Highlights► Develops an efficient framework to determine epidemic sizes in structured populations. ► Optimal allocation of vaccine is highly heterogeneous. ► For low vaccine supplies may be optimal to focus on a single population. ► Greater heterogeneity within populations leads to more equitable allocations.
HIV prevalence worldwide among people who inject drugs (PWID) is around 19%. Harm reduction for PWID includes needle-syringe programs (NSPs) and opioid substitution therapy (OST) but often coupled with antiretroviral therapy (ART) for people living with HIV. Numerous studies have examined the effectiveness of each harm reduction strategy. This commentary discusses the evidence of effectiveness of the packages of harm reduction services and their cost-effectiveness with respect to HIV-related outcomes as well as estimate resources required to meet global and regional coverage targets. NSPs have been shown to be safe and very effective in reducing HIV transmission in diverse settings; there are many historical and very recent examples in diverse settings where the absence of, or reduction in, NSPs have resulted in exploding HIV epidemics compared to controlled epidemics with NSP implementation. NSPs are relatively inexpensive to implement and highly cost-effective according to commonly used willingness-to-pay thresholds. There is strong evidence that substitution therapy is effective, reducing the risk of HIV acquisition by 54% on average among PWID. OST is relatively expensive to implement when only HIV outcomes are considered; other societal benefits substantially improve the cost-effectiveness ratios to be highly favourable. Many studies have shown that ART is cost-effective for keeping people alive but there is only weak supportive, but growing evidence, of the additional effectiveness and cost-effectiveness of ART as prevention among PWID. Packages of combined harm reduction approaches are highly likely to be more effective and cost-effective than partial approaches. The coverage of harm reduction programs remains extremely low across the world. The total annual costs of scaling up each of the harm reduction strategies from current coverage levels, by region, to meet WHO guideline coverage targets are high with ART greatest, followed by OST and then NSPs. But scale-up of all three approaches is essential. These interventions can be cost-effective by most thresholds in the short-term and cost-saving in the long-term.
World Bank and Australian NHMRC.
Optima is a software package for modeling HIV epidemics and interventions that we developed to address practical policy and program problems encountered by funders, governments, health planners, and program implementers. Optima's key feature is its ability to perform resource optimization to meet strategic HIV objectives, including HIV-related financial commitment projections and health economic assessments. Specifically, Optima allows users to choose a set of objectives (such as minimizing new infections, minimizing HIV-related deaths, and/or minimizing long-term financial commitments) and then determine the optimal resource allocation (and thus program coverage levels) for meeting those objectives. These optimizations are based on the following: calibrations to epidemiological data; assumptions about the costs of program implementation and the corresponding coverage levels; and the effects of these programs on clinical, behavioral, and other epidemiological outcomes. Optima is flexible for which population groups (specified by behavioral, epidemiological, and/or geographical factors) and which HIV programs are modeled, the amount of input data used, and the types of outputs generated. Here, we introduce this model and compare it with existing HIV models that have been used previously to inform decisions about HIV program funding and coverage targets. Optima has already been used in more than 20 countries, and there is increasing demand from stakeholders to have a tool that can perform evidence-based HIV epidemic analyses, revise and prioritize national strategies based on available resources, set program coverage targets, amend subnational program implementation plans, and inform the investment strategies of governments and their funding partners.
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