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Role of Routine HIV Testing in Concentrated Epidemics Operations Research for Optimizing the HIV Testing Program in an Urban Canadian Setting. K Vasarhelyi, S Kok, JSG Montaner, AR Rutherford, R Barrios, K McPherson, M Thumath, L Tran, A Nathoo, R Gustafson.

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Role of Routine HIV Testing in Concentrated Epidemics Operations Research for Optimizing the HIV Testing Program in an Urban Canadian Setting

K Vasarhelyi, S Kok, JSG Montaner, AR Rutherford,

R Barrios, K McPherson, M Thumath, L Tran,

A Nathoo, R Gustafson

collaboration of academic and public health partners
Collaboration of Academic and Public Health Partners
  • BC Centre for Excellence in HIV/AIDS
  • Vancouver Coastal Health
  • Providence Health Care
  • The IRMACS Centre

A poster for the Vancouver Coastal Health / Providence Health Care social marketing campaign promoting routine HIV testing

The IRMACS Centre

The BC Centre for Excellence in HIV/AIDS & Providence Health Care

stakeholder s questions
Stakeholder’s Questions
  • Should we do it?

Can routine voluntary HIV testing make a useful contribution to controlling the HIV epidemic in Vancouver?

  • How can we do it?

What is the best way to integrate routine voluntary HIV testing into the current testing program?

the hiv epidemic in vancouver
The HIV Epidemic in Vancouver
  • Concentrated epidemic
  • MSM, IDU, sex workers1
  • HIV prevalence ~12 / 10002
  • >200 new diagnoses / year in past 10 years3
  • <150 new diagnoses in 20123
  • HIV testing traditionally risk-based
  • No routine testing guidelines in Canada

MSM – men who have sex with men; IDU – injection drug user

McInnes et al., 2009, Harm Reduction Journal

BC Centre for Disease Control (Vancouver’s population 600,000) / Vancouver Coastal Health

what is the optimal mix of testing methods for vancouver
What is the optimal mix of testing methods for Vancouver?

Routine Testing

Generalized epidemics

Lower yield

Lower cost/test

Risk-based Testing

Concentrated epidemics

Higher yield

Higher cost/test

what is the optimal mix of testing methods for vancouver1
What is the optimal mix of testing methods for Vancouver?

Routine Testing

Generalized epidemics

Lower yield

Lower cost/test

Risk-based Testing

Concentrated epidemics

Higher yield

Higher cost/test

COST

YIELD

what is the optimal mix of testing methods for vancouver2
What is the optimal mix of testing methods for Vancouver?

Objectives

  • Minimize morbidity
  • Minimize mortality
  • Minimize HIV incidence
what is the optimal mix of testing methods for vancouver3
What is the optimal mix of testing methods for Vancouver?

Objective

  • Minimize morbidity
  • Minimize mortality
  • Minimize HIV incidence
operations research and optimization
Operations Research and Optimization
  • Find best intervention to meet objective
  • Intervention is resource allocation
  • Optimal distribution of newresources
  • Optimal realignment of existingresources
model development
Model Development

Step 1

Qualitative Model for

Cascade of Care

Step 2

Qualitative Model for

HIV Testing Program

Step 3

Combine

Step 4

System Dynamics / HIV Transmission

Simulation Model of Cascade of Care with Detailed HIV Testing Program

model development1
Model Development

Step 1

Qualitative Model for

Cascade of Care

Step 2

Qualitative Model for

HIV Testing Program

General Population

MSM

Other Key Populations

(IDU, Sex workers)

Step 3

Combine

Step 4

System Dynamics / HIV Transmission

Simulation Model of Cascade of Care with Detailed HIV Testing Program

qualitative model of the cascade of care
Qualitative Model of the Cascade of Care

Decisions and activities in the HIV care continuumdefined through consultations with system experts

qualitative model of the cascade of care1
Qualitative Model of the Cascade of Care

Decisions and activities in the HIV care continuumdefined through consultations with system experts

RETENTION

IN

CARE

DIAGNOSIS

LINKAGE

TO

CARE

qualitative model of the hiv testing program
Qualitative Model of the HIV Testing Program

Vancouver Coastal Health for STOP HIV/AIDS Project, Vancouver, Canada (2013)

qualitative model of the hiv testing program1
Qualitative Model of the HIV Testing Program

Routine Testing in

HOSPITALS

Vancouver Coastal Health for STOP HIV/AIDS Project, Vancouver, Canada (2013)

hiv testing resources
HIV Testing Resources
  • No $ estimate available
  • Cost of 1 Risk-Based Test > Cost of 1 Routine Test
  • Considered 1:1 to 9:1 cost ratios

+

Cost Ratio

Number of

Tests / Month

Total HIV Testing Resources

question 1 is routine testing effective in reducing hiv incidence in vancouver
Question 1Is routine testing effective in reducing HIV incidence in Vancouver?
  • SIMULATON SCENARIO
  • Increase total testing budget by 50%.
  • Invest all new resources in one program:
    • Risk-based testing or
    • Routine testing in high-prevalence settings or
    • Routine testing in hospitals
  • Compare 5-year cumulative incidence.
relative effectiveness of testing programs in reducing 5 year cumulative hiv incidence
Relative effectiveness of testing programsin reducing 5-year cumulative HIV incidence

Risk-based Testing

Up to 83 infections averted in 5 years

Routine Testing in

High-Prevalence Settings

Up to 274 infections

averted in 5 years

Routine Testing in

Hospitals

Up to 104 infections averted in 5 years

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Question 2How many infections would be averted by increasing routine testing in hospitals and improving engagement in treatment?

SIMULATION SCENARIO

Increase total testing budget by 50%.

Invest all new resources in routine testing in hospitals.

Increase immediate treatment initiation after linkage to care from 38% to 75%and reduce loss to follow-up from 26% to 10%.

Compare 5-year cumulative incidence.

slide24
Question 3How many infections would be averted by realigning existing resources between risk-based and routine testing in hospitals?

SIMULATION SCENARIO

Keep total testing budget the same.

Realign existing resources between risk-based testing and routine testing in hospitals in 5% increments.

Compare 5-year cumulative incidence.

slide25
Optimal resource allocation to risk-based testing and routine testing in hospitals to minimize HIV incidence
slide26
Optimal resource allocation to risk-based testing and routine testing in hospitals to minimize HIV incidence
conclusions1
Conclusions
  • Routine HIV testing in Vancouver is likely to be averting infections, especially in high-prevalence settings. In general routine testing may play an important role in controlling concentrated HIV epidemics.
  • Optimizing across the cascade of care could avert additional infections.
  • Realigning existing resources may improve efficiency of the testing program.
conclusions2
Conclusions
  • Next steps include
    • Morbidity and mortality as optimization objectives
    • Developing other parts of the model of cascade
  • Operations research and optimization provide powerful methods to inform implementation of WHO guidelines on early treatment initiation.
collaborators sponsors
Collaborators & Sponsors

BC Centre for

Excellence in HIV/AIDS

Silvia Guillemi

Guillaume Colley

Susan Shurgold

Benita Yip

Vancouver Coastal Health &

Providence Health Care

Kendra McPherson

Meaghan Thumath

Lynn Tran

Reka Gustafson

Afshan Nathoo

Allison Macbeth

Chris Buchner

Val Munroe

Jat Sandhu

Ellen Demlow

Tim Chu

Scott Harrison

IRMACS

Pam Borghardt

Peter Borwein

Brian Corrie

Felix Breden

Kelly Gardner

Alexa van der Waall

BC Centre for

Disease Control

Mark Gilbert

Travis Salway Hottes

Gina Ogilvie

University

of Zurich

Lukas Ahrenberg

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