Department of Pharmaceutical and Health Economics, School of Pharmacy.
Leonard D. Schaeffer Center for Health Policy, University of Southern California, Los Angeles.
Clin Infect Dis. 2016 Dec 1;63(11):1495-1504. doi: 10.1093/cid/ciw578. Epub 2016 Aug 23.
Substantial gaps remain in understanding the trade-offs between the costs and benefits of choosing alternative human immunodeficiency virus (HIV) prevention strategies, including test-and-treat (expanded HIV testing combined with immediate treatment) and PrEP (initiation of preexposure prophylaxis by high-risk uninfected individuals) strategies.
We develop a mathematical epidemiological model to simulate HIV incidence among men residing in Los Angeles County, California, aged 15-65 years, who have sex with men. We combine these incidence data with an economic model to estimate the discounted cost, effectiveness (quality-adjusted life-years [QALYs]), and incremental cost-effectiveness ratios of various HIV prevention strategies using a societal perspective and a lifetime horizon.
PrEP and test-and-treat yield the largest reductions in HIV incidence, and are highly cost-effective ($27 863/QALY and $19 302/QALY, respectively) relative to status quo and at a US willingness-to-pay threshold of $150 000/QALY saved. Status quo and 12 test-and-treat and PrEP strategies determine the frontier for efficient decisions. More aggressive strategies are costlier, but more effective, albeit with diminishing returns. The relative effectiveness of PrEP is sensitive to the initial HIV prevalence rate, PrEP and antiretroviral therapy (ART) adherence and initiation rates, the probabilities of HIV transmission, and the rates of sexual partner mixing.
PrEP and test-and-treat offer cost-effective alternatives to the status quo. The success of these strategies depends on ART and PrEP adherence and initiation rates. The lack of evidence on adherence behaviors toward PrEP, therefore, warrants further studies.
在理解选择替代人类免疫缺陷病毒（HIV）预防策略的成本效益权衡方面仍存在很大差距，包括检测和治疗（扩大 HIV 检测并结合立即治疗）和 PrEP（高危未感染个体开始进行暴露前预防）策略。
我们开发了一个数学流行病学模型，以模拟加利福尼亚州洛杉矶县 15-65 岁男性的 HIV 发病率，这些男性与男性发生性行为。我们将这些发病率数据与经济模型相结合，从社会角度和终身视角估计各种 HIV 预防策略的贴现成本、效果（质量调整生命年[QALY]）和增量成本效益比。
PrEP 和检测和治疗可最大程度地降低 HIV 发病率，与现状相比，具有很高的成本效益（分别为 27863 美元/QALY 和 19302 美元/QALY），且达到美国愿意支付的 150000 美元/QALY 节省阈值。现状和 12 种检测和治疗以及 PrEP 策略确定了有效决策的前沿。更积极的策略更昂贵，但更有效，尽管收益递减。PrEP 的相对效果对初始 HIV 流行率、PrEP 和抗逆转录病毒疗法（ART）的依从性和起始率、HIV 传播的概率以及性伴侣混合的速率敏感。
PrEP 和检测和治疗为现状提供了具有成本效益的替代方案。这些策略的成功取决于 ART 和 PrEP 的依从性和起始率。由于缺乏对 PrEP 依从性行为的证据，因此需要进一步研究。
