April Kimmel

April Kimmel

Associate Professor, Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine

Dissertation Title:  "Efficiency and Equity Concerns for HIV Treatment Scale-up in Developing Countries"

HIV disease, a life-threatening but treatable illness, kills approximately 2 million individuals annually and about 2.7 million new infections occur each year. Developing countries, particularly in sub-Saharan Africa, contend with a disproportionate burden of this disease, with approximately 40% of HIV-infected individuals residing in these settings receiving treatment. While recent international initiatives to combat HIV/AIDS suggest HIV treatment provision will continue to increase, the magnitude of the HIV/AIDS epidemic and recent global financial crisis places the financial, human, and physical capacity needs for HIV treatment provision in question. In this context, this dissertation seeks to examine efficiency and equity concerns for HIV treatment scale-up in developing countries. Three distinct methodologies were used to evaluate HIV treatment programs and policies in two sub-Saharan African countries, Côte d’ Ivoire and South Africa.

Chapter 1 assesses the incremental benefits and cost-effectiveness of laboratory monitoring to guide switching antiretroviral therapy in HIV-infected individuals in Côte d’Ivoire. CD4 count and HIV RNA monitoring to guide switching was found to improve survival and, under most conditions, to be cost-effective according to international standards.

Chapter 2 describes development of a framework capable of quantifying the relative preferences of South African decision makers for alternative HIV treatment programs. Intended also to relate relative preferences to different ethical considerations, the framework systematically outlines a multi-stage, iterative process to develop a discrete choice experiment. The final process included identification of initial candidate priorities, collection and analysis of primary qualitative information to further isolate contextually relevant antiretroviral program characteristics, definition of characteristics that reflect treatment priorities for HIV-infected South Africans and different ethical principles, and survey instrument design.

In Chapter 3, a mathematical programming model was developed to highlight the trade-offs among competing treatment policy goals of improving individual health outcomes, population health outcomes, and the number individuals receiving treatment. In evaluating one treatment area — treatment discontinuation after antiretroviral failure — in the context of Côte d’Ivoire, model results confirm that at the individual level, treatment discontinuation decreases life expectancy and treatment resource consumption. At the population level, however, treatment discontinuation generally increased population life expectancy and the number receiving treatment.


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