运用微观模拟模型为洛杉矶县的 EHE 实施策略提供信息。
Using Microsimulation Modeling to Inform EHE Implementation Strategies in Los Angeles County.
机构信息
Department of Health Policy and Management, John Hopkins Bloomberg School of Public Health, Baltimore, MD.
Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, CA.
出版信息
J Acquir Immune Defic Syndr. 2022 Jul 1;90(S1):S167-S176. doi: 10.1097/QAI.0000000000002977.
BACKGROUND
Pre-exposure prophylaxis (PrEP) is essential to ending HIV. Yet, uptake remains uneven across racial and ethnic groups. We aimed to estimate the impacts of alternative PrEP implementation strategies in Los Angeles County.
SETTING
Men who have sex with men, residing in Los Angeles County.
METHODS
We developed a microsimulation model of HIV transmission, with inputs from key local stakeholders. With this model, we estimated the 15-year (2021-2035) health and racial and ethnic equity impacts of 3 PrEP implementation strategies involving coverage with 9000 additional PrEP units annually, above the Status-quo coverage level. Strategies included PrEP allocation equally (strategy 1), proportionally to HIV prevalence (strategy 2), and proportionally to HIV diagnosis rates (strategy 3), across racial and ethnic groups. We measured the degree of relative equalities in the distribution of the health impacts using the Gini index (G) which ranges from 0 (perfect equality, with all individuals across all groups receiving equal health benefits) to 1 (total inequality).
RESULTS
HIV prevalence was 21.3% in 2021 [Black (BMSM), 31.1%; Latino (LMSM), 18.3%, and White (WMSM), 20.7%] with relatively equal to reasonable distribution across groups (G, 0.28; 95% confidence interval [CI], 0.26 to 0.34). During 2021-2035, cumulative incident infections were highest under Status-quo (n = 24,584) and lowest under strategy 3 (n = 22,080). Status-quo infection risk declined over time among all groups but remained higher in 2035 for BMSM (incidence rate ratio, 4.76; 95% CI: 4.58 to 4.95), and LMSM (incidence rate ratio, 1.74; 95% CI: 1.69 to 1.80), with the health benefits equally to reasonably distributed across groups (G, 0.32; 95% CI: 0.28 to 0.35). Relative to Status-quo, all other strategies reduced BMSM-WMSM and BMSM-LMSM disparities, but none reduced LMSM-WMSM disparities by 2035. Compared to Status-quo, strategy 3 reduced the most both incident infections (% infections averted: overall, 10.2%; BMSM, 32.4%; LMSM, 3.8%; WMSM, 3.5%) and HIV racial inequalities (G reduction, 0.08; 95% CI: 0.02 to 0.14).
CONCLUSIONS
Microsimulation models developed with early, continuous stakeholder engagement and inputs yield powerful tools to guide policy implementation.
背景
暴露前预防（PrEP）对于终结艾滋病至关重要。然而，其使用率在不同种族和族裔群体之间仍不均衡。我们旨在评估在洛杉矶县实施替代 PrEP 策略的影响。
地点
与男性发生性关系的男性，居住在洛杉矶县。
方法
我们开发了一种 HIV 传播的微观模拟模型，输入来自当地主要利益相关者。使用该模型，我们估计了 2021-2035 年三种 PrEP 实施策略的 15 年（2021-2035 年）健康和种族与族裔公平影响，这三种策略涉及每年增加 9000 个 PrEP 单位，超过了现状覆盖水平。策略包括在种族和族裔群体中平等分配 PrEP（策略 1）、按 HIV 流行率比例分配（策略 2）和按 HIV 诊断率比例分配（策略 3）。我们使用基尼指数（G）衡量健康影响分布的相对平等程度，该指数的范围从 0（完全平等，所有个体在所有群体中都获得平等的健康益处）到 1（完全不平等）。
结果
2021 年 HIV 流行率为 21.3%（黑人 [BMSM]，31.1%；拉丁裔 [LMSM]，18.3%，白人 [WMSM]，20.7%），分布相对均衡（G，0.28；95%置信区间 [CI]，0.26 至 0.34）。在 2021-2035 年期间，在现状下累积的感染人数最多（n=24584），在策略 3 下最低（n=22080）。所有群体的现状感染风险随时间下降，但 BMSM（发病率比，4.76；95%CI：4.58 至 4.95）和 LMSM（发病率比，1.74；95%CI：1.69 至 1.80）的感染风险在 2035 年仍较高，健康益处在群体中得到了公平合理的分配（G，0.32；95%CI：0.28 至 0.35）。与现状相比，所有其他策略都减少了 BMSM-WMSM 和 BMSM-LMSM 之间的差距，但没有一种策略能在 2035 年减少 LMSM-WMSM 之间的差距。与现状相比，策略 3 减少了最多的感染病例（%感染避免：总体，10.2%；BMSM，32.4%；LMSM，3.8%；WMSM，3.5%）和 HIV 种族不平等（G 减少，0.08；95%CI：0.02 至 0.14）。
结论
与早期、持续的利益相关者参与和投入相结合的微观模拟模型为指导政策实施提供了有力工具。
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