | - Olivia Hayward
- Health Economics and Outcomes Research Ltd, Pontprennau, Cardiff, United Kingdom
| | - Ian Jacob
- Health Economics and Outcomes Research Ltd, Pontprennau, Cardiff, United Kingdom
- * E-mail: (IJ); (NVdV)
| | - Erin Arthurs
- Health Economics & Outcomes Research, GlaxoSmithKline, Toronto, Ontario, Canada
| | - Debbie Becker
- Quadrant Health Economics Inc, Cambridge, Ontario, Canada
| | - Sarah-Jane Anderson
- Value Evidence and Outcomes, GlaxoSmithKline, Brentford, Middlesex, United Kingdom
| | - Vasiliki Chounta
- Global Health Outcomes, ViiV Healthcare Ltd, Brentford, Middlesex, United Kingdom
| | - Nicolas Van de Velde
- Global Health Outcomes, ViiV Healthcare Ltd, Brentford, Middlesex, United Kingdom
- * E-mail: (IJ); (NVdV)
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Suraratdecha C, Stuart RM, Edwards M, Moore R, Liu N, Wilson DP, Albalak R. Costs of providing HIV care and optimal allocation of HIV resources in Guyana. PLoS One 2020; 15:e0238499. [PMID: 33119591 PMCID: PMC7595312 DOI: 10.1371/journal.pone.0238499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 08/18/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Great strides in responding to the HIV epidemic have led to improved access to and uptake of HIV services in Guyana, a lower-middle-income country with a generalized HIV epidemic. Despite efforts to scale up HIV treatment and adopt the test and start strategy, little is known about costs of HIV services across the care cascade. METHODS We collected cost data from the national laboratory and nine selected treatment facilities in five of the country's ten Regions, and estimated the costs associated with HIV testing and services (HTS) and antiretroviral therapy (ART) from a provider perspective from January 1, 2016 to December 31, 2016. We then used the unit costs to construct four resource allocation scenarios. In the first two scenarios, we calculated how close Guyana would currently be to its 2020 targets if the allocation of funding across programs and regions over 2017-2020 had (a) remained unchanged from latest-reported levels, or (b) been optimally distributed to minimize incidence and deaths. In the next two, we estimated the resources that would have been required to meet the 2020 targets if those resources had been distributed (a) according to latest-reported patterns, or (b) optimally to minimize incidence and deaths. RESULTS The mean cost per test was US$15 and the mean cost per person tested positive was US$796. The mean annual cost per of maintaining established adult and pediatric patients on ART were US$428 and US$410, respectively. The mean annual cost of maintaining virally suppressed patients was US$648. Cost variation across sites may suggest opportunities for improvements in efficiency, or may reflect variation in facility type and patient volume. There may also be scope for improvements in allocative efficiency; we estimated a 28% reduction in the total resources required to meet Guyana's 2020 targets if funds had been optimally distributed to minimize infections and deaths. CONCLUSIONS We provide the first estimates of costs along the HIV cascade in the Caribbean and assessed efficiencies using novel context-specific data on the costs associated with diagnostic, treatment, and viral suppression. The findings call for better targeting of services, and efficient service delivery models and resource allocation, while scaling up HIV services to maximize investment impact.
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Affiliation(s)
- Chutima Suraratdecha
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Robyn M. Stuart
- Department of Mathematical Sciences, University of Copenhagen, Copenhagen, Denmark
- Burnet Institute, Melbourne, Australia
- * E-mail:
| | | | | | - Nadia Liu
- Ministry of Public Health, Georgetown, Guyana
| | - David P. Wilson
- Department of Mathematical Sciences, University of Copenhagen, Copenhagen, Denmark
- Monash University, Melbourne, Australia
- Kirby Institute, University of New South Wales, Sydney, Australia
- Department of Microbial Pathogenesis, University of Maryland, Baltimore, United States of America
| | - Rachel Albalak
- U.S. Centers for Disease Control and Prevention, Caribbean Region Office, Barbados, Santo Domingo, Dominican Republic
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Hughes CS, Brown J, Murombedzi C, Chirenda T, Chareka G, Mhlanga F, Mateveke B, Gitome S, Makurumure T, Matubu A, Mgodi N, Chirenje Z, Kahn JG. Estimated costs for the delivery of safer conception strategies for HIV-discordant couples in Zimbabwe: a cost analysis. BMC Health Serv Res 2020; 20:940. [PMID: 33046066 PMCID: PMC7552466 DOI: 10.1186/s12913-020-05784-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 06/05/2020] [Accepted: 09/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In recent years, safer conception strategies have been developed to help HIV-serodiscordant couples conceive a child without transmitting HIV to the seronegative partner. The SAFER clinical trial assessed implementation of these strategies in Zimbabwe. METHODS As a part of the SAFER study, we estimated the costs (in 2017 $US) associated with individual and combination strategies, in the trial setting and real-world practice, from a healthcare system perspective. Safer conception strategies included: 1) ART with frequent viral load testing until achieving undetectable viral load (ART-VL); 2) daily oral pre-exposure prophylaxis (PrEP); 3) semen-washing with intrauterine insemination; and 4) manual self-insemination at home. For costs in the trial, we used a micro-costing approach, including a time and motion study to quantify personnel effort, and estimated the cost per couple for individual and combination strategies for a mean of 6 months of safer services. For real-world practice, we modeled costs for three implementation scenarios, representing differences from the trial in input prices (paid by the Ministry of Health and Child Care [MOHCC]), intervention intensity, and increments to current HIV prevention and treatment practices and guidelines. We used one-way sensitivity analyses to assess the impact of uncertainty in input variables. RESULTS Individual strategy costs were $769-$1615 per couple in the trial; $185-$563 if using MOHCC prices. Under the target intervention intensity and using MOHCC prices, individual strategy costs were $73-$360 per couple over and above the cost of current HIV clinical practices. The cost of delivering the most commonly selected combination, ART-VL plus PrEP, ranged from $166-$517 per couple under the three real-world scenarios. Highest costs were for personnel, lab tests, and strategy-specific consumables, in variable proportions by clinical strategy and analysis scenario. Total costs were most affected by uncertainty in the price of PrEP, number of semen-washing attempts, and scale-up of semen-washing capacity. CONCLUSIONS Safer conception methods have costs that may be affordable in many low-resource settings. These cost data will help implementers and policymakers add safer conception services. Cost-effectiveness analysis is needed to assess value for money for safer conception services overall and for safer strategy combinations. TRIAL REGISTRATION Registry Name: Clinicaltrials.gov. TRIAL REGISTRATION NUMBER NCT03049176 . Registration date: February 9, 2017.
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Affiliation(s)
- Carolyn Smith Hughes
- Institute for Global Health Sciences, University of California, 550 16th Street, 3rd Floor, San Francisco, 94158, USA.
| | - Joelle Brown
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, USA
| | - Caroline Murombedzi
- College of Health Sciences Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Thandiwe Chirenda
- College of Health Sciences Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Gift Chareka
- College of Health Sciences Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Felix Mhlanga
- College of Health Sciences Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | | | - Serah Gitome
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Allen Matubu
- College of Health Sciences Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Nyaradzo Mgodi
- College of Health Sciences Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Zvavahera Chirenje
- College of Health Sciences Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - James G Kahn
- Department of Epidemiology and Biostatistics, University of California, San Francisco, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, USA
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Valbert F, Wolf E, Schewe K, Klauke S, Hanhoff N, Hoffmann C, Preis S, Pahmeier K, Wasem J, Neumann A. Cost of Human Immunodeficiency Virus (HIV) and Determinants of Healthcare Costs in HIV-Infected Treatment-Naive Patients Initiated on Antiretroviral Therapy in Germany: Experiences of the PROPHET Study. Value Health 2020; 23:1324-1331. [PMID: 33032776 DOI: 10.1016/j.jval.2020.04.1836] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 03/16/2020] [Accepted: 04/17/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES The purpose of the prospective clinical and pharmacoeconomic outcomes study of different first-line antiretroviral treatment strategies (PROPHET) was to examine the healthcare costs of human immunodeficiency virus (HIV)-infected persons in Germany treated with different antiretroviral therapy (ART) strategies and to identify variables associated with high costs. METHODS The setting was a 24-month prospective multicenter observational cohort study in a German HIV-specialized care setting from 2014 to 2017. A microcosting approach was used for the estimation of healthcare costs. Data were obtained via electronic case report forms. The costs were calculated from both the societal and the statutory health insurance perspective. Regression models were performed that took into consideration the impact of several independent variables. RESULTS Four hundred thirty-four patients from 24 centers throughout Germany were included. Average annual healthcare costs were €20 118 (standard deviation [SD] €6451) per patient from the societal perspective (n = 336) and €17 306 (SD €4106) from the statutory health insurance perspective (n = 292). Expenditures for the ART medication had the highest impact. Total costs declined in the second year of therapy. There was a significant association between the amount of total cost and clinical or therapeutic variables from both perspectives; a diagnosis of acquired immune deficiency syndrome (AIDS) led to higher costs as well as the chosen ART strategy. Age also increased cost from the statutory health insurance perspective. CONCLUSIONS The main cost driver of the healthcare costs for HIV-positive patients was antiretroviral drug expenses. Further variables that influenced the costs were identified. The results provide a detailed overview of the resource use of patients in the PROPHET cohort.
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Affiliation(s)
- Frederik Valbert
- Institute for Health Care Management and Research, University of Duisburg-Essen, Essen, Germany.
| | - Eva Wolf
- MUC Research GmbH, Munich, Germany
| | - Knud Schewe
- German Association of Physicians Specializing in HIV Care Registered Association, Berlin, Germany
| | | | - Nikola Hanhoff
- German Association of Physicians Specializing in HIV Care Registered Association, Berlin, Germany
| | | | | | - Kathrin Pahmeier
- Institute for Health Care Management and Research, University of Duisburg-Essen, Essen, Germany
| | - Jürgen Wasem
- Institute for Health Care Management and Research, University of Duisburg-Essen, Essen, Germany
| | - Anja Neumann
- Institute for Health Care Management and Research, University of Duisburg-Essen, Essen, Germany
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Giraud JS, Doisne M, Chan Hew Wai A, Majerholc C, Fourn E, Sejean K, Trichereau J, Bonan B, Zucman D. De-simplifying single-tablet antiretroviral treatments for cost savings in France: From the patient perspectives to a 6-month follow-up on generics. PLoS One 2020; 15:e0239704. [PMID: 32976493 PMCID: PMC7518587 DOI: 10.1371/journal.pone.0239704] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 09/13/2020] [Indexed: 11/19/2022] Open
Abstract
In developed countries, most people living with HIV/AIDS are treated with costly brand single-tablet regimens. Given the economic impact, French guidelines recommend using generic antiretroviral therapy when possible to decrease antiretroviral therapy costs. We aimed to study HIV-infected patients’ acceptability to switch from a brand single-tablet regimens [abacavir/lamivudine/dolutegravir (Triumeq®) or emtricitabine/tenofovir disoproxil fumarate/rilpivirine (Eviplera®)] to a treatment comprising of two pills: one is a fixed-dose generic combination of 2 Nucleoside Analogs and the second tablet is the third antiretroviral. This study was a prospective observational study in a French hospital. During their follow-up, patients on stable single-tablet regimens were made aware of the possible cost-saving. They were questioned about their willingness and barriers accepting the substitution. Participants chose between the two regimens, either to remain on single-tablet regimens or switch to the de-simplified regimen. Six months later, a second survey was given to the patient who chose to de-simplify and HIV viral load was controlled. The study included 98 patients: 60 receiving emtricitabine/tenofovir disoproxil fumarate/rilpivirine (Eviplera®) and 38 on abacavir/lamivudine/dolutegravir (Triumeq®). Forty-five patients accepted the de-simplified treatment, 37 refused and 16 were undecided and followed the decision offered by their physician. The main reason for unwillingness to switch is the number of pills (77.3%). In multivariate model analysis, male patients (p = 0.001) who have taken antiretroviral therapy for over 20 years (p = 0.04) and who retrieve their treatment in their community hospital (p = 0.03) are more likely to accept the switch. Fifty-one patients accepted to replace their single-tablet regimens and six months later, the majority was satisfied; only four returned to single-tablet regimens because of suspected side effects. Half of the people living with HIV/AIDS in our cohort accepted to switch from brand single-tablet regimens to a two-tablet regimen containing generic drugs within a process that emphasizes health expenditure savings.
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Affiliation(s)
| | | | | | | | - Erwan Fourn
- HIV Department, Foch Hospital, Suresnes, France
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Choi H, Suh J, Lee W, Kim JH, Kim JH, Seong H, Ahn JY, Jeong SJ, Ku NS, Park YS, Yeom JS, Kim C, Kwon HD, Smith DM, Lee J, Choi JY. Cost-effectiveness analysis of pre-exposure prophylaxis for the prevention of HIV in men who have sex with men in South Korea: a mathematical modelling study. Sci Rep 2020; 10:14609. [PMID: 32884082 PMCID: PMC7471951 DOI: 10.1038/s41598-020-71565-y] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 08/12/2020] [Indexed: 11/10/2022] Open
Abstract
In February 2018, the Ministry of Food and Drug Safety in Korea approved tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) co-formulate for use in pre-exposure prophylaxis (PrEP) for the prevention of human immunodeficiency virus (HIV) infection. This study aimed to estimate the cost-effectiveness of PrEP in men who have sex with men (MSM), a major risk group emerging in Korea. A dynamic compartmental model was developed for HIV transmission and progression in MSM aged 15-64 years. With a combined model including economic analysis, we estimated averted HIV infections, changes in HIV prevalence, discounted costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). PrEP was evaluated in both the general MSM and high-risk MSM populations and was assumed to reduce infection risk by 80%. Implementing PrEP in all MSM would avert 75.2% HIV infections and facilitate a gain of 37,372 QALYs at a cost of $274,822 per QALY gained over 20 years relative to the status quo. Initiating PrEP in high-risk MSM with an average of eight partners per year (around 20% of MSM) would improve the cost-effectiveness, averting 78.0% HIV infections and add 29,242 QALYs at a cost of $51,597 per QALY gained, which is within the willingness-to-pay threshold for Korea of $56,000/QALY gained. This result was highly sensitive to annual PrEP costs, quality-of-life for people who are on PrEP, and initial HIV prevalence. Initiating PrEP in a larger proportion of MSM in Korea would prevent more HIV infections, but at an increasing cost per QALY gained. Focusing PrEP on higher risk MSM and any reduction in PrEP cost would improve cost-effectiveness.
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Affiliation(s)
- Heun Choi
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jiyeon Suh
- Department of Computational Science and Engineering, Yonsei University, Seoul, Republic of Korea
| | - Woonji Lee
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jun Hyoung Kim
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung Ho Kim
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hye Seong
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin Young Ahn
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Su Jin Jeong
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Nam Su Ku
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yoon Soo Park
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joon Sup Yeom
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Changsoo Kim
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hee-Dae Kwon
- Department of Mathematics, Inha University, Incheon, Republic of Korea
| | - Davey M Smith
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
| | - Jeehyun Lee
- Department of Computational Science and Engineering, Yonsei University, Seoul, Republic of Korea
- Department of Mathematics, Yonsei University, Seoul, Republic of Korea
| | - Jun Yong Choi
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Yonsei University Health System, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea.
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16
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Nichols BE, Offorjebe OA, Cele R, Shaba F, Balakasi K, Chivwara M, Hoffman RM, Long LC, Rosen S, Dovel K. Economic evaluation of facility-based HIV self-testing among adult outpatients in Malawi. J Int AIDS Soc 2020; 23:e25612. [PMID: 32909387 PMCID: PMC7507468 DOI: 10.1002/jia2.25612] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 07/24/2020] [Accepted: 08/02/2020] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION HIV self-testing (HIVST) in outpatient departments (OPD) is a promising strategy for HIV testing in Malawi, given high OPD patient volumes and substantial wait times. To evaluate the relative cost and expected impact of facility-based HIVST (FB-HIVST) at OPDs in Malawi for increasing HIV status awareness, we conducted an economic evaluation of an HIVST cluster-randomized controlled trial. METHODS A cluster-randomized trial was conducted at 15 sites in Malawi from September 2017 to February 2018 with three arms: 1) Standard provider-initiated-testing-and-counselling (PITC); 2) Optimized PITC (additional provider training and job-aids) and 3) FB-HIVST (HIVST demonstration, distribution and kit use in OPD, private kit interpretation and optional HIV counselling). The total production cost per newly identified positive and per person newly initiated on ART were calculated by study arm. These were calculated as the total cost of testing everyone divided by the number of newly identified positives; and the total cost of testing everyone divided by the number of those initiated on ART. Cost-outcomes were calculated under three cost scenarios: (1) full study costs, (2) routine implementation costs and (3) routine implementation + reduced cost for HIVST kits. RESULTS The average cost per person newly diagnosed in the full study cost scenario was $101, $156 and $189, and cost per person initiated on ART was $121, $156 and $279 for Standard PITC, Optimized PITC and FB-HIVST respectively. In the routine implementation cost scenario, the average cost per person newly diagnosed was reduced to $83, and $93, and cost per person initiated on ART to $83, and $137 for Optimized PITC and FB-HIVST respectively. In the negotiated HIVST cost scenario, the average cost per person newly diagnosed was reduced to $55 and cost per person newly initiated on ART reduced to $81 in the FB-HIVST arm. CONCLUSIONS While the cost per new ART initiation through FB-HIVST was higher than Standard PITC, FB-HIVST could become cost-saving compared to PITC if the cost of kits is reduced or if treatment linkage rate were increased in the FB-HIVST arm. For high volume OPDs, HIVST may increase facility capacity and increase the number of newly diagnosed positives.
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Affiliation(s)
- Brooke E Nichols
- Department of Global HealthSchool of Public HealthBoston UniversityBostonMAUSA
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - O Agatha Offorjebe
- David Geffen School of MedicineUniversity of California Los AngelesLos AngelesCAUSA
- Charles R. Drew University of Medicine and ScienceLos AngelesCAUSA
| | - Refiloe Cele
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | | | | | | | - Risa M Hoffman
- Partners in HopeLilongweMalawi
- Division of Infectious DiseasesDepartment of MedicineUniversity of California Los AngelesLos AngelesCAUSA
| | - Lawrence C Long
- Department of Global HealthSchool of Public HealthBoston UniversityBostonMAUSA
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Sydney Rosen
- Department of Global HealthSchool of Public HealthBoston UniversityBostonMAUSA
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Kathryn Dovel
- Partners in HopeLilongweMalawi
- Division of Infectious DiseasesDepartment of MedicineUniversity of California Los AngelesLos AngelesCAUSA
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Dada DA, Aku E, David KB. COVID-19 pandemic and antiretrovirals (ARV) availability in Nigeria: recommendations to prevent shortages. Pan Afr Med J 2020; 35:149. [PMID: 33193964 PMCID: PMC7608769 DOI: 10.11604/pamj.supp.2020.35.149.25639] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 08/21/2020] [Indexed: 12/02/2022] Open
Abstract
HIV/AIDS is an infectious disease that has claimed the lives of millions of people worldwide. Currently, there is no vaccine that has been developed in a bid to fight this deadly infection, however, antiretrovirals (ARVs), which are drugs used in the treatment of HIV infection are routinely prescribed to infected persons. They act via several mechanisms of action to reduce the severity of infection and rate of infectivity of the virus by decreasing the viral load while increasing CD4 counts. COVID-19 pandemic has resulted in unprecedented events affecting almost all areas of humans' life including availability of medicines and other consumables. This paper analyses the availability of ARVs during COVID-19 era and offered recommendations to be adopted in order to prevent shortages.
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Affiliation(s)
- David Adelekan Dada
- Faculty of Pharmaceutical Sciences, Kaduna State University, Kaduna, Nigeria
| | - Emmanuel Aku
- Department of Microbiology, Kaduna State University, Kaduna, Nigeria
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Goossens AJM, Cheung KL, Sijstermans E, Conde R, Gonzalez JGR, Hiligsmann M. A discrete choice experiment to assess patients' preferences for HIV treatment in the rural population in Colombia. J Med Econ 2020; 23:803-811. [PMID: 32098539 DOI: 10.1080/13696998.2020.1735398] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Aim: To elicit patients' preferences for HIV treatment of the rural population in Colombia.Methods: A discrete choice experiment (DCE), conducted in a HIV clinic in Bogotá, was used to examine the trade-off between five HIV treatment attributes: effect on life expectancy, effect on physical activity, risk of moderate side-effects, accessibility to clinic, and economic costs to access controls. Attributes selection was based on literature review, expert consultation and a focus group with six patients. An efficient experimental design was used to define two versions of the questionnaire with each of 12 choice sets and a dominance task was added to check reliability. A mixed logit model was then used to analyse the data and sub-group analyses were conducted on the basis of age, gender, education, and sexual preference.Results: A total of 129 HIV patients were included for analysis. For all treatment attributes, significant differences between at least two levels were observed, meaning that all attributes were significant predictors of choice. Patients valued the effect on physical activity (conditional relative importance of 27.5%) and the effect on life expectancy (26.0%) the most. Sub-group analyses regard age and education showed significant differences: younger patients and high educated patients valued the effect on physical activity the most important, whereas older patients mostly valued the effect on life expectancy and low educated patients mostly valued the accessibility to clinic.Limitations: One potential limitation is selection bias, as only patients from one HIV clinic were reached. Additionally, questionnaires were partly administered in the waiting rooms, which potentially led to noise in the data.Conclusions: This study suggests that all HIV treatment characteristics included in this DCE were important and that HIV patients from rural Colombia valued short-term efficacy (i.e. effect on physical activity) and long-term efficacy (i.e. effect on life expectancy) the most.
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Affiliation(s)
- Anne J M Goossens
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Kei Long Cheung
- Department of Clinical Sciences, College of Health and Life Sciences, Brunel University London, London, United Kingdom
| | - Eric Sijstermans
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Rafael Conde
- Centro de Investigación Clínica ACISC, Asistencia Científica de Alta Complejida, Bogota, Colombia
| | - Javier G R Gonzalez
- Rosario Graduate School of Business, School of Business, Administración en Salud, Universidad del Rosario, Bogotá, Colombia
| | - Mickael Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
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Sijstermans E, Cheung KL, Goossens AJM, Conde R, Gonzalez JGR, Hiligsmann M. A discrete choice experiment to assess patients' preferences for HIV treatment in the urban population in Colombia. J Med Econ 2020; 23:812-818. [PMID: 32098614 DOI: 10.1080/13696998.2020.1735399] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Aim: This study aimed to assess patients' preferences for HIV treatment in an urban Colombian population.Methods: A Discrete Choice Experiment (DCE) was conducted. Urban Colombian HIV patients were asked to repetitively choose between two hypothetical treatments that differ in regard to five attributes 'effect on life expectancy', 'effect on physical activity', 'risk of moderate side effects, 'accessibility to clinic' and 'economic cost to access controls'. Twelve choice sets were made using an efficient design. A Mixed Logit Panel Model was used for the analysis and subgroup analyses were performed according to age, gender, education level and sexual preference.Results: A total of 224 HIV patients were included. All attributes were significant, indicating that there were differences between at least two levels of each attribute. Patients preferred to be able to perform all physical activity without difficulty, to have large positive effects on life expectancy, to travel less than 2 h, to have lower risk of side-effects and to have subsidized travel costs. The attributes 'effect on physical activity' and 'effects on life expectancy' were deemed the most important. Sub-analyses showed that higher educated patients placed more importance on the large positive effects of HIV treatment, and a more negative preference for subsidized travel cost (5% level).Limitations: A potential limitation is selection bias as it is difficult to make a systematic urban/rural division of respondents. Additional, questionnaires were partly administered in the waiting rooms, which potentially led to some noise in the data.Conclusions: Findings suggests that short-term efficacy (i.e. effect on physical activity) and long-term efficacy (i.e. effect on life expectancy) are the most important treatment characteristics for HIV urban patients in Colombia. Preference data could provide relevant information for clinical and policy decision-making to optimize HIV care.
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Affiliation(s)
- Eric Sijstermans
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Kei Long Cheung
- Department of Clinical Sciences, College of Health and Life Sciences, Brunel University London, London, UK
| | - Anne J M Goossens
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Rafael Conde
- Centro de Investigación Clínica ACISC, Asistencia Científica de Alta Complejida, Bogota, Colombia
| | - Javier G R Gonzalez
- Rosario Graduate School of Business, School of Business, Administración en Salud, Universidad del Rosario, Bogotá, Colombia
| | - Mickael Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
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Ochoa-Moreno I, Bautista-Arredondo S, McCoy SI, Buzdugan R, Mangenah C, Padian NS, Cowan FM. Costs and economies of scale in the accelerated program for prevention of mother-to-child transmission of HIV in Zimbabwe. PLoS One 2020; 15:e0231527. [PMID: 32433715 PMCID: PMC7239451 DOI: 10.1371/journal.pone.0231527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 06/27/2019] [Accepted: 03/25/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Despite a growing body of literature on HIV service costs in sub-Saharan Africa, only a few studies have estimated the facility-level cost of prevention of Mother-to-Child Transmission (PMTCT) services, and even fewer provide insights into the variation of PMTCT costs across facilities. In this study, we present the first empirical costs estimation of the accelerated program for the prevention of mother-to-child transmission of HIV in Zimbabwe and investigate the determinants of heterogeneity of the facility-level average cost per service. To understand such variation, we explored the association between average costs per service and supply-and demand-side characteristics, and quality of services. One aspect of the supply-side we explore carefully is the scale of production-which we define as the annual number of women tested or the yearly number of HIV-positive women on prophylaxis. METHODS We collected rich data on the costs and PMTCT services provided by 157 health facilities out of 699 catchment areas in five provinces in Zimbabwe for 2013. In each health facility, we measured total costs and the number of women covered with PMTCT services and estimated the average cost per woman tested and the average cost per woman on either ARV prophylaxis or ART. We refer to these facility-level average costs per service as unitary costs. We also collected information on potential determinants of the variation of unitary costs. On the supply-side, we gathered data on the scale of production, staff composition and on the types of antenatal and family planning services provided. On the demand side, we measured the total population at the catchment area and surveyed eligible pairs of mothers and infants about previous use of HIV testing and prenatal care, and on the HIV status of both mothers and infants. We explored the determinants of unitary cost variation using a two-stage linear regression strategy. RESULTS The average annual total cost of the PMTCT program per facility was US$16,821 (median US$8,920). The average cost per pregnant woman tested was US$80 (median US$47), and the average cost per HIV-positive pregnant woman initiated on ARV prophylaxis or treatment was US$786 annually (median US$420). We found substantial heterogeneity of unitary costs across facilities regardless of facility type. The scale of production was a strong predictor of unitary costs variation across facilities, with a negative and statistically significant correlation between the two variables (p<0.01). CONCLUSIONS These findings are the first empirical estimations of PMTCT costs in Zimbabwe. Unitary costs were found to be heterogeneous across health facilities, with evidence consistent with economies of scale.
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Affiliation(s)
- I. Ochoa-Moreno
- National Institute of Public Health, Cuernavaca, Mexico
- University of York, York, England, United Kingdom
| | - S. Bautista-Arredondo
- National Institute of Public Health, Cuernavaca, Mexico
- University of California, Berkeley, California, United States of America
| | - S. I. McCoy
- University of California, Berkeley, California, United States of America
| | - R. Buzdugan
- University of California, Berkeley, California, United States of America
| | - C. Mangenah
- Centre for Sexual Health and HIV/AIDS Research, Harare, Zimbabwe
| | - N. S. Padian
- University of California, Berkeley, California, United States of America
| | - F. M. Cowan
- Liverpool School of Tropical Medicine, Liverpool, England, United Kingdom
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21
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Walensky RP, Horn T, McCann NC, Freedberg KA, Paltiel AD. Comparative Pricing of Branded Tenofovir Alafenamide-Emtricitabine Relative to Generic Tenofovir Disoproxil Fumarate-Emtricitabine for HIV Preexposure Prophylaxis: A Cost-Effectiveness Analysis. Ann Intern Med 2020; 172:583-590. [PMID: 32150602 PMCID: PMC7217721 DOI: 10.7326/m19-3478] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Tenofovir alafenamide-emtricitabine (F/TAF) was recently approved as a noninferior and potentially safer option than tenofovir disoproxil fumarate-emtricitabine (F/TDF) for HIV preexposure prophylaxis (PrEP) in the United States. Objective To estimate the greatest possible clinical benefits and economic savings attributable to the improved safety profile of F/TAF and the maximum price payers should be willing to pay for F/TAF over generic F/TDF. Design Cost-effectiveness analysis. Data Sources Published literature on F/TDF safety (in persons with and those without HIV) and the cost and quality-of-life effects of fractures and end-stage renal disease (ESRD). Target Population Age-stratified U.S. men who have sex with men (MSM) using PrEP. Time Horizon Five years. Perspective Health care sector. Intervention Preexposure prophylaxis with F/TAF versus F/TDF. Outcome Measures Fractures averted, cases of ESRD averted, quality-adjusted life-years (QALYs) saved, costs, incremental cost-effectiveness ratios (ICERs), and maximum justifiable price for F/TAF compared with generic F/TDF. Results of Base-Case Analysis Over a 5-year horizon, compared with F/TDF, F/TAF averted 2101 fractures and 25 cases of ESRD for the 123 610 MSM receiving PrEP, with an ICER of more than $7 million per QALY. At a 50% discount for generic F/TDF ($8300 per year) and a societal willingness to pay up to $100 000 per QALY, the maximum fair price for F/TAF was $8670 per year. Results of Sensitivity Analysis Among persons older than 55 years, the ICER for F/TAF remained more than $3 million per QALY and the maximum permissible fair price for F/TAF was $8970 per year. Results were robust to alternative time horizons and PrEP-using population sizes. Limitation Intermittent use and on-demand PrEP were not considered. Conclusion In the presence of a generic F/TDF alternative, the improved safety of F/TAF is worth no more than an additional $370 per person per year. Primary Funding Source National Institute of Allergy and Infectious Diseases, National Institute on Drug Abuse, National Institute of Mental Health, and Massachusetts General Hospital Executive Committee on Research.
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Affiliation(s)
- Rochelle P Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital, Harvard University Center for AIDS Research, Harvard Medical School, Boston, Massachusetts (R.P.W.)
| | - Tim Horn
- National Alliance of State and Territorial AIDS Directors, Washington, DC (T.H.)
| | - Nicole C McCann
- Massachusetts General Hospital, Boston, Massachusetts (N.C.M.)
| | - Kenneth A Freedberg
- Massachusetts General Hospital and Harvard University Center for AIDS Research, Harvard Medical School, Boston, Massachusetts (K.A.F.)
| | - A David Paltiel
- Yale School of Public Health, New Haven, Connecticut (A.D.P.)
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22
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Davis W, Mantsios A, Karver T, Murray M, Punekar Y, Ward D, Bredeek UF, Moreno S, Merino D, Knobel H, Campis A, Kerrigan D. "It made me more confident that I have it under control": Patient and provider perspectives on moving to a two-drug ART regimen in the United States and Spain. PLoS One 2020; 15:e0232473. [PMID: 32357195 PMCID: PMC7194407 DOI: 10.1371/journal.pone.0232473] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 04/15/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Two-drug regimens (2DR) to treat HIV infection have the potential to reduce long-term toxicity and increase therapeutic options for people living with HIV (PLHIV). Prior phase III trials, SWORD-1 and SWORD-2, as well as GEMINI-1 and GEMINI-2, have demonstrated that a dolutegravir-based 2DR is as effective as three- or four-drug regimens among virologically suppressed patients. Limited information exists, however, on patient and provider experiences with 2DR to inform roll-out and integration into routine clinical care. METHODS We conducted 39 in-depth interviews with PLHIV currently on 2DR in the context of routine care and 8 of their clinical care providers in the United States (U.S.) and Spain. Participants included 33 male and 6 female PLHIV and 8 providers. Interview topics explored perceptions of and experiences with 2DR compared to prior anti-retroviral regimens (ARVs), side effects, patient satisfaction, and clinical performance. Interviews were audio-recorded, transcribed and analyzed using thematic content analysis. RESULTS Participants viewed 2DR as a significant and positive advance, in terms of its ability to effectively treat HIV with reduced toxicity and essentially no reported side effects. Patients noted the central role providers played in the decision to switch to a 2DR regimen and, among U.S. participants, the importance of insurance coverage making this preferred option feasible. Patients and providers agreed that a 2DR regimen would be appropriate for any PLHIV regardless of whether they were treatment naïve or had significant experience with ARVs. CONCLUSIONS Participants' experiences with a 2DR regimen were positive with no participants, reporting side effects and all reporting continued viral suppression. Providers valued the reduced toxicity offered by 2DR and served as the primary gateway to a transition to 2DR for patients in both settings. This study provides a foundation for further research on the transition to 2DR regimens in other populations and contexts including low- and middle-income settings.
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Affiliation(s)
- Wendy Davis
- Center on Health, Risk and Society, American University, Washington, D.C., United States of America
- * E-mail:
| | - Andrea Mantsios
- Center on Health, Risk and Society, American University, Washington, D.C., United States of America
| | - Tahilin Karver
- Center on Health, Risk and Society, American University, Washington, D.C., United States of America
| | - Miranda Murray
- Center on Health, Risk and Society, American University, Washington, D.C., United States of America
| | - Yogesh Punekar
- ViiV Healthcare, Raleigh, North Carolina, United States of America
| | - Douglas Ward
- Dupont Circle Physicians Group, Washington, D.C., United States of America
| | - U. Fritz Bredeek
- Metropolis Medical Group, San Francisco, California, United States of America
| | | | | | | | | | - Deanna Kerrigan
- Center on Health, Risk and Society, American University, Washington, D.C., United States of America
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23
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Chan SS, Chappel AR, Maddox KEJ, Hoover KW, Huang YLA, Zhu W, Cohen SM, Klein PW, De Lew N. Pre-exposure prophylaxis for preventing acquisition of HIV: A cross-sectional study of patients, prescribers, uptake, and spending in the United States, 2015-2016. PLoS Med 2020; 17:e1003072. [PMID: 32275654 PMCID: PMC7147726 DOI: 10.1371/journal.pmed.1003072] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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: 08/14/2019] [Accepted: 03/12/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND In 2015, there were approximately 40,000 new HIV diagnoses in the United States. Pre-exposure prophylaxis (PrEP) is an effective strategy that reduces the risk of HIV acquisition; however, uptake among those who can benefit from it has lagged. In this study, we 1) compared the characteristics of patients who were prescribed PrEP with individuals newly diagnosed with HIV infection, 2) identified the specialties of practitioners prescribing PrEP, 3) identified metropolitan statistical areas (MSAs) within the US where there is relatively low uptake of PrEP, and 4) reported median amounts paid by patients and third-party payors for PrEP. METHODS AND FINDINGS We analyzed prescription drug claims for individuals prescribed PrEP in the Integrated Dataverse (IDV) from Symphony Health for the period of September 2015 to August 2016 to describe PrEP patients, prescribers, relative uptake, and payment methods in the US. Data were available for 75,839 individuals prescribed PrEP, and findings were extrapolated to approximately 101,000 individuals, which is less than 10% of the 1.1 million adults for whom PrEP was indicated. Compared to individuals with newly diagnosed HIV infection, PrEP patients were more likely to be non-Hispanic white (45% versus 26.2%), older (25% versus 19% at ages 35-44), male (94% versus 81%), and not reside in the South (30% versus 52% reside in the South).Using a ratio of the number of PrEP patients within an MSA to the number of newly diagnosed individuals with HIV infection, we found MSAs with relatively low uptake of PrEP were concentrated in the South. Of the approximately 24,000 providers who prescribed PrEP, two-thirds reported primary care as their specialty. Compared to the types of payment methods that people living with diagnosed HIV (PLWH) used to pay for their antiretroviral treatment in 2015 to 2016 reported in the Centers for Disease Control and Prevention (CDC) HIV Surveillance Special Report, PrEP patients were more likely to have used commercial health insurance (80% versus 35%) and less likely to have used public healthcare coverage or a publicly sponsored assistance program to pay for PrEP (12% versus 45% for Medicaid). Third-party payors covered 95% of the costs of PrEP. Overall, we estimated the median annual per patient out-of-pocket spending on PrEP was approximately US$72. Limitations of this study include missing information on prescription claims of patients not included in the database, and for those included, some patients were missing information on patient diagnosis, race/ethnicity, educational attainment, and income (34%-36%). CONCLUSIONS Our findings indicate that in 2015-2016, many individuals in the US who could benefit from being on PrEP were not receiving this HIV prevention medication, and those prescribed PrEP had a significantly different distribution of characteristics from the broader population that is at risk for acquiring HIV. PrEP patients were more likely to pay for PrEP using commercial or private insurance, whereas PLWH were more likely to pay for their antiretroviral treatment using publicly sponsored programs. Addressing the affordability of PrEP and otherwise promoting its use among those with indications for PrEP represents an important opportunity to help end the HIV epidemic.
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Affiliation(s)
- Stephanie S. Chan
- US Department of Health and Human Services (HHS), Office of the Assistant Secretary for Planning and Evaluation, Office of Health Policy, Washington, DC, United States of America
- * E-mail:
| | - Andre R. Chappel
- US Department of Health and Human Services (HHS), Office of the Assistant Secretary for Planning and Evaluation, Office of Health Policy, Washington, DC, United States of America
| | - Karen E. Joynt Maddox
- Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
| | - Karen W. Hoover
- HHS, Centers for Disease Control and Prevention, Division of HV/AIDS Prevention, Epidemiology Branch, Atlanta, Georgia, United States of America
| | - Ya-lin A. Huang
- HHS, Centers for Disease Control and Prevention, Division of HV/AIDS Prevention, Epidemiology Branch, Atlanta, Georgia, United States of America
| | - Weiming Zhu
- HHS, Centers for Disease Control and Prevention, Division of HV/AIDS Prevention, Epidemiology Branch, Atlanta, Georgia, United States of America
| | - Stacy M. Cohen
- HHS, Health Resources and Services Administration, HIV/AIDS Bureau, Rockville, Maryland, United States of America
| | - Pamela W. Klein
- HHS, Health Resources and Services Administration, HIV/AIDS Bureau, Rockville, Maryland, United States of America
| | - Nancy De Lew
- US Department of Health and Human Services (HHS), Office of the Assistant Secretary for Planning and Evaluation, Office of Health Policy, Washington, DC, United States of America
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24
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Goedel WC, Mimiaga MJ, King MRF, Safren SA, Mayer KH, Chan PA, Marshall BDL, Biello KB. Potential Impact of Targeted HIV Pre-Exposure Prophylaxis Uptake Among Male Sex Workers. Sci Rep 2020; 10:5650. [PMID: 32221469 PMCID: PMC7101419 DOI: 10.1038/s41598-020-62694-5] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/04/2020] [Indexed: 11/29/2022] Open
Abstract
Little is known about the potential population-level impact of HIV pre-exposure prophylaxis (PrEP) use among cisgender male sex workers (MSWs), a high-risk subset of cisgender men who have sex with men (MSM). Using an agent-based model, we simulated HIV transmission among cisgender MSM in Rhode Island to determine the impacts of PrEP implementation where cisgender MSWs were equally ("standard expansion") or five times as likely ("focused expansion") to initiate PrEP compared to other cisgender MSM. Without PrEP, the model predicted 920 new HIV infections over a decade, or an average incidence of 0.39 per 100 person-years. In a focused expansion scenario where 15% of at-risk cisgender MSM used PrEP, the total number of new HIV infections was reduced by 58.1% at a cost of $57,180 per quality-adjusted life-year (QALY) gained. Focused expansion of PrEP use among cisgender MSWs may be an efficient and cost-effective strategy for reducing HIV incidence in the broader population of cisgender MSM.
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Affiliation(s)
- William C Goedel
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, United States
| | - Matthew J Mimiaga
- Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, Rhode Island, United States
- Fenway Institute, Fenway Health, Boston, Massachusetts, United States
| | - Maximilian R F King
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, United States
| | - Steven A Safren
- Fenway Institute, Fenway Health, Boston, Massachusetts, United States
- Department of Psychology, College of Arts and Sciences, University of Miami, Coral Gables, Florida, United States
| | - Kenneth H Mayer
- Fenway Institute, Fenway Health, Boston, Massachusetts, United States
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
- Department of Global Health and Population, T.H. Chan School of Public Health, Harvard University, Cambridge, Massachusetts, United States
| | - Philip A Chan
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, United States
| | - Brandon D L Marshall
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, United States.
| | - Katie B Biello
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, United States
- Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, Rhode Island, United States
- Fenway Institute, Fenway Health, Boston, Massachusetts, United States
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25
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Walker SM, Cox E, Revill P, Musiime V, Bwakura‐Dangarembizi M, Mallewa J, Cheruiyot P, Maitland K, Ford N, Gibb DM, Walker AS, Soares M. The cost-effectiveness of prophylaxis strategies for individuals with advanced HIV starting treatment in Africa. J Int AIDS Soc 2020; 23:e25469. [PMID: 32219991 PMCID: PMC7099175 DOI: 10.1002/jia2.25469] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 01/14/2020] [Accepted: 02/06/2020] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Many HIV-positive individuals in Africa have advanced disease when initiating antiretroviral therapy (ART) so have high risks of opportunistic infections and death. The REALITY trial found that an enhanced-prophylaxis package including fluconazole reduced mortality by 27% in individuals starting ART with CD4 <100 cells/mm3 . We investigated the cost-effectiveness of this enhanced-prophylaxis package versus other strategies, including using cryptococcal antigen (CrAg) testing, in individuals with CD4 <200 cells/mm3 or <100 cells/mm3 at ART initiation and all individuals regardless of CD4 count. METHODS The REALITY trial enrolled from June 2013 to April 2015. A decision-analytic model was developed to estimate the cost-effectiveness of six management strategies in individuals initiating ART in the REALITY trial countries. Strategies included standard-prophylaxis, enhanced-prophylaxis, standard-prophylaxis with fluconazole; and three CrAg testing strategies, the first stratifying individuals to enhanced-prophylaxis (CrAg-positive) or standard-prophylaxis (CrAg-negative), the second to enhanced-prophylaxis (CrAg-positive) or enhanced-prophylaxis without fluconazole (CrAg-negative) and the third to standard-prophylaxis with fluconazole (CrAg-positive) or without fluconazole (CrAg-negative). The model estimated costs, life-years and quality-adjusted life-years (QALY) over 48 weeks using three competing mortality risks: cryptococcal meningitis; tuberculosis, serious bacterial infection or other known cause; and unknown cause. RESULTS Enhanced-prophylaxis was cost-effective at cost-effectiveness thresholds of US$300 and US$500 per QALY with an incremental cost-effectiveness ratio (ICER) of US$157 per QALY in the CD4 <200 cells/mm3 population providing enhanced-prophylaxis components are sourced at lowest available prices. The ICER reduced in more severely immunosuppressed individuals (US$113 per QALY in the CD4 <100 cells/mm3 population) and increased in all individuals regardless of CD4 count (US$722 per QALY). Results were sensitive to prices of the enhanced-prophylaxis components. Enhanced-prophylaxis was more effective and less costly than all CrAg testing strategies as enhanced-prophylaxis still conveyed health gains in CrAg-negative patients and savings from targeting prophylaxis based on CrAg status did not compensate for costs of CrAg testing. CrAg testing strategies did not become cost-effective unless the price of CrAg testing fell below US$2.30. CONCLUSIONS The REALITY enhanced-prophylaxis package in individuals with advanced HIV starting ART reduces morbidity and mortality, is practical to administer and is cost-effective. Efforts should continue to ensure that components are accessed at lowest available prices.
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Affiliation(s)
| | - Edward Cox
- Centre for Health EconomicsUniversity of YorkYorkUK
| | - Paul Revill
- Centre for Health EconomicsUniversity of YorkYorkUK
| | | | | | - Jane Mallewa
- College of MedicineUniversity of Malawi and Malawi‐Liverpool‐Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
| | | | - Kathryn Maitland
- KEMRI Wellcome Trust Research ProgrammeKilifiKenya
- Department of Infectious DiseasesImperial CollegeLondonUK
| | - Nathan Ford
- HIV/AIDS Department and Global Hepatitis ProgrammeWorld Health OrganizationGenevaSwitzerland
| | | | | | - Marta Soares
- Centre for Health EconomicsUniversity of YorkYorkUK
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Tucker A, Tembo T, Tampi RP, Mutale J, Mukumba‐Mwenechanya M, Sharma A, Dowdy DW, Moore CB, Geng E, Holmes CB, Sikazwe I, Sohn H. Redefining and revisiting cost estimates of routine ART care in Zambia: an analysis of ten clinics. J Int AIDS Soc 2020; 23:e25431. [PMID: 32064766 PMCID: PMC7025092 DOI: 10.1002/jia2.25431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 10/11/2019] [Accepted: 11/20/2019] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Accurate costing is key for programme planning and policy implementation. Since 2011, there have been major changes in eligibility criteria and treatment regimens with price reductions in ART drugs, programmatic changes resulting in clinical task-shifting and decentralization of ART delivery to peripheral health centres making existing evidence on ART care costs in Zambia out-of-date. As decision makers consider further changes in ART service delivery, it is important to understand the current drivers of costs for ART care. This study provides updates on costs of ART services for HIV-positive patients in Zambia. METHODS We evaluated costs, assessed from the health systems perspective and expressed in 2016 USD, based on an activity-based costing framework using both top-down and bottom-up methods with an assessment of process and capacity. We collected primary site-level costs and resource utilization data from government documents, patient chart reviews and time-and-motion studies conducted in 10 purposively selected ART clinics. RESULTS The cost of providing ART varied considerably among the ten clinics. The average per-patient annual cost of ART service was $116.69 (range: $59.38 to $145.62) using a bottom-up method and $130.32 (range: $94.02 to $162.64) using a top-down method. ART drug costs were the main cost driver (67% to 7% of all costs) and are highly sensitive to the types of patient included in the analysis (long-term vs. all ART patients, including those recently initiated) and the data sources used (facility vs. patient level). Missing capacity costs made up 57% of the total difference between the top-down and bottom-up estimates. Variability in cost across the ten clinics was associated with operational characteristics. CONCLUSIONS Real-world costs of current routine ART services in Zambia are considerably lower than previously reported estimates and sensitive to operational factors and methods used. We recommend collection and monitoring of resource use and capacity data to periodically update cost estimates.
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Affiliation(s)
- Austin Tucker
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Tannia Tembo
- Center for Infectious Disease Research (CIDRZ)LusakaZambia
| | - Radhika P Tampi
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Jacob Mutale
- Center for Infectious Disease Research (CIDRZ)LusakaZambia
| | | | - Anjali Sharma
- Center for Infectious Disease Research (CIDRZ)LusakaZambia
| | - David W Dowdy
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Carolyn B Moore
- Center for Infectious Disease Research (CIDRZ)LusakaZambia
- University of AlabamaBirminghamALUSA
| | - Elvin Geng
- Department of Internal MedicineWashington University School of Medicine in St. LouisSt. LouisMOUSA
- Center for Dissemination and ImplementationInstitute for Public Health at Washington University in St. LouisSt. LouisMOUSA
| | - Charles B Holmes
- Center for Infectious Disease Research (CIDRZ)LusakaZambia
- Johns Hopkins University School of MedicineBaltimoreMDUSA
- Georgetown University School of MedicineWashingtonDCUSA
| | | | - Hojoon Sohn
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
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Millham LRI, Scott JA, Sax PE, Shebl FM, Reddy KP, Losina E, Walensky RP, Freedberg KA. Clinical and Economic Impact of Ibalizumab for People With Multidrug-Resistant HIV in the United States. J Acquir Immune Defic Syndr 2020; 83:148-156. [PMID: 31929403 PMCID: PMC7066538 DOI: 10.1097/qai.0000000000002241] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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] [Indexed: 11/25/2022]
Abstract
BACKGROUND We projected the clinical outcomes, cost-effectiveness, and budget impact of ibalizumab plus an optimized background regimen (OBR) for people with multidrug-resistant (MDR) HIV in the United States. METHODS Using the Cost-Effectiveness of Preventing AIDS Complications microsimulation model and a health care sector perspective, we compared 2 treatment strategies for MDR HIV: (1) IBA + OBR-ibalizumab plus OBR and (2) OBR-OBR alone. Ibalizumab efficacy and cohort characteristics were from trial data: mean age 49 years, 85% male, and mean CD4 150/µL. Six-month viral suppression was 50% with IBA + OBR and 0% with OBR. The ibalizumab loading dose cost $10,500, and subsequent ibalizumab injections cost $8400/month; OBR cost $4500/month. Incremental cost-effectiveness ratios (ICERs) were calculated using discounted (3%/year) quality-adjusted life years (QALYs) and costs. ICERs ≤$100,000/QALY were considered cost-effective. We performed sensitivity analysis on key parameters and examined budget impact. RESULTS In the base case, 5-year survival increased from 38% with OBR to 47% with IBA + OBR. Lifetime costs were $301,700/person with OBR and $661,800/person with IBA + OBR; the ICER for IBA + OBR compared with OBR was $260,900/QALY. IBA + OBR was not cost-effective even with 100% efficacy. IBA + OBR became cost-effective at base case efficacy if ibalizumab cost was reduced by ≥88%. For an estimated 12,000 people with MDR HIV in the United States, IBA + OBR increased care costs by $1.8 billion (1.5% of total treatment budget) over 5 years. CONCLUSIONS For people with MDR HIV lacking other treatment options, ibalizumab will substantially increase survival when effective. Although adding ibalizumab to OBR is not cost-effective, the low number of eligible patients in the United States makes the budget impact relatively small.
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Affiliation(s)
- Lucia R I Millham
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Justine A Scott
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Paul E Sax
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA
| | - Fatma M Shebl
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Krishna P Reddy
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Elena Losina
- Harvard Medical School, Boston, MA
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Rochelle P Walensky
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
- Harvard University Center for AIDS Research, Cambridge, MA; and
| | - Kenneth A Freedberg
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
- Harvard University Center for AIDS Research, Cambridge, MA; and
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
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Ward T, Sugrue D, Hayward O, McEwan P, Anderson SJ, Lopes S, Punekar Y, Oglesby A. Estimating HIV Management and Comorbidity Costs Among Aging HIV Patients in the United States: A Systematic Review. J Manag Care Spec Pharm 2020; 26:104-116. [PMID: 32011956 PMCID: PMC10391104 DOI: 10.18553/jmcp.2020.26.2.104] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND As life expectancy of patients infected with human immunodeficiency virus (HIV) approaches that of the general population, the composition of HIV management costs is likely to change. OBJECTIVES To (a) review treatment and disease management costs in HIV, including costs of adverse events (AEs) related to antiretroviral therapy (ART) and long-term toxicities, and (b) explore the evolving cost drivers. METHODS A targeted literature review between January 2012 and November 2017 was conducted using PubMed and major conferences. Articles reporting U.S. costs of HIV management, acquired immunodeficiency syndrome (AIDS)-defining events, end of life care, and ART-associated comorbidities such as cardiovascular disease (CVD), chronic kidney disease (CKD), and osteoporosis were included. All costs were inflated to 2017 U.S. dollars. A Markov model-based analysis was conducted to estimate the effect of increased life expectancy on costs associated with HIV treatment and management. RESULTS 22 studies describing HIV costs in the United States were identified, comprising 16 cost-effectiveness analysis studies, 5 retrospective analyses of health care utilization, and 1 cost analysis in a resource-limited setting. Management costs per patient per month, including routine care costs (on/off ART), non-HIV medication, opportunistic infection prophylaxis, inpatient utilization, outpatient utilization, and emergency department utilization were reported as CD4+ cell-based health state costs ranging from $1,192 for patients with CD4 > 500 cells/mm3 to $2,873 for patients with CD4 < 50 cells/mm3. Event costs for AEs ranged from $0 for headache, pain, vomiting, and lipodystrophy to $31,545 for myocardial infarction. The mean monthly per-patient costs for CVD management, CKD management, and osteoporosis were $5,898, $6,108, and $4,365, respectively. Improvements in life expectancy, approaching that of the general population in 2018, are projected to increase ART-related and AE costs by 35.4% and comorbidity costs by 175.8% compared with estimated costs with HIV life expectancy observed in 1996. CONCLUSIONS This study identified and summarized holistic cost estimates appropriate for use within U.S. HIV cost-effectiveness analyses and demonstrates an increasing contribution of comorbidity outcomes, primarily associated with aging in addition to long-term treatment with ART, not typically evaluated in contemporary HIV cost-effectiveness analyses. DISCLOSURES This analysis was sponsored by ViiV Healthcare, which had no role in the analyses and interpretation of study results. Ward, Sugrue, Hayward, and McEwan are employees of HEOR Ltd, which received funding from ViiV Healthcare to conduct this study. Anderson is an employee of GlaxoSmithKline and holds shares in the company. Punekar and Oglesby are employees of ViiV Healthcare and hold shares in GlaxoSmithKline. Lopes was employed by ViiV Healthcare at the time of the study and holds shares in GlaxoSmithKline.
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Affiliation(s)
| | | | | | | | | | - Sara Lopes
- ViiV Healthcare, Brentford, United Kingdom
| | | | - Alan Oglesby
- ViiV Healthcare, Research Triangle, North Carolina
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Benson C, Emond B, Lefebvre P, Lafeuille MH, Côté-Sergent A, Tandon N, Chow W, Dunn K. Rapid Initiation of Antiretroviral Therapy Following Diagnosis of Human Immunodeficiency Virus Among Patients with Commercial Insurance Coverage. J Manag Care Spec Pharm 2020; 26:129-141. [PMID: 31747358 PMCID: PMC10391294 DOI: 10.18553/jmcp.2019.19175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND New guidelines for the treatment of human immunodeficiency virus (HIV) advocate for rapid initiation of antiretroviral therapy (ART) ≤ 7 days after HIV diagnosis with agents that have a high genetic barrier to resistance, good tolerability, and convenient dosing. OBJECTIVE To describe characteristics, time to ART initiation, and health care costs in commercially insured patients living with HIV in the United States who are treated ≤ 60 days after HIV diagnosis. METHODS IBM MarketScan Research Databases (January 1, 2012-December 31, 2017) were used to identify ART-naive adults with HIV-1, ≥ 6 months of continuous eligibility before first HIV diagnosis, and ART initiation ≤ 60 days of first diagnosis. ART regimen had to include a protease inhibitor (PI), an integrase strand transfer inhibitor (INSTI), or a non-nucleoside reverse transcriptase inhibitor (NNRTI) with ≥ 2 nucleoside reverse transcriptase inhibitors. Cohorts were formed based on time to ART initiation after diagnosis: ≤ 7 days or 8-60 days. Health care costs were evaluated at 6, 12, 24, and 36 months after diagnosis among patients with ≥ 36 months of continuous eligibility. RESULTS Among 9,351 patients, median time to treatment was 31.0 days. Patients initiating ART > 60 days after HIV diagnosis were excluded (N = 2,608 [27.9%]), while 6,743 (72.1%) initiated ART ≤ 60 days after diagnosis and were analyzed; 18.3% and 81.7% were classified in the ≤ 7 days and 8-60 days cohorts, respectively. For all analyzed patients, mean age was 38.0 (SD = 12.0) years and 13.2% were female; 12.7%, 56.2%, and 31.1% initiated a PI, INSTI, or NNRTI-based regimen, respectively. Elvitegravir (32.9%), efavirenz (20.9%), dolutegravir (18.5%), and darunavir (8.5%) were the most commonly used antiretrovirals; most patients (74.3%) were initiated on single-tablet regimens. PI-based regimens were more common in the ≤ 7 days cohort (PI = 18.1%; darunavir = 11.4%) than in the 8-60 days cohort (PI = 11.5%; darunavir = 7.8%). INSTI-based regimens were more common in the 8-60 days cohort (INSTI = 57.7%; elvitegravir = 33.8%) than in the ≤ 7 days cohort (INSTI = 49.2%; elvitegravir = 29.1%). NNRTI-based regimens were as common in the ≤ 7 days (32.7%) and 8-60 days (30.7%) cohorts. Mean total accumulated costs were lower among patients in the ≤ 7 days cohort than in the 8-60 days cohort at all time points analyzed after diagnosis (e.g., 36 months: ≤ 7 days = $109,456; 8-60 days = $116,870). Total per-patient per-month costs decreased over time in the ≤ 7 days (i.e., 6 months = $4,359; 36 months = $3,040) and 8-60 days cohort (6 months = $4,727; 36 months = $3,246). CONCLUSIONS Although 72.1% of patients initiated ART ≤ 60 days after HIV diagnosis, only 18.3% initiated ART ≤ 7 days. Many patients initiating ART ≤ 7 days used suboptimal agents with low rather than high genetic barriers to resistance (i.e., efavirenz and elvitegravir) or agents (dolutegravir) coformulated with other antiretrovirals that require testing to prevent hypersensitivity reactions. Patients in the ≤ 7 days cohort showed lower total health care costs relative to those in the 8-60 days cohort, highlighting the potential long-term benefits of rapid ART initiation. DISCLOSURES This study was supported by Janssen Scientific Affairs, which was involved in the study design, interpretation of results, manuscript preparation, and publication decisions. Emond, Lefebvre, Lafeuille, and Côté-Sergent are employees of Analysis Group, a consulting company that was contracted by Janssen Scientific Affairs to conduct this study and develop the manuscript. Benson, Tandon, Chow, and Dunn are employees of Janssen Scientific Affairs and stockholders of Johnson & Johnson. Part of the material in this study has been presented at the AMCP 2019 Annual Meeting; March 25-28, 2019; San Diego, CA.
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Affiliation(s)
| | | | | | | | | | - Neeta Tandon
- Janssen Scientific Affairs, Titusville, New Jersey
| | - Wing Chow
- Janssen Scientific Affairs, Titusville, New Jersey
| | - Keith Dunn
- Janssen Scientific Affairs, Titusville, New Jersey
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Benson C, Emond B, Romdhani H, Lefebvre P, Côté-Sergent A, Shohoudi A, Tandon N, Chow W, Dunn K. Long-Term Benefits of Rapid Antiretroviral Therapy Initiation in Reducing Medical and Overall Health Care Costs Among Medicaid-Covered Patients with Human Immunodeficiency Virus. J Manag Care Spec Pharm 2020; 26:117-128. [PMID: 31747357 PMCID: PMC10391060 DOI: 10.18553/jmcp.2019.19174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND New guidelines for the treatment of human immunodeficiency virus (HIV) suggest that morbidity and mortality could be reduced if antiretroviral therapy (ART) was initiated immediately after diagnosis, regardless of CD4 cell count. OBJECTIVE To assess real-world time to ART initiation and describe medical, pharmacy, and total health care costs in the 6-, 12-, 24-, and 36-month periods after HIV diagnosis based on time to ART initiation among Medicaid-covered patients. METHODS Multistate Medicaid data (January 2012-March 2017) was used to identify adults with HIV-1 initiating ART ≤ 360 days of initial HIV-1 diagnosis. People living with HIV (PLWH) were sorted into mutually exclusive cohorts based on time from diagnosis to ART initiation (≤ 14 days, > 14 to ≤ 60 days, > 60 to ≤ 180 days, and > 180 to ≤ 360 days). ART regimen had to include a protease inhibitor, an integrase strand transfer inhibitor, or a non-nucleoside reverse transcriptase inhibitor, with ≥ 2 nucleoside reverse transcriptase inhibitors. Medical, pharmacy, and total health care costs in the 6, 12, 24, and 36 months following HIV diagnosis were stratified by timeliness of ART initiation. RESULTS Of 974 patients, 347 (35.6%) initiated ART > 360 days after diagnosis and were excluded. Among the remaining 627 eligible patients, mean age was 39.9 years, 42.7% were female, and 53.9% were black. Among them, 128 (20.4%) were treated ≤ 14 days, 228 (36.4%) between > 14 and ≤ 60 days, 163 (26.0%) between > 60 and ≤ 180 days, and 108 (17.2%) between > 180 and ≤ 360 days. Among patients treated ≤ 180 days, 4.6% had ≥ 1 opportunistic infection in the 6-month period before ART initiation; this proportion reached 5.6% for patients treated >180 and ≤ 360 days. Over the 6-, 12-, 24-, and 36-month periods after diagnosis, per-patient-per-month (PPPM) medical costs were lower for patients who initiated ART ≤ 14 days than for those who initiated > 180 and ≤ 360 days after diagnosis (6 months: $1,611 [≤ 14 days] vs. $3,008 [> 180 and ≤ 360 days]; 12 months: $1,188 vs. $2,110; 24 months: $754 vs. $1,368; 36 months: $651 vs. $1,196). Over the same periods, medical costs generally accounted for > 50% of total health care costs for patients who initiated ART between > 60 and ≤ 180 days and > 180 and ≤ 360 days and for 30%-40% of total health care costs for patients treated ≤ 14 days and between > 14 and ≤ 60 days. Total PPPM health care costs increased with delay of ART initiation in the 36-month period after diagnosis ($2,058 [treated ≤ 14 days] vs. $2,310 [treated between > 180 and ≤ 360 days]). CONCLUSIONS In this study from 2012 to 2017 of Medicaid PLWH treated with ART, 20.4% initiated ART ≤14 days of HIV diagnosis. Patients with delayed ART initiation accumulated more total health care costs in the 36-month period after HIV diagnosis than those initiated within 14 days, highlighting the long-term benefit of rapid ART initiation. An important opportunity remains to engage PLWH in care more rapidly. DISCLOSURES This study was supported by Janssen Scientific Affairs, which was involved in the study design, interpretation of results, manuscript preparation, and publication decisions. Emond, Romdhani, Lefebvre, and Côté-Sergent are employees of Analysis Group, a consulting company that was contracted by Janssen Scientific Affairs to conduct this study and develop the manuscript. Shohoudi was an employee of Analysis Group at the time the study was conducted. Benson, Tandon, Chow, and Dunn are employees and stockholders of Johnson & Johnson. Parts of the material in this study have been presented at the HIV Drug Therapy Meeting; October 28-31, 2018; Glasgow, UK, and the AMCP Annual Meeting; March 25-28, 2019; San Diego, CA.
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Affiliation(s)
| | | | | | | | | | | | - Neeta Tandon
- Janssen Scientific Affairs, Titusville, New Jersey
| | - Wing Chow
- Janssen Scientific Affairs, Titusville, New Jersey
| | - Keith Dunn
- Janssen Scientific Affairs, Titusville, New Jersey
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van Vliet MM, Hendrickson C, Nichols BE, Boucher CAB, Peters RPH, van de Vijver DAMC. Epidemiological impact and cost-effectiveness of providing long-acting pre-exposure prophylaxis to injectable contraceptive users for HIV prevention in South Africa: a modelling study. J Int AIDS Soc 2019; 22:e25427. [PMID: 31855323 PMCID: PMC6922023 DOI: 10.1002/jia2.25427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 11/08/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Although pre-exposure prophylaxis (PrEP.) is an efficacious HIV prevention strategy, its preventive benefit has not been shown among young women in sub-Saharan Africa, likely due to non-adherence. Adherence may be improved with the use of injectable long-acting PrEP methods currently being developed. We hypothesize that providing long-acting PrEP to women using injectable contraceptives, the most frequently used contraceptive method in South Africa, could improve adherence to PrEP, result in a reduction of new HIV infections, and be a relatively easy-to-reach target population. In this modelling study, we assessed the epidemiological impact and cost-effectiveness of providing long-acting PrEP to injectable contraceptive users in Limpopo, South Africa. METHODS We developed a deterministic mathematical model calibrated to the HIV epidemic in Limpopo. Long-acting PrEP was provided to 50% of HIV negative injectable contraceptive users in 2018 and scaled-up over two years. We estimated the number of HIV infections that could be averted by 2030 and the drug price of long-acting PrEP for which this intervention would be cost-effective over a time horizon of 40 years, from a healthcare payer perspective. In the base-case scenario we assumed long-acting PrEP is 75% effective in preventing HIV infections and 85% of infected individuals are on antiretroviral drug therapy (ART) by 2030. In sensitivity analyses we adjusted PrEP effectiveness and ART coverage. Costs between $519 and $1119 per disability-adjusted life-year (DALY) averted were considered potentially cost-effective, and <$519 as cost-effective. RESULTS Without long-acting injectable PrEP, 224,000 (interquartile range 176,000 to 271,000) new infections will occur by 2030; use of long-acting injectable PrEP could prevent 21,000 (17,000 to 26,000) or 9.8% (8.9% to 10.6%) new HIV infections by 2030 (including 6000 (4000 to 7000) in men). Long-acting PrEP would prevent 34,000 (29,000 to 39,000) or 12,000 (8000 to 15,000) at 75% and 95% ART coverage by 2030 respectively. To be considered potentially cost-effective the annual long-acting PrEP drug price should be <$16, and/or ART coverage remains at <85% in 2030. CONCLUSIONS Providing long-acting PrEP to injectable contraceptive users in Limpopo is only potentially cost-effective when long-acting PrEP drug prices are low. If low prices are not feasible, providing long-acting PrEP only to women at high risk of HIV infection will become important.
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Affiliation(s)
| | - Cheryl Hendrickson
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Brooke E Nichols
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | | | - Remco PH Peters
- Department of Medical MicrobiologySchool of Public Health & Primary Care (CAPHRI)Maastricht University Medical CentreMaastrichtThe Netherlands
- Anova Health InstituteJohannesburgSouth Africa
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Goedel WC, Chan PA, King MRF, Prosperi MCF, Marshall BDL, Galárraga O. Cost-Effectiveness of a Statewide Pre-Exposure Prophylaxis Program for Gay, Bisexual, and Other Men Who Have Sex with Men. R I Med J (2013) 2019; 102:36-39. [PMID: 31675786 PMCID: PMC7461153] [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] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Pre-exposure prophylaxis (PrEP) is an effective tool for preventing HIV infection among men who have sex with men (MSM), but its cost-effectiveness has varied across settings. Using an agent-based model, we projected the cost-effectiveness of a statewide PrEP program for MSM in Rhode Island over the next decade. In the absence of PrEP, the model predicted an average of 830 new HIV infections over ten years. Scaling up the existing PrEP program to cover 15% of MSM with ten or more partners each year could reduce the number of new HIV infections by 33.1% at a cost of $184,234 per quality-adjusted life-year (QALY) gained. Expanded PrEP use among MSM at high risk for HIV infection has the potential to prevent a large number of new HIV infections but the high drug-related costs may limit the cost-effectiveness of this intervention.
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Affiliation(s)
- William C Goedel
- Department of Epidemiology, School of Public Health, Brown University, Providence, RI
| | - Philip A Chan
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI
| | - Maximilian R F King
- Department of Epidemiology, School of Public Health, Brown University, Providence, RI
| | - Mattia C F Prosperi
- Department of Epidemiology, College of Public Health and Health Professions, University of Florida, Gainesville, Fl
| | - Brandon D L Marshall
- Department of Epidemiology, School of Public Health, Brown University, Providence, RI
| | - Omar Galárraga
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI
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Fatti G, Jackson D, Goga AE, Shaikh N, Eley B, Nachega JB, Grimwood A. The effectiveness and cost-effectiveness of community-based support for adolescents receiving antiretroviral treatment: an operational research study in South Africa. J Int AIDS Soc 2019; 21 Suppl 1. [PMID: 29485714 PMCID: PMC5978711 DOI: 10.1002/jia2.25041] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [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: 05/08/2017] [Accepted: 12/11/2017] [Indexed: 12/19/2022] Open
Abstract
Introduction Adolescents and youth receiving antiretroviral treatment (ART) in sub‐Saharan Africa have high attrition and inadequate ART outcomes, and evaluations of interventions improving ART outcomes amongst adolescents are very limited. Sustainable Development Goal (SDG) target 3c is to substantially increase the health workforce in developing countries. We measured the effectiveness and cost‐effectiveness of community‐based support (CBS) provided by lay health workers for adolescents and youth receiving ART in South Africa. Methods A retrospective cohort study including adolescents and youth who initiated ART at 47 facilities. Previously unemployed CBS‐workers provided home‐based ART‐related education, psychosocial support, symptom screening for opportunistic infections and support to access government grants. Outcomes were compared between participants who received CBS plus standard clinic‐based care versus participants who received standard care only. Cumulative incidences of all‐cause mortality and loss to follow‐up (LTFU), adherence measured using medication possession ratios (MPRs), CD4 count slope, and virological suppression were analysed using multivariable Cox, competing‐risks regression, generalized estimating equations and mixed‐effects models over five years of ART. An expenditure approach was used to determine the incremental cost of CBS to usual care from a provider perspective. Incremental cost‐effectiveness ratios were calculated as annual cost per patient‐loss (through death or LTFU) averted. Results Amongst 6706 participants included, 2100 (31.3%) received CBS. Participants who received CBS had reduced mortality, adjusted hazard ratio (aHR) = 0.52 (95% CI: 0.37 to 0.73; p < 0.0001). Cumulative LTFU was 40% lower amongst participants receiving CBS (29.9%) compared to participants without CBS (38.9%), aHR = 0.60 (95% CI: 0.51 to 0.71); p < 0.0001). The effectiveness of CBS in reducing attrition ranged from 42.2% after one year to 35.9% after five years. Virological suppression was similar after three years, but after five years 18.8% CBS participants versus 37.2% non‐CBS participants failed to achieve viral suppression, adjusted odds ratio = 0.24 (95% CI: 0.06 to 1.03). There were no significant differences in MPR or CD4 slope. The cost of CBS was US$49.5/patient/year. The incremental cost per patient‐loss averted was US$600 and US$776 after one and two years, respectively. Conclusions CBS for adolescents and youth receiving ART was associated with substantially reduced patient attrition, and is a low‐cost intervention with reasonable cost‐effectiveness that can aid progress towards several health, economic and equality‐related SDG targets.
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Affiliation(s)
- Geoffrey Fatti
- Kheth'ImpiloCape TownSouth Africa
- The South African Department of Science and Technology/National Research Foundation (DST‐NRF)Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA)Stellenbosch UniversityStellenboschSouth Africa
| | - Debra Jackson
- UNICEFNew YorkNYUSA
- School of Public HealthUniversity of the Western CapeCape TownSouth Africa
| | - Ameena E Goga
- Health Systems Research UnitSouth African Medical Research CouncilPretoriaSouth Africa
- Department of PaediatricsUniversity of PretoriaPretoriaSouth Africa
| | | | - Brian Eley
- Department of Paediatrics and Child HealthRed Cross War Memorial Children's HospitalUniversity of Cape TownCape TownSouth Africa
| | - Jean B Nachega
- Departments of Epidemiology, Infectious Diseases and MicrobiologyUniversity of Pittsburgh Graduate School of Public HealthPittsburghPAUSA
- Department of Medicine and Centre for Infectious DiseasesFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
- Departments of Epidemiology and International HealthJohns Hopkins University Bloomberg School of Public HealthBaltimoreMDUSA
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Galárraga O, Sosa-Rubí SG. Conditional economic incentives to improve HIV prevention and treatment in low-income and middle-income countries. Lancet HIV 2019; 6:e705-e714. [PMID: 31578955 PMCID: PMC7725432 DOI: 10.1016/s2352-3018(19)30233-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [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: 10/03/2018] [Revised: 06/24/2019] [Accepted: 07/01/2019] [Indexed: 10/25/2022]
Abstract
New and innovative approaches are needed to improve the prevention, diagnosis, and treatment of HIV in low-income and middle-income countries. Several trials use conditional economic incentives (CEIs) to improve HIV outcomes. Most CEI interventions use a traditional economic theory approach, although some interventions incorporate behavioural economics, which combines traditional economics with insights from psychology. Incentive interventions that are appropriately implemented can increase HIV testing rates and voluntary male circumcision, and they can improve other HIV prevention and treatment outcomes in certain settings in the short term. More research is needed to uncover theory-based mechanisms that increase the duration of incentive effects and provide strategies for susceptible individuals, which will help to address common constraints and biases that can influence health-related decisions.
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Affiliation(s)
- Omar Galárraga
- Brown University School of Public Health, Providence, RI, USA
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Banigbe B, Audet CM, Okonkwo P, Arije OO, Bassi E, Clouse K, Simmons M, Aliyu MH, Freedberg KA, Ahonkhai AA. Effect of PEPFAR funding policy change on HIV service delivery in a large HIV care and treatment network in Nigeria. PLoS One 2019; 14:e0221809. [PMID: 31553735 PMCID: PMC6760763 DOI: 10.1371/journal.pone.0221809] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 01/11/2019] [Accepted: 08/15/2019] [Indexed: 01/10/2023] Open
Abstract
The transition to PEPFAR 2.0 with its focus on country ownership was accompanied by substantial funding cuts. We describe the impact of this transition on HIV care in a large network of HIV clinics in Nigeria. We surveyed 30 comprehensive HIV treatment clinics to assess services supported before (October 2013-September 2014) and after (October 2014-September 2015) the PEPFAR funding policy change, the impact of these policy changes on service delivery areas, and response of clinics to the change. We compared differences in support for staffing, laboratory services, and clinical operations pre- and post-policy change using paired t-tests. We used framework analysis to assess answers to open ended questions describing responses to the policy change. Most sites (83%, n = 25) completed the survey. The majority were public (60%, n = 15) and secondary (68%, n = 17) facilities. Clinics had a median of 989 patients in care (IQR: 543-3326). All clinics continued to receive support for first and second line antiretrovirals and CD4 testing after the policy change, while no clinics received support for other routine drug monitoring labs. We found statistically significant reductions in support for viral load testing, staff employment, defaulter tracking, and prevention services (92% vs. 64%, p = 0.02; 80% vs. 20%, 100% vs. 44%, 84% vs. 16%, respectively, p<0.01 for all) after the policy change. Service delivery was hampered by interrupted laboratory services and reduced wages and staff positions leading to reduced provider morale, and compromised quality of care. Almost all sites (96%) introduced user fees to address funding shortages. Clinics in Nigeria are experiencing major challenges in providing routine HIV services as a result of PEPFAR's policy changes. Funding cutbacks have been associated with compromised quality of care, staff shortages, and reliance on fee-based care for historically free services. Sustainable HIV services funding models are urgently needed.
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Affiliation(s)
| | - Carolyn M. Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Friends in Global Health, Maputo, Mozambique
| | | | - Olujide O. Arije
- Institute of Public Health, Obafemi Awolowo University, Ile-Ife, Nigeria
| | | | - Kate Clouse
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Division of Infectious Disease, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Melynda Simmons
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Muktar H. Aliyu
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Kenneth A. Freedberg
- Division of Infectious Disease and General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Harvard University Center for AIDS Research (CFAR), Boston, Massachusetts, United States of America
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Aima A. Ahonkhai
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Division of Infectious Disease, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Division of Infectious Disease and General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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Abstract
BACKGROUND Microfinance interventions have the potential to improve HIV treatment outcomes, but the mechanisms through which they operate are not entirely clear. OBJECTIVES To construct a synthesizing conceptual framework for the impact of microfinance interventions on HIV treatment outcomes using evidence from our systematic review. METHODS We conducted a systematic review by searching electronic databases and journals from 1996 to 2018 to assess the effects of microfinance interventions on HIV treatment outcomes, including adherence, retention, viral suppression, and CD4 cell count. RESULTS All studies in the review showed improved adherence, retention, and viral suppression, but varied in CD4 cell count following participation in microfinance interventions-overall supporting microfinance's positive role in improving HIV treatment outcomes. Our synthesizing conceptual framework identifies potential mechanisms through which microfinance impacts HIV treatment outcomes through hypothesized intermediate outcomes. CONCLUSION Greater emphasis should be placed on assessing the effect mechanisms and intermediate behaviors to generate a sound theoretical basis for microfinance interventions.
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Affiliation(s)
| | - Becky Genberg
- Epidemiology Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-2, Providence, RI, 02912, USA
| | - Omar Galárraga
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-2, Providence, RI, 02912, USA.
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Adamson B, Garrison L, Barnabas RV, Carlson JJ, Kublin J, Dimitrov D. Competing biomedical HIV prevention strategies: potential cost-effectiveness of HIV vaccines and PrEP in Seattle, WA. J Int AIDS Soc 2019; 22:e25373. [PMID: 31402591 PMCID: PMC6689690 DOI: 10.1002/jia2.25373] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 07/21/2019] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Promising HIV vaccine candidates are steadily progressing through the clinical trial pipeline. Once available, HIV vaccines will be an important complement but also potential competitor to other biomedical prevention tools such as pre-exposure prophylaxis (PrEP). Accordingly, the value of HIV vaccines and the policies for rollout may depend on that interplay and tradeoffs with utilization of existing products. In this economic modelling analysis, we estimate the cost-effectiveness of HIV vaccines considering their potential interaction with PrEP and condom use. METHODS We developed a dynamic model of HIV transmission among the men who have sex with men population (MSM), aged 15-64 years, in Seattle, WA offered PrEP and HIV vaccine over a time horizon of 2025-2045. A healthcare sector perspective with annual discount rate of 3% for costs (2017 USD) and quality-adjusted life years (QALYs) was used. The primary economic endpoint is the incremental cost-effectiveness ratio (ICER) when compared to no HIV vaccine availability. RESULTS HIV vaccines improved population health and increased healthcare costs. Vaccination campaigns achieving 90% coverage of high-risk men and 60% coverage of other men within five years of introduction are projected to avoid 40% of new HIV infections between 2025 and 2045. This increased total healthcare costs by $30 million, with some PrEP costs shifted to HIV vaccine spending. HIV vaccines are estimated to have an ICER of $42,473/QALY, considered cost-effective using a threshold of $150,000/QALY. Results were most sensitive to HIV vaccine efficacy and future changes in the cost of PrEP drugs. Sensitivity analysis found ranges of 30-70% HIV vaccine efficacy remained cost-effective. Results were also sensitive to reductions in condom use among PrEP and vaccine users. CONCLUSIONS Access to an HIV vaccine is desirable as it could increase the overall effectiveness of combination HIV prevention efforts and improve population health. Planning for the rollout and scale-up of HIV vaccines should carefully consider the design of policies that guide interactions between vaccine and PrEP utilization and potential competition.
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Affiliation(s)
- Blythe Adamson
- Department of PharmacyThe Comparative Health Outcomes, Policy, and Economics (CHOICE) InstituteUniversity of WashingtonSeattleWAUSA
- Vaccine and Infectious Diseases DivisionFred Hutchinson Cancer Research CenterSeattleWAUSA
- Flatiron HealthNew YorkNYUSA
| | - Louis Garrison
- Department of PharmacyThe Comparative Health Outcomes, Policy, and Economics (CHOICE) InstituteUniversity of WashingtonSeattleWAUSA
| | - Ruanne V Barnabas
- Vaccine and Infectious Diseases DivisionFred Hutchinson Cancer Research CenterSeattleWAUSA
- Division of Allergy and Infectious DiseasesDepartment of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Josh J Carlson
- Department of PharmacyThe Comparative Health Outcomes, Policy, and Economics (CHOICE) InstituteUniversity of WashingtonSeattleWAUSA
| | - James Kublin
- Division of Allergy and Infectious DiseasesDepartment of Global HealthUniversity of WashingtonSeattleWAUSA
- HIV Vaccine Trials NetworkFred Hutchinson Cancer Research CenterSeattleWAUSA
| | - Dobromir Dimitrov
- Vaccine and Infectious Diseases DivisionFred Hutchinson Cancer Research CenterSeattleWAUSA
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Hidalgo-Tenorio C, Cortés LL, Gutiérrez A, Santos J, Omar M, Gálvez C, Sequera S, Jesús SED, Téllez F, Fernández E, García C, Pasquau J. DOLAMA study: Effectiveness, safety and pharmacoeconomic analysis of dual therapy with dolutegravir and lamivudine in virologically suppressed HIV-1 patients. Medicine (Baltimore) 2019; 98:e16813. [PMID: 31393412 PMCID: PMC6708975 DOI: 10.1097/md.0000000000016813] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Dolutegravir (DTG) has shown effectiveness in combination with rilpivirine in with experience of antiretroviral therapy (ART) and with 3TC in naïve patients (GEMINI trial). The main objectives of this real-life study were to analyze the effectiveness and safety of 3TC plus DTG in virologically suppressed HIV-1 patients and to conduct a pharmacoeconomic analysis.We conducted an observational, retrospective and multicenter study of HIV+ patients pretreated for at least 6 months with ART that was then simplified to 3TC + DTG for any reason. We gathered data on viral loads (VLs) during exposure to the DT, calculating the rate with VL < 50 copies/mL at week 48, and on associated adverse effects.The 177 HIV+ patients were collected, 77.4% male, with average age of 48.5 years and mean count of 252.2cell/μL CD4+ nadir lymphocytes; 96.6% had VL < 50 copies/mL and 674 cells/μL CD4+ lymphocytes. Median time since HIV diagnosis was 15 years, and median ART duration was 13 years, and 34.5% of patients were on mono- or dual-therapy before the switch. At week 48, 82.4% of patients had VL < 50 cop/μL using an intention-to-treat (ITT) analysis, 89.6% according to mITT, and 96.7% according to Per-Protocol analysis. 3.3% patients had virological failure (VF). These effectiveness data and costs were compared with those for 2 reference triple therapies (DTG/ABC/3TC and EVG/cobi/FTC/TAF) in a cost minimization analysis, showing cost savings with administration of DTG+3TC (2741 &OV0556;/year vs DTG/ABC/3TC and 4164 &OV0556;/year vs EVG/cobi/FTC/TAF) and in a cost-effectiveness analysis, finding the DT to be the most cost-effective approach (ICER = -548 vs DTG/ABC/3TC and ICER = -4,627&OV0556; vs EVG/cobi/FTC/TAF)The combination of 3TC with DTG appears to be a safe and effective option for the simplification of ART in pretreated and virologically stable HIV-positive patients, being cost-effective and offering the same effectiveness as the triple therapy it replaces.
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Affiliation(s)
| | - Luis López Cortés
- Department of Infectious Diseases, Virgen del Rocio University Hospitals, Seville
| | - Alicia Gutiérrez
- Department of Infectious Diseases, Virgen del Rocio University Hospitals, Seville
| | - Jesús Santos
- Unit of Infectious Diseases, Virgen de las Victoria University Hospital, Málaga
| | - Mohamed Omar
- Unit of Infectious Diseases, Hospital Complex of Jaen
| | - Carmen Gálvez
- Unit of Infectious Diseases, Hospital Torrecárdenas Hospital, Almería
| | - Sergio Sequera
- Unit of Infectious Diseases, Virgen de las Nieves University Hospital, Granada
| | | | - Franciso Téllez
- Unit of Infectious Diseases, University Hospital Puerto Real, Cádiz
| | - Elisa Fernández
- Internal medicine Service, Hospital Poniente, Almería, Spain
| | - Coral García
- Unit of Infectious Diseases, Virgen de las Nieves University Hospital, Granada
| | - Juan Pasquau
- Unit of Infectious Diseases, Virgen de las Nieves University Hospital, Granada
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Reidy M, Gardiner E, Pretorius C, Glaubius R, Torjesen K, Kripke K. Evaluating the potential impact and cost-effectiveness of dapivirine vaginal ring pre-exposure prophylaxis for HIV prevention. PLoS One 2019; 14:e0218710. [PMID: 31242240 PMCID: PMC6594614 DOI: 10.1371/journal.pone.0218710] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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: 10/26/2018] [Accepted: 06/07/2019] [Indexed: 11/19/2022] Open
Abstract
Background Expanded HIV prevention options are needed to increase uptake of HIV prevention among women, especially in generalized epidemics. As the dapivirine vaginal ring moves forward through regulatory review and open-label extension studies, the potential public health impact and cost-effectiveness of this new prevention method are not fully known. We used mathematical modeling to explore the impact and cost-effectiveness of the ring in different implementation scenarios alongside scale-up of other HIV prevention interventions. Given the knowledge gaps about key factors influencing the ring’s implementation, including potential uptake and delivery costs, we engaged in a stakeholder consultation process to elicit plausible parameter ranges and explored scenarios to identify the possible range of impact, cost, and cost-effectiveness. Methods and findings We used the Goals model to simulate scenarios of oral and ring pre-exposure prophylaxis (PrEP) implementation among female sex workers and among other women ≤21 years or >21 years with multiple male partners, in Kenya, South Africa, Uganda, and Zimbabwe. In these scenarios, we varied antiretroviral therapy (ART) coverage, dapivirine ring coverage and ring effectiveness (encompassing efficacy and adherence) by risk group. Following discussions with stakeholders, the maximum level of PrEP coverage (oral and/or ring) considered in each country was equal to modern contraception use minus condom use in the two age groups. We assessed results for 18 years, from 2018 to 2035. In South Africa, for example, the HIV infections averted by PrEP (ring plus oral PrEP) ranged from 310,000 under the highest-impact scenario (including ART held constant at 2017 levels, high ring coverage, and 85% ring effectiveness) to 55,000 under the lowest-impact scenario (including ART reaching the UNAIDS 90-90-90 targets by 2020, low ring coverage, and 30% ring effectiveness). This represented a range of 6.4% to 2.2% of new HIV infections averted. Given our assumptions, the addition of the ring results in 11% to 132% more impact than oral PrEP alone. The cost per HIV infection averted for the ring ranged from US$13,000 to US$121,000. Conclusions This analysis offers a wide range of scenarios given the considerable uncertainty over ring uptake, consistency of use, and effectiveness, as well as HIV testing, prevention, and treatment use over the next two decades. This could help inform donors and implementers as they decide where to allocate resources in order to maximize the impact of the dapivirine ring in light of funding and implementation constraints. Better understanding of the cost and potential uptake of the intervention would improve our ability to estimate its cost-effectiveness and assess where it can have the most impact.
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Affiliation(s)
- Meghan Reidy
- Avenir Health, Washington, District of Columbia, United States of America
| | | | - Carel Pretorius
- Avenir Health, Glastonbury, Connecticut, United States of America
| | - Robert Glaubius
- Avenir Health, Glastonbury, Connecticut, United States of America
| | | | - Katharine Kripke
- Avenir Health, Washington, District of Columbia, United States of America
- * E-mail:
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Belenky N, Pence BW, Cole SR, Dusetzina SB, Edmonds A, Oberlander J, Plankey M, Adedimeji A, Wilson TE, Cohen J, Cohen MH, Milam JE, Adimora AA. Impact of Medicare Part D on mental health treatment and outcomes for dual eligible beneficiaries with HIV. AIDS Care 2019; 31:505-512. [PMID: 30189747 PMCID: PMC6342646 DOI: 10.1080/09540121.2018.1516283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 05/04/2018] [Accepted: 08/21/2018] [Indexed: 10/28/2022]
Abstract
Depression is common among women with HIV and untreated depression can result in poor quality of life and worsen HIV outcomes. Women with HIV who are dually enrolled in Medicaid and Medicare faced a potential disruption in medication access when Medicare Part D was implemented in 2006. The goal of this study was to estimate the effects of Medicare Part D implementation on antidepressant use, depressive symptoms, and hospitalization in Medicaid-Medicare dual eligible women with HIV. This study used 2003-2008 data from the Women's Interagency HIV Study. The effects of Medicare Part D were estimated using a difference-in-differences approach, adjusting for temporal trends using a matched control group of Medicaid-only enrollees. Before Medicare Part D implementation, dual eligibles differed from Medicaid-only enrollees in antidepressant use and hospitalization, despite having identical prescription drug coverage through Medicaid. For dual enrollees, the transition to Medicare Part D was not associated with changes in antidepressant use, depressive symptoms, or hospitalization. We did not find disruptive effects on antidepressant use and related outcomes among dual eligibles in this study. Stable antidepressant use may be due to better access to medical care for dual eligibles through Medicare both before and after Medicare Part D implementation, which may have eclipsed any effects of the transition. It may also signal that classification of antidepressants as a protected drug class under Medicare Part D was effective in preventing psychiatric medication disruption.
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Affiliation(s)
- Nadya Belenky
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Brian W. Pence
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Stephen R. Cole
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Stacie B. Dusetzina
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Andrew Edmonds
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jonathan Oberlander
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Social Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michael Plankey
- Division of Infectious Diseases and Travel Medicine, Department of Medicine, Georgetown University, Washington, DC
| | - Adebola Adedimeji
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Tracey E. Wilson
- Department of Community Health Sciences School of Public Health, State University of New York, Downstate Medical Center, Brooklyn, New York
| | - Jennifer Cohen
- Department of Clinical Pharmacy, University of California, San Francisco, California
| | - Mardge H. Cohen
- Department of Medicine, Stroger Hospital and Rush University, Chicago, Illinois
| | - Joel E. Milam
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA
| | - Adaora A. Adimora
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- Division of Infectious Diseases, School of Medicine, The University of North Carolina at Chapel Hill, NC
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Silverman E. Once-a-day HIV Treatment: Pricey But Perhaps Worth It. Manag Care 2019; 28:33-34. [PMID: 31188122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The annual pharmacy costs for single tablet regimens were $6,100 less compared with regimens involving multiple pills, at least among HIV patients who were taking the medicines as intended, according to an Express Scripts analysis. On average, the company found that health plans could save about $4,160 per patient per year.
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Malati CY, Golin R, O'Brien L, Sugandhi N, Srivastava M, Larson C, Phelps BR. Pursuing use of optimal formulations for paediatric HIV epidemic control - a look at the use of LPV/r oral pellets and oral granules. J Int AIDS Soc 2019; 22:e25267. [PMID: 30983152 PMCID: PMC6462808 DOI: 10.1002/jia2.25267] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 03/05/2019] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Despite a significant reduction in mother-to-child transmission of HIV, an estimated 180,000 children were infected with HIV in 2017, and only 52% of children under 15 years of age living with HIV (CLHIV) are on life-saving antiretroviral therapy (ART). Without effective treatment, half of CLHIV die before the age of two years and only one in five survives to five years of age. DISCUSSION Over the past four years, the United States Food and Drug Administration tentatively approved new formulations of lopinavir/ritonavir (LPV/r) in the form of oral pellets and oral granules. However, the slow uptake of the aforementioned formulations in the low- and middle-income countries with the highest paediatric HIV burden is largely due to three challenges: limited manufacturing capacity; current unit cost of the pellets and granules; and slow uptake of these new formulations by policy makers and health care workers. CONCLUSIONS Solutions to overcome these barriers include ensuring availability of an adequate supply of LPV/r oral pellets and oral granules, considering all programmatic and clinical factors when selecting paediatric ART formulations, and leveraging current resources to decrease paediatric HIV morbidity and mortality.
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Affiliation(s)
| | - Rachel Golin
- United States Agency for International DevelopmentWashingtonDCUSA
| | | | | | - Meena Srivastava
- United States Agency for International DevelopmentWashingtonDCUSA
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Meyer-Rath G, van Rensburg C, Chiu C, Leuner R, Jamieson L, Cohen S. The per-patient costs of HIV services in South Africa: Systematic review and application in the South African HIV Investment Case. PLoS One 2019; 14:e0210497. [PMID: 30807573 PMCID: PMC6391029 DOI: 10.1371/journal.pone.0210497] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [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: 08/10/2018] [Accepted: 12/23/2018] [Indexed: 12/29/2022] Open
Abstract
Background In economic analyses of HIV interventions, South Africa is often used as a case in point, due to the availability of good epidemiological and programme data and the global relevance of its epidemic. Few analyses however use locally relevant cost data. We reviewed available cost data as part of the South African HIV Investment Case, a modelling exercise to inform the optimal use of financial resources for the country’s HIV programme. Methods We systematically reviewed publication databases for published cost data covering a large range of HIV interventions and summarised relevant unit costs (cost per person receiving a service) for each. Where no data was found in the literature, we constructed unit costs either based on available information regarding ingredients and relevant public-sector prices, or based on expenditure records. Results Only 42 (5%) of 1,047 records included in our full-text review reported primary cost data on HIV interventions in South Africa, with 71% of included papers covering ART. Other papers detailed the costs of HCT, MMC, palliative and inpatient care; no papers were found on the costs of PrEP, social and behaviour change communication, and PMTCT. The results informed unit costs for 5 of 11 intervention categories included in the Investment Case, with the remainder costed based on ingredients (35%) and expenditure data (10%). Conclusions A large number of modelled economic analyses of HIV interventions in South Africa use as inputs the same, often outdated, cost analyses, without reference to additional literature review. More primary cost analyses of non-ART interventions are needed.
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Affiliation(s)
- Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Center for Global Health and Development, Boston University, Boston, Massachusetts, United States of America
- * E-mail:
| | - Craig van Rensburg
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Calvin Chiu
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rahma Leuner
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lise Jamieson
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Steve Cohen
- Strategic Development Consultants, Pietermaritzburg, South Africa
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Pillai N, Foster N, Hanifa Y, Ndlovu N, Fielding K, Churchyard G, Chihota V, Grant AD, Vassall A. Patient costs incurred by people living with HIV/AIDS prior to ART initiation in primary healthcare facilities in Gauteng, South Africa. PLoS One 2019; 14:e0210622. [PMID: 30742623 PMCID: PMC6370193 DOI: 10.1371/journal.pone.0210622] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 03/24/2017] [Accepted: 12/29/2018] [Indexed: 11/18/2022] Open
Abstract
Purpose To quantify costs to patients of accessing HIV care prior to ART initiation. Materials and methods Using a cross-sectional study design, costs incurred by HIV-positive patients prior to ART initiation were estimated at urban primary healthcare facilities in South Africa. Costs included direct costs, indirect (productivity) costs, carer and coping costs (value of assets sold and money borrowed). The percentage of individual income spent on healthcare was calculated and compared by patient income tertiles and CD4 count strata. Results 289 patients (69% female, mean age 37 (SD: 10) years, median CD4 317 (IQR: 138–494) cells/mm3) were interviewed. The total mean monthly cost of pre-ART care was US$15.71. Indirect costs accounted for $2.59 (16.49%) of this when time was valued using the patient’s reported income. The mean monthly patient costs were $31.61, $12.78, $12.65 and $11.93 for those with a CD4 count <100, 101–350, 351–500 and >500 cells/mm3 respectively. The percentage of individual income spent on healthcare was 7.25% for those with a CD4 count <100 cells/mm3 and 4.05% for those with a CD4 count >500 cells/mm3. Conclusions Despite the provision of charge-free services at public clinics, care prior to ART initiation can be costly, particularly for the poor and unemployed. Our study adds to the growing body of evidence that highlights the need to consider policies to reduce the economic barriers to HIV service access, particularly for low income or unwell patient groups, such as improving access to disability grants.
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Affiliation(s)
- Natasha Pillai
- Social and Mathematical Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nicola Foster
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Yasmeen Hanifa
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Katherine Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Gavin Churchyard
- Aurum Institute, Johannesburg, South Africa
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Violet Chihota
- Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Alison D. Grant
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, South Africa
| | - Anna Vassall
- Social and Mathematical Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
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Adamson B, El-Sadr W, Dimitrov D, Gamble T, Beauchamp G, Carlson JJ, Garrison L, Donnell D. The Cost-Effectiveness of Financial Incentives for Viral Suppression: HPTN 065 Study. Value Health 2019; 22:194-202. [PMID: 30711064 PMCID: PMC6362462 DOI: 10.1016/j.jval.2018.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 07/15/2018] [Accepted: 09/02/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of financial incentives for human immunodeficiency virus (HIV) viral suppression compared to standard of care. STUDY DESIGN Mathematical model of 2-year intervention offering financial incentives ($70 quarterly) for viral suppression (<400 copies/ml3) based on the HPTN 065 clinical trial with HIV patients in the Bronx, NY and Washington, D.C. METHODS A disease progression model with HIV transmission risk equations was developed following guidelines from the Second Panel on Cost-Effectiveness in Health and Medicine. We used health care sector and societal perspectives, 3% discount rate, and lifetime horizon. Data sources included trial data (baseline N = 16,208 patients), CDC HIV Surveillance data, and published literature. Outcomes were costs (2017 USD), quality-adjusted life years (QALYs), HIV infections prevented, and incremental cost-effectiveness ratio (ICER). RESULTS Financial incentives for viral suppression were estimated to be cost-saving from a societal perspective and cost-effective ($49,877/QALY) from a health care sector perspective. Compared to the standard of care, financial incentives gain 0.06 QALYs and lower discounted lifetime costs by $4210 per patient. The model estimates that incentivized patients transmit 9% fewer infections than the standard-of-care patients. In the sensitivity analysis, ICER 95% credible intervals ranged from cost-saving to $501,610/QALY with 72% of simulations being cost-effective using a $150,000/QALY threshold. Modeling results are limited by uncertainty in efficacy from the clinical trial. CONCLUSIONS Financial incentives, as used in HTPN 065, are estimated to improve quality and length of life, reduce HIV transmissions, and save money from a societal perspective. Financial incentives offer a promising option for enhancing the benefits of medication in the United States.
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Affiliation(s)
- Blythe Adamson
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, WA, USA; Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
| | | | - Dobromir Dimitrov
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Theresa Gamble
- HPTN Leadership and Operations Center, Science Facilitation Department, FHI 360, Durham, NC, USA
| | - Geetha Beauchamp
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Josh J Carlson
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - Louis Garrison
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - Deborah Donnell
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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Kasaie P, Radford M, Kapoor S, Jung Y, Hernandez Novoa B, Dowdy D, Shah M. Economic and epidemiologic impact of guidelines for early ART initiation irrespective of CD4 count in Spain. PLoS One 2018; 13:e0206755. [PMID: 30395635 PMCID: PMC6218062 DOI: 10.1371/journal.pone.0206755] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 10/18/2018] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Emerging data suggest that early antiretroviral therapy (ART) could reduce serious AIDS and non-AIDS events and deaths but could also increase costs. In January 2016, the Spanish guidelines were updated to recommend ART at any CD4 count. However, the epidemiologic and economic impacts of early ART initiation in Spain remain unclear. METHODS The Johns Hopkins HIV Economic-Epidemiologic Mathematical Model (JHEEM) was utilized to estimate costs, transmissions, and outcomes in Spain over 20 years. We compared implementation of guidelines for early ART initiation to a counterfactual scenario deferring ART until CD4-counts fall below 350 cells/mm3. We additionally studied the impact of early ART initiation in combination with improvements to HIV screening, care linkage and engagement. RESULTS Early ART initiation (irrespective of CD4-count) is expected to avert 20,100 [95% Uncertainty Range (UR) 11,100-83,000] new HIV cases over the next two decades compared to delayed ART (28% reduction), at an incremental health system cost of €1.05 billion [€0.66 - €1.63] billion, and an incremental cost-effectiveness ratio (ICER) of €29,700 [€13,700 - €41,200] per QALY gained. Projected ICERs declined further over longer time horizon; e.g., an ICER of €12,691 over 30 years. Furthermore, the impact of early ART initiation was potentiated by improved HIV screening among high-risk individuals, averting an estimated 41,600 [23,200-172,200] HIV infections (a 58% decline) compared to delayed ART. CONCLUSIONS Recommendations for ART initiation irrespective of CD4-counts are cost-effective and could avert > 30% of new cases in Spain. Improving HIV diagnosis can amplify this impact.
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Affiliation(s)
- Parastu Kasaie
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - Sunaina Kapoor
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Younghee Jung
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - David Dowdy
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Maunank Shah
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
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Kinoshita M, Oka S. Migrant patients living with HIV/AIDS in Japan: Review of factors associated with high dropout rate in a leading medical institution in Japan. PLoS One 2018; 13:e0205184. [PMID: 30339665 PMCID: PMC6195273 DOI: 10.1371/journal.pone.0205184] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 08/28/2018] [Indexed: 12/27/2022] Open
Abstract
The present study aimed to identify factors associated with retention in HIV/AIDS care among migrant patients who visited the outpatient clinic of the AIDS Clinical Center, National Center for Global Health and Medicine in Tokyo, Japan. We reviewed the records of 551 selected (78 non-Japanese and 473 Japanese) patients who started visiting our clinic between 2011 and 2014. A total of 390 patients (70.8%: 38 non-Japanese and 352 Japanese) continued their visits during the study: from the date of their first visit to the end of 2015. The difference in retention rate was not significant (Incidence Rate Ratio (IRR) = 0.89, p = 0.27), but the loss-to-follow-up cases were considerably high among non-Japanese patients (n = 13, Incidence rate (IR) = 24.6 per 100,000 person-days, IRR = 3.65, p<0.01 after adjusting for time since diagnosis). The results showed, nevertheless, that there was no apparent association between retention and factors peculiar to non-Japanese. Twelve out of thirteen lost-to-follow-up non-Japanese patients held legal status to reside in Japan and were eligible for public health services. Nine had limited fluency in Japanese language, and six used alternative verbal communication. Further studies are needed to identify the factors responsible for the high dropout rate and to improve the care of migrant patients living with HIV/AIDS.
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Affiliation(s)
- Mari Kinoshita
- AIDS Clinical Center, National Center for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan
- * E-mail:
| | - Shinichi Oka
- AIDS Clinical Center, National Center for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan
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Felsher M, Szep Z, Krakower D, Martinez-Donate A, Tran N, Roth AM. "I Don't Need PrEP Right Now": A Qualitative Exploration of the Barriers to PrEP Care Engagement Through the Application of the Health Belief Model. AIDS Educ Prev 2018; 30:369-381. [PMID: 30332306 PMCID: PMC8558876 DOI: 10.1521/aeap.2018.30.5.369] [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] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
The Health Belief Model has been useful for studying uptake of HIV prevention behaviors and has had limited application to understanding utilization of pre-exposure prophylaxis (PrEP), a biomedical strategy to reduce HIV acquisition. We recruited 90 persons undergoing HIV screening and educated them about PrEP. We followed up with 35 participants approximately 3 weeks later and quantitatively assessed PrEP uptake. No participant had initiated PrEP. We conducted in-depth interviews with 15 participants to explore situational factors impacting this decision. In this paper we provide an overview of PrEP-related engagement using qualitative data to contextualize (in)action. While participants perceived PrEP as beneficial, perceived benefits did not outweigh real- and perceived barriers, such as financial and time-related constraints. In order to promote PrEP uptake, cues to action that increase the benefits of PrEP during seasons of risk, and interventions that reduce real and perceived barriers are needed.
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Affiliation(s)
- Marisa Felsher
- Drexel University, Dornsife School of Public Health, Philadelphia, Pennsylvania
| | - Zsofia Szep
- Drexel University College of Medicine, Division of Infectious Diseases and HIV Medicine, Philadelphia
| | - Douglas Krakower
- Beth Israel Deaconess Medical Center, Infectious Diseases/Department of Medicine, Boston, Massachusetts
| | - Ana Martinez-Donate
- Drexel University, Dornsife School of Public Health, Philadelphia, Pennsylvania
| | - Nguyen Tran
- Drexel University, Dornsife School of Public Health, Philadelphia, Pennsylvania
| | - Alexis M Roth
- Drexel University, Dornsife School of Public Health, Philadelphia, Pennsylvania
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Affiliation(s)
- Stefano Vella
- Director, Center for Global Health, Istituto Superiore di Sanità, Rome, Italy.
| | - David Wilson
- Global HIV/AIDS Program Director, The World Bank, Washington, DC, USA
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