Ades A E, Ratcliffe J, Gibb D M, Sculpher M J
Department of Epidemiology and Public Health, Institute of Child Health, London, England.
Pharmacoeconomics. 2000 Jul;18(1):9-22. doi: 10.2165/00019053-200018010-00002.
In the absence of interventions, 20% of infants born to women infected with HIV acquire infection from their mother at or before delivery. A further 15% are infected through breast feeding. Prenatal testing for HIV allows infected women to be reliably identified so that they can receive antiretroviral therapy and, in countries with safe water supplies, be advised not to breast feed. These and other interventions can reduce the risk of transmission to 5% or less. Economic evaluations of prenatal testing for HIV are reviewed and compared in this article, and future research priorities outlined. These studies set the costs of testing and intervention against the averted lifetime costs of paediatric infection, and generate estimates of the HIV prevalence threshold above which there would be a net cost saving, or calculate the cost per life-year saved given a particular prevalence. In the developed world, prenatal testing has been adopted in many countries, and recent economic analyses broadly support this. Future research is likely to focus on the incremental benefits of different antiretroviral regimens in lowering transmission rates still further, with or without elective caesarean section, and the possibility that some may lead to adverse effects in uninfected infants exposed to them in utero. Some earlier assessments in resource-poor settings concluded that prenatal testing was unaffordable or of doubtful cost effectiveness. This negative conclusion appears to be the result of very low estimates of the lifetime costs of paediatric HIV infection, together with developed world conceptions of pre-test counselling. The demonstration that nevirapine reduces transmission risk at a low cost has transformed the outlook, and there is hope that antiretrovirals can act prophylactically to prevent infection of the breast-fed child. However, to achieve a sustained reduction in vertical transmission there may be a need to evaluate the need for a strengthened infrastructure to deliver prenatal HIV testing and treatment, as well as programmes to reduce HIV incidence in adults.
在没有干预措施的情况下，感染艾滋病毒的妇女所生婴儿中有20%在分娩时或分娩前会从母亲那里感染艾滋病毒。另有15%是通过母乳喂养感染的。对艾滋病毒进行产前检测能够可靠地识别出感染妇女，以便她们能够接受抗逆转录病毒治疗，并且在有安全供水的国家，建议她们不要进行母乳喂养。这些干预措施及其他措施可将传播风险降低至5%或更低。本文对艾滋病毒产前检测的经济评估进行了综述和比较，并概述了未来的研究重点。这些研究将检测和干预的成本与避免的儿童感染终生成本进行了对比，并得出了艾滋病毒流行率阈值的估计值，高于该阈值会有净成本节约，或者计算出在特定流行率下每挽救一个生命年的成本。在发达国家，许多国家已采用产前检测，近期的经济分析大体上支持这一做法。未来的研究可能会聚焦于不同抗逆转录病毒方案在进一步降低传播率方面的增量效益，无论是否进行选择性剖宫产，以及某些方案可能会对子宫内接触这些方案的未感染婴儿产生不良反应的可能性。一些早期在资源匮乏环境下的评估得出结论，产前检测难以承受或成本效益存疑。这一负面结论似乎是由于对儿童艾滋病毒感染的终生成本估计过低，以及发达国家对检测前咨询的观念所致。奈韦拉平能以低成本降低传播风险这一事实改变了局面，人们希望抗逆转录病毒药物能够起到预防作用，防止母乳喂养的儿童感染。然而，为了持续降低垂直传播率，可能需要评估是否需要加强基础设施以提供艾滋病毒产前检测和治疗，以及降低成年人艾滋病毒发病率的项目。
