Kazemian Pooyan, Costantini Sydney, Neilan Anne M, Resch Stephen C, Walensky Rochelle P, Weinstein Milton C, Freedberg Kenneth A
Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA.
Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.
J Biomed Inform. 2020 Jul;107:103475. doi: 10.1016/j.jbi.2020.103475. Epub 2020 Jun 8.
BACKGROUND: Microsimulation models of human immunodeficiency virus (HIV) disease that simulate individual patients one at a time and assess clinical and economic outcomes of HIV interventions often provide key details regarding direct individual clinical benefits ("individual benefit"), but they may lack detail on transmissions, and thus may underestimate an intervention's indirect benefits ("community benefit"). Dynamic transmission models can be used to simulate HIV transmissions, but they may do so at the expense of the clinical detail of microsimulations. We sought to develop, validate, and demonstrate a practical, novel method that can be integrated into existing HIV microsimulation models to capture this community benefit, integrating the effects of reduced transmission while keeping the clinical detail of microsimulations. METHODS: We developed a new method to capture the community benefit of HIV interventions by estimating HIV transmissions from the primary cohort of interest. The method captures the benefit of averting infections within the cohort of interest by estimating a corresponding gradual decline in incidence within the cohort. For infections averted outside the cohort of interest, our method estimates transmissions averted based on reductions in HIV viral load within the cohort, and the benefit (life-years gained and cost savings) of averting those infections based on the time they were averted. To assess the validity of our method, we paired it with the Cost-effectiveness of Preventing AIDS Complications (CEPAC) Model - a validated and widely-published microsimulation model of HIV disease. We then compared the consistency of model-estimated outcomes against outcomes of a widely-validated dynamic compartmental transmission model of HIV disease, the HIV Optimization and Prevention Economics (HOPE) model, using the intraclass correlation coefficient (ICC) with a two-way mixed effects model. Replicating an analysis done with HOPE, validation endpoints were number of HIV transmissions averted by offering pre-exposure prophylaxis (PrEP) to men who have sex with men (MSM) and people who inject drugs (PWID) in the US at various uptake and efficacy levels. Finally, we demonstrated an application of our method in a different setting by evaluating the clinical and economic outcomes of a PrEP program for MSM in India, a country currently considering PrEP rollout for this high-risk group. RESULTS: The new method paired with CEPAC demonstrated excellent consistency with the HOPE model (ICC = 0.98 for MSM and 0.99 for PWID). With only the individual benefit of the intervention incorporated, a PrEP program for MSM in India averted 43,000 transmissions over a 5-year period and resulted in a lifetime incremental cost-effectiveness ratio (ICER) of US$2,300/year-of-life saved (YLS) compared to the status quo. After applying both the direct (individual) and indirect (community) benefits, PrEP averted 86,000 transmissions over the same period and resulted in an ICER of US$600/YLS. CONCLUSIONS: Our method enables HIV microsimulation models that evaluate clinical and economic outcomes of HIV interventions to estimate the community benefit of these interventions (in terms of survival gains and cost savings) efficiently and without sacrificing clinical detail. This method addresses an important methodological gap in health economics microsimulation modeling and allows decision scientists to make more accurate policy recommendations.
背景:人类免疫缺陷病毒(HIV)疾病的微观模拟模型一次模拟一名个体患者,并评估HIV干预措施的临床和经济结果,这些模型通常会提供有关直接个体临床益处(“个体效益”)的关键细节,但可能缺乏关于传播的细节,因此可能会低估干预措施的间接益处(“社区效益”)。动态传播模型可用于模拟HIV传播,但这样做可能会以牺牲微观模拟的临床细节为代价。我们试图开发、验证并展示一种实用的新方法,该方法可以整合到现有的HIV微观模拟模型中以捕捉这种社区效益,在保留微观模拟临床细节的同时整合传播减少的影响。 方法:我们开发了一种新方法,通过估计来自主要感兴趣队列的HIV传播来捕捉HIV干预措施的社区效益。该方法通过估计队列内发病率相应的逐渐下降来捕捉在感兴趣队列内避免感染的效益。对于在感兴趣队列之外避免的感染,我们的方法根据队列内HIV病毒载量的降低来估计避免的传播,并根据避免这些感染的时间来估计避免这些感染的效益(获得的生命年数和成本节省)。为了评估我们方法的有效性,我们将其与预防艾滋病并发症成本效益(CEPAC)模型配对——这是一个经过验证且广泛发表的HIV疾病微观模拟模型。然后,我们使用组内相关系数(ICC)和双向混合效应模型,将模型估计结果与一个经过广泛验证的HIV疾病动态房室传播模型——HIV优化与预防经济学(HOPE)模型的结果进行一致性比较。重复HOPE进行的一项分析,验证终点是在美国以不同的接受率和疗效水平为男男性行为者(MSM)和注射吸毒者(PWID)提供暴露前预防(PrEP)所避免的HIV传播数量。最后,我们通过评估印度一项针对MSM的PrEP计划的临床和经济结果,展示了我们方法在不同环境中的应用,印度目前正在考虑为这一高危群体推广PrEP。 结果:与CEPAC配对的新方法与HOPE模型显示出极好的一致性(MSM的ICC = 0.98,PWID的ICC = 0.99)。仅纳入干预措施的个体效益时,印度针对MSM的PrEP计划在5年内避免了43,000次传播,与现状相比,终身增量成本效益比(ICER)为每年每挽救一个生命年(YLS)2300美元。应用直接(个体)和间接(社区)效益后同一时期PrEP避免了86,000次传播,ICER为每年每YLS 600美元。 结论:我们的方法使评估HIV干预措施临床和经济结果的HIV微观模拟模型能够有效估计这些干预措施的社区效益(就生存获益和成本节省而言),且不牺牲临床细节。该方法解决了健康经济学微观模拟建模中一个重要的方法学差距,并使决策科学家能够做出更准确的政策建议。
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