Unité d'Epidémiologie des Maladies Emergentes, Institut Pasteur, Paris, France.
PLoS One. 2010 Nov 9;5(11):e13856. doi: 10.1371/journal.pone.0013856.
Cryptococcal infection is a frequent cause of mortality in Cambodian HIV-infected patients with CD4+ count ≤100 cells/µl. This study assessed the cost-effectiveness of three strategies for cryptococcosis prevention in HIV-infected patients.
A MARKOV DECISION TREE WAS USED TO COMPARE THE FOLLOWING STRATEGIES AT THE TIME OF HIV DIAGNOSIS: no intervention, one time systematic serum cryptococcal antigen (CRAG) screening and treatment of positive patients, and systematic primary prophylaxis with fluconazole. The trajectory of a hypothetical cohort of HIV-infected patients with CD4+ count ≤100 cells/µl initiating care was simulated over a 1-year period (cotrimoxazole initiation at enrollment; antiretroviral therapy within 3 months). Natural history and cost data (US$ 2009) were from Cambodia. Efficacy data were from international literature.
In a population in which 81% of patients had a CD4+ count ≤50 cells/ µl and 19% a CD4+ count between 51-100 cells/µl, the proportion alive 1 year after enrollment was 61% (cost $ 472) with no intervention, 70% (cost $ 483) with screening, and 72% (cost $ 492) with prophylaxis. After one year of follow-up, the cost-effectiveness of screening vs. no intervention was US$ 180/life year gained (LYG). The cost-effectiveness of prophylaxis vs. screening was $ 511/LYG. The cost-effectiveness of prophylaxis vs. screening was estimated at $1538/LYG if the proportion of patients with CD4+ count ≤50 cells/µl decreased by 75%.
In a high endemic area of cryptococcosis and HIV infection, serum CRAG screening and prophylaxis are two cost effective strategies to prevent AIDS associated cryptococcosis in patients with CD4+ count ≤100 cells/µl, at a short-term horizon, screening being more cost-effective but less effective than prophylaxis. Systematic primary prophylaxis may be preferred in patients with CD4+ below 50 cells/µl while systematic serum CRAG screening for early targeted treatment may be preferred in patients with CD4+ between 51-100 cells/µl.
在柬埔寨 CD4+计数≤100 个/μL 的 HIV 感染患者中，隐球菌感染是导致死亡的常见原因。本研究评估了三种隐球菌病预防策略在 HIV 感染患者中的成本效益。
使用 MARKOV 决策树在 HIV 诊断时比较以下策略：不干预、一次系统性血清隐球菌抗原（CRAG）筛查和治疗阳性患者、以及氟康唑系统性初级预防。模拟了一个假设的 CD4+计数≤100 个/μL 的 HIV 感染患者队列的轨迹，该队列在 1 年内开始接受治疗（在入组时开始使用复方新诺明；在 3 个月内开始抗逆转录病毒治疗）。自然史和成本数据（2009 年美元）来自柬埔寨。疗效数据来自国际文献。
在一个 81%的患者 CD4+计数≤50 个/μL 和 19%的患者 CD4+计数在 51-100 个/μL 的人群中，入组后 1 年的存活率为 61%（成本 472 美元），不干预为 70%（成本 483 美元），筛查为 72%（成本 492 美元）。随访 1 年后，与不干预相比，筛查的成本效益为每获得 1 个生命年增加 180 美元（LYG）。与筛查相比，预防的成本效益为 511 美元/LYG。如果 CD4+计数≤50 个/μL 的患者比例降低 75%，预防与筛查相比的成本效益估计为 1538 美元/LYG。
在隐球菌病和 HIV 感染高发地区，血清 CRAG 筛查和预防是两种预防 CD4+计数≤100 个/μL 的 HIV 感染患者发生 AIDS 相关隐球菌病的具有成本效益的策略，从短期来看，筛查的成本效益更高，但效果不如预防。在 CD4+计数低于 50 个/μL 的患者中，系统的初级预防可能更为优先，而在 CD4+计数在 51-100 个/μL 的患者中，进行系统性血清 CRAG 筛查以进行早期靶向治疗可能更为优先。
