Yale School of Management, 135 Prospect Street, New Haven, CT, 06520, USA,
J Gen Intern Med. 2013 Oct;28(10):1294-301. doi: 10.1007/s11606-013-2417-1. Epub 2013 Apr 16.
Recent clinical trials of male circumcision, oral pre-exposure prophylaxis (PrEP), and a vaginal microbicide gel have shown partial effectiveness at reducing HIV transmission, stimulating interest in implementing portfolios of biomedical prevention programs.
To evaluate the effectiveness and cost-effectiveness of combination biomedical HIV prevention and treatment scale-up in South Africa, given uncertainty in program effectiveness.
Dynamic HIV transmission and disease progression model with Monte Carlo simulation and cost-effectiveness analysis.
Men and women aged 15 to 49 years in South Africa.
HIV screening and counseling, antiretroviral therapy (ART), male circumcision, PrEP, microbicide, and select combinations.
HIV incidence, prevalence, discounted costs, discounted quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios.
Providing half of all uninfected persons with PrEP averts 28 % of future HIV infections for $9,000/QALY gained, but the affordability of such a program is questionable. Given limited resources, annual HIV screening and ART utilization by 75 % of eligible infected persons could avert one-third of new HIV infections, for approximately $1,000/QALY gained. Male circumcision is more cost-effective, but disproportionately benefits men. A comprehensive portfolio of expanded screening, ART, male circumcision, microbicides, and PrEP could avert 62 % of new HIV infections, reducing HIV prevalence from a projected 14 % to 10 % after 10 years. This strategy doubles treatment initiation and adds 31 million QALYs to the population. Despite uncertainty in program effectiveness, a comprehensive portfolio costs less than $10,000/QALY gained in 33 % of simulation iterations and less than $30,000/QALY gained in 90 % of iterations, assuming an annual microbicide cost of $100.
A portfolio of modestly-effective biomedical HIV prevention programs, including male circumcision, vaginal microbicides, and oral PrEP, could substantially reduce HIV incidence and prevalence in South Africa and be likely cost-effective. Given limited resources, PrEP is the least cost-effective intervention of those considered.
最近的男性包皮环切术、口服暴露前预防（PrEP）和阴道杀微生物剂凝胶的临床试验表明，这些方法在降低 HIV 传播方面具有一定效果，这激发了人们对实施多种生物医学预防方案的兴趣。
评估在南非实施组合生物医学 HIV 预防和治疗方案扩大规模的效果和成本效益，因为方案效果存在不确定性。
具有蒙特卡罗模拟和成本效益分析的动态 HIV 传播和疾病进展模型。
南非年龄在 15 至 49 岁的男性和女性。
HIV 筛查和咨询、抗逆转录病毒治疗（ART）、男性包皮环切术、PrEP、杀微生物剂以及特定组合。
HIV 发病率、流行率、贴现成本、贴现质量调整生命年（QALY）和增量成本效益比。
为一半的未感染者提供 PrEP 可预防未来 28%的 HIV 感染，每获得一个 QALY 需花费 9000 美元，但这样的项目是否负担得起是值得怀疑的。鉴于资源有限，如果有 75%符合条件的感染者每年接受 HIV 筛查和 ART 治疗，可预防三分之一的新 HIV 感染，每获得一个 QALY 需花费约 1000 美元。男性包皮环切术更具成本效益，但不成比例地使男性受益。扩大筛查、ART、男性包皮环切术、杀微生物剂和 PrEP 的综合组合方案可预防 62%的新 HIV 感染，将 10 年后的 HIV 流行率从预计的 14%降低到 10%。这一策略使治疗启动增加一倍，并使人群的 QALY 增加 3100 万。尽管方案效果存在不确定性，但在 33%的模拟迭代中，综合组合方案的成本低于每获得一个 QALY 10000 美元，在 90%的迭代中低于每获得一个 QALY 30000 美元，假设每年杀微生物剂的成本为 100 美元。
包括男性包皮环切术、阴道杀微生物剂和口服 PrEP 在内的一系列适度有效的生物医学 HIV 预防方案可大大降低南非的 HIV 发病率和流行率，且很可能具有成本效益。鉴于资源有限，在考虑的干预措施中，PrEP 的成本效益最低。
