Section of Infectious Diseases, Boston Medical Center (BMC), 801 Massachusetts Ave, 2nd Floor, Boston, MA, 02118, USA; Boston University School of Medicine, 801 Massachusetts Ave, 2nd Floor, Boston, MA, 02118, USA.
Boston University School of Public Health, Department of Health Law, Policy and Management, 715 Albany Street, T3-West, Boston, MA, 02118-2526, USA.
Int J Drug Policy. 2019 Oct;72:160-168. doi: 10.1016/j.drugpo.2019.05.010. Epub 2019 May 10.
Untreated opioid use disorder (OUD) affects the care of HIV/HCV co-infected people who inject opioids. Despite active injection opioid use, there is evidence of increasing engagement in HIV care and adherence to HIV medications among HIV/HCV co-infected persons. However, less than one-half of this population is offered HCV treatment onsite. Treatment for OUD is also rare and largely occurs offsite. Integrating buprenorphine-naloxone (BUP-NX) into onsite care for HIV/HCV co-infected persons may improve outcomes, but the clinical impact and costs are unknown. We evaluated the clinical impact, costs, and cost-effectiveness of integrating (BUP-NX) into onsite HIV/HCV treatment compared with the status quo of offsite referral for medications for OUD.
We used a Monte Carlo microsimulation of HCV to compare two strategies for people who inject opioids: 1) standard HIV care with onsite HCV treatment and referral to offsite OUD care (status quo) and 2) standard HIV care with onsite HCV and BUP-NX treatment (integrated care). Both strategies assume that all individuals are already in HIV care. Data from national databases, clinical trials, and cohorts informed model inputs. Outcomes included mortality, HCV reinfection, quality-adjusted life years (QALYs), costs (2017 US dollars), and incremental cost-effectiveness ratios.
Integrated care reduced HCV reinfections by 7%, cases of cirrhosis by 1%, and liver-related deaths by 3%. Compared to the status quo, this strategy also resulted in an estimated 11/1,000 fewer non-liver attributable deaths at one year and 28/1,000 fewer of these deaths at five years, at a cost-effectiveness ratio of $57,100/QALY. Integrated care remained cost-effective in sensitivity analyses that varied the proportion of the population actively injecting opioids, availability of BUP-NX, and quality of life weights.
Integrating BUP-NX for OUD into treatment for HIV/HCV co-infected adults who inject opioids increases life expectancy and is cost-effective at a $100,000/QALY threshold.
未经治疗的阿片类药物使用障碍（OUD）会影响同时感染 HIV/HCV 的滥用阿片类药物者的护理。尽管存在积极的注射阿片类药物使用，但有证据表明，HIV/HCV 共感染人群中越来越多地参与 HIV 护理并坚持使用 HIV 药物。然而，只有不到一半的人群在现场获得 HCV 治疗。阿片类药物使用障碍的治疗也很少见，并且主要在现场之外进行。将丁丙诺啡纳洛酮（BUP-NX）整合到 HIV/HCV 共感染者的现场护理中可能会改善结局，但临床影响和成本尚不清楚。我们评估了将（BUP-NX）整合到现场 HIV/HCV 治疗中与 OUD 药物场外转诊的现状相比对 HIV/HCV 共感染者的临床影响、成本和成本效益。
我们使用 HCV 的蒙特卡罗微模拟来比较两种针对阿片类药物注射者的策略：1）现场 HCV 治疗和场外 OUD 护理转诊的标准 HIV 护理（现状）和 2）现场 HCV 和 BUP-NX 治疗的标准 HIV 护理（整合护理）。这两种策略都假设所有个体都已经接受了 HIV 护理。国家数据库、临床试验和队列的数据为模型输入提供了信息。结果包括死亡率、HCV 再感染、质量调整生命年（QALYs）、成本（2017 年美元）和增量成本效益比。
与现状相比，整合护理减少了 7%的 HCV 再感染、1%的肝硬化病例和 3%的与肝脏相关的死亡。与现状相比，这一策略还导致一年时每 1000 人中估计减少 11 例非肝脏归因死亡，五年时减少 28 例此类死亡，增量成本效益比为 57100 美元/QALY。在敏感性分析中，整合护理仍然具有成本效益，这些分析改变了活跃注射阿片类药物人群的比例、BUP-NX 的可用性和生活质量权重。
将丁丙诺啡纳洛酮（BUP-NX）纳入治疗同时感染 HIV/HCV 的阿片类药物注射者，可增加预期寿命，在 10 万美元/QALY 的阈值下具有成本效益。
