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 Table of Contents  
REVIEW ARTICLES
Year : 2019  |  Volume : 10  |  Issue : 3  |  Page : 89-96

The economic burden of HIV and type 2 diabetes comorbidity: Implications for care in countries with high burden of HIV


1 Discipline of Public Health, College of Health Sciences, Howard College Campus, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
2 Discipline of Public Health, College of Health Sciences, Howard College Campus, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa; Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa

Date of Web Publication27-Aug-2019

Correspondence Address:
Dr. Sakhile K S Masuku
College of Health Sciences, University of KwaZulu-Natal, Private Bag, X54001, Durban 4000.
South Africa
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jod.jod_50_18

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  Abstract 

The economic burden of human immunodeficiency virus (HIV) and diabetes shows the need to design interventions to delay the development of type 2 diabetes in HIV-positive population. In 2015 alone, approximately US$19 billion was spent in the HIV/acquired immunodeficiency syndrome response in low- and middle-income countries. Approximately 57% of the total HIV resources in low- and middle-income countries come from the local government budgets. Rising numbers of new HIV infections in many countries mean that US$26.2 billion will be required for the response to the epidemic in 2020. On the other hand, the cost of diabetes mellitus alone is projected to be US$745 billion by 2030 and approximately US$300 billion is estimated to be the cost incurred in low- and middle-income countries. People diagnosed with diabetes at the age of 40 years spent US$124,600 more than those without diabetes over their remaining lifetime. The co-occurrence of type 2 diabetes and HIV increases the economic burden at patient and country level, hence there is a need to identify interventions for preventing diabetes among people living with HIV. This review has shown that both lifestyle and pharmacologic interventions are proven effective and cost-effective. Lifestyle modification, metformin intervention, and diabetes surveillance among people living with HIV are cost-effective strategies that can effectively prevent the development of diabetes in this population. There is also a need for the health policy to support the implementation of these strategies. Health and social policies should support the funding of intensive lifestyle and metformin interventions for diabetes prevention in high-risk groups.

Keywords: Diabetes prevention, economic burden, human immunodeficiency virus, lifestyle, metformin, people living with HIV, type 2 diabetes mellitus


How to cite this article:
Masuku SK, Tsoka-Gwegweni JM, Sartorius B. The economic burden of HIV and type 2 diabetes comorbidity: Implications for care in countries with high burden of HIV. J Diabetol 2019;10:89-96

How to cite this URL:
Masuku SK, Tsoka-Gwegweni JM, Sartorius B. The economic burden of HIV and type 2 diabetes comorbidity: Implications for care in countries with high burden of HIV. J Diabetol [serial online] 2019 [cited 2019 Sep 16];10:89-96. Available from: http://www.journalofdiabetology.org/text.asp?2019/10/3/89/265418




  Global Burden of Human Immunodeficiency Virus Infection Top


Since the last three decades, human immunodeficiency (HIV) infection has remained a query of disquiet globally. It has demanded more than 35 million lives,[1] without being selective of age or gender. Since the beginning of the epidemic, more than 70 million people have been infected with HIV, and by the end of 2015 approximately 36.7 million (34.0–39.8 million) people were living with HIV.[1] The reproductive age group, 15–49 years, is the most affected group, with an estimated prevalence of 0.8% (0.7%–0.9%).[1] There were approximately 350 daily acquired immunodeficiency syndrome (AIDS)-related deaths among children and adolescents (aged 0–19 years) in 2015; 86% of them occurred in sub-Saharan Africa and 11% in Asia and the Pacific.[2]

Apparently, the estimated number of people living with HIV (PLHIV) has been increasing over the years. For instance, in 2010, approximately 34 million people were living with HIV.[3] In 2014, the number increased to 35 million.[4] By the end of 2015, that number had increased by approximately 1.7 million to 36.7 million.[1] Without refuting such concerns, it is worth noting that with intensified HIV prevention and control strategies, more and new people learnt their HIV-positive status. For instance, the number of health facilities providing HIV testing and counseling increased to 177,000 in 2014 in 129 countries, rising up from 143,000 in 2011 in the 129 countries.[5] Hence, the observed increase in prevalence may be indicating that the prevalence of HIV has been underreported in the past, and that it may still be underreported. For instance, it is still estimated that approximately 40% of all PLHIV do not know that they have the virus,[2] implying that as HIV surveillance is intensified the prevalence is yet to increase.

Of all the regions in the world, the sub-Saharan African (SSA) region is the most hard-hit by HIV. This region remains most severely affected, with nearly 1 in every 25 adults (4.4%) living with HIV, and nearly 70% of all PLHIV globally come from this region.[1] In fact, approximately 25.5 million PLHIV live in the SSA region, with a majority of them (an estimated 19 million) living in the eastern part of the region.[6] The southern part of this region contributed 46% of all new HIV infections globally in 2015.[6] Of all HIV-related deaths globally, 72% come from the SSA region.[4] This is clearly depicted by epidemiologic statistic from some countries from this region. For instance, in Swaziland, from the first HIV reported case in 1986, HIV has been rampantly spreading throughout the population,[7] to the current prevalence rate of 26% in the reproductive age group of 15–49 years;[8] and among pregnant women receiving antenatal care (ANC), HIV infection has been steadily increasing from 3.9% in 1992 to 41.1% in 2010.[9]

Burden of noncommunicable disease

Although HIV is a cause for concern globally, noncommunicable diseases (NCDs) are becoming important determinants of hospital admissions and they contribute to a large proportion of in-hospital mortality. For instance, in Swaziland, according to the health management information system (HMIS) database 2013, outpatient and inpatient data from all health facilities reveal that NCDs were responsible for 1,233,967 cases.[10] The NCDs represent 13.2% of all cases seen at the OPD among which 17% account for the admitted patients. The proportion of NCDs that patients present with at OPD includes hypertension at 6.5%, diabetes mellitus (DM) at 2.4%, and injuries and road traffic accidents at 3.3% to mention but a few.[11] In the past decade, a consistent increase in the total number of admissions because of NCDs has been documented by the HMIS.[12] Only 0.7% of the government support goes to NCD prevention,[13] which implies that those having NCDs may be required to spend a lot. In the years, 2008–2013, the average number of days that a patient diagnosed with diabetes spent in hospital is 10 days.[12] Even though a majority of health care offered in public health facilities is seldom paid for, travelling fees to hospitals, consultations, and investigations may pose as a barrier to accessing essential care.

Among the NCDs, DM is one of the most important NCDs of public health concern in both developed and developing countries. DM prevalence has been increasing in the past decades.[14],[15] The number of people with DM has risen from 108 million in 1980 to 422 million in 2014.[16] The global prevalence of DM among adults over 18 years of age has risen from 4.7% in 1980 to 8.5% in 2014.[16] Since 1998, diabetes prevalence projections have always shown a large and increasing burden. For instance, in 1998, DM burden projections estimated that 300 million adults globally will be having DM by 2025.[17] In 2004, the World Health Organization estimated that 170 million adults in 2000 had DM globally, and on projections, the number was expected to increase to 366 million adults by 2030.[18] The International Diabetes Federation estimated that 194 million people in 2003 had DM,[19] and in 2006, the global burden was estimated at 246 million people,[20] and had risen to 282 million in 2010.[21] In 2011, DM prevalence was projected to increase by 50.7% by 2030.[17] In 2013, a global DM prevalence of 382 million people was reported, and projections show an expected increase to 592 million people in 2035.[22]

It comes as concerning news that contrary to the popular perception that diseases such as DM are more common in high-income countries, diabetes prevalence has been rising more rapidly in middle- and low-income countries.[16] Even more concerning is that people with diabetes in low- and middle-income countries are mostly those below 50 years (59%),[16] which is the most sexually active group, and having the highest HIV disease burden,[1] compared to the high-income countries with diabetes predominantly common in those above 50 years (74%).[16] The projection of DM burden over the next coming 13 years in low-income countries is simply disturbing. DM projections estimate that low-income countries will experience a 108% increase by 2030, with low-middle-income countries (LMIC) experiencing a 60% increase.[21] The upper-middle-income countries are projected to experience a 51% increment, with the least (28%) increment expected from high-income countries.[21] Either than the fact that the global burden of DM is projected to double from 180 million to 366 million by 2030,[18] 80% of which is expected to come from LMIC; NCD deaths occur at younger ages in LMIC compared to that in high-income countries.[23] Deaths occurring at younger ages cumulatively result in losses[21] economically, which may adversely affect the economic situation of a country.


  Economic Burden of Human Immunodeficiency Virus and Noncommunicable Diseases Top


Many studies have shown a close link between HIV and NCDs.[24],[25],[26] Many NCDs such as diabetes, hypertension, and other cardiovascular diseases are inherent in HIV infection itself,[27],[28] being on antiretroviral therapy (ART) regardless of regime,[29],[30] and the duration on ART.[31],[32] The prevalence of DM among the HIV-positive population has been increasing and concerning, particularly in developing countries.[33] Although diabetes alone is a debilitative condition, HIV affects the quality of life and substantially reduces the life span. The co-occurrence of the two conditions does not only affect the quality of life but come with medical costs, at patient and country level.

The growing concern of HIV and DM comorbidity relates to the increasing medical cost of care in general. Studies on prices of medicines and other items have shown that the cost of medical care is very high and increasing. For instance, a recent study conducted in Swaziland investigated prices, availability, and affordability of medicines along the supply chain among private and public health facilities in the Manzini region in Swaziland. Its findings showed a mean availability of medicines of 68% in the public sector, implying that sometimes patients need to buy some medicines from the private sector (pharmacy) wage.[34] The private sector originator brand medicines were priced 32.4 times higher than the international reference prices, whereas the price of the lowest priced generic equivalent was 7.32 times higher.[34] The originator brand costs 473% more than the lowest priced generic equivalent wage.[34] The total cumulative markups for individual medicines range from 190.99% to 440.27% and the largest contributor to add-on cost was the retail markup (31%–53%). The standard treatment with originator brands costs more than a day’s wage.[34] The aforementioned suggests that comorbidity of HIV and diabetes can be much costlier for patients, hence the motivation to estimate the economic impact of HIV and DM is coexisting.

Of increasing concern is the cost and necessary funding to meet HIV care demands. In 2015 alone, US$19 billion was invested in the HIV/AIDS response in low- and middle-income countries, with 57% of the total HIV resources in these countries coming from domestic budgets.[35] Rising numbers of new HIV infections in many countries mean that US$26.2 billion will be required for the response to the epidemic in 2020.[35] It is mind-numbing to imagine the cost of care in cases of HIV/tuberculosis or HIV and other NCDs.

Although the cost of HIV care increases, the burden of diabetes among PLHIV implies more economic consequences. DM together with other prevalent NCDs in LMIC are estimated to cost 4% of the countries’ gross domestic product (World Economic Forum and the Harvard School of Public Health, 2011). The global cost of DM alone is projected to be $745 billion by 2030 accounting for $300 billion, which is expected to cost LMIC.[36]

Studies have shown that compared to a nondiabetic person, the medical expenditure of a person who is diabetic is higher. The per capita medical spending for a person who is diabetic is more than twice that of nondiabetic person.[37] For instance, the expected yearly expenditure for a newly diabetes diagnosed person at 40 years is US$8500 annually, whereas a comparable nondiabetic person spends US$3900.[38] A diabetic person diagnosed at 40 years spent US$124,600 more, if not discounted, the cost rose to US$211,400, than a comparable nondiabetic person.[38] If diagnosed with diabetes at 50 years, the discounted lifetime excess medical spending was US$91,200, and the costs decreased if diabetes was diagnosed later in life.[38] It is worth mentioning that these costs do not take into account the cost of HIV care, implying that the costs could be higher.

Of note is that excess lifetime medical spending due to diabetes for women is higher than that for men. One study showed that regardless of age at diagnosis, a person with diabetes spent considerably more on health care after the age of 65 years than a nondiabetic person.[38] Health-care spending on diabetes after the age of 65 years was between US$23,900 and US$40,900, and was dependent on sex and age at diagnosis.[38] Of the total lifetime medical spending for an average patient with diabetes diagnosed at 50 years, prescription medications and inpatient care accounted for 44% and 35% of costs, respectively. Outpatient care and other medical care accounted for 17% and 4% of costs, respectively.[38]

On the basis of the aforementioned studies, the economic burden of diabetes is very high, and it is only logical to expect that the comorbidity of HIV and type 2 diabetes (T2DM), which account for 90%–95% of diabetes cases[39] to be higher. On another note, T2DM has been found to be preventable through lifestyle or pharmacological interventions.[40],[41],[42] The high cost associated with diabetes implies that reducing incidence through prevention might lower lifetime medical spending and alleviate some of the future economic burden of treating diabetes. It is worth noting that such economic estimations are lacking for many developing countries, particularly in the SSA region, yet they would indicate the urgency of quantifying the burden of DM, economic effects to inform policies, and developing a model of care for those at risk. It is now necessary more than ever to find and implement cost-effective approaches in the prevention of diabetes, especially among PLHIV.


  Cost-effective Approaches to Reduce Co-occurrence of Human Immunodeficiency Virus and Diabetes Top


There have been many arguments on the cost-effectiveness of preventing chronic diseases. Some researchers argue that curtain prevention approaches are not cost saving. For instance, although prevention averts costs from treating the disease, it may also extend life expectancy and thus could result in more years of health-care spending and possibly in greater lifetime medical spending.[38] Considering the shortened life expectancy seen with diabetes, there are arguments whether lifetime medical costs for people without diabetes exceed the medical costs in the shortened life expectancy seen with diabetes. Previous studies of the economic consequences of diabetes prevention[43],[44] have yielded mixed findings. Some studies have suggested that preventing diabetes, like preventing some other chronic diseases, would increase medical costs in part because of increased life spans. Other studies[45],[46],[47],[48] have found that diabetes prevention would lead to substantial long-term cost savings, despite the extended life expectancy.

It is worth noting that the goal of public health is to improve the quality of life through cost-effective approaches, not cost saving. From a health system perspective, the value of delaying or preventing the development of T2DM is that it delays or prevents the direct medical costs of diabetes including the costs of diabetes education and nutritional counseling, glucose monitoring, anti-hyperglycemic treatments, and surveillance and treatment of complications.[49],[50],[51] From a societal perspective, diabetes prevention reduces health-care-related costs to the individual not reimbursed by the health system and time lost from work and usual activities.[49] It also improves quality of life.

In many cases, chronic disease prevention has been found to be cost-effective but not cost saving,[52] which suffices in public health. Preventing a case of diabetes is more cost-effective than incurring the potential lifetime cost of diabetes. Much of the economic burden of diabetes is related to its complications and comorbidities.[37] Review of four published studies of intensive glycemic management for T2DM suggests that prevention is more cost-effective than the treatment of diabetes.[53],[54],[55] Using the prevention approach, people who develop diabetes are screen-detected very early in their clinical course and have few complications. The costs of diabetes increase with the duration of diabetes and with the presence of complications and comorbidities and would be expected to be lower for persons with short durations of diabetes and for those without complications.[56] Patients with new clinically diagnosed diabetes have been reported to have cost 2.1 times those of individuals without diabetes, and the incremental cost of diabetes is apparent from the time of diagnosis.[50]

Studies have shown that delaying diabetes through prevention offers more health and economic benefits. For instance, among men diagnosed with diabetes at the age of 40 years, 34% were expected to survive to the age of 80 years; among men of the same age who never developed diabetes, 55% were expected to survive to the age of 80 years.[38] Taking the example of America, the increase in health-care expenditures is related to the increase in the size of the population with diagnosed diabetes. The large proportion of expenditures incurred by the population at 65 years of age and the large proportion of expenditures related to late diabetes complications suggest that the interventions to delay or prevent the development of diabetes in at-risk Americans and the treatments to delay or prevent the development of complications and comorbidities in Americans with diagnosed diabetes, may be most effective in stemming the growing economic burden of diabetes.[37] In studies, it has also been evident that despite a shorter life expectancy, people with diagnosed diabetes accumulated substantially greater lifetime medical spending than similar people without diabetes. The excess lifetime costs were smaller for people diagnosed at older ages, primarily because they had a shorter remaining life expectancy.[38]

Another example of cost-effectiveness of prevention can be drawn from the American situation of diabetes. Over the past three decades, the number of Americans with diagnosed diabetes has more than tripled, from 6 million in 1980 to 21 million in 2010.[57] Given the current size of the US population with diabetes, coupled with more than 79 million people with prediabetes who are at a high risk of developing T2DM,[58] the lifetime cost estimates suggest that medical spending associated with diabetes will add an enormous burden to health-care costs and will persist for at least the next several decades. For instance, in 2011 nearly 150,000 Americans were diagnosed with diabetes between the ages of 65 and 69 years.[59] On the basis of our estimates, this cohort of patients with newly diagnosed diabetes alone would be expected to add US$4.6 billion to future medical spending, the majority of which would be paid by Medicare. Without effective diabetes prevention, increased medical spending because of diabetes will have a major fiscal impact on Medicare. Some researchers have suggested that the increasing prevalence of diabetes has been one of the leading causes of the growth in Medicare spending.[60] Prevention might avoid US$124,600 (discounted) in lifetime medical spending if a new case of diabetes can be prevented at the age of 40 years.[38] If prevented at the age of 50 years, (discounted) spending of US$91,200 might be avoided over a lifetime.[38]

The actual savings from intervention, if any, certainly would depend on many factors such as using interventions that are both effective at preventing diabetes and durable. T2DM has been found to be preventable through lifestyle or pharmacological interventions.[39],[40],[41],[42] These interventions and their effectiveness are discussed below.

Lifestyle changes

A structured lifestyle modification program has been found to reduce the risk of diabetes by 50%–58%.[39],[40] Intensive lifestyle interventions can delay or prevent progression from impaired glucose tolerance to T2DM.[53],[39] Randomized controlled clinical trials have clearly demonstrated the efficacy of lifestyle interventions in delaying the onset of T2DM.[61],[62] One randomized controlled clinical trial, the Diabetes Prevention Program (DPP), showed that intensive lifestyle intervention (lifestyle) reduced the incidence of T2DM by 58% over 2.8 years.[39] A second study followed the DPP study participants over a duration of 10 years. It revealed that the incidence of diabetes during the 10-year average follow-up after randomization was reduced by 34% in those initially randomized to lifestyle.[40]

Some studies have shown that lifestyle modification can be implementable in health care. For instance, observational follow-up studies of clinical trials have shown that the benefits of lifestyle interventions persist for 7–20 years.[40],[48],[63] On another note, translational studies have shown that lifestyle interventions can be adapted and translated into primary care.[64],[65],[66] Lifestyle interventions can also be successfully translated into community practice through organizations such as Young Men’s Christian Associations[67],[68] and diabetes self-management education programs.[69] For instance, in Finland, lifestyle interventions for diabetes prevention were successfully translated into a National Diabetes Prevention Program (DPP), and a 1-year follow-up study showed that the approach was effective.[70] This approach can be replicated in many settings, especially in HIV-positive populations.

Furthermore, emerging studies suggest that such risk reduction could be achieved at a reasonably low cost.[55] Studies also suggest a favorable long-term financial gain from diabetes prevention.[38] For instance, in the DPP study, the direct medical care costs of nonintervention-related medical care were 34%–44% higher among participants who were diabetic compared to nondiabetic.[40] Every year after randomization, quality of life improved for participants on lifestyle intervention compared to those on metformin. The undiscounted, cumulative, quality of well-being score gained over 10 years was greatest for lifestyle (6.89) intervention participants.[40] Even when the direct nonmedical costs of lifestyle interventions are considered, the interventions were cost-effective. From a health system perspective, with both costs and health outcomes discounted at 3% per year, the cost of lifestyle intervention was cost-effective.[40] Lifestyle was generally less expensive and more effective, but when compared to metformin, lifestyle cost more but produced better health outcomes.[40]

These findings suggest the importance of incorporating lifestyle modification into HIV care as an approach to prevent T2DM among PLHIV. There is a need for a model of care that can link lifestyle modification with HIV care to ensure effective implementation of lifestyle interventions among PLHIV.

Diabetes prevention using metformin

Pharmacological interventions have been implicated as another approach to diabetes prevention. In randomized controlled clinical trials, pharmacologic interventions have shown that at least three classes of oral antidiabetic medications are effective in delaying the onset of T2DM.[39],[69],[70] By delaying the onset of diabetes, such interventions reduce the cumulative incidence of diabetes complications and result in longer lives and improved quality of life.[71] The DPP study also showed that metformin intervention reduced the incidence of T2DM by 31% over 2.8 years.[39] In a 10-year follow-up study of the DPP participants, the diabetes prevention program outcomes study (DPPOS) study observed that the incidence of diabetes during the 10-year average follow-up after randomization was reduced by 18% in those initially randomized to metformin.[40] The cumulative, undiscounted, per participant quality of well-being score gained over 10 years was 6.79 for metformin. It is worth noting that the metformin intervention, as per the aforementioned study findings, is less effective in preventing T2DM compared to lifestyle intervention.

Besides being effective in preventing development of T2DM, metformin comes with less cost. For instance, in the DPP study, each cost was approximately US$140 per participant per year for metformin. The estimated cost of the DPP group lifestyle intervention (US$2995) was approximately one-third less than that of the lifestyle intervention.[39] It is worth noting, though, that the costs of lifestyle were substantially less during the 10 years of diabetes prevention program outcomes study (DPPOS) follow-up study, partly because of the change from an individual- to a group-implemented intervention and because fewer visits took place. This highlights an even more cost-effective way of implementing the lifestyle intervention. The metformin intervention can be an alternative or combined to lifestyle intervention as per the needs of patients.


  Active Surveillance for Diabetes Top


Some studies have shown that active surveillance of diabetes offers many benefits. It leads to early diagnosis of diabetes and prevents complications.[40] Surveillance of diabetes involves screening of risk factors of diabetes such as being overweight, obese, and of having glucose intolerance. In addition, early aggressive management of glycemia and cardiovascular risk factors must be implemented for persons diagnosed with diabetes. This approach has been argued from different research perspectives. For instance, studies of the lifetime costs for an obese person relative to a person with normal body weight show mixed results: estimated excess lifetime medical costs for people with obesity range from US$3790 less to US$39,000 more than the costs for those who are nonobese.[72],[73] Some factors explaining this difference may be that, first, the impact of obesity on longevity remains unclear,[74] but diabetes is known to be associated with a relatively modest loss of life years.[75] Second, obesity, when considered alone, results in much lower annual excess medical costs than diabetes, that is, US$940–US$1150 for obesity compared to US$2000–US$4700 for diabetes, when compared with costs for people who are nonobese.[72],[73] It is worth mentioning that many studies have shown the close link between obesity and diabetes,[23],[24] and if obesity alone comes with health costs, it is worth preventing it and averts subsequent cost that could be incurred in case diabetes develops. Screening for glucose intolerance in the overweight and obese population and implementing lifestyle and metformin interventions would have favorable cost-effectiveness ratios.[55],[56],[76]

This approach works best when used as a strategy for identifying patients to enroll on the lifestyle and metformin interventions. This implies that a combination of the three approaches depending on a patient’s need can effectively prevent diabetes. Although the cost-effectiveness of a combination of the three approaches has not been evaluated, ranking patients as per their needs in diabetes prevention can be suggested in program implementation. These interventions should be advocated for in the health policy.[37] There is also a need for complimentary societal interventions to delay the onset of T2DM, such as school/community-based health promotion programs and interventions that address advertising, food availability and price, and even tax policy.


  Conclusion Top


The growing economic and societal burden of HIV and diabetes depicts the need to implement interventions to delay the development of T2DM among PLHIV. Both intensive lifestyle and pharmacologic interventions are proven effective and cost-effective. Health and social policies should support the funding of intensive lifestyle and metformin interventions for diabetes prevention in high-risk groups. It is also necessary to increase access to care, including self-management education and nutritional counseling, and ensuring access to necessary treatments and supplies. These are critical interventions, especially in light of the proven value of early intensive treatment in preventing chronic complications.


  Compliance with Ethical Standards Top


Ethical approval

This article does not contain any studies with human participants performed by any of the authors.

Informed consent

This article does not contain any studies with human participants performed by any of the authors, hence there was no need for consent from participants.

Financial support and sponsorship

This study was conducted as part academic qualification, hence except for university scholarship, there was no funding obtained to conduct the study.

Conflicts of interest

There are no conflicts of interest.



 
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