Sahu Maitreyi, Bayer Cara J, Roberts D Allen, van Rooyen Heidi, van Heerden Alastair, Shahmanesh Maryam, Asiimwe Stephen, Sausi Kombi, Sithole Nsika, Ying Roger, Rao Darcy W, Krows Meighan L, Shapiro Adrienne E, Baeten Jared M, Celum Connie, Revill Paul, Barnabas Ruanne V
Department of Health Metrics Sciences, University of Washington, Seattle, WA, United States of America.
Department of Global Health, University of Washington, Seattle, WA, United States of America.
PLOS Glob Public Health. 2023 Sep 5;3(9):e0000610. doi: 10.1371/journal.pgph.0000610. eCollection 2023.
Community-based delivery and monitoring of antiretroviral therapy (ART) for HIV has the potential to increase viral suppression for individual- and population-level health benefits. However, the cost-effectiveness and budget impact are needed for public health policy. We used a mathematical model of HIV transmission in KwaZulu-Natal, South Africa, to estimate population prevalence, incidence, mortality, and disability-adjusted life-years (DALYs) from 2020 to 2060 for two scenarios: 1) standard clinic-based HIV care and 2) five-yearly home testing campaigns with community ART for people not reached by clinic-based care. We parameterised model scenarios using observed community-based ART efficacy. Using a health system perspective, we evaluated incremental cost-effectiveness and net health benefits using a threshold of $750/DALY averted. In a sensitivity analysis, we varied the discount rate; time horizon; costs for clinic and community ART, hospitalisation, and testing; and the proportion of the population receiving community ART. Uncertainty ranges (URs) were estimated across 25 best-fitting parameter sets. By 2060, community ART following home testing averted 27.9% (UR: 24.3-31.5) of incident HIV infections, 27.8% (26.8-28.8) of HIV-related deaths, and 18.7% (17.9-19.7) of DALYs compared to standard of care. Adolescent girls and young women aged 15-24 years experienced the greatest reduction in incident HIV (30.7%, 27.1-34.7). In the first five years (2020-2024), community ART required an additional $44.9 million (35.8-50.1) annually, representing 14.3% (11.4-16.0) of the annual HIV budget. The cost per DALY averted was $102 (85-117) for community ART compared with standard of care. Providing six-monthly refills instead of quarterly refills further increased cost-effectiveness to $78.5 per DALY averted (62.9-92.8). Cost-effectiveness was robust to sensitivity analyses. In a high-prevalence setting, scale-up of decentralised ART dispensing and monitoring can provide large population health benefits and is cost-effective in preventing death and disability due to HIV.
基于社区的抗逆转录病毒疗法（ART）用于治疗艾滋病毒，有潜力提高病毒抑制水平，从而为个人和人群健康带来益处。然而，公共卫生政策需要了解其成本效益和预算影响。我们使用了南非夸祖鲁 - 纳塔尔省的艾滋病毒传播数学模型，来估计2020年至2060年两种情况下的人群患病率、发病率、死亡率和伤残调整生命年（DALYs）：1）基于标准诊所的艾滋病毒护理；2）针对未获得诊所护理的人群开展为期五年的家庭检测活动，并提供社区抗逆转录病毒疗法。我们使用观察到的基于社区的抗逆转录病毒疗法疗效对模型情景进行参数化。从卫生系统的角度出发，我们使用每避免一个伤残调整生命年750美元的阈值来评估增量成本效益和净健康效益。在敏感性分析中，我们改变了贴现率、时间范围、诊所和社区抗逆转录病毒疗法的成本、住院费用、检测费用以及接受社区抗逆转录病毒疗法的人群比例。在25个最佳拟合参数集上估计了不确定性范围（URs）。到2060年，与标准护理相比，家庭检测后的社区抗逆转录病毒疗法避免了27.9%（UR：24.3 - 31.5）的新发艾滋病毒感染、27.8%（26.8 - 28.8）的艾滋病毒相关死亡以及18.7%（17.9 - 19.7）的伤残调整生命年。15至24岁的少女和年轻女性新发艾滋病毒感染减少幅度最大（30.7%，27.1 - 34.7）。在头五年（2020 - 2024年），社区抗逆转录病毒疗法每年需要额外4490万美元（3580 - 5010万美元），占年度艾滋病毒预算的14.3%（11.4 - 16.0）。与标准护理相比，社区抗逆转录病毒疗法每避免一个伤残调整生命年的成本为102美元（85 - 117美元）。提供六个月的药物补充而非季度补充可进一步将成本效益提高到每避免一个伤残调整生命年78.5美元（62.9 - 92.8美元）。成本效益对敏感性分析具有稳健性。在高流行环境中，扩大分散式抗逆转录病毒疗法的分发和监测可带来巨大的人群健康益处，并且在预防艾滋病毒导致的死亡和残疾方面具有成本效益。
