aMedical Practice Evaluation Center bDivision of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA cInstituto Nacional de Saùde, Maputo, Mozambique dDivision of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA eDesmond Tutu HIV Centre, Cape Town, South Africa fCenter for Decision Science, Harvard T.H. Chan School of Public Health, Boston gClinton Health Access Initiative, Boston hHarvard University Center for AIDS Research, Harvard Medical School, Boston, Massachusetts, USA iClinton Health Access Initiative, Gaborone, Botswana jBiostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, USA.
AIDS. 2017 Sep 24;31(15):2135-2145. doi: 10.1097/QAD.0000000000001586.
To examine the clinical and economic value of point-of-care CD4 (POC-CD4) or viral load monitoring compared with current practices in Mozambique, a country representative of the diverse resource limitations encountered by HIV treatment programs in sub-Saharan Africa.
DESIGN/METHODS: We use the Cost-Effectiveness of Preventing AIDS Complications-International model to examine the clinical impact, cost (2014 US$), and incremental cost-effectiveness ratio [$/year of life saved (YLS)] of ART monitoring strategies in Mozambique. We compare: monitoring for clinical disease progression [clinical ART monitoring strategy (CLIN)] vs. annual POC-CD4 in rural settings without laboratory services and biannual laboratory CD4 (LAB-CD4), biannual POC-CD4, and annual viral load in urban settings with laboratory services. We examine the impact of a range of values in sensitivity analyses, using Mozambique's 2014 per capita gross domestic product ($620) as a benchmark cost-effectiveness threshold.
In rural settings, annual POC-CD4 compared to CLIN improves life expectancy by 2.8 years, reduces time on failed ART by 0.6 years, and yields an incremental cost-effectiveness ratio of $480/YLS. In urban settings, biannual POC-CD4 is more expensive and less effective than viral load. Compared to biannual LAB-CD4, viral load improves life expectancy by 0.6 years, reduces time on failed ART by 1.0 year, and is cost-effective ($440/YLS).
In rural settings, annual POC-CD4 improves clinical outcomes and is cost-effective compared to CLIN. In urban settings, viral load has the greatest clinical benefit and is cost-effective compared to biannual POC-CD4 or LAB-CD4. Tailoring ART monitoring strategies to specific settings with different available resources can improve clinical outcomes while remaining economically efficient.
在莫桑比克（一个代表撒哈拉以南非洲国家艾滋病毒治疗项目面临多样化资源限制的国家），检验即时护理 CD4（POC-CD4）或病毒载量监测与现行做法相比的临床和经济价值。
设计/方法：我们使用预防艾滋病并发症的成本效益国际模型，检验莫桑比克抗逆转录病毒治疗监测策略的临床影响、成本（2014 年美元）和增量成本效益比（每节省 1 年生命所需成本[YLS]）。我们比较了以下几种方案：针对临床疾病进展的监测（临床 ART 监测策略[CLIN]）与农村地区缺乏实验室服务时的年度 POC-CD4、农村地区无实验室服务时的每两年一次实验室 CD4（LAB-CD4）、农村地区无实验室服务时的每两年一次 POC-CD4、以及城市地区有实验室服务时的年度病毒载量。我们使用莫桑比克 2014 年人均国内生产总值（620 美元）作为基准成本效益阈值，在敏感性分析中检验了一系列不同数值的影响。
在农村地区，与 CLIN 相比，年度 POC-CD4 可将预期寿命延长 2.8 年，将失败 ART 时间缩短 0.6 年，增量成本效益比为 480 美元/YLS。在城市地区，与病毒载量相比，每两年一次的 POC-CD4 更昂贵，效果更差。与每两年一次的 LAB-CD4 相比，病毒载量可将预期寿命延长 0.6 年，将失败 ART 时间缩短 1.0 年，且具有成本效益（440 美元/YLS）。
在农村地区，与 CLIN 相比，年度 POC-CD4 改善了临床结局，且具有成本效益。在城市地区，与每两年一次的 POC-CD4 或 LAB-CD4 相比，病毒载量具有最大的临床获益，且具有成本效益。根据不同的资源状况，针对特定环境制定 ART 监测策略，可以在保持经济高效的同时改善临床结局。
