Sweat M, Gregorich S, Sangiwa G, Furlonge C, Balmer D, Kamenga C, Grinstead O, Coates T
School of Hygiene and Public Health, Johns Hopkins University, Baltimore, MD 21205, USA.
Lancet. 2000 Jul 8;356(9224):113-21. doi: 10.1016/S0140-6736(00)02447-8.
BACKGROUND: Access to HIV-1 voluntary counselling and testing (VCT) is severely limited in less-developed countries. We undertook a multisite trial of HIV-1 VCT to assess its impact, cost, and cost-effectiveness in less-developed country settings. METHODS: The cost-effectiveness of HIV-1 VCT was estimated for a hypothetical cohort of 10000 people seeking VCT in urban east Africa. Outcomes were modelled based on results from a randomised controlled trial of HIV-1 VCT in Tanzania and Kenya. Our main outcome measures included programme cost, number of HIV-1 infections averted, cost per HIV-1 infection averted, and cost per disability-adjusted life-year (DALY) saved. We also modelled the impact of targeting VCT by HIV-1 prevalence of the client population, and the proportion of clients who receive VCT as a couple compared with as individuals. Sensitivity analysis was done on all model parameters. FINDINGS: HIV-1 VCT was estimated to avert 1104 HIV-1 infections in Kenya and 895 in Tanzania during the subsequent year. The cost per HIV-1 infection averted was US$249 and $346, respectively, and the cost per DALY saved was $12.77 and $17.78. The intervention was most cost-effective for HIV-1-infected people and those who received VCT as a couple. The cost-effectiveness of VCT was robust, with a range for the average cost per DALY saved of $5.16-27.36 in Kenya, and $6.58-45.03 in Tanzania. Analysis of targeting showed that increasing the proportion of couples to 70% reduces the cost per DALY saved to $10.71 in Kenya and $13.39 in Tanzania, and that targeting a population with HIV-1 prevalence of 45% decreased the cost per DALY saved to $8.36 in Kenya and $11.74 in Tanzania. INTERPRETATION: HIV-1 VCT is highly cost-effective in urban east African settings, but slightly less so than interventions such as improvement of sexually transmitted disease services and universal provision of nevirapine to pregnant women in high-prevalence settings. With the targeting of VCT to populations with high HIV-1 prevalence and couples the cost-effectiveness of VCT is improved significantly.
背景：在欠发达国家，获得艾滋病病毒1型自愿咨询检测（VCT）的机会极为有限。我们开展了一项艾滋病病毒1型VCT多中心试验，以评估其在欠发达国家环境中的影响、成本及成本效益。 方法：针对东非城市中假设的10000名寻求VCT的人群，估算艾滋病病毒1型VCT的成本效益。结局根据坦桑尼亚和肯尼亚艾滋病病毒1型VCT随机对照试验的结果进行建模。我们的主要结局指标包括项目成本、避免的艾滋病病毒1型感染数、避免每例艾滋病病毒1型感染的成本以及每挽救一个伤残调整生命年（DALY）的成本。我们还对根据服务对象人群的艾滋病病毒1型流行率进行VCT目标设定的影响，以及接受VCT的夫妇与个人比例进行了建模。对所有模型参数进行了敏感性分析。 结果：估计在随后一年中，艾滋病病毒1型VCT在肯尼亚可避免1104例艾滋病病毒1型感染，在坦桑尼亚可避免895例。避免每例艾滋病病毒1型感染的成本分别为249美元和346美元，每挽救一个DALY的成本为12.77美元和17.78美元。该干预措施对艾滋病病毒1型感染者和以夫妇形式接受VCT的人最具成本效益。VCT的成本效益很稳健，在肯尼亚，每挽救一个DALY的平均成本范围为5.16 - 27.36美元，在坦桑尼亚为6.58 - 45.03美元。目标设定分析表明，将夫妇比例提高到70%可使肯尼亚每挽救一个DALY的成本降至10.71美元，坦桑尼亚降至13.39美元；针对艾滋病病毒1型流行率为45%的人群进行目标设定，可使肯尼亚每挽救一个DALY的成本降至8.36美元，坦桑尼亚降至11.74美元。 解读：艾滋病病毒1型VCT在东非城市环境中具有很高的成本效益，但略低于改善性传播疾病服务和在高流行环境中向孕妇普遍提供奈韦拉平之类的干预措施。将VCT目标设定为艾滋病病毒1型高流行人群和夫妇，VCT的成本效益可显著提高。
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