A novel method to estimate the indirect community benefit of HIV interventions using a microsimulation model of HIV disease.,Journal of Biomedical informatics

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A novel method to estimate the indirect community benefit of HIV interventions using a microsimulation model of HIV disease.
Journal of Biomedical informatics ( IF 4.0 ) Pub Date : 2020-06-08 , DOI: 10.1016/j.jbi.2020.103475
Pooyan Kazemian ₁ , Sydney Costantini ₂ , Anne M Neilan ₃ , Stephen C Resch ₄ , Rochelle P Walensky ₅ , Milton C Weinstein ₄ , Kenneth A Freedberg ₆

Affiliation

Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA.
Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.
Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Division of General Academic Pediatrics, Department of Pediatrics, Massachusetts General Hospital, Boston, USA.
Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.
Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA; Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.

Background

Microsimulation models of human immunodeficiency virus (HIV) disease that simulate individual patients one at a time and assess clinical and economic outcomes of HIV interventions often provide key details regarding direct individual clinical benefits (“individual benefit”), but they may lack detail on transmissions, and thus may underestimate an intervention’s indirect benefits (“community benefit”). Dynamic transmission models can be used to simulate HIV transmissions, but they may do so at the expense of the clinical detail of microsimulations. We sought to develop, validate, and demonstrate a practical, novel method that can be integrated into existing HIV microsimulation models to capture this community benefit, integrating the effects of reduced transmission while keeping the clinical detail of microsimulations.

Methods

We developed a new method to capture the community benefit of HIV interventions by estimating HIV transmissions from the primary cohort of interest. The method captures the benefit of averting infections within the cohort of interest by estimating a corresponding gradual decline in incidence within the cohort. For infections averted outside the cohort of interest, our method estimates transmissions averted based on reductions in HIV viral load within the cohort, and the benefit (life-years gained and cost savings) of averting those infections based on the time they were averted. To assess the validity of our method, we paired it with the Cost-effectiveness of Preventing AIDS Complications (CEPAC) Model – a validated and widely-published microsimulation model of HIV disease. We then compared the consistency of model-estimated outcomes against outcomes of a widely-validated dynamic compartmental transmission model of HIV disease, the HIV Optimization and Prevention Economics (HOPE) model, using the intraclass correlation coefficient (ICC) with a two-way mixed effects model. Replicating an analysis done with HOPE, validation endpoints were number of HIV transmissions averted by offering pre-exposure prophylaxis (PrEP) to men who have sex with men (MSM) and people who inject drugs (PWID) in the US at various uptake and efficacy levels. Finally, we demonstrated an application of our method in a different setting by evaluating the clinical and economic outcomes of a PrEP program for MSM in India, a country currently considering PrEP rollout for this high-risk group.

Results

The new method paired with CEPAC demonstrated excellent consistency with the HOPE model (ICC=0.98 for MSM and 0.99 for PWID). With only the individual benefit of the intervention incorporated, a PrEP program for MSM in India averted 43,000 transmissions over a 5-year period and resulted in a lifetime incremental cost-effectiveness ratio (ICER) of US$2,300/year-of-life saved (YLS) compared to the status quo. After applying both the direct (individual) and indirect (community) benefits, PrEP averted 86,000 transmissions over the same period and resulted in an ICER of US$600/YLS.

Conclusions

Our method enables HIV microsimulation models that evaluate clinical and economic outcomes of HIV interventions to estimate the community benefit of these interventions (in terms of survival gains and cost savings) efficiently and without sacrificing clinical detail. This method addresses an important methodological gap in health economics microsimulation modeling and allows decision scientists to make more accurate policy recommendations.

中文翻译：

一种使用艾滋病毒疾病微观模拟模型来估计艾滋病毒干预措施间接社区效益的新方法。

背景

人类免疫缺陷病毒 (HIV) 疾病的微观模拟模型一次模拟一名患者并评估 HIV 干预措施的临床和经济结果，通常提供有关直接个人临床效益（“个人效益”）的关键细节，但可能缺乏传播细节，因此可能会低估干预措施的间接效益（“社区效益”）。动态传播模型可用于模拟艾滋病毒传播，但这样做可能会牺牲微观模拟的临床细节。我们试图开发、验证和展示一种实用的新颖方法，该方法可以集成到现有的 HIV 微观模拟模型中，以获取这一社区利益，整合减少传播的影响，同时保留微观模拟的临床细节。

方法

我们开发了一种新方法，通过估计主要关注人群的艾滋病毒传播情况来获取艾滋病毒干预措施的社区效益。该方法通过估计队列内发病率相应的逐渐下降来捕获避免感兴趣队列内感染的好处。对于感兴趣群体之外避免的感染，我们的方法根据群体内 HIV 病毒载量的减少来估计避免的传播，并根据避免时间来估计避免这些感染的好处（获得的生命年和节省的成本）。为了评估我们方法的有效性，我们将其与预防艾滋病并发症的成本效益 (CEPAC) 模型配对，这是一种经过验证且广泛发布的 HIV 疾病微观模拟模型。然后，我们使用类内相关系数 (ICC) 和双向混合模型，将模型估计结果与广泛验证的 HIV 疾病动态区室传播模型（HIV 优化和预防经济学 (HOPE) 模型）的结果进行了一致性比较。效应模型。重复使用 HOPE 进行的分析，验证终点是通过向美国男男性行为者 (MSM) 和注射吸毒者 (PWID) 提供暴露前预防 (PrEP) 所避免的 HIV 传播数量，其吸收率和功效各异水平。最后，我们通过评估印度 MSM 的 PrEP 计划的临床和经济结果，展示了我们的方法在不同环境中的应用，印度目前正在考虑针对这一高危人群推出 PrEP。

结果

与 CEPAC 配合使用的新方法与 HOPE 模型表现出良好的一致性（MSM 的 ICC=0.98，PWID 的 ICC=0.99）。仅考虑干预措施的个人效益，印度针对 MSM 的 PrEP 计划在 5 年内避免了 43,000 例传播，并导致终生增量成本效益比 (ICER) 为 2,300 美元/年挽救生命（ YLS）与现状相比。在应用直接（个人）和间接（社区）效益后，PrEP 在同一时期避免了 86,000 例传播，ICER 为 600 美元/YLS。