Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School.
Department of Epidemiology, Laney Graduate School, Emory University, Atlanta, GA, USA.
Int J Epidemiol. 2019 Feb 1;48(1):217-227. doi: 10.1093/ije/dyy203.
BACKGROUND: The impact and cost-effectiveness of couples' voluntary HIV counselling and testing (CVCT) has not been quantified in real-world settings. We quantify cost-per-HIV-infection averted by CVCT in Zambia from the donor's perspective. METHODS: From 2010 to 2016, CVCT was established in 73 Zambian government clinics. The cost-per-HIV-infection averted (CHIA) of CVCT was calculated using observed expenditures and effectiveness over longitudinal follow-up. These observed measures parameterized hypothetical 5-year nationwide implementations of: 'CVCT'; 'treatment-as-prevention (TasP) for discordant couples' identified by CVCT; and 'population TasP' for all HIV+ cohabiting persons identified by individual testing. RESULTS: In all, 207 428 couples were tested (US $52/couple). Among discordant couples in which HIV+ partners self-reported antiretroviral therapy (ART), HIV incidence was 8.5/100 person-years before and 1.8/100 person-years after CVCT (79% reduction). Corresponding reductions for non-ART-using discordant and concordant negative couples were 63% and 47%, respectively. CVCT averted an estimated 58% of new infections at US $659 CHIA. In nationwide implementation models, CVCT would prevent 17 times the number of infections vs 'TasP for discordant couples' at 86% of the cost, and nine times the infections vs 'population TasP' at 28% of the cost. CONCLUSIONS: CVCT is a cost-effective, feasible prevention strategy in Zambia. We demonstrate the novel, added effectiveness of providing CVCT to ART users, for whom ART use alone only partially mitigated transmission risk. Our results indicate a major policy shift (supporting development of CVCT indicators, budgets and targets) and have clinical implications (suggesting promotion of CVCT in ART clinics as a high-impact prevention strategy).
背景：在真实环境中，尚未对夫妇自愿艾滋病毒咨询和检测（CVCT）的影响和成本效益进行量化。我们从捐赠者的角度量化了赞比亚 CVCT 避免每例艾滋病毒感染的成本。
方法：2010 年至 2016 年，在 73 家赞比亚政府诊所建立了 CVCT。使用纵向随访中的观察到的支出和效果计算了 CVCT 避免的每例艾滋病毒感染成本（CHIA）。这些观察到的措施参数化了假设的 5 年全国范围内实施的三种情况：“CVCT”；通过 CVCT 确定的 HIV 阳性且治疗方案不同的夫妇的“治疗即预防（TasP）”；以及通过个体检测确定的所有 HIV 阳性同居者的“人群 TasP”。
结果：共有 207428 对夫妇接受了检测（每对夫妇 52 美元）。在 HIV 阳性伴侣自述接受抗逆转录病毒治疗（ART）的 HIV 阳性伴侣中，在 CVCT 之前 HIV 发病率为每 100 人年 8.5 例，之后为每 100 人年 1.8 例（降低了 79%）。对于未接受 ART 的 HIV 阳性且治疗方案不同的夫妇和 HIV 阴性且治疗方案一致的夫妇，相应的降低比例分别为 63%和 47%。CVCT 避免了每例 HIV 感染的成本为 659 美元，估计节省了 58%的新感染。在全国实施模型中，与“针对 HIV 阳性且治疗方案不同的夫妇的 TasP”相比，CVCT 可以预防的感染数量是前者的 17 倍，而与“人群 TasP”相比，CVCT 可以预防的感染数量是前者的 9 倍，而 CVCT 的成本仅为前者的 28%。
结论：CVCT 是赞比亚一种具有成本效益且可行的预防策略。我们证明了为接受 ART 的人提供 CVCT 的新的、额外的有效性，因为仅使用 ART 部分减轻了传播风险。我们的研究结果表明了重大政策转变（支持开发 CVCT 指标、预算和目标），并具有临床意义（建议在 ART 诊所推广 CVCT，将其作为一种高影响力的预防策略）。
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