Allel Kasim, Cust Henry, Mfochive Iliassou, Szawlowski Sandie, Nitcheu Emile, Tamgno Eric Defo, Moyoum Stephanie, Noo Julienne, Billong Serge, Tamoufe Ubald, Lepine Aurelia
University College London, London, UK
Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
BMJ Glob Health. 2025 Feb 18;10(2):e017870. doi: 10.1136/bmjgh-2024-017870.
HIV prevalence disproportionately affects high-risk populations, particularly female sex workers in Africa. Women and girls engaging in transactional sex (WGTS) face similar health risks from unsafe practices, economic vulnerabilities and stigma. However, they are not recognised.
Using existing literature and data from the POWER randomised controlled trial, we developed a deterministic compartmental model to assess HIV dynamics among WGTS, their sugar daddies and low-risk populations. We evaluated the cost-effectiveness of a new structural intervention to prevent HIV among WGTS in urban Cameroon by reducing the financial need to engage in transactional sex in the case of illness and injury shocks to the household. The intervention provided free healthcare to WGTS and their economic dependents through a zero-cost health insurance package. We explored the cost-effectiveness of this intervention considering various population coverage levels (0%, 25%, 50%, 75% and 100%). We calculated the incremental cost-effectiveness ratio (ICER) per disability-adjusted life-year (DALY) and HIV infections averted, employing both univariable and global sensitivity analyses. Probabilistic sensitivity analyses considered all parameters, including the insurance effect in reducing HIV, comparing simulated ICERs to willingness-to-pay thresholds. We also compared the health insurance strategy with expanding pre-exposure prophylaxis (PrEP) coverage. All costs were evaluated in 2023 UK pounds (£) using a 3% discount rate, with Cameroon's gross domestic product (GDP) per capita recorded at £1239.
Implementing health insurance coverage levels of 25%, 50%, 75% and 100% yielded ICERs/DALY averted of £2795 (£2483-£2824), £2541 (£2370-£2592), £2263 (£2156-£2316) and £1952 (£1891-£1998), respectively, compared with 0% coverage. Probabilistic sensitivity analysis indicated an ICER=£2128/DALY averted at 100% coverage, with 58% of simulations showing ICERs<GDP per capita. Maintaining health insurance's effect in reducing HIV above 70% could provide significant health and economic benefits. However, antiretroviral therapy (ART) efficacy significantly impacted HIV infection prevention (partial rank correlation coefficient=-0.62, p<0.001) in global sensitivity analyses; expanding ART could reduce the cost-effectiveness of health insurance. While PrEP alone is not cost-effective, combining 20% PrEP coverage with 75%-100% health insurance for WGTS maximises DALYs averted (ICER/DALY averted=£2436-£2102) and reduces infections.
A comprehensive health insurance scheme for women in Cameroon could significantly reduce HIV infections and DALYs, promoting a more inclusive and targeted healthcare policy for women at high risk of HIV.
艾滋病毒流行对高危人群的影响尤为严重，在非洲，女性性工作者受影响的比例过高。从事交易性性行为的妇女和女孩面临着因不安全行为、经济脆弱性和耻辱感带来的类似健康风险。然而，她们并未得到认可。
利用现有文献和POWER随机对照试验的数据，我们开发了一个确定性的房室模型，以评估从事交易性性行为的妇女及其“糖爹”和低风险人群中的艾滋病毒动态。我们通过减少家庭因病伤冲击而从事交易性性行为的经济需求，评估了一种新的结构性干预措施在喀麦隆城市预防从事交易性性行为妇女感染艾滋病毒的成本效益。该干预措施通过零成本医疗保险套餐为从事交易性性行为的妇女及其经济受抚养人提供免费医疗保健。我们考虑了不同的人群覆盖水平（0%、25%、50%、75%和100%），探讨了这种干预措施的成本效益。我们计算了每避免一个残疾调整生命年（DALY）和每避免一例艾滋病毒感染的增量成本效益比（ICER），采用了单变量和全局敏感性分析。概率敏感性分析考虑了所有参数，包括保险在减少艾滋病毒方面的效果，将模拟的ICER与支付意愿阈值进行比较。我们还将医疗保险策略与扩大暴露前预防（PrEP）覆盖范围进行了比较。所有成本均以2023年英镑（£）为单位进行评估，使用3%的贴现率，喀麦隆人均国内生产总值（GDP）记录为1239英镑。
与0%覆盖相比，实施25%、50%、75%和100%的医疗保险覆盖水平分别产生每避免一个DALY的ICER为2795英镑（2483 - 2824英镑）、2541英镑（2370 - 2592英镑）、2263英镑（2156 - 2316英镑）和1952英镑（1891 - 1998英镑）。概率敏感性分析表明，100%覆盖时每避免一个DALY的ICER = 2128英镑，58%的模拟显示ICER低于人均GDP。将医疗保险在减少艾滋病毒方面的效果维持在70%以上可带来显著的健康和经济效益。然而，在全局敏感性分析中，抗逆转录病毒疗法（ART）的疗效对预防艾滋病毒感染有显著影响（偏秩相关系数 = -0.62，p < 0.001）；扩大ART可能会降低医疗保险的成本效益。虽然单独使用PrEP不具有成本效益，但将20%的PrEP覆盖与75% - 100%的从事交易性性行为妇女医疗保险相结合，可最大程度地避免DALY（每避免一个DALY的ICER = 2436 - 2102英镑）并减少感染。
喀麦隆为妇女制定的全面医疗保险计划可显著减少艾滋病毒感染和DALY，促进为艾滋病毒高风险妇女制定更具包容性和针对性的医疗保健政策。
