Department of Health Policy, London School of Economics and Political Science, London, UK.
Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
Lancet Glob Health. 2021 May;9(5):e668-e680. doi: 10.1016/S2214-109X(21)00034-6. Epub 2021 Mar 12.
BACKGROUND: The HPTN 071 (PopART) trial showed that a combination HIV prevention package including universal HIV testing and treatment (UTT) reduced population-level incidence of HIV compared with standard care. However, evidence is scarce on the costs and cost-effectiveness of such an intervention. METHODS: Using an individual-based model, we simulated the PopART intervention and standard care with antiretroviral therapy (ART) provided according to national guidelines for the 21 trial communities in Zambia and South Africa (for all individuals aged >14 years), with model parameters and primary cost data collected during the PopART trial and from published sources. Two intervention scenarios were modelled: annual rounds of PopART from 2014 to 2030 (PopART 2014-30; as the UNAIDS Fast-Track target year) and three rounds of PopART throughout the trial intervention period (PopART 2014-17). For each country, we calculated incremental cost-effectiveness ratios (ICERs) as the cost per disability-adjusted life-year (DALY) and cost per HIV infection averted. Cost-effectiveness acceptability curves were used to indicate the probability of PopART being cost-effective compared with standard care at different thresholds of cost per DALY averted. We also assessed budget impact by projecting undiscounted costs of the intervention compared with standard care up to 2030. FINDINGS: During 2014-17, the mean cost per person per year of delivering home-based HIV counselling and testing, linkage to care, promotion of ART adherence, and voluntary medical male circumcision via community HIV care providers for the simulated population was US$6·53 (SD 0·29) in Zambia and US$7·93 (0·16) in South Africa. In the PopART 2014-30 scenario, median ICERs for PopART delivered annually until 2030 were $2111 (95% credible interval [CrI] 1827-2462) per HIV infection averted in Zambia and $3248 (2472-3963) per HIV infection averted in South Africa; and $593 (95% CrI 526-674) per DALY averted in Zambia and $645 (538-757) per DALY averted in South Africa. In the PopART 2014-17 scenario, PopART averted one infection at a cost of $1318 (1098-1591) in Zambia and $2236 (1601-2916) in South Africa, and averted one DALY at $258 (225-298) in Zambia and $326 (266-391) in South Africa, when outcomes were projected until 2030. The intervention had almost 100% probability of being cost-effective at thresholds greater than $700 per DALY averted in Zambia, and greater than $800 per DALY averted in South Africa, in the PopART 2014-30 scenario. Incremental programme costs for annual rounds until 2030 were $46·12 million (for a mean of 341 323 people) in Zambia and $30·24 million (for a mean of 165 852 people) in South Africa. INTERPRETATION: Combination prevention with universal home-based testing can be delivered at low annual cost per person but accumulates to a considerable amount when scaled for a growing population. Combination prevention including UTT is cost-effective at thresholds greater than $800 per DALY averted and can be an efficient strategy to reduce HIV incidence in high-prevalence settings. FUNDING: US National Institutes of Health, President's Emergency Plan for AIDS Relief, International Initiative for Impact Evaluation, Bill & Melinda Gates Foundation.
背景：HPTN 071（PopART）试验表明，与标准护理相比，包括普遍艾滋病毒检测和治疗（UTT）的综合艾滋病毒预防方案降低了人群层面的艾滋病毒发病率。然而，关于这种干预措施的成本和成本效益的证据很少。
方法：我们使用基于个体的模型模拟了 PopART 干预措施和标准护理，标准护理是根据赞比亚和南非的 21 个试验社区的国家指南提供抗逆转录病毒治疗（ART）（适用于所有年龄> 14 岁的人），模型参数和主要成本数据是在 PopART 试验期间和从已发表的来源收集的。模拟了两种干预方案：从 2014 年到 2030 年每年进行一轮 PopART（PopART 2014-30；作为联合国艾滋病规划署快速通道目标年）和在整个试验干预期间进行三轮 PopART（PopART 2014-17）。对于每个国家，我们计算了增量成本效益比（ICER），即每残疾调整生命年（DALY）和每避免感染艾滋病毒的成本。使用成本效益接受曲线来表示与标准护理相比，PopART 在不同的每避免 DALY 成本阈值下具有成本效益的概率。我们还通过预测干预措施与标准护理相比到 2030 年的无折扣成本来评估预算影响。
结果：在 2014-17 年期间，为模拟人群提供基于家庭的艾滋病毒咨询和检测、与护理机构联系、促进抗逆转录病毒药物的依从性以及通过社区艾滋病毒护理提供者进行自愿男性割礼的社区艾滋病毒护理提供者每人每年的平均成本分别为赞比亚 6.53 美元（SD 0.29）和南非 7.93 美元（0.16）。在 PopART 2014-30 方案中，每年提供直至 2030 年的 PopART 的中值 ICER 为赞比亚每避免 1 例感染的成本为 2111 美元（95%可信区间[CrI]为 1827-2462），南非为每避免 1 例感染的成本为 3248 美元（2472-3963）；赞比亚每避免 1 例 DALY 的成本为 593 美元（95%CrI 为 526-674），南非为每避免 1 例 DALY 的成本为 645 美元（538-757）。在 PopART 2014-17 方案中，PopART 在赞比亚每避免 1 例感染的成本为 1318 美元（1098-1591），南非为每避免 1 例感染的成本为 2236 美元（1601-2916），在赞比亚每避免 1 例 DALY 的成本为 258 美元（225-298），南非为每避免 1 例 DALY 的成本为 326 美元（266-391），当预测结果到 2030 年时。在 PopART 2014-30 方案中，在阈值大于每避免 700 美元的 DALY 的情况下，干预措施几乎有 100%的可能性具有成本效益，在阈值大于每避免 800 美元的 DALY 的情况下，干预措施具有成本效益，在赞比亚，在南非，这一比例为 800 美元。在 2030 年之前每年进行一轮的增量方案成本分别为赞比亚 4612 万美元（适用于平均 341323 人）和南非 3024 万美元（适用于平均 165852 人）。
解释：包括普遍家庭艾滋病毒检测和治疗的综合预防措施可以以每人每年的低费用提供，但随着人口的增长，费用会累积到相当大的数额。包括 UTT 的综合预防措施在每避免 800 美元以上的 DALY 的阈值上具有成本效益，并且可以成为降低高流行地区艾滋病毒发病率的有效策略。
资助：美国国立卫生研究院、总统艾滋病紧急救援计划、国际影响评估倡议、比尔和梅林达盖茨基金会。
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