Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
J Int AIDS Soc. 2020 Oct;23(10):e25629. doi: 10.1002/jia2.25629.
In 2017, the Aurum Institute, with support from Unitaid, launched an initiative to expand short-course therapy for the prevention of tuberculosis (TB) in 12 high-burden countries. This study aimed to investigate the importance of "catalytic" effects beyond the original project timeframe when estimating cost-effectiveness of such large investments.
We estimated the cost-effectiveness of the IMPAACT4TB (I4TB) initiative from a health system perspective, using a 10-year time horizon. We first conservatively estimated costs using a "top-down" approach considering only the direct health benefits of providing TB preventive therapy to people initiating antiretroviral therapy (ART) through I4TB activities. We then re-estimated the incremental cost-effectiveness of I4TB incorporating the costs and health benefits of potential catalytic effects beyond the program itself.
We estimated that TB preventive therapy through the I4TB initiative alone would prevent 14 201 cases of active TB and 1562 TB deaths over 10 years with an up-front investment of $52.5 million; the estimated incremental cost-effectiveness was $1580 per disability-adjusted life year (DALY) averted. If this initiative could achieve its desired catalytic effects, an additional 375 648 cases and 41 321 deaths could be averted, at an incremental cost of $546 million and cost-effectiveness of $713 per DALY averted.
Our findings provide donors with reasonable evidence of value for money to support investment in short-course TB preventive therapy for people initiating ART in high-burden settings. Our study also illustrates the importance of considering long-term secondary ("catalytic") effects when evaluating the cost-effectiveness of large-scale initiatives designed to change a global policy landscape.
2017 年，奥鲁姆研究所（Aurum Institute）在无国界医生组织（Unitaid）的支持下，发起了一项倡议，旨在 12 个高负担国家扩大预防结核病（TB）短程疗法。本研究旨在探讨在估计此类大规模投资的成本效益时，超出原项目时间框架的“催化”效应的重要性。
我们从卫生系统的角度，使用 10 年的时间范围，估计了 IMPAACT4TB（I4TB）倡议的成本效益。我们首先使用“自上而下”的方法保守地估计成本，仅考虑通过 I4TB 活动为开始接受抗逆转录病毒疗法（ART）的人提供结核病预防性治疗的直接健康益处。然后，我们重新估计了 I4TB 的增量成本效益，纳入了超出计划本身的潜在催化效应的成本和健康效益。
我们估计，仅通过 I4TB 倡议提供结核病预防性治疗，在 10 年内将预防 14201 例活动性结核病和 1562 例结核病死亡，前期投资 5250 万美元；估计的增量成本效益为每避免一个残疾调整生命年（DALY）花费 1580 美元。如果这一倡议能够实现其预期的催化效应，还可以避免另外 375648 例和 41321 例死亡，增量成本为 5460 万美元，增量成本效益为每避免一个 DALY 花费 713 美元。
我们的研究结果为捐助者提供了合理的投资价值证据，以支持在高负担环境中为开始接受 ART 的人提供短程结核病预防性治疗的投资。我们的研究还说明了在评估旨在改变全球政策格局的大规模倡议的成本效益时，考虑长期的二级（“催化”）效应的重要性。
