扩大南非艾滋病治疗和预防的抗逆转录病毒治疗服务：2011-2050 年的估计成本和成本效益。

BACKGROUND

Antiretroviral Treatment (ART) significantly reduces HIV transmission. We conducted a cost-effectiveness analysis of the impact of expanded ART in South Africa.

METHODS

We model a best case scenario of 90% annual HIV testing coverage in adults 15-49 years old and four ART eligibility scenarios: CD4 count <200 cells/mm(3) (current practice), CD4 count <350, CD4 count <500, all CD4 levels. 2011-2050 outcomes include deaths, disability adjusted life years (DALYs), HIV infections, cost, and cost per DALY averted. Service and ART costs reflect South African data and international generic prices. ART reduces transmission by 92%. We conducted sensitivity analyses.

RESULTS

Expanding ART to CD4 count <350 cells/mm(3) prevents an estimated 265,000 (17%) and 1.3 million (15%) new HIV infections over 5 and 40 years, respectively. Cumulative deaths decline 15%, from 12.5 to 10.6 million; DALYs by 14% from 109 to 93 million over 40 years. Costs drop $504 million over 5 years and $3.9 billion over 40 years with breakeven by 2013. Compared with the current scenario, expanding to <500 prevents an additional 585,000 and 3 million new HIV infections over 5 and 40 years, respectively. Expanding to all CD4 levels decreases HIV infections by 3.3 million (45%) and costs by $10 billion over 40 years, with breakeven by 2023. By 2050, using higher ART and monitoring costs, all CD4 levels saves $0.6 billion versus current; other ART scenarios cost $9-194 per DALY averted. If ART reduces transmission by 99%, savings from all CD4 levels reach $17.5 billion. Sensitivity analyses suggest that poor retention and predominant acute phase transmission reduce DALYs averted by 26% and savings by 7%.

CONCLUSION

Increasing the provision of ART to <350 cells/mm3 may significantly reduce costs while reducing the HIV burden. Feasibility including HIV testing and ART uptake, retention, and adherence should be evaluated.

背景

抗逆转录病毒治疗（ART）可显著降低 HIV 传播。我们在南非进行了扩大 ART 影响的成本效益分析。

方法

我们构建了一个最佳案例情景，即每年对 15-49 岁成年人进行 90%的 HIV 检测，并设定了四种 ART 资格标准：CD4 计数<200 个细胞/mm³（当前做法）、CD4 计数<350、CD4 计数<500、所有 CD4 水平。2011-2050 年的结果包括死亡、残疾调整生命年（DALYs）、HIV 感染、成本以及每避免一个 DALY 的成本。服务和 ART 成本反映了南非的数据和国际通用价格。ART 将传播率降低 92%。我们进行了敏感性分析。

结果

将 ART 扩大到 CD4 计数<350 个细胞/mm³可分别预防未来 5 年和 40 年内估计的 265,000（17%）和 130 万（15%）例新的 HIV 感染。40 年内，累计死亡人数减少 15%，从 1250 万人降至 1060 万人；DALYs 减少 14%，从 1.09 亿降至 9300 万人。5 年内成本降低 5.04 亿美元，40 年内降低 39 亿美元，2013 年达到收支平衡。与当前情景相比，扩大到<500 个细胞/mm³可分别预防未来 5 年和 40 年内额外的 585,000 和 300 万例新的 HIV 感染。扩大到所有 CD4 水平可将 HIV 感染减少 330 万例（45%），并在 40 年内降低 100 亿美元的成本，2023 年达到收支平衡。到 2050 年，使用更高的 ART 和监测成本，所有 CD4 水平的成本比当前节省 6 亿美元；其他 ART 方案每避免一个 DALY 的成本为 9-194 美元。如果 ART 将传播率降低 99%，则所有 CD4 水平的节省将达到 175 亿美元。敏感性分析表明，保留效果不佳和主要急性传播阶段将分别使避免的 DALYs 减少 26%，并使节省减少 7%。