Department of Global Health and Population, Harvard School of Public Health, Boston, MA 02115, USA.
Proc Natl Acad Sci U S A. 2012 Dec 26;109(52):21271-6. doi: 10.1073/pnas.1209017110. Epub 2012 Dec 6.
The HIV Prevention Trials Network (HPTN) 052 study, which showed the effectiveness of antiretroviral treatment in reducing HIV transmission, has been hailed as a "game changer" in the fight against HIV, prompting calls for scaling up treatment as prevention (TasP). However, it is unclear how TasP can be financed, given flat-lining support for global HIV programs. We assess whether TasP is indeed a game changer or if comparable benefits are obtainable at similar or lower cost by increasing coverage of medical male circumcision (MMC) and antiretroviral treatment (ART) at CD4 <350/μL. We develop a new mathematical model and apply it to South Africa, finding that high ART coverage combined with high MMC coverage provides approximately the same HIV incidence reduction as TasP, for $5 billion less over 2009-2020. MMC outperforms ART significantly in cost per infection averted ($1,096 vs. $6,790) and performs comparably in cost per death averted ($5,198 vs. $5,604). TasP is substantially less cost effective at $8,375 per infection and $7,739 per death averted. The prevention benefits of HIV treatment are largely reaped with high ART coverage. The most cost-effective HIV prevention strategy is to expand MMC coverage and then scale up ART, but the most cost-effective HIV-mortality reduction strategy is to scale up MMC and ART jointly. TasP is cost effective by commonly used absolute benchmarks but it is far less cost effective than MMC and ART. Given South Africa's current annual ART spending, the $5 billion in savings offered by MMC and ART over TasP in the next decade, for similar health benefits, challenges the widely hailed status of TasP as a game changer.
艾滋病毒预防试验网络（HPTN）052 研究表明，抗逆转录病毒治疗在降低艾滋病毒传播方面的有效性，被誉为艾滋病毒防治的“游戏规则改变者”，促使人们呼吁扩大治疗即预防（TasP）。然而，在全球艾滋病毒规划支持持平的情况下，尚不清楚如何为 TasP 提供资金。我们评估 TasP 是否确实是一个游戏规则改变者，或者通过在 CD4<350/μL 时增加医疗男性割礼（MMC）和抗逆转录病毒治疗（ART）的覆盖范围，是否可以以类似或更低的成本获得可比的效益。我们开发了一种新的数学模型，并将其应用于南非，发现高 ART 覆盖率与高 MMC 覆盖率相结合，可提供与 TasP 大致相同的艾滋病毒发病率降低，在 2009-2020 年期间可节省 50 亿美元。MMC 在每避免一例感染的成本方面明显优于 ART（1096 美元与 6790 美元），在每避免一例死亡的成本方面表现相当（5198 美元与 5604 美元）。TasP 的成本效益要低得多，每避免一例感染的成本为 8375 美元，每避免一例死亡的成本为 7739 美元。艾滋病毒治疗的预防效益在高 ART 覆盖率下得到了很大程度的实现。最具成本效益的艾滋病毒预防策略是扩大 MMC 覆盖率，然后扩大 ART，但最具成本效益的艾滋病毒死亡率降低策略是联合扩大 MMC 和 ART。TasP 符合常用的绝对基准，但它的成本效益远低于 MMC 和 ART。考虑到南非目前的年度 ART 支出，在未来十年内，MMC 和 ART 比 TasP 节省 50 亿美元，用于获得类似的健康效益，这对 TasP 作为游戏规则改变者的广泛赞誉提出了挑战。
