Suchergebnisse

AbstractIntroductionThe Spectrum/AIM model is used by national HIV programs and UNAIDS to prepare annual estimates of key HIV indicators. This article describes key updates to paediatric and adult models for the 2021 round of HIV estimates.MethodsPotential updates to Spectrum arise due to newly available data, new analyses of existing data, and the need for new issues to be addressed. Updates are guided by experts through the UNAIDS Reference Group on Estimates, Modelling and Projections. Changes are tested and assessed for impact before being accepted into the final model.ResultsSpectrum tracks children living with HIV by CD4% for ages 0–4 and CD4 count for ages 5–14. Data from IeDEA treatment sites have been used to map the transition from CD4% to CD4 count at age 5. Breastfeeding patterns in sub‐Saharan Africa have been updated with the latest survey data and estimates of continuation on antiretroviral therapy (ART) with breastfeeding have been revised based on recent studies. Model assumptions about the CD4 counts of people who drop out of ART have been revised to account for CD4 count increases while on treatment. If available, monthly data on numbers on ART can now be used to estimate the effects of COVID‐19‐related disruptions during 2020.ConclusionsThese changes are intended to provide more accurate estimates of HIV burden. The effects of these changes on paediatric indicators are small except in countries with new surveys that might have updated patterns of breastfeeding. Changes to the adult model have little effect on total new infections. AIDS‐related deaths will be somewhat lower in countries that have data on ART drop out but might be increased by HIV care disruptions due to COVID‐19. The updated model uses newly available data to improve the estimation of paediatric and adult HIV indicators.

AbstractIntroductionInfant HIV prophylaxis with broadly neutralizing anti‐HIV antibodies (bNAbs) could provide long‐acting protection against vertical transmission. We sought to estimate the potential clinical impact and cost‐effectiveness of hypothetical bNAb prophylaxis programmes for children known to be HIV exposed at birth in three sub‐Saharan African settings.MethodsWe conducted a cost‐effectiveness analysis using the CEPAC‐Pediatric model, simulating cohorts of infants from birth through death in Côte d'Ivoire, South Africa and Zimbabwe. These settings were selected to reflect a broad range of HIV care cascade characteristics, antenatal HIV prevalence and budgetary constraints. We modelled strategies targeting bNAbs to only WHO‐designated "high‐risk" HIV‐exposed infants (HR‐HIVE) or to all HIV‐exposed infants (HIVE). We compared four prophylaxis approaches within each target population: standard of care oral antiretroviral prophylaxis (SOC), andSOCplus bNAbs at birth (1‐dose), at birth and 3 months (2‐doses), or every 3 months throughout breastfeeding (Extended). Base‐case model inputs included bNAb efficacy (60%/dose), effect duration (3 months/dose) and costs ($60/dose), based on published literature. Outcomes included paediatric HIV incidence and incremental cost‐effectiveness ratios (ICERs) calculated from discounted life expectancy and lifetime HIV‐related costs.ResultsThe model projects that bNAbs would reduce absolute infant HIV incidence by 0.3–2.2% (9.6–34.9% relative reduction), varying by country, prophylaxis approach and target population. In all three settings,HR‐HIVE–1‐dosewould be cost‐saving compared toSOC. Using a 50% GDP per capita ICER threshold,HIVE‐Extendedwould be cost‐effective in all three settings with ICERs of $497/YLS in Côte d'Ivoire, $464/YLS in South Africa and $455/YLS in Zimbabwe. In all three settings, bNAb strategies would remain cost‐effective at costs up to $200/dose if efficacy is ≥30%. If the bNAb effect duration were reduced to 1 month, the cost‐effective strategy would becomeHR‐HIVE–1‐dosein Côte d'Ivoire and Zimbabwe andHR‐HIVE–2‐dosesin South Africa. Findings regarding the cost‐effectiveness of bNAb implementation strategies remained robust in sensitivity analyses regarding breastfeeding duration, maternal engagement in postpartum care, early infant diagnosis uptake and antiretroviral treatment costs.ConclusionsAt current efficacy and cost estimates, bNAb prophylaxis for HIV‐exposed children in sub‐Saharan African settings would be a cost‐effective intervention to reduce vertical HIV transmission.

AbstractIntroductionTo improve the diagnosis and survival of children living with HIV (CLWH), the World Health Organization recommends testing approaches beyond traditional infant HIV testing programmes. Information about undiagnosed HIV prevalence among children of varying ages in the general population is needed to guide innovative national/subnational case‐finding and testing approaches.MethodsWe used the Cost‐Effectiveness of Preventing AIDS Complications (CEPAC)‐Pediatric model to estimate the prevalence of undiagnosed HIV in 2‐, 5‐ and 10‐year‐old children in South Africa, Côte d'Ivoire and Zimbabwe in 2018. We simulated cohorts of children born in 2008 (10‐year‐olds), 2013 (5‐year‐olds) and 2016 (2‐year‐olds). Country‐/year‐specific inputs for pregnant/breastfeeding women included: HIV prevalence (4.2–32.3%), HIV incidence (0.03–0.24%/month), knowledge of HIV status (27–89%) and antiretroviral drug coverage (36–95%). Paediatric inputs included early infant testing coverage (6–95%) and breastfeeding duration (0–20 months). We projected the proportion of surviving CLWH in whom HIV remained undiagnosed and the undiagnosed HIV prevalence among surviving children of each age in the general population. For children born in 2016, we projected survival and diagnosis of all CLWH through 2026. We conducted sensitivity analyses on model parameters.ResultsIn 2018, the projected proportion of surviving CLWH whose HIV remained undiagnosed in South Africa/Côte d'Ivoire/Zimbabwe was 44.2%/55.8%/52.9% among 2‐year‐old CLWH; 29.0%/37.8%/33.2% among 5‐year‐old CLWH; and 18.3%/25.4%/23.1% among 10‐year‐old CLWH. Projected general population undiagnosed HIV prevalence in South Africa/Côte d'Ivoire/Zimbabwe was 0.44%/0.32%/0.68% among 2‐year‐olds; 0.25%/0.17%/0.41% among 5‐year‐olds; and 0.24%/0.14%/0.38% among 10‐year‐olds. Among all CLWH born in 2016, 50–54% were projected to die without HIV diagnosis (and subsequently without treatment) within 10 years after birth; 80–85% of these deaths occurred in the first 2 years.ConclusionsProjected population‐level undiagnosed HIV prevalence is low and sharply decreases after age 2, with more CLWH dying than being diagnosed. Despite low undiagnosed prevalence in the general population of older children, we project that a large proportion of CLWH remain undiagnosed, suggesting that innovative strategies targeting untested children of all ages outside of health facility settings should be prioritized. Programmes could consider routine testing of the general population of children below 2 in all settings and children of all ages in high‐prevalence settings.