1 Kirby Institute, The University of New South Wales , Sydney, New South Wales, Australia .
AIDS Patient Care STDS. 2014 Jul;28(7):365-71. doi: 10.1089/apc.2014.0016.
This study determines an optimal strategy for scaling up ART in Vietnam by examining three initiation thresholds [350 cells/mm(3), 500 cells/mm(3), and treat all people living with HIV (PLHIV) regardless of CD4 cell counts] and treatment commencement rates among treatment-eligible PLHIV ranging from 5% to 100% within 12 months of diagnosis. Incremental cost-effectiveness ratios (ICERs) were calculated using a Markov model, based on data from a cohort of 3449 patients who initiated ART between January 1, 2005 and December 31, 2009 in 13 outpatient clinics across six provinces in Vietnam. Our analyses indicated that raising treatment eligibility criteria, in line with WHO guidelines (CD4 ≤500 cells/mm(3)) or removing CD4-based criteria would both be cost-effective in Vietnam. However, the cost-effective strategy from an economic viewpoint is first to increase coverage substantially among those with lowest CD4 levels, and only when coverage increases towards saturation should initiation criteria be lifted. Universal coverage under current guidelines would cost an additional $85 million and $96 million per year if the treatment threshold was 500 cells/mm(3). These scenarios would avert 15,000 and 22,000 HIV-related deaths in 2010-2019, with ICERs of $500-$660 per QALY gained. It is imperative to increase treatment coverage for newly diagnosed PLHIV in Vietnam according to the current guidelines prior to increasing the CD4 threshold for ART initiation.
本研究通过考察三种起始阈值[350 个细胞/mm³、500 个细胞/mm³和治疗所有 HIV 感染者（PLHIV），无论其 CD4 细胞计数如何]和治疗开始率（在诊断后 12 个月内，从 5%到 100%），来确定在越南扩大 ART 的最佳策略。增量成本效益比（ICER）是使用马尔可夫模型根据来自于 2005 年 1 月 1 日至 2009 年 12 月 31 日期间在越南六个省的 13 个门诊诊所中开始接受 ART 的 3449 名患者的队列数据计算得出的。我们的分析表明，提高治疗资格标准，符合世卫组织的指南（CD4≤500 个细胞/mm³）或取消基于 CD4 的标准，在越南都是具有成本效益的。然而，从经济角度来看，具有成本效益的策略是首先在 CD4 水平最低的人群中大幅提高覆盖率，只有当覆盖率接近饱和时，才应取消启动标准。根据当前的指南，普遍覆盖将额外花费 8500 万美元和 9600 万美元，每年如果治疗阈值为 500 个细胞/mm³。在 2010-2019 年，这些方案将避免 15000 至 22000 例与 HIV 相关的死亡，增量成本效益比为每获得一个 QALY 的 500-660 美元。根据当前的指南，增加新诊断的 PLHIV 的治疗覆盖率是当务之急，然后再提高 ART 启动的 CD4 阈值。
