Walensky Rochelle P, Borre Ethan D, Bekker Linda-Gail, Hyle Emily P, Gonsalves Gregg S, Wood Robin, Eholié Serge P, Weinstein Milton C, Anglaret Xavier, Freedberg Kenneth A, Paltiel A David
From Massachusetts General Hospital, Brigham and Women's Hospital, Harvard University Center for AIDS Research, Harvard Medical School, Harvard T.H. Chan School of Public Health, and Boston University School of Public Health, Boston, Massachusetts; Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Centre Hospitalier Universitaire de Treichville and Treichville University Hospital, Abidjan, Côte d'Ivoire; University of Bordeaux, Bordeaux, France; and Yale School of Public Health, New Haven, Connecticut.
Ann Intern Med. 2017 Nov 7;167(9):618-629. doi: 10.7326/M17-1358. Epub 2017 Aug 29.
Resource-limited nations must consider their response to potential contractions in international support for HIV programs.
To evaluate the clinical, epidemiologic, and budgetary consequences of alternative HIV program scale-back strategies in 2 recipient nations, the Republic of South Africa (RSA) and Côte d'Ivoire (CI).
Model-based comparison between current standard (CD4 count at presentation of 0.260 × 109 cells/L, universal antiretroviral therapy [ART] eligibility, and 5-year retention rate of 84%) and scale-back alternatives, including reduced HIV detection, no ART or delayed initiation (when CD4 count is <0.350 × 109 cells/L), reduced investment in retention, and no viral load monitoring or second-line ART.
Published RSA- and CI-specific estimates of the HIV care continuum, ART efficacy, and HIV-related costs.
HIV-infected persons, including future incident cases.
5 and 10 years.
Modified societal perspective, excluding time and productivity costs.
HIV transmissions and deaths, years of life, and budgetary outlays (2015 U.S. dollars).
RESULTS OF BASE-CASE ANALYSIS: At 10 years, scale-back strategies increase projected HIV transmissions by 0.5% to 19.4% and deaths by 0.6% to 39.1%. Strategies can produce budgetary savings of up to 30% but no more. Compared with the current standard, nearly every scale-back strategy produces proportionally more HIV deaths (and transmissions, in RSA) than savings. When the least harmful and most efficient alternatives for achieving budget cuts of 10% to 20% are applied, every year of life lost will save roughly $900 in HIV-related outlays in RSA and $600 to $900 in CI.
Scale-back programs, when combined, may result in clinical and budgetary synergies and offsets.
The magnitude and details of budget cuts are not yet known, nor is the degree to which other international partners might step in to restore budget shortfalls.
Scaling back international aid to HIV programs will have severe adverse clinical consequences; for similar economic savings, certain programmatic scale-back choices result in less harm than others.
National Institutes of Health and Steve and Deborah Gorlin MGH Research Scholars Award.
资源有限的国家必须考虑如何应对国际社会对艾滋病项目支持可能出现的缩减。
评估在两个受援国，即南非共和国（RSA）和科特迪瓦（CI），采用替代的艾滋病项目缩减策略所产生的临床、流行病学和预算方面的后果。
基于模型比较当前标准（就诊时CD4细胞计数为0.260×10⁹个/升，普遍符合抗逆转录病毒疗法[ART]标准，5年留存率为84%）与缩减替代方案，包括减少艾滋病检测、不进行ART或延迟启动（当CD4细胞计数<0.350×10⁹个/升时）、减少在留存方面的投入，以及不进行病毒载量监测或二线ART。
已发表的针对RSA和CI的艾滋病护理连续过程、ART疗效及艾滋病相关成本的特定估计值。
艾滋病感染者，包括未来的新发病例。
5年和10年。
修正后的社会视角，不包括时间和生产力成本。
艾滋病传播和死亡情况、生命年数以及预算支出（2015年美元）。
在10年时，缩减策略会使预计的艾滋病传播增加0.5%至19.4%，死亡增加0.6%至39.1%。这些策略最多可节省30%的预算，但不会更多。与当前标准相比，几乎每种缩减策略导致的艾滋病死亡（以及在RSA的传播）比例都高于节省的预算比例。当采用实现10%至20%预算削减的危害最小且效率最高的替代方案时，在RSA每失去一年生命将节省约900美元的艾滋病相关支出，在CI则节省600至900美元。
当综合实施缩减项目时，可能会产生临床和预算方面的协同效应及抵消作用。
预算削减的幅度和细节尚不清楚，其他国际伙伴可能介入弥补预算缺口的程度也未知。
缩减对艾滋病项目的国际援助将产生严重的不良临床后果；为实现类似的经济节省，某些项目缩减选择造成的危害小于其他选择。
美国国立卫生研究院以及史蒂夫和黛博拉·戈林麻省总医院研究学者奖。
