Affordable HIV prevention tools are needed in Eastern and Southern Africa (ESA). Several promising long-acting pre-exposure prophylaxis (LA-PrEP) products are available or in development. However, ESA settings face severe healthcare resource constraints. We aimed to estimate the threshold price at which LA-PrEP products could be cost-effective in three ESA settings.
We adapted an agent-based model, EMOD-HIV, to simulate LA-PrEP (monthly oral, 2- and 6-monthly injectable) rollout in South Africa, Zimbabwe and Kenya. Due to uncertainties about LA-PrEP use, we examined a range of coverages (5%−20% of HIV-negative sexually active adults) and extents to which LA-PrEP use will be concentrated among those most at risk (prioritized rollout from higher- to lower-risk groups vs. uniform rollout among sexually active adults). To evaluate a 20-year commitment to LA-PrEP delivery, we assumed LA-PrEP was scaled up to target coverage from 2025 to 2030 and maintained at target levels before ending in 2045. We estimated maximum per-dose and per-year LA-PrEP costs that achieve cost-effectiveness (<US$500 per disability-adjusted life-year averted) over 35 years (until 2060), compared to a scenario of daily oral PrEP only. Sensitivity analyses varied PrEP scale-up speeds and eligible populations.
Risk-prioritized LA-PrEP for 5% of adults was projected to avert 11–21% of HIV acquisitions across settings, with 3–5 times more HIV acquisitions averted and 3–5 times higher maximum cost compared to non-prioritized rollout. Six-monthly injectable PrEP supported the highest per-dose cost: in the scenario with the most cost-effective LA-PrEP use (5% risk-prioritized rollout), the maximum per-dose price in South Africa was $52.99 (95% CI: $48.82–$57.21), in Zimbabwe $14.64 (95% CI: $12.04–$17.38) and in western Kenya $7.50 (95% CI: $6.73–$8.27). For monthly oral PrEP, corresponding per-dose costs were $5.02 (95% CI: $4.67–$5.37), $1.45 (95% CI: $1.10–$1.79) and $0.87 (95% CI: $0.80–$0.93). Results were sensitive to eligible population and prioritization, and moderately sensitive to scale-up speed and product effectiveness.
LA-PrEP is likely to require reduced pricing and/or risk-prioritized rollout to be cost-effective in ESA.
There has been significant progress in the rollout of oral pre-exposure prophylaxis (PrEP) for the prevention of HIV. The introduction of long-acting prevention methods holds the potential to improve HIV prevention uptake and use, however, presents unique complexities regarding HIV diagnosis and potential for resistance. Quantifying and understanding the scenarios within which seroconversions occur may help to inform approaches to identifying acute HIV in programmes delivering PrEP at scale.
This paper documents ctra series of seroconversions within a large implementation study conducted in eight Department of Health facilities and four linked mobile clinics in four areas of South Africa. Using routinely collected data, we conducted a descriptive analysis of clients who seroconverted after initiating oral PrEP and determined the distribution of time from oral PrEP initiation to seroconversion as well as the proportion of days covered by oral PrEP. A seroconversion was defined as any HIV-positive diagnosis after initiation of PrEP. Time to seroconversion was calculated as the number of days between the first PrEP initiation and the date of HIV diagnosis. The proportion of days covered by PrEP was calculated as the number of days of PrEP prescribed over the number of days between PrEP initiation and HIV seroconversion. We conducted a logistic regression to determine factors associated with seroconversion.
Of the 11,882 clients initiated on PrEP between January 2019 and October 2022 who attended at least one follow-up visit, 112 (0.9%) seroconverted after PrEP initiation. Among those who seroconverted, the median proportion of days covered by PrEP between initiation and seroconversion was 33%. In the period between PrEP initiation and seroconversion, almost all (n = 93, 83.0%) had not used PrEP consistently, with only 19 (17.0%) having consistent PrEP use, all of whom were identified at the 1-month follow-up visit and were likely missed acute acquisitions. Younger age and geographical area were associated with seroconversion.
This study reports a low number of seroconversions among a large cohort of PrEP users in a real-world implementation study, the majority of which occurred among clients who had interrupted or discontinued PrEP use.
In the current era of universal antiretroviral treatment (ART), health systems have the dual challenge of a growing number of people living with HIV and on ART who are also receiving chronic, life-long treatment for non-communicable diseases. Current evidence suggests that 6-month multi-month dispensing (6MMD) can maintain at least equivalent clinical outcomes to conventional care and reduce costs, but little is known when integrating 6MMD for multiple conditions. We examined the cost-effectiveness of integrated multi-month drug dispensing for people living with HIV and hypertension.
Using an age- and sex-specific hybrid decision tree and Markov state-transition model, we constructed a 100,000-person simulated population cohort who may develop HIV and hypertension and initiate treatment at clinics in South Africa over a 10-year time horizon. We assessed the incremental costs and effectiveness of 6MMD versus conventional care from a health system perspective under different conditions of care-seeking, eligibility and uptake of 6MMD for clinically stable patients. Model inputs were sourced from previously published literature. 6MMD was defined as reducing the frequency of clinic visits by increasing the number of medications dispensed to stable patients at each visit from 3 to 6 months. For the integrated 6MMD, we assumed that comorbid patients receive both HIV and hypertension drugs at the same facility on the same day.
Our study demonstrates that integrated 6MMD for HIV and hypertension in South Africa can avert between 0.8 and 1 DALYs and increase health systems costs between $24 and $49 per patient per year, compared to the status quo. One-way sensitivity analysis showed that HTN drug cost and prevalence of HIVHTN and HIV were key drivers in the cost per DALYs averted. Overall, integrated 6MMD with a greater proportion of well-controlled patients and lower mortality rates led to greater cost savings or better cost-effectiveness (less than $50 per DALY averted) across a wide range of loss-to-follow-up (LTFU) factor variation.
By better controlling disease among patients already in care, integrated 6MMD can be more beneficial than the status quo treatment by resulting in fewer cases of LTFU and fewer deaths through high-quality care.
Hepatitis C virus (HCV) prevalence and adverse outcomes are higher among people with human immunodeficiency virus (HIV) than people without HIV. Yet, HCV prevalence among people with HIV in Cameroon remains unknown, with HCV diagnosis and treatment largely inaccessible due to care centralization by specialists with high out-of-pocket costs. Integration of HCV services into routine HIV care by general practitioners could improve diagnosis and treatment coverage. We aimed to examine HCV prevalence and treatment cure rate among people with HIV attending 11 HIV clinics in the Centre Region of Cameroon.
We offered HCV rapid antibody testing, and, if positive, RNA testing to all persons ≥21 years, on HIV ART for ≥6 months and with suppressed HIV RNA (<1000 copies) who attended HIV counselling and treatment appointments between 20 April 2021 and 31 May 2022. Participants with an HCV RNA positive test received 12 weeks of pangenotypic sofosbuvir/velpatasvir. We calculated the cure rate as the proportion of participants with a sustained virological response 12 weeks after treatment completion (SVR12) among all starting and completing treatment.
We tested 8266 persons for HCV antibodies, 316 (3.8%, 95% CI = 3.4−4.3%) of whom were anti-HCV positive. Of these, 286 (90.5%) were sampled for HCV RNA, 20 (6.3%) ineligible, 5 (1.6%) declined, 4 (1.3%) left before sampling and 1 (0.3%) had an unknown reason. Among 286 sampled, 251 (87.8%) had detectable HCV RNA. Of these, 173 (68.9%) enrolled for treatment, 55 (21.9%) were eligible but not enrolled (49 lost-to-follow-up, 6 denied) and 23 (9.2%) were ineligible. Of 173 enrolled, 165 completed treatment, 6 were lost-to-follow-up and 2 were excluded due to treatment interruption. SVR12 was achieved in 93.6% (n = 162; 95% CI: 88.9–96.8%) of those enrolled and 98.2% (95% CI: 94.8–99.6%) of treatment completers. All three initially not achieving SVR12 were cured with second-line treatment (sofosbuvir/velpatasvir/voxilaprevir).
Our study demonstrates the viability of integrating HCV testing and treatment into routine HIV care in Cameroon, yielding new HCV diagnoses and high cure rates. Cameroon can use this strategy to achieve HCV elimination goals, although improvements in testing uptake, diagnosis and treatment access, and laboratory capacity are needed.
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