Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA.
Health Economics and Epidemiology Research Office (HE2RO), University of the Witwatersrand, Johannesburg, South Africa.
Lancet Glob Health. 2022 Sep;10(9):e1298-e1306. doi: 10.1016/S2214-109X(22)00310-2.
In this so-called treat-all era, antiretroviral therapy (ART) interruptions contribute to an increasing proportion of HIV infections and deaths. Many strategies to improve retention on ART cost more than standard of care. In this study, we aimed to estimate the upper-bound costs at which such interventions should be adopted.
In this combined analysis, we compared the infections averted, disability-adjusted life-years (DALYs) averted, and upper-bound costs of interventions that improve ART retention in three HIV models with diverse structures, assumptions, and baseline settings: EMOD in South Africa, Optima in Malawi, and Synthesis in sub-Saharan African low-income and middle-income countries (LMICs). We modelled estimates over a 40-year time horizon, from a baseline of Jan 1, 2022, when interventions would be implemented, to Jan 1, 2062. We varied increment of ART retention (25%, 50%, 75%, and 100% retention), the extent to which interventions could be targeted towards individuals at risk of interrupting ART, and cost-effectiveness thresholds in each setting.
Despite simulating different settings and epidemic trends, all three models produced consistent estimates of health benefit (ie, DALYs averted) and transmission reduction per increment in retention. The range of estimates was 1·35-3·55 DALYs and 0·12-0·20 infections averted over the 40-year time horizon per additional person-year retained on ART. Upper-bound costs varied by setting and intervention effectiveness. Improving retention by 25% among all people receiving ART, regardless of risk of ART interruption, gave an upper-bound cost per person-year of US$2-6 in Optima (Malawi), $43-68 in Synthesis (LMICs in sub-Saharan Africa), and $28-180 in EMOD (South Africa). A maximally targeted and effective retention intervention had an upper-bound cost per person-year of US$93-223 in Optima (Malawi), $871-1389 in Synthesis (LMICs in sub-Saharan Africa), and $1013-6518 in EMOD (South Africa).
Upper-bound costs that could improve ART retention vary across sub-Saharan African settings and are likely to be similar to or higher than was estimated before the start of the treat-all era. Upper-bound costs could be increased by targeting interventions to those most at risk of interrupting ART.
Bill & Melinda Gates Foundation.
在所谓的“治必愈”时代，抗逆转录病毒疗法（ART）中断导致艾滋病毒感染和死亡人数比例不断增加。许多旨在提高 ART 保留率的策略的成本都高于常规护理。在这项研究中，我们旨在估算此类干预措施的最高成本，以确定其是否值得采用。
在这项综合分析中，我们比较了三种 HIV 模型中提高 ART 保留率的干预措施所避免的感染、残疾调整生命年（DALYs）和最高成本，这些模型具有不同的结构、假设和基线设置：南非的 EMOD、马拉维的 Optima 和撒哈拉以南非洲低收入和中等收入国家（LMICs）的 Synthesis。我们在 40 年的时间内进行了建模估计，从 2022 年 1 月 1 日（干预措施实施的基线）到 2062 年 1 月 1 日。我们在每个设置中改变了 ART 保留率的增量（25%、50%、75%和 100%保留）、干预措施可以针对中断 ART 风险的个体的程度以及成本效益阈值。
尽管模拟了不同的设置和流行趋势，但所有三种模型都产生了一致的健康效益（即避免的 DALYs）和每增加一个人年保留率的传播减少的估计值。在 40 年的时间内，每个额外的人年保留在 ART 上的估计值范围为 1.35-3.55 DALYs 和 0.12-0.20 感染。上限成本因设置和干预效果而异。在接受 ART 的所有人中，无论中断 ART 的风险如何，保留率提高 25%，在 Optima（马拉维）的人均年成本上限为 2-6 美元，在 Synthesis（撒哈拉以南非洲的 LMICs）为 43-68 美元，在 EMOD（南非）为 28-180 美元。针对最有可能中断 ART 的个体的最有效保留干预措施的上限成本在 Optima（马拉维）为 93-223 美元，在 Synthesis（撒哈拉以南非洲的 LMICs）为 871-1389 美元，在 EMOD（南非）为 1013-6518 美元。
提高 ART 保留率的最高成本因撒哈拉以南非洲地区的不同而有所差异，可能与“治必愈”时代开始之前的估计值相似或更高。通过将干预措施针对最有可能中断 ART 的个体，上限成本可能会增加。
比尔及梅琳达·盖茨基金会。
