在广泛流行的环境中，通过家庭检测和咨询来降低艾滋病毒发病率：一项数学建模分析。
Home testing and counselling to reduce HIV incidence in a generalised epidemic setting: a mathematical modelling analysis.
机构信息
Department of Global Health, University of Washington, Seattle, WA, USA.
Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA.
出版信息
Lancet HIV. 2016 Jun;3(6):e275-82. doi: 10.1016/S2352-3018(16)30009-1. Epub 2016 May 11.
BACKGROUND
Home HIV testing and counselling (HTC) achieves high levels of HIV testing and linkage to care. Periodic home HTC, particularly targeted to those with high HIV viral load, might facilitate expansion of antiretroviral therapy (ART) coverage. We used a mathematical model to assess the effect of periodic home HTC programmes on HIV incidence in KwaZulu-Natal, South Africa.
METHODS
We developed a dynamic HIV transmission model with parameters, primary cost data, and measures of viral suppression collected from a prospective study of home HTC in KwaZulu-Natal. In our model, we assumed home HTC took place every 5 years with ART initiation for people with CD4 counts of 350 cells per μL or less. For individuals with CD4 counts of more than 350 cells per μL, we compared increasing ART coverage for those with 350-500 cells per μL with initiating treatment for those who have viral loads of more than 10 000 copies per mL.
FINDINGS
Maintaining the presently observed level of 36% viral suppression in HIV-positive people, HIV incidence decreases by 33·8% over 10 years. Home HTC every 5 years with linkage to care with ART initiation at CD4 counts of 350 cells per μL or less reduces HIV incidence by 40·6% over 10 years. Expansion of ART to people with CD4 counts of more than 350 cells per μL who also have a viral load of 10 000 copies per mL or more decreases HIV incidence by 51·6%, and this was the most cost-effective strategy for prevention of HIV infections at US$2960 per infection averted. Expansion of ART eligibility CD4 counts of 350-500 cells per μL is cost-effective at $900 per quality-adjusted life-year gained. Following health economic guidelines, expansion of ART use to individuals who have viral loads of more than 10 000 copies per mL among those with CD4 counts of more than 350 cells per μL was cost-effective to reduce HIV-related morbidity.
INTERPRETATION
Our results show that province-wide home HTC every 5 years can be a cost-effective strategy to increase ART coverage and reduce HIV burden. Expanded ART initiation criteria that includes individuals with high viral load will improve the effectiveness of home HTC in linking individuals to ART who are at high risk of transmitting HIV, thereby preventing morbidity and onward transmission.
FUNDING
National Institutes of Health.
背景
家庭 HIV 检测和咨询（HTC）可实现高水平的 HIV 检测和与护理的衔接。定期家庭 HIVC，特别是针对 HIV 病毒载量高的人群，可能有助于扩大抗逆转录病毒治疗（ART）的覆盖范围。我们使用数学模型来评估南非夸祖鲁-纳塔尔省定期家庭 HIVC 方案对 HIV 发病率的影响。
方法
我们使用从夸祖鲁-纳塔尔省家庭 HIVC 前瞻性研究中收集的参数、主要成本数据和病毒抑制测量值，开发了一个动态 HIV 传播模型。在我们的模型中，我们假设每 5 年进行一次家庭 HIVC，对于 CD4 计数为 350 个细胞/μL 或更低的人，启动 ART。对于 CD4 计数超过 350 个细胞/μL 的个体，我们比较了将 350-500 个细胞/μL 的 ART 覆盖率增加与对病毒载量超过 10000 拷贝/毫升的人开始治疗的情况。
结果
保持目前观察到的 HIV 阳性人群中 36%的病毒抑制水平，HIV 发病率在 10 年内下降 33.8%。每 5 年进行一次家庭 HIVC，并在 CD4 计数为 350 个细胞/μL 或更低时与护理衔接，启动 ART，可使 10 年内 HIV 发病率降低 40.6%。将 CD4 计数超过 350 个细胞/μL 且病毒载量为 10000 拷贝/毫升或更高的人纳入 ART 治疗，可使 HIV 发病率降低 51.6%，这是预防 HIV 感染的最具成本效益的策略，每避免一次感染的成本为 2960 美元。将 ART 纳入 CD4 计数为 350-500 个细胞/μL 的合格标准具有成本效益，每获得一个质量调整生命年的成本为 900 美元。根据卫生经济学指南，扩大 ART 的使用范围，将病毒载量超过 10000 拷贝/毫升的 CD4 计数超过 350 个细胞/μL 的个体纳入其中，以降低与 HIV 相关的发病率，是降低 HIV 相关发病率的成本效益策略。
结论
我们的研究结果表明，全省范围内每 5 年进行一次家庭 HIVC 可以成为增加 ART 覆盖率和降低 HIV 负担的具有成本效益的策略。扩大 ART 起始标准，包括病毒载量高的人群，将提高家庭 HIVC 将高危人群与 ART 衔接的效果，从而预防发病率和传播。
资金来源
美国国立卫生研究院。
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