美国扩大艾滋病毒筛查和抗逆转录病毒治疗的成本效益和人群结果。
The cost-effectiveness and population outcomes of expanded HIV screening and antiretroviral treatment in the United States.
机构信息
Yale School of Management, New Haven, Connecticut 06520, USA.
出版信息
Ann Intern Med. 2010 Dec 21;153(12):778-89. doi: 10.7326/0003-4819-153-12-201012210-00004.
BACKGROUND
Although recent guidelines call for expanded routine screening for HIV, resources for antiretroviral therapy (ART) are limited, and all eligible persons are not currently receiving treatment.
OBJECTIVE
To evaluate the effects on the U.S. HIV epidemic of expanded ART, HIV screening, or interventions to reduce risk behavior.
DESIGN
Dynamic mathematical model of HIV transmission and disease progression and cost-effectiveness analysis.
DATA SOURCES
Published literature.
TARGET POPULATION
High-risk (injection drug users and men who have sex with men) and low-risk persons aged 15 to 64 years in the United States.
TIME HORIZON
Twenty years and lifetime (costs and quality-adjusted life-years [QALYs]).
PERSPECTIVE
Societal.
INTERVENTION
Expanded HIV screening and counseling, treatment with ART, or both.
OUTCOME MEASURES
New HIV infections, discounted costs and QALYs, and incremental cost-effectiveness ratios.
RESULTS OF BASE-CASE ANALYSIS: One-time HIV screening of low-risk persons coupled with annual screening of high-risk persons could prevent 6.7% of a projected 1.23 million new infections and cost $22,382 per QALY gained, assuming a 20% reduction in sexual activity after screening. Expanding ART utilization to 75% of eligible persons prevents 10.3% of infections and costs $20,300 per QALY gained. A combination strategy prevents 17.3% of infections and costs $21,580 per QALY gained.
RESULTS OF SENSITIVITY ANALYSIS
With no reduction in sexual activity, expanded screening prevents 3.7% of infections. Earlier ART initiation when a CD4 count is greater than 0.350 × 10(9) cells/L prevents 20% to 28% of infections. Additional efforts to halve high-risk behavior could reduce infections by 65%.
LIMITATION
The model of disease progression and treatment was simplified, and acute HIV screening was excluded.
CONCLUSION
Expanding HIV screening and treatment simultaneously offers the greatest health benefit and is cost-effective. However, even substantial expansion of HIV screening and treatment programs is not sufficient to markedly reduce the U.S. HIV epidemic without substantial reductions in risk behavior.
PRIMARY FUNDING SOURCE
National Institute on Drug Abuse, National Institutes of Health, and Department of Veterans Affairs.
背景
尽管最近的指南呼吁扩大对 HIV 的常规筛查，但抗逆转录病毒治疗 (ART) 的资源有限，并非所有符合条件的人目前都在接受治疗。
目的
评估扩大 ART、HIV 筛查或减少风险行为干预措施对美国 HIV 流行的影响。
设计
HIV 传播和疾病进展的动态数学模型和成本效益分析。
数据来源
已发表的文献。
目标人群
15 至 64 岁的美国高危人群（注射毒品使用者和男男性行为者）和低危人群。
时间范围
20 年和终生（成本和质量调整生命年 [QALYs]）。
视角
社会。
干预措施
扩大 HIV 筛查和咨询、ART 治疗或两者兼有。
结果测量
新的 HIV 感染、贴现成本和 QALYs，以及增量成本效益比。
基础分析结果
对低危人群进行一次性 HIV 筛查，并对高危人群进行年度筛查，可预防预计 123 万例新感染中的 6.7%，并假设筛查后性行为减少 20%，每获得一个 QALY 的成本为 22,382 美元。将 ART 的使用率扩大到 75%，可预防 10.3%的感染，每获得一个 QALY 的成本为 20,300 美元。联合策略可预防 17.3%的感染，每获得一个 QALY 的成本为 21,580 美元。
敏感性分析结果
如果性行为没有减少，扩大筛查可预防 3.7%的感染。当 CD4 计数大于 0.350×10(9)个细胞/L 时，更早开始 ART 治疗可预防 20%至 28%的感染。进一步努力将高危行为减半，可减少 65%的感染。
局限性
疾病进展和治疗模型被简化，急性 HIV 筛查被排除在外。
结论
同时扩大 HIV 筛查和治疗可提供最大的健康益处，且具有成本效益。然而，即使大幅扩大 HIV 筛查和治疗计划，如果不大幅减少风险行为，也不足以显著减少美国的 HIV 流行。
主要资金来源
美国国立药物滥用研究所、美国国立卫生研究院和美国退伍军人事务部。
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