Moodley Nishila, Gray Glenda, Bertram Melanie
Department of Health Sciences, University of the Witwatersrand, South Africa.
South African HVTN AIDS Vaccine Early Stage Investigator Program [SHAPe].
Clin Res HIV AIDS. 2016;3(1). Epub 2016 Nov 27.
South Africa has the highest global burden of human immunodefciency virus [HIV]. The study compared the cost-effectiveness of individual and combination HIV preventive strategies against the current rollout of ART and possible ART scale-up.
Adolescents attending South African schools in 2012 were included in the semi-Markov running annual cycles. The ART and HIV counseling and testing program [comparator] was weighed against the interventions [viz. HIV vaccine, a dual vaccine strategy [HIV and HPV vaccines], oral pre-exposure prophylaxis [PrEP] and voluntary medical male circumcision [VMMC]; and various combinations thereof. Quality-adjusted life years [QALY] determined changes in HIV associated mortality and infections averted. One-way and probabilistic sensitivity analysis determined parameter uncertainty. Discount rates of 3% with a lifetime horizon [70 years] were applied.
Dual vaccination was highly cost-effective strategy [US$ 7 per QALY gained] and averted 29% of new HIV infections. VMMC [US$ 30 per QALY gained] proved more cost-effective than HIV vaccination alone [US$ 93 per QALY gained], though VMMC averted 6% more new infections than the HIV vaccine when considered among male participants. PrEP interventions were the least cost-effective with pharmaceutical and human resource spending driving the costs. Combined dual vaccination and VMMC strategies were a dominant intervention. Strategies involving PrEP were the least cost-effective.
VMMC, HIV vaccination and dual vaccination strategies were more cost-effective than any PrEP strategies. A multi-intervention biomedical approach could avert considerable new HIV infections and present a cost-effective use of resources; particularly where large scale multi-interventional randomized controlled trials are absent.
南非是全球人类免疫缺陷病毒（HIV）负担最重的国家。本研究比较了个体和联合HIV预防策略与当前抗逆转录病毒治疗（ART）的推广及可能的ART扩大规模的成本效益。
纳入2012年在南非学校就读的青少年，采用半马尔可夫年度循环模型。将ART及HIV咨询与检测项目（对照）与干预措施（即HIV疫苗、双疫苗策略（HIV和人乳头瘤病毒疫苗）、口服暴露前预防（PrEP）和自愿医学男性包皮环切术（VMMC）；及其各种组合）进行权衡比较。质量调整生命年（QALY）确定了HIV相关死亡率和避免感染的变化。单向和概率敏感性分析确定参数不确定性。应用3%的贴现率，终生期限为70年。
双疫苗接种是一种高成本效益的策略（每获得一个QALY成本为7美元），可避免29%的新发HIV感染。VMMC（每获得一个QALY成本为30美元）被证明比单独的HIV疫苗接种（每获得一个QALY成本为93美元）更具成本效益，不过在男性参与者中考虑时，VMMC比HIV疫苗多避免6%的新发感染。PrEP干预措施成本效益最低，药物和人力资源支出推动了成本。联合双疫苗接种和VMMC策略是主要干预措施。涉及PrEP的策略成本效益最低。
VMMC、HIV疫苗接种和双疫苗接种策略比任何PrEP策略更具成本效益。一种多干预生物医学方法可以避免大量新发HIV感染，并实现资源的成本效益利用；特别是在缺乏大规模多干预随机对照试验的情况下。
