Ronald Scott Braithwaite

Introduction: KwaZulu-Natal (KZN), South Africa’s provincial HIV epicentre with a prevalence of over 20%, strives to accelerate progress toward the global End the HIV Epidemic (EHE) 2030 goal. This modelling study aimed to maximize HIV prevention in KZN, given resource constraints. Methods: We performed allocative efficiency analyses (i.e. identifying the allocation of resources that maximizes benefits) with an HIV compartmental transmission model calibrated to HIV prevalence and incidence in KZN since 1990, under two perspectives, 1) “status quo,” building on 2022 funding and coverage levels and allocating additional resources, and 2) “perfect reallocation,” shifting resources toward more efficient interventions before allocating additional resources. Outcomes included infections averted, quality-adjusted life years added, time to reach the EHE goal, and annual programmatic costs. Results: With “status quo,” KZN will fall short of the 2030 EHE goal by approximately 500,000 infections, requiring additional annual expenditures of US$355 million across 11 interventions, from greatest to least efficiency: long-acting PrEP; HIV self-testing; DREAMS; index testing; VMMC; defaulter tracing; community-based testing; differentiated care; condom distribution, ART adherence support for detectable viral load; and oral PrEP. Alternatively, a “perfect reallocation” strategy that shifts funds from lower-efficiency to higher-efficiency interventions could avert 240,000 additional infections, narrowing the EHE gap by nearly half and reducing additional annual expenditures to US$344 million to close the gap. Conclusions: KZN will require additional resources to achieve its 2030 EHE goals, but strategic prioritization and reallocation toward more efficient interventions can maximize HIV prevention within resource constraints.

Background: Differentiated service delivery (DSD) is increasingly available for HIV treatment. DSD has been shown to improve treatment retention, but DSD modalities incur higher costs than the clinic-based standard-of-care (SoC). We conducted a cost-effectiveness (CE) analysis to assess what DSD modalities, in what settings, would constitute an efficient use of limited HIV program resources. Methods: We adapted two validated mathematical models (EMOD-HIV and HIV Synthesis) to project HIV trends (incidence, prevalence, mortality), disability-adjusted life years (DALYs), and costs (2021 USD) arising from DSD versus SoC over 2022–2062 in four settings: South Africa, Malawi, Zambia, and a collective representation of African low- and middle-income countries (LMICs). We compared three DSD modalities: healthcare worker-managed community adherence groups (CAG), client-managed urban adherence group (UAG), and home ART delivery (HomeART). We calculated incremental cost-effectiveness ratios (ICERs) of DSD versus SoC from the health system perspective using country-specific CE thresholds, and performed one-way sensitivity analyses for key assumptions. Results: Community adherence groups (ICER: $274–$604/DALY averted) and UAG (ICER: $590–$720/DALY averted) were cost-effective for all country/model settings. HomeART was dominated by UAG in all settings. In nearly all settings, CE estimates of CAG were robust to uncertainty in DSD effectiveness (except Zambia), DSD costs, CE threshold (except South Africa), HIV-associated disability weights, and discount rates. Cost-effectiveness of UAG was highly sensitive to uncertainty in DSD effectiveness in all settings. Conclusions: Community adherence groups and UAG can provide cost-effective alternatives to the clinic-based SoC in multiple African settings.

Using a validated HIV transmission model for Zimbabwe, we simulated January 2025 U.S. President's Plan for AIDS Relief (PEPFAR) funding cuts’ impacts on HIV incidence and HIV-related deaths. We found extending funding cuts through 2030 would increase HIV incidence by 78% and add 85 000 infections, producing 25 000 additional HIV-related deaths. However, if PEPFAR reinstated funding within 12 months, much or all of this harm could be offset through more efficient resource allocation, specifically, reallocating funds for oral PrEP towards long-acting PrEP.

Background: Inappropriate imaging to stage low-risk prostate cancer is considered low-value care. Determining the effectiveness of a theory-based intervention—Prostate Cancer Imaging Stewardship (PCIS)—to promote guideline-concordant imaging. Methods: A stepped-wedge, cluster-randomized trial, PCIS, was conducted between March 2018 and March 2021 at 10 Veterans Health Administration medical centers (VAMCs) initially selected for prostate cancer volume, geographic diversity, and willingness to participate. Intervention initiations at sites were randomized in 3-month intervals. We enrolled 61 urology providers who treat prostate cancer at participating sites. Outcomes were assessed among 2302 patients with incident prostate cancer aged 18-85 years. PCIS combines 3 evidence-based provider-focused behavior change strategies: (1) Clinical Reminder Order Check triggered when a provider attempted to order imaging for a patient with prostate-specific antigen < 20 ng/mL, (2) VAMC-level academic detailing at initiation and every 3 months thereafter, and (3) Audit and Feedback for providers to improve their imaging performance. The main outcome was guideline-discordant nuclear medicine bone scan (NMBS) imaging for low-risk prostate cancer patients. Results: NMBS imaging would be consistent with National Comprehensive Cancer Network guidelines in 878 patients (38%) and inconsistent in 1424 patients (62%). Among patients not requiring NMBS, 141/690 (20.4%) received guideline-discordant imaging (ie, NMBS ordered) during Control compared with 109/734 (14.9%) during Intervention (odds ratio [OR] = 0.54, P = .04). Among patients requiring a NMBS, 29 of 425 (6.8%) did not receive one (ie, guideline-discordant imaging) during Control compared with 25 of 453 (5.5%) during the Intervention (OR = 1.36, P = .36). Conclusion: PCIS significantly reduced low-value, guideline-discordant NMBS imaging among low-risk prostate cancer patients without negatively affecting necessary imaging for high-risk patients. Clinical Trials Registration: NCT03445559.

Introduction. Diminishing marginal lifespan utility (DMLU) implies that a particular lifespan increment (e.g., 1 life-year) confers lesser marginal utility if added to longer lifespans (e.g., 90 y to 91 y) than to shorter lifespans (e.g., 60 y to 61 y) if quality of life is unchanged. Because DMLU is difficult to disambiguate from discounting, risk attitude, and other elements of utility “curvature,” it is poorly characterized. However, the imperative to consider equity in cost-effectiveness analysis (CEA) renders its characterization more important. Methods. I add certainty to the characterization of DMLU through literature review and illustrative example. The literature review synthesizes stated preference studies of utility curvature that exclude risk or probability. The example compares alternative valuations of approaches to reduce inequality in cystic fibrosis outcomes between US centers serving mostly White patients and centers serving mostly non-Black Hispanic patients, with versus without DMLU. Results. The existence of DMLU is likely, and empirical data support its relevance over typical CEA time horizons. The imperative to consider equity in CEA magnifies the importance of DMLU for several reasons. First, intergenerational CEAs require lower discount rates that are less likely to incidentally absorb DMLU. Second, DMLU is incompatible with the use of absolute measures of inequality aversion. Third, DMLU may bias the interpretation of relative measures of inequality aversion toward prioritarianism. Finally, not considering DMLU implicitly biases life-year–based metrics against equity. Conclusion. DMLU is likely to exist, can benefit from additional characterization, and may merit inclusion in CEA alongside discounting. Omitting consideration of DMLU will sometimes confer an antiequity bias and may affect the interpretation of CEAs incorporating inequality aversion. Highlights: Diminishing marginal lifespan utility (DMLU) means that the value of extending lifespan may differ based on the duration of life already lived. DMLU is not typically considered in cost-effectiveness analyses. Not considering DMLU may bias cost-effectiveness analyses against equity. Not considering DMLU may reduce the accuracy of distributive cost-effectiveness analyses and other approaches to consider equity along with efficiency.

US regulators and payers avoid using quality-adjusted life-years (QALYs) for reasons including concerns about disability and age discrimination. Various modifications of the QALY health utility function have been proposed to address discrimination concerns but are unintuitive to some and appear to alter the usual typical QALY tradeoffs between life expectancy and quality of life. I assert that it is unnecessary to further modify typical QALY tradeoffs to address discrimination concerns because, while discrimination and inequality are distinct concepts, aversion to them can be represented by the same mathematical formulation. Accordingly, formulating QALYs based on inequality aversion, as is sometimes done in distributional cost-effectiveness analyses, may be used to counter disability and/or age-based discrimination concerns. I illustrate using a hypothetical example of a lifesaving therapy, applied across varying ages and baseline disability levels, and adjusted for varying levels of the Atkinson inequality-aversion parameter epsilon (ε). I conclude that adjusting QALYs for inequality aversion using ε ranging from approximately 1 to 2 may remediate concerns about QALY-based disability and/or age discrimination in some cases. Highlights: Important barriers to the use of QALYs in the United States include concerns about disability and age discrimination. Modifications to the utility function underlying QALYs have been proposed to mitigate these concerns, but some find them challenging to consider and/or to apply. Unrelated to these concerns, QALYs have been adapted within the framework of distributional cost-effectiveness analysis to allow consideration of inequality as well as efficiency. I outline how this framework can also remediate concerns about disability and age discrimination.

Background: Given the disproportionate rates of incarceration and lower life expectancy (LE) among Black sexual minority men (BSMM) and Black transgender women (BTW) with HIV, we modeled the impact of decarceration and screening for psychiatric conditions and substance use on LE of US BSMM/BTW with HIV. Methods: We augmented a microsimulation model previously validated to predict LE and leading causes of death in the US with estimates from the HPTN 061 cohort and the Veteran's Aging Cohort Studies. We estimated independent associations among psychiatric and substance use disorders, to simulate the influence of treatment of one condition on improvement on others. We used this augmented simulation to estimate LE for BSMM/BTW with HIV with a history of incarceration under alternative policies of decarceration (ie, reducing the fraction exposed to incarceration), screening for psychiatric conditions and substance use, or both. Results: Baseline LE was 61.3 years. Reducing incarceration by 25%, 33%, 50%, and 100% increased LE by 0.29, 0.31, 0.53, and 1.08 years, respectively, versus no reductions in incarceration. When reducing incarceration by 33% and implementing screening for alcohol, tobacco, substance use, and depression, in which a positive screen triggers diagnostic assessment for all psychiatric and substance use conditions and linkage to treatment, LE increased by 1.52 years compared with no screening or decarceration. Discussion: LE among BSMM/BTW with HIV is short compared with other people with HIV. Reducing incarceration and improving screening and treatment of psychiatric conditions and substance use could substantially increase LE in this population.

Public health experts often assume that any policy promoting healthful behavior change is inherently and self-evidently ethical. This assumption is incorrect. This Viewpoint describes why evaluating the ethics of a policy to promote healthful behavior change should require (1) valuing consequences for wellbeing proportionately to consequences for health, (2) valuing changes to the distributional equity of health and wellbeing together with their aggregate improvement, and (3) anticipating and surveilling for unintended consequences sufficiently important to offset benefits. I illustrate these three requirements through a hypothetical salt restriction policy, which is unethical if it evokes strong preferences that detract from wellbeing, disproportionately confers health benefits to those who are already healthy, or elicits unintended consequences that offset health benefits. I discuss why analogies of salt restriction mandates are inappropriate. In summary, public health decision-makers should employ more structured, explicit and comprehensive criteria when considering the ethical consequences of policies.