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- - - UNDERSTANDING THE POTENTIAL IMPACT OF A COMBINATION HIV PREVENTION INTERVENTION IN A HYPER-ENDEMIC COMMUNITY

Saturday, 4th of May 2013

• UNDERSTANDING THE POTENTIAL IMPACT OF A COMBINATION HIV PREVENTION INTERVENTION IN A HYPER-ENDEMIC COMMUNITY

Ramzi A. Alsallaq * E-mail: ramzi.alsallaq@gmail.com Affiliation: Global Health, University of Washington, Seattle, Washington, United States of America

Jared M. Baeten,  Affiliations: Global Health, University of Washington, Seattle, Washington, United States of America, Medicine, University of Washington, Seattle, Washington, United States of America, Epidemiology, University of Washington, Seattle, Washington, United States of America

Connie L. Celum, Affiliations: Global Health, University of Washington, Seattle, Washington, United States of America, Medicine, University of Washington, Seattle, Washington, United States of America, Epidemiology, University of Washington, Seattle, Washington, United States of America

James P. Hughes, Affiliation: Biostatistics, University of Washington, Seattle, Washington, United States of America

Laith J. Abu-Raddad, Affiliations: Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America, Infectious Disease Epidemiology Group, Weill Cornell Medical College - Qatar, Qatar Foundation - Education City, Doha, Qatar, Department of Public Health, Weill Cornell Medical College, Cornell University, New York, New York, United States of America

Ruanne V. Barnabas, Affiliations: Global Health, University of Washington, Seattle, Washington, United States of America, Medicine, University of Washington, Seattle, Washington, United States of America, Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America

Timothy B. Hallett Affiliation: School of Public Health, Imperial College London, London, United Kingdom

Abstract below; full text is at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0054575

Objectives

Despite demonstrating only partial efficacy in preventing new infections, available HIV prevention interventions could offer a powerful strategy when combined. In anticipation of combination HIV prevention programs and research studies we estimated the population-level impact of combining effective scalable interventions at high population coverage, determined the factors that influence this impact, and estimated the synergy between the components.

Methods

We used a mathematical model to investigate the effect on HIV incidence of a combination HIV prevention intervention comprised of high coverage of HIV testing and counselling, risk reduction following HIV diagnosis, male circumcision for HIV-uninfected men, and antiretroviral therapy (ART) for HIV-infected persons. The model was calibrated to data for KwaZulu-Natal, South Africa, where adult HIV prevalence is approximately 23%.

Results

Compared to current levels of HIV testing, circumcision, and ART, the combined intervention with ART initiation according to current guidelines could reduce HIV incidence by 47%, from 2.3 new infections per 100 person-years (pyar) to 1.2 per 100 pyar within 4 years and by almost 60%, to 1 per 100 pyar, after 25 years. Short-term impact is driven primarily by uptake of testing and reductions in risk behaviour following testing while long-term effects are driven by periodic HIV testing and retention in ART programs. If the combination prevention program incorporated HIV treatment upon diagnosis, incidence could be reduced by 63% after 4 years and by 76% (to about 0.5 per 100 pyar) after 15 years. The full impact of the combination interventions accrues over 10–15 years. Synergy is demonstrated between the intervention components.

Conclusion

High coverage combination of evidence-based strategies could generate substantial reductions in population HIV incidence in an African generalized HIV epidemic setting. The full impact could be underestimated by the short assessment duration of typical evaluations.

Citation: Alsallaq RA, Baeten JM, Celum CL, Hughes JP, Abu-Raddad LJ, et al. (2013) Understanding the Potential Impact of a Combination HIV Prevention Intervention in a Hyper-Endemic Community. PLoS ONE 8(1): e54575. doi:10.1371/journal.pone.0054575

Editor: Edward White, Yale School of Public Health, United States of America

Received: December 16, 2011; Accepted: December 13, 2012; Published: January 23, 2013

Copyright: © 2013 Alsallaq et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: This project was supported by a grant from the National Institutes of Health (1R01AI083034). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

e$� vlH��� epidemiological and cost data from the nine provinces of SA. The hypothetical one-year-long MC intervention with a budget of US$ 10 million targeted adult men 15-49 years of age in SA. The intervention was evaluated according to two criteria: an efficiency criterion, which focused on maximizing the number of HIV infections averted by the intervention, and an equity criterion (defined geographically), which focused on maximizing the chance that each male adult individual had access to the intervention regardless of his province.

 

RESULTS:

A purely efficient intervention would prevent 4,008 HIV infections over a year. In the meantime, a purely equitable intervention would avert 3,198 infections, which represents a 20% reduction in infection outcome as compared to the purely efficient scenario. A half efficient-half equitable scenario would prevent 3,749 infections, that is, a 6% reduction in infection outcome as compared to the purely efficient scenario.

CONCLUSIONS:

This paper provides a framework for resource allocation in the health sector which incorporates a simple equity metric in addition to efficiency. In the specific context of SA with a MC intervention for the prevention of HIV, incorporation of geographical equity only slightly reduces the overall efficiency of the intervention.