Bendavid Eran, Brandeau Margaret L, Wood Robin, Owens Douglas K
Division of General Internal Medicine, Center for Health Policy, Department of Management Science and Engineering, Stanford University, 117 Encina Commons, Stanford, CA 94305-8526, USA.
Arch Intern Med. 2010 Aug 9;170(15):1347-54. doi: 10.1001/archinternmed.2010.249.
Universal testing and treatment holds promise for reducing the burden of human immunodeficiency virus (HIV) in sub-Saharan Africa, but linkage from testing to treatment sites and retention in care are inadequate.
We developed a simulation of the HIV epidemic and HIV disease progression in South Africa to compare the outcomes of the present HIV treatment campaign (status quo) with 4 HIV testing and treating strategies that increase access to antiretroviral therapy: (1) universal testing and treatment without changes in linkage to care and loss to follow-up; (2) universal testing and treatment with improved linkage to care; (3) universal testing and treatment with reduced loss to follow-up; and (4) comprehensive HIV care with universal testing and treatment, improved linkage to care, and reduced loss to follow-up. The main outcome measures were survival benefits, new HIV infections, and HIV prevalence.
Compared with the status quo strategy, universal testing and treatment (1) was associated with a mean (95% uncertainty bounds) life expectancy gain of 12.0 months (11.3-12.2 months), and 35.3% (32.7%-37.5%) fewer HIV infections over a 10-year time horizon. Improved linkage to care (2), prevention of loss to follow-up (3), and comprehensive HIV care (4) provided substantial additional benefits: life expectancy gains compared with the status quo strategy were 16.1, 18.6, and 22.2 months, and new infections were 55.5%, 51.4%, and 73.2% lower, respectively. In sensitivity analysis, comprehensive HIV care reduced new infections by 69.7% to 76.7% under a broad set of assumptions.
Universal testing and treatment with current levels of linkage to care and loss to follow-up could substantially reduce the HIV death toll and new HIV infections. However, increasing linkage to care and preventing loss to follow-up provides nearly twice the benefits of universal testing and treatment alone.
普遍检测与治疗有望减轻撒哈拉以南非洲地区人类免疫缺陷病毒（HIV）的负担，但从检测到治疗地点的衔接以及治疗依从性方面存在不足。
我们对南非的HIV疫情和HIV疾病进展进行了模拟，以比较当前HIV治疗行动（现状）与4种增加抗逆转录病毒治疗可及性的HIV检测与治疗策略的结果：（1）普遍检测与治疗，不改变治疗衔接和失访情况；（2）普遍检测与治疗，改善治疗衔接；（3）普遍检测与治疗，减少失访；（4）全面HIV护理，包括普遍检测与治疗、改善治疗衔接以及减少失访。主要结局指标为生存获益、新发HIV感染和HIV患病率。
与现状策略相比，普遍检测与治疗（1）在10年时间范围内，平均（95%不确定区间）预期寿命增加12.0个月（11.3 - 12.2个月），HIV感染减少35.3%（32.7% - 37.5%）。改善治疗衔接（2）、预防失访（3）和全面HIV护理（4）带来了显著的额外益处：与现状策略相比，预期寿命增加分别为16.1、18.6和22.2个月，新发感染分别降低55.5%、51.4%和73.2%。在敏感性分析中，在一系列广泛假设下，全面HIV护理将新发感染减少69.7%至76.7%。
在当前治疗衔接和失访水平下进行普遍检测与治疗可大幅降低HIV死亡人数和新发HIV感染。然而，增加治疗衔接和预防失访带来的益处几乎是单纯普遍检测与治疗的两倍。
