The Cost-Effectiveness of Directly Observed Highly-Active Antiretroviral Therapy in the Third Trimester in HIV-Infected Pregnant Women

McCabe, Caitlin; Goldie, Sue J.; Fisman, David N.

doi:10.1371/journal.pone.0010154

Cited by 25 publications

(55 citation statements)

References 76 publications

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“…The recent changes in WHO recommendations to consider where feasible, the use of cART (instead of single-dose NVP) for prophylaxis in pregnant women reflect the increased effectiveness in PMTCT of longer and more complex regimens [2, 85–87] for the mother coupled with extension of maternal or infant prophylaxis during the neonatal/breastfeeding period [88–90]. The WHO has also endorsed consideration of the approach of initiating life-long cART in all pregnant women regardless of CD4 count, which has been adopted as national policy in Malawi [91, 92]. These new recommendations reflect the benefits of earlier initiation of ART for maternal health and infant survival, as well as to optimize PMTCT.…”

Section: Discussionmentioning

confidence: 99%

“…Indeed, a trial with peer mentors to improve maternal ART adherence antenatally and at the time of birth is underway in South Africa [90]. Furthermore, using a mathematical model McCabe et al [91] found that programs aimed at optimizing ART adherence using directly observed therapy would be cost-effective to decrease MTCT. Another trial, also underway in South Africa, is investing the role of male involvement on PMTCT ART adherence [92].…”

Section: Discussionmentioning

confidence: 99%

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Adherence to antiretroviral therapy during and after pregnancy in low-income, middle-income, and high-income countries

Nachega

Uthman

Anderson

et al. 2012

Aids

426

428

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Objective To estimate ART adherence rates during pregnancy and postpartum in high-, middle- and low-income countries. Design Systematic review and meta-analysis Methods MEDLINE, EMBASE, SCI Web of Science, NLM Gateway and Google scholar databases were searched. We included all studies reporting adherence rates as a primary or secondary outcome among HIV-infected pregnant women. Two independent reviewers extracted data on adherence and study characteristics. A random-effects model was used to pool adherence rates; sensitivity, heterogeneity, and publication bias were assessed. Results Of 72 eligible articles, 51studies involving 20,153 HIV-infected pregnant women were included. Most studies were from United States (n=14, 27%) followed by Kenya (n=6, 12%), South Africa (n=5, 10%), and Zambia (n=5, 10%). The threshold defining good adherence to ART varied across studies (>80%, >90%, >95%, 100%). A pooled analysis of all studies indicated a pooled estimate of 73.5% (95% confidence interval [CI] 69·3–77·5%, I2=97·7%) of pregnant women had adequate (>=80%) ART adherence. The pooled proportion of women with adequate adherence levels was higher during the antepartum (75·7%, 95% CI 71·5–79·7%) than during postpartum (53·0%, 95% 32.8% to 72·7%) (p=0·005). Selected reported barriers for non-adherence included physical, economic and emotional stresses, depression (especially post-delivery), alcohol or drug use, and ART dosing frequency or pill burden. Conclusion Our findings indicate that only 73·5% of pregnant women achieved optimal ART adherence. Reaching adequate ART adherence levels was a challenge in pregnancy, but especially during the postpartum period. Further research to investigate specific barriers and interventions to address them are urgently needed globally.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Adherence to antiretroviral therapy during and after pregnancy in low-income, middle-income, and high-income countries

Nachega

Uthman

Anderson

et al. 2012

Aids

426

428

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“…The models examined how a variety of HIV interventions such as vaccination [17-22], circumcision [23,24], condom usage [25-32], reduction in concurrency [25,26,29,32-34], HIV testing [15,28,35-37], anti-retroviral treatment [19,22,37-39], STD control [25,29,30,40-45], and prevention of mother to child transmission [18,46,47] can affect HIV incidence and prevalence in a wide variety of settings including North America [15,26,46], Australia [20,35,36] and sub-Saharan Africa [18,19,21,23-25,27,29,30,32-34,37-45,47]. These analyses were able to discuss the effects of interventions in less researched and accessible populations like MSM [15,17,20,22,26,28,35,36] and IDU [15,48].…”

Section: Discussionmentioning

confidence: 99%

Individual-Based Simulation Models of HIV Transmission: Reporting Quality and Recommendations

2013

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BackgroundIndividual-based modeling is a growing technique in the HIV transmission and prevention literature, but insufficient attention has been paid to formally evaluate the quality of reporting in this field. We present reporting recommendations for individual-based models for HIV treatment and prevention, assess the quality of reporting in the existing literature, and comment on the contribution of this model type to HIV policy and prediction.MethodsWe developed reporting recommendations for individual-based HIV transmission mathematical models, and through a systematic search, used them to evaluate the reporting in the existing literature. We identified papers that employed individual-based simulation models and were published in English prior to December 31, 2012. Articles were included if the models they employed simulated and tracked individuals, simulated HIV transmission between individuals in a particular population, and considered a particular treatment or prevention intervention. The papers were assessed with the reporting recommendations.FindingsOf 214 full text articles examined, 32 were included in the evaluation, representing 20 independent individual-based HIV treatment and prevention mathematical models. Manuscripts universally reported the objectives, context, and modeling conclusions in the context of the modeling assumptions and the model’s predictive capabilities, but the reporting of individual-based modeling methods, parameterization and calibration was variable. Six papers discussed the time step used and one discussed efforts to maintain internal validity in coding.ConclusionIndividual-based models represent detailed HIV transmission processes with the potential to contribute to inference and policy making for many different regions and populations. The rigor in reporting of assumptions, methods, and calibration of individual-based models focused on HIV transmission and prevention varies greatly. Higher standards for reporting of statistically rigorous calibration and model assumption testing need to be implemented to increase confidence in existing and future modeling results.

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“…17,20 Our group and others have used creative approaches to optimising adherence, including the use of directly observed therapy on labour and delivery units. [27][28][29][30][31] We also found that use of an NNRTI-based regimen may be associated with increased likelihood of achieving a viral load < 400 copies/ml and <1000 copies/ml. Given updated Centers for Disease Control and Prevention guidelines recommending third-trimester HIV antibody screening in many settings across the USA, there may be an increasing proportion of HIV-infected pregnant women identified later in pregnancy.…”

Section: Discussionmentioning

confidence: 77%

Time to viral load suppression in antiretroviral‐naive and ‐experienced HIV‐infected pregnant women on highly active antiretroviral therapy: implications for pregnant women presenting late in gestation

Aziz

Sokoloff²,

Kornak

et al. 2013

BJOG

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Objective To compare time to achieve viral load <400 copies/ml and <1000 copies/ml in HIV-infected antiretroviral (ARV) -naive versus ARVexperienced pregnant women on highly active antiretroviral therapy (HAART).Design Retrospective cohort study.Setting Three university medical centers, USA.Population HIV-infected pregnant women initiated or restarted on HAART during pregnancy. MethodsWe calculated time to viral load <400 copies/ml and <1000 copies/ ml in HIV-infected pregnant women on HAART who reported at least 50% adherence, stratifying based on previous ARV exposure history.Main outcome measures Time to HIV viral load <400 copies/ml and <1000 copies/ml. ResultsWe evaluated 138 HIV-infected pregnant women, comprising 76 ARVnaive and 62 ARV-experienced. Ninety-three percent of ARV-naive women achieved a viral load < 400 copies/ml during pregnancy compared with 92% of ARV-experienced women (P = 0.82). The median number of days to achieve a viral load < 400 copies/ml in the ARV-naive cohort was 25.0 (range 3.5-133; interquartile range 16-34) days compared with 27.0 (range 8-162.5; interquartile range 18.5-54.3) days in the ARV-experienced cohort (P = 0.02). In a multiple predictor analysis, women with higher adherence (adjusted relative hazard [aRH] per 10% increase in adherence 1.29, 95% confidence interval [CI] 1.08-1.54, P = 0.01) and receiving a non-nucleotide reverse transcriptase inhibitor (NNRTI) -based regimen (aRH 2.48, 95% CI 1.33-4.63, P = 0.01) were more likely to achieve viral load <400 copies/ml earlier. Increased baseline HIV log 10 viral load was associated with a later time of achieving viral load <400 copies/ml (aRH 0.60, 95% CI 0.39-0.92, P = 0.02). In a corresponding model of time to achieve viral load <1000 copies/ml, adherence (aRH per 10% increase in adherence 1.79, 95% CI 1.34-2.39, P < 0.001), receipt of NNRTI (aRH 2.95, 95% CI 1.23-7.06, P = 0.02), and CD4 cell count (aRH per 50 count increase in CD4 1.12, 95% CI 1.03-1.22, P = 0.01) were associated with an earlier time to achieve viral load below this threshold. Increasing baseline HIV log 10 viral load was associated with a longer time of achieving viral load <1000 copies/ml (aRH 0.54, 95% CI 0.34-0.86, P = 0.01). In multiple predictor models, previous ARV exposure was not significantly associated with time to achieve viral load below thresholds of <400 copies/ml and <1000 copies/ml.Conclusions Pregnant women with 50% adherence, whether ARV-naive or ARV-experienced, on average achieve a viral load <400 copies/ml within a median of 26 days and a viral load of <1000 copies/ml within a median of 14 days of HAART initiation. Increased adherence, receipt of NNRTI-based regimen and lower baseline HIV log 10 viral load were all statistically significant predictors of earlier time to achieve viral load <400 copies/ml and <1000 copies/ ml. Increased CD4 count was statistically significant as a predictor of earlier time to achieve viral load <1000 copies/ml.

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The Cost-Effectiveness of Directly Observed Highly-Active Antiretroviral Therapy in the Third Trimester in HIV-Infected Pregnant Women

Cited by 25 publications

References 76 publications

Adherence to antiretroviral therapy during and after pregnancy in low-income, middle-income, and high-income countries

Adherence to antiretroviral therapy during and after pregnancy in low-income, middle-income, and high-income countries

Individual-Based Simulation Models of HIV Transmission: Reporting Quality and Recommendations

Time to viral load suppression in antiretroviral‐naive and ‐experienced HIV‐infected pregnant women on highly active antiretroviral therapy: implications for pregnant women presenting late in gestation

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