Kowalska Justyna D, Wójcik Grzegorz, Rutkowski Jakub, Ankiersztejn-Bartczak Magdalena, Siewaszewicz Ewa
Department of Adults' Infectious Diseases, Medical University of Warsaw, Warsaw, Poland.
HIV Out-Patients Clinic, Hospital for Infectious Diseases in Warsaw, Warsaw, Poland.
PLoS One. 2017 Nov 13;12(11):e0186131. doi: 10.1371/journal.pone.0186131. eCollection 2017.
HIV epidemic remains a major global health issue. Data from cost-effectiveness analyses base on CD4+ count and morbidity in patients with symptomatic and asymptomatic HIV infection. The approach adopted in these analyses includes many other factors, previously not investigated. Additionally, we evaluate the impact of sexual HIV transmission due to delayed cART on the cost-effectiveness of care.
A lifetime Markov model (1-month cycle) was developed to estimate the cost per quality adjusted life years (QALY) for a 1- and 3-year delay in starting cART (as compared to starting immediately at linkage to care) lifetime costs, clinical outcomes and cost-effectiveness. Patients were categorized into having asymptomatic HIV, AIDS, Hodgkin's Lymphoma, and non-AIDS defining condition. Mortality rates and utility values were obtained from published literature. The number of new infected persons was estimated on the basis of sexual orientation, the number of sexual partners per year, the number of sex acts per month, frequency of condom use and use of cART. For the input Test and Keep in Care (TAK) project cohort data were used. Costs of care, cART and potential life-years lost were based on estimated total costs and the difference in expected QALY gained between an HIV-positive and an average person in Polish population. Costs were based on real expenditures of the Ministry of Health, National Health Fund, available studies and experts' opinion. Costs and effects were discounted at rates of 5% and 3.5%, respectively.
Input data were available for 141 patients form TAK cohort. The estimated number of new HIV infections in low, medium and high risk transmission groups were 0.28, 0.61, 2.07 with 1 and 0.82, 1.80, 6.11 with a 3-year delay, respectively. This reflected QALY loss due to cART delay of 0.52, 1.13, 3.84 and 2.02, 4.43, 15.03 for a 1- and 3-year delay, respectively. If additional costs of treatment and potential life-years lost due to new HIV infections were not taken into account, initiating cART immediately at linkage to care was not cost-saving irrespective of cART delay. Otherwise, when additional costs and QALY lost due to new HIV infections were included, immediate cART initiation was cost-saving regardless of the chosen scenarios.
If new HIV infections are not taken into account, then starting cART immediately does not dominate comparing to delaying cART. When taking into account HIV transmission in cost-effectiveness analysis, immediate initiation of HIV treatment is a profitable decision from the public payer's perspective.
艾滋病病毒流行仍是一个重大的全球卫生问题。成本效益分析的数据基于有症状和无症状艾滋病病毒感染者的CD4 +细胞计数和发病率。这些分析采用的方法包括许多以前未研究过的其他因素。此外，我们评估了因延迟启动抗逆转录病毒治疗（cART）导致的艾滋病病毒性传播对护理成本效益的影响。
建立了一个终身马尔可夫模型（1个月周期），以估计开始cART延迟1年和3年（与在与护理机构建立联系时立即开始相比）的每质量调整生命年（QALY）成本、终身成本、临床结果和成本效益。患者被分为无症状艾滋病病毒感染者、艾滋病患者、霍奇金淋巴瘤患者和非艾滋病定义疾病患者。死亡率和效用值来自已发表的文献。根据性取向、每年性伴侣数量、每月性行为次数、避孕套使用频率和cART使用情况估计新感染人数。对于输入数据，使用了“检测并持续护理”（TAK）项目队列数据。护理成本、cART成本和潜在生命年损失基于估计的总成本以及波兰人群中艾滋病病毒阳性者与普通人之间预期获得的QALY差异。成本基于卫生部、国家卫生基金的实际支出、现有研究和专家意见。成本和效果分别按5%和3.5%的贴现率进行贴现。
来自TAK队列的141名患者有可用的输入数据。低、中、高风险传播组中估计的新艾滋病病毒感染人数在延迟1年时分别为0.28、0.61、2.07，延迟3年时分别为0.82、1.80、6.11。这反映出延迟cART导致的QALY损失在延迟1年时分别为0.52、1.13、3.84，延迟3年时分别为2.02、4.43、15.03。如果不考虑因新的艾滋病病毒感染导致的额外治疗成本和潜在生命年损失，那么在与护理机构建立联系时立即开始cART无论cART延迟情况如何都不具有成本效益。否则，当包括因新的艾滋病病毒感染导致的额外成本和QALY损失时，无论选择何种方案，立即开始cART都具有成本效益。
如果不考虑新的艾滋病病毒感染，那么立即开始cART与延迟cART相比并不占优势。在成本效益分析中考虑艾滋病病毒传播时，从公共支付者的角度来看，立即开始艾滋病病毒治疗是一个有利可图的决定。
