Browsing by Author "Moolla, Haroon"

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    Open Access
    A multi-state model of treatment states in an antiretroviral treatment programme cohort in Cape Town
    (2022) Moolla, Haroon; Johnson, Leigh F
    Introduction A recent systematic review estimated that almost a quarter of patients in low- and middle-income countries are not retained on antiretroviral treatment (ART) beyond one year. Further, it is difficult to determine whether a patient who is not retained in care has interrupted their treatment, transferred to another treatment facility, or died. Previous studies have been deterministic in classifying loss to follow-up and treatment interruption. This study investigates treatment interruption and resumption rates when accounting for uncertainty in the occurrence of interruptions. The primary objective is to estimate the rate at which ART is interrupted and the rate at which ART is resumed after an interruption. Methods We fitted a multi-state model to data from the Khayelitsha cohort of the International Epidemiologic Databases to Evaluate AIDS. Between 2001 and 2012, 6796 adult patients starting ART were included. Potential treatment interruption periods were defined between contact points 3 or more months apart. To aid the model in determining if a patient truly interrupted treatment a CD4 count model was used. CD4 counts were modelled to drop to baseline by 3 months after the start of a treatment interruption. Bayesian estimation and Markov chain Monte Carlo were used to obtain posterior distributions of parameters. Several scenarios were used in sensitivity testing, including varying the threshold used to define potential treatment interruption periods, and either adjusting or excluding the data of those with CD4 counts that drop below baseline. Results The baseline annual rate of treatment interruption had a posterior mean of 0.060 (95% CI 0.038- 0.087) which is significantly lower than the prior distribution that had a mean of 0.145 (95% CI 0.080-0.229). The posterior distribution of the baseline annual rate of treatment resumption (mean 1.09; 95% CI 0.68-1.65) was consistent with the prior distribution (mean 1.46; 95% CI 0.21-3.90). The posterior distributions of the parameters related to treatment interruption and resumption did not change significantly in sensitivity testing. Conclusion This study indicates that treatment interruption rates may be significantly lower than previously estimated. The methodology of this study may be useful to those measuring retention within ART programmes. An important limitation was that the CD4 count model did not allow for CD4 counts to fall below baseline during periods of treatment interruption. This limits the generalisability of the posterior estimates of the parameters of the CD4 count model. Further research may require a more flexible CD4 count model.
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    A quantitative assessment of the consistency of projections from five mathematical models of the HIV epidemic in South Africa: a model comparison study
    (2023-10-27) Moolla, Haroon; Phillips, Andrew; ten Brink, Debra; Mudimu, Edinah; Stover, John; Bansi-Matharu, Loveleen; Martin-Hughes, Rowan; Wulan, Nisaa; Cambiano, Valentina; Smith, Jennifer; Bershteyn, Anna; Meyer-Rath, Gesine; Jamieson, Lise; Johnson, Leigh F.
    Abstract Background Mathematical models are increasingly used to inform HIV policy and planning. Comparing estimates obtained using different mathematical models can test the robustness of estimates and highlight research gaps. As part of a larger project aiming to determine the optimal allocation of funding for HIV services, in this study we compare projections from five mathematical models of the HIV epidemic in South Africa: EMOD-HIV, Goals, HIV-Synthesis, Optima, and Thembisa. Methods The five modelling groups produced estimates of the total population, HIV incidence, HIV prevalence, proportion of people living with HIV who are diagnosed, ART coverage, proportion of those on ART who are virally suppressed, AIDS-related deaths, total deaths, and the proportion of adult males who are circumcised. Estimates were made under a “status quo” scenario for the period 1990 to 2040. For each output variable we assessed the consistency of model estimates by calculating the coefficient of variation and examining the trend over time. Results For most outputs there was significant inter-model variability between 1990 and 2005, when limited data was available for calibration, good consistency from 2005 to 2025, and increasing variability towards the end of the projection period. Estimates of HIV incidence, deaths in people living with HIV, and total deaths displayed the largest long-term variability, with standard deviations between 35 and 65% of the cross-model means. Despite this variability, all models predicted a gradual decline in HIV incidence in the long-term. Projections related to the UNAIDS 95–95-95 targets were more consistent, with the coefficients of variation below 0.1 for all groups except children. Conclusions While models produced consistent estimates for several outputs, there are areas of variability that should be investigated. This is important if projections are to be used in subsequent cost-effectiveness studies.