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Journal ArticleDOI

HIV Treatment as Prevention: Issues in Economic Evaluation

10 Jul 2012-PLOS Medicine (Public Library of Science)-Vol. 9, Iss: 7
TL;DR: Economic evaluations of antiretroviral therapy in currently existing programs and in HIV treatment as prevention (TasP) programs should use cost functions that capture cost dependence on a number of factors, such as scale and scope of delivery.
Abstract: Meyer-Rath and Over assert in another article in the July 2012 PLoS Medicine Collection, “Investigating the Impact of Treatment on New HIV Infections”, that economic evaluations of antiretroviral therapy (ART) in currently existing programs and in HIV treatment as prevention (TasP) programs should use cost functions that capture cost dependence on a number of factors, such as scale and scope of delivery, health states, ART regimens, health workers' experience, patients' time on treatment, and the distribution of delivery across public and private sectors. We argue that for particular evaluation purposes (e.g., to establish the social value of TasP) and from particular perspectives (e.g., national health policy makers) less detailed cost functions may be sufficient. We then extend the discussion of economic evaluation of TasP, describing why ART outcomes and costs assessed in currently existing programs are unlikely to be generalizable to TasP programs for several fundamental reasons. First, to achieve frequent, widespread HIV testing and high uptake of ART immediately following an HIV diagnosis, TasP programs will require components that are not present in current ART programs and whose costs are not included in current estimates. Second, the early initiation of ART under TasP will change not only patients' disease courses and treatment experiences—which can affect behaviors that determine clinical treatment success, such as ART adherence and retention—but also quality of life and economic outcomes for HIV-infected individuals. Third, the preventive effects of TasP are likely to alter the composition of the HIV-infected population over time, changing its biological and behavioral characteristics and leading to different costs and outcomes for ART.

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Citations
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Journal ArticleDOI
01 Mar 2014-AIDS
TL;DR: A rapid systematic review of the global evidence on interventions that can improve adherence to ART, including individual-level interventions and changes to the structure of ART delivery, to inform the evidence base for the 2013 WHO consolidated antiretroviral guidelines.
Abstract: Introduction: Access to antiretroviral treatment (ART) has substantially improved over the past decade. In this new era of HIV as a chronic disease, the continued success of ART will depend critically on sustained high ART adherence. The objective of this review was to systematically review interventions that can improve adherence to ART, including individual-level interventions and changes to the structure of ART delivery, to inform the evidence base for the 2013 WHO consolidated antiretroviral guidelines. Design: A rapid systematic review. Methods: We conducted a rapid systematic review of the global evidence on interventions to improve adherence to ART, utilizing pre-existing systematic reviews to identify relevant research evidence complemented by screening of databases for articles published over the past 2 years on evidence from randomized controlled trials (RCTs). We searched five databases for both systematic reviews and primary RCT studies (Cochrane Library, EMBASE, MEDLINE, Web of Science, and WHO Global Health Library); we additionally searched ClinicalTrials.gov for RCT studies. We examined intervention effectiveness by different study characteristics, in particular, the specific populations who received the intervention. Results: A total of 124 studies met our selection criteria. Eighty-six studies were RCTs. More than 20 studies have tested the effectiveness of each of the following interventions, either singly or in combination with other interventions: cognitive-behavioural interventions, education, treatment supporters, directly observed therapy, and active adherence reminder devices (such as mobile phone text messages). Although there is strong evidence that all five of these interventions can significantly increase ART adherence in some settings, each intervention has also been found not to produce significant effects in several studies. Almost half (55) of the 124 studies investigated the effectiveness of combination interventions. Combination interventions tended to have effects that were similar to those of single interventions. The evidence base on interventions in key populations was weak, with the exception of interventions for people who inject drugs. Conclusion: Tested and effective adherence-enhancing interventions should be increasingly moved into implementation in routine programme and care settings, accompanied by rigorous evaluation of implementation impact and performance. Major evidence gaps on adherence-enhancing interventions remain, in particular, on the cost-effectiveness of interventions in different settings, long-term effectiveness, and effectiveness of interventions in specific populations, such as pregnant and breastfeeding women.

218 citations

Journal ArticleDOI
TL;DR: This work describes the current uses for phylogenetics in generalized epidemics and discusses their promise for elucidating transmission patterns and informing prevention trials, and reviews logistic and technical challenges inherent to large-scale molecular epidemiological studies of generalized Epidemics and suggest potential solutions.
Abstract: Efficient and effective HIV prevention measures for generalized epidemics in sub-Saharan Africa have not yet been validated at the population level. Design and impact evaluation of such measures requires fine-scale understanding of local HIV transmission dynamics. The novel tools of HIV phylogenetics and molecular epidemiology may elucidate these transmission dynamics. Such methods have been incorporated into studies of concentrated HIV epidemics to identify proximate and determinant traits associated with ongoing transmission. However, applying similar phylogenetic analyses to generalized epidemics, including the design and evaluation of prevention trials, presents additional challenges. Here we review the scope of these methods and present examples of their use in concentrated epidemics in the context of prevention. Next, we describe the current uses for phylogenetics in generalized epidemics and discuss their promise for elucidating transmission patterns and informing prevention trials. Finally, we review logistic and technical challenges inherent to large-scale molecular epidemiological studies of generalized epidemics and suggest potential solutions.

85 citations


Cites background from "HIV Treatment as Prevention: Issues..."

  • ...To sustain an ongoing ART scale-up, and the potential widespread implementation of TasP in the future, expanded financial and public health resources will be required.(7,8) However, the most biologically effective and financially efficient way...

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Journal ArticleDOI
TL;DR: A new mathematical model is developed and applied to South Africa, finding that high ART coverage combined with high MMC coverage provides approximately the same HIV incidence reduction as TasP, for $5 billion less over 2009–2020.
Abstract: The HIV Prevention Trials Network (HPTN) 052 study, which showed the effectiveness of antiretroviral treatment in reducing HIV transmission, has been hailed as a “game changer” in the fight against HIV, prompting calls for scaling up treatment as prevention (TasP). However, it is unclear how TasP can be financed, given flat-lining support for global HIV programs. We assess whether TasP is indeed a game changer or if comparable benefits are obtainable at similar or lower cost by increasing coverage of medical male circumcision (MMC) and antiretroviral treatment (ART) at CD4 <350/μL. We develop a new mathematical model and apply it to South Africa, finding that high ART coverage combined with high MMC coverage provides approximately the same HIV incidence reduction as TasP, for $5 billion less over 2009–2020. MMC outperforms ART significantly in cost per infection averted ($1,096 vs. $6,790) and performs comparably in cost per death averted ($5,198 vs. $5,604). TasP is substantially less cost effective at $8,375 per infection and $7,739 per death averted. The prevention benefits of HIV treatment are largely reaped with high ART coverage. The most cost-effective HIV prevention strategy is to expand MMC coverage and then scale up ART, but the most cost-effective HIV-mortality reduction strategy is to scale up MMC and ART jointly. TasP is cost effective by commonly used absolute benchmarks but it is far less cost effective than MMC and ART. Given South Africa’s current annual ART spending, the $5 billion in savings offered by MMC and ART over TasP in the next decade, for similar health benefits, challenges the widely hailed status of TasP as a game changer.

80 citations


Cites background from "HIV Treatment as Prevention: Issues..."

  • ...possibility that our analysis confirms TasP to be a game changer, because TasP is likely to require additional program components that are not part of current ART programs, such as intensified HIV testing campaigns (11)....

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  • ...Compounding such uncertainties is the fact that we do not yet have reliable estimates of the resources needed for implementing TasP, nor of its population-level benefits (11)....

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  • ...TasP on morbidity and quality of life, and on economic and social outcomes, in South Africa are currently largely unknown, but in the longer run may be similar to those of ART (11)....

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  • ..., frequent testing and retesting for HIV and ensuring high ART uptake among HIV-infected people who are not yet suffering significant symptoms (11)....

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Journal ArticleDOI
TL;DR: It is hoped that this article will provide a foundation upon which greater collaborations between disciplines will be formed, and will afford deeper insights into the key factors involved, to help strengthen the support for evidence-based decision-making in HIV prevention.
Abstract: Antiretroviral therapy (ART) for those infected with HIV can prevent onward transmission of infection, but biological efficacy alone is not enough to guide policy decisions about the role of ART in reducing HIV incidence. Epidemiology, economics, demography, statistics, biology, and mathematical modelling will be central in framing key decisions in the optimal use of ART. PLoS Medicine, with the HIV Modelling Consortium, has commissioned a set of articles that examine different aspects of HIV treatment as prevention with a forward-looking research agenda. Interlocking themes across these articles are discussed in this introduction. We hope that this article, and others in the collection, will provide a foundation upon which greater collaborations between disciplines will be formed, and will afford deeper insights into the key factors involved, to help strengthen the support for evidence-based decision-making in HIV prevention.

68 citations

Journal ArticleDOI
02 Jan 2013-AIDS
TL;DR: If IHC use increases HIV acquisition risk, reducing IHC could reduce new HIV infections; however, this must be balanced against other important consequences, including unintended pregnancy, which impacts maternal and infant mortality.
Abstract: BACKGROUND: Some but not all observational studieshave suggested an increase in risk of HIV acquisition for women using injectable hormonal contraception (IHC). METHODS: We used country-level data to explore the effects of reducing IHC use on the number of HIV infections the number of live births and the resulting net consequenceson AIDS deaths and maternal mortality for each country. RESULTS: High IHC use coincides with high HIV incidence primarily in southern and eastern Africa. If IHC does increase the risk of HIV acquisition this could generate 27 000-130 000 infections per year globally 87-88% of which occur in this region. Reducing IHC use could result in fewer HIV infections but also a substantial increase in live births and maternal mortality in countries with high IHC use high birth rates and high maternal mortality: mainly southern and eastern Africa South-East Asia and Central and South America. For most countries the net impactof reducing IHC use on maternal and AIDS-related deaths is dependent on the magnitude of the assumed IHC-HIV interaction. CONCLUSIONS: If IHC use increases HIV acquisition risk reducing IHC could reduce new HIV infections; however this must be balanced against other important consequences including unintended pregnancy which impacts maternal and infant mortality. Unless the true effect size approaches a relative risk of 2.19 it is unlikely that reductions in IHC could result in public health benefit with the possible exception of those countries in southern Africa with the largest HIV epidemics.

68 citations

References
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Journal ArticleDOI
TL;DR: Evidence suggests that treatment supporters, directly observed therapy, mobile-phone text messages, diary cards, and food rations can effectively increase adherence in sub-Saharan Africa, but some interventions are unlikely to have large or lasting effects, and others are effective only in specific settings.
Abstract: The success of potent antiretroviral treatment for HIV infection is primarily determined by adherence. We systematically review the evidence of effectiveness of interventions to increase adherence to antiretroviral treatment in sub-Saharan Africa. We identified 27 relevant reports from 26 studies of behavioural, cognitive, biological, structural, and combination interventions done between 2003 and 2010. Despite study diversity and limitations, evidence suggests that treatment supporters, directly observed therapy, mobile-phone text messages, diary cards, and food rations can effectively increase adherence in sub-Saharan Africa. However, some interventions are unlikely to have large or lasting effects, and others are effective only in specific settings. These findings emphasise the need for more research, particularly for randomised controlled trials, to examine the effect of context and specific features of intervention content on effectiveness. Future work should assess intervention targeting and selection of interventions based on behavioural theories relevant to sub-Saharan Africa.

259 citations

Posted Content
TL;DR: In this paper, the economic impacts of antiretroviral treatment on the labor supply of adults receiving treatment and household members' labor supply were studied. But, the results were limited to the first six months after treatment initiation.
Abstract: Using longitudinal survey data from western Kenya, this paper estimates the economic impacts of antiretroviral treatment. The responses in two important outcomes are studied: (1) labor supply of adult AIDS patients receiving treatment; and (2) labor supply of patients' household members. We find that within six months after treatment initiation, there is a 20 percent increase in patients' likelihood of participating in the labor force and a 35 percent increase in weekly hours worked. Since patient health would continue to decline without treatment, these labor supply responses are underestimates of the impact of treatment on the treated. The upper bound of the treatment impact, based on plausible assumptions about the counterfactual, is considerably larger. The responses in household members' labor supply are heterogeneous, with young boys and women working significantly less after initiation of treatment. The effects on child labor are important since they suggest potential schooling impacts from treatment.

180 citations

Journal ArticleDOI
TL;DR: Using longitudinal survey data collected in collaboration with a treatment program, this paper estimates the economic impacts of antiretroviral treatment on the labor supply of treated adult AIDS patients and individuals in patients’ households.
Abstract: This brief summarizes the results of a gender impact evaluation study, entitled The economic impact of acquired immunodeficiency syndrome (AIDS) treatment : labor supply in Western Kenya, conducted between 2003 and present in Kenya. The study observed the economic impacts of antiretroviral (ARV) treatment in Western Kenya on the individual level. Within six months, there is a 20 percent increase in the likelihood of participating in the labor force and a 35 percent increase in hours worked during the past week. For women, there is a large and significant increase of 20.8 percentage points in the labor force participation rate, but no significant increase in weekly hours worked. Since men have high levels of baseline participation to begin with, most of their response to improved health takes the form of additional hours worked. For women, baseline participation is low, so labor supply is the natural margin for change. For other household members, soon after initiation of ARV treatment for adult patients, there is a negative but insignificant change in the labor force participation rates of adults in the patients' households. For women in these households, the decline in labor supply is greater but not significant. The paper finds that the labor supply of younger boys in patients' households declines after the initiation of ARV therapy. In multiple patient households, both younger and older boys, as well as other adults in the household, work less after patients receive treatment. Funding for the study derived from the Economic and Social Research Council, Pfizer, The World Bank, Yale University's Center for Interdisciplinary Research on AIDS, the National Institute of Mental Health, the Social Science Research Council, and the Calderone Program at Columbia University.

178 citations

Journal ArticleDOI
TL;DR: Expanding HIV screening and treatment simultaneously offers the greatest health benefit and is cost-effective, however, even substantial expansion of HIV screenings and treatment programs is not sufficient to markedly reduce the U.S. HIV epidemic without substantial reductions in risk behavior.
Abstract: The incidence of HIV infections in the United States has remained steady over many years This cost-effectiveness analysis found that expanding HIV testing and treatment simultaneously was more ben

170 citations


Additional excerpts

  • ...A few mathematical modeling studies have predicted the cost-effectiveness of TasP, using cost estimates derived from currently existing ART programs [4–7]....

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Journal ArticleDOI
TL;DR: A mathematical model is constructed to examine the impact and cost-effectiveness of different strategies, including earlier initiation of ART and/or PrEP, for HIV-1 prevention for serodiscordant couples.
Abstract: Background: Antiretrovirals have substantial promise for HIV-1 prevention, either as antiretroviral treatment (ART) for HIV-1–infected persons to reduce infectiousness, or as pre-exposure prophylaxis (PrEP) for HIV-1–uninfected persons to reduce the possibility of infection with HIV-1. HIV-1 serodiscordant couples in long-term partnerships (one member is infected and the other is uninfected) are a priority for prevention interventions. Earlier ART and PrEP might both reduce HIV1 transmission in this group, but the merits and synergies of these different approaches have not been analyzed. Methods and Findings: We constructed a mathematical model to examine the impact and cost-effectiveness of different strategies, including earlier initiation of ART and/or PrEP, for HIV-1 prevention for serodiscordant couples. Although the cost of PrEP is high, the cost per infection averted is significantly offset by future savings in lifelong treatment, especially among couples with multiple partners, low condom use, and a high risk of transmission. In some situations, highly effective PrEP could be cost-saving overall. To keep couples alive and without a new infection, providing PrEP to the uninfected partner could be at least as cost-effective as initiating ART earlier in the infected partner, if the annual cost of PrEP is ,40% of the annual cost of ART and PrEP is .70% effective. Conclusions: Strategic use of PrEP and ART could substantially and cost-effectively reduce HIV-1 transmission in HIV-1 serodiscordant couples. New and forthcoming data on the efficacy of PrEP, the cost of delivery of ART and PrEP, and couples behaviours and preferences will be critical for optimizing the use of antiretrovirals for HIV-1 prevention. Please see later in the article for the Editors’ Summary.

153 citations


"HIV Treatment as Prevention: Issues..." refers background in this paper

  • ...Of course, the specific components required for successful TasP will depend on the particular TasP intervention strategy—universal population-wide HIV testing and treatment will use different approaches, and incur different costs, than TasP strategies targeted at people at high risk of HIV transmission, such as HIV-infected individuals in HIV-discordant couples [2,13,20]....

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