Eran Bendavid

All Publications

• Epidemic outcomes following government responses to COVID-19: Insights from nearly 100,000 models. Science advances Bendavid, E., Patel, C. J. 2024; 10 (23): eadn0671

  Abstract

  Government responses to COVID-19 are among the most globally impactful events of the 21st century. The extent to which responses-such as school closures-were associated with changes in COVID-19 outcomes remains unsettled. Multiverse analyses offer a systematic approach to testing a large range of models. We used daily data on 16 government responses in 181 countries in 2020-2021, and 4 outcomes-cases, infections, COVID-19 deaths, and all-cause excess deaths-to construct 99,736 analytic models. Among those, 42% suggest outcomes improved following more stringent responses ("helpful"). No subanalysis (e.g. limited to cases as outcome) demonstrated a preponderance of helpful or unhelpful associations. Among the 14 associations with P values < 1 × 10-30, 5 were helpful and 9 unhelpful. In summary, we find no patterns in the overall set of models that suggests a clear relationship between COVID-19 government responses and outcomes. Strong claims about government responses' impacts on COVID-19 may lack empirical support.

  View details for DOI 10.1126/sciadv.adn0671

  View details for PubMedID 38838157

• Global population profile of tropical cyclone exposure from 2002 to 2019. Nature Jing, R., Heft-Neal, S., Chavas, D. R., Griswold, M., Wang, Z., Clark-Ginsberg, A., Guha-Sapir, D., Bendavid, E., Wagner, Z. 2023

  Abstract

  Tropical cyclones have far-reaching impacts on livelihoods and population health that often persist years after the event [1,2,3,4]. Characterizing the demographic and socioeconomic profile and the vulnerabilities of exposed populations is essential to assess health and other risks associated with future tropical cyclone events [5]. Estimates of exposure to tropical cyclones are often regional rather than global [6] and do not consider population vulnerabilities [7]. Here, we combine spatially resolved annual demographic estimates with tropical cyclone wind fields estimates to construct a global profile of the populations exposed to tropical cyclones between 2002 and 2019. We find that approximately 560 million people are exposed yearly and that the number of people exposed has increased across all cyclone intensities over the study period. The age distribution of those exposed has shifted away from children (under-5) and towards older people (over-60) in recent years compared to the early 2000s. Populations exposed to tropical cyclones are more socioeconomically deprived than those unexposed within the same country, and this relationship is more pronounced for people exposed to higher-intensity storms. By characterizing the patterns and vulnerabilities of exposed populations, our results can help identify mitigation strategies and assess the global burden and future risks of tropical cyclones.

  View details for DOI 10.1038/s41586-023-06963-z

  View details for PubMedID 38122822

• COVID-19 policies: Remember measles. Science (New York, N.Y.) Guha-Sapir, D., Moitinho de Almeida, M., Keita, M., Greenough, G., Bendavid, E. 2020; 369 (6501): 261

  View details for DOI 10.1126/science.abc8637

  View details for PubMedID 32675365

• Seroprevalence of SARS-CoV-2-Specific Antibodies Among Adults in Los Angeles County, California, on April 10-11, 2020. JAMA Sood, N., Simon, P., Ebner, P., Eichner, D., Reynolds, J., Bendavid, E., Bhattacharya, J. 2020

  View details for DOI 10.1001/jama.2020.8279

  View details for PubMedID 32421144

• Armed conflict and child mortality in Africa: a geospatial analysis. Lancet (London, England) Wagner, Z., Heft-Neal, S., Bhutta, Z. A., Black, R. E., Burke, M., Bendavid, E. 2018

  Abstract

  BACKGROUND: A substantial portion of child deaths in Africa take place in countries with recent history of armed conflict and political instability. However, the extent to which armed conflict is an important cause of child mortality, especially in Africa, remains unknown.METHODS: We matched child survival with proximity to armed conflict using information in the Uppsala Conflict Data Program Georeferenced Events Dataset on the location and intensity of armed conflict from 1995 to 2015 together with the location, timing, and survival of infants younger than 1 year (primary outcome) in 35 African countries. We measured the increase in mortality risk for infants exposed to armed conflicts within 50 km in the year of birth and, to study conflicts' extended health risks, up to 250 km away and 10 years before birth. We also examined the effects of conflicts of varying intensity and chronicity (conflicts lasting several years), and effect heterogeneity by residence and sex of the child. We then estimated the number and portion of deaths of infants younger than 1 year related to conflict.FINDINGS: We identified 15 441 armed conflict events that led to 968 444 combat-related deaths and matched these data with 1·99 million births and 133 361 infant deaths (infant mortality of 67 deaths per 1000 births) between 1995 and 2015. A child born within 50 km of an armed conflict had a risk of dying before reaching age 1 year of 5·2 per 1000 births higher than being born in the same region during periods without conflict (95% CI 3·7-6·7; a 7·7% increase above baseline). This increased risk of dying ranged from a 3·0% increase for armed conflicts with one to four deaths to a 26·7% increase for armed conflicts with more than 1000 deaths. We find evidence of increased mortality risk from an armed conflict up to 100 km away, and for 8 years after conflicts, with cumulative increase in infant mortality two to four times higher than the contemporaneous increase. In the entire continent, the number of infant deaths related to conflict from 1995 to 2015 was between 3·2 and 3·6 times the number of direct deaths from armed conflicts.INTERPRETATION: Armed conflict substantially and persistently increases infant mortality in Africa, with effect sizes on a scale with malnutrition and several times greater than existing estimates of the mortality burden of conflict. The toll of conflict on children, who are presumably not combatants, underscores the indirect toll of conflict on civilian populations, and the importance of developing interventions to address child health in areas of conflict.FUNDING: The Doris Duke Charitable Foundation, and the Centre for Global Child Health at the Hospital for Sick Children.

  View details for PubMedID 30173907

• Sources of variation in under-5 mortality across sub-Saharan Africa: a spatial analysis. The Lancet. Global health Burke, M., Heft-Neal, S., Bendavid, E. 2016

  Abstract

  Detailed spatial understanding of levels and trends in under-5 mortality is needed to improve the targeting of interventions to the areas of highest need, and to understand the sources of variation in mortality. To improve this understanding, we analysed local-level information on child mortality across sub-Saharan Africa between 1980-2010.We used data from 82 Demographic and Health Surveys in 28 sub-Saharan African countries, including the location and timing of 3·24 million childbirths and 393 685 deaths, to develop high-resolution spatial maps of under-5 mortality in the 1980s, 1990s, and 2000s. These estimates were at a resolution of 0·1 degree latitude by 0·1 degree longitude (roughly 10 km × 10 km). We then analysed this spatial information to distinguish within-country versus between-country sources of variation in mortality, to examine the extent to which declines in mortality have been accompanied by convergence in the distribution of mortality, and to study localised drivers of mortality differences, including temperature, malaria burden, and conflict.In our sample of sub-Saharan African countries from the 1980s to the 2000s, within-country differences in under-5 mortality accounted for 74-78% of overall variation in under-5 mortality across space and over time. Mortality differed significantly across only 8-15% of country borders, supporting the role of local, rather than national, factors in driving mortality patterns. We found that by the end of the study period, 23% of the eligible children in the study countries continue to live in mortality hotspots-areas where, if current trends continue, the Sustainable Developent Goals mortality targets will not be met. In multivariate analysis, within-country mortality levels at each pixel were significantly related to local temperature, malaria burden, and recent history of conflict.Our findings suggest that sub-national determinants explain a greater portion of under-5 mortality than do country-level characteristics. Sub-national measures of child mortality could provide a more accurate, and potentially more actionable, portrayal of where and why children are still dying than can national statistics.The Stanford Woods Institute for the Environment.

  View details for DOI 10.1016/S2214-109X(16)30212-1

  View details for PubMedID 27793587

• Changes in Child Mortality Over Time Across the Wealth Gradient in Less-Developed Countries PEDIATRICS Bendavid, E. 2014; 134 (6): E1551-E1559

  Abstract

  It is unknown whether inequalities in under-5 mortality by wealth in low- and middle-income countries (LMICs) are growing or declining.All Demographic and Health Surveys conducted between 2002 and 2012 were used to measure under-5 mortality trends in 3 wealth tertiles. Two approaches were used to estimate changes in under-5 mortality: within-survey changes from all 54 countries, and between-survey changes for 29 countries with repeated survey waves. The principal outcome measures include annual decline in mortality, and the ratio of mortality between the poorest and least-poor wealth tertiles.Mortality information in 85 surveys from 929 224 households and 1 267 167 women living in 54 countries was used. In the subset of 29 countries with repeat surveys, mortality declined annually by 4.36, 3.36, and 2.06 deaths per 1000 live births among the poorest, middle, and least-poor tertiles, respectively (P = .031 for difference). The mortality ratio declined from 1.68 to 1.48 during the study period (P = .006 for trend). In the complete set of 85 surveys, the mortality ratio declined in 64 surveys (from 2.11 to 1.55), and increased in 21 surveys (from 1.58 to 1.88). Multivariate analyses suggest that convergence was associated with good governance (P ≤ .03 for 4 governance indicators: government effectiveness, rule of law, regulatory quality, and control of corruption).Overall, under-5 mortality in low- and middle-income countries has decreased faster among the poorest compared with the least poor between 1995 and 2012, but progress in some countries has lagged, especially with poor governance.

  View details for DOI 10.1542/peds.2014-2320

  View details for Web of Science ID 000345844200006

  View details for PubMedID 25384496

  View details for PubMedCentralID PMC4243072

• Cost-effectiveness analysis of pediatric cardiac surgery for common lesions in Rwanda. International journal of cardiology Mlambo, V. C., Ejigu, Y., Neil, K. L., Sendegeya, A., Ntihabose, C., Bendavid, E., d'Aci, P. R., Lin, Y. 2024: 132909

  Abstract

  Only 3 % of children in sub-Saharan Africa with congenital heart disease (CHD) have access to life-saving surgery. There is an urgent need to scale up the volume of cardiac procedures. Cost-utility analysis can assess the health economic impacts of performing congenital heart surgery in this region.We performed a cost-utility analysis comparing surgical intervention and medical management for a weighted case mix of the four most common CHDs in Rwanda. A Markov model was constructed to simulate the course of each strategy. Probability of peri-operative complications was derived from the local pediatric cardiac surgery program and risks of long-term outcomes from large, published cohort studies. Micro-costing was used to calculate expenses from program cost data. Health benefits were measured in quality-adjusted life years (QALYs). Deterministic and probabilistic sensitivity analysis was performed. Incremental cost-effectiveness ratios (ICER) were compared to a willingness-to-pay threshold three times the GDP per capita of Rwanda (USD$2898·60).Surgical intervention provided 17·15 additional discounted QALYs compared to medical management for an extra USD$6738·23. The ICER for surgical intervention was USD$269·52/QALY. Increasing the cost of surgery raised the ICER to a maximum of USD$580/QALY. In the probabilistic sensitivity analysis, surgery was cost-effective 100 % of the time including at one-times GDP per capita.Surgical intervention for common CHD in Rwanda is very cost-effective. The initial cost of surgery is compensated for by decades of additional life years. Increasing case complexity and decreasing the initial cost of surgery can make surgery even more cost-effective.

  View details for DOI 10.1016/j.ijcard.2024.132909

  View details for PubMedID 39710349

• Removing lead from the global economy. The Lancet. Planetary health Luby, S. P., Forsyth, J. E., Fatmi, Z., Rahman, M., Sultana, J., Plambeck, E. L., Miller, N. G., Bendavid, E., Winch, P. J., Hu, H., Lanphear, B., Landrigan, P. J. 2024; 8 (11): e966-e972

  Abstract

  Lead, an element toxic to countless biological processes, occurs naturally in the earth's lithosphere and is geologically sequestered from the biosphere at the earth's surface. When humans remove lead from the lithosphere and distribute it throughout the economy, its toxic effects impact throughout the web of life. Lead mining and manufacturing is a small industry that generates enormous harms. Lead impairs the growth, development, and reproduction of microbes, insects, plants, and animals. The annual human costs of lead exposure include 5·5 million premature adult deaths from cardiovascular disease and US$1·4 trillion in losses to the global economy from lead impairing children's cognitive development. Although the lead industry touts lead as the most recycled metal, most recycling occurs within countries that are incapable of enforcing environmental regulations. Millions of metric tonnes of lead are dispersed into the environment each year, disproportionately in low-income and middle-income countries. Substitutes for lead in the economy are available and we should act in the best interests of the planet and human health by eliminating lead from the global economy by 2035.

  View details for DOI 10.1016/S2542-5196(24)00244-4

  View details for PubMedID 39515356

• TC-GEN: Data-Driven Tropical Cyclone Downscaling Using Machine Learning-Based High-Resolution Weather Model JOURNAL OF ADVANCES IN MODELING EARTH SYSTEMS Jing, R., Gao, J., Cai, Y., Xi, D., Zhang, Y., Fu, Y., Emanuel, K., Diffenbaugh, N. S., Bendavid, E. 2024; 16 (10)

  View details for DOI 10.1029/2023MS004203

  View details for Web of Science ID 001326244700001

• AI and biosecurity: The need for governance. Science (New York, N.Y.) Bloomfield, D., Pannu, J., Zhu, A. W., Ng, M. Y., Lewis, A., Bendavid, E., Asch, S. M., Hernandez-Boussard, T., Cicero, A., Inglesby, T. 2024; 385 (6711): 831-833

  Abstract

  Governments should evaluate advanced models and if needed impose safety measures.

  View details for DOI 10.1126/science.adq1977

  View details for PubMedID 39172825

• Disparities in air pollution attributable mortality in the US population by race/ethnicity and sociodemographic factors. Nature medicine Geldsetzer, P., Fridljand, D., Kiang, M. V., Bendavid, E., Heft-Neal, S., Burke, M., Thieme, A. H., Benmarhnia, T. 2024

  Abstract

  There are large differences in premature mortality in the USA by race/ethnicity, education, rurality and social vulnerability index groups. Using existing concentration-response functions, published particulate matter (PM2.5) air pollution estimates, population estimates at the census tract level and county-level mortality data from the US National Vital Statistics System, we estimated the degree to which these mortality discrepancies can be attributed to differences in exposure and susceptibility to PM2.5. We show that differences in PM2.5-attributable mortality were consistently more pronounced by race/ethnicity than by education, rurality or social vulnerability index, with the Black American population having the highest proportion of deaths attributable to PM2.5 in all years from 1990 to 2016. Our model estimates that over half of the difference in age-adjusted all-cause mortality between the Black American and non-Hispanic white population was attributable to PM2.5 in the years 2000 to 2011. This difference decreased only marginally between 2000 and 2015, from 53.4% (95% confidence interval 51.2-55.9%) to 49.9% (95% confidence interval 47.8-52.2%), respectively. Our findings underscore the need for targeted air quality interventions to address environmental health disparities.

  View details for DOI 10.1038/s41591-024-03117-0

  View details for PubMedID 38951636

  View details for PubMedCentralID 7439614

• Panel stacking is a threat to consensus statement validity. Journal of clinical epidemiology Kepp, K. P., Aavitsland, P., Ballin, M., Balloux, F., Baral, S., Bardosh, K., Bauchner, H., Bendavid, E., Bhopal, R., Blumstein, D. T., Boffetta, P., Bourgeois, F., Brufsky, A., Collignon, P. J., Cripps, S., Cristea, I. A., Curtis, N., Djulbegovic, B., Faude, O., Flacco, M. E., Guyatt, G. H., Hajishengallis, G., Hemkens, L. G., Hoffmann, T., Joffe, A. R., Klassen, T. P., Koletsi, D., Kontoyiannis, D. P., Kuhl, E., La Vecchia, C., Lallukka, T., Lambris, J., Levitt, M., Makridakis, S., Maltezou, H. C., Manzoli, L., Marusic, A., Mavragani, C., Moher, D., Mol, B. W., Muka, T., Naudet, F., Noble, P. W., Nordström, A., Nordström, P., Pandis, N., Papatheodorou, S., Patel, C. J., Petersen, I., Pilz, S., Plesnila, N., Ponsonby, A. L., Rivas, M. A., Saltelli, A., Schabus, M., Schippers, M. C., Schünemann, H., Solmi, M., Stang, A., Streeck, H., Sturmberg, J. P., Thabane, L., Thombs, B. D., Tsakris, A., Wood, S. N., Ioannidis, J. P. 2024: 111428

  Abstract

  Consensus statements can be very influential in medicine and public health. Some of these statements use systematic evidence synthesis but others fail on this front. Many consensus statements use panels of experts to deduce perceived consensus through Delphi processes. We argue that stacking of panel members towards one particular position or narrative is a major threat, especially in absence of systematic evidence review. Stacking may involve financial conflicts of interest, but non-financial conflicts of strong advocacy can also cause major bias. Given their emerging importance, we describe here how such consensus statements may be misleading, by analysing in depth a recent high-impact Delphi consensus statement on COVID-19 recommendations as a case example. We demonstrate that many of the selected panel members and at least 35% of the core panel members had advocated towards COVID-19 elimination (zero-COVID) during the pandemic and were leading members of aggressive advocacy groups. These advocacy conflicts were not declared in the Delphi consensus publication, with rare exceptions. Therefore, we propose that consensus statements should always require rigorous evidence synthesis and maximal transparency on potential biases towards advocacy or lobbyist groups to be valid. While advocacy can have many important functions, its biased impact on consensus panels should be carefully avoided.

  View details for DOI 10.1016/j.jclinepi.2024.111428

  View details for PubMedID 38897481

• CALCIMIMETIC PRESCRIPTIONS FOLLOWING THE TRANSITIONAL DRUG ADD-ON PAYMENT ADJUSTMENT IN FEE-FOR-SERVICE MEDICARE PATIENTS ON DIALYSIS Caldwell, J., Cheng, X. S., Bendavid, E., Chertow, G. M., Lin, E. ELSEVIER SCIENCE INC. 2024: S213

  View details for Web of Science ID 001277006602073

• Sociodemographic and geographic variation in mortality attributable to air pollution in the United States. medRxiv : the preprint server for health sciences Geldsetzer, P., Fridljand, D., Kiang, M. V., Bendavid, E., Heft-Neal, S., Burke, M., Thieme, A. H., Benmarhnia, T. 2024

  Abstract

  There are large differences in premature mortality in the USA by racial/ethnic, education, rurality, and social vulnerability index groups. Using existing concentration-response functions, particulate matter (PM2.5) air pollution, population estimates at the tract level, and county-level mortality data, we estimated the degree to which these mortality discrepancies can be attributed to differences in exposure and susceptibility to PM2.5. We show that differences in mortality attributable to PM2.5 were consistently more pronounced between racial/ethnic groups than by education, rurality, or social vulnerability index, with the Black American population having by far the highest proportion of deaths attributable to PM2.5 in all years from 1990 to 2016. Over half of the difference in age-adjusted all-cause mortality between the Black American and non-Hispanic White population was attributable to PM2.5 in the years 2000 to 2011.

  View details for DOI 10.1101/2024.04.17.24305943

  View details for PubMedID 38699349

  View details for PubMedCentralID PMC11065005

• Duration of SARS-CoV-2 Culturable Virus Shedding in Children by Vaccination Status-Reply. JAMA pediatrics Kumar, N., Bendavid, E., Sood, N. 2024

  View details for DOI 10.1001/jamapediatrics.2023.6601

  View details for PubMedID 38345814

• U.S. global health aid policy and family planning in sub-Saharan Africa. Science advances Brooks, N., Gunther, M., Bendavid, E., Boyle, E. H., Grace, K., Miller, G. 2023; 9 (49): eadk2684

  Abstract

  The Trump administration reinstated and expanded the Mexico City Policy (MCP) in 2017 as the Protecting Life in Global Health Assistance (PLGHA) policy, forbidding international organizations receiving all U.S. health assistance from promoting abortion. Existing evidence suggests that abortion rates rise under the MCP, but the direct effect of U.S. funding restrictions on supply and use of family planning has received less attention. By studying PLGHA's impact on health service delivery providers and women in eight sub-Saharan African countries, we are able to fill this gap. We find that health facilities provide fewer family planning services, including emergency contraception, and that women are less likely to use contraception and more likely to have given birth recently under the policy. These findings suggest that PLGHA has important unintended consequences that are detrimental to reproductive health and the autonomous decision-making of health service providers and women.

  View details for DOI 10.1126/sciadv.adk2684

  View details for PubMedID 38055817

• The Shifting Prognosis of FLT3 Mutations in Acute Myeloid Leukemia in the Era of Targeted Therapy: A Real-World Study Using Large-Scale Electronic Health Record Data Schwede, M., Rodriguez, G., Henry, S., Wood, D., Mannis, G., Majeti, R., Chen, J., Bendavid, E., Zhang, T. Y. AMER SOC HEMATOLOGY. 2023

  View details for DOI 10.1182/blood-2023-187725

  View details for Web of Science ID 001159306703227

• Duration of SARS-CoV-2 Culturable Virus Shedding in Children. JAMA pediatrics Kumar, N., Bendavid, E., Sood, N. 2023

  View details for DOI 10.1001/jamapediatrics.2023.4511

  View details for PubMedID 37870828

  View details for PubMedCentralID PMC10594177

• Emergency department visits respond nonlinearly to wildfire smoke. Proceedings of the National Academy of Sciences of the United States of America Heft-Neal, S., Gould, C. F., Childs, M. L., Kiang, M. V., Nadeau, K. C., Duggan, M., Bendavid, E., Burke, M. 2023; 120 (39): e2302409120

  Abstract

  Air pollution negatively affects a range of health outcomes. Wildfire smoke is an increasingly important contributor to air pollution, yet wildfire smoke events are highly salient and could induce behavioral responses that alter health impacts. We combine geolocated data covering all emergency department (ED) visits to nonfederal hospitals in California from 2006 to 2017 with spatially resolved estimates of daily wildfire smoke PM[Formula: see text] concentrations and quantify how smoke events affect ED visits. Total ED visits respond nonlinearly to smoke concentrations. Relative to a day with no smoke, total visits increase by 1 to 1.5% in the week following low or moderate smoke days but decline by 6 to 9% following extreme smoke days. Reductions persist for at least a month. Declines at extreme levels are driven by diagnoses not thought to be acutely impacted by pollution, including accidental injuries and several nonurgent symptoms, and declines come disproportionately from less-insured populations. In contrast, health outcomes with the strongest physiological link to short-term air pollution increase dramatically in the week following an extreme smoke day: We estimate that ED visits for asthma, COPD, and cough all increase by 30 to 110%. Data from internet searches, vehicle traffic sensors, and park visits indicate behavioral changes on high smoke days consistent with declines in healthcare utilization. Because low and moderate smoke days vastly outweigh high smoke days, we estimate that smoke was responsible for an average of 3,010 (95% CI: 1,760-4,380) additional ED visits per year 2006 to 2017. Given the increasing intensity of wildfire smoke events, behavioral mediation is likely to play a growing role in determining total smoke impacts.

  View details for DOI 10.1073/pnas.2302409120

  View details for PubMedID 37722035

• Infant and Neonatal Mortality During the Covid-19 Pandemic: An Interrupted Time Series Analysis From Five Low- and Middle-Income Countries. medRxiv : the preprint server for health sciences Wagner, Z., Heft-Neal, S., Wang, Z., Jing, R., Bendavid, E. 2023

  Abstract

  The Covid-19 pandemic led to widespread changes to health and social institutions. The effects of the pandemic on neonatal and infant health outcomes in low- and middle-income countries (LMICs) are poorly understood, and nationally representative data characterizing changes to health care and outcomes is only now emerging.We used nationally representative survey data with vital status and perinatal care information on 2,959,203 children born in India, Madagascar, Cambodia, Nepal, and the Philippines. Using interrupted time series models, we estimated the change in neonatal mortality (death in first 30 days of life) and infant mortality (death in first year of life) following the start of the Covid-19 pandemic, controlling for granular location fixed-effects and seasonality.We analyzed 2,935,052 births (146,820 deaths) before March 2020 and 24,151 births (799 deaths) after March 2020. We estimated that infant mortality increased by 9.9 deaths per 1,000 live births after March 2020 (95% CI 5.0, 15.0; p<0.01; 22% increase) and neonatal mortality increased by 6.7 deaths per 1,000 live births (95% CI 2.4, 11.1; p<0.01; 27% increase). We observe increased mortality in all study countries. We also estimated a 3.8 percentage point reduction in antenatal care use (95% CI -4.9, -2.7; p<0.01) and a 5.6 percentage point reduction in facility deliveries (95% CI -7.2, -4.0; p<0.01) during the pandemic.Since the start of the Covid-19 pandemic, neonatal and infant mortality are higher than expected in five LMICs. Helping LMICs resume pre-pandemic declines in neonatal and infant mortality should be a major global priority.

  View details for DOI 10.1101/2023.08.03.23293619

  View details for PubMedID 37609306

  View details for PubMedCentralID PMC10441505

• The long reach of war's costs: building the evidence for action LANCET GLOBAL HEALTH Bendavid, E. 2023; 11 (6): E799-E800

  View details for Web of Science ID 001054172700001

• The long reach of war's costs: building the evidence for action. The Lancet. Global health Bendavid, E. 2023; 11 (6): e799-e800

  View details for DOI 10.1016/S2214-109X(23)00176-6

  View details for PubMedID 37202007

• An Effectiveness Analysis of Walk-in Stroke Centres in Northern Alberta Purdy, K., Jeerakathil, T., Owens, D., Bendavid, E. LIPPINCOTT WILLIAMS & WILKINS. 2023

  View details for DOI 10.1212/WNL.0000000000202003

  View details for Web of Science ID 001053672107069

• Seroprevalence Studies Are Critical Early Pandemic Tools, and They Were Underappreciated During Covid-19. American journal of public health Bendavid, E. 2023: e1-e2

  View details for DOI 10.2105/AJPH.2023.307259

  View details for PubMedID 36926963

• Exact inference for disease prevalence based on a test with unknown specificity and sensitivity. Journal of applied statistics Cai, B., Ioannidis, J. P., Bendavid, E., Tian, L. 2023; 50 (11-12): 2599-2623

  Abstract

  To make informative public policy decisions in battling the ongoing COVID-19 pandemic, it is important to know the disease prevalence in a population. There are two intertwined difficulties in estimating this prevalence based on testing results from a group of subjects. First, the test is prone to measurement error with unknown sensitivity and specificity. Second, the prevalence tends to be low at the initial stage of the pandemic and we may not be able to determine if a positive test result is a false positive due to the imperfect test specificity. The statistical inference based on a large sample approximation or conventional bootstrap may not be valid in such cases. In this paper, we have proposed a set of confidence intervals, whose validity doesn't depend on the sample size in the unweighted setting. For the weighted setting, the proposed inference is equivalent to hybrid bootstrap methods, whose performance is also more robust than those based on asymptotic approximations. The methods are used to reanalyze data from a study investigating the antibody prevalence in Santa Clara County, California in addition to several other seroprevalence studies. Simulation studies have been conducted to examine the finite-sample performance of the proposed method.

  View details for DOI 10.1080/02664763.2021.2019687

  View details for PubMedID 37529562

  View details for PubMedCentralID PMC10388830

• Clostridium difficile and other adverse events from overprescribed antibiotics for acute upper respiratory infection. Journal of internal medicine Carmichael, H., Asch, S. M., Bendavid, E. 2022

  Abstract

  BACKGROUND: Guidelines widely recommend avoiding antibiotics for many acute upper respiratory infections (aURIs) to avert adverse events in absence of likely benefit. However, the extent of harm from these antibiotics remains a subject of debate and could inform patient-centered decision-making. Prior estimates finding a number needed to harm (NNH) between 8-10 rely on patient-reported adverse events of any severity. In this analysis, we sought to estimate adverse events by only measuring comparatively severe events that require subsequent clinical evaluation.METHODS: We constructed a retrospective cohort including 51 million patient encounters. Using logistic regression models, we determined the adjusted odds ratio (aOR) of clinically detectable adverse events following antibiotic use compared with events among unexposed individuals with aURIs. Our outcomes included: candidiasis, diarrhea, Clostridium difficile infection (CDI), and a composite outcome.FINDINGS: From our analysis, 62.4% of the population received antibiotics in an aURI encounter. Observed adverse events in the antibiotic-exposed group were 54,279 and 46,936 for diarrhea and candidiasis, respectively, yielding an aOR of 1.24 and 1.61, and a NNH of 3126 and 1975. Observed events of CDI in the exposed group were 30,133, and aORs of isolated CDI and combined adverse events were 1.07 and 1.30, resulting in a NNH of 17,695 and 1150, respectively. Females were more likely to be diagnosed with any adverse event. Overall antibiotics were found to result in 5.7 additional cases of CDI per 100,000 outpatient prescriptions following an upper respiratory tract infection.INTERPRETATION: Despite higher NNH than previous methods of analysis, we find substantial iatrogenic harm associated with prescribing antibiotics in aURIs. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1111/joim.13597

  View details for PubMedID 36460621

• Geographically resolved social cost of anthropogenic emissions accounting for both direct and climate-mediated effects. Science advances Burney, J., Persad, G., Proctor, J., Bendavid, E., Burke, M., Heft-Neal, S. 2022; 8 (38): eabn7307

  Abstract

  The magnitude and distribution of physical and societal impacts from long-lived greenhouse gases are insensitive to the emission source location; the same is not true for major coemitted short-lived pollutants such as aerosols. Here, we combine novel global climate model simulations with established response functions to show that a given aerosol emission from different regions produces divergent air quality and climate changes and associated human system impacts, both locally and globally. The marginal global damages to infant mortality, crop productivity, and economic growth from aerosol emissions and their climate effects differ by more than an order of magnitude depending on source region, with certain regions creating global external climate changes and impacts much larger than those felt locally. The complex distributions of aerosol-driven societal impacts emerge from geographically distinct and region-specific aerosol-climate interactions, estimation of which is enabled by the full Earth System Modeling Framework used here.

  View details for DOI 10.1126/sciadv.abn7307

  View details for PubMedID 36149961

• Geographically resolved social cost of anthropogenic emissions accounting for both direct and climate-mediated effects SCIENCE ADVANCES Burney, J., Persad, G., Proctor, J., Bendavid, E., Burke, M., Heft-Neal, S. 2022; 8 (38)

  View details for Web of Science ID 000890031700015

• Massive covidization of research citations and the citation elite. Proceedings of the National Academy of Sciences of the United States of America Ioannidis, J. P., Bendavid, E., Salholz-Hillel, M., Boyack, K. W., Baas, J. 2022; 119 (28): e2204074119

  Abstract

  Massive scientific productivity accompanied the COVID-19 pandemic. We evaluated the citation impact of COVID-19 publications relative to all scientific work published in 2020 to 2021 and assessed the impact on scientist citation profiles. Using Scopus data until August 1, 2021, COVID-19 items accounted for 4% of papers published, 20% of citations received to papers published in 2020 to 2021, and >30% of citations received in 36 of the 174 disciplines of science (up to 79.3% in general and internal medicine). Across science, 98 of the 100 most-cited papers published in 2020 to 2021 were related to COVID-19; 110 scientists received ≥10,000 citations for COVID-19 work, but none received ≥10,000 citations for non-COVID-19 work published in 2020 to 2021. For many scientists, citations to their COVID-19 work already accounted for more than half of their total career citation count. Overall, these data show a strong covidization of research citations across science, with major impact on shaping the citation elite.

  View details for DOI 10.1073/pnas.2204074119

  View details for PubMedID 35867747

• Cost-effectiveness of easy-access, risk-informed oral pre-exposure prophylaxis in HIV epidemics in sub-Saharan Africa: a modelling study LANCET HIV Phillips, A. N., Bershteyn, A., Revill, P., Bansi-Matharu, L., Kripke, K., Boily, M., Martin-Hughes, R., Johnson, L. F., Mukandavire, Z., Jamieson, L., Meyer-Rath, G., Hallett, T. B., ten Brink, D., Kelly, S. L., Nichols, B. E., Bendavid, E., Mudimu, E., Taramusi, I., Smith, J., Dalal, S., Baggaley, R., Crowley, S., Terris-Prestholt, F., Godfrey-Faussett, P., Mukui, I., Jahn, A., Case, K. K., Havlir, D., Petersen, M., Kamya, M., Koss, C. A., Balzer, L. B., Apollo, T., Chidarikire, T., Mellors, J. W., Parikh, U. M., Godfrey, C., Cambiano, V., HIV Modelling Consortium 2022; 9 (5): E353-E362

  View details for Web of Science ID 000821930300014

• Cost-effectiveness of easy-access, risk-informed oral pre-exposure prophylaxis in HIV epidemics in sub-Saharan Africa: a modelling study. The lancet. HIV Phillips, A. N., Bershteyn, A., Revill, P., Bansi-Matharu, L., Kripke, K., Boily, M. C., Martin-Hughes, R., Johnson, L. F., Mukandavire, Z., Jamieson, L., Meyer-Rath, G., Hallett, T. B., Ten Brink, D., Kelly, S. L., Nichols, B. E., Bendavid, E., Mudimu, E., Taramusi, I., Smith, J., Dalal, S., Baggaley, R., Crowley, S., Terris-Prestholt, F., Godfrey-Faussett, P., Mukui, I., Jahn, A., Case, K. K., Havlir, D., Petersen, M., Kamya, M., Koss, C. A., Balzer, L. B., Apollo, T., Chidarikire, T., Mellors, J. W., Parikh, U. M., Godfrey, C., Cambiano, V. 2022; 9 (5): e353-e362

  Abstract

  Approaches that allow easy access to pre-exposure prophylaxis (PrEP), such as over-the-counter provision at pharmacies, could facilitate risk-informed PrEP use and lead to lower HIV incidence, but their cost-effectiveness is unknown. We aimed to evaluate conditions under which risk-informed PrEP use is cost-effective.We applied a mathematical model of HIV transmission to simulate 3000 setting-scenarios reflecting a range of epidemiological characteristics of communities in sub-Saharan Africa. The prevalence of HIV viral load greater than 1000 copies per mL among all adults (HIV positive and negative) varied from 1·1% to 7·4% (90% range). We hypothesised that if PrEP was made easily available without restriction and with education regarding its use, women and men would use PrEP, with sufficient daily adherence, during so-called seasons of risk (ie, periods in which individuals are at risk of acquiring infection). We refer to this as risk-informed PrEP. For each setting-scenario, we considered the situation in mid-2021 and performed a pairwise comparison of the outcomes of two policies: immediate PrEP scale-up and then continuation for 50 years, and no PrEP. We estimated the relationship between epidemic and programme characteristics and cost-effectiveness of PrEP availability to all during seasons of risk. For our base-case analysis, we assumed a 3-monthly PrEP cost of US$29 (drug $11, HIV test $4, and $14 for additional costs necessary to facilitate education and access), a cost-effectiveness threshold of $500 per disability-adjusted life-year (DALY) averted, an annual discount rate of 3%, and a time horizon of 50 years. In sensitivity analyses, we considered a cost-effectiveness threshold of $100 per DALY averted, a discount rate of 7% per annum, the use of PrEP outside of seasons of risk, and reduced uptake of risk-informed PrEP.In the context of PrEP scale-up such that 66% (90% range across setting-scenarios 46-81) of HIV-negative people with at least one non-primary condomless sex partner take PrEP in any given period, resulting in 2·6% (0·9-6·0) of all HIV negative adults taking PrEP at any given time, risk-informed PrEP was predicted to reduce HIV incidence by 49% (23-78) over 50 years compared with no PrEP. PrEP was cost-effective in 71% of all setting-scenarios, and cost-effective in 76% of setting-scenarios with prevalence of HIV viral load greater than 1000 copies per mL among all adults higher than 2%. In sensitivity analyses with a $100 per DALY averted cost-effectiveness threshold, a 7% per year discount rate, or with PrEP use that was less well risk-informed than in our base case, PrEP was less likely to be cost-effective, but generally remained cost-effective if the prevalence of HIV viral load greater than 1000 copies per mL among all adults was higher than 3%. In sensitivity analyses based on additional setting-scenarios in which risk-informed PrEP was less extensively used, the HIV incidence reduction was smaller, but the cost-effectiveness of risk-informed PrEP was undiminished.Under the assumption that making PrEP easily accessible for all adults in sub-Saharan Africa in the context of community education leads to risk-informed use, PrEP is likely to be cost-effective in settings with prevalence of HIV viral load greater than 1000 copies per mL among all adults higher than 2%, suggesting the need for implementation of such approaches, with ongoing evaluation.US Agency for International Development, US President's Emergency Plan for AIDS Relief, and Bill & Melinda Gates Foundation.

  View details for DOI 10.1016/S2352-3018(22)00029-7

  View details for PubMedID 35489378

• Health and development from preconception to 20 years of age and human capital. Lancet (London, England) Black, R. E., Liu, L., Hartwig, F. P., Villavicencio, F., Rodriguez-Martinez, A., Vidaletti, L. P., Perin, J., Black, M. M., Blencowe, H., You, D., Hug, L., Masquelier, B., Cousens, S., Gove, A., Vaivada, T., Yeung, D., Behrman, J., Martorell, R., Osmond, C., Stein, A. D., Adair, L. S., Fall, C. H., Horta, B., Menezes, A. M., Ramirez-Zea, M., Richter, L. M., Patton, G. C., Bendavid, E., Ezzati, M., Bhutta, Z. A., Lawn, J. E., Victora, C. G. 2022

  Abstract

  Optimal health and development from preconception to adulthood are crucial for human flourishing and the formation of human capital. The Nurturing Care Framework, as adapted to age 20 years, conceptualises the major influences during periods of development from preconception, through pregnancy, childhood, and adolescence that affect human capital. In addition to mortality in children younger than 5 years, stillbirths and deaths in 5-19-year-olds are important to consider. The global rate of mortality in individuals younger than 20 years has declined substantially since 2000, yet in 2019 an estimated 8·6 million deaths occurred between 28 weeks of gestation and 20 years of age, with more than half of deaths, including stillbirths, occurring before 28 days of age. The 1000 days from conception to 2 years of age are especially influential for human capital. The prevalence of low birthweight is high in sub-Saharan Africa and even higher in south Asia. Growth faltering, especially from birth to 2 years, occurs in most world regions, whereas overweight increases in many regions from the preprimary school period through adolescence. Analyses of cohort data show that growth trajectories in early years of life are strong determinants of nutritional outcomes in adulthood. The accrual of knowledge and skills is affected by health, nutrition, and home resources in early childhood and by educational opportunities in older children and adolescents. Linear growth in the first 2 years of life better predicts intelligence quotients in adults than increases in height in older children and adolescents. Learning-adjusted years of schooling range from about 4 years in sub-Saharan Africa to about 11 years in high-income countries. Human capital depends on children and adolescents surviving, thriving, and learning until adulthood.

  View details for DOI 10.1016/S0140-6736(21)02533-2

  View details for PubMedID 35489357

• Shifting the Demand for Vaccines: A Review of Strategies. Annual review of public health Sood, N., Nasserie, T., Joshi, S., Bendavid, E. 1800

  Abstract

  Vaccines prevent millions of deaths, and yet millions of people die each year from vaccine-preventable diseases. The primary reason for these deaths is that a significant fraction of the population chooses not to vaccinate. Why don't people vaccinate, and what can be done to increase vaccination rates besides providing free and easy access to vaccines? This review presents a conceptual framework, motivated by economic theory, of which factors shift the demand for vaccines. Next, it critically examines the literature on these demand shifters and interventions that target these demand shifters. The review concludes with offering directions for future research and lessons for public health decision-making. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

  View details for DOI 10.1146/annurev-publhealth-052620-093049

  View details for PubMedID 35081316

• The Effect of Healthcare Worker Density on Maternal Health Service Utilization in Sub-Saharan Africa. The American journal of tropical medicine and hygiene Rosser, J. I., Aluri, K. Z., Kempinsky, A., Richardson, S., Bendavid, E. 2022; 106 (3): 939-944

  Abstract

  Facility births and antenatal care (ANC) are key to improving maternal health. This study evaluates the relationship between physician and nurse/midwife densities and the use of key maternal health services in sub-Saharan Africa (SSA). We matched individual-level maternal health service indicators from Demographic and Health Surveys between 2008 and 2017, to country-level physician and nurse/midwife per-capita densities, across 35 SSA countries. We performed univariate and multivariate probit regression analyses to evaluate the association between healthcare worker (HCW) densities and facility births as our primary outcome and additional ANC services as secondary outcomes. We controlled for established maternal health predictors, including literacy, child marriage, reported problems accessing healthcare, GDP per capita, political instability, and government effectiveness scores. HCW density across SSA was low at 0.13 physicians and 0.91 nurses/midwives per 1,000 people, compared with 2010 worldwide mean densities of 1.33 and 3.07, respectively. The probability of facility birth increased by 9.8% (95% CI: 2.1-17.5%) for every additional physician per 1,000 people and 8.9% (95% CI: 7.1-9.7%) for every additional nurse/midwife per 1,000 people. HCW densities were also associated with increased likelihood of ANC by the respective provider type, and with antenatal testing for preeclampsia (urine and blood pressure checks). Other ANC services demonstrated variable relationships with HCW densities based on provider type. In 35 SSA countries, HCW density was positively associated with many key measures of maternal health service utilization including facility birth and ANC testing for preeclampsia.

  View details for DOI 10.4269/ajtmh.21-0727

  View details for PubMedID 35026729

• Exact inference for disease prevalence based on a test with unknown specificity and sensitivity JOURNAL OF APPLIED STATISTICS Cai, B., Ioannidis, J. A., Bendavid, E., Tian, L. 2022

  View details for DOI 10.1080/02664763.2021.2019687

  View details for Web of Science ID 000738502700001

• Mortality Along the Rheumatic Heart Disease Cascade of Care in Uganda. Circulation. Cardiovascular quality and outcomes Chang, A. Y., Barry, M., Bendavid, E., Watkins, D., Beaton, A. Z., Lwabi, P., Ssinabulya, I., Longenecker, C. T., Okello, E. 1800; 15 (1): e008445

  View details for DOI 10.1161/CIRCOUTCOMES.121.008445

  View details for PubMedID 35041475

• The demographic and socioeconomic correlates of behavior and HIV infection status across sub-Saharan Africa. Communications medicine Patel, C. J., Claypool, K. T., Chow, E., Chung, M., Mai, D., Chen, J., Bendavid, E. 2022; 2: 104

  Abstract

  Background: Predisposition to become HIV positive (HIV+) is influenced by a wide range of correlated economic, environmental, demographic, social, and behavioral factors. While evidence among a candidate handful have strong evidence, there is lack of a consensus among the vast array of variables measured in large surveys.Methods: We performed a comprehensive data-driven search for correlates of HIV positivity in >600,000 participants of the Demographic and Health Survey across 29 sub-Saharan African countries from 2003 to 2017. We associated a total of 7251 and of 6,288 unique variables with HIV positivity in females and males respectively in each of the 50 surveys. We performed a meta-analysis within countries to attain 29 country-specific associations.Results: Here we identify 344 (5.4% out possible) and 373 (5.1%) associations with HIV+in males and females, respectively, with robust statistical support. The associations are consistent in directionality across countries and sexes. The association sizes among individual correlates and their predictive capability were low to modest, but comparable to established factors. Among the identified associations, variables identifying being head of household among females was identified in 17 countries with a mean odds ratio (OR) of 2.5 (OR range: 1.1-3.5, R2=0.01). Other common associations were identified, including marital status, education, age, and ownership of land or livestock.Conclusions: Our continent-wide search for variables has identified under-recognized variables associated with being HIV+that are consistent across the continent and sex. Many of the association sizes are as high as established risk factors for HIV positivity, including male circumcision.

  View details for DOI 10.1038/s43856-022-00170-z

  View details for PubMedID 35992892

• Racial Disparities in Pediatric Kidney Transplantation under the New Kidney Allocation System in the United States. Clinical journal of the American Society of Nephrology : CJASN Krissberg, J., Kaufmann, M., Gupta, A., Bendavid, E., Stedman, M., Cheng, X., Tan, J., Grimm, P., Chaudhuri, A. 2021

  Abstract

  Background and Objectives: In December 2014, the Kidney Allocation System (KAS) was implemented to improve equity in access to transplantation, but preliminary studies in children show mixed results. Thus, we aimed to assess how the 2014 KAS policy change affected racial/ethnic disparities in pediatric kidney transplantation access and related outcomes. Design, setting, participants, and measurements: A retrospective cohort study of children <18 years of age active on the kidney transplant list from 2008 to 2019 using the Scientific Registry of Transplant Recipients. Log-logistic accelerated failure time models were used to determine time from first activation on the transplant list and time on dialysis to deceased-donor transplant, each with KAS era or race/ethnicity as the exposure of interest. We used logistic regression to assess odds of delayed graft function. Log-rank tests assessed time to graft loss within racial/ethnic groups across KAS eras. Results: All children experienced longer wait times from activation to transplantation post-KAS. In univariable analysis, Black or Hispanic children or other children of color experienced longer times from activation to transplant compared to White children in the both eras; this finding was largely attenuated after multivariable analysis (time ratio 1.16, (95% CI 1.01-1.32); 1.13 (1.00-1.28); 1.17 (0.96-1.41) post-KAS, respectively). Multivariable analysis also showed that racial/ethnic disparities in time from dialysis initiation to transplantation in the pre-KAS era was mitigated in the post-KAS era. There were no disparities in odds of delayed graft function. Black or Hispanic children experienced longer times with a functioning graft in the post-KAS era. Conclusions: No racial/ethnic disparities from activation to deceased donor transplantation were seen before or after implementation of KAS in multivariable analysis, while time on dialysis to transplantation and odds of short-term graft loss improved in equity after KAS, without compromising disparities in delayed graft function.

  View details for DOI 10.2215/CJN.06740521

  View details for PubMedID 34670797

• Racial and ethnic inequities in the early distribution of U.S. COVID-19 testing sites and mortality. European journal of clinical investigation Dalva-Baird, N. P., Alobuia, W. M., Bendavid, E., Bhattacharya, J. 2021: e13669

  Abstract

  BACKGROUND: In 2020, early U.S. COVID-19 testing sites offered diagnostic capacity to patients and were important sources of epidemiological data about the spread of the novel pandemic disease. However, little research has comprehensively described American testing sites' distribution by race/ethnicity and sought to identify any relation to known disparities in COVID-19 outcomes.METHODS: Locations of U.S. COVID-19 testing sites were gathered from April 16 to May 28, 2020. Geographic testing disparities were evaluated with comparisons of the demographic makeup of zip codes around each testing site versus Monte Carlo simulations, aggregated to statewide and nationwide levels. Testing disparities were compared to disparities in mortality observed one to three weeks later using multivariable regression between states, controlling for confounding disparities and characteristics.RESULTS: Nationwide, COVID-19 testing sites geographically overrepresented white residents on May 7, underrepresented Hispanic residents on April 16, May 7, and May 28, and overrepresented Black residents on May 28 compared to random distribution within counties, with new sites added over time exhibiting inconsistent disparities for Black and Hispanic populations. For every 1 percentage point increase in under-representation of Hispanic populations in zip codes with testing, mortality among the state's Hispanic population was 1.04 percentage points more over-representative (SE=0.415, P=0.01).CONCLUSIONS: American testing sites were not distributed equitably by race during this analysis, often underrepresenting minority populations who bear a disproportionate burden of COVID-19 cases and deaths. With an easy-to-implement measure of geographic disparity, these results provide empirical support for the consideration of access when distributing preventive resources.

  View details for DOI 10.1111/eci.13669

  View details for PubMedID 34390487

• Diverse experts' perspectives on ethical issues of using machine learning to predict HIV/AIDS risk in sub-Saharan Africa: a modified Delphi study. BMJ open Nichol, A. A., Bendavid, E., Mutenherwa, F., Patel, C., Cho, M. K. 2021; 11 (7): e052287

  Abstract

  OBJECTIVE: To better understand diverse experts' views about the ethical implications of ongoing research funded by the National Institutes of Health that uses machine learning to predict HIV/AIDS risk in sub-Saharan Africa (SSA) based on publicly available Demographic and Health Surveys data.DESIGN: Three rounds of semi-structured surveys in an online expert panel using a modified Delphi approach.PARTICIPANTS: Experts in informatics, African public health and HIV/AIDS and bioethics were invited to participate.MEASURES: Perceived importance of or agreement about relevance of ethical issues on 5-point unipolar Likert scales. Qualitative data analysis identified emergent themes related to ethical issues and development of an ethical framework and recommendations for open-ended questions.RESULTS: Of the 35 invited experts, 22 participated in the online expert panel (63%). Emergent themes were the inclusion of African researchers in all aspects of study design, analysis and dissemination to identify and address local contextual issues, as well as engagement of communities. Experts focused on engagement with health and science professionals to address risks, benefits and communication of findings. Respondents prioritised the mitigation of stigma to research participants but recognised trade-offs between privacy and the need to disseminate findings to realise public health benefits. Strategies for responsible communication of results were suggested, including careful word choice in presentation of results and limited dissemination to need-to-know stakeholders such as public health planners.CONCLUSION: Experts identified ethical issues specific to the African context and to research on sensitive, publicly available data and strategies for addressing these issues. These findings can be used to inform an ethical implementation framework with research stage-specific recommendations on how to use publicly available data for machine learning-based predictive analytics to predict HIV/AIDS risk in SSA.

  View details for DOI 10.1136/bmjopen-2021-052287

  View details for PubMedID 34321310

• Systematic identification and replication of factors associated with human papillomavirus vaccine initiation among adolescents in the United States using an environment-wide association study approach. Sexually transmitted infections Nasserie, T., Bendavid, E. 2021

  Abstract

  OBJECTIVE: Human papillomavirus (HPV) vaccination coverage is low among adolescents in the USA. Identification of factors associated with HPV vaccine initiation (receipt of ≥1dose) is critical for improving uptake. Our objective was to systematically investigate all eligible factors available in a nationally representative sample of adolescents to identify drivers of HPV vaccine initiation using a novel methodological approach.METHODS: We performed multiple cross-sectional analyses using data from the adolescent component of the National Immunization Surveys (NIS)-Teen between 2014 and 2019. Study participants were parents or caregivers of adolescents aged 13-17 years. Exposure variables measured sociodemographic and geographical characteristics, health conditions and healthcare provision. We tested the association between each factor and HPV vaccine initiation using univariate logistic regression and multivariate logistic regression adjusted for mother's age, mother's education level, mother's marital status, poverty status and adolescent's sex. We validated findings for each type of analysis within surveys, between surveys (across years 2014-2019) and across several subgroups (age, sex, poverty status and race/ethnicity).RESULTS: Six factors were replicated in the multivariate analysis. Most replicated factors characterised the role of healthcare providers and healthcare-seeking behaviours. After adjustment, provider HPV recommendation remained the most strongly associated with HPV vaccine initiation (2019 NIS-Teen: OR 13.4, 95% CI 11.3 to 17.3, p<0.001). The variance explained by a full model including replicated factors was 0.39.CONCLUSIONS: This is the first study to explore the association between all available factors in the NIS-Teen and HPV vaccine initiation in a systematic manner. Our study suggests that healthcare-seeking behaviours and interactions with the health system may be drivers of HPV vaccine initiation and warrant further study. Addressing these factors could improve the rate of HPV vaccine initiation among adolescents in the USA.

  View details for DOI 10.1136/sextrans-2021-054976

  View details for PubMedID 34039744

• Response to Letters Re: "Assessing mandatory stay- at- home and business closure effects on the spread of COVID- 19". European journal of clinical investigation Bendavid, E., Oh, C., Bhattacharya, J., Ioannidis, J. P. 2021: e13553

  Abstract

  We are pleased to see the active discussion around our study on the relationship between mandatory stay- at- home and business closures and COVID-19 spread.1 In this response, we address issues raised in three letters.2-4 The claim that the study had sample size of n=10 countries is incorrect.2 Each of the 16 regression models represented in Figure 4 included, on average, 1,362 data points (range 771-3,493) on 52 subnational units (range 27-129). Each panel regression is, in effect, a "mini-meta-analysis": the effect size is evaluated within each subnational unit, and the overall effect size is estimated from a pooling of these "within" effects. So while we aggregated the results to 10 countries, the sample size is not n=10.

  View details for DOI 10.1111/eci.13553

  View details for PubMedID 33756017

• Cost-effectiveness of statins for primary prevention of atherosclerotic cardiovascular disease among people living with HIV in the United States. Journal of the International AIDS Society Boettiger, D. C., Newall, A. T., Phillips, A., Bendavid, E., Law, M. G., Ryom, L., Reiss, P., Mocroft, A., Bonnet, F., Weber, R., El-Sadr, W., d'Arminio Monforte, A., de Wit, S., Pradier, C., Hatleberg, C. I., Lundgren, J., Sabin, C., Kahn, J. G., Kazi, D. S. 2021; 24 (3): e25690

  Abstract

  BACKGROUND: Expanding statin use may help to alleviate the excess burden of atherosclerotic cardiovascular disease in people living with HIV (PLHIV). Pravastatin and pitavastatin are preferred agents due to their lack of substantial interaction with antiretroviral therapy. We aimed to evaluate the cost-effectiveness of pravastatin and pitavastatin for the primary prevention of atherosclerotic cardiovascular disease among PLHIV in the United States.METHODS: We developed a microsimulation model that randomly selected (with replacement) individuals from the Data-collection on Adverse Effects of Anti-HIV Drugs study with follow-up between 2013 and 2016. Our study population was PLHIV aged 40 to 75years, stable on antiretroviral therapy, and not currently using lipid-lowering therapy. Direct medical costs and quality-adjusted life-years (QALYs) were assigned in annual cycles and discounted at 3% per year. We assumed a willingness-to-pay threshold of $100,000/QALY gained. The interventions assessed were as follows: (1) treating no one with statins; (2) treating everyone with generic pravastatin 40mg/day (drug cost $236/year) and (3) treating everyone with branded pitavastatin 4mg/day (drug cost $2,828/year). The model simulated each individual's probability of experiencing atherosclerotic cardiovascular disease over 20years.RESULTS: Persons receiving pravastatin accrued 0.024 additional QALYs compared with those not receiving a statin, at an incremental cost of $1338, giving an incremental cost-effectiveness ratio of $56,000/QALY gained. Individuals receiving pitavastatin accumulated 0.013 additional QALYs compared with those using pravastatin, at an additional cost of $18,251, giving an incremental cost-effectiveness ratio of $1,444,000/QALY gained. These findings were most sensitive to the pill burden associated with daily statin administration, statin costs, statin efficacy and baseline atherosclerotic cardiovascular disease risk. In probabilistic sensitivity analysis, no statin was optimal in 5.2% of simulations, pravastatin was optimal in 94.8% of simulations and pitavastatin was never optimal.CONCLUSIONS: Pravastatin was projected to be cost-effective compared with no statin. With substantial price reduction, pitavastatin may be cost-effective compared with pravastatin. These findings bode well for the expanded use of statins among PLHIV in the United States. To gain greater confidence in our conclusions it is important to generate strong, HIV-specific estimates on the efficacy of statins and the quality-of-life burden associated with taking an additional daily pill.

  View details for DOI 10.1002/jia2.25690

  View details for PubMedID 33749164

• COVID-19 antibody seroprevalence in Santa Clara County, California. International journal of epidemiology Bendavid, E., Mulaney, B., Sood, N., Shah, S., Bromley-Dulfano, R., Lai, C., Weissberg, Z., Saavedra-Walker, R., Tedrow, J., Bogan, A., Kupiec, T., Eichner, D., Gupta, R., Ioannidis, J. P., Bhattacharya, J. 2021

  Abstract

  BACKGROUND: Measuring the seroprevalence of antibodies to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is central to understanding infection risk and fatality rates. We studied Coronavirus Disease 2019 (COVID-19)-antibody seroprevalence in a community sample drawn from Santa Clara County.METHODS: On 3 and 4 April 2020, we tested 3328 county residents for immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies to SARS-CoV-2 using a rapid lateral-flow assay (Premier Biotech). Participants were recruited using advertisements that were targeted to reach county residents that matched the county population by gender, race/ethnicity and zip code of residence. We estimate weights to match our sample to the county by zip, age, sex and race/ethnicity. We report the weighted and unweighted prevalence of antibodies to SARS-CoV-2. We adjust for test-performance characteristics by combining data from 18 independent test-kit assessments: 14 for specificity and 4 for sensitivity.RESULTS: The raw prevalence of antibodies in our sample was 1.5% [exact binomial 95% confidence interval (CI) 1.1-2.0%]. Test-performance specificity in our data was 99.5% (95% CI 99.2-99.7%) and sensitivity was 82.8% (95% CI 76.0-88.4%). The unweighted prevalence adjusted for test-performance characteristics was 1.2% (95% CI 0.7-1.8%). After weighting for population demographics, the prevalence was 2.8% (95% CI 1.3-4.2%), using bootstrap to estimate confidence bounds. These prevalence point estimates imply that 53000 [95% CI 26000 to 82000 using weighted prevalence; 23000 (95% CI 14000-35000) using unweighted prevalence] people were infected in Santa Clara County by late March-many more than the 1200 confirmed cases at the time.CONCLUSION: The estimated prevalence of SARS-CoV-2 antibodies in Santa Clara County implies that COVID-19 was likely more widespread than indicated by the number of cases in late March, 2020. At the time, low-burden contexts such as Santa Clara County were far from herd-immunity thresholds.

  View details for DOI 10.1093/ije/dyab010

  View details for PubMedID 33615345

• Assessing Mandatory Stay-at-Home and Business Closure Effects on the Spread of COVID-19. European journal of clinical investigation Bendavid, E., Oh, C., Bhattacharya, J., Ioannidis, J. P. 2021: e13484

  Abstract

  BACKGROUND AND AIMS: The most restrictive non-pharmaceutical interventions (NPIs) for controlling the spread of COVID-19 are mandatory stay-at-home and business closures. Given the consequences of these policies, it is important to assess their effects. We evaluate the effects on epidemic case growth of more restrictive NPIs (mrNPIs), above and beyond those of less restrictive NPIs (lrNPIs).METHODS: We first estimate COVID-19 case growth in relation to any NPI implementation in subnational regions of 10 countries: England, France, Germany, Iran, Italy, Netherlands, Spain, South Korea, Sweden, and the US. Using first-difference models with fixed effects, we isolate the effects of mrNPIs by subtracting the combined effects of lrNPIs and epidemic dynamics from all NPIs. We use case growth in Sweden and South Korea, two countries that did not implement mandatory stay-at-home and business closures, as comparison countries for the other 8 countries (16 total comparisons).RESULTS: Implementing any NPIs was associated with significant reductions in case growth in 9 out of 10 study countries, including South Korea and Sweden that implemented only lrNPIs (Spain had a non-significant effect). After subtracting the epidemic and lrNPI effects, we find no clear, significant beneficial effect of mrNPIs on case growth in any country. In France, e.g., the effect of mrNPIs was +7% (95CI -5%-19%) when compared with Sweden, and +13% (-12%-38%) when compared with South Korea (positive means pro-contagion). The 95% confidence intervals excluded 30% declines in all 16 comparisons and 15% declines in 11/16 comparisons.CONCLUSIONS: While small benefits cannot be excluded, we do not find significant benefits on case growth of more restrictive NPIs. Similar reductions in case growth may be achievable with less restrictive interventions.

  View details for DOI 10.1111/eci.13484

  View details for PubMedID 33400268

• The political and security dimensions of the humanitarian health response to violent conflict. Lancet (London, England) Wise, P. H., Shiel, A. n., Southard, N. n., Bendavid, E. n., Welsh, J. n., Stedman, S. n., Fazal, T. n., Felbab-Brown, V. n., Polatty, D. n., Waldman, R. J., Spiegel, P. B., Blanchet, K. n., Dayoub, R. n., Zakayo, A. n., Barry, M. n., Martinez Garcia, D. n., Pagano, H. n., Black, R. n., Gaffey, M. F., Bhutta, Z. A. 2021

  Abstract

  The nature of armed conflict throughout the world is intensely dynamic. Consequently, the protection of non-combatants and the provision of humanitarian services must continually adapt to this changing conflict environment. Complex political affiliations, the systematic use of explosive weapons and sexual violence, and the use of new communication technology, including social media, have created new challenges for humanitarian actors in negotiating access to affected populations and security for their own personnel. The nature of combatants has also evolved as armed, non-state actors might have varying motivations, use different forms of violence, and engage in a variety of criminal activities to generate requisite funds. New health threats, such as the COVID-19 pandemic, and new capabilities, such as modern trauma care, have also created new challenges and opportunities for humanitarian health provision. In response, humanitarian policies and practices must develop negotiation and safety capabilities, informed by political and security realities on the ground, and guidance from affected communities. More fundamentally, humanitarian policies will need to confront a changing geopolitical environment, in which traditional humanitarian norms and protections might encounter wavering support in the years to come.

  View details for DOI 10.1016/S0140-6736(21)00130-6

  View details for PubMedID 33503458

• Clinical Outcomes, Echocardiographic Findings, and Care Quality Metrics for People Living with HIV and Rheumatic Heart Disease in Uganda. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Chang, A. Y., Rwebembera, J., Bendavid, E., Okello, E., Barry, M., Beaton, A. Z., Haeffele, C., Webel, A. R., Kityo, C., Longenecker, C. T. 2021

  Abstract

  Rheumatic Heart Disease (RHD) affects 41 million people worldwide, mostly in low- and middle-income countries, where it is co-endemic with HIV. HIV is also a chronic inflammatory disorder associated with cardiovascular complications, yet the epidemiology of patients affected by both diseases is poorly understood.Utilizing the Uganda National RHD Registry, we described the echocardiographic findings, clinical characteristics, medication prescription rates, and outcomes of all 73 people carrying concurrent diagnoses of HIV and RHD between 2009 and 2018. These individuals were compared to an age- and sex-matched cohort of 365 subjects with RHD only.The median age of the HIV-RHD group was 36 years (IQR 15) and 86% were women. The HIV-RHD cohort had higher rates of prior stroke/transient ischemic attack (12% vs 5%, p=0.02) than the RHD-only group, with this association persisting following multivariable adjustment (OR 3.08, p=0.03). Prevalence of other comorbidities, echocardiographic findings, prophylactic penicillin prescription rates, retention in clinical care, and mortality were similar between the two groups.Patients living with RHD and HIV in Uganda are a relatively young, predominantly female group. Although RHD-HIV comorbid individuals have higher rates of stroke, their similar all-cause mortality and RHD care quality metrics (such as retention in care) compared to those with RHD alone suggest rheumatic heart disease defines their clinical outcome more than HIV does. We believe this study to be one of the first reports of the epidemiologic profile and longitudinal outcomes of patients who carry diagnoses of both conditions.

  View details for DOI 10.1093/cid/ciab681

  View details for PubMedID 34382644

• The effects of armed conflict on the health of women and children. Lancet (London, England) Bendavid, E. n., Boerma, T. n., Akseer, N. n., Langer, A. n., Malembaka, E. B., Okiro, E. A., Wise, P. H., Heft-Neal, S. n., Black, R. E., Bhutta, Z. A. 2021

  Abstract

  Women and children bear substantial morbidity and mortality as a result of armed conflicts. This Series paper focuses on the direct (due to violence) and indirect health effects of armed conflict on women and children (including adolescents) worldwide. We estimate that nearly 36 million children and 16 million women were displaced in 2017, on the basis of international databases of refugees and internally displaced populations. From geospatial analyses we estimate that the number of non-displaced women and children living dangerously close to armed conflict (within 50 km) increased from 185 million women and 250 million children in 2000, to 265 million women and 368 million children in 2017. Women's and children's mortality risk from non-violent causes increases substantially in response to nearby conflict, with more intense and more chronic conflicts leading to greater mortality increases. More than 10 million deaths in children younger than 5 years can be attributed to conflict between 1995 and 2015 globally. Women of reproductive ages living near high intensity conflicts have three times higher mortality than do women in peaceful settings. Current research provides fragmentary evidence about how armed conflict indirectly affects the survival chances of women and children through malnutrition, physical injuries, infectious diseases, poor mental health, and poor sexual and reproductive health, but major systematic evidence is sparse, hampering the design and implementation of essential interventions for mitigating the harms of armed conflicts.

  View details for DOI 10.1016/S0140-6736(21)00131-8

  View details for PubMedID 33503456

• Visualizing the invisible: The effect of asymptomatic transmission on the outbreak dynamics of COVID-19 COMPUTER METHODS IN APPLIED MECHANICS AND ENGINEERING Peirlinck, M., Linka, K., Costabal, F., Bhattacharya, J., Bendavid, E., Ioannidis, J. A., Kuhl, E. 2020; 372

  View details for DOI 10.1016/j.cma.2020.113410

  View details for Web of Science ID 000592535100007

• Visualizing the invisible: The effect of asymptomatic transmission on the outbreak dynamics of COVID-19. Computer methods in applied mechanics and engineering Peirlinck, M., Linka, K., Sahli Costabal, F., Bhattacharya, J., Bendavid, E., Ioannidis, J. P., Kuhl, E. 2020; 372: 113410

  Abstract

  Understanding the outbreak dynamics of the COVID-19 pandemic has important implications for successful containment and mitigation strategies. Recent studies suggest that the population prevalence of SARS-CoV-2 antibodies, a proxy for the number of asymptomatic cases, could be an order of magnitude larger than expected from the number of reported symptomatic cases. Knowing the precise prevalence and contagiousness of asymptomatic transmission is critical to estimate the overall dimension and pandemic potential of COVID-19. However, at this stage, the effect of the asymptomatic population, its size, and its outbreak dynamics remain largely unknown. Here we use reported symptomatic case data in conjunction with antibody seroprevalence studies, a mathematical epidemiology model, and a Bayesian framework to infer the epidemiological characteristics of COVID-19. Our model computes, in real time, the time-varying contact rate of the outbreak, and projects the temporal evolution and credible intervals of the effective reproduction number and the symptomatic, asymptomatic, and recovered populations. Our study quantifies the sensitivity of the outbreak dynamics of COVID-19 to three parameters: the effective reproduction number, the ratio between the symptomatic and asymptomatic populations, and the infectious periods of both groups. For nine distinct locations, our model estimates the fraction of the population that has been infected and recovered by Jun 15, 2020 to 24.15% (95% CI: 20.48%-28.14%) for Heinsberg (NRW, Germany), 2.40% (95% CI: 2.09%-2.76%) for Ada County (ID, USA), 46.19% (95% CI: 45.81%-46.60%) for New York City (NY, USA), 11.26% (95% CI: 7.21%-16.03%) for Santa Clara County (CA, USA), 3.09% (95% CI: 2.27%-4.03%) for Denmark, 12.35% (95% CI: 10.03%-15.18%) for Geneva Canton (Switzerland), 5.24% (95% CI: 4.84%-5.70%) for the Netherlands, 1.53% (95% CI: 0.76%-2.62%) for Rio Grande do Sul (Brazil), and 5.32% (95% CI: 4.77%-5.93%) for Belgium. Our method traces the initial outbreak date in Santa Clara County back to January 20, 2020 (95% CI: December 29, 2019-February 13, 2020). Our results could significantly change our understanding and management of the COVID-19 pandemic: A large asymptomatic population will make isolation, containment, and tracing of individual cases challenging. Instead, managing community transmission through increasing population awareness, promoting physical distancing, and encouraging behavioral changes could become more relevant.

  View details for DOI 10.1016/j.cma.2020.113410

  View details for PubMedID 33518823

  View details for PubMedCentralID PMC7831913

• Comparison of World Health Organization and Demographic and Health Surveys data to estimate sub-national deworming coverage in pre-school aged children. PLoS neglected tropical diseases Lo, N. C., Gupta, R., Addiss, D. G., Bendavid, E., Heft-Neal, S., Mikhailov, A., Montresor, A., Mbabazi, P. S. 2020; 14 (8): e0008551

  Abstract

  BACKGROUND: The key metric for monitoring the progress of deworming programs in controlling soil-transmitted helminthiasis (STH) is national drug coverage reported to the World Health Organization (WHO). There is increased interest in utilizing geographically-disaggregated data to estimate sub-national deworming coverage and equity, as well as gender parity. The Demographic and Health Surveys (DHS) offer a potential source of sub-national data. This study aimed to compare deworming coverage routinely reported to WHO and estimated by DHS in pre-school aged children to inform global STH measurement and evaluation.METHODOLOGY: We compared sub-national deworming coverage in pre-school aged children reported to WHO and estimated by DHS aligned geospatially and temporally. We included data from Burundi (2016-2017), Myanmar (2015-2016), and the Philippines (2017) based on data availability. WHO provided data on the date and sub-national coverage per mass drug administration reported by Ministries of Health. DHS included maternally-reported deworming status within the past 6 months for each child surveyed. We estimated differences in sub-national deworming coverage using WHO and DHS data, and performed sensitivity analyses.PRINCIPAL FINDINGS: We compared data on pre-school aged children from 13 of 18 districts in Burundi (N = 6,835 in DHS), 11 of 15 districts in Myanmar (N = 1,462 in DHS) and 16 of 17 districts in the Philippines (N = 7,594 in DHS) following data exclusion. The national deworming coverages estimated by DHS in Burundi, Myanmar, and the Philippines were 75.5% (95% CI: 73.7%-77.7%), 47.0% (95% CI: 42.7%-51.3%), and 48.0% (95% CI: 46.0%-50.0%), respectively. The national deworming coverages reported by WHO in Burundi, Myanmar, and the Philippines were 80.1%, 93.6% and 75.7%, respectively. The mean absolute differences in district-level coverage reported to WHO and estimated by DHS in Burundi, Myanmar, and the Philippines were 9.5%, 41.5%, and 24.6%, respectively. Across countries, coverage reported to WHO was frequently higher than DHS estimates (32 of 40 districts). National deworming coverage from DHS estimates were similar by gender within countries.CONCLUSIONS AND SIGNIFICANCE: Agreement of deworming coverage reported to WHO and estimated by DHS data was heterogeneous across countries, varying from broadly compatible in Burundi to largely discrepant in Myanmar. DHS data could complement deworming data reported to WHO to improve data monitoring practices and serve as an independent sub-national source of coverage data.

  View details for DOI 10.1371/journal.pntd.0008551

  View details for PubMedID 32804925

• Dust pollution from the Sahara and African infant mortality NATURE SUSTAINABILITY Heft-Neal, S., Burney, J., Bendavid, E., Voss, K. K., Burke, M. 2020

  View details for DOI 10.1038/s41893-020-0562-1

  View details for Web of Science ID 000544156000008

• Cost-effectiveness analysis of pre-ART HIV drug resistance testing in Kenyan women. EClinicalMedicine Duarte, H. A., Babigumira, J. B., Enns, E. A., Stauffer, D. C., Shafer, R. W., Beck, I. A., Garrison, L. P., Chung, M. H., Frenkel, L. M., Bendavid, E. 2020; 22: 100355

  Abstract

  Background: The prevalence of pre-treatment drug resistance (PDR) to non-nucleoside reverse-transcriptase inhibitor (NNRTI) agents is increasing in sub-Saharan Africa, which may decrease the effectiveness of efavirenz-based antiretroviral therapy (ART) programs. However, due to recent safety concerns, there has been hesitancy to replace efavirenz-based ART with dolutegravir in women of reproductive potential. Our objective was to evaluate whether PDR testing for women not initiating dolutegravir-based ART would be a cost-effective strategy to address the challenges posed by PDR.Methods: We developed an HIV drug resistance model that simulates the emergence and transmission of resistance mutations, calibrated to the Kenyan epidemic. We modeled three care strategies for PDR testing among women not initiating dolutegravir-based ART: no PDR testing, PDR testing with a low-cost point mutation assay, known as oligonucleotide ligation assay (OLA), and PDR testing with consensus sequencing. Using a health sector perspective, this model was used to evaluate the health outcomes, lifetime costs, and cost-effectiveness under each strategy over a 15-year time horizon starting in 2019.Findings: OLA and CS PDR testing were projected to have incremental cost-effectiveness ratios (ICER) of $10,741/QALY gained and $134,396/QALY gained, respectively, which are not cost-effective by national income standards. Viral suppression rates among women at 12 months after ART initiation were 87·8%, 89·0%, and 89·3% with no testing, OLA testing, and CS testing, respectively. PDR testing with OLA and CS were associated with a 0.5% and 0.6% reduction in incidence rate compared to no PDR testing. Initial PDR prevalence among women was 13.1% in 2019. By 2034, this prevalence was 17·6%, 17·4%, and 17·3% with no testing, OLA testing, and CS testing, respectively.Interpretation: PDR testing for women is unlikely to be cost-effective in Kenya whether one uses a low-cost assay, such as OLA, or consensus sequencing.Funding: National Institutes of Health, Gilead Sciences.

  View details for DOI 10.1016/j.eclinm.2020.100355

  View details for PubMedID 32490370

• What counts as development assistance for reproductive, maternal, newborn, and child health? The Lancet. Global health Templin, T., Bendavid, E. 2020; 8 (3): e312–e313

  View details for DOI 10.1016/S2214-109X(20)30042-5

  View details for PubMedID 32087157

• Health and Economic Outcomes of Posterior Spinal Fusion for Children With Neuromuscular Scoliosis. Hospital pediatrics Lin, J. L., Tawfik, D. S., Gupta, R., Imrie, M., Bendavid, E., Owens, D. K. 2020

  Abstract

  OBJECTIVES: Neuromuscular scoliosis (NMS) can result in severe disability. Nonoperative management minimally slows scoliosis progression, but operative management with posterior spinal fusion (PSF) carries high risks of morbidity and mortality. In this study, we compare health and economic outcomes of PSF to nonoperative management for children with NMS to identify opportunities to improve care.METHODS: We performed a cost-effectiveness analysis. Our decision analytic model included patients aged 5 to 20 years with NMS and a Cobb angle ≥50°, with a base case of 15-year-old patients. We estimated costs, life expectancy, quality-adjusted life-years (QALYs), and incremental cost-effectiveness from published literature and conducted sensitivity analyses on all model inputs.RESULTS: We estimated that PSF resulted in modestly decreased discounted life expectancy (10.8 years) but longer quality-adjusted life expectancy (4.84 QALYs) than nonoperative management (11.2 years; 3.21 QALYs). PSF costs $75400 per patient. Under base-case assumptions, PSF costs $50100 per QALY gained. Our findings were sensitive to quality of life (QoL) and life expectancy, with PSF favored if it significantly increased QoL.CONCLUSIONS: In patients with NMS, whether PSF is cost-effective depends strongly on the degree to which QoL improved, with larger improvements when NMS is the primary cause of debility, but limited data on QoL and life expectancy preclude a definitive assessment. Improved patient-centered outcome assessments are essential to understanding the effectiveness of NMS treatment alternatives. Because the degree to which PSF influences QoL substantially impacts health outcomes and varies by patient, clinicians should consider shared decision-making during PSF-related consultations.

  View details for DOI 10.1542/hpeds.2019-0153

  View details for PubMedID 32079619

• COMPARING METHODS FOR MODEL CALIBRATION WITH HIGH UNCERTAINTY: MODELING CHOLERA IN BANGLADESH Ryckman, T., Luby, S., Owens, D. K., Bendavid, E., Goldhaber-Fiebert, J. D. SAGE PUBLICATIONS INC. 2020: E186–E187

  View details for Web of Science ID 000509275600163

• Women, children and adolescents in conflict countries: an assessment of inequalities in intervention coverage and survival. BMJ global health Akseer, N., Wright, J., Tasic, H., Everett, K., Scudder, E., Amsalu, R., Boerma, T., Bendavid, E., Kamali, M., Barros, A. J., da Silva, I. C., Bhutta, Z. A. 2020; 5 (1): e002214

  Abstract

  Introduction: Conflict adversely impacts health and health systems, yet its effect on health inequalities, particularly for women and children, has not been systematically studied. We examined wealth, education and urban/rural residence inequalities for child mortality and essential reproductive, maternal, newborn and child health interventions between conflict and non-conflict low-income and middle-income countries (LMICs).Methods: We carried out a time-series multicountry ecological study using data for 137 LMICs between 1990 and 2017, as defined by the 2019 World Bank classification. The data set covers approximately 3.8million surveyed mothers (15-49 years) and 1.1million children under 5 years including newborns (<1month), young children (1-59 months) and school-aged children and adolescents (5-14 years). Outcomes include annual maternal and child mortality rates and coverage (%) of family planning services, 1+antenatalcare visit, skilled attendant at birth (SBA), exclusive breast feeding (0-5 months), early initiation of breast feeding (within 1hour), neonatal protection against tetanus, newborn postnatal care within 2days, 3 doses of diphtheria, pertussis and tetanus vaccine, measles vaccination, and careseeking for pneumonia and diarrhoea.Results: Conflict countries had consistently higher maternal and child mortality rates than non-conflict countries since 1990 and these gaps persist despite rates continually declining for both groups. Access to essential reproductive and maternal health services for poorer, less educated and rural-based families was several folds worse in conflict versus non-conflict countries.Conclusions: Inequalities in coverage of reproductive/maternal health and child vaccine interventions are significantly worse in conflict-affected countries. Efforts to protect maternal and child health interventions in conflict settings should target the most disadvantaged families including the poorest, least educated and those living in rural areas.

  View details for DOI 10.1136/bmjgh-2019-002214

  View details for PubMedID 32133179

• What counts as development assistance for reproductive, maternal, newborn, and child health? LANCET GLOBAL HEALTH Templin, T., Bendavid, E. 2020; 8 (3): E312–E313

  View details for Web of Science ID 000514852000005

• Visualizing the invisible: The effect of asymptomatic transmission on the outbreak dynamics of COVID-19. medRxiv : the preprint server for health sciences Peirlinck, M. n., Linka, K. n., Costabal, F. S., Bhattacharya, J. n., Bendavid, E. n., Ioannidis, J. P., Kuhl, E. n. 2020

  Abstract

  Understanding the outbreak dynamics of the COVID-19 pandemic has important implications for successful containment and mitigation strategies. Recent studies suggest that the population prevalence of SARS-CoV-2 antibodies, a proxy for the number of asymptomatic cases, could be an order of magnitude larger than expected from the number of reported symptomatic cases. Knowing the precise prevalence and contagiousness of asymptomatic transmission is critical to estimate the overall dimension and pandemic potential of COVID-19. However, at this stage, the effect of the asymptomatic population, its size, and its outbreak dynamics remain largely unknown. Here we use reported symptomatic case data in conjunction with antibody seroprevalence studies, a mathematical epidemiology model, and a Bayesian framework to infer the epidemiological characteristics of COVID-19. Our model computes, in real time, the time-varying contact rate of the outbreak, and projects the temporal evolution and credible intervals of the effective reproduction number and the symptomatic, asymptomatic, and recovered populations. Our study quantifies the sensitivity of the outbreak dynamics of COVID-19 to three parameters: the effective reproduction number, the ratio between the symptomatic and asymptomatic populations, and the infectious periods of both groups For nine distinct locations, our model estimates the fraction of the population that has been infected and recovered by Jun 15, 2020 to 24.15% (95% CI: 20.48%-28.14%) for Heinsberg (NRW, Germany), 2.40% (95% CI: 2.09%-2.76%) for Ada County (ID, USA), 46.19% (95% CI: 45.81%-46.60%) for New York City (NY, USA), 11.26% (95% CI: 7.21%-16.03%) for Santa Clara County (CA, USA), 3.09% (95% CI: 2.27%-4.03%) for Denmark, 12.35% (95% CI: 10.03%-15.18%) for Geneva Canton (Switzerland), 5.24% (95% CI: 4.84%-5.70%) for the Netherlands, 1.53% (95% CI: 0.76%-2.62%) for Rio Grande do Sul (Brazil), and 5.32% (95% CI: 4.77%-5.93%) for Belgium. Our method traces the initial outbreak date in Santa Clara County back to January 20, 2020 (95% CI: December 29, 2019 - February 13, 2020). Our results could significantly change our understanding and management of the COVID-19 pandemic: A large asymptomatic population will make isolation, containment, and tracing of individual cases challenging. Instead, managing community transmission through increasing population awareness, promoting physical distancing, and encouraging behavioral changes could become more relevant.

  View details for DOI 10.1101/2020.05.23.20111419

  View details for PubMedID 32869035

  View details for PubMedCentralID PMC7457606

• Racial disparities in knowledge, attitudes and practices related to COVID-19 in the USA. Journal of public health (Oxford, England) Alobuia, W. M., Dalva-Baird, N. P., Forrester, J. D., Bendavid, E. n., Bhattacharya, J. n., Kebebew, E. n. 2020

  Abstract

  Recent reports indicate racial disparities in the rates of infection and mortality from the 2019 novel coronavirus (coronavirus disease 2019 [COVID-19]). The aim of this study was to determine whether disparities exist in the levels of knowledge, attitudes and practices (KAPs) related to COVID-19.We analyzed data from 1216 adults in the March 2020 Kaiser Family Foundation 'Coronavirus Poll', to determine levels of KAPs across different groups. Univariate and multivariate regression analysis was used to identify predictors of KAPs.In contrast to White respondents, Non-White respondents were more likely to have low knowledge (58% versus 30%; P < 0.001) and low attitude scores (52% versus 27%; P < 0.001), but high practice scores (81% versus 59%; P < 0.001). By multivariate regression, White race (odds ratio [OR] 3.06; 95% confidence interval [CI]: 1.70-5.50), higher level of education (OR 1.80; 95% CI: 1.46-2.23) and higher income (OR 2.06; 95% CI: 1.58-2.70) were associated with high knowledge of COVID-19. Race, sex, education, income, health insurance status and political views were all associated with KAPs.Racial and socioeconomic disparity exists in the levels of KAPs related to COVID-19. More work is needed to identify educational tools that tailor to specific racial and socioeconomic groups.

  View details for DOI 10.1093/pubmed/fdaa069

  View details for PubMedID 32490519

• Statins for atherosclerotic cardiovascular disease prevention in people living with HIV in Thailand: a cost-effectiveness analysis. Journal of the International AIDS Society Boettiger, D. C., Newall, A. T., Chattranukulchai, P. n., Chaiwarith, R. n., Khusuwan, S. n., Avihingsanon, A. n., Phillips, A. n., Bendavid, E. n., Law, M. G., Kahn, J. G., Ross, J. n., Bautista-Arredondo, S. n., Kiertiburanakul, S. n. 2020; 23 Suppl 1: e25494

  Abstract

  People living with HIV (PLHIV) have an elevated risk of atherosclerotic cardiovascular disease (CVD) compared to their HIV-negative peers. Expanding statin use may help alleviate this burden. However, the choice of statin in the context of antiretroviral therapy is challenging. Pravastatin and pitavastatin improve cholesterol levels in PLHIV without interacting substantially with antiretroviral therapy. They are also more expensive than most statins. We evaluated the cost-effectiveness of pravastatin and pitavastatin for the primary prevention of CVD among PLHIV in Thailand who are not currently using lipid-lowering therapy.We developed a discrete-state microsimulation model that randomly selected (with replacement) individuals from the TREAT Asia HIV Observational Database cohort who were aged 40 to 75 years, receiving antiretroviral therapy in Thailand, and not using lipid-lowering therapy. The model simulated each individual's probability of experiencing CVD. We evaluated: (1) treating no one with statins; (2) treating everyone with pravastatin 20mg/day (drug cost 7568 Thai Baht ($US243)/year) and (3) treating everyone with pitavastatin 2 mg/day (drug cost 8182 Baht ($US263)/year). Direct medical costs and quality-adjusted life-years (QALYs) were assigned in annual cycles over a 20-year time horizon and discounted at 3% per year. We assumed the Thai healthcare sector perspective.Pravastatin was estimated to be less effective and less cost-effective than pitavastatin and was therefore dominated (extended) by pitavastatin. Patients receiving pitavastatin accumulated 0.042 additional QALYs compared with those not using a statin, at an extra cost of 96,442 Baht ($US3095), giving an incremental cost-effectiveness ratio of 2,300,000 Baht ($US73,812)/QALY gained. These findings were sensitive to statin costs and statin efficacy, pill burden, and targeting of PLHIV based on CVD risk. At a willingness-to-pay threshold of 160,000 Baht ($US5135)/QALY gained, we estimated that pravastatin would become cost-effective at an annual cost of 415 Baht ($US13.30)/year and pitavastatin would become cost-effective at an annual cost of 600 Baht ($US19.30)/year.Neither pravastatin nor pitavastatin were projected to be cost-effective for the primary prevention of CVD among PLHIV in Thailand who are not currently using lipid-lowering therapy. We do not recommend expanding current use of these drugs among PLHIV in Thailand without substantial price reduction.

  View details for DOI 10.1002/jia2.25494

  View details for PubMedID 32562359

• Drought and intimate partner violence towards women in 19 countries in sub-Saharan Africa during 2011-2018: A population-based study. PLoS medicine Epstein, A. n., Bendavid, E. n., Nash, D. n., Charlebois, E. D., Weiser, S. D. 2020; 17 (3): e1003064

  Abstract

  Drought has many known deleterious impacts on human health, but little is known about the relationship between drought and intimate partner violence (IPV). We aimed to evaluate this relationship and to assess effect heterogeneity between population subgroups among women in 19 sub-Saharan African countries.We used data from 19 Demographic and Health Surveys from 2011 to 2018 including 83,990 partnered women aged 15-49 years. Deviations in rainfall in the year before the survey date were measured relative to the 29 previous years using Climate Hazards Group InfraRed Precipitation with Station data, with recent drought classified as ordinal categorical variable (severe: ≤10th percentile; mild/moderate: >10th percentile to ≤30th percentile; none: >30th percentile). We considered 4 IPV-related outcomes: reporting a controlling partner (a risk factor for IPV) and experiencing emotional violence, physical violence, or sexual violence in the 12 months prior to survey. Logistic regression was used to estimate marginal risk differences (RDs). We evaluated the presence of effect heterogeneity by age group and employment status. Of the 83,990 women included in the analytic sample, 10.7% (9,019) experienced severe drought and 23.4% (19,639) experienced mild/moderate drought in the year prior to the survey, with substantial heterogeneity across countries. The mean age of respondents was 30.8 years (standard deviation 8.2). The majority of women lived in rural areas (66.3%) and were married (73.3%), while less than half (42.6%) were literate. Women living in severe drought had higher risk of reporting a controlling partner (marginal RD in percentage points = 3.0, 95% CI 1.3, 4.6; p < 0.001), experiencing physical violence (marginal RD = 0.8, 95% CI 0.1, 1.5; p = 0.019), and experiencing sexual violence (marginal RD = 1.2, 95% CI 0.4, 2.0; p = 0.001) compared with women not experiencing drought. Women living in mild/moderate drought had higher risk of reporting physical (marginal RD = 0.7, 95% CI 0.2, 1.1; p = 0.003) and sexual violence (marginal RD = 0.7, 95% CI 0.3, 1.2; p = 0.001) compared with those not living in drought. We did not find evidence for an association between drought and emotional violence. In analyses stratified by country, we found 3 settings where drought was protective for at least 1 measure of IPV: Namibia, Tanzania, and Uganda. We found evidence for effect heterogeneity (additive interaction) for the association between drought and younger age and between drought and employment status, with stronger associations between drought and IPV among adolescent girls and unemployed women. This study is limited by its lack of measured hypothesized mediating variables linking drought and IPV, prohibiting a formal mediation analysis. Additional limitations include the potential for bias due to residual confounding and potential non-differential misclassification of the outcome measures leading to an attenuation of observed associations.Our findings indicate that drought was associated with measures of IPV towards women, with larger positive associations among adolescent girls and unemployed women. There was heterogeneity in these associations across countries. Weather shocks may exacerbate vulnerabilities among women in sub-Saharan Africa. Future work should further evaluate potential mechanisms driving these relationships.

  View details for DOI 10.1371/journal.pmed.1003064

  View details for PubMedID 32191701

• Methods for Model Calibration under High Uncertainty: Modeling Cholera in Bangladesh. Medical decision making : an international journal of the Society for Medical Decision Making Ryckman, T. n., Luby, S. n., Owens, D. K., Bendavid, E. n., Goldhaber-Fiebert, J. D. 2020: 272989X20938683

  Abstract

  Background. Published data on a disease do not always correspond directly to the parameters needed to simulate natural history. Several calibration methods have been applied to computer-based disease models to extract needed parameters that make a model's output consistent with available data. Objective. To assess 3 calibration methods and evaluate their performance in a real-world application. Methods. We calibrated a model of cholera natural history in Bangladesh, where a lack of active surveillance biases available data. We built a cohort state-transition cholera natural history model that includes case hospitalization to reflect the passive surveillance data-generating process. We applied 3 calibration techniques: incremental mixture importance sampling, sampling importance resampling, and random search with rejection sampling. We adapted these techniques to the context of wide prior uncertainty and many degrees of freedom. We evaluated the resulting posterior parameter distributions using a range of metrics and compared predicted cholera burden estimates. Results. All 3 calibration techniques produced posterior distributions with a higher likelihood and better fit to calibration targets as compared with prior distributions. Incremental mixture importance sampling resulted in the highest likelihood and largest number of unique parameter sets to better inform joint parameter uncertainty. Compared with naïve uncalibrated parameter sets, calibrated models of cholera in Bangladesh project substantially more cases, many of which are not detected by passive surveillance, and fewer deaths. Limitations. Calibration cannot completely overcome poor data quality, which can leave some parameters less well informed than others. Calibration techniques may perform differently under different circumstances. Conclusions. Incremental mixture importance sampling, when adapted to the context of high uncertainty, performs well. By accounting for biases in data, calibration can improve model projections of disease burden.

  View details for DOI 10.1177/0272989X20938683

  View details for PubMedID 32639859

• Health outcomes and cost-effectiveness of treating depression in people with HIV in Sub-Saharan Africa: a model-based analysis. AIDS care Zhong, H. n., Arjmand, I. K., Brandeau, M. L., Bendavid, E. n. 2020: 1–7

  Abstract

  High prevalence of depression among people living with HIV (PLHIV) impedes antiretroviral therapy (ART) adherence and viral suppression. We estimate the effectiveness and cost-effectiveness of strategies to treat depression among PLHIV in Sub-Saharan Africa (SSA). We developed a microsimulation model of HIV disease and care in Uganda which captured individuals' depression status and the relationship between depression and HIV behaviors. We consider a strategy of screening for depression and providing antidepressant therapy with fluoxetine at ART initiation or re-initiation (if a patient has dropped out). We estimate that over 10 years this strategy would reduce prevalence of depression among PLHIV by 16.0% [95% uncertainty bounds 15.8%, 16.1%] from a baseline prevalence of 28%, increase adherence to ART by 1.0% [1.0%, 1.0%], and decrease rates of loss to followup by 3.7% [3.4%, 4.1%]. This would decrease first-line ART failure rates by 2.5% [2.3%, 2.8%] and increase viral suppression rates by 1.0% [1.0%, 1.0%]. This strategy costs $15/QALY compared to the status quo, and was highly cost-effective over a broad range of sensitivity analyses. We conclude that screening for and treating depression among PLHIV in SSA with fluoxetine would be effective in improving HIV treatment outcomes and would be highly cost-effective.

  View details for DOI 10.1080/09540121.2020.1719966

  View details for PubMedID 31986900

• IMPACT OF A LARGE US GOVERNMENT NUTRITION PROGRAM ON UNDER-FIVE NUTRITION IN SUB-SAHARAN AFRICA: AN EVALUATION OF FEED THE FUTURE Ryckman, T., Robinson, M., Pedersen, C., Bhattacharya, J., Bendavid, E. SAGE PUBLICATIONS INC. 2020: E100–E101

  View details for Web of Science ID 000509275600091

• Cost Effectiveness of Endoscopic Resection vs Transanal Resection of Complex Benign Rectal Polyps CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Yu, J. X., Russell, W., Ching, J. H., Kim, N., Bendavid, E., Owens, D. K., Kaltenbach, T. 2019; 17 (13): 2740-+

  View details for DOI 10.1016/j.cgh.2019.02.041

  View details for Web of Science ID 000497972200024

• The 2016 California policy to eliminate nonmedical vaccine exemptions and changes in vaccine coverage: An empirical policy analysis PLOS MEDICINE Nyathi, S., Karpel, H. C., Sainani, K. L., Maldonado, Y., Hotez, P. J., Bendavid, E., Lo, N. C. 2019; 16 (12)

  View details for DOI 10.1371/journal.pmed.1002994.r005

  View details for Web of Science ID 000507280500007

• DOLUTEGRAVIR ROLLOUT AND EXPECTED PREVALENCE OF PRETREATMENT DRUG RESISTANCE TO ANTIRETROVIRAL THERAPY AMONG KENYAN WOMEN Duarte, H., Enns, E., Stauffer, D., Shafer, R., Bendavid, E. BMJ PUBLISHING GROUP. 2019: A137–A138

  View details for DOI 10.1136/sextrans-2019-sti.348

  View details for Web of Science ID 000506050102003

• Impact of Health Aid Investments on Public Opinion of the United States: Analysis of Global Attitude Surveys From 45 Countries, 2002-2016 AMERICAN JOURNAL OF PUBLIC HEALTH Jakubowski, A., Mai, D., Asch, S. M., Bendavid, E. 2019; 109 (7): 1034–41

  View details for DOI 10.2105/AJPH.2019.305084

  View details for Web of Science ID 000470105300049

• USA aid policy and induced abortion in sub-Saharan Africa: an analysis of the Mexico City Policy. The Lancet. Global health Brooks, N., Bendavid, E., Miller, G. 2019

  Abstract

  BACKGROUND: The Mexico City Policy, first announced by US President Ronald Reagan and since lifted and reinstated by presidents along partisan lines, prohibits US foreign assistance to any organisation that performs or provides counselling on abortion. Many organisations affected by this policy are also providers of modern contraception. If the policy reduces these organisations' ability to supply modern contraceptives, it could have the unintended consequence of increasing abortion rates.METHODS: We empirically examined patterns of modern contraception use, pregnancies, and abortion among women in 26 countries in sub-Saharan Africa in response to the reinstatement and subsequent repeal of the Mexico City Policy across three presidential administrations (William Clinton, George W Bush, and Barack Obama). We combine individual-level data on pregnancies and abortions from 743 691 women, country-year data on modern contraception use, and annual data on development assistance for family planning and reproductive health in a difference-in-difference framework to examine relative changes in use of modern contraception, pregnancy, and abortion in response to the policy.FINDINGS: We found that when the Mexico City Policy was in effect (2001-08), abortion rates rose among women in countries highly exposed to the policy by 4·8 abortions per 10 000 woman-years (95% CI 1·5 to 8·1, p=0·0041) relative to women in low-exposure countries and relative to periods when the policy was rescinded in 1995-2000 and 2009-14, a rise of approximately 40%. We found a symmetric reduction in use of modern contraception by 3·15 percentage points (relative decrease of 13·5%; 95% CI -4·9 to -1·4; p=0·0006) and increase in pregnancies by 3·2 percentage points (relative increase of 12%; 95% CI 1·6 to 4·8; p<0·0001) while the policy was enacted.INTERPRETATION: Our findings suggest that curbing US assistance to family planning organisations, especially those that consider abortion as a method of family planning, increases abortion prevalence in sub-Saharan African countries most affected by the policy.FUNDING: The William and Flora Hewlett Foundation, the Doris Duke Charitable Foundation, the David and Lucile Packard Foundation, and the Stanford Earth Dean's Fellowship.

  View details for DOI 10.1016/S2214-109X(19)30267-0

  View details for PubMedID 31257094

• Back to the root causes of war: food shortages Reply LANCET Wagner, Z., Heft-Neal, S., Bhutta, Z. A., Black, R. E., Burke, M., Bendavid, E. 2019; 393 (10175): 982

  View details for Web of Science ID 000460604200020

• Back to the root causes of war: food shortages - Authors' reply. Lancet (London, England) Wagner, Z., Heft-Neal, S., Bhutta, Z. A., Black, R. E., Burke, M., Bendavid, E. 2019; 393 (10175): 982

  View details for PubMedID 30860044

• Cost Effectiveness of Endoscopic Resection vs Transanal Resection of Complex Benign Rectal Polyps. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association Yu, J. X., Russell, W. A., Ching, J. H., Kim, N., Bendavid, E., Owens, D. K., Kaltenbach, T. 2019

  Abstract

  BACKGROUND & AIMS: Complex benign rectal polyps can be managed with transanal surgery or with endoscopic resection (ER). Though the complication rate after ER is lower than transanal surgery, recurrence is higher. Patients lost to follow up after ER might therefore be at increased risk for rectal cancer. We evaluated the costs, benefits, and cost effectiveness of ER compared to 2 surgical techniques for removing complex rectal polyps, using a 50-year time horizon-this allowed us to capture rates of cancer development among patients lost from follow-up surveillance.METHODS: We created a Markov model to simulate the lifetime outcomes and costs of ER, transanal endoscopic microsurgery (TEM), and transanal minimally invasive surgery (TAMIS) for the management of a complex benign rectal polyp. We assessed the effect of surveillance by allowing a portion of the patients to be lost to follow up. We calculated the cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio or each intervention over a 50-year time horizon.RESULTS: We found that TEM was slightly more effective than TAMIS and ER (TEM, 19.54 QALYs; TAMIS, 19.53 QALYs; and ER19.53, QALYs), but ER had a lower lifetime discounted cost (ER cost $7161, TEM cost $10,459, and TAMIS cost $11,253). TEM was not cost effective compared to ER, with an incremental cost-effectiveness ratio of $485,333/QALY. TAMIS was ruled out by extended dominance. TEM became cost effective when the mortality from ER exceeded 0.63%, or if loss to follow up exceeded 25.5%.CONCLUSIONS: Using a Markov model, we found that ER, TEM, and TAMIS have similar effectiveness, but ER is less expensive, in management of benign rectal polyps. As the rate of loss to follow up increases, transanal surgery becomes more effective relative to ER.

  View details for PubMedID 30849517

• Age distribution, trends, and forecasts of under-5 mortality in 31 sub-Saharan African countries: A modeling study. PLoS medicine Mejía-Guevara, I., Zuo, W., Bendavid, E., Li, N., Tuljapurkar, S. 2019; 16 (3): e1002757

  Abstract

  Despite the sharp decline in global under-5 deaths since 1990, uneven progress has been achieved across and within countries. In sub-Saharan Africa (SSA), the Millennium Development Goals (MDGs) for child mortality were met only by a few countries. Valid concerns exist as to whether the region would meet new Sustainable Development Goals (SDGs) for under-5 mortality. We therefore examine further sources of variation by assessing age patterns, trends, and forecasts of mortality rates.Data came from 106 nationally representative Demographic and Health Surveys (DHSs) with full birth histories from 31 SSA countries from 1990 to 2017 (a total of 524 country-years of data). We assessed the distribution of age at death through the following new demographic analyses. First, we used a direct method and full birth histories to estimate under-5 mortality rates (U5MRs) on a monthly basis. Second, we smoothed raw estimates of death rates by age and time by using a two-dimensional P-Spline approach. Third, a variant of the Lee-Carter (LC) model, designed for populations with limited data, was used to fit and forecast age profiles of mortality. We used mortality estimates from the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) to adjust, validate, and minimize the risk of bias in survival, truncation, and recall in mortality estimation. Our mortality model revealed substantive declines of death rates at every age in most countries but with notable differences in the age patterns over time. U5MRs declined from 3.3% (annual rate of reduction [ARR] 0.1%) in Lesotho to 76.4% (ARR 5.2%) in Malawi, and the pace of decline was faster on average (ARR 3.2%) than that observed for infant (IMRs) (ARR 2.7%) and neonatal (NMRs) (ARR 2.0%) mortality rates. We predict that 5 countries (Kenya, Rwanda, Senegal, Tanzania, and Uganda) are on track to achieve the under-5 sustainable development target by 2030 (25 deaths per 1,000 live births), but only Rwanda and Tanzania would meet both the neonatal (12 deaths per 1,000 live births) and under-5 targets simultaneously. Our predicted NMRs and U5MRs were in line with those estimated by the UN IGME by 2030 and 2050 (they overlapped in 27/31 countries for NMRs and 22 for U5MRs) and by the Institute for Health Metrics and Evaluation (IHME) by 2030 (26/31 and 23/31, respectively). This study has a number of limitations, including poor data quality issues that reflected bias in the report of births and deaths, preventing reliable estimates and predictions from a few countries.To our knowledge, this study is the first to combine full birth histories and mortality estimates from external reliable sources to model age patterns of under-5 mortality across time in SSA. We demonstrate that countries with a rapid pace of mortality reduction (ARR ≥ 3.2%) across ages would be more likely to achieve the SDG mortality targets. However, the lower pace of neonatal mortality reduction would prevent most countries from achieving those targets: 2 countries would reach them by 2030, 13 between 2030 and 2050, and 13 after 2050.

  View details for DOI 10.1371/journal.pmed.1002757

  View details for PubMedID 30861006

  View details for PubMedCentralID PMC6413894

• The 2016 California policy to eliminate nonmedical vaccine exemptions and changes in vaccine coverage: An empirical policy analysis. PLoS medicine Nyathi, S. n., Karpel, H. C., Sainani, K. L., Maldonado, Y. n., Hotez, P. J., Bendavid, E. n., Lo, N. C. 2019; 16 (12): e1002994

  Abstract

  Vaccine hesitancy, the reluctance or refusal to receive vaccination, is a growing public health problem in the United States and globally. State policies that eliminate nonmedical ("personal belief") exemptions to childhood vaccination requirements are controversial, and their effectiveness to improve vaccination coverage remains unclear given limited rigorous policy analysis. In 2016, a California policy (Senate Bill 277) eliminated nonmedical exemptions from school entry requirements. The objective of this study was to estimate the association between California's 2016 policy and changes in vaccine coverage.We used a quasi-experimental state-level synthetic control analysis and a county-level difference-in-differences analysis to estimate the impact of the 2016 California policy on vaccination coverage and prevalence of exemptions to vaccine requirements (nonmedical and medical). We used publicly available state-level data from the US Centers for Disease Control and Prevention on coverage of measles, mumps, and rubella (MMR) vaccination, nonmedical exemption, and medical exemption in children entering kindergarten. We used county-level data individually requested from state departments of public health on overall vaccine coverage and exemptions. Based on data availability, we included state-level data for 45 states, including California, from 2011 to 2017 and county-level data for 17 states from 2010 to 2017. The prespecified primary study outcome was MMR vaccination in the state analysis and overall vaccine coverage in the county analysis. In the state-level synthetic control analysis, MMR coverage in California increased by 3.3% relative to its synthetic control in the postpolicy period (top 2 of 43 states evaluated in the placebo tests, top 5%), nonmedical exemptions decreased by 2.4% (top 2 of 43 states evaluated in the placebo tests, top 5%), and medical exemptions increased by 0.4% (top 1 of 44 states evaluated in the placebo tests, top 2%). In the county-level analysis, overall vaccination coverage increased by 4.3% (95% confidence interval [CI] 2.9%-5.8%, p < 0.001), nonmedical exemptions decreased by 3.9% (95% CI 2.4%-5.4%, p < 0.001), and medical exemptions increased by 2.4% (95% CI 2.0%-2.9%, p < 0.001). Changes in vaccination coverage across counties after the policy implementation from 2015 to 2017 ranged from -6% to 26%, with larger increases in coverage in counties with lower prepolicy vaccine coverage. Results were robust to alternative model specifications. The limitations of the study were the exclusion of a subset of US states from the analysis and the use of only 2 years of postpolicy data based on data availability.In this study, implementation of the California policy that eliminated nonmedical childhood vaccine exemptions was associated with an estimated increase in vaccination coverage and a reduction in nonmedical exemptions at state and county levels. The observed increase in medical exemptions was offset by the larger reduction in nonmedical exemptions. The largest increases in vaccine coverage were observed in the most "high-risk" counties, meaning those with the lowest prepolicy vaccine coverage. Our findings suggest that government policies removing nonmedical exemptions can be effective at increasing vaccination coverage.

  View details for DOI 10.1371/journal.pmed.1002994

  View details for PubMedID 31869328

• Women and children living in areas of armed conflict in Africa: a geospatial analysis of mortality and orphanhood. The Lancet. Global health Wagner, Z. n., Heft-Neal, S. n., Wise, P. H., Black, R. E., Burke, M. n., Boerma, T. n., Bhutta, Z. A., Bendavid, E. n. 2019

  Abstract

  The population effects of armed conflict on non-combatant vulnerable populations are incompletely understood. We aimed to study the effects of conflict on mortality among women of childbearing age (15-49 years) and on orphanhood among children younger than 15 years in Africa.We tested the extent to which mortality among women aged 15-49 years, and orphanhood among children younger than 15 years, increased in response to nearby armed conflict in Africa. Data on location, timing, and intensity of armed conflicts were obtained from the Uppsala Conflict Data Program, and data on the location, timing, and outcomes of women and children from Demographic and Health Surveys done in 35 African countries from 1990 to 2016. Mortality among women was obtained from sibling survival data. We used cluster-area fixed-effects regression models to compare survival of women during periods of nearby conflict (within 50 km) to survival of women in the same area during times without conflict. We used similar methods to examine the extent to which children living near armed conflicts are at increased risk of becoming orphans. We examined the effects of varying conflict intensity using number of direct battle deaths and duration of consecutive conflict exposure.We analysed data on 1 629 352 women (19 286 387 person-years), of which 103 011 (6·3%) died (534·1 deaths per 100 000 women-years), and 2 354 041 children younger than 15 years, of which 204 276 (8·7%) had lost a parent. On average, conflict within 50 km increased women's mortality by 112 deaths per 100 000 person-years (95% CI 97-128; a 21% increase above baseline), and the probability that a child has lost at least one parent by 6·0% (95% CI 3-8). This effect was driven by high-intensity conflicts: exposure to the highest (tenth) decile conflict in terms of conflict-related deaths increased the probability of female mortality by 202% (187-218) and increased the likelihood of orphanhood by 42% compared with a conflict-free period. Among the conflict-attributed deaths, 10% were due to maternal mortality.African women of childbearing age are at a substantially increased risk of death from nearby high-intensity armed conflicts. Children exposed to conflict are analogously at increased risk of becoming orphans. This work fills gaps in literature on the harmful effects of armed conflict on non-combatants and highlights the need for humanitarian interventions to protect vulnerable populations.Bill & Melinda Gates Foundation to the BRANCH Consortium.

  View details for DOI 10.1016/S2214-109X(19)30407-3

  View details for PubMedID 31669039

• Impact of Feed the Future initiative on nutrition in children aged less than 5 years in sub-Saharan Africa: difference-in-differences analysis. BMJ (Clinical research ed.) Ryckman, T. n., Robinson, M. n., Pedersen, C. n., Bhattacharya, J. n., Bendavid, E. n. 2019; 367: l6540

  Abstract

  To evaluate the impact of the US government's Feed the Future initiative on nutrition outcomes in children younger than 5 years in sub-Saharan Africa.Difference-in-differences quasi-experimental approach.Households in 33 low and lower middle income countries in sub-Saharan Africa.883 309 children aged less than 5 years with weight, height, and age recorded in 118 surveys conducted in 33 countries between 2000 and 2017: 388 052 children were from Feed the Future countries and 495 257 were from non-Feed the Future countries.A difference-in-differences approach was used to compare outcomes among children in intervention countries after implementation of the initiative with children before its introduction and children in non-intervention countries, controlling for relevant covariates, time invariant national differences, and time trends. The primary outcome was stunting (height for age >2 standard deviations below a reference median), a key indicator of undernutrition in children. Secondary outcomes were wasting (low weight for height) and underweight (low weight for age).Across all years and countries, 38.3% of children in the study sample were stunted, 8.9% showed wasting, and 21.3% were underweight. In the first six years of Feed the Future's implementation, children in 12 countries with the initiative exhibited a 3.9 percentage point (95% confidence interval 2.4 to 5.5) greater decline in stunting, a 1.1 percentage point (0.1 to 2.1) greater decline in wasting, and a 2.8 percentage point (1.6 to 4.0) greater decline in underweight levels compared with children in 21 countries without the initiative and compared with trends in undernutrition before Feed the Future was launched. These decreases translate to around two million fewer stunted and underweight children aged less than 5 years and around a half million fewer children with wasting. For context, about 22 million children were stunted, 11 million children were underweight, and four million children were wasted in the Feed the Future countries at baseline.Feed the Future's activities were closely linked to notable improvements in stunting and underweight levels and moderate improvements in wasting in children younger than 5 years. These findings highlight the effectiveness of this large, country tailored initiative focused on agriculture and food security and have important implications for the future of this and other nutrition interventions worldwide.

  View details for DOI 10.1136/bmj.l6540

  View details for PubMedID 31826875

• State of deworming coverage and equity in low-income and middle-income countries using household health surveys: a spatiotemporal cross-sectional study. The Lancet. Global health Lo, N. C., Heft-Neal, S. n., Coulibaly, J. T., Leonard, L. n., Bendavid, E. n., Addiss, D. G. 2019

  Abstract

  Mass deworming against soil-transmitted helminthiasis, which affects 1 billion of the poorest people globally, is one of the largest public health programmes for neglected tropical diseases, and is intended to be equitable. However, the extent to which treatment programmes for deworming achieve equitable coverage across wealth class and sex is unclear and the public health metric of national deworming coverage does not include representation of equity. This study aims to measure both coverage and equity in global, national, and subnational deworming to guide future programmatic evaluation, investment, and metric design.We used nationally representative, geospatial, household data from Demographic and Health Surveys that measured mother-reported deworming in children of preschool age (12-59 months). Deworming was defined as children having received drugs for intestinal parasites in the previous 6 months before the survey. We estimated deworming coverage disaggregated by geography, wealth quintile, and sex, and computed an equity index. We examined trends in coverage and equity index across countries, within countries, and over time. We used a regression model to compute the household correlates of deworming and ecological correlates of equitable deworming.Our study included 820 883 children living in 50 countries from Africa, the Americas, Asia, and Europe that are endemic for soil-transmitted helminthiasis using 77 Demographic and Health Surveys from December, 2003, to October, 2017. In these countries, the mean deworming coverage in preschool children was estimated at 33·0% (95% CI 32·9-33·1). The subnational coverage ranged from 0·5% to 87·5%, and within-country variation was greater than between-country variation. Of the 31 countries reporting that they reached the WHO goal of more than 75% national coverage, 30 had inequity in deworming, with treatment concentrated in wealthier populations. We did not detect systematic differences in deworming equity by sex.Substantial inequities in mass deworming programmes are common as wealthier populations have consistently higher coverage than that of the poor, including in countries reporting to have reached the WHO goal of more than 75% national coverage. These inequities seem to be geographically heterogeneous, modestly improving over time, with no evidence of sex differences in inequity. Future reporting of deworming coverage should consider disaggregation by geography, wealth, and sex with incorporation of an equity index to complement the conventional public health metric of national deworming coverage.Bill & Melinda Gates Foundation, Stanford University Medical Scientist Training Program.

  View details for DOI 10.1016/S2214-109X(19)30413-9

  View details for PubMedID 31558383

• Age distribution, trends, and forecasts of under-5 mortality in 31 sub-Saharan African countries: A modeling study PLoS Medicine Mejía-Guevara, I., Zuo, W., Bendavid, E., Li, N., Tuljapurkar, S. 2019; 16 (3): 1-21

  View details for DOI 10.1371/journal.pmed.1002757

• Impact of Health Aid Investments on Public Opinion of the United States: Analysis of Global Attitude Surveys From 45 Countries, 2002-2016. American journal of public health Jakubowski, A. n., Mai, D. n., Asch, S. M., Bendavid, E. n. 2019: e1–e8

  Abstract

  Objectives. To assess whether increasing health aid investments affected public opinion of the United States in recipient populations. Methods. We linked health aid data from the United States to nationally representative opinion poll surveys from 45 countries conducted between 2002 and 2016. We exploited the abrupt and substantial increase in health aid when the US President's Emergency Plan for AIDS Relief (PEPFAR) and President's Malaria Initiative (PMI) were launched to assess unique changes in opinions of the United States following program onset. We also ascertained increased exposure to health aid from the United States by systematically searching for mentions of US health aid programs in popular press. Results. Favorability ratings of the United States increased within countries in proportion to health aid and were significantly higher after implementation of PEPFAR and PMI. Higher US health aid was associated with more references to that aid in the popular press. Conclusions. Our study was the first, to our knowledge, to show that US investments in health aid improved the United States' image abroad. Public Health Implications. Sustained global health investments may offer important returns to the United States as well as to the recipient populations. (Am J Public Health. Published online ahead of print May 16, 2019: e1-e8. doi:10.2105/AJPH.2019.305084).

  View details for PubMedID 31095407

• The overweight and obesity transition from the wealthy to the poor in low- and middle-income countries: A survey of household data from 103 countries. PLoS medicine Templin, T. n., Cravo Oliveira Hashiguchi, T. n., Thomson, B. n., Dieleman, J. n., Bendavid, E. n. 2019; 16 (11): e1002968

  Abstract

  In high-income countries, obesity prevalence (body mass index greater than or equal to 30 kg/m2) is highest among the poor, while overweight (body mass index greater than or equal to 25 kg/m2) is prevalent across all wealth groups. In contrast, in low-income countries, the prevalence of overweight and obesity is higher among wealthier individuals than among poorer individuals. We characterize the transition of overweight and obesity from wealthier to poorer populations as countries develop, and project the burden of overweight and obesity among the poor for 103 countries.Our sample used 182 Demographic and Health Surveys and World Health Surveys (n = 2.24 million respondents) from 1995 to 2016. We created a standard wealth index using household assets common among all surveys and linked national wealth by country and year identifiers. We then estimated the changing probability of overweight and obesity across every wealth decile as countries' per capita gross domestic product (GDP) rises using logistic and linear fixed-effect regression models. We found that obesity rates among the wealthiest decile were relatively stable with increasing national wealth, and the changing gradient was largely due to increasing obesity prevalence among poorer populations (3.5% [95% uncertainty interval: 0.0%-8.3%] to 14.3% [9.7%-19.0%]). Overweight prevalence among the richest (45.0% [35.6%-54.4%]) and the poorest (45.5% [35.9%-55.0%]) were roughly equal in high-income settings. At $8,000 GDP per capita, the adjusted probability of being obese was no longer highest in the richest decile, and the same was true of overweight at $10,000. Above $25,000, individuals in the richest decile were less likely than those in the poorest decile to be obese, and the same was true of overweight at $50,000. We then projected overweight and obesity rates by wealth decile to 2040 for all countries to quantify the expected rise in prevalence in the relatively poor. Our projections indicated that, if past trends continued, the number of people who are poor and overweight will increase in our study countries by a median 84.4% (range 3.54%-383.4%), most prominently in low-income countries. The main limitations of this study included the inclusion of cross-sectional, self-reported data, possible reverse causality of overweight and obesity on wealth, and the lack of physical activity and food price data.Our findings indicate that as countries develop economically, overweight prevalence increased substantially among the poorest and stayed mostly unchanged among the wealthiest. The relative poor in upper- and lower-middle income countries may have the greatest burden, indicating important planning and targeting needs for national health programs.

  View details for DOI 10.1371/journal.pmed.1002968

  View details for PubMedID 31774821

• COMPARISON OF WORLD HEALTH ORGANIZATION AND DEMOGRAPHIC AND HEALTH SURVEY DATA TO ESTIMATE SUB-NATIONAL DEWORMING COVERAGE IN PRE-SCHOOL CHILDREN Lo, N. C., Gupta, R., Addiss, D. G., Bendavid, E., Heft-Neal, S., Mikhailov, A., Montresor, A., Mbabazi, P. AMER SOC TROP MED & HYGIENE. 2019: 616

  View details for Web of Science ID 000507364505117

• Modeling the implementation of population-level isoniazid preventive therapy for tuberculosis control in a high HIV-prevalence setting. AIDS (London, England) Rhines, A. S., Feldman, M. W., Bendavid, E. 2018

  Abstract

  BACKGROUND: We model the epidemiological impact of providing isoniazid preventive therapy (IPT) to South African adolescents, among whom HIV prevalence is low, latent TB prevalence is high, and school-based programs may enable population-level coverage.METHODS: We simulate a dynamic compartmental model of age-structured HIV and TB co-epidemics in South Africa. HIV dynamics are modeled by infection status, CD4 count, and antiretroviral therapy; TB dynamics are modeled by disease stage, diagnosis, treatment, and IPT status. We analyze the effects of continuous IPT coverage among adolescents from 5% (baseline) to 90%.RESULTS: Our model is calibrated to WHO and UNAIDS epidemiological estimates. In simulations, increasing IPT coverage to 50% among adolescents reduced active TB incidence by 5% to 34%. Increasing coverage to 90% led to a 9% to 40% reduction in active TB incidence. Expanded IPT access causes TB incidence to decline in the general population of HIV-positive individuals, as well as in adult HIV-positive individuals.CONCLUSIONS: Targeting IPT to a secondary school population with high latent TB prevalence and low HIV prevalence, where risk of false-negative diagnosis of active TB is low and IPT benefits are more established, could have substantial benefits to adolescents and spillover benefits to the adult population.

  View details for PubMedID 30096067

• Robust relationship between air quality and infant mortality in Africa NATURE Heft-Neal, S., Burney, J., Bendavid, E., Burke, M. 2018; 559 (7713): 254-+

  View details for DOI 10.1038/s41586-018-0263-3

  View details for Web of Science ID 000438240900056

• Anticipated burden and mitigation of carbon-dioxide-induced nutritional deficiencies and related diseases: A simulation modeling study. PLoS medicine Weyant, C., Brandeau, M. L., Burke, M., Lobell, D. B., Bendavid, E., Basu, S. 2018; 15 (7): e1002586

  Abstract

  BACKGROUND: Rising atmospheric carbon dioxide concentrations are anticipated to decrease the zinc and iron concentrations of crops. The associated disease burden and optimal mitigation strategies remain unknown. We sought to understand where and to what extent increasing carbon dioxide concentrations may increase the global burden of nutritional deficiencies through changes in crop nutrient concentrations, and the effects of potential mitigation strategies.METHODS AND FINDINGS: For each of 137 countries, we incorporated estimates of climate change, crop nutrient concentrations, dietary patterns, and disease risk into a microsimulation model of zinc and iron deficiency. These estimates were obtained from the Intergovernmental Panel on Climate Change, US Department of Agriculture, Statistics Division of the Food and Agriculture Organization of the United Nations, and Global Burden of Disease Project, respectively. In the absence of increasing carbon dioxide concentrations, we estimated that zinc and iron deficiencies would induce 1,072.9 million disability-adjusted life years (DALYs) globally over the period 2015 to 2050 (95% credible interval [CrI]: 971.1-1,167.7). In the presence of increasing carbon dioxide concentrations, we estimated that decreasing zinc and iron concentrations of crops would induce an additional 125.8 million DALYs globally over the same period (95% CrI: 113.6-138.9). This carbon-dioxide-induced disease burden is projected to disproportionately affect nations in the World Health Organization's South-East Asia and African Regions (44.0 and 28.5 million DALYs, respectively), which already have high existing disease burdens from zinc and iron deficiencies (364.3 and 299.5 million DALYs, respectively), increasing global nutritional inequalities. A climate mitigation strategy such as the Paris Agreement (an international agreement to keep global temperatures within 2°C of pre-industrial levels) would be expected to avert 48.2% of this burden (95% CrI: 47.8%-48.5%), while traditional public health interventions including nutrient supplementation and disease control programs would be expected to avert 26.6% of the burden (95% CrI: 23.8%-29.6%). Of the traditional public health interventions, zinc supplementation would be expected to avert 5.5%, iron supplementation 15.7%, malaria mitigation 3.2%, pneumonia mitigation 1.6%, and diarrhea mitigation 0.5%. The primary limitations of the analysis include uncertainty regarding how food consumption patterns may change with climate, how disease mortality rates will change over time, and how crop zinc and iron concentrations will decline from those at present to those in 2050.CONCLUSIONS: Effects of increased carbon dioxide on crop nutrient concentrations are anticipated to exacerbate inequalities in zinc and iron deficiencies by 2050. Proposed Paris Agreement strategies are expected to be more effective than traditional public health measures to avert the increased inequality.

  View details for PubMedID 29969442

• Anticipated burden and mitigation of carbondioxide-induced nutritional deficiencies and related diseases: A simulation modeling study PLOS MEDICINE Weyant, C., Brandeau, M. L., Burke, M., Lobell, D. B., Bendavid, E., Basu, S. 2018; 15 (7)

  View details for DOI 10.1371/journal.pmed.1002586

  View details for Web of Science ID 000440339700001

• Robust relationship between air quality and infant mortality in Africa. Nature Heft-Neal, S., Burney, J., Bendavid, E., Burke, M. 2018

  Abstract

  Poor air quality is thought to be an important mortality risk factor globally1-3, but there is little direct evidence from the developing world on how mortality risk varies with changing exposure to ambient particulate matter. Current global estimates apply exposure-response relationships that have been derived mostly from wealthy, mid-latitude countries to spatial population data 4 , and these estimates remain unvalidated across large portions of the globe. Here we combine household survey-based information on the location and timing of nearly 1million births across sub-Saharan Africa with satellite-based estimates 5 of exposure to ambient respirable particulate matter with an aerodynamic diameter less than 2.5mum (PM2.5) to estimate the impact of air quality on mortality rates among infants in Africa. We find that a 10mugm-3 increase in PM2.5 concentration is associated with a 9% (95% confidence interval, 4-14%) rise in infant mortality across the dataset. This effect has not declined over the last 15 years and does not diminish with higher levels of household wealth. Our estimates suggest that PM2.5 concentrations above minimum exposure levels were responsible for 22% (95% confidence interval, 9-35%) of infant deaths in our 30 study countries and led to 449,000 (95% confidence interval, 194,000-709,000) additional deaths of infants in 2015, an estimate that is more than three times higher than existing estimates that attribute death of infants to poor air quality for these countries2,6. Upward revision of disease-burden estimates in the studied countries in Africa alone would result in a doubling of current estimates of global deaths of infants that are associated with air pollution, and modest reductions in African PM2.5 exposures are predicted to have health benefits to infants that are larger than most known health interventions.

  View details for PubMedID 29950722

• Cost Effectiveness of Radiation and Chemotherapy for High-Risk Low Grade Glioma Qian, Y., Maruyama, S., Kim, H., Pollom, E. L., Kumar, K. A., Harris, J. P., Chin, A. L., Pitt, A., Bendavid, E., Owens, D. K., Durkee, B. Y., Soltys, S. G. ELSEVIER SCIENCE INC. 2018: E26

  View details for Web of Science ID 000432447200062

• The fog of development: evaluating the Millennium Villages Project LANCET GLOBAL HEALTH Bendavid, E. 2018; 6 (5): E470–E471

  View details for PubMedID 29653612

• Systematic identification of correlates of HIV infection: an X-wide association study AIDS Patel, C. J., Bhattacharya, J., Ioannidis, J. A., Bendavid, E. 2018; 32 (7): 933–43

  Abstract

  Better identification of at-risk groups could benefit HIV-1 care programmes. We systematically identified HIV-1 risk factors in two nationally representative cohorts of women in the Demographic and Health Surveys.We identified and replicated the association of 1415 social, economic, environmental, and behavioral factors with HIV-1 status. We used the 2007 and 2013-2014 surveys conducted among 5715 and 15 433 Zambian women, respectively (688 shared factors). We used false discovery rate criteria to identify factors that are strongly associated with HIV-1 in univariate and multivariate models of the entire population, as well as in subgroups stratified by wealth, residence, age, and past HIV-1 testing.In the univariate analysis, we identified 102 and 182 variables that are associated with HIV-1 in the two surveys, respectively (79 factors were associated in both). Factors that were associated with HIV-1 status in full-sample analyses and in subgroups include being formerly married (adjusted OR 2007, 2.8, P < 10; 2013-2014 2.8, P < 10), widowhood (aOR 3.7, P < 10; and 4.2, P < 10), genital ulcers within 12 months (aOR 2.4, P < 10; and 2.2, P < 10), and having a woman head of the household (aOR 1.7, P < 10; and 2.1, P < 10), while owning a bicycle (aOR 0.6, P < 10; and 0.6, P < 10) and currently breastfeeding (aOR 0.5, P < 10; and 0.4, P < 10) were associated with decreased risk. Area under the curve for HIV-1 positivity was 0.76-0.82.Our X-wide association study identifies under-recognized factors related to HIV-1 infection, including widowhood, breastfeeding, and gender of head of the household. These features could be used to improve HIV-1 identification programs.

  View details for PubMedID 29424772

• Cost-effectiveness analysis of asymptomatic peripheral artery disease screening with the ABI test VASCULAR MEDICINE Itoga, N. K., Minami, H. R., Chelvakumar, M., Pearson, K., Mell, M. M., Bendavid, E., Owens, D. K. 2018; 23 (2): 97–106

  Abstract

  Screening for asymptomatic peripheral artery disease (aPAD) with the ankle-brachial index (ABI) test is hypothesized to reduce disease progression and cardiovascular (CV) events by identifying individuals who may benefit from early initiation of medical therapy. Using a Markov model, we evaluated the cost effectiveness of initiating medical therapy (e.g. statin and ACE-inhibitor) after a positive ankle-brachial index (ABI) screen in 65-year-old patients. We modeled progression to symptomatic PAD (sPAD) and CV events with and without ABI screening, evaluating differences in costs and quality-adjusted life years (QALYs). The cost of the ABI test, physician visit, new medication, CV events, and interventions for sPAD were incorporated in the model. We performed sensitivity analysis on model variables with uncertainty. Our model found an incremental cost of US $338 and an incremental QALY of 0.00380 with one-time ABI screening, resulting in an incremental cost-effectiveness ratio (ICER) of $88,758/QALY over a 35-year period. The variables with the largest effects in the ICER were aPAD disease prevalence, cost of monthly medication after a positive screen and 2-year medication adherence rates. Screening high-risk populations, such as tobacco users, where the prevalence of PAD may be 2.5 times higher, decreases the ICER to $24,092/QALY. Our analysis indicates the cost effectiveness of one-time screening for aPAD depends on prevalence, medication costs, and adherence to therapies for CV disease risk reduction. Screening in higher-risk populations under favorable assumptions about medication adherence results in the most favorable cost effectiveness, but limitations in the primary data preclude definitive assessment of cost effectiveness.

  View details for PubMedID 29345540

  View details for PubMedCentralID PMC5893367

• Impact and cost-effectiveness of snail control to achieve disease control targets for schistosomiasis. Proceedings of the National Academy of Sciences of the United States of America Lo, N. C., Gurarie, D. n., Yoon, N. n., Coulibaly, J. T., Bendavid, E. n., Andrews, J. R., King, C. H. 2018

  Abstract

  Schistosomiasis is a parasitic disease that affects over 240 million people globally. To improve population-level disease control, there is growing interest in adding chemical-based snail control interventions to interrupt the lifecycle of Schistosoma in its snail host to reduce parasite transmission. However, this approach is not widely implemented, and given environmental concerns, the optimal conditions for when snail control is appropriate are unclear. We assessed the potential impact and cost-effectiveness of various snail control strategies. We extended previously published dynamic, age-structured transmission and cost-effectiveness models to simulate mass drug administration (MDA) and focal snail control interventions against Schistosoma haematobium across a range of low-prevalence (5-20%) and high-prevalence (25-50%) rural Kenyan communities. We simulated strategies over a 10-year period of MDA targeting school children or entire communities, snail control, and combined strategies. We measured incremental cost-effectiveness in 2016 US dollars per disability-adjusted life year and defined a strategy as optimally cost-effective when maximizing health gains (averted disability-adjusted life years) with an incremental cost-effectiveness below a Kenya-specific economic threshold. In both low- and high-prevalence settings, community-wide MDA with additional snail control reduced total disability by an additional 40% compared with school-based MDA alone. The optimally cost-effective scenario included the addition of snail control to MDA in over 95% of simulations. These results support inclusion of snail control in global guidelines and national schistosomiasis control strategies for optimal disease control, especially in settings with high prevalence, "hot spots" of transmission, and noncompliance to MDA.

  View details for PubMedID 29301964

• GLOBAL STATE OF INEQUITY IN DEWORMING COVERAGE IN LOW-INCOME AND MIDDLE-INCOME COUNTRIES: A SPATIOTEMPORAL STUDY OF HOUSEHOLD HEALTH SURVEYS Lo, N., Heft-Neal, S., Coulibaly, J., Bendavid, E., Addiss, D. AMER SOC TROP MED & HYGIENE. 2018: 239

  View details for Web of Science ID 000461386603095

• Deworming in pre-school age children: A global empirical analysis of health outcomes. PLoS neglected tropical diseases Lo, N. C., Snyder, J. n., Addiss, D. G., Heft-Neal, S. n., Andrews, J. R., Bendavid, E. n. 2018; 12 (5): e0006500

  Abstract

  There is debate over the effectiveness of deworming children against soil-transmitted helminthiasis (STH) to improve health outcomes, and current evidence may be limited in study design and generalizability. However, programmatic deworming continues throughout low and middle-income countries.We performed an empirical evaluation of the relationship between deworming in pre-school age children (ages 1-4 years) within the previous 6 months, as proxy-reported by the mother, and health outcomes of weight, height, and hemoglobin. We used nationally representative cross-sectional data from 45 countries using the Demographic and Health Surveys (DHS) during the period 2005-2016. We used logistic regression with coarsened exact matching, fixed effects for survey and year, and person-level covariates. We included data on 325,115 children in 45 STH-endemic countries from 66 DHS surveys. Globally in STH-endemic countries, children who received deworming treatment were less likely to be stunted (1.2 percentage point decline from mean of 36%; 95% CI [-1.9, -0.5%]; p<0.001), but we did not detect consistent associations between deworming and anemia or weight. In sub-Saharan Africa, we found that children who received deworming treatment were less likely to be stunted (1.1 percentage point decline from mean of 36%; 95% CI [-2.1, -0.2%]; p = 0.01) and less likely to have anemia (1.8 percentage point decline from mean of 58%; 95% CI [-2.8, -0.7%]; p<0.001), but we did not detect consistent associations between deworming and weight. These findings were robust across multiple statistical models, and we did not find consistently measurable associations with data from non-endemic settings.Among pre-school age children, we detected a robust and consistent association between deworming and reduced stunting, with additional evidence for reduced anemia in sub-Saharan Africa. We did not find a consistent relationship between deworming and improved weight. This global empirical analysis provides evidence to support the deworming of pre-school age children.

  View details for PubMedID 29852012

• Impact of primary care provider density on detection and diagnosis of cutaneous melanoma. PloS one Fleming, N. H., Grade, M. M., Bendavid, E. 2018; 13 (7): e0200097

  Abstract

  INTRODUCTION: Early diagnosis of cutaneous melanoma is critical in preventing melanoma-associated deaths, but the role of primary care providers (PCPs) in diagnosing melanoma is underexplored. We aimed to explore the association of PCP density with melanoma incidence and mortality.METHODS: All cases of cutaneous melanoma diagnosed in the United States from 2008-2012 and reported in the Surveillance, Epidemiology, and End Results (SEER) database were analyzed in 2016. County-level primary care physician density was obtained from the Area Health Resources File (AHRF). We conducted multivariate linear regression using 1) average annual melanoma incidence or 2) average annual melanoma mortality by county as primary outcomes, adjusting for demographic confounders and dermatologist density. Cox proportional hazard regression was conducted using individual outcome data from SEER with the same covariates.RESULTS: Across 611 counties, 167,305 cases of melanoma were analyzed. Per 100,000 people, an additional 10 PCPs per county was associated with 1.62 additional cases of melanoma per year (95% CI 1.06-2.18, p<0.001). This increased incidence occurred disproportionally in early-stage melanoma (Stage 0: 0.69 cases (0.38-1.00), p<0.001; Stage I: 0.63 cases (0.37-0.89), p<0.001; Stage II: 0.11 cases (0.03-0.19), p = 0.005). There was no statistically significant association between PCP density and incidence of stage III or IV melanoma, or with melanoma-specific mortality. Survival analysis demonstrated elimination of 5-year post-diagnosis mortality risk in medically underserved counties after adjusting for stage.CONCLUSIONS: Higher densities of PCPs may be linked to increased diagnosis of early-stage melanoma without corresponding decreases in late-stage diagnoses or melanoma-associated mortality.

  View details for PubMedID 30005065

• EVALUATION OF A URINE POOLING STRATEGY FOR THE RAPID AND COST-EFFICIENT PREVALENCE CLASSIFICATION OF SCHISTOSOMIASIS Lo, N. C., Coulibaly, J. T., Bendavid, E., N'Goran, E. K., Utzinger, J., Keiser, J., Bogoch, I. I., Andrews, J. R. AMER SOC TROP MED & HYGIENE. 2017: 559–60

  View details for Web of Science ID 000412851503340

• Cost-Effectiveness of Radiation and Chemotherapy for High-Risk Low Grade Glioma Qian, Y., Maruyama, S., Kim, H., Pollom, E., Kumar, K. A., Harris, J. P., Chin, A. L., Pitt, A., Bendavid, E., Owens, D., Durkee, B. Y., Soltys, S. G. ELSEVIER SCIENCE INC. 2017: S37

  View details for DOI 10.1016/j.ijrobp.2017.06.098

  View details for Web of Science ID 000411559106163

• The relationship between burden of childhood disease and foreign aid for child health BMC HEALTH SERVICES RESEARCH Bavinger, J., Wise, P., Bendavid, E. 2017; 17: 655

  Abstract

  We sought to examine the relationship between child specific health aid (CHA) and burden of disease. Based on existing evidence, we hypothesized that foreign aid for child health would not be proportional to burden of disease.In order to examine CHA and burden of disease, we obtained estimates of these parameters from established sources. Estimates of disability adjusted life years (DALYs) in children (0-5 years) were obtained from the World Health Organization for 2000 and 2012. The 10 most burdensome disease categories in each continent, excluding high-income countries, were identified for study. Descriptions of all foreign aid commitments between 1996 and 2009 were obtained from AidData, and an algorithm to designate the target diseases of the commitments was constructed. Data were examined in scatterplots for trends.The most burdensome childhood diseases varied by continent. In all continents, newborn diseases, vaccine-preventable diseases (lower respiratory diseases, measles, meningitis, tetanus, and pertussis), and diarrheal diseases ranked within the four most burdensome diseases. Infectious diseases such as malaria, tuberculosis, and HIV were also among the ten most burdensome diseases in sub-Saharan Africa, and non-communicable diseases were associated with much of the burden in the other continents. CHA grew from $7.4 billion in 1996 to $17.7 billion in 2009 for our study diseases. Diarrheal diseases and malnutrition received the most CHA as well as the most CHA per DALY. CHA directed at HIV increased dramatically over our study period, from $227,000 in 1996 to $3.4 billion in 2008. Little aid was directed at injuries such as drowning, car accidents, and fires, as well as complex medical diseases such as leukemia and endocrine disorders.CHA has grown significantly over the last two decades. There is no clear relationship between CHA and burden of disease. This report provides a description of foreign aid for child health, and hopes to inform policy and decision-making regarding foreign aid.

  View details for PubMedID 28915813

• Childhood Illness and the Gender Gap in Adolescent Education in Low- and Middle-Income Countries PEDIATRICS Alsan, M., Xing, A., Wise, P., Darmstadt, G. L., Bendavid, E. 2017; 140 (1)

  Abstract

  Achieving gender equality in education is an important development goal. We tested the hypothesis that the gender gap in adolescent education is accentuated by illnesses among young children in the household.Using Demographic and Health Surveys on 41 821 households in 38 low- and middle-income countries, we used linear regression to estimate the difference in the probability adolescent girls and boys were in school, and how this gap responded to illness episodes among children <5 years old. To test the hypothesis that investments in child health are related to the gender gap in education, we assessed the relationship between the gender gap and national immunization coverage.In our sample of 120 708 adolescent boys and girls residing in 38 countries, girls were 5.08% less likely to attend school than boys in the absence of a recent illness among young children within the same household (95% confidence interval [CI], 5.50%-4.65%). This gap increased to 7.77% (95% CI, 8.24%-7.30%) and 8.53% (95% CI, 9.32%-7.74%) if the household reported 1 and 2 or more illness episodes, respectively. The gender gap in schooling in response to illness was larger in households with a working mother. Increases in child vaccination rates were associated with a closing of the gender gap in schooling (correlation coefficient = 0.34, P = .02).Illnesses among children strongly predict a widening of the gender gap in education. Investments in early childhood health may have important effects on schooling attainment for adolescent girls.

  View details for PubMedID 28759395

  View details for PubMedCentralID PMC5495535

• Differentiated Human Immunodeficiency Virus RNA Monitoring in Resource-Limited Settings: An Economic Analysis. Clinical infectious diseases Negoescu, D. M., Zhang, Z., Bucher, H. C., Bendavid, E. 2017; 64 (12): 1724-1730

  Abstract

  Viral load (VL) monitoring for patients receiving antiretroviral therapy (ART) is recommended worldwide. However, the costs of frequent monitoring are a barrier to implementation in resource-limited settings. The extent to which personalized monitoring frequencies may be cost-effective is unknown.We created a simulation model parameterized using person-level longitudinal data to assess the benefits of flexible monitoring frequencies. Our data-driven model tracked human immunodeficiency virus (HIV)-infected individuals for 10 years following ART initiation. We optimized the interval between viral load tests as a function of patients' age, gender, education, duration since ART initiation, adherence behavior, and the cost-effectiveness threshold. We compared the cost-effectiveness of the personalized monitoring strategies to fixed monitoring intervals every 1, 3, 6, 12, and 24 months.Shorter fixed VL monitoring intervals yielded increasing benefits (6.034 to 6.221 discounted quality-adjusted life-years [QALYs] per patient with monitoring every 24 to 1 month over 10 years, respectively, standard error = 0.005 QALY), at increasing average costs: US$3445 (annual monitoring) to US$5393 (monthly monitoring) per patient, respectively (standard error = US$3.7). The adaptive policy optimized for low-income contexts achieved 6.142 average QALYs at a cost of US$3524, similar to the fixed 12-month policy (6.135 QALYs, US$3518). The adaptive policy optimized for middle-income resource settings yields 0.008 fewer QALYs per person, but saves US$204 compared to monitoring every 3 months.The benefits from implementing adaptive vs fixed VL monitoring policies increase with the availability of resources. In low- and middle-income countries, adaptive policies achieve similar outcomes to simpler, fixed-interval policies.

  View details for DOI 10.1093/cid/cix177

  View details for PubMedID 28329208

• Disease ecology, health and the environment: a framework to account for ecological and socio-economic drivers in the control of neglected tropical diseases PHILOSOPHICAL TRANSACTIONS OF THE ROYAL SOCIETY B-BIOLOGICAL SCIENCES Garchitorena, A., Sokolow, S. H., Roche, B., Ngonghala, C. N., Jocque, M., Lund, A., Barry, M., MORDECAI, E. A., Daily, G. C., Jones, J. H., Andrews, J. R., Bendavid, E., Luby, S. P., LaBeaud, A. D., Seetah, K., Guegan, J. F., Bonds, M. H., De Leo, G. A. 2017; 372 (1722)

  Abstract

  Reducing the burden of neglected tropical diseases (NTDs) is one of the key strategic targets advanced by the Sustainable Development Goals. Despite the unprecedented effort deployed for NTD elimination in the past decade, their control, mainly through drug administration, remains particularly challenging: persistent poverty and repeated exposure to pathogens embedded in the environment limit the efficacy of strategies focused exclusively on human treatment or medical care. Here, we present a simple modelling framework to illustrate the relative role of ecological and socio-economic drivers of environmentally transmitted parasites and pathogens. Through the analysis of system dynamics, we show that periodic drug treatments that lead to the elimination of directly transmitted diseases may fail to do so in the case of human pathogens with an environmental reservoir. Control of environmentally transmitted diseases can be more effective when human treatment is complemented with interventions targeting the environmental reservoir of the pathogen. We present mechanisms through which the environment can influence the dynamics of poverty via disease feedbacks. For illustration, we present the case studies of Buruli ulcer and schistosomiasis, two devastating waterborne NTDs for which control is particularly challenging.This article is part of the themed issue 'Conservation, biodiversity and infectious disease: scientific evidence and policy implications'.

  View details for DOI 10.1098/rstb.2016.0128

  View details for PubMedID 28438917

• Malaria control adds to the evidence for health aid effectiveness PLOS MEDICINE Bendavid, E. 2017; 14 (6): e1002320

  Abstract

  In this Perspective, Eran Bendavid discusses the broader political and health consequences of US foreign aid in light of the study by Aleksandra Jakubowski and colleagues of the President's Malaria Initiative in sub-Saharan Africa.

  View details for PubMedID 28609465

• Home Dialysis in the Prospective Payment System Era. Journal of the American Society of Nephrology Lin, E., Cheng, X. S., Chin, K., Zubair, T., Chertow, G. M., Bendavid, E., Bhattacharya, J. 2017

  Abstract

  The ESRD Prospective Payment System introduced two incentives to increase home dialysis use: bundling injectable medications into a single payment for treatment and paying for home dialysis training. We evaluated the effects of the ESRD Prospective Payment System on home dialysis use by patients starting dialysis in the United States from January 1, 2006 to August 31, 2013. We analyzed data on dialysis modality, insurance type, and comorbidities from the United States Renal Data System. We estimated the effect of the policy on home dialysis use with multivariable logistic regression and compared the effect on Medicare Parts A/B beneficiaries with the effect on patients with other types of insurance. The ESRD Prospective Payment System associated with a 5.0% (95% confidence interval [95% CI], 4.0% to 6.0%) increase in home dialysis use by the end of the study period. Home dialysis use increased by 5.8% (95% CI, 4.3% to 6.9%) among Medicare beneficiaries and 4.1% (95% CI, 2.3% to 5.4%) among patients covered by other forms of health insurance. The difference between these groups was not statistically significant (1.8%; 95% CI, -0.2% to 3.8%). Conversely, in both populations, the training add-on did not associate with increases in home dialysis use beyond the effect of the policy. The ESRD Prospective Payment System bundling, but not the training add-on, associated with substantial increases in home dialysis, which were identical for both Medicare and non-Medicare patients. These spill-over effects suggest that major payment changes in Medicare can affect all patients with ESRD.

  View details for DOI 10.1681/ASN.2017010041

  View details for PubMedID 28490435

• Cost Effectiveness Analysis of Peripheral Arterial Disease Screening With the Ankle-Brachial Index Test Itoga, N. K., Minami, H., Chelvakumar, M., Pearson, K., Mell, M. W., Bendavid, E., Owens, D. K. LIPPINCOTT WILLIAMS & WILKINS. 2017

  View details for Web of Science ID 000408316600195

• Cost Effectiveness of Endoscopic Mucosal Resection Compared to Transanal Resection of Complex Rectal Polyps Yu, J. X., Russell, W. A., Kim, N. G., Ching, J., Bendavid, E., Owens, D. K., Kaltenbach, T. R. MOSBY-ELSEVIER. 2017: AB371

  View details for DOI 10.1016/j.gie.2017.03.858

  View details for Web of Science ID 000403087401055

• A novel framework to account for ecological drivers in the control and elimination of environmentally transmitted disease: a modelling study De Leo, G. A., Sokolow, S. H., Garchitorena, A., Ngonghala, C. N., Lund, A., Barry, M., Burke, K. S., Mordecai, E. A., Daily, G. C., Jones, J. H., Andrews, J. R., Bendavid, E., Luby, S. P., LaBeaud, A., Seetah, K., Guegan, J., Lafferty, K., Wood, C. L., Jones, I. J., Bonds, M. H. ELSEVIER SCIENCE INC. 2017: 5

  View details for Web of Science ID 000406739900006

• A call to strengthen the global strategy against schistosomiasis and soil-transmitted helminthiasis: the time is now. The Lancet. Infectious diseases Lo, N. C., Addiss, D. G., Hotez, P. J., King, C. H., Stothard, J. R., Evans, D. S., Colley, D. G., Lin, W., Coulibaly, J. T., Bustinduy, A. L., Raso, G., Bendavid, E., Bogoch, I. I., Fenwick, A., Savioli, L., Molyneux, D., Utzinger, J., Andrews, J. R. 2017; 17 (2): e64-e69

  Abstract

  In 2001, the World Health Assembly (WHA) passed the landmark WHA 54.19 resolution for global scale-up of mass administration of anthelmintic drugs for morbidity control of schistosomiasis and soil-transmitted helminthiasis, which affect more than 1·5 billion of the world's poorest people. Since then, more than a decade of research and experience has yielded crucial knowledge on the control and elimination of these helminthiases. However, the global strategy has remained largely unchanged since the original 2001 WHA resolution and associated WHO guidelines on preventive chemotherapy. In this Personal View, we highlight recent advances that, taken together, support a call to revise the global strategy and guidelines for preventive chemotherapy and complementary interventions against schistosomiasis and soil-transmitted helminthiasis. These advances include the development of guidance that is specific to goals of morbidity control and elimination of transmission. We quantify the result of forgoing this opportunity by computing the yearly disease burden, mortality, and lost economic productivity associated with maintaining the status quo. Without change, we estimate that the population of sub-Saharan Africa will probably lose 2·3 million disability-adjusted life-years and US$3·5 billion of economic productivity every year, which is comparable to recent acute epidemics, including the 2014 Ebola and 2015 Zika epidemics. We propose that the time is now to strengthen the global strategy to address the substantial disease burden of schistosomiasis and soil-transmitted helminthiasis.

  View details for DOI 10.1016/S1473-3099(16)30535-7

  View details for PubMedID 27914852

  View details for PubMedCentralID PMC5280090

• The Impact of Intensity Modulated Radiation Therapy on Hospitalization Outcomes in the SEER-Medicare Population With Anal Squamous Cell Carcinoma. International journal of radiation oncology, biology, physics Pollom, E. L., Wang, G., Harris, J. P., Koong, A. C., Bendavid, E., Bhattacharya, J., Chang, D. T. 2017

  Abstract

  We examined the impact of intensity modulated radiation therapy (IMRT) on hospitalization rates in the Surveillance, Epidemiology, and End Results (SEER)-Medicare population with anal squamous cell carcinoma (SCC).We performed a retrospective cohort study using the SEER-Medicare database. We identified patients with nonmetastatic anal SCC diagnosed between 2001 and 2011 and treated with chemoradiation therapy. We assessed the relation between IMRT and first hospitalization by use of a multivariate competing-risk model, as well as instrumental variable analysis, using provider IMRT affinity as our instrument.Of the 1165 patients included in our study, 458 (39%) received IMRT. IMRT use increased over time and was associated more with regional and provider characteristics than with patient characteristics. The 3- and 6-month cumulative incidences of first hospitalization were 41.9% (95% confidence interval [CI], 37.3%-46.4%) and 47.6% (95% CI, 43.0%-52.2%), respectively, for the IMRT cohort and 46.7% (95% CI, 43.0%-50.4%) and 52.1% (95% CI, 48.4%-55.7%), respectively, for the non-IMRT cohort. IMRT was associated with a decreased hazard of first hospitalization compared with 3-dimensional radiation techniques (hazard ratio, 0.70; 95% CI, 0.58-0.84; P=.0002). Instrumental variable analysis suggested an even greater reduction in hospitalizations with IMRT after controlling for unmeasured confounders. There was a trend toward improved overall survival with IMRT, with an adjusted hazard ratio of 0.77 (95% CI, 0.59-1.00; P=.05).The use of IMRT is associated with reduced hospitalizations in elderly patients with anal SCC. Further work is warranted to understand the long-term health and cost impact of IMRT, particularly for patient subgroups most at risk of toxicity and hospitalization.

  View details for DOI 10.1016/j.ijrobp.2017.01.006

  View details for PubMedID 28258896

• Effect of Meat Price on Race and Gender Disparities in Obesity, Mortality and Quality of Life in the US: A Model-Based Analysis PLOS ONE Pitt, A., Bendavid, E. 2017; 12 (1)

  Abstract

  There are large differences in the burden and health implications of obesity by race and gender in the US. It is unclear to what extent policies modifying caloric consumption change the distribution of the burden of obesity and related health outcomes. Meat is a large component of the American diet. We investigate how changing meat prices (that may result from policies or from exogenous factors that reduce supply) might impact the burden of obesity by race and gender.We construct a microsimulation model that evaluates the 15-year body-mass index (BMI) and mortality impact of changes in meat price (5, 10, 25, and 50% increase) in the US adult population stratified by age, gender, race, and BMI.Under each price change evaluated, relative to the status quo, white males, black males, and black females are expected to realize more dramatic reduction in 2030 obesity prevalence than white females. Life expectancy gains are also projected to differ by subpopulation, with black males far less likely to benefit from an increase in meat prices than other groups.Changing meat prices has considerable potential to affect population health differently by race and gender. In designing interventions that alter the price of foods to consumers, it is not sufficient to assess health effects based solely on the population as a whole, since differential effects across subpopulations may be substantial.

  View details for DOI 10.1371/journal.pone.0168710

  View details for Web of Science ID 000391612300047

  View details for PubMedID 28045931

  View details for PubMedCentralID PMC5207744

• Cost-Effectiveness of Radiation and Chemotherapy for High-Risk Low-Grade Glioma. Neuro-oncology Qian, Y. n., Maruyama, S. n., Kim, H. n., Pollom, E. L., Kumar, K. A., Chin, A. L., Harris, J. P., Chang, D. T., Pitt, A. n., Bendavid, E. n., Owens, D. K., Durkee, B. Y., Soltys, S. G. 2017

  Abstract

  The addition of PCV (procarbazine, lomustine, vincristine) chemotherapy to radiotherapy (RT) for patients with high-risk (≥ 40 years old or sub-totally resected) low-grade glioma (LGG) results in an absolute median survival benefit of over 5 years. We evaluated the cost-effectiveness of this treatment strategy.A decision tree with an integrated three-state Markov model was created to follow patients with high risk LGG after surgery treated with RT vs. RT+PCV. Patients existed in one of 3 health states: stable, progressive, and dead. Survival and freedom from progression were modeled to reflect the results of RTOG 9802 using time-dependent transition probabilities. Health utility values and costs of care were derived from the literature and national registry databases. Analysis was conducted from the healthcare perspective. Deterministic and probabilistic sensitivity analysis explored uncertainty in model parameters.Modeled outcomes demonstrated agreement with clinical data in expected benefit of addition of PCV to RT. The addition of PCV to RT yielded an incremental benefit of 4.77 quality-adjusted life-years (QALYs) (9.94 for RT+PCV vs. 5.17 for RT alone) at an incremental cost of $48,635 ($188,234 for RT+PCV vs. $139,598 for RT alone), resulting in an incremental cost-effectiveness ratio of $10,186 per QALY gained. Probabilistic sensitivity analysis demonstrates that within modeled distributions of parameters, RT+PCV has 99.96% probability of being cost-effectiveness at a willingness-to-pay threshold of $100,000 per QALY.The addition of PCV to RT is a cost-effective treatment strategy for patients with high-risk LGG.

  View details for PubMedID 28666368

• Diagnostic staging laparoscopy in gastric cancer treatment: A cost-effectiveness analysis. Journal of surgical oncology Li, K. n., Cannon, J. G., Jiang, S. Y., Sambare, T. D., Owens, D. K., Bendavid, E. n., Poultsides, G. A. 2017

  Abstract

  Accurate preoperative staging helps avert morbidity, mortality, and cost associated with non-therapeutic laparotomy in gastric cancer (GC) patients. Diagnostic staging laparoscopy (DSL) can detect metastases with high sensitivity, but its cost-effectiveness has not been previously studied. We developed a decision analysis model to assess the cost-effectiveness of preoperative DSL in GC workup.Analysis was based on a hypothetical cohort of GC patients in the U.S. for whom initial imaging shows no metastases. The cost-effectiveness of DSL was measured as cost per quality-adjusted life-year (QALY) gained. Drivers of cost-effectiveness were assessed in sensitivity analysis.Preoperative DSL required an investment of $107 012 per QALY. In sensitivity analysis, DSL became cost-effective at a threshold of $100 000/QALY when the probability of occult metastases exceeded 31.5% or when test sensitivity for metastases exceeded 86.3%. The likelihood of cost-effectiveness increased from 46% to 93% when both parameters were set at maximum reported values.The cost-effectiveness of DSL for GC patients is highly dependent on patient and test characteristics, and is more likely when DSL is used selectively where procedure yield is high, such as for locally advanced disease or in detecting peritoneal and superficial versus deep liver lesions.

  View details for PubMedID 29205366

• ADDITION OF SNAIL CONTROL TO ACHIEVE DISEASE CONTROL TARGETS SCHISTOSOMIASIS: A COST-EFFECTIVENESS MODELING STUDY Lo, N. C., Gurarie, D., Yoon, N., Coulibaly, J. T., Bendavid, E., Andrews, J. R., King, C. H. AMER SOC TROP MED & HYGIENE. 2017: 394

  View details for Web of Science ID 000423215203634

• Cost-effectiveness of malaria preventive treatment for HIV-infected pregnant women in sub-Saharan Africa. Malaria journal Choi, S. E., Brandeau, M. L., Bendavid, E. n. 2017; 16 (1): 403

  Abstract

  Malaria is a leading cause of morbidity and mortality among HIV-infected pregnant women in sub-Saharan Africa: at least 1 million pregnancies among HIV-infected women are complicated by co-infection with malaria annually, leading to increased risk of premature delivery, severe anaemia, delivery of low birth weight infants, and maternal death. Current guidelines recommend either daily cotrimoxazole (CTX) or intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) for HIV-infected pregnant women to prevent malaria and its complications. The cost-effectiveness of CTX compared to IPTp-SP among HIV-infected pregnant women was assessed.A microsimulation model of malaria and HIV among pregnant women in five malaria-endemic countries in sub-Saharan Africa was constructed. Four strategies were compared: (1) 2-dose IPTp-SP at current IPTp-SP coverage of the country ("2-IPT Low"); (2) 3-dose IPTp-SP at current coverage ("3-IPT Low"); (3) 3-dose IPTp-SP at the same coverage as antiretroviral therapy (ART) in the country ("3-IPT High"); and (4) daily CTX at ART coverage. Outcomes measured include maternal malaria, anaemia, low birth weight (LBW), and disability-adjusted life years (DALYs). Sensitivity analyses assessed the effect of adherence to CTX.Compared with the 2-IPT Low Strategy, women receiving CTX had 22.5% fewer LBW infants (95% CI 22.3-22.7), 13.5% fewer anaemia cases (95% CI 13.4-13.5), and 13.6% fewer maternal malaria cases (95% CI 13.6-13.7). In all simulated countries, CTX was the preferred strategy, with incremental cost-effectiveness ratios ranging from cost-saving to $3.9 per DALY averted from a societal perspective. CTX was less effective than the 3-IPT High Strategy when more than 18% of women stopped taking CTX during the pregnancy.In malarious regions of sub-Saharan Africa, daily CTX for HIV-infected pregnant women regardless of CD4 cell count is cost-effective compared with 3-dose IPTp-SP as long as more than 82% of women adhere to daily dosing.

  View details for PubMedID 28985732

• Mortality along the continuum of HIV care in Rwanda: a model-based analysis BMC INFECTIOUS DISEASES Bendavid, E., Stauffer, D., Remera, E., Nsanzimana, S., Kanters, S., Mills, E. J. 2016; 16

  Abstract

  HIV is the leading cause of death among adults in sub-Saharan Africa. However, mortality along the HIV care continuum is poorly described. We combine demographic, epidemiologic, and health services data to estimate where are people with HIV dying along Rwanda's care continuum.We calibrated an age-structured HIV disease and transmission stochastic simulation model to the epidemic in Rwanda. We estimate mortality among HIV-infected individuals in the following states: untested, tested without establishing care in an antiretroviral therapy (ART) program (unlinked), in care before initiating ART (pre-ART), lost to follow-up (LTFU) following ART initiation, and retained in active ART care. We estimated mortality among people living with HIV in Rwanda through 2025 under current conditions, and with improvements to the HIV care continuum.In 2014, the greatest portion of deaths occurred among those untested (35.4%), followed by those on ART (34.1%), reflecting the large increase in the population on ART. Deaths among those LTFU made up 11.8% of all deaths among HIV-infected individuals in 2014, and in the base case this portion increased to 18.8% in 2025, while the contribution to mortality declined among those untested, unlinked, and in pre-ART. In our model only combined improvements to multiple aspects of the HIV care continuum were projected to reduce the total number of deaths among those with HIV, estimated at 8177 in 2014, rising to 10,659 in the base case, and declining to 5,691 with combined improvements in 2025.Mortality among those untested for HIV contributes a declining portion of deaths among HIV-infected individuals in Rwanda, but the portion of deaths among those LTFU is expected to increase the most over the next decade. Combined improvements to the HIV care continuum might be needed to reduce the number of deaths among those with HIV.

  View details for DOI 10.1186/s12879-016-2052-7

  View details for Web of Science ID 000389084100001

  View details for PubMedID 27905895

  View details for PubMedCentralID PMC5134104

• Breast Density Notification Legislation and Breast Cancer Stage at Diagnosis: Early Evidence from the SEER Registry. Journal of general internal medicine Richman, I., Asch, S. M., Bendavid, E., Bhattacharya, J., Owens, D. K. 2016: -?

  Abstract

  Twenty-eight states have passed breast density notification laws, which require physicians to inform women of a finding of dense breasts on mammography.To evaluate changes in breast cancer stage at diagnosis after enactment of breast density notification legislation.Using a difference-in-differences analysis, we examined changes in stage at diagnosis among women with breast cancer in Connecticut, the first state to enact legislation, compared to changes among women in control states. We used data from the Surveillance, Epidemiology, and End Results Program (SEER) registry, 2005-2013.Women ages 40-74 with breast cancer.Breast density notification legislation, enacted in Connecticut in October of 2009.Breast cancer stage at diagnosis.Our study included 466,930 women, 25,592 of whom lived in Connecticut. Legislation was associated with a 1.38-percentage-point (95 % CI 0.12 to 2.63) increase in the proportion of women in Connecticut versus control states who had localized invasive cancer at the time of diagnosis, and a 1.12-percentage-point (95 % CI -2.21 to -0.08) decline in the proportion of women with ductal carcinoma in situ at diagnosis. Breast density notification legislation was not associated with a change in the proportion of women in Connecticut versus control states with regional-stage (-0.09 percentage points, 95 % CI -1.01 to 1.02) or metastatic disease (-0.24, 95 % CI -0.75 to 0.28). County-level analyses and analyses limited to women younger than 50 found no statistically significant associations.Single intervention state, limited follow-up, potential confounding from unobserved trends.Breast density notification legislation in Connecticut was associated with a small increase in the proportion of women diagnosed with localized invasive breast cancer in individual-level but not county-level analyses. Whether this finding reflects potentially beneficial early detection or potentially harmful overdiagnosis is not known. Legislation was not associated with changes in regional or metastatic disease.

  View details for PubMedID 27844260

• Feasibility of achieving the 2025 WHO global tuberculosis targets in South Africa, China, and India: a combined analysis of 11 mathematical models. The Lancet. Global health Houben, R. M., Menzies, N. A., Sumner, T., Huynh, G. H., Arinaminpathy, N., Goldhaber-Fiebert, J. D., Lin, H., Wu, C., Mandal, S., Pandey, S., Suen, S., Bendavid, E., Azman, A. S., Dowdy, D. W., Bacaër, N., Rhines, A. S., Feldman, M. W., Handel, A., Whalen, C. C., Chang, S. T., Wagner, B. G., Eckhoff, P. A., Trauer, J. M., Denholm, J. T., McBryde, E. S., Cohen, T., Salomon, J. A., Pretorius, C., Lalli, M., Eaton, J. W., Boccia, D., Hosseini, M., Gomez, G. B., Sahu, S., Daniels, C., Ditiu, L., Chin, D. P., Wang, L., Chadha, V. K., Rade, K., Dewan, P., Hippner, P., Charalambous, S., Grant, A. D., Churchyard, G., Pillay, Y., Mametja, L. D., Kimerling, M. E., Vassall, A., White, R. G. 2016; 4 (11): e806-e815

  Abstract

  The post-2015 End TB Strategy proposes targets of 50% reduction in tuberculosis incidence and 75% reduction in mortality from tuberculosis by 2025. We aimed to assess whether these targets are feasible in three high-burden countries with contrasting epidemiology and previous programmatic achievements.11 independently developed mathematical models of tuberculosis transmission projected the epidemiological impact of currently available tuberculosis interventions for prevention, diagnosis, and treatment in China, India, and South Africa. Models were calibrated with data on tuberculosis incidence and mortality in 2012. Representatives from national tuberculosis programmes and the advocacy community provided distinct country-specific intervention scenarios, which included screening for symptoms, active case finding, and preventive therapy.Aggressive scale-up of any single intervention scenario could not achieve the post-2015 End TB Strategy targets in any country. However, the models projected that, in the South Africa national tuberculosis programme scenario, a combination of continuous isoniazid preventive therapy for individuals on antiretroviral therapy, expanded facility-based screening for symptoms of tuberculosis at health centres, and improved tuberculosis care could achieve a 55% reduction in incidence (range 31-62%) and a 72% reduction in mortality (range 64-82%) compared with 2015 levels. For India, and particularly for China, full scale-up of all interventions in tuberculosis-programme performance fell short of the 2025 targets, despite preventing a cumulative 3·4 million cases. The advocacy scenarios illustrated the high impact of detecting and treating latent tuberculosis.Major reductions in tuberculosis burden seem possible with current interventions. However, additional interventions, adapted to country-specific tuberculosis epidemiology and health systems, are needed to reach the post-2015 End TB Strategy targets at country level.Bill and Melinda Gates Foundation.

  View details for DOI 10.1016/S2214-109X(16)30199-1

  View details for PubMedID 27720688

• Cost-effectiveness and resource implications of aggressive action on tuberculosis in China, India, and South Africa: a combined analysis of nine models. The Lancet. Global health Menzies, N. A., Gomez, G. B., Bozzani, F., Chatterjee, S., Foster, N., Baena, I. G., Laurence, Y. V., Qiang, S., Siroka, A., Sweeney, S., Verguet, S., Arinaminpathy, N., Azman, A. S., Bendavid, E., Chang, S. T., Cohen, T., Denholm, J. T., Dowdy, D. W., Eckhoff, P. A., Goldhaber-Fiebert, J. D., Handel, A., Huynh, G. H., Lalli, M., Lin, H., Mandal, S., McBryde, E. S., Pandey, S., Salomon, J. A., Suen, S., Sumner, T., Trauer, J. M., Wagner, B. G., Whalen, C. C., Wu, C., Boccia, D., Chadha, V. K., Charalambous, S., Chin, D. P., Churchyard, G., Daniels, C., Dewan, P., Ditiu, L., Eaton, J. W., Grant, A. D., Hippner, P., Hosseini, M., Mametja, D., Pretorius, C., Pillay, Y., Rade, K., Sahu, S., Wang, L., Houben, R. M., Kimerling, M. E., White, R. G., Vassall, A. 2016; 4 (11): e816-e826

  Abstract

  The post-2015 End TB Strategy sets global targets of reducing tuberculosis incidence by 50% and mortality by 75% by 2025. We aimed to assess resource requirements and cost-effectiveness of strategies to achieve these targets in China, India, and South Africa.We examined intervention scenarios developed in consultation with country stakeholders, which scaled up existing interventions to high but feasible coverage by 2025. Nine independent modelling groups collaborated to estimate policy outcomes, and we estimated the cost of each scenario by synthesising service use estimates, empirical cost data, and expert opinion on implementation strategies. We estimated health effects (ie, disability-adjusted life-years averted) and resource implications for 2016-35, including patient-incurred costs. To assess resource requirements and cost-effectiveness, we compared scenarios with a base case representing continued current practice.Incremental tuberculosis service costs differed by scenario and country, and in some cases they more than doubled existing funding needs. In general, expansion of tuberculosis services substantially reduced patient-incurred costs and, in India and China, produced net cost savings for most interventions under a societal perspective. In all three countries, expansion of access to care produced substantial health gains. Compared with current practice and conventional cost-effectiveness thresholds, most intervention approaches seemed highly cost-effective.Expansion of tuberculosis services seems cost-effective for high-burden countries and could generate substantial health and economic benefits for patients, although substantial new funding would be required. Further work to determine the optimal intervention mix for each country is necessary.Bill & Melinda Gates Foundation.

  View details for DOI 10.1016/S2214-109X(16)30265-0

  View details for PubMedID 27720689

• Cost-effectiveness and resource implications of aggressive action on tuberculosis in China, India, and South Africa: a combined analysis of nine models LANCET GLOBAL HEALTH Menzies, N. A., Gomez, G. B., Bozzani, F., Chatterjee, S., Foster, N., Garcia Baena, I., Laurence, Y. V., Qiang, S., Siroka, A., Sweeney, S., Verguet, S., Arinaminpathy, N., Azman, A. S., Bendavid, E., Chang, S. T., Cohen, T., Denholm, J. T., Dowdy, D. W., Eckhoff, P. A., Goldhaber-Fiebert, J. D., Handel, A., Huynh, G. H., Lalli, M., Lin, H., Mandal, S., McBryde, E. S., Pandey, S., Salomon, J. A., Suen, S., Sumner, T., Trauer, J. M., Wagner, B. G., Whalen, C. C., Wu, C., Boccia, D., Chadha, V. K., Charalambous, S., Chin, D. P., Churchyard, G., Daniels, C., Dewan, P., Ditiu, L., Eaton, J. W., Grant, A. D., Hippner, P., Hosseini, M., Mametja, D., Pretorius, C., Pillay, Y., Rade, K., Sahu, S., Wang, L., Houben, R. M., Kimerling, M. E., White, R. G., Vassall, A. 2016; 4 (11): E816-E826

  Abstract

  The post-2015 End TB Strategy sets global targets of reducing tuberculosis incidence by 50% and mortality by 75% by 2025. We aimed to assess resource requirements and cost-effectiveness of strategies to achieve these targets in China, India, and South Africa.We examined intervention scenarios developed in consultation with country stakeholders, which scaled up existing interventions to high but feasible coverage by 2025. Nine independent modelling groups collaborated to estimate policy outcomes, and we estimated the cost of each scenario by synthesising service use estimates, empirical cost data, and expert opinion on implementation strategies. We estimated health effects (ie, disability-adjusted life-years averted) and resource implications for 2016-35, including patient-incurred costs. To assess resource requirements and cost-effectiveness, we compared scenarios with a base case representing continued current practice.Incremental tuberculosis service costs differed by scenario and country, and in some cases they more than doubled existing funding needs. In general, expansion of tuberculosis services substantially reduced patient-incurred costs and, in India and China, produced net cost savings for most interventions under a societal perspective. In all three countries, expansion of access to care produced substantial health gains. Compared with current practice and conventional cost-effectiveness thresholds, most intervention approaches seemed highly cost-effective.Expansion of tuberculosis services seems cost-effective for high-burden countries and could generate substantial health and economic benefits for patients, although substantial new funding would be required. Further work to determine the optimal intervention mix for each country is necessary.Bill & Melinda Gates Foundation.

  View details for DOI 10.1016/S2214-109X(16)30265-0

  View details for Web of Science ID 000386811200023

• Past and Future Performance: PEPFAR in the Landscape of Foreign Aid for Health CURRENT HIV/AIDS REPORTS Bendavid, E. 2016; 13 (5): 256-262

  Abstract

  This review traces the course of the US President's Emergency Plan for AIDS Relief (PEPFAR) as a foreign aid program. It illustrates how the epidemiologic and geopolitical environments of the early 2000s influenced PEPFAR's early directions and contributed to its successes. In addition to scaling up infrastructure and care delivery platforms, PEPFAR led to large increases in the number of people receiving antiretroviral therapy and reductions in mortality. These successes, in turn, have brought its principal challenges-its outsized budget, narrow focus, and problem of entitlement-into sharp relief. PEPFAR's recent evolution, then, has been in response to these challenges. This review suggests that PEPFAR's early formulation as an emergency response relieved it from a need to articulate clear goals, and that this freedom is now leading to new challenges as it struggles to identify priorities in the face of expectations to do more with a flat budget.

  View details for DOI 10.1007/s11904-016-0326-8

  View details for Web of Science ID 000384544000003

  View details for PubMedID 27485837

  View details for PubMedCentralID PMC5035203

• Assessment of global guidelines for preventive chemotherapy against schistosomiasis and soil-transmitted helminthiasis: a cost-effectiveness modelling study LANCET INFECTIOUS DISEASES Lo, N. C., Lai, Y., Karagiannis-Voules, D., Bogoch, I. I., Coulibaly, J. T., Bendavid, E., Utzinger, J., Vounatsou, P., Andrews, J. R. 2016; 16 (9): 1065-1075

  Abstract

  WHO guidelines recommend annual treatment for schistosomiasis or soil-transmitted helminthiasis when prevalence in school-aged children is at or above a threshold of 50% and 20%, respectively. Separate treatment guidelines are used for these two helminthiases, and integrated community-wide treatment is not recommended. We assessed the cost-effectiveness of changing prevalence thresholds and treatment guidelines under an integrated delivery framework.We developed a dynamic, age-structured transmission and cost-effectiveness model that simulates integrated preventive chemotherapy programmes against schistosomiasis and soil-transmitted helminthiasis. We assessed a 5-year treatment programme with praziquantel (40 mg/kg per treatment) against schistosomiasis and albendazole (400 mg per treatment) against soil-transmitted helminthiasis at 75% coverage. We defined strategies as highly cost-effective if the incremental cost-effectiveness ratio was less than the World Bank classification for a low-income country (gross domestic product of US$1045 per capita). We calculated the prevalence thresholds for cost-effective preventive chemotherapy of various strategies, and estimated treatment needs for sub-Saharan Africa.Annual preventive chemotherapy against schistosomiasis was highly cost-effective in treatment of school-aged children at a prevalence threshold of 5% (95% uncertainty interval [UI] 1·7-5·2; current guidelines recommend treatment at 50% prevalence) and for community-wide treatment at a prevalence of 15% (7·3-18·5; current recommendation is unclear, some community treatment recommended at 50% prevalence). Annual preventive chemotherapy against soil-transmitted helminthiasis was highly cost-effective in treatment of school-aged children at a prevalence of 20% (95% UI 5·4-30·5; current guidelines recommend treatment at 20% prevalence) and the entire community at 60% (35·3-85·1; no guidelines available). When both helminthiases were co-endemic, prevalence thresholds using integrated delivery were lower. Using this revised treatment framework, we estimated that treatment needs would be six times higher than WHO guidelines for praziquantel and two times higher for albendazole. An additional 21·3% (95% Bayesian credible interval 20·4-22·2) of the population changed from receiving non-integrated treatment under WHO guidelines to integrated treatment (both praziquantel and albendazole). Country-specific economic differences resulted in heterogeneity around these prevalence thresholds.Annual preventive chemotherapy programmes against schistosomiasis and soil-transmitted helminthiasis are likely to be highly cost-effective at prevalences lower than WHO recommendations. These findings support substantial treatment scale-up, community-wide coverage, integrated treatment in co-endemic settings that yield substantial cost synergies, and country-specific treatment guidelines.Doris Duke Charitable Foundation, Mount Sinai Hospital-University Health Network AMO Innovation Fund, and Stanford University Medical Scholars Programme.

  View details for DOI 10.1016/S1473-3099(16)30073-1

  View details for Web of Science ID 000381655200036

  View details for PubMedID 27286968

• Deciphering the Effects of Injectable Pre-exposure Prophylaxis for Combination Human Immunodeficiency Virus Prevention. Open forum infectious diseases Glaubius, R. L., Parikh, U. M., Hood, G., Penrose, K. J., Bendavid, E., Mellors, J. W., Abbas, U. L. 2016; 3 (3): ofw125

  Abstract

  Background.  A long-acting injectable formulation of rilpivirine (RPV), under investigation as antiretroviral pre-exposure prophylaxis (PrEP), may facilitate PrEP adherence. In contrast, cross-resistance between RPV and nonnucleoside reverse-transcriptase inhibitors comprising first-line antiretroviral therapy (ART) could promote human immunodeficiency virus (HIV) drug resistance and reduce PrEP's effectiveness. Methods.  We use novel mathematical modeling of different RPV PrEP scale-up strategies in KwaZulu-Natal, South Africa, to investigate their effects on HIV prevention and drug resistance, compared with a reference scenario without PrEP. Results.  Pre-exposure prophylaxis scale-up modestly increases the proportion of prevalent drug-resistant infections, from 33% to ≤37%. The change in the number of prevalent drug-resistant infections depends on the interplay between PrEP factors (coverage, efficacy, delivery reliability, and scale-up strategy) and the level of cross-resistance between PrEP and ART. An optimistic scenario of 70% effective RPV PrEP (90% efficacious and 80% reliable delivery), among women aged 20-29 years, prevents 17% of cumulative infections over 10 years while decreasing prevalent resistance; however, prevention decreases and resistance increases with more conservative assumptions. Uncertainty analysis assuming 40%-70% cross-resistance prevalence predicts an increase in prevalent resistance unless PrEP's effectiveness exceeds 90%. Conclusions.  Prioritized scale-up of injectable PrEP among women in KwaZulu-Natal could reduce HIV infections, but suboptimal effectiveness could promote the spread of drug resistance.

  View details for DOI 10.1093/ofid/ofw125

  View details for PubMedID 27703992

  View details for PubMedCentralID PMC5047428

• Antiretroviral Treatment Scale-Up and Tuberculosis Mortality in High TB/HIV Burden Countries: An Econometric Analysis PLOS ONE Yan, I., Bendavid, E., Korenromp, E. L. 2016; 11 (8)

  Abstract

  Antiretroviral therapy (ART) reduces mortality in patients with active tuberculosis (TB), but the population-level relationship between ART coverage and TB mortality is untested. We estimated the reduction in population-level TB mortality that can be attributed to increasing ART coverage across 41 high HIV-TB burden countries.We compiled TB mortality trends between 1996 and 2011 from two sources: (1) national program-reported TB death notifications, adjusted for annual TB case detection rates, and (2) WHO TB mortality estimates. National coverage with ART, as proportion of HIV-infected people in need, was obtained from UNAIDS. We applied panel linear regressions controlling for HIV prevalence (5-year lagged), coverage of TB interventions (estimated by WHO and UNAIDS), gross domestic product per capita, health spending from domestic sources, urbanization, and country fixed effects.Models suggest that that increasing ART coverage was followed by reduced TB mortality, across multiple specifications. For death notifications at 2 to 5 years following a given ART scale-up, a 1% increase in ART coverage predicted 0.95% faster mortality rate decline (p = 0.002); resulting in 27% fewer TB deaths in 2011 alone than would have occurred without ART. Based on WHO death estimates, a 1% increase in ART predicted a 1.0% reduced TB death rate (p<0.001), and 31% fewer deaths in 2011. TB mortality was higher at higher HIV prevalence (p<0.001), but not related to coverage of isoniazid preventive therapy, cotrimoxazole preventive therapy, or other covariates.This econometric analysis supports a substantial impact of ART on population-level TB mortality realized already within the first decade of ART scale-up, that is apparent despite variable-quality mortality data.

  View details for DOI 10.1371/journal.pone.0160481

  View details for Web of Science ID 000381577000021

  View details for PubMedID 27536864

  View details for PubMedCentralID PMC4990253

• Cost-effectiveness of Injectable Preexposure Prophylaxis for HIV Prevention in South Africa CLINICAL INFECTIOUS DISEASES Glaubius, R. L., Hood, G., Penrose, K. J., Parikh, U. M., Mellors, J. W., Bendavid, E., Abbas, U. L. 2016; 63 (4): 539–47

  Abstract

  Long-acting injectable antiretrovirals such as rilpivirine (RPV) could promote adherence to preexposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) prevention. However, the cost-effectiveness of injectable PrEP is unclear.We constructed a dynamic model of the heterosexual HIV epidemic in KwaZulu-Natal, South Africa, and analyzed scenarios of RPV PrEP scale-up for combination HIV prevention in comparison with a reference scenario without PrEP. We estimated new HIV infections, life-years and costs, and incremental cost-effectiveness ratios (ICERs), over 10-year and lifetime horizons, assuming a societal perspective.Compared with no PrEP, unprioritized scale-up of RVP PrEP covering 2.5%-15% of adults prevented up to 9% of new infections over 10 years. HIV prevention doubled (17%) when the same coverage was prioritized to 20- to 29-year-old women, costing $10 880-$19 213 per infection prevented. Prioritization of PrEP to 80% of individuals at highest behavioral risk achieved comparable prevention (4%-8%) at <1% overall coverage, costing $298-$1242 per infection prevented. Over lifetime, PrEP scale-up among 20- to 29-year-old women was very cost-effective (<$1600 per life-year gained), dominating unprioritized PrEP, while risk prioritization was cost-saving. PrEP's 10-year impact decreased by almost 50% with increases in ICERs (up to 4.2-fold) in conservative base-case analysis. Sensitivity analysis identified PrEP's costs, efficacy, and reliability of delivery as the principal drivers of uncertainty in PrEP's cost-effectiveness, and PrEP remained cost-effective under the assumption of universal access to second-line antiretroviral therapy.Compared with no PrEP, prioritized scale-up of RPV PrEP in KwaZulu-Natal could be very cost-effective or cost-saving, but suboptimal PrEP would erode benefits and increase costs.

  View details for PubMedID 27193745

  View details for PubMedCentralID PMC4967601

• Evaluation of a Urine Pooling Strategy for the Rapid and Cost-Efficient Prevalence Classification of Schistosomiasis. PLoS neglected tropical diseases Lo, N. C., Coulibaly, J. T., Bendavid, E., N'Goran, E. K., Utzinger, J., Keiser, J., Bogoch, I. I., Andrews, J. R. 2016; 10 (8)

  Abstract

  A key epidemiologic feature of schistosomiasis is its focal distribution, which has important implications for the spatial targeting of preventive chemotherapy programs. We evaluated the diagnostic accuracy of a urine pooling strategy using a point-of-care circulating cathodic antigen (POC-CCA) cassette test for detection of Schistosoma mansoni, and employed simulation modeling to test the classification accuracy and efficiency of this strategy in determining where preventive chemotherapy is needed in low-endemicity settings.We performed a cross-sectional study involving 114 children aged 6-15 years in six neighborhoods in Azaguié Ahoua, south Côte d'Ivoire to characterize the sensitivity and specificity of the POC-CCA cassette test with urine samples that were tested individually and in pools of 4, 8, and 12. We used a Bayesian latent class model to estimate test characteristics for individual POC-CCA and quadruplicate Kato-Katz thick smears on stool samples. We then developed a microsimulation model and used lot quality assurance sampling to test the performance, number of tests, and total cost per school for each pooled testing strategy to predict the binary need for school-based preventive chemotherapy using a 10% prevalence threshold for treatment.The sensitivity of the urine pooling strategy for S. mansoni diagnosis using pool sizes of 4, 8, and 12 was 85.9%, 79.5%, and 65.4%, respectively, when POC-CCA trace results were considered positive, and 61.5%, 47.4%, and 30.8% when POC-CCA trace results were considered negative. The modeled specificity ranged from 94.0-97.7% for the urine pooling strategies (when POC-CCA trace results were considered negative). The urine pooling strategy, regardless of the pool size, gave comparable and often superior classification performance to stool microscopy for the same number of tests. The urine pooling strategy with a pool size of 4 reduced the number of tests and total cost compared to classical stool microscopy.This study introduces a method for rapid and efficient S. mansoni prevalence estimation through examining pooled urine samples with POC-CCA as an alternative to widely used stool microscopy.

  View details for DOI 10.1371/journal.pntd.0004894

  View details for PubMedID 27504954

  View details for PubMedCentralID PMC4978437

• Cost-Effectiveness of HIV Preexposure Prophylaxis for People Who Inject Drugs in the United States ANNALS OF INTERNAL MEDICINE Bernard, C. L., Brandeau, M. L., Humphreys, K., Bendavid, E., Holodniy, M., Weyant, C., Owens, D. K., Goldhaber-Fiebert, J. D. 2016; 165 (1): 10-?

  View details for DOI 10.7326/M15-2634

  View details for Web of Science ID 000379215800003

• Deciphering the Effects of Injectable Pre-exposure Prophylaxis for Combination Human Immunodeficiency Virus Prevention OPEN FORUM INFECTIOUS DISEASES Glaubius, R. L., Parikh, U. M., Hood, G., Penrose, K. J., Bendavid, E., Mellors, J. W., Abbas, U. L. 2016; 3 (3)

  View details for DOI 10.1093/ofid/ofw125

  View details for Web of Science ID 000388571700029

• Abstinence Funding Was Not Associated With Reductions In HIV Risk Behavior In Sub-Saharan Africa HEALTH AFFAIRS Lo, N. C., Lowe, A., Bendavid, E. 2016; 35 (5): 856-863

  Abstract

  The President's Emergency Plan for AIDS Relief (PEPFAR) has been the largest funder of abstinence and faithfulness programming in sub-Saharan Africa, with a cumulative investment of over US $1.4 billion in the period 2004-13. We examined whether PEPFAR funding for abstinence and faithfulness programs, which aimed to reduce the risk of HIV transmission, was associated with a relative change in five outcomes indicative of high-risk sexual behavior: number of sexual partners in the past twelve months for men and for women, age at first sexual intercourse for men and for women, and teenage pregnancies. Using nationally representative surveys from twenty-two sub-Saharan African countries, we compared trends between people living in countries that received PEPFAR abstinence and faithfulness funding and those living in countries that did not in the period 1998-2013. We found no evidence to suggest that PEPFAR funding was associated with population-level reductions in any of the five outcomes. These results suggest that alternative funding priorities for HIV prevention may yield greater health benefits.

  View details for DOI 10.1377/hlthaff.2015.0828

  View details for Web of Science ID 000375796700015

  View details for PubMedID 27140992

• EVALUATING THE EFFECT OF BREAST DENSITY NOTIFICATION LEGISLATION ON BREAST CANCER STAGE AT DIAGNOSIS Richman, I. B., Asch, S., Bendavid, E., Bhattacharya, J., Owens, D. K. SPRINGER. 2016: S214

  View details for Web of Science ID 000392201600224

• Systematic Motorcycle Management and Health Care Delivery: A Field Trial AMERICAN JOURNAL OF PUBLIC HEALTH Mehta, K. M., Rerolle, F., Rammohan, S. V., Albohm, D. C., Muwowo, G., Moseson, H., Sept, L., Lee, H. L., Bendavid, E. 2016; 106 (1): 87-94

  Abstract

  We investigated whether managed transportation improves outreach-based health service delivery to rural village populations.We examined systematic transportation management in a small-cluster interrupted time series field trial. In 8 districts in Southern Zambia, we followed health workers at 116 health facilities from September 2011 to March 2014. The primary outcome was the average number of outreach trips per health worker per week. Secondary outcomes were health worker productivity, motorcycle performance, and geographical coverage.Systematic fleet management resulted in an increase of 0.9 (SD = 1.0) trips to rural villages per health worker per week (P < .001), village-level health worker productivity by 20.5 (SD = 5.9) patient visits, 10.2 (SD = 1.5) measles immunizations, and 5.2 (SD = 5.4) child growth assessments per health worker per week. Motorcycle uptime increased by 3.5 days per week (P < .001), use by 1.5 days per week (P < .001), and mean distance by 9.3 kilometers per trip (P < .001). Geographical coverage of health outreach increased in experimental (P < .001) but not control districts.Systematic motorcycle management improves basic health care delivery to rural villages in resource-poor environments through increased health worker productivity and greater geographical coverage.

  View details for DOI 10.2105/AJPH.2015.302891

  View details for PubMedID 26562131

• Sustainable HIV treatment in Africa through viral-load-informed differentiated care NATURE Phillips, A., Shroufi, A., Vojnov, L., Cohn, J., Roberts, T., Ellman, T., Bonner, K., Rousseau, C., Garnett, G., Cambiano, V., Nakagawa, F., Ford, D., Bansi-Matharu, L., Miners, A., Lundgren, J. D., Eaton, J. W., Parkes-Ratanshi, R., Katz, Z., Maman, D., Ford, N., Vitoria, M., Doherty, M., Dowdy, D., Nichols, B., Murtagh, M., Wareham, M., Palamountain, K. M., Musanhu, C. C., Stevens, W., Katzenstein, D., Ciaranello, A., Barnabas, R., Braithwaite, R. S., Bendavid, E., Nathoo, K. J., van de Vijver, D., Wilson, D. P., Holmes, C., Bershteyn, A., Walker, S., Raizes, E., Jani, I., Nelson, L. J., Peeling, R., Terris-Prestholt, F., Murungu, J., Mutasa-Apollo, T., Hallett, T. B., Revill, P. 2015; 528 (7580): S68-S76

  Abstract

  There are inefficiencies in current approaches to monitoring patients on antiretroviral therapy in sub-Saharan Africa. Patients typically attend clinics every 1 to 3 months for clinical assessment. The clinic costs are comparable with the costs of the drugs themselves and CD4 counts are measured every 6 months, but patients are rarely switched to second-line therapies. To ensure sustainability of treatment programmes, a transition to more cost-effective delivery of antiretroviral therapy is needed. In contrast to the CD4 count, measurement of the level of HIV RNA in plasma (the viral load) provides a direct measure of the current treatment effect. Viral-load-informed differentiated care is a means of tailoring care so that those with suppressed viral load visit the clinic less frequently and attention is focussed on those with unsuppressed viral load to promote adherence and timely switching to a second-line regimen. The most feasible approach to measuring viral load in many countries is to collect dried blood spot samples for testing in regional laboratories; however, there have been concerns over the sensitivity and specificity of this approach to define treatment failure and the delay in returning results to the clinic. We use modelling to synthesize evidence and evaluate the cost-effectiveness of viral-load-informed differentiated care, accounting for limitations of dried blood sample testing. We find that viral-load-informed differentiated care using dried blood sample testing is cost-effective and is a recommended strategy for patient monitoring, although further empirical evidence as the approach is rolled out would be of value. We also explore the potential benefits of point-of-care viral load tests that may become available in the future.

  View details for DOI 10.1038/nature16046

  View details for Web of Science ID 000365606000013

  View details for PubMedCentralID PMC4932825

• Sustainable HIV treatment in Africa through viral-load-informed differentiated care. Nature Phillips, A., Shroufi, A., Vojnov, L., Cohn, J., Roberts, T., Ellman, T., Bonner, K., Rousseau, C., Garnett, G., Cambiano, V., Nakagawa, F., Ford, D., Bansi-Matharu, L., Miners, A., Lundgren, J. D., Eaton, J. W., Parkes-Ratanshi, R., Katz, Z., Maman, D., Ford, N., Vitoria, M., Doherty, M., Dowdy, D., Nichols, B., Murtagh, M., Wareham, M., Palamountain, K. M., Chakanyuka Musanhu, C., Stevens, W., Katzenstein, D., Ciaranello, A., Barnabas, R., Braithwaite, R. S., Bendavid, E., Nathoo, K. J., van de Vijver, D., Wilson, D. P., Holmes, C., Bershteyn, A., Walker, S., Raizes, E., Jani, I., Nelson, L. J., Peeling, R., Terris-Prestholt, F., Murungu, J., Mutasa-Apollo, T., Hallett, T. B., Revill, P. 2015; 528 (7580): S68-76

  Abstract

  There are inefficiencies in current approaches to monitoring patients on antiretroviral therapy in sub-Saharan Africa. Patients typically attend clinics every 1 to 3 months for clinical assessment. The clinic costs are comparable with the costs of the drugs themselves and CD4 counts are measured every 6 months, but patients are rarely switched to second-line therapies. To ensure sustainability of treatment programmes, a transition to more cost-effective delivery of antiretroviral therapy is needed. In contrast to the CD4 count, measurement of the level of HIV RNA in plasma (the viral load) provides a direct measure of the current treatment effect. Viral-load-informed differentiated care is a means of tailoring care so that those with suppressed viral load visit the clinic less frequently and attention is focussed on those with unsuppressed viral load to promote adherence and timely switching to a second-line regimen. The most feasible approach to measuring viral load in many countries is to collect dried blood spot samples for testing in regional laboratories; however, there have been concerns over the sensitivity and specificity of this approach to define treatment failure and the delay in returning results to the clinic. We use modelling to synthesize evidence and evaluate the cost-effectiveness of viral-load-informed differentiated care, accounting for limitations of dried blood sample testing. We find that viral-load-informed differentiated care using dried blood sample testing is cost-effective and is a recommended strategy for patient monitoring, although further empirical evidence as the approach is rolled out would be of value. We also explore the potential benefits of point-of-care viral load tests that may become available in the future.

  View details for DOI 10.1038/nature16046

  View details for PubMedID 26633768

  View details for PubMedCentralID PMC4932825

• Health and Economic Implications of National Treatment Coverage for Cardiovascular Disease in India Cost-Effectiveness Analysis CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Basu, S., Bendavid, E., Sood, N. 2015; 8 (6): 541-551

  Abstract

  Whether to cover cardiovascular disease costs is an increasingly pressing question for low- and middle-income countries. We sought to identify the impact of expanding national insurance to cover primary prevention, secondary prevention, and tertiary treatment for cardiovascular disease in India.We incorporated data from coverage experiments into a validated microsimulation model of myocardial infarction and stroke in India to evaluate the cost-effectiveness of alternate coverage strategies. Coverage of primary prevention alone saved 3.6 million disability-adjusted life-years (DALY) per annum at an incremental cost-effectiveness ratio of $469 per DALY averted when compared with the status quo of no coverage. Coverage of primary and secondary preventions was dominated by a strategy of covering primary prevention and tertiary treatment, which prevented 6.6 million DALYs at an incremental cost-effectiveness ratio of $2241 per DALY averted, when compared with that of primary prevention alone. The combination of all 3 categories yielded the greatest impact at an incremental cost per DALY averted of $5588 when compared with coverage of primary prevention plus tertiary treatment. When compared with the status quo of no coverage, coverage of all 3 categories of prevention/treatment yielded an incremental cost-effectiveness ratio of $1331 per DALY averted. In sensitivity analyses, coverage of primary preventive treatments remained cost-effective even if adherence and access to therapy were low, but tertiary coverage would require avoiding unnecessary procedures to remain cost-effective.Coverage of all 3 major types of cardiovascular treatment would be expected to have high impact and reasonable cost-effectiveness in India across a broad spectrum of access and adherence levels.

  View details for DOI 10.1161/CIRCOUTCOMES.115.001994

  View details for Web of Science ID 000364791200004

  View details for PubMedID 26555122

  View details for PubMedCentralID PMC4801228

• Reply to Young et al. Clinical infectious diseases Desai, M., Joyce, V., Bendavid, E., Olshen, R. A., Hlatky, M., Chow, A., Holodniy, M., Barnett, P., Owens, D. K. 2015; 61 (7): 1207-1208

  View details for DOI 10.1093/cid/civ517

  View details for PubMedID 26123931

• Cost-effectiveness of improvements in diagnosis and treatment accessibility for tuberculosis control in India. international journal of tuberculosis and lung disease Suen, S., Bendavid, E., Goldhaber-Fiebert, J. D. 2015; 19 (9): 1115-?

  Abstract

  Inaccurate diagnosis and inaccessibility of care undercut the effectiveness of high-quality anti-tuberculosis treatment and select for resistance. Rapid diagnostic systems, such as Xpert(®) MTB/RIF for tuberculosis (TB) diagnosis and drug susceptibility testing (DST), and programs that provide high-quality DOTS anti-tuberculosis treatment to patients in the unregulated private sector (public-private mix [PPM]), may help address these challenges, albeit at increased cost.We extended a microsimulation model of TB in India calibrated to demographic, epidemiologic, and care trends to evaluate 1) replacing DST with Xpert; 2) replacing microscopy and culture with Xpert to diagnose multidrug-resistant TB (MDR-TB) and non-MDR-TB; 3) implementing nationwide PPM; and combinations of (3) with (1) or (2).PPM (assuming costs of $38/person) and Xpert improved health and increase costs relative to the status quo. PPM alone or with Xpert cost <1 gross domestic product/capita per quality-adjusted life-year gained relative to the next best intervention, and dominated Xpert interventions excluding PPM.While both PPM and Xpert are promising tools for combatting TB in India, PPM should be prioritized over Xpert, as private sector engagement is more cost-effective than Xpert alone and, if sufficient resources are available, would substantially increase the value of Xpert if both interventions are implemented together.

  View details for DOI 10.5588/ijtld.15.0158

  View details for PubMedID 26260835

• Cost-effectiveness of improvements in diagnosis and treatment accessibility for tuberculosis control in India INTERNATIONAL JOURNAL OF TUBERCULOSIS AND LUNG DISEASE Suen, S., Bendavid, E., Goldhaber-Fiebert, J. D. 2015; 19 (9): 1115-1124

  Abstract

  Inaccurate diagnosis and inaccessibility of care undercut the effectiveness of high-quality anti-tuberculosis treatment and select for resistance. Rapid diagnostic systems, such as Xpert(®) MTB/RIF for tuberculosis (TB) diagnosis and drug susceptibility testing (DST), and programs that provide high-quality DOTS anti-tuberculosis treatment to patients in the unregulated private sector (public-private mix [PPM]), may help address these challenges, albeit at increased cost.We extended a microsimulation model of TB in India calibrated to demographic, epidemiologic, and care trends to evaluate 1) replacing DST with Xpert; 2) replacing microscopy and culture with Xpert to diagnose multidrug-resistant TB (MDR-TB) and non-MDR-TB; 3) implementing nationwide PPM; and combinations of (3) with (1) or (2).PPM (assuming costs of $38/person) and Xpert improved health and increase costs relative to the status quo. PPM alone or with Xpert cost <1 gross domestic product/capita per quality-adjusted life-year gained relative to the next best intervention, and dominated Xpert interventions excluding PPM.While both PPM and Xpert are promising tools for combatting TB in India, PPM should be prioritized over Xpert, as private sector engagement is more cost-effective than Xpert alone and, if sufficient resources are available, would substantially increase the value of Xpert if both interventions are implemented together.

  View details for DOI 10.5588/ijtld.15.0158

  View details for Web of Science ID 000359894400022

  View details for PubMedID 26260835

• Risk of Cardiovascular Events Associated With Current Exposure to HIV Antiretroviral Therapies in a US Veteran Population. Clinical infectious diseases Desai, M., Joyce, V., Bendavid, E., Olshen, R. A., Hlatky, M., Chow, A., Holodniy, M., Barnett, P., Owens, D. K. 2015; 61 (3): 445-452

  Abstract

   To characterize the association of antiretroviral drug combinations on risk of cardiovascular events. Certain antiretroviral medications for human immunodeficiency virus (HIV) have been implicated in increasing risk of cardiovascular disease. However, antiretroviral drugs are typically prescribed in combination. We characterized the association of current exposure to antiretroviral drug combinations on risk of cardiovascular events including myocardial infarction, stroke, percutaneous coronary intervention, and coronary artery bypass surgery. We used the Veterans Health Administration Clinical Case Registry to analyze data from 24 510 patients infected with HIV from January 1996 through December 2009. We assessed the association of current exposure to 15 antiretroviral drugs and 23 prespecified combinations of agents on the risk of cardiovascular event by using marginal structural models and Cox models extended to accommodate time-dependent variables. Over 164 059 person-years of follow-up, 934 patients had a cardiovascular event. Current exposure to abacavir, efavirenz, lamivudine, and zidovudine was significantly associated with increased risk of cardiovascular event, with odds ratios ranging from 1.40 to 1.53. Five combinations were significantly associated with increased risk of cardiovascular event, all of which involved lamivudine. One of these-efavirenz, lamivudine, and zidovudine-was the second most commonly used combination and was associated with a risk of cardiovascular event that is 1.60 times that of patients not currently exposed to the combination (odds ratio = 1.60, 95% confidence interval, 1.25-2.04). In the VA cohort, exposure to both individual drugs and drug combinations was associated with modestly increased risk of a cardiovascular event.

  View details for DOI 10.1093/cid/civ316

  View details for PubMedID 25908684

• Health Aid Is Allocated Efficiently, But Not Optimally: Insights From A Review Of Cost-Effectiveness Studies. Health affairs Bendavid, E., Duong, A., Sagan, C., Raikes, G. 2015; 34 (7): 1188-1195

  Abstract

  Development assistance from high-income countries to the health sectors of low- and middle-income countries (health aid) is an important source of funding for health in low- and middle-income countries. However, the relationship between health aid and the expected health improvements from those expenditures-the cost-effectiveness of targeted interventions-remains unknown. We reviewed the literature for cost-effectiveness of interventions targeting five disease categories: HIV; malaria; tuberculosis; noncommunicable diseases; and maternal, newborn, and child health. We measured the alignment between health aid and cost-effectiveness, and we examined the possibility of better alignment by simulating health aid reallocation. The relationship between health aid and incremental cost-effectiveness ratios is negative and significant: More health aid is going to disease categories with more cost-effective interventions. Changing the allocation of health aid earmarked funding could lead to greater health gains even without expanding overall disbursements. The greatest improvements in the alignment would be achieved by reallocating some aid from HIV or maternal, newborn, and child health to malaria or TB. We conclude that health aid is generally aligned with cost-effectiveness considerations, but in some countries this alignment could be improved.

  View details for DOI 10.1377/hlthaff.2015.0001

  View details for PubMedID 26153314

• International aid and natural disasters: a pre- and post-earthquake longitudinal study of the healthcare infrastructure in leogane, haiti. American journal of tropical medicine and hygiene Kligerman, M., Barry, M., Walmer, D., Bendavid, E. 2015; 92 (2): 448-453

  Abstract

  The reconstruction of healthcare systems in developing countries after natural disasters is poorly understood. Using data collected before and after the 2010 Haiti earthquake, we detail the response of aid agencies and their interaction with local healthcare providers in Leogane, the city closest to the epicenter. We find that the period after the earthquake was associated with an increase in the total number of healthcare facilities, inpatient beds, and surgical facilities and that international aid has been a driving force behind this recovery. Aid has funded 12 of 13 new healthcare facilities that have opened since the earthquake as well as the reconstruction of 7 of 8 healthcare facilities that have been rebuilt. Despite increases in free, aid-financed healthcare, private Haitian healthcare facilities have remained at a constant number. The planned phase-out of several aid-financed facilities, however, will leave Leogane with fewer inpatient beds and healthcare services compared with the pre-earthquake period.

  View details for DOI 10.4269/ajtmh.14-0379

  View details for PubMedID 25510716

  View details for PubMedCentralID PMC4347354

• Mortality changes after grants from the Global Fund to Fight AIDS, tuberculosis and malaria: an econometric analysis from 1995 to 2010. BMC public health Yan, I., Korenromp, E., Bendavid, E. 2015; 15 (1): 977-?

  Abstract

  Since its founding in 2002, the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) has become the dominant multilateral health financier in low- and middle-income countries. The health impact of the Global Fund remains unknown because existing evaluations measure intermediate outcomes or do not account for preexisting and counterfactual trends.We conducted an econometric analysis of data from all countries eligible to receive Global Fund grants from 1995 to 2010, prior to and during the Global Fund's activities. We analyzed three outcomes: all-cause adult (15-59 years), all-cause under-five, and malaria-specific under-five mortality. Our main exposure was a continuous longitudinal measure of Global Fund disbursements per capita. We used panel fixed effect regressions, and analyzed mortality trends controlling for health spending, health worker density (a measure of health system capacity), gross domestic product, urbanization, and country fixed-effects.We find that following Global Fund disbursements, adult mortality rate declined by 1.4 % per year faster with every $10 per capita increase in disbursements (p = 0.005). Similarly, malaria-specific under-five mortality declined by 6.9 % per year faster (p = 0.033) with every $10 high per capita Global Fund disbursements. However, we find no association between Global Fund support and all-cause under-five mortality. These findings were consistent after subanalyses by baseline HIV prevalence, adjusting for effects of concurrent health aid from other donors, and varying time lags between funding and mortality changes.Grants from the Global Fund are closely related to accelerated reductions in all-cause adult mortality and malaria-specific under-five mortality. However, up to 2010 the Global Fund has not measurably contributed to reducing all-cause under-five mortality.

  View details for DOI 10.1186/s12889-015-2305-1

  View details for PubMedID 26416543

  View details for PubMedCentralID PMC4587875

• Comparing Decisions for Malaria Testing and Presumptive Treatment: A Net Health Benefit Analysis MEDICAL DECISION MAKING Basu, S., Modrek, S., Bendavid, E. 2014; 34 (8): 996-1005

  Abstract

  Rapid tests for malaria are being distributed through vendors to individual patients, presenting the dilemma of determining how individuals are incentivized to pursue testing for malaria, versus the traditional approach of presumptively treating fevers with antimalarial drugs.We incorporated testing and treatment data from 6 African countries into a dynamic model of malaria transmission and nonmalarial causes of fever to investigate how variations in the epidemiologic risk of malaria and the prices of rapid diagnostic tests (RDTs) and treatments affect testing and treatment choices from the perspective of febrile patients, public health officials, and drug shop owners. In environments falling below a critical threshold infection rate (entomological inoculation rate) of 282 for patients older than 5 years (95% confidence interval [CI]: 275-289) or 300 for 0- to 5-year-olds (95% CI: 203-307), testing was more beneficial than presumptive therapy in terms of health and financial costs to patients. Infection and cost conditions generally aligned the best patient-level strategy with the best public health strategy to minimize an overall population's morbidity and mortality from both malaria and nonmalarial causes of fever. However, the infection and cost conditions of very high malaria transmission settings did not align patient interests or public health interests with the interests of private drug shop owners. In such settings, a further lowering of testing prices may realign the interests of all 3 parties.A threshold transmission rate exists under which malaria testing confers more health and financial benefits to patients than presumptive treatment. Studying local transmission rates and testing and treatment costs may facilitate an approach to align the interests of individual patients, public health officials, and distributors of tests and therapies.

  View details for DOI 10.1177/0272989X14533609

  View details for Web of Science ID 000344064400008

• Comparing decisions for malaria testing and presumptive treatment: a net health benefit analysis. Medical decision making Basu, S., Modrek, S., Bendavid, E. 2014; 34 (8): 996-1005

  Abstract

  Rapid tests for malaria are being distributed through vendors to individual patients, presenting the dilemma of determining how individuals are incentivized to pursue testing for malaria, versus the traditional approach of presumptively treating fevers with antimalarial drugs.We incorporated testing and treatment data from 6 African countries into a dynamic model of malaria transmission and nonmalarial causes of fever to investigate how variations in the epidemiologic risk of malaria and the prices of rapid diagnostic tests (RDTs) and treatments affect testing and treatment choices from the perspective of febrile patients, public health officials, and drug shop owners. In environments falling below a critical threshold infection rate (entomological inoculation rate) of 282 for patients older than 5 years (95% confidence interval [CI]: 275-289) or 300 for 0- to 5-year-olds (95% CI: 203-307), testing was more beneficial than presumptive therapy in terms of health and financial costs to patients. Infection and cost conditions generally aligned the best patient-level strategy with the best public health strategy to minimize an overall population's morbidity and mortality from both malaria and nonmalarial causes of fever. However, the infection and cost conditions of very high malaria transmission settings did not align patient interests or public health interests with the interests of private drug shop owners. In such settings, a further lowering of testing prices may realign the interests of all 3 parties.A threshold transmission rate exists under which malaria testing confers more health and financial benefits to patients than presumptive treatment. Studying local transmission rates and testing and treatment costs may facilitate an approach to align the interests of individual patients, public health officials, and distributors of tests and therapies.

  View details for DOI 10.1177/0272989X14533609

  View details for PubMedID 24829277

• Government health insurance for people below poverty line in India: quasi-experimental evaluation of insurance and health outcomes BMJ-BRITISH MEDICAL JOURNAL Sood, N., Bendavid, E., Mukherji, A., Wagner, Z., Nagpal, S., Mullen, P. 2014; 349

  Abstract

  To evaluate the effects of a government insurance program covering tertiary care for people below the poverty line in Karnataka, India, on out-of-pocket expenditures, hospital use, and mortality.Geographic regression discontinuity study.572 villages in Karnataka, India.31,476 households (22,796 below poverty line and 8680 above poverty line) in 300 villages where the scheme was implemented and 28,633 households (21,767 below poverty line and 6866 above poverty line) in 272 neighboring matched villages ineligible for the scheme.A government insurance program (Vajpayee Arogyashree scheme) that provided free tertiary care to households below the poverty line in about half of villages in Karnataka from February 2010 to August 2012.Out-of-pocket expenditures, hospital use, and mortality.Among households below the poverty line, the mortality rate from conditions potentially responsive to services covered by the scheme (mostly cardiac conditions and cancer) was 0.32% in households eligible for the scheme compared with 0.90% among ineligible households just south of the eligibility border (difference of 0.58 percentage points, 95% confidence interval 0.40 to 0.75; P<0.001). We found no difference in mortality rates for households above the poverty line (households above the poverty line were not eligible for the scheme), with a mortality rate from conditions covered by the scheme of 0.56% in eligible villages compared with 0.55% in ineligible villages (difference of 0.01 percentage points, -0.03 to 0.03; P=0.95). Eligible households had significantly reduced out-of-pocket health expenditures for admissions to hospitals with tertiary care facilities likely to be covered by the scheme (64% reduction, 35% to 97%; P<0.001). There was no significant increase in use of covered services, although the point estimate of a 44.2% increase approached significance (-5.1% to 90.5%; P=0.059). Both reductions in out-of-pocket expenditures and potential increases in use might have contributed to the observed reductions in mortality.Insuring poor households for efficacious but costly and underused health services significantly improves population health in India.

  View details for DOI 10.1136/bmj.g5114

  View details for Web of Science ID 000342426400001

  View details for PubMedCentralID PMC4161676

• Government health insurance for people below poverty line in India: quasi-experimental evaluation of insurance and health outcomes BMJ-BRITISH MEDICAL JOURNAL Sood, N., Bendavid, E., Mukherji, A., Wagner, Z., Nagpal, S., Mullen, P. 2014; 349

  View details for DOI 10.1136/bmj.g5114

  View details for Web of Science ID 000341691300001

• Population-level associations between antiretroviral therapy scale-up and all-cause mortality in South Africa INTERNATIONAL JOURNAL OF STD & AIDS Larson, E., Bendavid, E., Tuoane-Nkhasi, M., Mbengashe, T., Goldman, T., Wilson, M., Klausner, J. D. 2014; 25 (9): 636-642

  Abstract

  Our aim was to describe the association between increasing access to antiretroviral therapy and all-cause mortality in South Africa from 2005 to 2009. We undertook a longitudinal, population-level study, using antiretroviral monitoring data reported by PEPFAR implementing partners and province-level and national all-cause mortality records from Statistics South Africa (provider of official South African government statistics) to analyse the association between antiretroviral therapy and mortality. Using mixed effects models with a random intercept for province, we estimated the contemporaneous and lagging association between antiretroviral therapy and all-cause mortality in South Africa. We also conducted subgroup analyses and estimated the number of deaths averted. For each 100 HIV-infected individuals on antiretroviral therapy reported by PEPFAR implementing partners in South African treatment programmes, there was an associated 2.9 fewer deaths that year (95% CI: 1.5, 4.2) and 6.3 fewer deaths the following year (95% CI: 4.6, 8.0). The associated decrease in mortality the year after treatment reporting was seen in both adults and children, and men and women. Treatment provided from 2005 to 2008 was associated with 28,305 deaths averted from 2006 to 2009. The scale-up of antiretroviral therapy in South Africa was associated with a significant reduction in national all-cause mortality.

  View details for DOI 10.1177/0956462413515639

  View details for Web of Science ID 000339329600003

• Population-level associations between antiretroviral therapy scale-up and all-cause mortality in South Africa. International journal of STD & AIDS Larson, E., Bendavid, E., Tuoane-Nkhasi, M., Mbengashe, T., Goldman, T., Wilson, M., Klausner, J. D. 2014; 25 (9): 636-42

  Abstract

  Our aim was to describe the association between increasing access to antiretroviral therapy and all-cause mortality in South Africa from 2005 to 2009. We undertook a longitudinal, population-level study, using antiretroviral monitoring data reported by PEPFAR implementing partners and province-level and national all-cause mortality records from Statistics South Africa (provider of official South African government statistics) to analyse the association between antiretroviral therapy and mortality. Using mixed effects models with a random intercept for province, we estimated the contemporaneous and lagging association between antiretroviral therapy and all-cause mortality in South Africa. We also conducted subgroup analyses and estimated the number of deaths averted. For each 100 HIV-infected individuals on antiretroviral therapy reported by PEPFAR implementing partners in South African treatment programmes, there was an associated 2.9 fewer deaths that year (95% CI: 1.5, 4.2) and 6.3 fewer deaths the following year (95% CI: 4.6, 8.0). The associated decrease in mortality the year after treatment reporting was seen in both adults and children, and men and women. Treatment provided from 2005 to 2008 was associated with 28,305 deaths averted from 2006 to 2009. The scale-up of antiretroviral therapy in South Africa was associated with a significant reduction in national all-cause mortality.

  View details for DOI 10.1177/0956462413515639

  View details for PubMedID 24352117

• The relationship of health aid to population health improvements. JAMA internal medicine Bendavid, E., Bhattacharya, J. 2014; 174 (6): 881-887

  Abstract

  International aid to the health sector is an important component of all health spending in many developing countries. The relationship between health aid and changes in population health among aid recipients remains unknown.To quantify the relationship between health aid and changes in life expectancy and mortality in children younger than 5 years (under-5 mortality) among aid recipient nations.Cross-country panel data analysis of the relationship between measures of health aid, life expectancy, and under-5 mortality. Using difference models for longitudinal data with fixed effects for countries and years, we estimated the unique relationship between health aid and changes in life expectancy and under-5 mortality, controlling for gross domestic product per capita, urbanization, and total fertility rate.A total of 140 aid-recipient countries between 1974 and 2010.Annual amount of development assistance directed to the health sector in constant 2010 US dollars.Improvements in under-5 mortality and life expectancy in the period following aid receipt.Between 1974 and 2010, each 1% increase in health aid was associated with 0.24 months greater increase in life expectancy (95% CI, 0.02-0.46) (P = .03) and a 0.14 per 1000 live births faster decline in the probability of under-5 deaths per 1000 live births (95% CI, 0.02-0.26) (P = .02). The association between health aid and health improvements has strengthened over time, with the closest association occurring between 2000 and 2010. Health improvements associated with health aid are measurable for 3 to 5 years after aid disbursement. These findings imply that an increase of $1 billion in health aid could be associated with 364,800 fewer under-5 deaths (95% CI, 98,400-630,000).International aid to the health sector is related to increasing life expectancy and declining under-5 mortality. The benefits from aid appear to last for several years and have been greatest between 2000 and 2010, possibly because of improving health technologies or effective targeting of aid.

  View details for DOI 10.1001/jamainternmed.2014.292

  View details for PubMedID 24756557

• The relationship of health aid to population health improvements. JAMA internal medicine Bendavid, E., Bhattacharya, J. 2014; 174 (6): 881-887

  Abstract

  International aid to the health sector is an important component of all health spending in many developing countries. The relationship between health aid and changes in population health among aid recipients remains unknown.To quantify the relationship between health aid and changes in life expectancy and mortality in children younger than 5 years (under-5 mortality) among aid recipient nations.Cross-country panel data analysis of the relationship between measures of health aid, life expectancy, and under-5 mortality. Using difference models for longitudinal data with fixed effects for countries and years, we estimated the unique relationship between health aid and changes in life expectancy and under-5 mortality, controlling for gross domestic product per capita, urbanization, and total fertility rate.A total of 140 aid-recipient countries between 1974 and 2010.Annual amount of development assistance directed to the health sector in constant 2010 US dollars.Improvements in under-5 mortality and life expectancy in the period following aid receipt.Between 1974 and 2010, each 1% increase in health aid was associated with 0.24 months greater increase in life expectancy (95% CI, 0.02-0.46) (P = .03) and a 0.14 per 1000 live births faster decline in the probability of under-5 deaths per 1000 live births (95% CI, 0.02-0.26) (P = .02). The association between health aid and health improvements has strengthened over time, with the closest association occurring between 2000 and 2010. Health improvements associated with health aid are measurable for 3 to 5 years after aid disbursement. These findings imply that an increase of $1 billion in health aid could be associated with 364,800 fewer under-5 deaths (95% CI, 98,400-630,000).International aid to the health sector is related to increasing life expectancy and declining under-5 mortality. The benefits from aid appear to last for several years and have been greatest between 2000 and 2010, possibly because of improving health technologies or effective targeting of aid.

  View details for DOI 10.1001/jamainternmed.2014.292

  View details for PubMedID 24756557

• Is Health Aid Reaching the Poor? Analysis of Household Data from Aid Recipient Countries PLOS ONE Bendavid, E. 2014; 9 (1)

  Abstract

  To determine the extent to which the narrowing of child mortality across wealth gradients has been related to foreign aid to the health sector in low- and middle-income countries.Mortality and wealth data on 989,901 under-5 children from 957,674 households in 49 aid recipient countries in Africa, Asia, South America, and the Caribbean between 1993 and 2012 were used in the analysis. Declines in under-5 mortality in the four poorest wealth quantiles were compared to the decline among the wealthiest at varying levels of health aid per capita using fixed effects multivariable regression models and controlling for maternal education, urbanization, and domestic spending on health among recipient countries.Each additional dollar in total health aid per capita was associated with 5.7 fewer deaths per 10,000 child-years among children in the poorest relative to the wealthiest households (p<0.001). This was also true when measured in percent declines (1.90% faster decline in under-5 mortality among the poorest compared with the wealthiest with each dollar in total health aid, p = 0.008). The association was stronger when using health aid specifically for malaria than total health aid, 12.60% faster decline among the poorest compared with the wealthiest with each dollar in malaria aid, p = 0.001.Foreign aid to the health sector is preferentially related to reductions in under-5 mortality among the poorest compared with the wealthiest. Health aid addressing malaria, which imposes a disproportionate burden among the poor, may explain the observed effect.

  View details for DOI 10.1371/journal.pone.0084025

  View details for Web of Science ID 000329460800027

  View details for PubMedID 24404148

  View details for PubMedCentralID PMC3880283

• Disease control implications of India's changing multi-drug resistant tuberculosis epidemic. PloS one Suen, S., Bendavid, E., Goldhaber-Fiebert, J. D. 2014; 9 (3)

  Abstract

  Multi-drug resistant tuberculosis (MDR TB) is a major health challenge in India that is gaining increasing public attention, but the implications of India's evolving MDR TB epidemic are poorly understood. As India's MDR TB epidemic is transitioning from a treatment-generated to transmission-generated epidemic, we sought to evaluate the potential effectiveness of the following two disease control strategies on reducing the prevalence of MDR TB: a) improving treatment of non-MDR TB; b) shortening the infectious period between the activation of MDR TB and initiation of effective MDR treatment.We developed a dynamic transmission microsimulation model of TB in India. The model followed individuals by age, sex, TB status, drug resistance status, and treatment status and was calibrated to Indian demographic and epidemiologic TB time trends. The main effectiveness measure was reduction in the average prevalence reduction of MDR TB over the ten years after control strategy implementation. We find that improving non-MDR cure rates to avoid generating new MDR cases will provide substantial non-MDR TB benefits but will become less effective in reducing MDR TB prevalence over time because more cases will occur from direct transmission - by 2015, the model estimates 42% of new MDR cases are transmission-generated and this proportion continues to rise over time, assuming equal transmissibility of MDR and drug-susceptible TB. Strategies that disrupt MDR transmission by shortening the time between MDR activation and treatment are projected to provide greater reductions in MDR prevalence compared with improving non-MDR treatment quality: implementing MDR diagnostic improvements in 2017 is expected to reduce MDR prevalence by 39%, compared with 11% reduction from improving non-MDR treatment quality.As transmission-generated MDR TB becomes a larger driver of the MDR TB epidemic in India, rapid and accurate MDR TB diagnosis and treatment will become increasingly effective in reducing MDR TB cases compared to non-MDR TB treatment improvements.

  View details for DOI 10.1371/journal.pone.0089822

  View details for PubMedID 24608234

  View details for PubMedCentralID PMC3946521

• Government health insurance for people below poverty line in India: quasi-experimental evaluation of insurance and health outcomes. BMJ (Clinical research ed.) Sood, N., Bendavid, E., Mukherji, A., Wagner, Z., Nagpal, S., Mullen, P. 2014; 349: g5114-?

  Abstract

  To evaluate the effects of a government insurance program covering tertiary care for people below the poverty line in Karnataka, India, on out-of-pocket expenditures, hospital use, and mortality.Geographic regression discontinuity study.572 villages in Karnataka, India.31,476 households (22,796 below poverty line and 8680 above poverty line) in 300 villages where the scheme was implemented and 28,633 households (21,767 below poverty line and 6866 above poverty line) in 272 neighboring matched villages ineligible for the scheme.A government insurance program (Vajpayee Arogyashree scheme) that provided free tertiary care to households below the poverty line in about half of villages in Karnataka from February 2010 to August 2012.Out-of-pocket expenditures, hospital use, and mortality.Among households below the poverty line, the mortality rate from conditions potentially responsive to services covered by the scheme (mostly cardiac conditions and cancer) was 0.32% in households eligible for the scheme compared with 0.90% among ineligible households just south of the eligibility border (difference of 0.58 percentage points, 95% confidence interval 0.40 to 0.75; P<0.001). We found no difference in mortality rates for households above the poverty line (households above the poverty line were not eligible for the scheme), with a mortality rate from conditions covered by the scheme of 0.56% in eligible villages compared with 0.55% in ineligible villages (difference of 0.01 percentage points, -0.03 to 0.03; P=0.95). Eligible households had significantly reduced out-of-pocket health expenditures for admissions to hospitals with tertiary care facilities likely to be covered by the scheme (64% reduction, 35% to 97%; P<0.001). There was no significant increase in use of covered services, although the point estimate of a 44.2% increase approached significance (-5.1% to 90.5%; P=0.059). Both reductions in out-of-pocket expenditures and potential increases in use might have contributed to the observed reductions in mortality.Insuring poor households for efficacious but costly and underused health services significantly improves population health in India.

  View details for DOI 10.1136/bmj.g5114

  View details for PubMedID 25214509

• Comparative effectiveness and cost-effectiveness of antiretroviral therapy and pre-exposure prophylaxis for HIV prevention in South Africa. BMC medicine Alistar, S. S., Grant, P. M., Bendavid, E. 2014; 12: 46-?

  Abstract

  Antiretroviral therapy (ART) and oral pre-exposure prophylaxis (PrEP) are effective in reducing HIV transmission in heterosexual adults. The epidemiologic impact and cost-effectiveness of combined prevention approaches in resource-limited settings remain unclear.We develop a dynamic mathematical model of the HIV epidemic in South Africa's adult population. We assume ART reduces HIV transmission by 95% and PrEP by 60%. We model two ART strategies: scaling up access for those with CD4 counts ≤ 350 cells/μL (Guidelines) and for all identified HIV-infected individuals (Universal). PrEP strategies include use in the general population (General) and in high-risk individuals (Focused). We consider strategies where ART, PrEP, or both are scaled up to 100% of remaining eligible individuals yearly. We measure infections averted, quality-adjusted life-years (QALYs) gained and incremental cost-effectiveness ratios over 20 years.Scaling up ART to 50% of eligible individuals averts 1,513,000 infections over 20 years (Guidelines) and 3,591,000 infections (Universal). Universal ART is the most cost-effective strategy at any scale ($160-$220/QALY versus comparable scale Guidelines ART expansion). General PrEP is costly and provides limited benefits beyond ART scale-up ($7,680/QALY to add 100% PrEP to 50% Universal ART). Cost-effectiveness of General PrEP becomes less favorable when ART is widely given ($12,640/QALY gained when added to 100% Universal ART). If feasible, Focused PrEP is cost saving or highly cost effective versus status quo and when added to ART strategies.Expanded ART coverage to individuals in early disease stages may be more cost-effective than current guidelines. PrEP can be cost-saving if delivered to individuals at increased risk of infection.

  View details for DOI 10.1186/1741-7015-12-46

  View details for PubMedID 24629217

• Disease Control Implications of India's Changing Multi-Drug Resistant Tuberculosis Epidemic. PloS one Suen, S., Bendavid, E., Goldhaber-Fiebert, J. D. 2014; 9 (3)

  View details for DOI 10.1371/journal.pone.0089822

  View details for PubMedID 24608234

• Comparative effectiveness and cost-effectiveness of antiretroviral therapy and pre-exposure prophylaxis for HIV prevention in South Africa. BMC medicine Alistar, S. S., Grant, P. M., Bendavid, E. 2014; 12: 46-?

  Abstract

  Antiretroviral therapy (ART) and oral pre-exposure prophylaxis (PrEP) are effective in reducing HIV transmission in heterosexual adults. The epidemiologic impact and cost-effectiveness of combined prevention approaches in resource-limited settings remain unclear.We develop a dynamic mathematical model of the HIV epidemic in South Africa's adult population. We assume ART reduces HIV transmission by 95% and PrEP by 60%. We model two ART strategies: scaling up access for those with CD4 counts ≤ 350 cells/μL (Guidelines) and for all identified HIV-infected individuals (Universal). PrEP strategies include use in the general population (General) and in high-risk individuals (Focused). We consider strategies where ART, PrEP, or both are scaled up to 100% of remaining eligible individuals yearly. We measure infections averted, quality-adjusted life-years (QALYs) gained and incremental cost-effectiveness ratios over 20 years.Scaling up ART to 50% of eligible individuals averts 1,513,000 infections over 20 years (Guidelines) and 3,591,000 infections (Universal). Universal ART is the most cost-effective strategy at any scale ($160-$220/QALY versus comparable scale Guidelines ART expansion). General PrEP is costly and provides limited benefits beyond ART scale-up ($7,680/QALY to add 100% PrEP to 50% Universal ART). Cost-effectiveness of General PrEP becomes less favorable when ART is widely given ($12,640/QALY gained when added to 100% Universal ART). If feasible, Focused PrEP is cost saving or highly cost effective versus status quo and when added to ART strategies.Expanded ART coverage to individuals in early disease stages may be more cost-effective than current guidelines. PrEP can be cost-saving if delivered to individuals at increased risk of infection.

  View details for DOI 10.1186/1741-7015-12-46

  View details for PubMedID 24629217

• Risk of Cardiovascular Disease from Antiretroviral Therapy for HIV: A Systematic Review PLOS ONE Bavinger, C., Bendavid, E., Niehaus, K., Olshen, R. A., Olkin, I., Sundaram, V., Wein, N., Holodniy, M., Hou, N., Owens, D. K., Desai, M. 2013; 8 (3)

  Abstract

  Recent studies suggest certain antiretroviral therapy (ART) drugs are associated with increases in cardiovascular disease.We performed a systematic review and meta-analysis to summarize the available evidence, with the goal of elucidating whether specific ART drugs are associated with an increased risk of myocardial infarction (MI).We searched Medline, Web of Science, the Cochrane Library, and abstract archives from the Conference on Retroviruses and Opportunistic Infections and International AIDS Society up to June 2011 to identify published articles and abstracts.Eligible studies were comparative and included MI, strokes, or other cardiovascular events as outcomes.Eligibility screening, data extraction, and quality assessment were performed independently by two investigators.Random effects methods and Fisher's combined probability test were used to summarize evidence.Twenty-seven studies met inclusion criteria, with 8 contributing to a formal meta-analysis. Findings based on two observational studies indicated an increase in risk of MI for patients recently exposed (usually defined as within last 6 months) to abacavir (RR 1.92, 95% CI 1.51-2.42) and protease inhibitors (PI) (RR 2.13, 95% CI 1.06-4.28). Our analysis also suggested an increased risk associated with each additional year of exposure to indinavir (RR 1.11, 95% CI 1.05-1.17) and lopinavir (RR 1.22, 95% CI 1.01-1.47). Our findings of increased cardiovascular risk from abacavir and PIs were in contrast to four published meta-analyses based on secondary analyses of randomized controlled trials, which found no increased risk from cardiovascular disease.Although observational studies implicated specific drugs, the evidence is mixed. Further, meta-analyses of randomized trials did not find increased risk from abacavir and PIs. Our findings that implicate specific ARTs in the observational setting provide sufficient evidence to warrant further investigation of this relationship in studies designed for that purpose.

  View details for DOI 10.1371/journal.pone.0059551

  View details for Web of Science ID 000317418500051

  View details for PubMedID 23555704

  View details for PubMedCentralID PMC3608726

• Risk of cardiovascular disease from antiretroviral therapy for HIV: a systematic review. PloS one Bavinger, C., Bendavid, E., Niehaus, K., Olshen, R. A., Olkin, I., Sundaram, V., Wein, N., Holodniy, M., Hou, N., Owens, D. K., Desai, M. 2013; 8 (3)

  Abstract

  Recent studies suggest certain antiretroviral therapy (ART) drugs are associated with increases in cardiovascular disease.We performed a systematic review and meta-analysis to summarize the available evidence, with the goal of elucidating whether specific ART drugs are associated with an increased risk of myocardial infarction (MI).We searched Medline, Web of Science, the Cochrane Library, and abstract archives from the Conference on Retroviruses and Opportunistic Infections and International AIDS Society up to June 2011 to identify published articles and abstracts.Eligible studies were comparative and included MI, strokes, or other cardiovascular events as outcomes.Eligibility screening, data extraction, and quality assessment were performed independently by two investigators.Random effects methods and Fisher's combined probability test were used to summarize evidence.Twenty-seven studies met inclusion criteria, with 8 contributing to a formal meta-analysis. Findings based on two observational studies indicated an increase in risk of MI for patients recently exposed (usually defined as within last 6 months) to abacavir (RR 1.92, 95% CI 1.51-2.42) and protease inhibitors (PI) (RR 2.13, 95% CI 1.06-4.28). Our analysis also suggested an increased risk associated with each additional year of exposure to indinavir (RR 1.11, 95% CI 1.05-1.17) and lopinavir (RR 1.22, 95% CI 1.01-1.47). Our findings of increased cardiovascular risk from abacavir and PIs were in contrast to four published meta-analyses based on secondary analyses of randomized controlled trials, which found no increased risk from cardiovascular disease.Although observational studies implicated specific drugs, the evidence is mixed. Further, meta-analyses of randomized trials did not find increased risk from abacavir and PIs. Our findings that implicate specific ARTs in the observational setting provide sufficient evidence to warrant further investigation of this relationship in studies designed for that purpose.

  View details for DOI 10.1371/journal.pone.0059551

  View details for PubMedID 23555704

  View details for PubMedCentralID PMC3608726

• Considerations in assessing the evidence and implications of aid displacement from the health sector. PLoS medicine Batniji, R., Bendavid, E. 2013; 10 (1)

  View details for DOI 10.1371/journal.pmed.1001364

  View details for PubMedID 23319893

  View details for PubMedCentralID PMC3539939

• Performance of serum biomarkers for the early detection of invasive aspergillosis in febrile, neutropenic patients: a multi-state model. PloS one Schwarzinger, M., Sagaon-Teyssier, L., Cabaret, O., Bretagne, S., Cordonnier, C., Pautas, C., Maury, S., Hicheri, Y., Botterel, F., Foulet, F., Vekhoff, A., Chaoui, D., Cornet, M., Agnamey, P., Farhat, H., Castaigne, S., Eloy, O., Suarez, F., Buzyn, A., Delarue, R., Challier, S., Dhedin, N., Aljijakli, A., Delabesse, E., Datry, A., Isnard, F., Fouillard, L., Poirot, J., Meliani, L., Adès, L., Bouges-Michel, C., Deniau, M., Kuhnowski, F., Dreyfus, F., Paugam, A., Baixench, M., Leclercq, R., Reman, O., Duhamel, C., Bourrhis, J., Chehata, S., Chachati, I., Foissaud, V., Macnab, C., Tilly, H., Leprêtre, S., Gray, C., Raffoux, E., Lacroix, C., Goldhaber-Fiebert, J. D., Bendavid, E., Farley, B. J. 2013; 8 (6)

  Abstract

  The performance of serum biomarkers for the early detection of invasive aspergillosis expectedly depends on the timing of test results relative to the empirical administration of antifungal therapy during neutropenia, although a dynamic evaluation framework is lacking.We developed a multi-state model describing simultaneously the likelihood of empirical antifungal therapy and the risk of invasive aspergillosis during neutropenia. We evaluated whether the first positive test result with a biomarker is an independent predictor of invasive aspergillosis when both diagnostic information used to treat and risk factors of developing invasive aspergillosis are taken into account over time. We applied the multi-state model to a homogeneous cohort of 185 high-risk patients with acute myeloid leukemia. Patients were prospectively screened for galactomannan antigenemia twice a week for immediate treatment decision; 2,214 serum samples were collected on the same days and blindly assessed for (1->3)- β-D-glucan antigenemia and a quantitative PCR assay targeting a mitochondrial locus.The usual evaluation framework of biomarker performance was unable to distinguish clinical benefits of β-glucan or PCR assays. The multi-state model evidenced that the risk of invasive aspergillosis is a complex time function of neutropenia duration and risk management. The quantitative PCR assay accelerated the early detection of invasive aspergillosis (P = .010), independently of other diagnostic information used to treat, while β-glucan assay did not (P = .53).The performance of serum biomarkers for the early detection of invasive aspergillosis is better apprehended by the evaluation of time-varying predictors in a multi-state model. Our results provide strong rationale for prospective studies testing a preemptive antifungal therapy, guided by clinical, radiological, and bi-weekly blood screening with galactomannan antigenemia and a standardized quantitative PCR assay.

  View details for DOI 10.1371/journal.pone.0065776

  View details for PubMedID 23799048

  View details for PubMedCentralID PMC3683047

• Balancing Immunological Benefits and Cardiovascular Risks of Antiretroviral Therapy: When Is Immediate Treatment Optimal? CLINICAL INFECTIOUS DISEASES Negoescu, D. M., Owens, D. K., Brandeau, M. L., Bendavid, E. 2012; 55 (10): 1392-1399

  Abstract

  We developed a mathematical model to identify the timing of antiretroviral therapy (ART) initiation that optimizes patient outcomes as a function of patient CD4 count, age, cardiac mortality risk, sex, and personal preferences. Our goal was to find the conditions that maximize patient quality-adjusted life expectancy (QALE) in the context of our model. Under the assumption that ART confers disease progression and mortality benefits at any CD4 count, immediate treatment initiation yields the greatest remaining QALE for young patients under most circumstances. The timing of ART initiation depends on the magnitude of benefit from ART at high CD4 counts, the magnitude of increases in cardiac risk, and patients' preferences. If ART reduces HIV progression at high CD4 counts, immediate ART is preferable for most newly infected individuals <35 years even if ART doubles age- and sex-specific cardiac risk.

  View details for DOI 10.1093/cid/cis731

  View details for PubMedID 22942203

• Cost Effectiveness of Screening Strategies for Early Identification of HIV and HCV Infection in Injection Drug Users PLOS ONE Cipriano, L. E., Zaric, G. S., Holodniy, M., Bendavid, E., Owens, D. K., Brandeau, M. L. 2012; 7 (9)

  Abstract

  To estimate the cost, effectiveness, and cost effectiveness of HIV and HCV screening of injection drug users (IDUs) in opioid replacement therapy (ORT).Dynamic compartmental model of HIV and HCV in a population of IDUs and non-IDUs for a representative U.S. urban center with 2.5 million adults (age 15-59).We considered strategies of screening individuals in ORT for HIV, HCV, or both infections by antibody or antibody and viral RNA testing. We evaluated one-time and repeat screening at intervals from annually to once every 3 months. We calculated the number of HIV and HCV infections, quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs).Adding HIV and HCV viral RNA testing to antibody testing averts 14.8-30.3 HIV and 3.7-7.7 HCV infections in a screened population of 26,100 IDUs entering ORT over 20 years, depending on screening frequency. Screening for HIV antibodies every 6 months costs $30,700/QALY gained. Screening for HIV antibodies and viral RNA every 6 months has an ICER of $65,900/QALY gained. Strategies including HCV testing have ICERs exceeding $100,000/QALY gained unless awareness of HCV-infection status results in a substantial reduction in needle-sharing behavior.Although annual screening for antibodies to HIV and HCV is modestly cost effective compared to no screening, more frequent screening for HIV provides additional benefit at less cost. Screening individuals in ORT every 3-6 months for HIV infection using both antibody and viral RNA technologies and initiating ART for acute HIV infection appears cost effective.

  View details for DOI 10.1371/journal.pone.0045176

  View details for PubMedID 23028828

• PEPFAR and Adult Mortality Reply JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Bendavid, E., Holmes, C. B., Miller, G. 2012; 308 (10): 972–73

  View details for DOI 10.1001/jama.2012.9249

  View details for Web of Science ID 000308579300014

• Characteristics of US Emergency Departments That Offer Routine Human Immunodeficiency Virus Screening ACADEMIC EMERGENCY MEDICINE Berg, L. J., Delgado, M. K., Ginde, A. A., Montoy, J. C., Bendavid, E., Camargo, C. A. 2012; 19 (8): 894-900

  Abstract

  The association between emergency department (ED) characteristics, ED director's perceptions of preventive services, and the availability of human immunodeficiency virus (HIV) screening are unknown. The authors hypothesized that, after adjusting for ED operational and demographic characteristics, teaching hospital status would be associated with increased availability, and ED crowding and ED director agreement with barriers to screening would be associated with decreased availability.This was a secondary, cross-sectional analysis on previously collected data from 2008 to 2009 regarding availability of ED preventive services. Data were obtained from a random sample of 277 EDs in which ED directors provided information on ED characteristics and availability of HIV screening and rated five barriers to providing preventive services. The association between the availability of HIV screening and teaching hospital and crowding status, ED volume, urban-rural location, ownership, geographic region, patient demographics, state HIV testing consent laws, and ED director opinions on barriers to providing preventive services were determined in univariate analyses and a multivariate logistic regression model.Nineteen percent of the sampled EDs offer HIV screening. Teaching hospitals offer HIV screening more frequently than nonteaching hospitals (38% vs. 18%; p = 0.03), but after adjusting for other characteristics in a multivariate model, this association was not significant (relative risk ratio [RR] = 2.07, 95% confidence interval [CI] = 0.91 to 3.59). ED crowding also was not significantly associated with screening availability (RR = 0.66, 95% CI = 0.34 to 1.21). However, public ownership (RR = 2.13, 95% CI = 1.28 to 3.14), 24-hour social work (RR = 1.87, 95% CI = 1.02 to 2.99), uninsured population ≥35% (RR = 2.48, 95% CI = 1.39 to 3.69), increased local nonwhite minority population percentage (RR = 1.14 per 10%, 95% CI = 1.02 to 1.26), and state laws allowing opt-out consent for testing (RR = 1.76, 95% CI = 1.01 to 2.74) were associated with increased availability of screening in multivariable analysis. EDs whose directors were concerned about added costs were associated with decreased availability of screening (RR = 0.45, 95% CI = 0.23 to 0.85).After adjusting for other ED operational and demographic characteristics, ED crowding and teaching hospital affiliation were not independently associated with the availability of HIV screening. EDs whose directors were concerned about the cost of preventive services were less likely to provide routine HIV screening. Addressing ED director's concerns about the added costs of ED preventive services, increasing social work availability, and implementing testing laws consistent with Centers for Disease Control and Prevention (CDC) recommendations may facilitate increased adoption of ED HIV screening.

  View details for DOI 10.1111/j.1553-2712.2012.01401.x

  View details for Web of Science ID 000307772300001

  View details for PubMedID 22849642

• HIV and Africa's elderly: the problems and possibilities. AIDS Bendavid, E., Ford, N., Mills, E. J. 2012; 26: S85-91

  Abstract

  Demographic changes and the increasing availability and coverage of antiretroviral therapy imply that the burden of HIV is shifting to older age groups in sub-Saharan Africa. However, very little is known about the burden of disease and the unique considerations required to adequately treat and retain older Africans. In this review, we summarize the epidemiological data on HIV prevalence among older Africans, and review progress and barriers to accessing treatment and care. The unique clinical considerations distinguishing the management of older HIV-infected Africans are summarized, with a focus on cardiovascular disease, neuropsychiatric conditions, oncologic illness, and musculoskeletal morbidity. The review concludes by suggesting opportunities for improving our knowledge about and management of HIV among older Africans, including prevention opportunities and potential technologies, including a polypill for reducing comorbidity in this under-recognized highly vulnerable group.

  View details for PubMedID 22781181

• HIV Treatment as Prevention: Systematic Comparison of Mathematical Models of the Potential Impact of Antiretroviral Therapy on HIV Incidence in South Africa PLOS MEDICINE Eaton, J. W., Johnson, L. F., Salomon, J. A., Baernighausen, T., Bendavid, E., Bershteyn, A., Bloom, D. E., Cambiano, V., Fraser, C., Hontelez, J. A., Humair, S., Klein, D. J., Long, E. F., Phillips, A. N., Pretorius, C., Stover, J., Wenger, E. A., Williams, B. G., Hallett, T. B. 2012; 9 (7)

  Abstract

  Many mathematical models have investigated the impact of expanding access to antiretroviral therapy (ART) on new HIV infections. Comparing results and conclusions across models is challenging because models have addressed slightly different questions and have reported different outcome metrics. This study compares the predictions of several mathematical models simulating the same ART intervention programmes to determine the extent to which models agree about the epidemiological impact of expanded ART.Twelve independent mathematical models evaluated a set of standardised ART intervention scenarios in South Africa and reported a common set of outputs. Intervention scenarios systematically varied the CD4 count threshold for treatment eligibility, access to treatment, and programme retention. For a scenario in which 80% of HIV-infected individuals start treatment on average 1 y after their CD4 count drops below 350 cells/µl and 85% remain on treatment after 3 y, the models projected that HIV incidence would be 35% to 54% lower 8 y after the introduction of ART, compared to a counterfactual scenario in which there is no ART. More variation existed in the estimated long-term (38 y) reductions in incidence. The impact of optimistic interventions including immediate ART initiation varied widely across models, maintaining substantial uncertainty about the theoretical prospect for elimination of HIV from the population using ART alone over the next four decades. The number of person-years of ART per infection averted over 8 y ranged between 5.8 and 18.7. Considering the actual scale-up of ART in South Africa, seven models estimated that current HIV incidence is 17% to 32% lower than it would have been in the absence of ART. Differences between model assumptions about CD4 decline and HIV transmissibility over the course of infection explained only a modest amount of the variation in model results.Mathematical models evaluating the impact of ART vary substantially in structure, complexity, and parameter choices, but all suggest that ART, at high levels of access and with high adherence, has the potential to substantially reduce new HIV infections. There was broad agreement regarding the short-term epidemiologic impact of ambitious treatment scale-up, but more variation in longer term projections and in the efficiency with which treatment can reduce new infections. Differences between model predictions could not be explained by differences in model structure or parameterization that were hypothesized to affect intervention impact.

  View details for DOI 10.1371/journal.pmed.1001245

  View details for Web of Science ID 000307106400005

  View details for PubMedCentralID PMC3393664

• HIV Development Assistance and Adult Mortality in Africa JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Bendavid, E., Holmes, C. B., Bhattacharya, J., Miller, G. 2012; 307 (19): 2060-2067

  Abstract

  The effect of global health initiatives on population health is uncertain. Between 2003 and 2008, the US President's Emergency Plan for AIDS Relief (PEPFAR), the largest initiative ever devoted to a single disease, operated intensively in 12 African focus countries. The initiative's effect on all-cause adult mortality is unknown.To determine whether PEPFAR was associated with relative changes in adult mortality in the countries and districts where it operated most intensively.Using person-level data from the Demographic and Health Surveys, we conducted cross-country and within-country analyses of adult mortality (annual probability of death per 1000 adults between 15 and 59 years old) and PEPFAR's activities. Across countries, we compared adult mortality in 9 African focus countries (Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, Tanzania, Uganda, and Zambia) with 18 African nonfocus countries from 1998 to 2008. We performed subnational analyses using information on PEPFAR's programmatic intensity in Tanzania and Rwanda. We employed difference-in-difference analyses with fixed effects for countries and years as well as personal and time-varying area characteristics.Adult all-cause mortality.We analyzed information on 1 538 612 adults, including 60 303 deaths, from 41 surveys in 27 countries, 9 of them focus countries. In 2003, age-adjusted adult mortality was 8.3 per 1000 adults in the focus countries (95% CI, 8.0-8.6) and 8.5 per 1000 adults (95% CI, 8.3-8.7) in the nonfocus countries. In 2008, mortality was 4.1 per 1000 (95% CI, 3.6-4.6) in the focus countries and 6.9 per 1000 (95% CI, 6.3-7.5) in the nonfocus countries. The adjusted odds ratio of mortality among adults living in focus countries compared with nonfocus countries between 2004 and 2008 was 0.84 (95% CI, 0.72-0.99; P = .03). Within Tanzania and Rwanda, the adjusted odds ratio of mortality for adults living in districts where PEPFAR operated more intensively was 0.83 (95% CI, 0.72-0.97; P = .02) and 0.75 (95% CI, 0.56-0.99; P = .04), respectively, compared with districts where it operated less intensively.Between 2004 and 2008, all-cause adult mortality declined more in PEPFAR focus countries relative to nonfocus countries. It was not possible to determine whether PEPFAR was associated with mortality effects separate from reductions in HIV-specific deaths.

  View details for Web of Science ID 000304048200025

  View details for PubMedID 22665105

• The Cost-Effectiveness of Preexposure Prophylaxis for HIV Prevention in the United States in Men Who Have Sex With Men ANNALS OF INTERNAL MEDICINE Juusola, J. L., Brandeau, M. L., Owens, D. K., Bendavid, E. 2012; 156 (8): 541-U144

  Abstract

  A recent randomized, controlled trial showed that daily oral preexposure chemoprophylaxis (PrEP) was effective for HIV prevention in men who have sex with men (MSM). The Centers for Disease Control and Prevention recently provided interim guidance for PrEP in MSM at high risk for HIV. Previous studies did not reach a consistent estimate of its cost-effectiveness.To estimate the effectiveness and cost-effectiveness of PrEP in MSM in the United States.Dynamic model of HIV transmission and progression combined with a detailed economic analysis.Published literature.MSM aged 13 to 64 years in the United States.Lifetime.Societal.PrEP was evaluated in both the general MSM population and in high-risk MSM and was assumed to reduce infection risk by 44% on the basis of clinical trial results.New HIV infections, discounted quality-adjusted life-years (QALYs) and costs, and incremental cost-effectiveness ratios.Initiating PrEP in 20% of MSM in the United States would reduce new HIV infections by an estimated 13% and result in a gain of 550,166 QALYs over 20 years at a cost of $172,091 per QALY gained. Initiating PrEP in a larger proportion of MSM would prevent more infections but at an increasing cost per QALY gained (up to $216,480 if all MSM receive PrEP). Preexposure chemoprophylaxis in only high-risk MSM can improve cost-effectiveness. For MSM with an average of 5 partners per year, PrEP costs approximately $50,000 per QALY gained. Providing PrEP to all high-risk MSM for 20 years would cost $75 billion more in health care-related costs than the status quo and $600,000 per HIV infection prevented, compared with incremental costs of $95 billion and $2 million per infection prevented for 20% coverage of all MSM.PrEP in the general MSM population would cost less than $100,000 per QALY gained if the daily cost of antiretroviral drugs for PrEP was less than $15 or if PrEP efficacy was greater than 75%.When examining PrEP in high-risk MSM, the investigators did not model a mix of low- and high-risk MSM because of lack of data on mixing patterns.PrEP in the general MSM population could prevent a substantial number of HIV infections, but it is expensive. Use in high-risk MSM compares favorably with other interventions that are considered cost-effective but could result in annual PrEP expenditures of more than $4 billion.National Institute on Drug Abuse, Department of Veterans Affairs, and National Institute of Allergy and Infectious Diseases.

  View details for DOI 10.1059/0003-4819-156-8-201204170-00001

  View details for PubMedID 22508731

• HIV treatment as prevention: systematic comparison of mathematical models of the potential impact of antiretroviral therapy on HIV incidence in South Africa. PLoS medicine Eaton, J. W., Johnson, L. F., Salomon, J. A., Bärnighausen, T., Bendavid, E., Bershteyn, A., Bloom, D. E., Cambiano, V., Fraser, C., Hontelez, J. A., Humair, S., Klein, D. J., Long, E. F., Phillips, A. N., Pretorius, C., Stover, J., Wenger, E. A., Williams, B. G., Hallett, T. B. 2012; 9 (7)

  Abstract

  Many mathematical models have investigated the impact of expanding access to antiretroviral therapy (ART) on new HIV infections. Comparing results and conclusions across models is challenging because models have addressed slightly different questions and have reported different outcome metrics. This study compares the predictions of several mathematical models simulating the same ART intervention programmes to determine the extent to which models agree about the epidemiological impact of expanded ART.Twelve independent mathematical models evaluated a set of standardised ART intervention scenarios in South Africa and reported a common set of outputs. Intervention scenarios systematically varied the CD4 count threshold for treatment eligibility, access to treatment, and programme retention. For a scenario in which 80% of HIV-infected individuals start treatment on average 1 y after their CD4 count drops below 350 cells/µl and 85% remain on treatment after 3 y, the models projected that HIV incidence would be 35% to 54% lower 8 y after the introduction of ART, compared to a counterfactual scenario in which there is no ART. More variation existed in the estimated long-term (38 y) reductions in incidence. The impact of optimistic interventions including immediate ART initiation varied widely across models, maintaining substantial uncertainty about the theoretical prospect for elimination of HIV from the population using ART alone over the next four decades. The number of person-years of ART per infection averted over 8 y ranged between 5.8 and 18.7. Considering the actual scale-up of ART in South Africa, seven models estimated that current HIV incidence is 17% to 32% lower than it would have been in the absence of ART. Differences between model assumptions about CD4 decline and HIV transmissibility over the course of infection explained only a modest amount of the variation in model results.Mathematical models evaluating the impact of ART vary substantially in structure, complexity, and parameter choices, but all suggest that ART, at high levels of access and with high adherence, has the potential to substantially reduce new HIV infections. There was broad agreement regarding the short-term epidemiologic impact of ambitious treatment scale-up, but more variation in longer term projections and in the efficiency with which treatment can reduce new infections. Differences between model predictions could not be explained by differences in model structure or parameterization that were hypothesized to affect intervention impact.

  View details for DOI 10.1371/journal.pmed.1001245

  View details for PubMedID 22802730

• United States aid policy and induced abortion in Sub-Saharan Africa BULLETIN OF THE WORLD HEALTH ORGANIZATION Bendavid, E., Avila, P., Miller, G. 2011; 89 (12): 873-880

  Abstract

  To determine whether the Mexico City Policy, a United States government policy that prohibits funding to nongovernmental organizations performing or promoting abortion, was associated with the induced abortion rate in sub-Saharan Africa.Women in 20 African countries who had induced abortions between 1994 and 2008 were identified in Demographic and Health Surveys. A country's exposure to the Mexico City Policy was considered high (or low) if its per capita assistance from the United States for family planning and reproductive health was above (or below) the median among study countries before the policy's reinstatement in 2001. Using logistic regression and a difference-in-difference design, the authors estimated the differential change in the odds of having an induced abortion among women in high exposure countries relative to low exposure countries when the policy was reinstated.The study included 261,116 women aged 15 to 44 years. A comparison of 1994-2000 with 2001-2008 revealed an adjusted odds ratio for induced abortion of 2.55 for high-exposure countries versus low-exposure countries under the policy (95% confidence interval, CI: 1.76-3.71). There was a relative decline in the use of modern contraceptives in the high-exposure countries over the same time period.The induced abortion rate in sub-Saharan Africa rose in high-exposure countries relative to low-exposure countries when the Mexico City Policy was reintroduced. Reduced financial support for family planning may have led women to substitute abortion for contraception. Regardless of one's views about abortion, the findings may have important implications for public policies governing abortion.

  View details for DOI 10.2471/BLT.11.091660

  View details for Web of Science ID 000297885400020

  View details for PubMedID 22271944

  View details for PubMedCentralID PMC3260902

• Health system determinants of infant, child and maternal mortality: A cross-sectional study of UN member countries GLOBALIZATION AND HEALTH Muldoon, K. A., Galway, L. P., Nakajima, M., Kanters, S., Hogg, R. S., Bendavid, E., Mills, E. J. 2011; 7

  Abstract

  Few studies have examined the link between health system strength and important public health outcomes across nations. We examined the association between health system indicators and mortality rates.We used mixed effects linear regression models to investigate the strength of association between outcome and explanatory variables, while accounting for geographic clustering of countries. We modelled infant mortality rate (IMR), child mortality rate (CMR), and maternal mortality rate (MMR) using 13 explanatory variables as outlined by the World Health Organization.Significant protective health system determinants related to IMR included higher physician density (adjusted rate ratio [aRR] 0.81; 95% Confidence Interval [CI] 0.71-0.91), higher sustainable access to water and sanitation (aRR 0.85; 95% CI 0.78-0.93), and having a less corrupt government (aRR 0.57; 95% CI 0.40-0.80). Out-of-pocket expenditures on health (aRR 1.29; 95% CI 1.03-1.62) were a risk factor. The same four variables were significantly related to CMR after controlling for other variables. Protective determinants of MMR included access to water and sanitation (aRR 0.88; 95% CI 0.82-0.94), having a less corrupt government (aRR 0.49; 95%; CI 0.36-0.66), and higher total expenditures on health per capita (aRR 0.84; 95% CI 0.77-0.92). Higher fertility rates (aRR 2.85; 95% CI: 2.02-4.00) were found to be a significant risk factor for MMR.Several key measures of a health system predict mortality in infants, children, and maternal mortality rates at the national level. Improving access to water and sanitation and reducing corruption within the health sector should become priorities.

  View details for DOI 10.1186/1744-8603-7-42

  View details for Web of Science ID 000298816800001

  View details for PubMedID 22023970

  View details for PubMedCentralID PMC3247841

• Comparative Analysis of Old-Age Mortality Estimations in Africa PLOS ONE Bendavid, E., Seligman, B., Kubo, J. 2011; 6 (10)

  Abstract

  Survival to old ages is increasing in many African countries. While demographic tools for estimating mortality up to age 60 have improved greatly, mortality patterns above age 60 rely on models based on little or no demographic data. These estimates are important for social planning and demographic projections. We provide direct estimations of older-age mortality using survey data.Since 2005, nationally representative household surveys in ten sub-Saharan countries record counts of living and recently deceased household members: Burkina Faso, Côte d'Ivoire, Ethiopia, Namibia, Nigeria, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe. After accounting for age heaping using multiple imputation, we use this information to estimate probability of death in 5-year intervals ((5)q(x)). We then compare our (5)q(x) estimates to those provided by the World Health Organization (WHO) and the United Nations Population Division (UNPD) to estimate the differences in mortality estimates, especially among individuals older than 60 years old.We obtained information on 505,827 individuals (18.4% over age 60, 1.64% deceased). WHO and UNPD mortality models match our estimates closely up to age 60 (mean difference in probability of death -1.1%). However, mortality probabilities above age 60 are lower using our estimations than either WHO or UNPD. The mean difference between our sample and the WHO is 5.9% (95% CI 3.8-7.9%) and between our sample is UNPD is 13.5% (95% CI 11.6-15.5%). Regardless of the comparator, the difference in mortality estimations rises monotonically above age 60.Mortality estimations above age 60 in ten African countries exhibit large variations depending on the method of estimation. The observed patterns suggest the possibility that survival in some African countries among adults older than age 60 is better than previously thought. Improving the quality and coverage of vital information in developing countries will become increasingly important with future reductions in mortality.

  View details for DOI 10.1371/journal.pone.0026607

  View details for Web of Science ID 000296507500095

  View details for PubMedID 22028921

  View details for PubMedCentralID PMC3197519

• Assessing effectiveness and cost-effectiveness of concurrency reduction for HIV prevention INTERNATIONAL JOURNAL OF STD & AIDS Enns, E. A., Brandeau, M. L., Igeme, T. K., Bendavid, E. 2011; 22 (10): 558-567

  Abstract

  We estimated the effectiveness and cost-effectiveness of changes in concurrent sexual partnerships in reducing the spread of HIV in sub-Saharan Africa. Using data from Swaziland, Tanzania, Uganda and Zambia, we estimated country-specific concurrency behaviour from sexual behaviour survey data on the number of partners in the past 12 months, and we developed a network model to compare the impact of three behaviour changes on the HIV epidemic: (1) changes in concurrent partnership patterns to strict monogamy; (2) partnership reduction among those with the greatest number of partners; and (3) partnership reduction among all individuals. We estimated the number of new HIV infections over 10 years and the cost per infection averted. Given our assumptions and model structure, we find that reducing concurrency among high-risk individuals averts the most infections and increasing monogamy the least (11.7% versus 8.7% reduction in new infections, on average, for a 10% reduction in concurrent partnerships). A campaign that costs US$1 per person annually is likely cost-saving if it reduces concurrency by 9% on average, given our baseline estimates of concurrency. In sensitivity analysis, the rank ordering of behaviour change scenarios was unaffected by potential over-estimation of concurrency, though the number of infections averted decreased and the cost per HIV infection averted increased. Concurrency reduction programmes may be effective and cost-effective in reducing HIV incidence in sub-Saharan Africa if they can achieve even modest impacts at similar costs to past mass media campaigns in the region. Reduced concurrency among high-risk individuals appears to be most effective in reducing HIV incidence, but concurrency reduction in other risk groups may yield nearly as much benefit.

  View details for DOI 10.1258/ijsa.2011.010322

  View details for Web of Science ID 000296991200004

  View details for PubMedID 21998175

  View details for PubMedCentralID PMC3230224

• The cost-effectiveness of symptom-based testing and routine screening for acute HIV infection in men who have sex with men in the USA AIDS Juusola, J. L., Brandeau, M. L., Long, E. F., Owens, D. K., Bendavid, E. 2011; 25 (14): 1779-1787

  Abstract

  Acute HIV infection often causes influenza-like illness (ILI) and is associated with high infectivity. We estimated the effectiveness and cost-effectiveness of strategies to identify and treat acute HIV infection in men who have sex with men (MSM) in the USA.Dynamic model of HIV transmission and progression.We evaluated three testing approaches: viral load testing for individuals with ILI, expanded screening with antibody testing, and expanded screening with antibody and viral load testing. We included treatment with antiretroviral therapy for individuals identified as acutely infected.New HIV infections, discounted quality-adjusted life years (QALYs) and costs, and incremental cost-effectiveness ratios.At the present rate of HIV-antibody testing, we estimated that 538,000 new infections will occur among MSM over the next 20 years. Expanding antibody screening coverage to 90% of MSM annually reduces new infections by 2.8% and costs US$ 12,582 per QALY gained. Symptom-based viral load testing with ILI is more expensive than expanded antibody screening, but is more effective and costs US$ 22,786 per QALY gained. Combining expanded antibody screening with symptom-based viral load testing prevents twice as many infections compared to expanded antibody screening alone, and costs US$ 29,923 per QALY gained. Adding viral load testing to all annual HIV tests costs more than US$ 100,000 per QALY gained.Use of HIV viral load testing in MSM with ILI prevents more infections than does expanded annual antibody screening alone and is inexpensive relative to other screening interventions. Clinicians should consider symptom-based viral load testing in MSM, in addition to encouraging annual antibody screening.

  View details for DOI 10.1097/QAD.0b013e328349f067

  View details for PubMedID 21716076

• HAS ALL THIS MONEY TRANSLATED INTO IMPROVED HEALTH? Bendavid, E. OXFORD UNIV PRESS INC. 2011: S80

  View details for Web of Science ID 000294114600313

• The relation of price of antiretroviral drugs and foreign assistance with coverage of HIV treatment in Africa: retrospective study BRITISH MEDICAL JOURNAL Bendavid, E., Leroux, E., Bhattacharya, J., Smith, N., Miller, G. 2010; 341

  Abstract

  To determine the association of reductions in price of antiretroviral drugs and foreign assistance for HIV with coverage of antiretroviral treatment.Retrospective study.Africa.13 African countries, 2003-8.A price index of first line antiretroviral therapy with data on foreign assistance for HIV was used to estimate the associations of prices and foreign assistance with antiretroviral coverage (percentage of people with advanced HIV infection receiving antiretroviral therapy), controlling for national public health spending, HIV prevalence, governance, and fixed effects for countries and years.Between 2003 and 2008 the annual price of first line antiretroviral therapy decreased from $1177 (£733; €844) to $96 and foreign assistance for HIV per capita increased from $0.4 to $13.8. At an annual price of $100, a $10 decrease was associated with a 0.16% adjusted increase in coverage (95% confidence interval 0.11% to 0.20%; 0.19% unadjusted, 0.14% to 0.24%). Each additional $1 per capita in foreign assistance for HIV was associated with a 1.0% adjusted increase in coverage (0.7% to 1.2%; 1.4% unadjusted, 1.1% to 1.6%). If the annual price of antiretroviral therapy stayed at $100, foreign assistance would need to quadruple to $64 per capita to be associated with universal coverage. Government effectiveness and national public health expenditures were also positively associated with increasing coverage.Reductions in price of antiretroviral drugs were important in broadening coverage of HIV treatment in Africa from 2003 to 2008, but their future role may be limited. Foreign assistance and national public health expenditures for HIV seem more important in expanding future coverage.

  View details for DOI 10.1136/bmj.c6218

  View details for Web of Science ID 000284586600002

  View details for PubMedID 21088074

  View details for PubMedCentralID PMC2987231

• The US Global Health Initiative Informing Policy With Evidence JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Bendavid, E., Miller, G. 2010; 304 (7): 791-792

  View details for PubMedID 20716743

• Comparative Effectiveness of HIV Testing and Treatment in Highly Endemic Regions ARCHIVES OF INTERNAL MEDICINE Bendavid, E., Brandeau, M. L., Wood, R., Owens, D. K. 2010; 170 (15): 1347-1354

  Abstract

  Universal testing and treatment holds promise for reducing the burden of human immunodeficiency virus (HIV) in sub-Saharan Africa, but linkage from testing to treatment sites and retention in care are inadequate.We developed a simulation of the HIV epidemic and HIV disease progression in South Africa to compare the outcomes of the present HIV treatment campaign (status quo) with 4 HIV testing and treating strategies that increase access to antiretroviral therapy: (1) universal testing and treatment without changes in linkage to care and loss to follow-up; (2) universal testing and treatment with improved linkage to care; (3) universal testing and treatment with reduced loss to follow-up; and (4) comprehensive HIV care with universal testing and treatment, improved linkage to care, and reduced loss to follow-up. The main outcome measures were survival benefits, new HIV infections, and HIV prevalence.Compared with the status quo strategy, universal testing and treatment (1) was associated with a mean (95% uncertainty bounds) life expectancy gain of 12.0 months (11.3-12.2 months), and 35.3% (32.7%-37.5%) fewer HIV infections over a 10-year time horizon. Improved linkage to care (2), prevention of loss to follow-up (3), and comprehensive HIV care (4) provided substantial additional benefits: life expectancy gains compared with the status quo strategy were 16.1, 18.6, and 22.2 months, and new infections were 55.5%, 51.4%, and 73.2% lower, respectively. In sensitivity analysis, comprehensive HIV care reduced new infections by 69.7% to 76.7% under a broad set of assumptions.Universal testing and treatment with current levels of linkage to care and loss to follow-up could substantially reduce the HIV death toll and new HIV infections. However, increasing linkage to care and preventing loss to follow-up provides nearly twice the benefits of universal testing and treatment alone.

  View details for PubMedID 20696960

• AIDS and declining support for dependent elderly people in Africa: retrospective analysis using demographic and health surveys BRITISH MEDICAL JOURNAL Kautz, T., Bendavid, E., Bhattacharya, J., Miller, G. 2010; 340

  Abstract

  To determine the relation between the HIV/AIDS epidemic and support for dependent elderly people in Africa.Retrospective analysis using data from Demographic and Health Surveys.22 African countries between 1991 and 2006.123,176 individuals over the age of 60.We investigated how three measures of the living arrangements of older people have been affected by the HIV/AIDS epidemic: the number of older individuals living alone (that is, the number of unattended elderly people); the number of older individuals living with only dependent children under the age of 10 (that is, in missing generation households); and the number of adults age 18-59 (that is, prime age adults) per household where an older person lives.An increase in annual AIDS mortality of one death per 1000 people was associated with a 1.5% increase in the proportion of older individuals living alone (95% CI 1.2% to 1.9%) and a 0.4% increase in the number of older individuals living in missing generation households (95% CI 0.3% to 0.6%). Increases in AIDS mortality were also associated with fewer prime age adults in households with at least one older person and at least one prime age adult (P<0.001). These findings suggest that in our study countries, which encompass 70% of the sub-Saharan population, the HIV/AIDS epidemic could be responsible for 582,200-917,000 older individuals living alone without prime age adults and 141,000-323,100 older individuals being the sole caregivers for young children.Africa's HIV/AIDS epidemic might be responsible for a large number of older people losing their support and having to care for young children. This population has previously been under-recognised. Efforts to reduce HIV/AIDS deaths could have large "spillover" benefits for elderly people in Africa.

  View details for DOI 10.1136/bmj.c2841

  View details for Web of Science ID 000279051900002

  View details for PubMedID 20554660

  View details for PubMedCentralID PMC2886852

• Evaluating Outcomes of the President's Emergency Plan for AIDS Relief in Africa RESPONSE ANNALS OF INTERNAL MEDICINE Bendavid, E. 2010; 152 (2): 132–33

  View details for DOI 10.7326/0003-4819-152-2-201001190-00021

  View details for Web of Science ID 000273953000013

• The relationship between HIV testing, stigma, and health service usage AIDS CARE-PSYCHOLOGICAL AND SOCIO-MEDICAL ASPECTS OF AIDS/HIV Young, S. D., Bendavid, E. 2010; 22 (3): 373-380

  Abstract

  We explore whether HIV stigma is associated with seeking to conceal testing interest. We examine 86,899 outpatient visits in a 1993-1997 national survey and compare HIV testing to four non-stigmatized tests: spirometry, allergy testing, mammography, and colonoscopy. We explore whether people testing for HIV, compared to people receiving control services, listed reasons for visit (RFV) less related to the test performed, listed their interest in testing more frequently as a non-primary RFV, and received more services unrelated to testing. A total of 48.7% of people tested for HIV listed a reason unrelated to testing as their primary RFV (spirometry: 8.9%; allergy testing: 29.3%), and 69.9% of people asking to test requested HIV testing as a secondary RFV (spirometry: 52%; allergy testing: 0%). People who tested for HIV received more services (M=1.83 additional services) than non-testers (M=0.95) on an index of seven services. We did not find this association for spirometry, allergy testing, colonoscopy, or mammography. We interpret these results to indicate that stigma may have behavioral correlates and that people may attempt to avoid HIV stigma by seeking a psychological cover for HIV testing. To our knowledge, this is the first study to attempt to use observational data on health service usage for assessing stigma and people's attempts to deal with HIV testing stigma.

  View details for DOI 10.1080/09540120903193666

  View details for Web of Science ID 000277313600013

  View details for PubMedID 20390518

  View details for PubMedCentralID PMC3059845

• Cost-effectiveness of antiretroviral regimens in the World Health Organization's treatment guidelines: a South African analysis AIDS Bendavid E, Grant PM, Talbot A, Owens DK, Zolopa A 2010
• Switch from enfuvirtide to raltegravir in virologically suppressed HIV-1 infected patients: Effects on level of residual viremia and quality of life JOURNAL OF CLINICAL VIROLOGY Grant, P. M., Palmer, S., Bendavid, E., Talbot, A., Slamowitz, D. C., Cain, P., Kobayashi, S. S., Balamane, M., Zolopa, A. R. 2009; 46 (4): 305-308

  Abstract

  Raltegravir is a potential treatment option for virologically suppressed HIV-1 infected patients on enfuvirtide with injection site reactions.To characterize safety and efficacy of an enfuvirtide to raltegravir switch including changes in T-cells, quality of life, and residual viremia.In patients with viral load <50 copies/mL and injection site reactions, enfuvirtide was switched to raltegravir without additional changes to the antiretroviral regimen. Virologic failure was defined as a viral load >1000 copies/mL or two consecutive viral load measurements between 50 and 1000 copies/mL (low-level viremia). Over the 24 week study, we compared changes in T-cells, injection site reactions, quality of life, and residual viremia, as measured through the single-copy assay which can detect plasma virus down to a single copy, using paired t-tests.Fourteen patients with a median CD4+ T-cell count of 420 cells/microL were enrolled. After the switch, two patients experienced virologic failure due to confirmed low-level viremia. However, both patients subsequently were re-suppressed, one without any changes to his regimen. There was no change in CD4+ T-cell count. Injection site reactions resolved. However, there was little reported change in quality of life. The baseline median level of residual viremia was 6 copies/mL and did not change after the switch to raltegravir.A switch to raltegravir in virologically suppressed patients on enfuvirtide is effective in maintaining immunologic and virologic control at 24 weeks but did not result in a change in residual viremia.

  View details for DOI 10.1016/j.jcv.2009.09.025

  View details for Web of Science ID 000272460900002

  View details for PubMedID 19819183

• Expanding Antiretroviral Options in Resource-Limited Settings-A Cost-Effectiveness Analysis JAIDS-JOURNAL OF ACQUIRED IMMUNE DEFICIENCY SYNDROMES Bendavid, E., Wood, R., Katzenstein, D. A., Bayoumi, A. M., Owens, D. K. 2009; 52 (1): 106-113

  Abstract

  Current World Health Organization (WHO) guidelines for treatment of HIV in resource-limited settings call for 2 antiretroviral regimens. The effectiveness and cost-effectiveness of increasing the number of antiretroviral regimens is unknown.Using a simulation model, we compared the survival and costs of current WHO regimens with two 3-regimen strategies: an initial regimen of 3 nucleoside reverse transcriptase inhibitors followed by the WHO regimens and the WHO regimens followed by a regimen with a second-generation boosted protease inhibitor (2bPI). We evaluated monitoring with CD4 counts only and with both CD4 counts and viral load. We used cost and effectiveness data from Cape Town and tested all assumptions in sensitivity analyses.Over the lifetime of the cohort, 25.6% of individuals failed both WHO regimens by virologic criteria. However, when patients were monitored using CD4 counts alone, only 6.5% were prescribed additional highly active antiretroviral therapy due to missed and delayed detection of failure. The life expectancy gain for individuals who took a 2bPI was 6.7-8.9 months, depending on the monitoring strategy. When CD4 alone was available, adding a regimen with a 2bPI was associated with an incremental cost-effectiveness ratio of $2581 per year of life gained, and when viral load was available, the ratio was $6519 per year of life gained. Strategies with triple-nucleoside reverse transcriptase inhibitor regimens in initial therapy were dominated. Results were sensitive to the price of 2bPIs.About 1 in 4 individuals who start highly active antiretroviral therapy in sub-Saharan Africa will fail currently recommended regimens. At current prices, adding a regimen with a 2bPI is cost effective for South Africa and other middle-income countries by WHO standards.

  View details for PubMedID 19448557

• The President's Emergency Plan for AIDS Relief in Africa: An Evaluation of Outcomes ANNALS OF INTERNAL MEDICINE Bendavid, E., Bhattacharya, J. 2009; 150 (10): 688-U5

  Abstract

  Since 2003, the President's Emergency Plan for AIDS Relief (PEPFAR) has been the most ambitious initiative to address the global HIV epidemic. However, the effect of PEPFAR on HIV-related outcomes is unknown.To assess the effect of PEPFAR on HIV-related deaths, the number of people living with HIV, and HIV prevalence in sub-Saharan Africa.Comparison of trends before and after the initiation of PEPFAR's activities.12 African focus countries and 29 control countries with a generalized HIV epidemic from 1997 to 2007 (451 country-year observations).A 5-year, $15 billion program for HIV treatment, prevention, and care that started in late 2003.HIV-related deaths, the number of people living with HIV, and HIV prevalence.Between 2004 and 2007, the difference in the annual change in the number of HIV-related deaths was 10.5% lower in the focus countries than in the control countries (P = 0.001). The difference in trends between the groups before 2003 was not significant. The annual growth in the number of people living with HIV was 3.7% slower in the focus countries than in the control countries from 1997 to 2002 (P = 0.05), but during PEPFAR's activities, the difference was no longer significant. The difference in the change in HIV prevalence did not significantly differ throughout the study period. These estimates were stable after sensitivity analysis.The selection of the focus countries was not random, which limits the generalizability of the results.After 4 years of PEPFAR activity, HIV-related deaths decreased in sub-Saharan African focus countries compared with control countries, but trends in adult prevalence did not differ. Assessment of epidemiologic effectiveness should be part of PEPFAR's evaluation programs.Agency for Healthcare Research and Quality.

  View details for Web of Science ID 000266285300004

  View details for PubMedID 19349625

• Cost-effectiveness of Strategies for Monitoring the Response to Antiretroviral Therapy in Resource-Limited Settings Reply ARCHIVES OF INTERNAL MEDICINE Bendavid, E., Owens, D. K. 2009; 169 (9): 904-905

  View details for Web of Science ID 000265994000017

• Cost-effectiveness of HIV monitoring strategies in resource-limited settings - A Southern African analysis ARCHIVES OF INTERNAL MEDICINE Bendavid, E., Young, S. D., Katzenstein, D. A., Bayoumi, A. M., Sanders, G. D., Owens, D. K. 2008; 168 (17): 1910-1918

  Abstract

  Although the number of infected persons receiving highly active antiretroviral therapy (HAART) in low- and middle-income countries has increased dramatically, optimal disease management is not well defined.We developed a model to compare the costs and benefits of 3 types of human immunodeficiency virus monitoring strategies: symptom-based strategies, CD4-based strategies, and CD4 counts plus viral load strategies for starting, switching, and stopping HAART. We used clinical and cost data from southern Africa and performed a cost-effectiveness analysis. All assumptions were tested in sensitivity analyses.Compared with the symptom-based approaches, monitoring CD4 counts every 6 months and starting treatment at a threshold of 200/muL was associated with a gain in life expectancy of 6.5 months (61.9 months vs 68.4 months) and a discounted lifetime cost savings of US $464 per person (US $4069 vs US $3605, discounted 2007 dollars). The CD4-based strategies in which treatment was started at the higher threshold of 350/microL provided an additional gain in life expectancy of 5.3 months at a cost-effectiveness of US $107 per life-year gained compared with a threshold of 200/microL. Monitoring viral load with CD4 was more expensive than monitoring CD4 counts alone, added 2.0 months of life, and had an incremental cost-effectiveness ratio of US $5414 per life-year gained relative to monitoring of CD4 counts. In sensitivity analyses, the cost savings from CD4 count monitoring compared with the symptom-based approaches was sensitive to cost of inpatient care, and the cost-effectiveness of viral load monitoring was influenced by the per test costs and rates of virologic failure.Use of CD4 monitoring and early initiation of HAART in southern Africa provides large health benefits relative to symptom-based approaches for HAART management. In southern African countries with relatively high costs of hospitalization, CD4 monitoring would likely reduce total health care expenditures. The cost-effectiveness of viral load monitoring depends on test prices and rates of virologic failure.

  View details for PubMedID 18809819

• Monitoring of antiretroviral therapy in low-resource settings LANCET Bendavid, E. 2008; 372 (9635): 288-289

  View details for Web of Science ID 000258042800020

  View details for PubMedID 18657700

• Systematic review: The effects of growth hormone on athletic performance ANNALS OF INTERNAL MEDICINE Liu, H., Bravata, D. M., Olkin, I., Friedlander, A., Liu, V., Roberts, B., Bendavid, E., Saynina, O., Salpeter, S. R., Garber, A. M., Hoffman, A. R. 2008; 148 (10): 747-U59

  Abstract

  Human growth hormone is reportedly used to enhance athletic performance, although its safety and efficacy for this purpose are poorly understood.To evaluate evidence about the effects of growth hormone on athletic performance in physically fit, young individuals.MEDLINE, EMBASE, SPORTDiscus, and Cochrane Collaboration databases were searched for English-language studies published between January 1966 and October 2007.Randomized, controlled trials that compared growth hormone treatment with no growth hormone treatment in community-dwelling healthy participants between 13 and 45 years of age.2 authors independently reviewed articles and abstracted data.44 articles describing 27 study samples met inclusion criteria; 303 participants received growth hormone, representing 13.3 person-years of treatment. Participants were young (mean age, 27 years [SD, 3]), lean (mean body mass index, 24 kg/m2 [SD, 2]), and physically fit (mean maximum oxygen uptake, 51 mL/kg of body weight per minute [SD, 8]). Growth hormone dosage (mean, 36 microg/kg per day [SD, 21]) and treatment duration (mean, 20 days [SD, 18] for studies giving growth hormone for >1 day) varied. Lean body mass increased in growth hormone recipients compared with participants who did not receive growth hormone (increase, 2.1 kg [95% CI, 1.3 to 2.9 kg]), but strength and exercise capacity did not seem to improve. Lactate levels during exercise were statistically significantly higher in 2 of 3 studies that evaluated this outcome. Growth hormone-treated participants more frequently experienced soft tissue edema and fatigue than did those not treated with growth hormone.Few studies evaluated athletic performance. Growth hormone protocols in the studies may not reflect real-world doses and regimens.Claims that growth hormone enhances physical performance are not supported by the scientific literature. Although the limited available evidence suggests that growth hormone increases lean body mass, it may not improve strength; in addition, it may worsen exercise capacity and increase adverse events. More research is needed to conclusively determine the effects of growth hormone on athletic performance.

  View details for Web of Science ID 000256372200004

  View details for PubMedID 18347346

• Complication rates on weekends and weekdays in US hospitals AMERICAN JOURNAL OF MEDICINE Bendavid, E., Kaganova, Y., Needleman, J., Gruenberg, L., Weissman, J. S. 2007; 120 (5): 422-428

  Abstract

  Recent studies and anecdotal evidence suggest that patient safety may be compromised on weekends. Our objective was to determine whether rates of complications in hospitals are higher on weekends than on weekdays.We examined records from 4,967,114 admissions to acute care hospitals in 3 states and analyzed complication rates using the Patient Safety Indicators. We selected 8 indicators that could be assigned to a single day: complications of anesthesia, retained foreign bodies, postoperative hemorrhage, accidental cuts and lacerations during procedures, birth trauma, obstetric trauma during vaginal deliveries with and without instrumentation, and obstetric trauma during cesarean delivery. Odds ratios (ORs) comparing weekends versus weekdays were adjusted for demographics, type of admission, and admission route. In a subgroup analysis of surgical complications, we restricted the population to patients who underwent cardiac or vascular procedures.Four of the 8 complications occurred more frequently on weekends: postoperative hemorrhage (OR 1.07, 95% confidence interval [CI], 1.01-1.14), newborn trauma (OR 1.06, 95% CI, 1.03-1.10), vaginal deliveries without instrumentation (OR 1.03, 95% CI, 1.02-1.04), and obstetric trauma during cesarean sections (OR 1.36, 95% CI, 1.29-1.44). Complications related to anesthesia occurred less frequently on weekends (OR 0.86). Among patients undergoing vascular procedures, surgical complications occurred more frequently on weekends (OR 1.46, 95% CI, 1.16-1.85).Rates of complications are marginally higher on weekends than on weekdays for some surgical and newborn complications, but more significantly for obstetric trauma and for surgical complications involving patients undergoing vascular procedures. Hospitals should work toward increasing the robustness of safeguards on weekends.

  View details for DOI 10.1016/j.amjmed.2006.05.067

  View details for Web of Science ID 000246061900012

  View details for PubMedID 17466653

• Hospital workload and adverse events MEDICAL CARE Weissman, J. S., Rothschild, J. M., Bendavid, E., Sprivulis, P., Cook, E. F., Evans, R. S., Kaganova, Y., Bender, M., David-Kasdan, J., Haug, P., Lloyd, J., Selbovitz, L. G., Murff, H. J., Bates, D. W. 2007; 45 (5): 448-455

  Abstract

  Hospitals are under pressure to increase revenue and lower costs, and at the same time, they face dramatic variation in clinical demand.: We sought to determine the relationship between peak hospital workload and rates of adverse events (AEs).A random sample of 24,676 adult patients discharged from the medical/surgical services at 4 US hospitals (2 urban and 2 suburban teaching hospitals) from October 2000 to September 2001 were screened using administrative data, leaving 6841 cases to be reviewed for the presence of AEs. Daily workload for each hospital was characterized by volume, throughput (admissions and discharges), intensity (aggregate DRG weight), and staffing (patient-to-nurse ratios). For volume, we calculated an "enhanced" occupancy rate that accounted for same-day bed occupancy by more than 1 patient. We used Poisson regressions to predict the likelihood of an AE, with control for workload and individual patient complexity, and the effects of clustering.One urban teaching hospital had enhanced occupancy rates more than 100% for much of the year. At that hospital, admissions and patients per nurse were significantly related to the likelihood of an AE (P < 0.05); occupancy rate, discharges, and DRG-weighted census were significant at P < 0.10. For example, a 0.1% increase in the patient-to-nurse ratio led to a 28% increase in the AE rate. Results at the other 3 hospitals varied and were mainly non significant.Hospitals that operate at or over capacity may experience heightened rates of patient safety events and might consider re-engineering the structures of care to respond better during periods of high stress.

  View details for Web of Science ID 000246374200011

  View details for PubMedID 17446831

• Data withholding and the next generation of scientists: Results of a national survey ACADEMIC MEDICINE Vogeli, C., Yucel, R., Bendavid, E., Jones, L. M., Anderson, M. S., Louis, K. S., Campbell, E. G. 2006; 81 (2): 128-136

  Abstract

  To provide the first national data on the nature, extent, and consequences of withholding among life science trainees.In 2003, the authors surveyed 1,077 second-year doctoral students and postdoctoral fellows in life sciences at 50 U.S. universities, with a comparison group of trainees in computer science and chemical engineering. The study variables examined trainees' exposure to and the consequences of data withholding.Two hundred forty-six trainees (23.0%) reported that they had asked for and been denied access to information, data, materials, or programming associated with published research and 221 (20.6%) to unpublished research. Eighty-five trainees (7.9%) reported that they had denied another academic scientist's request(s) related to their own published research. Five hundred thirty-three trainees (50.8%) reported that withholding had had a negative effect on the progress of their research, 508 (48.5%) on the rate of discovery in their lab/research group, 472 (45.0%) on the quality of their relationships with academic scientists, 346 (33.0%) on the quality of their education, and 299 (28.5%) on the level of communication in their lab/research group. Trainees denied access to research were significantly more likely to report that data withholding had had a negative effect on several aspects of the educational experience.Data withholding had demonstrated negative effects on trainees. The life sciences, more so than chemical engineering or computer science, will have to address this issue among its trainees. Failure to do so could result in delayed research, inefficient training, and a culture of withholding among future life scientists.

  View details for Web of Science ID 000235023100005

  View details for PubMedID 16436573

• Should US hospitals go 24/7? AMERICAN JOURNAL OF MEDICINE Weissman, J. S., Bendavid, E. 2004; 117 (3): 202-203

  View details for DOI 10.1016/j.amjmed.2004.04.005

  View details for Web of Science ID 000223049500011

  View details for PubMedID 15276598

• Data-sharing and data-withholding in genetics and the life sciences: results of a national survey of technology transfer officers. Journal of health care law & policy Campbell, E. G., Bendavid, E. 2003; 6 (2): 241-255

  View details for PubMedID 15017960

• Potential Contributions of Clinical and Community Testing in Identifying Persons with Undiagnosed HIV Infection in the United States. Journal of the International Association of Providers of AIDS Care Kahn, J. G., Bendavid, E. n., Dietz, P. M., Hutchinson, A. n., Horvath, H. n., McCabe, D. n., Wolitski, R. J. ; 19: 2325958220950902

  Abstract

  An estimated 166,155 individuals in the United States have undiagnosed HIV infection. We modeled the numbers of HIV-infected individuals who could be diagnosed in clinical and community settings by broadly implementing HIV screening guidelines.United States.We modeled testing for general population (once lifetime) and high-risk populations (annual): men who have sex with men, people who inject drugs, and high-risk heterosexuals. We used published data on HIV infections, HIV testing, engagement in clinical care, and risk status disclosure.In clinical settings, about 76 million never-tested low-risk and 2.6 million high-risk individuals would be tested, yielding 36,000 and 55,000 HIV diagnoses, respectively. In community settings, 30 million low-risk and 4.4 million high-risk individuals would be tested, yielding 75,000 HIV diagnoses.HIV testing in clinical and community settings diagnoses similar numbers of individuals. Lifetime and risk-based testing are both needed to substantially reduce undiagnosed HIV.

  View details for DOI 10.1177/2325958220950902

  View details for PubMedID 32885701