Cost-effectiveness of point-of-care testing with task-shifting for HIV care in South Africa: a modelling study.
Cost-effectiveness of point-of-care testing with task-shifting for HIV care in South Africa: a modelling study.
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DOI：
10.1016/s2352-3018(20)30279-4
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发表时间：
2021-04
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通讯作者：
Drain PK
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作者：
Sharma M;Mudimu E;Simeon K;Bershteyn A;Dorward J;Violette LR;Akullian A;Abdool Karim SS;Celum C;Garrett N;Drain PK
需要在低资源环境下进行治疗监测的抗逆转录病毒疗法(ART)人数正在迅速增加。ART监测的护理点(POC)检测可能会减轻中央实验室的负担，改善临床结果，但其成本效益尚不清楚。我们使用了南非STREAM试验的成本和效果数据，该试验评估了POC检测病毒载量、CD4计数和肌酐的情况，与没有任务转移的基于实验室的检测相比，将任务从专业注册护士转移到较低级别的注册护士。我们对一个基于代理的网络模型EMOD-HIV进行了参数化，以预测在南非实施这种干预的影响。我们假设POC监测将病毒抑制率提高了9%，社区ART交付的登记人数增加了25%，转向二线ART的人数增加了1%，如STREAM中所述。我们评估了20年来在不同的诊所规模(每月10-50名患者开始抗逆转录病毒治疗)中POC的实施情况。在我们的主要分析中，我们使用了500美元/残疾调整后生命年(DALY)避免的成本效益阈值。预计在70%的抗逆转录病毒治疗患者中进行POC检测将使艾滋病毒感染减少4.5%，艾滋病毒相关死亡减少3.9%。在每月启动30次抗逆转录病毒疗法的诊所中，干预的增量成本-效果比为197美元/避免DALY(90%模型变异性：−为27美元，863美元)；当不同的背景病毒抑制、ART退出和干预效果不同时，结果仍然具有成本效益。假设POC测试没有增加社区ART交付的注册人数，则ICER为1,149美元(90%模型可变性：184美元，3,886美元)，超过了成本效益阈值。在较高的诊疗量(≥40次/月)下，POC检测节省了成本，而在较低的诊疗量(20名患者/月)下，ICER为734美元(90%模型变异性：184美元，3,886美元)。在南非中等规模的诊所，POC测试是一种有希望的战略，可以经济高效地改善患者的预后。结果对干预措施的变化对社区ART交付的登记影响最为敏感。美国国立卫生研究院
The number of persons on antiretroviral therapy (ART) requiring treatment monitoring in low-resource settings is rapidly increasing. Point-of-care (POC) testing for ART monitoring may alleviate burden on centralized laboratories and improve clinical outcomes, but its cost-effectiveness is unknown. We used cost and effectiveness data from the STREAM trial in South Africa, which evaluated POC testing for viral load, CD4 count, and creatinine, with task-shifting from professional to lower-cadre registered nurses compared to laboratory-based testing without task-shifting. We parameterized an agent-based network model, EMOD-HIV, to project the impact of implementing this intervention in South Africa. We assumed POC monitoring increased viral suppression by 9%, enrollment into community-based ART delivery by 25%, and switching to second-line ART by 1%, as reported in STREAM. We evaluated POC implementation in varying clinic sizes (10–50 patient initiating ART/month) over 20 years. We used a cost-effectiveness threshold of $500 USD/disability adjusted life year (DALY) averted for our main analysis. POC testing at 70% coverage of ART patients was projected to reduce HIV infections by 4.5% and HIV-related deaths by 3.9%. In clinics with 30 ART initiations/month, the intervention had an incremental cost-effectiveness ratio (ICER) of $197/DALY averted (90% model variability: −$27, $863); results remained cost-effective when varying background viral suppression, ART dropout, and intervention effectiveness. Assuming POC testing did not increase enrollment into community ART delivery produced an ICER of $1,149 (90% model variability: $184, $3,886), exceeding the cost-effectiveness threshold. At higher clinic volumes (≥40 ART initiations/month), POC testing was cost-saving and at lower clinic volumes (20 patients initiating ART/month) the ICER was $734 (90% model variability: $184, $3,886). POC testing is a promising strategy to cost-effectively improve patient outcomes in moderately-sized clinics in South Africa. Results are most sensitive to changes in intervention impact on enrollment into community-based ART delivery. National Institutes of Health