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1.
BMC Med ; 19(1): 95, 2021 Apr 20.
Artigo em Inglês | MEDLINE | ID: mdl-33874940

RESUMO

BACKGROUND: Large-scale rural-to-urban migration has changed the epidemiology of tuberculosis (TB) in large Chinese cities. We estimated the contribution of TB importation, reactivation of latent infection, and local transmission to new TB cases in Shanghai, and compared the potential impact of intervention options. METHODS: We developed a transmission dynamic model of TB for Songjiang District, Shanghai, which has experienced high migration over the past 25 years. We calibrated the model to local demographic data, TB notifications, and molecular epidemiologic studies. We estimated epidemiological drivers as well as future outcomes of current TB policies and compared this base-case scenario with scenarios describing additional targeted interventions focusing on migrants or vulnerable residents. RESULTS: The model captured key demographic and epidemiological features of TB among migrant and resident populations in Songjiang District, Shanghai. Between 2020 and 2035, we estimate that over 60% of TB cases will occur among migrants and that approximately 43% of these cases will result from recent infection. While TB incidence will decline under current policies, we estimate that additional interventions-including active screening and preventive treatment for migrants-could reduce TB incidence by an additional 20% by 2035. CONCLUSIONS: Migrant-focused TB interventions could produce meaningful health benefits for migrants, as well as for young residents who receive indirect protection as a result of reduced TB transmission in Shanghai. Further studies to measure cost-effectiveness are needed to evaluate the feasibility of these interventions in Shanghai and similar urban centers experiencing high migration volumes.

2.
Am J Epidemiol ; 2021 Apr 08.
Artigo em Inglês | MEDLINE | ID: mdl-33831148

RESUMO

Estimates of the reproductive number for novel pathogens such as severe acute respiratory syndrome coronavirus 2 are essential for understanding the potential trajectory of the epidemic and the level of intervention that is needed to bring the epidemic under control. However, most methods for estimating the basic reproductive number (R0) and time-varying effective reproductive number (Rt) assume that the fraction of cases detected and reported is constant through time. We explore the impact of secular changes in diagnostic testing and reporting on estimates of R0 and Rt using simulated data. We then compare these patterns to data on reported cases of coronavirus disease and testing practices from different states in the United States from March 4 to August 30, 2020. We find that changes in testing practices and delays in reporting can result in biased estimates of R0 and Rt. Examination of changes in the daily number of tests conducted and the percent of patients testing positive may be helpful for identifying the potential direction of bias. Changes in diagnostic testing and reporting processes should be monitored and taken into consideration when interpreting estimates of the reproductive number of coronavirus disease.

3.
Health Policy Plan ; 2021 Mar 18.
Artigo em Inglês | MEDLINE | ID: mdl-33734362

RESUMO

The world is not on track to achieve the goals for immunization coverage and equity described by the World Health Organization's Global Vaccine Action Plan. Many countries struggle to increase coverage of routine vaccination, and there is little evidence about how to do so effectively. In India in 2016, only 62% of children had received a full course of basic vaccines. In response, in 2017-18 the government implemented Intensified Mission Indradhanush (IMI), a nationwide effort to improve coverage and equity using a campaign-style strategy. Campaign-style approaches to routine vaccine delivery like IMI, sometimes called 'periodic intensification of routine immunization' (PIRI), are widely used, but there is little robust evidence on their effectiveness. We conducted a quasi-experimental evaluation of IMI using routine data on vaccine doses delivered, comparing districts participating and not participating in IMI. Our sample included all districts that could be merged with India's 2016 Demographic and Health Surveys data and had available data for the full study period. We used controlled interrupted time-series analysis to estimate the impact of IMI during the 4-month implementation period and in subsequent months. This method assumes that, if IMI had not occurred, vaccination trends would have changed in the same way in the participating and not participating districts. We found that, during implementation, IMI increased delivery of 13 infant vaccines, with a median effect of 10.6% (95% confidence interval 5.1% to 16.5%). We did not find evidence of a sustained effect during the 8 months after implementation ended. Over the 12 months from the beginning of implementation, we estimated reductions in the number of under-immunized children that were large but not statistically significant, ranging from 3.9% (-6.9% to 13.7%) to 35.7% (-7.5% to 77.4%) for different vaccines. The largest effects were for the first doses of vaccines against diphtheria-tetanus-pertussis and polio: IMI reached approximately one-third of children who would otherwise not have received these vaccines. This suggests that PIRI can be successful in increasing routine immunization coverage, particularly for early infant vaccines, but other approaches may be needed for sustained coverage improvements.

4.
Epidemics ; 35: 100443, 2021 Feb 20.
Artigo em Inglês | MEDLINE | ID: mdl-33676092

RESUMO

BACKGROUND: Evidence on local disease burden and the completeness of case detection represent important information for TB control programs. We present a new method for estimating subnational TB incidence and the fraction of individuals with incident TB who are diagnosed and treated in Brazil. METHODS: We compiled data on TB notifications and TB-related mortality in Brazil and specified an analytic model approximating incidence as the number of individuals exiting untreated active disease (sum of treatment initiation, death before treatment, and self-cure). We employed a Bayesian inference approach to synthesize data and adjust for known sources of bias. We estimated TB incidence and the fraction of cases treated, for each Brazilian state and the Federal District over 2008-2017. FINDINGS: For 2017, TB incidence was estimated as 41.5 (95 % interval: 40.7, 42.5) per 100 000 nationally, and ranged from 11.7-88.3 per 100 000 across states. The fraction of cases treated was estimated as 91.9 % (89.6 %, 93.7 %) nationally and ranged 86.0 %-94.8 % across states, with an estimated 6.9 (5.3, 9.2) thousand cases going untreated in 2017. Over 2008-2017, incidence declined at an average annual rate of 1.4 % (1.1 %, 1.9 %) nationally, and -1.1%-4.2 % across states. Over this period there was a 0.5 % (0.2 %, 0.9 %) average annual increase in the fraction of incident TB cases treated. INTERPRETATION: Time-series estimates of TB burden and the fraction of cases treated can be derived from routinely-collected data and used to understand variation in TB outcomes and trends.

5.
Emerg Infect Dis ; 27(3): 957-960, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33622464

RESUMO

We adapted a mathematical modeling approach to estimate tuberculosis (TB) incidence and fraction treated for 101 municipalities of Brazil during 2008-2017. We found the average TB incidence rate decreased annually (0.95%), and fraction treated increased (0.30%). We estimated that 9% of persons with TB did not receive treatment in 2017.

6.
Med Decis Making ; 41(4): 379-385, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33535889

RESUMO

Mathematical modeling has played a prominent and necessary role in the current coronavirus disease 2019 (COVID-19) pandemic, with an increasing number of models being developed to track and project the spread of the disease, as well as major decisions being made based on the results of these studies. A proliferation of models, often diverging widely in their projections, has been accompanied by criticism of the validity of modeled analyses and uncertainty as to when and to what extent results can be trusted. Drawing on examples from COVID-19 and other infectious diseases of global importance, we review key limitations of mathematical modeling as a tool for interpreting empirical data and informing individual and public decision making. We present several approaches that have been used to strengthen the validity of inferences drawn from these analyses, approaches that will enable better decision making in the current COVID-19 crisis and beyond.

7.
JMIR Public Health Surveill ; 7(1): e25538, 2021 01 15.
Artigo em Inglês | MEDLINE | ID: mdl-33406053

RESUMO

BACKGROUND: Nowcasting approaches enhance the utility of reportable disease data for trend monitoring by correcting for delays, but implementation details affect accuracy. OBJECTIVE: To support real-time COVID-19 situational awareness, the New York City Department of Health and Mental Hygiene used nowcasting to account for testing and reporting delays. We conducted an evaluation to determine which implementation details would yield the most accurate estimated case counts. METHODS: A time-correlated Bayesian approach called Nowcasting by Bayesian Smoothing (NobBS) was applied in real time to line lists of reportable disease surveillance data, accounting for the delay from diagnosis to reporting and the shape of the epidemic curve. We retrospectively evaluated nowcasting performance for confirmed case counts among residents diagnosed during the period from March to May 2020, a period when the median reporting delay was 2 days. RESULTS: Nowcasts with a 2-week moving window and a negative binomial distribution had lower mean absolute error, lower relative root mean square error, and higher 95% prediction interval coverage than nowcasts conducted with a 3-week moving window or with a Poisson distribution. Nowcasts conducted toward the end of the week outperformed nowcasts performed earlier in the week, given fewer patients diagnosed on weekends and lack of day-of-week adjustments. When estimating case counts for weekdays only, metrics were similar across days when the nowcasts were conducted, with Mondays having the lowest mean absolute error of 183 cases in the context of an average daily weekday case count of 2914. CONCLUSIONS: Nowcasting using NobBS can effectively support COVID-19 trend monitoring. Accounting for overdispersion, shortening the moving window, and suppressing diagnoses on weekends-when fewer patients submitted specimens for testing-improved the accuracy of estimated case counts. Nowcasting ensured that recent decreases in observed case counts were not overinterpreted as true declines and supported officials in anticipating the magnitude and timing of hospitalizations and deaths and allocating resources geographically.


Assuntos
/epidemiologia , Vigilância em Saúde Pública/métodos , Teorema de Bayes , Humanos , Cidade de Nova Iorque/epidemiologia , Estudos Retrospectivos
9.
Med Decis Making ; 41(4): 386-392, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33504258

RESUMO

Policy makers need decision tools to determine when to use physical distancing interventions to maximize the control of COVID-19 while minimizing the economic and social costs of these interventions. We describe a pragmatic decision tool to characterize adaptive policies that combine real-time surveillance data with clear decision rules to guide when to trigger, continue, or stop physical distancing interventions during the current pandemic. In model-based experiments, we find that adaptive policies characterized by our proposed approach prevent more deaths and require a shorter overall duration of physical distancing than alternative physical distancing policies. Our proposed approach can readily be extended to more complex models and interventions.

10.
Epidemiology ; 32(1): 70-78, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33009253

RESUMO

BACKGROUND: Risk of tuberculosis (TB) declines over time since Mycobacterium tuberculosis infection, but progression to clinical disease is still possible decades later. In the United States, most TB cases result from the progression of latent TB infection acquired over 2 years ago. METHODS: We synthesized evidence on TB natural history and incidence trends using a transmission-dynamic model. For the 2020 US population, we estimated average time since infection and annual, cumulative, and remaining lifetime risks of progression to TB, by nativity and age. RESULTS: For a newly infected adult with no other risk factors for progression to TB, estimated rates of progression declined from 38 (95% uncertainty interval: 33, 46) to 0.38 (0.32, 0.45) per 1000 person-years between the first and 25th year since infection. Cumulative risk over 25 years from new infection was 7.9% (7.0, 8.9). In 2020, an estimated average age of individuals with prevalent infection was 62 (61, 63) for the US-born population, 55 (54, 55) for non-US-born, and 57 (56, 58) overall. Average risks of developing TB over the remaining lifetime were 1.2% (1.0, 1.4) for US-born, 2.2% (1.8, 2.6) for non-US-born, and 1.9% (1.6, 2.2) for the general population. Risk estimates were higher for younger age groups. CONCLUSIONS: Our analysis suggests that, although newly infected individuals face appreciable lifetime TB risks, most US individuals with latent TB infection were infected long ago, and face low future risks of developing TB. Better approaches are needed for identifying recently infected individuals and those with elevated progression risks.

11.
Epidemics ; 33: 100419, 2020 Nov 10.
Artigo em Inglês | MEDLINE | ID: mdl-33242759

RESUMO

In the United States, new tuberculosis cases are increasingly concentrated within non-native-born populations. We estimated trends and differences in tuberculosis incidence rates for the non-U.S.-born population, at a resolution unobtainable from raw data. We obtained non-U.S.-born tuberculosis case reports for 2000-2016 from the National Tuberculosis Surveillance System, and population data from the American Community Survey and 2000 U.S. Census. We constructed generalized additive regression models to estimate incidence rates in terms of birth country, entry year, age at entry, and number of years since entry into the United States and described how these factors contribute to overall tuberculosis risk. Controlling for other factors, tuberculosis incidence rates were lower for more recent immigration cohorts, with an incidence risk ratio (IRR) of 10.2 (95 % confidence interval 7.0, 14.7) for the 1950 entry cohort compared to its 2016 counterpart. Greater years since entry and younger age at entry were associated with substantially lower incidence rates. IRRs for birth country varied between 8.86 (6.78, 11.52) for Somalia and 0.02 (0.01, 0.03) for Canada, compared to all non-U.S.-born residents in 2016. IRRs were positively correlated with WHO predicted incidence rate and negatively associated with wealth level for the birth country. Lower country wealth level was also associated with shallower declines in tuberculosis over time. Tuberculosis risks differ by several orders of magnitude within the non-U.S.-born population. A better understanding of these differences will allow more effective targeting of tuberculosis prevention efforts. The methods presented here may also be relevant for understanding tuberculosis trends in other high-income countries.

12.
J Acquir Immune Defic Syndr ; 85(5): 643-650, 2020 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-33177475

RESUMO

BACKGROUND: To assist the Malawi Ministry of Health to evaluate 2 competing strategies for scale-up of isoniazid preventive therapy (IPT) among HIV-positive adults receiving antiretroviral therapy. SETTING: Malawi. METHODS: We used a multidistrict, compartmental model of the Malawi tuberculosis (TB)/HIV epidemic to compare the anticipated health impacts of 6-month versus continuous IPT programs over a 12-year horizon while respecting a US$10.8 million constraint on drug costs in the first 3 years. RESULTS: The 6-month IPT program could be implemented nationwide, whereas the continuous IPT alternative could be introduced in 14 (of the 27) districts. By the end of year 12, the continuous IPT strategy was predicted to avert more TB cases than the 6-month alternative, although not statistically significant (2368 additional cases averted; 95% projection interval [PI], -1459 to 5023). The 6-month strategy required fewer person-years of IPT to avert a case of TB or death than the continuous strategy. For both programs, the mean reductions in TB incidence among people living with HIV by year 12 were expected to be <10%, and the cumulative numbers of IPT-related hepatotoxicity to exceed the number of all-cause deaths averted in the first 3 years. CONCLUSIONS: With the given budgetary constraint, the nationwide implementation of 6-month IPT would be more efficient and yield comparable health benefits than implementing a continuous IPT program in fewer districts. The anticipated health effects associated with both IPT strategies suggested that a combination of different TB intervention strategies would likely be required to yield a greater impact on TB control in settings such as Malawi, where antiretroviral therapycoverage is relatively high.

13.
medRxiv ; 2020 Oct 20.
Artigo em Inglês | MEDLINE | ID: mdl-33106814

RESUMO

To account for delays between specimen collection and report, the New York City Department of Health and Mental Hygiene used a time-correlated Bayesian nowcasting approach to support real-time COVID-19 situational awareness. We retrospectively evaluated nowcasting performance for case counts among residents diagnosed during March-May 2020, a period when the median reporting delay was 2 days. Nowcasts with a 2-week moving window and a negative binomial distribution had lower mean absolute error, lower relative root mean square error, and higher 95% prediction interval coverage than nowcasts conducted with a 3-week moving window or with a Poisson distribution. Nowcasts conducted toward the end of the week outperformed nowcasts performed earlier in the week, given fewer patients diagnosed on weekends and lack of day-of-week adjustments. When estimating case counts for weekdays only, metrics were similar across days the nowcasts were conducted, with Mondays having the lowest mean absolute error, of 183 cases in the context of an average daily weekday case count of 2,914. Nowcasting ensured that recent decreases in observed case counts were not overinterpreted as true declines and supported health department leadership in anticipating the magnitude and timing of hospitalizations and deaths and allocating resources geographically.

15.
BMC Public Health ; 20(1): 1363, 2020 Sep 05.
Artigo em Inglês | MEDLINE | ID: mdl-32891137

RESUMO

BACKGROUND: Chlamydia screening in high schools offers a way to reach adolescents outside of a traditional clinic setting. Using transmission dynamic modeling, we examined the potential impact of high-school-based chlamydia screening programs on the burden of infection within intervention schools and surrounding communities, under varying epidemiological and programmatic conditions. METHODS: A chlamydia transmission model was calibrated to epidemiological data from three different settings. Philadelphia and Chicago are two high-burden cities with existing school-based screening programs. Rural Iowa does not have an existing program but represents a low-burden setting. We modeled the effects of the two existing programs to analyze the potential influence of program coverage and student participation. All three settings were used to examine a broader set of hypothetical programs with varying coverage levels and time trends in participation. RESULTS: In the modeled Philadelphia program, prevalence among the intervention schools' sexually active 15-18 years old population was 4.34% (95% credible interval 3.75-4.71%)after 12 program years compared to 5.03% (4.39-5.43%) in absence of the program. In the modeled Chicago program, prevalence was estimated as 5.97% (2.60-7.88%) after 4 program years compared to 7.00% (3.08-9.29%) without the program. In the broader hypothetical scenarios including both high-burden and low-burden settings, impact of school-based screening programs was greater in absolute terms in the higher-prevalence settings, and benefits in the community were approximately proportional to population coverage of intervention schools. Most benefits were garnered if the student participation did not decline over time. CONCLUSIONS: Sustained high student participation in school-based screening programs and broad coverage of schools within a target community are likely needed to maximize program benefits in terms of reduced burden of chlamydia in the adolescent population.


Assuntos
Infecções por Chlamydia/prevenção & controle , Chlamydia trachomatis , Programas de Rastreamento , Serviços de Saúde Escolar , Instituições Acadêmicas , Estudantes , Adolescente , Chicago/epidemiologia , Infecções por Chlamydia/diagnóstico , Infecções por Chlamydia/epidemiologia , Infecções por Chlamydia/microbiologia , Feminino , Humanos , Iowa/epidemiologia , Masculino , Modelos Teóricos , Aceitação pelo Paciente de Cuidados de Saúde , Philadelphia/epidemiologia , Prevalência
16.
Artigo em Inglês | MEDLINE | ID: mdl-32925361

RESUMO

BACKGROUND: To assist the Malawi Ministry of Health to evaluate two competing strategies for scale-up of isoniazid preventive therapy (IPT) among HIV-positive adults receiving ART. SETTING: Malawi. METHODS: We used a multi-district, compartmental model of the Malawi TB/HIV epidemic to compare the anticipated health impacts of 6-month versus continuous IPT programs over a 12-year horizon, while respecting a US$10.8 million constraint on drug costs in the first three years. RESULTS: The 6-month IPT program could be implemented nationwide while the continuous IPT alternative could be introduced in 14 (out of 27) districts. By the end of year 12, the continuous IPT strategy was predicted to avert more TB cases than the 6-month alternative, although not statistically significantly (2368 additional cases averted; 95%PI, -1459, 5023). The 6-month strategy required fewer person-years of IPT to avert a case of TB or death than the continuous strategy. For both programs, the mean reductions in TB incidence among PLHIV by year 12 were expected to be <10%, and the cumulative numbers of IPT-related hepatotoxicity to exceed the number of all-cause deaths averted in the first three years. CONCLUSION: With the given budgetary constraint, nationwide implementation of 6-month IPT would be more efficient and yield comparable health benefits than implementing continuous IPT program in fewer districts. The anticipated health effects associated with both IPT strategies suggested a combination of different TB intervention strategies would likely be required to yield greater impact on TB control in settings like Malawi, where ART coverage is relatively high.

18.
Lancet Glob Health ; 8(9): e1223-e1233, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32827484

RESUMO

BACKGROUND: In settings of high tuberculosis incidence, previously treated individuals remain at high risk of recurrent tuberculosis and contribute substantially to overall disease burden. Whether tuberculosis case finding and preventive interventions among previously treated people are cost-effective has not been established. We aimed to estimate costs and health benefits of annual post-treatment follow-up examinations and secondary preventive therapy for tuberculosis in a tuberculosis-endemic setting. METHODS: We developed a transmission-dynamic mathematical model and calibrated it to data from two high-incidence communities of approximately 40 000 people in suburban Cape Town, South Africa. We used the model to estimate overall cost and disability-adjusted life-years (DALYs) associated with annual follow-up examinations and secondary isoniazid preventive therapy (IPT), alone and in combination, among individuals completing tuberculosis treatment. We investigated scenarios under which these interventions were restricted to the first year after treatment completion, or extended indefinitely. For each intervention scenario, we projected health system costs and DALYs averted with respect to the current status quo of tuberculosis control. All estimates represent mean values derived from 1000 epidemic trajectories simulated over a 10-year period (2019-28), with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values. FINDINGS: We estimated that a single follow-up examination at the end of the first year after treatment completion combined with 12 months of secondary IPT would avert 2472 DALYs (95% UI -888 to 7801) over a 10-year period and is expected to be cost-saving compared with current control efforts. Sustained annual follow-up and continuous secondary IPT beyond the first year after treatment would avert an additional 1179 DALYs (-1769 to 4377) over 10 years at an expected additional cost of US$18·2 per DALY averted. Strategies of follow-up without secondary IPT were dominated (ie, expected to result in lower health impact at higher costs) by strategies that included secondary IPT. INTERPRETATION: In this high-incidence setting, post-treatment follow-up and secondary preventive therapy can accelerate declines in tuberculosis incidence and potentially save resources for tuberculosis control. Empirical trials to assess the feasibility of these interventions in settings most severely affected by tuberculosis are needed. FUNDING: National Institutes of Health, Günther Labes Foundation, Oskar Helene Heim Foundation.


Assuntos
Assistência ao Convalescente/economia , Prevenção Secundária/economia , Tuberculose/epidemiologia , Tuberculose/prevenção & controle , Análise Custo-Benefício , Humanos , Incidência , Modelos Teóricos , África do Sul/epidemiologia
19.
Am J Respir Crit Care Med ; 202(11): 1567-1575, 2020 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-32645277

RESUMO

Rationale: Most U.S. residents who develop tuberculosis (TB) were born abroad, and U.S. TB incidence is increasingly driven by infection risks in other countries.Objectives: To estimate the potential impact of effective global TB control on health and economic outcomes in the United States.Methods: We estimated outcomes using linked mathematical models of TB epidemiology in the United States and migrants' birth countries. A base-case scenario extrapolated country-specific TB incidence trends. We compared this with scenarios in which countries achieve 90% TB incidence reductions between 2015 and 2035, as targeted by the World Health Organization's End TB Strategy ("effective global TB control"). We also considered pessimistic scenarios of flat TB incidence trends in individual countries.Measurements and Main Results: We estimated TB cases, deaths, and costs and the total economic burden of TB in the United States. Compared with the base-case scenario, effective global TB control would avert 40,000 (95% uncertainty interval, 29,000-55,000) TB cases in the United States in 2020-2035. TB incidence rates in 2035 would be 43% (95% uncertainty interval, 34-54%) lower than in the base-case scenario, and 49% (95% uncertainty interval, 44-55%) lower than in 2020. Summed over 2020-2035, this represents 0.8 billion dollars (95% uncertainty interval, 0.6-1.0 billion dollars) in averted healthcare costs and $2.5 billion dollars (95% uncertainty interval, 1.7-3.6 billion dollars) in productivity gains. The total U.S. economic burden of TB (including the value of averted TB deaths) would be 21% (95% uncertainty interval, 16-28%) lower (18 billion dollars [95% uncertainty level, 8-32 billion dollars]).Conclusions: In addition to producing major health benefits for high-burden countries, strengthened efforts to achieve effective global TB control could produce substantial health and economic benefits for the United States.

20.
J Int AIDS Soc ; 23 Suppl 1: e25507, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32562364

RESUMO

INTRODUCTION: Despite growing enthusiasm for integrating treatment of non-communicable diseases (NCDs) into human immunodeficiency virus (HIV) care and treatment services in sub-Saharan Africa, there is little evidence on the potential health and financial consequences of such integration. We aim to study the cost-effectiveness of basic NCD-HIV integration in a Ugandan setting. METHODS: We developed an epidemiologic-cost model to analyze, from the provider perspective, the cost-effectiveness of integrating hypertension, diabetes mellitus (DM) and high cholesterol screening and treatment for people living with HIV (PLWH) receiving antiretroviral therapy (ART) in Uganda. We utilized cardiovascular disease (CVD) risk estimations drawing from the previously established Globorisk model and systematic reviews; HIV and NCD risk factor prevalence from the World Health Organization's STEPwise approach to Surveillance survey and global databases; and cost data from national drug price lists, expert consultation and the literature. Averted CVD cases and corresponding disability-adjusted life years were estimated over 10 subsequent years along with incremental cost-effectiveness of the integration. RESULTS: Integrating services for hypertension, DM, and high cholesterol among ART patients in Uganda was associated with a mean decrease of the 10-year risk of a CVD event: from 8.2 to 6.6% in older PLWH women (absolute risk reduction of 1.6%), and from 10.7 to 9.5% in older PLWH men (absolute risk reduction of 1.2%), respectively. Integration would yield estimated net costs between $1,400 and $3,250 per disability-adjusted life year averted among older ART patients. CONCLUSIONS: Providing services for hypertension, DM and high cholesterol for Ugandan ART patients would reduce the overall CVD risk among these patients; it would amount to about 2.4% of national HIV/AIDS expenditure, and would present a cost-effectiveness comparable to other standalone interventions to address NCDs in low- and middle-income country settings.

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