Yale School of Management, New Haven, Connecticut 06520, USA.
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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