Meyer-Rath Gesine, van Rensburg Craig, Larson Bruce, Jamieson Lise, Rosen Sydney
Department of Global Health, Boston University School of Public Health, Boston, United States of America.
Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
PLoS One. 2017 Oct 26;12(10):e0186496. doi: 10.1371/journal.pone.0186496. eCollection 2017.
The use of cost-effectiveness thresholds based on a country's income per capita has been criticized for not being relevant to decision making, in particular in middle-income countries such as South Africa. The recent South African HIV Investment Case produced an alternative cost-effectiveness threshold for HIV prevention and treatment interventions based on estimates of life years saved and the country's committed HIV budget.
We analysed the optimal mix of HIV interventions over a baseline of the current HIV programme under the committed HIV budget for 2016-2018. We calculated the incremental cost-effectiveness ratio (ICER) as cost per life-year saved (LYS) of 16 HIV prevention and treatment interventions over 20 years (2016-2035). We iteratively evaluated the most cost effective option (defined by an intervention and its coverage) over a rolling baseline to which the more cost effective options had already been added, thereby allowing for diminishing marginal returns to interventions. We constrained the list of interventions to those whose combined cost was affordable under the current HIV budget. Costs are presented from the government perspective, unadjusted for inflation and undiscounted, in 2016 USD.
The current HIV budget of about $1.6 billion per year was sufficient to pay for the expansion of condom availability, medical male circumcision, universal treatment, and infant testing at 6 weeks to maximum coverage levels, while also implementing a social and behavior change mass media campaign with a message geared at increasing testing uptake and reducing the number of sexual partners. The combined ICER of this package of services was $547/ LYS. The ICER of the next intervention that was above the affordability threshold was $872/LYS.
The results of the South African HIV Investment Case point to an HIV cost-effectiveness threshold based on affordability under the current budget of $547-872 per life year saved, a small fraction of the country's GDP per capita of about $6,000.
基于一个国家人均收入的成本效益阈值在决策中被批评为不相关，特别是在南非这样的中等收入国家。最近的南非艾滋病投资案例基于挽救的生命年估计数和该国承诺的艾滋病预算，为艾滋病预防和治疗干预措施产生了一个替代的成本效益阈值。
我们在2016 - 2018年承诺的艾滋病预算下，分析了当前艾滋病项目基线之上艾滋病干预措施的最佳组合。我们计算了16种艾滋病预防和治疗干预措施在20年（2016 - 2035年）内每挽救一个生命年（LYS）的成本所对应的增量成本效益比（ICER）。我们在一个滚动基线上迭代评估最具成本效益的选项（由一种干预措施及其覆盖范围定义），在这个基线上已经添加了更具成本效益的选项，从而考虑到干预措施的边际收益递减。我们将干预措施列表限制在那些在当前艾滋病预算下综合成本可承受的措施。成本从政府角度列出，未根据通货膨胀进行调整且未折现，以2016年美元计。
目前每年约16亿美元的艾滋病预算足以支付扩大避孕套供应、医学男性包皮环切术、普及治疗以及6周龄婴儿检测至最大覆盖水平的费用，同时还实施一场社会和行为改变的大众媒体宣传活动，其信息旨在提高检测接受度并减少性伴侣数量。这一揽子服务的综合ICER为547美元/生命年。高于可承受阈值的下一个干预措施的ICER为872美元/生命年。
南非艾滋病投资案例的结果表明，基于当前预算可承受性的艾滋病成本效益阈值为每挽救一个生命年547 - 872美元，这只是该国人均国内生产总值约6000美元的一小部分。
