The Kirby Institute, University of New South Wales, Kensington, NSW, Australia.
Thai Red Cross Society AIDS Research Centre, Bangkok, Thailand.
Lancet HIV. 2015 May;2(5):e200-7. doi: 10.1016/S2352-3018(15)00020-X. Epub 2015 Mar 29.
Despite the high prevalence of HIV in men who have sex with men (MSM) in Bangkok, little investment in HIV prevention for MSM has been made. HIV testing and treatment coverage remains low. Through a pragmatic programme-planning approach, we assess possible service linkage and provision of HIV testing and antiretroviral treatment (ART) to MSM in Bangkok, and the most cost-effective scale-up strategy.
We obtained epidemiological and service capacity data from the Thai National Health Security Office database for 2011. We surveyed 13 representative medical facilities for detailed operational costs of HIV-related services for sexually active MSM (defined as having sex with men in the past 12 months) in metropolitan Bangkok. We estimated the costs of various ART scale-up scenarios, accounting for geographical accessibility across Bangkok. We used an HIV transmission population-based model to assess the cost-effectiveness of the scenarios.
For present HIV testing (23% [95% CI 17-36] of MSM at high risk in 2011) and ART provision (20% of treatment-eligible MSM at high risk on ART in 2011) to be sustained, a US$73·8 million ($51·0 million to $97·0 million) investment during the next decade would be needed, which would link an extra 43,000 (27,900-58,000) MSM at high risk to HIV testing and 5100 (3500-6700) to ART, achieving an ART coverage of 44% for MSM at high risk in 2022. An additional $55·3 million investment would link an extra 46,700 (30,300-63,200) MSM to HIV testing and 12,600 (8800-16,600) to ART, achieving universal ART coverage of this population by 2022. This increased investment is achievable within present infrastructure capacity. Consequently, an estimated 5100 (3600-6700) HIV-related deaths and 3700 (2600-4900) new infections could be averted in MSM by 2022, corresponding to a 53% reduction in deaths and a 35% reduction in infections from 2012 levels. The expansion would cost an estimated $10,809 (9071-13,274) for each HIV-related death, $14,783 (12,389-17,960) per new infection averted, and $351 (290-424) per disability-adjusted life-year averted.
Spare capacity in Bangkok's medical facilities can be used to expand ART access for MSM with large epidemiological benefits. The expansion needs increased funding directed to MSM services, but given the epidemiological trends, is probably cost effective. Our modelling approach and outcomes are likely to be applicable to other settings.
World Bank Group and Australian National Health and Medical Research Council.
尽管曼谷男男性行为者（MSM）中的艾滋病毒感染率很高，但针对 MSM 的艾滋病毒预防工作投入很少。艾滋病毒检测和治疗覆盖率仍然很低。通过务实的方案规划方法，我们评估了在曼谷为 MSM 提供艾滋病毒检测和抗逆转录病毒治疗（ART）服务的可能服务联系和最具成本效益的扩大规模策略。
我们从泰国国家卫生安全办公室数据库中获取了 2011 年的流行病学和服务能力数据。我们对曼谷大都市地区的 13 个有代表性的医疗设施进行了调查，以了解与艾滋病毒相关的服务的详细运营成本，这些服务针对有性行为的 MSM（定义为过去 12 个月与男性发生性行为的人）。我们估计了各种 ART 扩大规模方案的成本，同时考虑了曼谷各地的地理可达性。我们使用艾滋病毒传播人群模型来评估方案的成本效益。
为了维持目前的艾滋病毒检测（2011 年高危 MSM 中有 23%[95%CI 17-36]接受检测）和 ART 提供（2011 年高危 MSM 中有 20%接受治疗），未来十年需要投资 7380 万美元（5100 万美元至 9700 万美元），这将使额外的 43000 名（27900-58000 名）高危 MSM 接受艾滋病毒检测，5100 名（3500-6700 名）接受 ART，到 2022 年，高危 MSM 的 ART 覆盖率达到 44%。额外投资 5530 万美元，将使额外的 46700 名（30300-63200 名）高危 MSM 接受艾滋病毒检测，12600 名（8800-16600 名）接受 ART，到 2022 年，该人群的 ART 覆盖率将达到全覆盖。在目前的基础设施能力范围内，可以实现这一增加的投资。因此，到 2022 年，MSM 中估计可避免 5100 名（3600-6700 名）与艾滋病毒相关的死亡和 3700 名（2600-4900 名）新感染，与 2012 年相比，死亡人数减少 53%，感染人数减少 35%。扩大规模估计将使每例与艾滋病毒相关的死亡成本增加 10809 美元（9071 美元至 13274 美元），每例新感染成本增加 14783 美元（12389 美元至 17960 美元），每例残疾调整生命年增加 351 美元（290 美元至 424 美元）。
曼谷医疗设施的剩余能力可用于扩大 MSM 的 ART 服务，这将带来巨大的流行病学效益。扩大规模需要增加针对 MSM 服务的资金，但鉴于流行病学趋势，这可能是具有成本效益的。我们的建模方法和结果可能适用于其他环境。
世界银行集团和澳大利亚国家卫生和医学研究理事会。
