以社区为基础的策略在加强南非农村地区艾滋病毒护理连续性方面的成本效益：一项健康经济建模分析。

BACKGROUND

Home HIV counselling and testing (HTC) achieves high coverage of testing and linkage to care compared with existing facility-based approaches, particularly among asymptomatic individuals. In a modelling analysis we aimed to assess the effect on population-level health and cost-effectiveness of a community-based package of home HTC in KwaZulu-Natal, South Africa.

METHODS

We parameterised an individual-based model with data from home HTC and linkage field studies that achieved high coverage (91%) and linkage to antiretroviral therapy (80%) in rural KwaZulu-Natal, South Africa. Costs were derived from a linked microcosting study. The model simulated 10,000 individuals over 10 years and incremental cost-effectiveness ratios were calculated for the intervention relative to the existing status quo of facility-based testing, with costs discounted at 3% annually.

FINDINGS

The model predicted implementation of home HTC in addition to current practice to decrease HIV-associated morbidity by 10–22% and HIV infections by 9–48% with increasing CD4 cell count thresholds for antiretroviral therapy initiation. Incremental programme costs were US$2·7 million to $4·4 million higher in the intervention scenarios than at baseline, and costs increased with higher CD4 cell count thresholds for antiretroviral therapy initiation; antiretroviral therapy accounted for 48–87% of total costs. Incremental cost-effectiveness ratios per disability-adjusted life-year averted were $1340 at an antiretroviral therapy threshold of CD4 count lower than 200 cells per μL, $1090 at lower than 350 cells per μL, $1150 at lower than 500 cells per μL, and $1360 at universal access to antiretroviral therapy.

INTERPRETATION

Community-based HTC with enhanced linkage to care can result in increased HIV testing coverage and treatment uptake, decreasing the population burden of HIV-associated morbidity and mortality. The incremental cost-effectiveness ratios are less than 20% of South Africa's gross domestic product per person, and are therefore classed as very cost effective. Home HTC can be a viable means to achieve UNAIDS' ambitious new targets for HIV treatment coverage.

FUNDING

National Institutes of Health, Bill & Melinda Gates Foundation, Wellcome Trust.

背景

与现有的基于机构的方法相比，家庭 HIV 咨询和检测（HTC）在实现高检测覆盖率和与护理的衔接方面效果显著，尤其是针对无症状个体。在一项建模分析中，我们旨在评估在南非夸祖鲁-纳塔尔省实施以社区为基础的家庭 HTC 综合套餐对人群健康和成本效益的影响。

方法

我们使用来自家庭 HTC 和衔接实地研究的数据来对个体模型进行参数化，这些研究在南非夸祖鲁-纳塔尔省实现了高覆盖率（91%）和与抗逆转录病毒治疗（ART）的衔接（80%）。成本源自关联的微观成本研究。该模型模拟了 10000 个人在 10 年内的情况，并计算了相对于现有基于机构的检测现状的干预措施的增量成本效益比，成本按每年 3%贴现。

发现

模型预测，在目前的实践基础上，增加家庭 HTC 可以降低 10%至 22%的 HIV 相关发病率，并降低 9%至 48%的 HIV 感染率，同时提高抗逆转录病毒治疗开始的 CD4 细胞计数阈值。在干预情景中，与基线相比，方案成本增加了 270 万至 4400 万美元，随着抗逆转录病毒治疗开始时 CD4 细胞计数阈值的提高，成本也随之增加；抗逆转录病毒治疗占总成本的 48%至 87%。在低于 200 个细胞/μL、低于 350 个细胞/μL、低于 500 个细胞/μL 和普遍获得抗逆转录病毒治疗时，每避免一个残疾调整生命年的增量成本效益比分别为 1340 美元、1090 美元、1150 美元和 1360 美元。

解释

强化衔接以提供关怀的社区 HTC 可以提高 HIV 检测覆盖率和治疗参与度，从而降低 HIV 相关发病率和死亡率对人群的影响。增量成本效益比低于南非每人国内生产总值的 20%，因此被归类为非常具有成本效益。家庭 HTC 可以成为实现联合国艾滋病规划署（UNAIDS）雄心勃勃的新治疗覆盖目标的可行手段。