CROI 2016 Abstract eBook

Abstract Listing

Poster Abstracts

1049 Optimizing Resource Allocation to Reduce HIV Incidence Across Sub-Saharan Africa Jessica McGillen ; Sarah-Jane Anderson;Timothy Hallett Imperial Coll London, London, UK

Background: New prevention interventions offer substantial promise for capitalizing on previous progress against the HIV pandemic; but it has been unclear how these can be deployed jointly to best effect and this is complicated by geospatial heterogeneities in the epidemic and its drivers. We hypothesize that a strategy which confronts epidemic heterogeneity and considers available prevention interventions holistically—by allocating resources optimally between countries, subnational regions, population groups, and interventions—can achieve significantly greater impact than maintaining current patterns and bring us closer to the ambitious goal of ending AIDS as a public health threat by 2030. Methods: We have developed a mathematical model that captures 80% of the HIV burden across sub-Saharan Africa, describing HIV transmission dynamics among adults in low-risk and key populations at the subnational (administrative level 1) scale in 18 countries. In each subnational region we have calibrated the model against antenatal clinic, survey, census, key population, and treatment data. We use this modeling framework to interrogate the performance of combination prevention strategies that exploit epidemic heterogeneity to varying degrees. Results: The models find that, given our assumptions, optimizing combinations of available prevention interventions according to subnational epidemiology can reduce overall HIV incidence by 75% from 2010 levels by 2030, exceeding the 50% reduction achievable under current allocation patterns for the same total expenditure. Moreover, we confirm that single-value thresholds (for example based on incidence) are insufficient metrics for determining when a particular intervention should be used; instead a holistic ‘allocation’ perspective should be taken. Broadly, a transition from current allocation patterns to the optimal topography would shift funds out of regions with declining epidemics and into those with emerging epidemics and high disease burdens. Conclusions: While details of future funding allocation depend on economic and political factors beyond our scope, this work leverages both the powerful suite of available prevention strategies and our understanding of the geospatial heterogeneity of HIV to set out the direction of travel toward the most cost-effective and impactful overall pattern of funding for sub-Saharan Africa. 1050 New ARVs Could Represent Over USD 3 Billion in Cost Savings Through 2025 Vineet R. Prabhu , Clinton Hlth Access Initiative, Boston, MA, USA Background: Several new antiretrovirals (ARVs) are likely to be introduced in low-and middle-income countries (LMICs) by 2019 that represent a range of clinical and cost advantages to current products. These include tenofovir alafenamide fumarate (TAF), low dose efavirenz (EFV400), and dolutegravir (DTG). As programs evaluate adoption of these products, it is important that they understand the cost savings implications of doing so. Methods: CHAI’s forecast for currently available products was used as baseline. Historical uptake analogs as well as theoretical curves that fit a Gompertz function were used to model competition between new and current products based on anticipated clinical and price differentiation. Competitive sets were as follows: TAF displacing tenofovir disoproxil fumarate (TDF) and zidovudine (AZT) in first-line, EFV400 and DTG displacing EFV600 and nevirapine (NVP) in first-line, and DTG replacing TDF and AZT-based backbones in second-line. Prices over time were estimated based on market intelligence using rawmaterial costs, formulation costs, threshold volumes required for economies of scale, and manufacturer profit margins. Each product’s annual cost savings was calculated by multiplying the price differential between new and current products by the number of patients projected to be on the relevant new product each year. Results: TAF was projected to aggressively replace TDF and AZT in first-line. By 2025, TAF would represent over 95% of that market and savings of over USD 1.5 billion. For first-line treatment, DTG was projected to aggressively replace EFV600 and NVP, representing 80-90% of that market by 2025, with EFV400 representing most of the remainder. Collectively, DTG and EFV400 may represent total savings of over USD 1 billion through 2025. Lastly, DTG was projected to replace over 90% of TDF and AZT-based backbone use in second-line, with associated cost savings of USD 300 million through 2025. Current pricing methodologies and plans to advance approach will be shared. Conclusions: TAF, EFV400, and DTG will enable programs in LMICs to put more patients on treatment due to lower per capita spend. Our findings support concerted efforts by national programs and donors to advocate for accelerated availability and strongly encourage uptake of new ARVs to realize their savings potential. Clear commitments for rapid adoption of these products would encourage more manufacturers to produce larger “at-scale” volumes at competitive prices, and help increase patients on care.

Poster Abstracts

1051 Impact of Improving HIV Care and Treatment and Initiating PrEP in the United States, 2015-2020 Emine Yaylali 1 ; Paul Farnham 1 ; Evin Jacobson 1 ; BenjaminT. Allaire 2 ; Danielle L.Wagner 3 ; Katherine A. Hicks 4 ; Amanda A. Honeycutt 2 ; Stephanie L. Sansom 1 1 CDC, Atlanta, GA, USA; 2 RTI, Research Triangle Park, NC, USA; 3 RTI, Waltham, MA, USA; 4 RTI Hlth Solutions, Research Triangle Park, NC, USA

Background: Key strategies to reduce HIV incidence in the US are 1) improving diagnosis, care and treatment of people living with HIV (PLWH), and 2) delivering pre-exposure prophylaxis (PrEP) to people at risk for HIV. National HIV/AIDS Strategy (NHAS) 2020 goals provide targets for the first strategy, including increasing to 90% the proportion of PLWH who are diagnosed, to 85% the proportion linked to care (LTC), and to 80% the proportion diagnosed who achieve VLS. Clinical trials have established a large reduction in HIV transmission risk among PLWH who achieve VLS and the efficacy of PrEP in preventing HIV among men who have sex with men (MSM), people who inject drugs (PWID), and high- risk heterosexuals (HRH). However, the effectiveness of PrEP when layered onto improvements in the diagnosis, care and treatment of PLWH has not been well established. Methods: We developed a dynamic, compartmental model of HIV transmission. In the base case, we estimated that in 2015, 87% of PLWH were diagnosed, 80% LTC and 36% VLS among diagnosed. In one scenario, we increased diagnosis to 90%, LTC to 85% and VLS to 60% by 2020. We repeated that scenario with VLS increased to 80%. For the base case and scenarios, we assessed the effect on HIV incidence from 2015 to 2020 of improvements in diagnosis, LTC and VLS alone. We then assessed the marginal benefit of initiating PrEP

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CROI 2016