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Estimation of the cost-effectiveness of HIV prevention portfolios for people who inject drugs in the United States: A model-based analysis.

Abstract The risks of HIV transmission associated with the opioid epidemic make cost-effective programs for people who inject drugs (PWID) a public health priority. Some of these programs have benefits beyond prevention of HIV-a critical consideration given that injection drug use is increasing across most United States demographic groups. To identify high-value HIV prevention program portfolios for US PWID, we consider combinations of four interventions with demonstrated efficacy: opioid agonist therapy (OAT), needle and syringe programs (NSPs), HIV testing and treatment (Test & Treat), and oral HIV pre-exposure prophylaxis (PrEP).
PMID
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Authors

Mayor MeshTerms

Cost-Benefit Analysis

Models, Theoretical

Keywords
Journal Title plos medicine
Publication Year Start




PMID- 28542184
OWN - NLM
STAT- MEDLINE
DA  - 20170525
DCOM- 20170620
LR  - 20170620
IS  - 1549-1676 (Electronic)
IS  - 1549-1277 (Linking)
VI  - 14
IP  - 5
DP  - 2017 May
TI  - Estimation of the cost-effectiveness of HIV prevention portfolios for people who 
      inject drugs in the United States: A model-based analysis.
PG  - e1002312
LID - 10.1371/journal.pmed.1002312 [doi]
AB  - BACKGROUND: The risks of HIV transmission associated with the opioid epidemic
      make cost-effective programs for people who inject drugs (PWID) a public health
      priority. Some of these programs have benefits beyond prevention of HIV-a
      critical consideration given that injection drug use is increasing across most
      United States demographic groups. To identify high-value HIV prevention program
      portfolios for US PWID, we consider combinations of four interventions with
      demonstrated efficacy: opioid agonist therapy (OAT), needle and syringe programs 
      (NSPs), HIV testing and treatment (Test & Treat), and oral HIV pre-exposure
      prophylaxis (PrEP). METHODS AND FINDINGS: We adapted an empirically calibrated
      dynamic compartmental model and used it to assess the discounted costs (in 2015
      US dollars), health outcomes (HIV infections averted, change in HIV prevalence,
      and discounted quality-adjusted life years [QALYs]), and incremental
      cost-effectiveness ratios (ICERs) of the four prevention programs, considered
      singly and in combination over a 20-y time horizon. We obtained epidemiologic,
      economic, and health utility parameter estimates from the literature, previously 
      published models, and expert opinion. We estimate that expansions of OAT, NSPs,
      and Test & Treat implemented singly up to 50% coverage levels can be
      cost-effective relative to the next highest coverage level (low, medium, and high
      at 40%, 45%, and 50%, respectively) and that OAT, which we assume to have
      immediate and direct health benefits for the individual, has the potential to be 
      the highest value investment, even under scenarios where it prevents fewer
      infections than other programs. Although a model-based analysis can provide only 
      estimates of health outcomes, we project that, over 20 y, 50% coverage with OAT
      could avert up to 22,000 (95% CI: 5,200, 46,000) infections and cost US$18,000
      (95% CI: US$14,000, US$24,000) per QALY gained, 50% NSP coverage could avert up
      to 35,000 (95% CI: 8,900, 43,000) infections and cost US$25,000 (95% CI:
      US$7,000, US$76,000) per QALY gained, 50% Test & Treat coverage could avert up to
      6,700 (95% CI: 1,200, 16,000) infections and cost US$27,000 (95% CI: US$15,000,
      US$48,000) per QALY gained, and 50% PrEP coverage could avert up to 37,000
      (22,000, 58,000) infections and cost US$300,000 (95% CI: US$162,000, US$667,000) 
      per QALY gained. When coverage expansions are allowed to include combined
      investment with other programs and are compared to the next best intervention,
      the model projects that scaling OAT coverage up to 50%, then scaling NSP coverage
      to 50%, then scaling Test & Treat coverage to 50% can be cost-effective, with
      each coverage expansion having the potential to cost less than US$50,000 per QALY
      gained relative to the next best portfolio. In probabilistic sensitivity
      analyses, 59% of portfolios prioritized the addition of OAT and 41% prioritized
      the addition of NSPs, while PrEP was not likely to be a priority nor a
      cost-effective addition. Our findings are intended to be illustrative, as data on
      achievable coverage are limited and, in practice, the expansion scenarios
      considered may exceed feasible levels. We assumed independence of interventions
      and constant returns to scale. Extensive sensitivity analyses allowed us to
      assess parameter sensitivity, but the use of a dynamic compartmental model
      limited the exploration of structural sensitivities. CONCLUSIONS: We estimate
      that OAT, NSPs, and Test & Treat, implemented singly or in combination, have the 
      potential to effectively and cost-effectively prevent HIV in US PWID. PrEP is not
      likely to be cost-effective in this population, based on the scenarios we
      evaluated. While local budgets or policy may constrain feasible coverage levels
      for the various interventions, our findings suggest that investments in combined 
      prevention programs can substantially reduce HIV transmission and improve health 
      outcomes among PWID.
FAU - Bernard, Cora L
AU  - Bernard CL
AUID- ORCID: http://orcid.org/0000-0002-1967-6356
AD  - Department of Management Science and Engineering, Stanford University, Stanford, 
      California, United States of America.
FAU - Owens, Douglas K
AU  - Owens DK
AD  - VA Palo Alto Health Care System, Palo Alto, California, United States of America.
AD  - Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes
      Research, Stanford University, Stanford, California, United States of America.
FAU - Goldhaber-Fiebert, Jeremy D
AU  - Goldhaber-Fiebert JD
AD  - Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes
      Research, Stanford University, Stanford, California, United States of America.
FAU - Brandeau, Margaret L
AU  - Brandeau ML
AD  - Department of Management Science and Engineering, Stanford University, Stanford, 
      California, United States of America.
LA  - eng
PT  - Journal Article
DEP - 20170524
PL  - United States
TA  - PLoS Med
JT  - PLoS medicine
JID - 101231360
SB  - IM
MH  - *Cost-Benefit Analysis
MH  - Drug Users
MH  - HIV Infections/epidemiology/*prevention & control
MH  - Humans
MH  - *Models, Theoretical
MH  - Prevalence
MH  - Primary Prevention/*economics
MH  - Substance Abuse, Intravenous/epidemiology/*prevention & control
MH  - United States/epidemiology
PMC - PMC5443477
EDAT- 2017/05/26 06:00
MHDA- 2017/06/21 06:00
CRDT- 2017/05/26 06:00
PHST- 2016/10/07 [received]
PHST- 2017/04/28 [accepted]
AID - 10.1371/journal.pmed.1002312 [doi]
AID - PMEDICINE-D-16-03267 [pii]
PST - epublish
SO  - PLoS Med. 2017 May 24;14(5):e1002312. doi: 10.1371/journal.pmed.1002312.
      eCollection 2017 May.