Paltiel A David, Weinstein Milton C, Kimmel April D, Seage George R, Losina Elena, Zhang Hong, Freedberg Kenneth A, Walensky Rochelle P
Department of Epidemiology and Public Health, Yale School of Medicine, New Haven, Conn 06520-8034, USA.
N Engl J Med. 2005 Feb 10;352(6):586-95. doi: 10.1056/NEJMsa042088.
BACKGROUND: Although the Centers for Disease Control and Prevention (CDC) recommend routine HIV counseling, testing, and referral (HIVCTR) in settings with at least a 1 percent prevalence of HIV, roughly 280,000 Americans are unaware of their human immunodeficiency virus (HIV) infection. The effect of expanded screening for HIV is unknown in the era of effective antiretroviral therapy. METHODS: We developed a computer simulation model of HIV screening and treatment to compare routine, voluntary HIVCTR with current practice in three target populations: "high-risk" (3.0 percent prevalence of undiagnosed HIV infection; 1.2 percent annual incidence); "CDC threshold" (1.0 percent and 0.12 percent, respectively); and "U.S. general" (0.1 percent and 0.01 percent). Input data were derived from clinical trials and observational cohorts. Outcomes included quality-adjusted survival, cost, and cost-effectiveness. RESULTS: In the high-risk population, the addition of one-time screening for HIV antibodies with an enzyme-linked immunosorbent assay (ELISA) to current practice was associated with earlier diagnosis of HIV (mean CD4 cell count at diagnosis, 210 vs. 154 per cubic millimeter). One-time screening also improved average survival time among HIV-infected patients (quality-adjusted survival, 220.7 months vs. 219.8 months). The incremental cost-effectiveness was 36,000 dollars per quality-adjusted life-year gained. Testing every five years cost 50,000 dollars per quality-adjusted life-year gained, and testing every three years cost 63,000 dollars per quality-adjusted life-year gained. In the CDC threshold population, the cost-effectiveness ratio for one-time screening with ELISA was 38,000 dollars per quality-adjusted life-year gained, whereas testing every five years cost 71,000 dollars per quality-adjusted life-year gained, and testing every three years cost 85,000 dollars per quality-adjusted life-year gained. In the U.S. general population, one-time screening cost 113,000 dollars per quality-adjusted life-year gained. CONCLUSIONS: In all but the lowest-risk populations, routine, voluntary screening for HIV once every three to five years is justified on both clinical and cost-effectiveness grounds. One-time screening in the general population may also be cost-effective.
背景：尽管美国疾病控制与预防中心（CDC）建议在艾滋病毒感染率至少为1%的场所开展常规艾滋病毒咨询、检测及转诊服务（HIVCTR），但仍有大约28万美国人未意识到自己感染了人类免疫缺陷病毒（HIV）。在有效的抗逆转录病毒治疗时代，扩大艾滋病毒筛查的效果尚不清楚。 方法：我们开发了一个艾滋病毒筛查和治疗的计算机模拟模型，以比较常规的、自愿的HIVCTR与当前在三个目标人群中的做法：“高危人群”（未诊断出的艾滋病毒感染率为3.0%；年发病率为1.2%）；“CDC阈值人群”（分别为1.0%和0.12%）；以及“美国普通人群”（0.1%和0.01%）。输入数据来自临床试验和观察性队列。结果包括质量调整后的生存期、成本和成本效益。 结果：在高危人群中，在当前做法的基础上增加一次用酶联免疫吸附测定（ELISA）检测艾滋病毒抗体与艾滋病毒的更早诊断相关（诊断时的平均CD4细胞计数，每立方毫米210个对154个）。一次性筛查也改善了艾滋病毒感染患者的平均生存时间（质量调整后的生存期，220.7个月对219.8个月）。每获得一个质量调整生命年的增量成本效益为36,000美元。每五年检测一次，每获得一个质量调整生命年的成本为50,000美元，每三年检测一次，每获得一个质量调整生命年的成本为63,000美元。在CDC阈值人群中，用ELISA进行一次性筛查的成本效益比为每获得一个质量调整生命年38,000美元，而每五年检测一次，每获得一个质量调整生命年的成本为71,000美元，每三年检测一次，每获得一个质量调整生命年的成本为85,000美元。在美国普通人群中，一次性筛查每获得一个质量调整生命年的成本为113,000美元。 结论：除了风险最低的人群外，基于临床和成本效益的理由，每三到五年进行一次常规的、自愿的艾滋病毒筛查是合理的。在普通人群中进行一次性筛查也可能具有成本效益。
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