Evaluating Alternative Designs of a Multilevel HIV Intervention inMaharashtra India: The Impact of Stakeholder Constraints

摘要

>Background. Multilevel interventions combine individual component interventions, and their design can be informed by decision analysis. Our objective was to identify the optimal combination of interventions for alcohol-using HIV+ individuals on antiretroviral drug therapy in Maharashtra, India, explicitly considering stakeholder constraints. >Methods. Using an HIV simulation, we evaluated the expected net monetary benefit (ENMB), the probability of lying on the efficiency frontier (PEF), and annual program costs of 5,836 unique combinations of 15 single-focused HIV risk-reduction interventions. We evaluated scenarios of 1) no constraints (i.e., maximize expected value), 2) short-term budget constraints (limits on annual programmatic costs of US$200,000 and $400,000), and 3) a constraint stemming from risk aversion (requiring that the strategy has >50% PEF). >Results. With no constraints, the combination including long individual alcohol counseling, text-message adherence support, long group counseling for sex-risk, and long individual counseling for sex-risk (annual cost = $428,886; PEF ∼27%) maximized ENMB and would be the optimal design. With a cost constraint of $400,000, the combinationincluding long individual alcohol counseling, text-message adherencesupport, brief group counseling for sex-risk, and longindividual counseling for sex-risk (annual cost = $374,745; PEF∼4%) maximized ENMB. With a cost constraint of $200,000, the combinationincluding long individual alcohol counseling, text-message adherencesupport, and brief group counseling for sex-risk(annual cost = $187,335; PEF ∼54%) maximized ENMB. With the risk aversionconstraint, the same configuration (long individual alcohol counseling,text-message support, and brief group counseling forsex-risk) maximized health benefit. >Conclusion.Evaluating the costs, risks, and projected benefits of alternatives supportsinformed decision making prior to initiating study; however, stakeholderconstraints should be explicitly included and discussed when using decisionanalyses to guide study design.