Scaling Up the 2010 World Health Organization HIV Treatment Guidelines in Resource-Limited Settings: A Model-Based Analysis
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{"title"=>"Scaling up the 2010 World Health Organization HIV treatment guidelines in resource-limited settings: A model-based analysis", "type"=>"journal", "authors"=>[{"first_name"=>"Rochelle P.", "last_name"=>"Walensky", "scopus_author_id"=>"6602540593"}, {"first_name"=>"Robin", "last_name"=>"Wood", "scopus_author_id"=>"7404053384"}, {"first_name"=>"Andrea L.", "last_name"=>"Ciaranello", "scopus_author_id"=>"6506141936"}, {"first_name"=>"A. David", "last_name"=>"Paltiel", "scopus_author_id"=>"7004306826"}, {"first_name"=>"Sarah B.", "last_name"=>"Lorenzana", "scopus_author_id"=>"36696536400"}, {"first_name"=>"Xavier", "last_name"=>"Anglaret", "scopus_author_id"=>"26643306600"}, {"first_name"=>"Adam W.", "last_name"=>"Stoler", "scopus_author_id"=>"36627755200"}, {"first_name"=>"Kenneth A.", "last_name"=>"Freedberg", "scopus_author_id"=>"7004947755"}], "year"=>2010, "source"=>"PLoS Medicine", "identifiers"=>{"issn"=>"15491277", "isbn"=>"1549-1676", "pmid"=>"21209794", "scopus"=>"2-s2.0-78650472932", "pui"=>"360215978", "doi"=>"10.1371/journal.pmed.1000382", "sgr"=>"78650472932"}, "id"=>"3e20ee6c-388b-34ef-89fd-ff6672e77003", "abstract"=>"BACKGROUND: The new 2010 World Health Organization (WHO) HIV treatment guidelines recommend earlier antiretroviral therapy (ART) initiation (CD4<350 cells/µl instead of CD4<200 cells/µl), multiple sequential ART regimens, and replacement of first-line stavudine with tenofovir. This paper considers what to do first in resource-limited settings where immediate implementation of all of the WHO recommendations is not feasible.\\n\\nMETHODS AND FINDINGS: We use a mathematical model and local input data to project clinical and economic outcomes in a South African HIV-infected cohort (mean age = 32.8 y, mean CD4 = 375/µl). For the reference strategy, we assume that all patients initiate stavudine-based ART with WHO stage III/IV disease and receive one line of ART (stavudine/WHO/one-line). We rank-in survival, cost-effectiveness, and equity terms-all 12 possible combinations of the following: (1) stavudine replacement with tenofovir, (2) ART initiation (by WHO stage, CD4<200 cells/µl, or CD4<350 cells/µl), and (3) one or two regimens, or lines, of available ART. Projected life expectancy for the reference strategy is 99.0 mo. Considering each of the guideline components separately, 5-y survival is maximized with ART initiation at CD4<350 cells/µl (stavudine/<350/µl/one-line, 87% survival) compared with stavudine/WHO/two-lines (66%) and tenofovir/WHO/one-line (66%). The greatest life expectancies are achieved via the following stepwise programmatic additions: stavudine/<350/µl/one-line (124.3 mo), stavudine/<350/µl/two-lines (177.6 mo), and tenofovir/<350/µl/two-lines (193.6 mo). Three program combinations are economically efficient: stavudine/<350/µl/one-line (cost-effectiveness ratio, US$610/years of life saved [YLS]), tenofovir/<350/µl/one-line (US$1,140/YLS), and tenofovir/<350/µl/two-lines (US$2,370/YLS).\\n\\nCONCLUSIONS: In settings where immediate implementation of all of the new WHO treatment guidelines is not feasible, ART initiation at CD4<350 cells/µl provides the greatest short- and long-term survival advantage and is highly cost-effective.", "link"=>"http://www.mendeley.com/research/scaling-up-2010-world-health-organization-hiv-treatment-guidelines-resourcelimited-settings-modelbas-10", "reader_count"=>62, "reader_count_by_academic_status"=>{"Unspecified"=>1, "Professor > Associate Professor"=>3, "Researcher"=>15, "Student > Doctoral Student"=>5, "Student > Ph. D. Student"=>4, "Student > Postgraduate"=>3, "Student > Master"=>19, "Other"=>5, "Student > Bachelor"=>2, "Lecturer"=>1, "Lecturer > Senior Lecturer"=>2, "Professor"=>2}, "reader_count_by_user_role"=>{"Unspecified"=>1, "Professor > Associate Professor"=>3, "Researcher"=>15, "Student > Doctoral Student"=>5, "Student > Ph. D. Student"=>4, "Student > Postgraduate"=>3, "Student > Master"=>19, "Other"=>5, "Student > Bachelor"=>2, "Lecturer"=>1, "Lecturer > Senior Lecturer"=>2, "Professor"=>2}, "reader_count_by_subject_area"=>{"Unspecified"=>4, "Engineering"=>1, "Nursing and Health Professions"=>1, "Mathematics"=>1, "Medicine and Dentistry"=>35, "Agricultural and Biological Sciences"=>5, "Business, Management and Accounting"=>1, "Pharmacology, Toxicology and Pharmaceutical Science"=>1, "Chemistry"=>2, "Social Sciences"=>6, "Economics, Econometrics and Finance"=>4, "Biochemistry, Genetics and Molecular Biology"=>1}, "reader_count_by_subdiscipline"=>{"Engineering"=>{"Engineering"=>1}, "Medicine and Dentistry"=>{"Medicine and Dentistry"=>35}, "Chemistry"=>{"Chemistry"=>2}, "Social Sciences"=>{"Social Sciences"=>6}, "Economics, Econometrics and Finance"=>{"Economics, Econometrics and Finance"=>4}, "Agricultural and Biological Sciences"=>{"Agricultural and Biological Sciences"=>5}, "Nursing and Health Professions"=>{"Nursing and Health Professions"=>1}, "Business, Management and Accounting"=>{"Business, Management and Accounting"=>1}, "Mathematics"=>{"Mathematics"=>1}, "Biochemistry, Genetics and Molecular Biology"=>{"Biochemistry, Genetics and Molecular Biology"=>1}, "Unspecified"=>{"Unspecified"=>4}, "Pharmacology, Toxicology and Pharmaceutical Science"=>{"Pharmacology, Toxicology and Pharmaceutical Science"=>1}}, "reader_count_by_country"=>{"Mozambique"=>1, "United States"=>2, "Brazil"=>1, "Italy"=>1, "South Africa"=>1, "Kenya"=>1, "Switzerland"=>1, "Indonesia"=>1}, "group_count"=>5}

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  • {"files"=>["https://ndownloader.figshare.com/files/811104"], "description"=>"<p>The reference strategy and the strategies selected in the stepwise progression in <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000382#pmed-1000382-t002\" target=\"_blank\">Table 2</a> are shown in bold.</p>a<p>We use the following nomenclature to define the strategies: nucleoside analog used in first line/ART initiation criterion/number of available regimens. All strategies with initiation criteria indicated by a CD4 count threshold assume availability of CD4 count monitoring; WHO indicates WHO stage III/IV disease.</p>b<p>Strongly dominated (more expensive but confer less clinical benefit than some other strategy) <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000382#pmed.1000382-Gold1\" target=\"_blank\">[12]</a>.</p>c<p>Weakly dominated (more expensive but confer less clinical benefit than some combination of other strategies) <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000382#pmed.1000382-Gold1\" target=\"_blank\">[12]</a>.</p>", "links"=>[], "tags"=>["incremental", "cost-effectiveness", "ratios", "12", "stepwise", "combinations", "2010", "hiv"], "article_id"=>481457, "categories"=>["Medicine", "Cancer", "Information And Computing Sciences"], "users"=>["Rochelle P. Walensky", "Robin Wood", "Andrea L. Ciaranello", "A. David Paltiel", "Sarah B. Lorenzana", "Xavier Anglaret", "Adam W. Stoler", "Kenneth A. Freedberg"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1000382.t003", "stats"=>{"downloads"=>1, "page_views"=>1, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Life_expectancy_costs_and_incremental_cost_effectiveness_ratios_of_the_12_possible_stepwise_combinations_and_no_ART_from_the_reference_strategy_to_full_implementation_of_2010_WHO_HIV_treatment_guidelines_/481457", "title"=>"Life expectancy, costs, and incremental cost-effectiveness ratios of the 12 possible stepwise combinations (and no ART) from the reference strategy to full implementation of 2010 WHO HIV treatment guidelines.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2010-12-21 00:24:17"}
  • {"files"=>["https://ndownloader.figshare.com/files/810968"], "description"=>"<p>The clinical and economic outcomes of all combinations of scale-up interventions are examined. The efficient frontier (marked by the line) connects the non-dominated strategies in the cost-effectiveness plane. Strategies below and to the right of the efficient frontier are those that are either strongly or weakly dominated by other options (see <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000382#s3\" target=\"_blank\">Methods</a>). As illustrated in the upper panel, strategies based on clinical criteria (WHO stage III/IV) alone fall far below the efficient frontier (lower right oval), indicating their relatively high cost for the comparative benefit gained. Strategies in the upper left oval are those representing CD4 monitoring and one line of ART. Strategies incorporating a second-line regimen (upper right oval) all confer large survival benefits but at increased costs. The lower panel examines potential country situations. For instance, a country with a current stavudine/WHO/one-line policy could switch to a tenofovir/<350/µl/one-line policy (open arrow) and both decrease projected per-person lifetime costs and improve survival. A country with a stavudine/<200/µl/one-line policy could decrease per-person costs and also improve outcomes by changing to a stavudine/<350/µl/one-line policy (solid arrowhead). Countries with a stavudine/<200/µl/two-lines policy would require increased per-person expenditures to achieve the survival benefits associated with tenofovir/<350/µl/two-lines (dotted arrow). To illustrate the impact of a policy requiring that all persons receive the same intervention, we examine the arbitrary affordability threshold of US$11,500 per person. The bracket (upper right) denotes the per person survival loss (14.5 mo) attributable to a policy requiring that all persons receive the same intervention.</p>", "links"=>[], "tags"=>["outcomes", "scale-up"], "article_id"=>481330, "categories"=>["Medicine", "Cancer", "Information And Computing Sciences"], "users"=>["Rochelle P. Walensky", "Robin Wood", "Andrea L. Ciaranello", "A. David Paltiel", "Sarah B. Lorenzana", "Xavier Anglaret", "Adam W. Stoler", "Kenneth A. Freedberg"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1000382.g003", "stats"=>{"downloads"=>0, "page_views"=>4, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Clinical_and_economic_outcomes_of_each_of_the_scale_up_interventions_/481330", "title"=>"Clinical and economic outcomes of each of the scale-up interventions.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2010-12-21 00:22:10"}
  • {"files"=>["https://ndownloader.figshare.com/files/811054"], "description"=>"<p>We use the following nomenclature to define the strategies: nucleoside analog used in first line/ART initiation criterion/number of available regimens. All strategies with initiation criteria indicated by a CD4 count threshold assume availability of CD4 count monitoring. For each step, the option that maximizes survival is shown in bold.</p><p><sup><b>a</b></sup>Change relative to the program selected in the previous step.</p>", "links"=>[], "tags"=>["expectancies", "choices", "stepwise", "progression", "2010", "hiv"], "article_id"=>481414, "categories"=>["Medicine", "Cancer", "Information And Computing Sciences"], "users"=>["Rochelle P. Walensky", "Robin Wood", "Andrea L. Ciaranello", "A. David Paltiel", "Sarah B. Lorenzana", "Xavier Anglaret", "Adam W. Stoler", "Kenneth A. Freedberg"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1000382.t002", "stats"=>{"downloads"=>3, "page_views"=>3, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Projected_life_expectancies_associated_with_alternative_choices_in_the_stepwise_progression_toward_full_implementation_of_the_2010_WHO_HIV_treatment_guidelines_/481414", "title"=>"Projected life expectancies associated with alternative choices in the stepwise progression toward full implementation of the 2010 WHO HIV treatment guidelines.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2010-12-21 00:23:34"}
  • {"files"=>["https://ndownloader.figshare.com/files/810784"], "description"=>"<p>Clinical and policy decisions result in 12 possible implementation strategies. These strategies are listed in <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000382#pmed.1000382.s005\" target=\"_blank\">Text S1</a>. Squares represent decision points. The reference strategy is bolded. d4t, stavudine; TDF, tenofovir.</p>", "links"=>[], "tags"=>["decisions", "12"], "article_id"=>481151, "categories"=>["Medicine", "Cancer", "Information And Computing Sciences"], "users"=>["Rochelle P. Walensky", "Robin Wood", "Andrea L. Ciaranello", "A. David Paltiel", "Sarah B. Lorenzana", "Xavier Anglaret", "Adam W. Stoler", "Kenneth A. Freedberg"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1000382.g001", "stats"=>{"downloads"=>3, "page_views"=>3, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Clinical_and_policy_decisions_yield_12_implementation_strategies_/481151", "title"=>"Clinical and policy decisions yield 12 implementation strategies.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2010-12-21 00:19:11"}
  • {"files"=>["https://ndownloader.figshare.com/files/810881"], "description"=>"<p>Model-projected survival curves (undiscounted) of the reference strategy (stavudine/WHO/one-line) and the three strategies projected to maximize life expectancy in stepwise progression toward the 2010 WHO guidelines (see <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000382#s4\" target=\"_blank\">Results</a> and <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000382#pmed-1000382-t002\" target=\"_blank\">Table 2</a> for details). Curves highlighting outcomes over the next 5 y are provided in <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000382#pmed.1000382.s004\" target=\"_blank\">Figure S4</a>. The 20-y horizon is presented here, not to imply that HIV treatment will remain unchanged over this time horizon, but rather to demonstrate when different interventions will have meaningful survival impacts. Median survival increases from 90 mo with stavudine/WHO/one-line (reference strategy) to 121 mo with the addition of CD4 monitoring and ART initiation at CD4<350 cells/µl (stavudine/<350/µl/one-line, step 1) to 177 mo with the addition of a second-line ART regimen (stavudine/<350/µl/two-lines, step 2). A subsequent switch from stavudine to tenofovir results in a comparatively modest survival advantage, with a median survival increase to 196 mo (tenofovir/<350/µl/two-lines, step 3). The survival curve of step 3 represents what might be expected when allthe 2010 WHO treatment guidelines are fully implemented.</p>", "links"=>[], "tags"=>["infectious diseases/hiv infection and aids", "public health and epidemiology/global health", "public health and epidemiology/health policy"], "article_id"=>481245, "categories"=>["Medicine", "Cancer", "Information And Computing Sciences"], "users"=>["Rochelle P. Walensky", "Robin Wood", "Andrea L. Ciaranello", "A. David Paltiel", "Sarah B. Lorenzana", "Xavier Anglaret", "Adam W. Stoler", "Kenneth A. Freedberg"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1000382.g002", "stats"=>{"downloads"=>1, "page_views"=>2, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Model_projected_survival_curves_/481245", "title"=>"Model-projected survival curves.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2010-12-21 00:20:45"}
  • {"files"=>["https://ndownloader.figshare.com/files/811141"], "description"=>"<p>“Range examined” indicates that we examined both extreme and intermediate values within the specified ranges.</p>a<p>Range indicated by CD4 count; details by CD4 strata are presented in the <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000382#pmed.1000382.s005\" target=\"_blank\">Text S1</a>.</p>b<p>The percent monthly risk of mild fungal infections is increased by 46.4% in the presence of co-trimoxazole <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000382#pmed.1000382-Anglaret1\" target=\"_blank\">[22]</a>.</p>c<p>Projected using published 24-wk data <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000382#pmed.1000382-Hammond1\" target=\"_blank\">[19]</a>.</p>d<p>Estimated from published 24- and 48-wk data <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000382#pmed.1000382-Gallant1\" target=\"_blank\">[24]</a>.</p>e<p>Estimated from published 24- and 48-wk data <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000382#pmed.1000382-Delfraissy1\" target=\"_blank\">[16]</a>.</p>", "links"=>[], "tags"=>["parameters", "2010"], "article_id"=>481503, "categories"=>["Medicine", "Cancer", "Information And Computing Sciences"], "users"=>["Rochelle P. Walensky", "Robin Wood", "Andrea L. Ciaranello", "A. David Paltiel", "Sarah B. Lorenzana", "Xavier Anglaret", "Adam W. Stoler", "Kenneth A. Freedberg"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1000382.t001", "stats"=>{"downloads"=>0, "page_views"=>3, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Model_input_parameters_for_analysis_of_the_2010_WHO_ART_guidelines_/481503", "title"=>"Model input parameters for analysis of the 2010 WHO ART guidelines.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2010-12-21 00:25:03"}
  • {"files"=>["https://ndownloader.figshare.com/files/404563", "https://ndownloader.figshare.com/files/404595", "https://ndownloader.figshare.com/files/404624", "https://ndownloader.figshare.com/files/404648", "https://ndownloader.figshare.com/files/404672", "https://ndownloader.figshare.com/files/404766", "https://ndownloader.figshare.com/files/404845"], "description"=>"<div><h3>Background</h3><p>The new 2010 World Health Organization (WHO) HIV treatment guidelines recommend earlier antiretroviral therapy (ART) initiation (CD4<350 cells/µl instead of CD4<200 cells/µl), multiple sequential ART regimens, and replacement of first-line stavudine with tenofovir. This paper considers what to do first in resource-limited settings where immediate implementation of all of the WHO recommendations is not feasible.</p><h3>Methods and Findings</h3><p>We use a mathematical model and local input data to project clinical and economic outcomes in a South African HIV-infected cohort (mean age = 32.8 y, mean CD4 = 375/µl). For the reference strategy, we assume that all patients initiate stavudine-based ART with WHO stage III/IV disease and receive one line of ART (stavudine/WHO/one-line). We rank—in survival, cost-effectiveness, and equity terms—all 12 possible combinations of the following: (1) stavudine replacement with tenofovir, (2) ART initiation (by WHO stage, CD4<200 cells/µl, or CD4<350 cells/µl), and (3) one or two regimens, or lines, of available ART. Projected life expectancy for the reference strategy is 99.0 mo. Considering each of the guideline components separately, 5-y survival is maximized with ART initiation at CD4<350 cells/µl (stavudine/<350/µl/one-line, 87% survival) compared with stavudine/WHO/two-lines (66%) and tenofovir/WHO/one-line (66%). The greatest life expectancies are achieved via the following stepwise programmatic additions: stavudine/<350/µl/one-line (124.3 mo), stavudine/<350/µl/two-lines (177.6 mo), and tenofovir/<350/µl/two-lines (193.6 mo). Three program combinations are economically efficient: stavudine/<350/µl/one-line (cost-effectiveness ratio, US$610/years of life saved [YLS]), tenofovir/<350/µl/one-line (US$1,140/YLS), and tenofovir/<350/µl/two-lines (US$2,370/YLS).</p><h3>Conclusions</h3><p>In settings where immediate implementation of all of the new WHO treatment guidelines is not feasible, ART initiation at CD4<350 cells/µl provides the greatest short- and long-term survival advantage and is highly cost-effective.</p><h3></h3><p><em>Please see later in the article for the Editors' Summary</em></p></div>", "links"=>[], "tags"=>["scaling", "2010", "hiv", "guidelines", "resource-limited", "model-based"], "article_id"=>139951, "categories"=>["Medicine", "Cancer", "Information And Computing Sciences"], "users"=>["Rochelle P. Walensky", "Robin Wood", "Andrea L. Ciaranello", "A. David Paltiel", "Sarah B. Lorenzana", "Xavier Anglaret", "Adam W. Stoler", "Kenneth A. Freedberg"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.1000382.s001", "https://dx.doi.org/10.1371/journal.pmed.1000382.s002", "https://dx.doi.org/10.1371/journal.pmed.1000382.s003", "https://dx.doi.org/10.1371/journal.pmed.1000382.s004", "https://dx.doi.org/10.1371/journal.pmed.1000382.s005", "https://dx.doi.org/10.1371/journal.pmed.1000382.s006", "https://dx.doi.org/10.1371/journal.pmed.1000382.s007"], "stats"=>{"downloads"=>27, "page_views"=>9, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/Scaling_Up_the_2010_World_Health_Organization_HIV_Treatment_Guidelines_in_Resource_Limited_Settings_A_Model_Based_Analysis/139951", "title"=>"Scaling Up the 2010 World Health Organization HIV Treatment Guidelines in Resource-Limited Settings: A Model-Based Analysis", "pos_in_sequence"=>0, "defined_type"=>4, "published_date"=>"2010-12-21 02:45:51"}

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  • {"unique-ip"=>"3", "full-text"=>"2", "pdf"=>"2", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2016", "month"=>"9"}
  • {"unique-ip"=>"5", "full-text"=>"4", "pdf"=>"2", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2016", "month"=>"10"}
  • {"unique-ip"=>"2", "full-text"=>"1", "pdf"=>"1", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2016", "month"=>"11"}
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  • {"unique-ip"=>"9", "full-text"=>"6", "pdf"=>"2", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"1", "cited-by"=>"2", "year"=>"2017", "month"=>"1"}
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  • {"unique-ip"=>"6", "full-text"=>"5", "pdf"=>"3", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2017", "month"=>"3"}
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  • {"unique-ip"=>"3", "full-text"=>"4", "pdf"=>"5", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2017", "month"=>"5"}
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  • {"unique-ip"=>"5", "full-text"=>"6", "pdf"=>"2", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2017", "month"=>"8"}
  • {"unique-ip"=>"5", "full-text"=>"3", "pdf"=>"1", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"1", "cited-by"=>"0", "year"=>"2017", "month"=>"9"}
  • {"unique-ip"=>"11", "full-text"=>"17", "pdf"=>"1", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"2", "supp-data"=>"1", "cited-by"=>"0", "year"=>"2017", "month"=>"10"}
  • {"unique-ip"=>"1", "full-text"=>"1", "pdf"=>"0", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2017", "month"=>"11"}
  • {"unique-ip"=>"5", "full-text"=>"5", "pdf"=>"3", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"4", "cited-by"=>"0", "year"=>"2018", "month"=>"1"}
  • {"unique-ip"=>"5", "full-text"=>"4", "pdf"=>"3", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2018", "month"=>"3"}
  • {"unique-ip"=>"7", "full-text"=>"9", "pdf"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2019", "month"=>"1"}
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  • {"unique-ip"=>"5", "full-text"=>"6", "pdf"=>"2", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2018", "month"=>"5"}
  • {"unique-ip"=>"3", "full-text"=>"1", "pdf"=>"2", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2018", "month"=>"6"}
  • {"unique-ip"=>"5", "full-text"=>"1", "pdf"=>"1", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"4", "cited-by"=>"0", "year"=>"2018", "month"=>"7"}
  • {"unique-ip"=>"4", "full-text"=>"4", "pdf"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2018", "month"=>"8"}
  • {"unique-ip"=>"4", "full-text"=>"3", "pdf"=>"2", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2018", "month"=>"9"}
  • {"unique-ip"=>"1", "full-text"=>"1", "pdf"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2018", "month"=>"10"}
  • {"unique-ip"=>"5", "full-text"=>"4", "pdf"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"2", "cited-by"=>"0", "year"=>"2018", "month"=>"11"}
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  • {"unique-ip"=>"5", "full-text"=>"4", "pdf"=>"1", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2019", "month"=>"2"}
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  • {"unique-ip"=>"5", "full-text"=>"5", "pdf"=>"1", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2019", "month"=>"8"}
  • {"unique-ip"=>"14", "full-text"=>"8", "pdf"=>"1", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"6", "supp-data"=>"1", "cited-by"=>"1", "year"=>"2019", "month"=>"9"}
  • {"unique-ip"=>"9", "full-text"=>"5", "pdf"=>"3", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"1", "year"=>"2019", "month"=>"10"}
  • {"unique-ip"=>"15", "full-text"=>"9", "pdf"=>"10", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2019", "month"=>"12"}
  • {"unique-ip"=>"25", "full-text"=>"25", "pdf"=>"2", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"3", "cited-by"=>"0", "year"=>"2020", "month"=>"2"}
  • {"unique-ip"=>"21", "full-text"=>"25", "pdf"=>"2", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2020", "month"=>"3"}
  • {"unique-ip"=>"15", "full-text"=>"16", "pdf"=>"2", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2020", "month"=>"4"}
  • {"unique-ip"=>"13", "full-text"=>"14", "pdf"=>"1", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2020", "month"=>"5"}
  • {"unique-ip"=>"17", "full-text"=>"18", "pdf"=>"2", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"1", "cited-by"=>"0", "year"=>"2020", "month"=>"6"}
  • {"unique-ip"=>"7", "full-text"=>"4", "pdf"=>"3", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"7", "cited-by"=>"0", "year"=>"2020", "month"=>"7"}
  • {"unique-ip"=>"5", "full-text"=>"4", "pdf"=>"2", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2020", "month"=>"8"}
  • {"unique-ip"=>"7", "full-text"=>"4", "pdf"=>"2", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2020", "month"=>"9"}
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Relative Metric

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