Department of Infectious Disease Epidemiology, Imperial College London, London, UK.
The Bill and Melinda Gates Foundation, Seattle, WA, USA.
J Int AIDS Soc. 2018 Nov;21(11):e25203. doi: 10.1002/jia2.25203.
INTRODUCTION: Setting and monitoring progress towards targets for HIV control is critical in ensuring responsive programmes. Here, we explore how to apply targets for reduction in HIV incidence to local settings and which indicators give the strongest signal of a change in incidence in the population and are therefore most important to monitor. METHODS: We use location-specific HIV transmission models, tailored to the epidemics in the counties and major cities in Kenya, to project a wide range of plausible future epidemic trajectories through varying behaviours, treatment coverage and prevention interventions. We look at the change in incidence across modelled scenarios in each location between 2015 and 2030 to inform local target setting. We also simulate the measurement of a library of potential indicators and assess which are most strongly associated with a change in incidence. RESULTS: Considerable variation was observed in the trajectory of the local epidemics under the plausible scenarios defined (only 10 of 48 locations saw a median reduction in incidence of greater than or equal to an 80% target by 2030). Indicators that provide strong signals in certain epidemic types may not perform consistently well in settings with different epidemiological features. Predicting changes in incidence is more challenging in advanced generalized epidemics compared to concentrated epidemics where changes in high-risk sub-populations track more closely to the population as a whole. Many indicators demonstrate only limited association with incidence (such as "condom use" or "pre-exposure prophylaxis coverage"). This is because many other factors (low effectiveness, impact of other interventions, countervailing changes in risk behaviours, etc.) can confound the relationship between interventions and their ultimate long-term impact, especially for an intervention with low expected coverage. The population prevalence of viral suppression shows the most consistent associations with long-term changes in incidence even in the largest generalized epidemics. CONCLUSIONS: Target setting should be appropriate for the local epidemic and what can feasibly be achieved. There is no one universally reliable indicator to predict future HIV incidence across settings. Thus, the signature of epidemic control must contain indications of success across a wide range of interventions and outcomes.
简介:设定和监测艾滋病毒控制目标的进展对于确保有针对性的方案至关重要。在这里,我们探讨如何将艾滋病毒发病率降低目标应用于地方环境,并确定哪些指标最能反映人群中发病率的变化,因此是监测的最重要指标。
方法:我们使用针对肯尼亚各县和主要城市流行情况定制的特定地点艾滋病毒传播模型,通过改变行为、治疗覆盖率和预防干预措施,预测各种可能的未来流行轨迹。我们观察每个地点在 2015 年至 2030 年期间,在不同模型情景下发病率的变化,为地方目标设定提供信息。我们还模拟了一系列潜在指标的测量,并评估了哪些指标与发病率的变化最密切相关。
结果:在所定义的合理情景下,地方流行的轨迹存在很大差异(到 2030 年,只有 48 个地点中的 10 个观察到发病率中位数降低 80%或以上)。在某些流行类型中提供强烈信号的指标在具有不同流行病学特征的环境中可能表现不一致。与集中流行相比,在高级综合流行中预测发病率变化更具挑战性,因为高危亚人群的变化更密切地跟踪整个人群。许多指标与发病率的相关性有限(例如“避孕套使用”或“暴露前预防覆盖率”)。这是因为许多其他因素(低效果、其他干预措施的影响、风险行为的抵消变化等)可能使干预措施及其最终的长期影响之间的关系复杂化,特别是对于预期覆盖率较低的干预措施。即使在最大的综合流行中,病毒抑制的人群流行率与发病率的长期变化也具有最一致的相关性。
结论:目标设定应适合当地流行情况和实际可行的情况。没有一个普遍可靠的指标可以预测不同环境下的未来艾滋病毒发病率。因此,流行控制的特征必须包含广泛的干预措施和结果的成功迹象。
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