Institute for Global Health, University College London, London, UK.
Centre for Health Economics, University of York, York, UK.
Lancet Glob Health. 2024 Sep;12(9):e1436-e1445. doi: 10.1016/S2214-109X(24)00224-9.
HIV prevalence and incidence has declined in East, Central, and Southern Africa (ECSA), but remains high among female sex workers (FSWs). Sex worker programmes have the potential to considerably increase access to HIV testing, prevention, and treatment. We aimed to quantify these improvements by modelling the potential effect of sex worker programmes at two different intensities on HIV incidence and key health outcomes, and assessed the programmes' potential cost-effectiveness in order to help inform HIV policy decisions.
Using a model previously used to review policy decisions in ECSA, we assumed a low-intensity sex worker programme had run from 2010 until 2023; this resulted in care disadvantages among FSWs being reduced, and also increased testing, condom use, and willingness to take pre-exposure prophylaxis (PrEP). After 2023, three policy options were considered: discontinuation, continuation, and a scale-up of the programme to high-intensity, which would have a broader reach, and higher influences on condom use, antiretroviral therapy (ART) adherence, testing, and PrEP use. Outputs of the key outcomes (the percentage of FSWs who were diagnosed with HIV, on ART, and virally suppressed; the percentage of FSWs with zero condomless partners, and HIV incidence) were compared in 2030. The maximum cost for a sex worker programme to be cost-effective was calculated over a 50-year time period and in the context of 10 million adults. The cost-effectiveness analysis was conducted from a health-care perspective; costs and disability-adjusted life-years were both discounted to present US$ values at 3% per annum.
Compared with continuing a low-intensity sex worker programme until 2030, discontinuation of the programme was calculated to result in a lower percentage of FSWs diagnosed (median 88·75% vs 91·37%; median difference compared to continuation of a low-intensity programme [90% range] 2·03 [-4·49 to 10·98]), a lower percentage of those diagnosed currently taking ART (86·35% vs 88·89%; 2·38 [-3·69 to 13·42]), and a lower percentage of FSWs on ART with viral suppression (87·49% vs 88·96%; 1·17 [-6·81 to 11·53]). Discontinuation of a low-intensity programme also resulted in an increase in HIV incidence among FSWs from 5·06 per 100 person-years (100 p-y; 90% range 0·52 to 22·21) to 4·05 per 100 p-y (0·21 to 21·15). Conversely, comparing a high-intensity sex worker programme until 2030 with discontinuation of the programme resulted in a higher percentage of FSWs diagnosed (median 95·81% vs 88·75; median difference compared to discontinuation [90% range] 6·36 [0·60 to 18·63]), on ART (93·93 vs 86.35%; median difference 7·13 [-0·65 to 26·48]), and with viral suppression (93·21% vs 87·49; median difference 7·13 [-0·65 to 26·48]). A high-intensity programme also resulted in HIV incidence in FSWs declining to 2·23 per 100 p-y (0·00 to 14·44), from 5·06 per 100 p-y (0·52 to 22·21) if the programme was discontinued. In the context of 10 million adults over a 50-year time period and a cost-effectiveness threshold of US$500 per disability-adjusted life-year averted, $34 million per year can be spent for a high-intensity programme to be cost-effective.
A sex worker programme, even with low-level interventions, has a positive effect on key outputs for FSWs. A high-intensity programme has a considerably higher effect; HIV incidence among FSW and in the general population can be substantially reduced, and should be considered for implementation by policy makers.
Wellcome Trust.
艾滋病毒在东非、中非和南非（ECSA）的流行率和发病率有所下降，但性工作者（FSW）中的发病率仍然很高。性工作者方案有可能大大增加艾滋病毒检测、预防和治疗的机会。我们旨在通过模型量化这些改进，该模型对两种不同强度的性工作者方案对艾滋病毒发病率和主要健康结果的潜在影响进行了建模，并评估了方案在成本效益方面的潜在效益，以帮助为艾滋病毒政策决策提供信息。
我们使用了之前用于审查 ECSA 政策决策的模型，假设从 2010 年到 2023 年实施了低强度的性工作者方案；这导致 FSW 的护理劣势减少，同时增加了检测、避孕套使用和接受暴露前预防（PrEP）的意愿。2023 年后，考虑了三种政策选择：停止、继续和扩大到高强度方案，该方案的覆盖面更广，对避孕套使用、抗逆转录病毒疗法（ART）依从性、检测和 PrEP 使用的影响也更大。在 2030 年比较了主要结果（诊断为 HIV、接受 ART 治疗和病毒抑制的 FSW 的百分比、零无保护伴侣的 FSW 的百分比和 HIV 发病率）的输出。在 50 年的时间内，以每 50 个残疾调整生命年（DALY）节省 500 美元的成本效益分析进行了最高成本的计算。成本效益分析从医疗保健的角度进行；成本和残疾调整生命年均以每年 3%的贴现率贴现为当前美元价值。
与继续实施低强度性工作者方案直至 2030 年相比，方案的停止被计算为导致诊断为 HIV 的 FSW 的比例降低（中位数 88.75%对 91.37%；与继续实施低强度方案的中位数差异（90%范围）为 2.03 [-4.49 至 10.98]），目前接受 ART 治疗的诊断为 HIV 的比例降低（中位数 86.35%对 88.89%；与继续实施低强度方案的中位数差异[90%范围]为 2.38 [-3.69 至 13.42]），以及接受 ART 治疗且病毒抑制的 FSW 的比例降低（中位数 87.49%对 88.96%；1.17 [-6.81 至 11.53]）。低强度方案的停止也导致 FSW 的 HIV 发病率从每 100 人年 5.06 例（100 p-y；90%范围 0.52 至 22.21）增加到每 100 p-y 4.05 例（0.21 至 21.15）。相反，与方案的停止相比，直到 2030 年实施高强度性工作者方案导致诊断为 HIV 的 FSW 的比例增加（中位数 95.81%对 88.75%；与停止方案的中位数差异[90%范围]为 6.36 [0.60 至 18.63]），接受 ART 治疗的比例（中位数 93.93%对 86.35%；中位数差异为 7.13 [-0.65 至 26.48]），以及病毒抑制的比例（中位数 93.21%对 87.49%；中位数差异为 7.13 [-0.65 至 26.48]）。高强度方案还导致 FSW 的 HIV 发病率下降到每 100 p-y 2.23 例（0.00 至 14.44），而如果方案停止，则每 100 p-y 5.06 例（0.52 至 22.21）。在 1000 万成年人的 50 年时间内，在每 50 个 DALY 节省 500 美元的成本效益阈值下，每年可以花费 3400 万美元用于高强度方案的成本效益。
性工作者方案，即使干预力度较低，也对 FSW 的主要结果产生了积极影响。高强度方案的效果要大得多；FSW 和普通人群中的 HIV 发病率可以大大降低，应该考虑由决策者实施。
威康信托基金会。
