The past decade has seen tremendous progress in the delivery of treatment of HIV-infected individuals worldwide. Better antiretroviral therapy (ART), improved laboratory monitoring, and evidence of ART as prevention have led to the possibility of beginning to reverse the AIDS pandemic. At the same time, limited resources worldwide have tempered the ability of the international community to optimally utilize these proven interventions. In 2004 and in 2008, NIAID awarded our research group funding to develop and expand the Cost-Effectiveness of Preventing AIDS Complications International (CEPAC-I) Model, a computer simulation of the natural history, clinical management, outcomes, and cost-effectiveness of HIV treatment in 3 resource- limited settings: South Africa, C?te d'lvoire, and India. In the last 5-year cycle of the project, this collaboration produced more than 105 original papers in peer-reviewed journals. In this continuation, we propose to further expand the CEPAC-I Model to reflect important developments in HIV/AIDS, and to address several of the most pressing questions in HIV care. We have three specific aims:
Specific Aim 1 : To examine the optimal packages of HIV care - ART initiation, monitoring strategies including use of point-of-care tests, and regimen sequencing - given varying resource constraints in South Africa, C?te d'Ivoire, India, and Brazil. We will create a new web-based 'metamodel'structure to allow clinical policy makers in other countries to access the capabilities of the CEPAC-I Model.
Specific Aim 2 : To define the benchmarks of clinical efficacy and cost by which new technologies - including long-acting ART and strategies for HIV eradication - may become viable and cost-effective options. We will perform analyses to establish performance requirements for new HIV treatments in resource-limited settings to be cost-effective. Novel modeling methods will incorporate patient heterogeneity as well as expanded probabilistic sensitivity analysis.
Specific Aim 3 : To project clinical outcomes, cost, and cost-effectiveness of detection and treatment for major co-morbidities in people with HIV, including hepatitis B and C viruses, TB, and hypertension. We will assess the cost-effectiveness of merging HIV care with screening and treatment for other common diseases in people with HIV. With new approaches to costing and budget impact analysis, we will assess the affordability of broadening HIV treatment programs. The assembled internationally-recognized, multidisciplinary research team has a lengthy record of disseminating findings to inform HIV care and guidelines, both in the US and internationally. To expand the project scope, we have added investigators from Brazil, the most HIV-affected country in Latin America. By leveraging the team's progress over the past 9 years and accomplishing the aims above, the proposed studies will answer many critical HIV clinical and policy questions facing the global HIV community.

Public Health Relevance

With extraordinary progress in delivering HIV treatment and care in resource-limited settings over the past decade, there is now unprecedented opportunity to further improve outcomes and reverse the trajectory of the HIV/AIDS pandemic. The CEPAC-International Model provides a detailed and sophisticated modeling environment which is uniquely able to address the role of clinical interventions in HIV in the context of their broader public health implications and economic impact. This methodology allows investigation of problems from multiple directions in four countries representing different regions of the world and provides clear insight into proven as well as evolving approaches to HIV care.

National Institute of Health (NIH)
Research Project (R01)
Project #
Application #
Study Section
AIDS Clinical Studies and Epidemiology Study Section (ACE)
Program Officer
Huebner, Robin E
Project Start
Project End
Budget Start
Budget End
Support Year
Fiscal Year
Total Cost
Indirect Cost
Massachusetts General Hospital
United States
Zip Code
Ramirez-Avila, Lynn; Regan, Susan; Chetty, Senica et al. (2015) HIV testing rates, prevalence, and knowledge among outpatients in Durban, South Africa: Time trends over four years. Int J STD AIDS 26:704-9
Luz, Paula M; Morris, Bethany L; Grinsztejn, Beatriz et al. (2015) Cost-effectiveness of genotype testing for primary resistance in Brazil. J Acquir Immune Defic Syndr 68:152-61
Doherty, Kathleen; Essajee, Shaffiq; Penazzato, Martina et al. (2014) Estimating age-based antiretroviral therapy costs for HIV-infected children in resource-limited settings based on World Health Organization weight-based dosing recommendations. BMC Health Serv Res 14:201
Kaplan, Richard; Caldwell, Judy; Middelkoop, Keren et al. (2014) Impact of ART on TB case fatality stratified by CD4 count for HIV-positive TB patients in Cape Town, South Africa (2009-2011). J Acquir Immune Defic Syndr 66:487-94
Tsai, Alexander C; Fricchione, Gregory L; Walensky, Rochelle P et al. (2014) Global health training in US graduate psychiatric education. Acad Psychiatry 38:426-32
Cardoso, Sandra W; Luz, Paula M; Velasque, Luciane et al. (2014) Effectiveness of first-line antiretroviral therapy in the IPEC cohort, Rio de Janeiro, Brazil. AIDS Res Ther 11:29
Andrews, Jason R; Morrow, Carl; Walensky, Rochelle P et al. (2014) Integrating social contact and environmental data in evaluating tuberculosis transmission in a South African township. J Infect Dis 210:597-603
Bassett, Ingrid V; Govindasamy, Darshini; Erlwanger, Alison S et al. (2014) Mobile HIV screening in Cape Town, South Africa: clinical impact, cost and cost-effectiveness. PLoS One 9:e85197
Drain, Paul K; Losina, Elena; Coleman, Sharon M et al. (2014) Diagnostic accuracy of a point-of-care urine test for tuberculosis screening among newly-diagnosed HIV-infected adults: a prospective, clinic-based study. BMC Infect Dis 14:110
O?Laughlin, Kelli N; Kasozi, Julius; Walensky, Rochelle P et al. (2014) Clinic-based routine voluntary HIV testing in a refugee settlement in Uganda. J Acquir Immune Defic Syndr 67:409-13

Showing the most recent 10 out of 117 publications