Modeling the Implementation of Universal Coverage for HIV Treatment as Prevention and its Impact on the HIV Epidemic

Ying, Roger; Barnabas, Ruanne V.; Williams, Brian G.

doi:10.1007/s11904-014-0232-x

Cited by 15 publications

(15 citation statements)

References 76 publications

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“…Given current efforts emphasizing the immediate treatment of all diagnosed persons [16, 17], we collapsed the second and third steps described above into a single step comprised of those with diagnosed yet untreated HIV infection. Thus, we sought to estimate the contribution of transmission from the following four steps in the HIV care continuum, those who are: undiagnosed, diagnosed but not on ART, on treatment but not suppressed, and suppressed.…”

Section: Methodsmentioning

confidence: 99%

The risk of HIV transmission at each step of the HIV care continuum among people who inject drugs: a modeling study

et al. 2017

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BackgroundPeople who inject drugs (PWID) are at continued risk for HIV in the U.S., and experience disparities across the HIV care continuum compared to other high-risk groups. Estimates of the risk of HIV transmission at each stage of the care continuum may assist in identifying public health priorities for averting incident infections among PWID, in addition to transmissions to sexual partners of PWID.MethodsWe created an agent-based model simulating HIV transmission and the HIV care continuum for PWID in New York City (NYC) in 2012. To account for sexual transmission arising from PWID to non-PWID, the simulation included the entire adult NYC population. Using surveillance data and estimates from the National HIV Behavioral Surveillance system, we simulated a dynamic sexual and injecting network. We estimated the proportion of HIV transmission events attributable to PWID in the following categories, those: without an HIV diagnosis (‘Undiagnosed’); diagnosed but not on antiretroviral therapy (ART) (‘Diagnosed − not on ART’); those who initiated ART but were not virally suppressed (‘Unsuppressed’); and, those who achieved viral suppression (‘Suppressed’).ResultsWe estimated HIV incidence among PWID to be 113 per 100,000 person-years in 2012, with an overall incidence rate for the entire adult NYC population of 33 per 100,000 person-years. Despite accounting for only 33% of the HIV-infected PWID population, the Undiagnosed were associated with 52.6% (95% simulation interval [95% SI]: 47.1–57.0%) of total transmission events. The Diagnosed − not on ART population contributed the second-largest proportion of HIV transmissions, with 36.6% (95% SI: 32.2–41.5%). The Unsuppressed population contributed 8.7% (95% SI: 5.6–11.8%), and Suppressed 2.1% (95% SI: 1.1–3.9%), relatively little of overall transmission.ConclusionsAmong PWID in NYC, more than half (53%) of transmissions were from those who were unaware of their infection status and more than 36% were due to PWID who knew their status, but were not on treatment. Our results indicate the importance of early diagnosis and interventions to engage diagnosed PWID on treatment to further suppress population-level HIV transmission. Future HIV prevention research should focus on the elimination of identified and potential barriers to the testing, diagnosis, and retention of PWID on HIV treatment.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-017-4528-9) contains supplementary material, which is available to authorized users.

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Section: Methodsmentioning

confidence: 99%

The risk of HIV transmission at each step of the HIV care continuum among people who inject drugs: a modeling study

et al. 2017

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“… 25,26 Averaging across all community HTC strategies, we estimate a cost of $25·00 per person tested (2012 US$) in sub-Saharan Africa. Mathematical modelling has increasingly been used to support analyses of effects and cost-effectiveness of changing treatment policy (recently reviewed by Ying and colleagues 42 ), but to our knowledge this analysis is the most detailed pairing of mathematical modelling with cost data for home-based testing done so far. We anticipate with interest the cost-effectiveness analyses that will accompany the large community-randomised controlled trials that are underway, 21–24 some of which are already using mathematical models to inform and monitor progress.…”

Section: Figurementioning

confidence: 99%

Cost-effectiveness of community-based strategies to strengthen the continuum of HIV care in rural South Africa: a health economic modelling analysis

et al. 2015

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SummaryBackgroundHome HIV counselling and testing (HTC) achieves high coverage of testing and linkage to care compared with existing facility-based approaches, particularly among asymptomatic individuals. In a modelling analysis we aimed to assess the effect on population-level health and cost-effectiveness of a community-based package of home HTC in KwaZulu-Natal, South Africa.MethodsWe parameterised an individual-based model with data from home HTC and linkage field studies that achieved high coverage (91%) and linkage to antiretroviral therapy (80%) in rural KwaZulu-Natal, South Africa. Costs were derived from a linked microcosting study. The model simulated 10 000 individuals over 10 years and incremental cost-effectiveness ratios were calculated for the intervention relative to the existing status quo of facility-based testing, with costs discounted at 3% annually.FindingsThe model predicted implementation of home HTC in addition to current practice to decrease HIV-associated morbidity by 10–22% and HIV infections by 9–48% with increasing CD4 cell count thresholds for antiretroviral therapy initiation. Incremental programme costs were US$2·7 million to $4·4 million higher in the intervention scenarios than at baseline, and costs increased with higher CD4 cell count thresholds for antiretroviral therapy initiation; antiretroviral therapy accounted for 48–87% of total costs. Incremental cost-effectiveness ratios per disability-adjusted life-year averted were $1340 at an antiretroviral therapy threshold of CD4 count lower than 200 cells per μL, $1090 at lower than 350 cells per μL, $1150 at lower than 500 cells per μL, and $1360 at universal access to antiretroviral therapy.InterpretationCommunity-based HTC with enhanced linkage to care can result in increased HIV testing coverage and treatment uptake, decreasing the population burden of HIV-associated morbidity and mortality. The incremental cost-effectiveness ratios are less than 20% of South Africa's gross domestic product per person, and are therefore classed as very cost effective. Home HTC can be a viable means to achieve UNAIDS' ambitious new targets for HIV treatment coverage.FundingNational Institutes of Health, Bill & Melinda Gates Foundation, Wellcome Trust.

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“…Emerging experimental and observational data have catalyzed an evolution in HIV prevention approaches highlighting the importance of the continuum of HIV care ranging from being aware of one’s diagnosis to viral suppression 1 . To date, the experimental data highlighting the link between lower viral load and decreased risk of onward transmission of HIV has focused on preventing vertical and heterosexual transmission with data from several prevention of mother to child HIV transmission (PMTCT) studies and also HPTN 052 2–4 .…”

Section: Introductionmentioning

confidence: 99%

Evaluating Respondent-Driven Sampling as an Implementation Tool for Universal Coverage of Antiretroviral Studies Among Men Who Have Sex With Men Living With HIV

Baral¹,

Ketende²,

Schwartz³

et al. 2015

JAIDS Journal of Acquired Immune Deficiency Syndromes

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Introduction The TRUST model based on experimental and observational data posits that integration of HIV prevention and universal coverage of antiretroviral treatment (UCT) at a trusted community venue provides a framework for achieving effective reduction in HIV-related morbidity and mortality among men who have sex with men (MSM) living with HIV as well as reducing HIV incidence. The analyses presented here evaluate the utility of respondent-driven sampling (RDS) as an implementation tool for engaging MSM in the TRUST intervention. Methods The TRUST integrated prevention and treatment model was established at a trusted community center serving MSM in Abuja Nigeria. Five seeds have resulted in 3–26 waves of accrual between March, 2013 and August, 2014 with results presented here characterizing HIV burden and engagement in HIV care for 722 men across study recruitment waves. For analytic purposes, the waves were collapsed into five groups; four equally spaced (0–4, 5–9, 10–14, 15–19) and one ranging from the 20 to the 26th wave with significance assessed using Pearson’s chi-squared test. Results In earlier waves, MSM were more likely to have reported testing for HIV (82.9% in waves 0–4, 47.7% in waves 20–26, p<0.01). In addition, biologically-confirmed HIV prevalence decreased from an average of 59.1 to 42.9% (p<0.05) in later waves. In earlier waves, about 80% of participants correctly reported their HIV status as compared to less than 25% in the later waves (p<0.01). Lastly, participants reporting being on ART decreased from 50% to 22.2 % in later waves (p<0.01). Conclusions Implementation science studies focused on demonstrating impact of universal HIV-treatment programs among people living with HIV necessitate different accrual methods than those focused on preventing HIV acquisition. Here, RDS was shown to be an efficient method for reaching marginalized populations of MSM living with HIV in Nigeria and engaging them in universal HIV treatment services.

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Modeling the Implementation of Universal Coverage for HIV Treatment as Prevention and its Impact on the HIV Epidemic

Cited by 15 publications

References 76 publications

The risk of HIV transmission at each step of the HIV care continuum among people who inject drugs: a modeling study

The risk of HIV transmission at each step of the HIV care continuum among people who inject drugs: a modeling study

Cost-effectiveness of community-based strategies to strengthen the continuum of HIV care in rural South Africa: a health economic modelling analysis

Evaluating Respondent-Driven Sampling as an Implementation Tool for Universal Coverage of Antiretroviral Studies Among Men Who Have Sex With Men Living With HIV

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