Allocating Resources for HIV Prevention: Determining an Optimal Intervention Scenario in Zambia Público

Abstract

A key strategy to end the HIV epidemic is the Fast-Track response, an international approach focused on the rapid scale-up of essential HIV prevention and treatment strategies. A component of this goal is the 90-90-90 targets, which aimed for 73% of people living with HIV (PLHIV) to be virally suppressed by 2020. Sub-Saharan Africa, a priority region for the response, is dependent on international funding for HIV programs, which has declined in recent years. With resource availability being tenuous, countries must scale-up HIV services in a cost-effective manner. In this dissertation, we focus on the HIV epidemic of Zambia to understand previous patterns in HIV care delays and to explore the potential epidemiologic and economic impacts of scaling-up HIV interventions. In Aim 1, we used an electronic health record database to explore the care continuum to characterize the delays experienced by PLHIV after engaging in care. We found that half of PLHIV were considered eligible for treatment at their first clinical visit, but less than 10% were prescribed treatment immediately once they were deemed eligible. In Aim 2, we used agent-based modeling to estimate the impact of different HIV testing, treatment, and retention strategies on HIV incidence in Zambia. We found that the current standard of care could lead to a 40% reduction in HIV incidence by 2030. Interventions including 1) immediate treatment initiation after diagnosis (test-and-treat) and 2) couples voluntary counseling and testing (CVCT) amplified these results, leading to a 71% and 64% reduction in HIV incidence, respectively, over a ten-year period. In Aim 3, we calculated the cost-effectiveness of strategies that would prevent HIV in Zambia. We found that integrating CVCT with a test-and-treat approach could avert approximately 130,000 infections while saving $100 million over ten years. We demonstrate the importance of scaling-up a test-and-treat approach, ensuring that all PLHIV have access to treatment, and the economic benefits of integrating cost-saving HIV interventions, such as CVCT into a test-and-treat setting. Our results will support policymakers in their decision-making process for allocating HIV resources as they face restrictive budgets and strive to achieve the Fast-Track goals.

Table of Contents

1 BACKGROUND 12

2 SUMMARY 32

3 SIGNIFICANCE AND OVERVIEW OF AIMS 34

4 SPECIFIC AIMS 36

5 AIM 1 37

6 AIM 2 62

7 AIM 3 100

8 PUBLIC HEALTH IMPLICATIONS AND FUTURE DIRECTIONS 127

9 REFERENCES 131

About this Dissertation

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School	Laney Graduate School
Department	Epidemiology
Degree	Ph.D.
Submission	Dissertation
Language	English
Research Field	Health Sciences, Epidemiology Economics, General
Palabra Clave	HIV prevention agent-based modeling Sub-Saharan Africa cost-effectiveness
Committee Chair / Thesis Advisor	Patrick Sullivan, Emory University Kristin Wall, Emory University
Committee Members	Anna Bershteyn, New York University Samuel Jenness, Emory University Phaedra Corso, Kennesaw State University

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