Early and late direct costs in a Southern African antiretroviral treatment programme: a retrospective cohort analysis.
Early and late direct costs in a Southern African antiretroviral treatment programme: a retrospective cohort analysis.
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DOI：
10.1371/journal.pmed.1000189
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发表时间：
2009-12
期刊：
影响因子：
15.8
通讯作者：
Maartens G
中科院分区：
文献类型：
--
作者：
Leisegang R;Cleary S;Hislop M;Davidse A;Regensberg L;Little F;Maartens G
Gary Maartens 及其同事描述了南部非洲艾滋病毒管理护理项目中的直接医疗保健成本，并确定了随着时间的推移成本的驱动因素。关于非洲抗逆转录病毒治疗 (ART) 计划的医疗保健费用的数据很少。我们的目标是描述南部非洲艾滋病毒管理护理计划中的直接卫生保健成本并确定随时间推移的成本驱动因素。我们分析了从开始基于非核苷逆转录酶抑制剂的 ART 之前 3 年到之后 5 年治疗参加管理式医疗计划的 HIV 感染成人的直接费用。开始 ART 的 CD4 细胞计数标准为 <350 个细胞/μl。我们使用具有对数链接函数和伽玛分布的广义线性模型探索了变量与平均总成本之间随时间的关联。我们的队列由 10,735 名患者（59.4% 为女性）组成，随访数据为 594,497 个月（接受 ART 的月数为 50.9%）。中位基线 CD4+ 细胞计数和病毒载量分别为 125 个细胞/μl 和 5.16 log10 拷贝/ml。在开始 ART 前后（从开始 ART 前 4 个月到开始 ART 后 4 个月），费用达到高峰，主要是由于住院治疗，此后费用在 5 年内趋于稳定。与平均总成本变化相关的变量随时间而变化。与较高成本的早期关键关联是低基线 CD4+ 细胞计数、高基线 HIV 病毒载量以及开始 ART 之前的 HIV 护理持续时间较短；而后来与较高成本的关联是较低的 ART 依从性、转向基于蛋白酶抑制剂的 ART 以及在较大年龄开始 ART。随着时间的推移，平均总成本的驱动因素发生了很大变化。在 CD4 计数较高时开始 ART 或延长 ART 前护理时间应可降低早期费用。监测 ART 依从性和改善依从性的干预措施应该可以降低后期成本。 ART 的成本模型应考虑这些与时间相关的成本驱动因素，并包括开始 ART 之前的成本。 请参阅本文后面的编辑摘要 大约有 3000 万人（仅撒哈拉以南非洲就有 2200 万人）感染了人体免疫机能丧失病毒 (HIV)，它是获得性免疫机能丧失综合症 (AIDS) 的病因。 HIV 会破坏免疫系统细胞（包括 CD4 细胞，一种淋巴细胞），使感染者容易受到其他感染。在艾滋病流行初期，艾滋病毒呈阳性的人平均在感染后 10 年内死亡。然后，在 1996 年，开发了高效抗逆转录病毒疗法（ART；强效抗逆转录病毒药物的组合）。对于生活在富裕发达国家的人们来说，艾滋病毒/艾滋病已成为一种可治疗的慢性疾病，但对于生活在低收入和中等收入国家的数百万艾滋病毒感染者来说，无法获得有效的治疗，艾滋病毒/艾滋病仍然是一种致命疾病。 2003年，这种情况被宣布为全球卫生紧急状态，各国政府、国际机构和资助机构开始实施计划，以提高发展中国家的抗逆转录病毒治疗覆盖率。截至2008年底，低收入和中等收入国家有950万需要抗逆转录病毒治疗的人，其中超过400万人正在接受治疗。在实现普遍获得抗逆转录病毒治疗方面正在取得良好进展，部分原因是发展中国家抗逆转录病毒药物的成本大幅下降。但抗逆转录病毒药物的提供并不是与 ART 相关的唯一直接成本。为接受 ART 的患者提供的全科医生、专科医生和产科相关护理、必要时的医院住宿以及监测 HIV 感染进展所需的检查（例如 CD4 细胞计数和病毒载量测量）都会产生相当大的费用。为了有效利用有限的资源，发展中国家的公共卫生官员需要尽可能多地了解艾滋病毒医疗保健的直接成本，但很少有研究调查这些成本，特别是在个人开始接受抗逆转录病毒治疗之前产生的成本。在这项研究中，研究人员探讨了南非私营部门艾滋病毒/艾滋病项目的医疗保健成本，并研究了在 ART 开始期间和 ART 后期阶段影响艾滋病毒医疗保健成本的变量。研究人员分析了南非超过 100,000 名参加私人 HIV 护理计划的 HIV 感染成年人从开始 ART 前 3 年到开始 ART 后 5 年的直接费用；在该计划中，当个人的 CD4 细胞计数低于 350 个细胞/微升血液时，他们开始接受 ART。研究人员发现，直接健康成本在开始 ART 前 4 个月到后 4 个月（“围 ART 期”）达到峰值，这主要是由医院费用驱动的。围 ART 期过后，成本下降（尽管未达到该时期之前的水平）并在接下来的 5 年内稳定在中间水平。详细的统计分析表明，与围 ART 期间较高费用相关的关键变量是基线 CD4 细胞计数低、基线 HIV 病毒载量高以及 ART 开始前 HIV 护理时间较短。与 ART 后期较高费用相关的关键变量是对药物治疗的依从性较低。也就是说，不定期服用抗逆转录病毒药物的患者的费用更高。这项研究涉及参加私人医疗保健计划的患者，其中启动 ART 的标准与世界卫生组织建议的在资源有限的环境中启动 ART 的标准有所不同。因此，研究人员计算的绝对平均总成本不太可能推广到南非和其他资源匮乏地区的公共艾滋病毒护理系统。然而，平均总成本的驱动因素随着时间的推移发生很大变化的发现可能具有普遍意义，并为公共卫生规划者提供了一些有用的信息，这些信息现在可以在其他资源更加有限的患者群体中进行测试。特别是，这项研究的结果表明，通过在较高的 CD4 细胞计数时开始 ART 或提供更长时间的 ART 前护理，可以降低 ART 计划的高额早期成本。此外，研究结果表明，监测 ART 依从性并引入干预措施来提高 ART 依从性可以减少 ART 计划的后续直接成本。请通过此摘要的在线版本访问这些网站：http://dx.doi.org/10.1371/journal.pmed.1000189。可从美国国家过敏和传染病研究所获得有关 HIV 感染和艾滋病的信息 HIV InSite 提供有关 HIV/艾滋病各个方面的全面信息 可从 Avert（一家国际艾滋病慈善机构）获得有关 HIV/艾滋病许多方面的信息，包括有关非洲 HIV 和艾滋病以及普遍获得艾滋病治疗的信息（英文和西班牙文） 世界卫生组织提供有关普遍获得艾滋病治疗的信息，包括 2009 年 9 月的进展报告（英文和法文） 美国疾病控制和预防中心预防还提供了有关全球应对艾滋病毒/艾滋病流行病的努力的信息
Gary Maartens and colleagues describe the direct heath care costs and identify the drivers of cost over time in an HIV managed care program in Southern Africa. There is a paucity of data on the health care costs of antiretroviral therapy (ART) programmes in Africa. Our objectives were to describe the direct heath care costs and establish the cost drivers over time in an HIV managed care programme in Southern Africa. We analysed the direct costs of treating HIV-infected adults enrolled in the managed care programme from 3 years before starting non-nucleoside reverse transcriptase inhibitor-based ART up to 5 years afterwards. The CD4 cell count criterion for starting ART was <350 cells/µl. We explored associations between variables and mean total costs over time using a generalised linear model with a log-link function and a gamma distribution. Our cohort consisted of 10,735 patients (59.4% women) with 594,497 mo of follow up data (50.9% of months on ART). Median baseline CD4+ cell count and viral load were 125 cells/µl and 5.16 log10 copies/ml respectively. There was a peak in costs in the period around ART initiation (from 4 mo before until 4 mo after starting ART) driven largely by hospitalisation, following which costs plateaued for 5 years. The variables associated with changes in mean total costs varied with time. Key early associations with higher costs were low baseline CD4+ cell count, high baseline HIV viral load, and shorter duration in HIV care prior to starting ART; whilst later associations with higher costs were lower ART adherence, switching to protease inhibitor-based ART, and starting ART at an older age. Drivers of mean total costs changed considerably over time. Starting ART at higher CD4 counts or longer pre-ART care should reduce early costs. Monitoring ART adherence and interventions to improve it should reduce later costs. Cost models of ART should take into account these time-dependent cost drivers, and include costs before starting ART. Please see later in the article for the Editors' Summary About 30 million people (22 million people in sub-Saharan Africa alone) are infected with the human immunodeficiency virus (HIV), the cause of acquired immunodeficiency syndrome (AIDS). HIV destroys immune system cells (including CD4 cells, a type of lymphocyte), leaving infected individuals susceptible to other infections. Early in the AIDS epidemic, on average HIV-positive people died within 10 years of infection. Then, in 1996, highly active antiretroviral therapy (ART; combinations of powerful antiretroviral drugs) was developed. For people living in affluent, developed countries HIV/AIDS became a chronic, treatable condition, but for the millions of HIV-infected people living in low- and middle-income countries, effective treatment was unavailable and HIV/AIDS remained a fatal illness. In 2003, this situation was declared a global health emergency and governments, international agencies, and funding bodies began to implement plans to increase ART coverage in developing countries. By the end of 2008, of the 9.5 million people in need of ART in low- and middle-income countries, more than 4 million people were receiving treatment. Good progress is being made towards achieving universal access to ART, partly because the cost of antiretroviral drugs has plummeted in developing countries. But the provision of antiretroviral drugs is not the only direct cost associated with ART. General practitioner, specialist, and maternity-related care for patients receiving ART, hospital accommodation when necessary, and the investigations that are needed to monitor the progress of HIV infection such as CD4 cell counts and viral load measurements all incur considerable costs. To use their limited resources effectively, public-health officials in developing countries need to know as much as possible about the direct costs of HIV health care but few studies have investigated these costs, particularly those incurred before an individual starts taking ART. In this study, the researchers explore health care costs in a South African private-sector HIV/AIDS program and examine the variables that drive the costs of HIV health care around the time of ART initiation and during later phases of ART. The researchers analyzed the direct costs of treating more than 100,000 HIV-infected adults enrolled in a private HIV care program in South Africa from 3 years before they started ART until up to 5 years after ART initiation; within this program, individuals began to receive ART when their CD4 cell count fell below 350 cells/µl of blood. The researchers found a peak in direct health costs from 4 months before to 4 months after starting ART (the “peri-ART” period), which was driven mainly by hospital costs. After the peri-ART period, costs dropped (although not to the levels seen before this period) and stabilized at an intermediate level for the next 5 years. Detailed statistical analyses suggest that the key variables associated with higher costs in the peri-ART period were a low baseline CD4 cell count, a high baseline HIV viral load, and a shorter time in HIV care before ART initiation. The key variable associated with higher costs later in ART was lower adherence to the drug therapy. That is, costs were higher among patients who did not take their antiretroviral drugs regularly. This study involved patients enrolled in a private health care program in which the criteria for initiating ART differed somewhat from those recommended by the World Health Organization for ART initiation in resource-limited settings. Thus, the absolute mean total costs calculated by the researchers are unlikely to be generalizable to public HIV care systems in South Africa and in other resource-poor settings. However, the finding that the drivers of mean total costs change considerably over time may be generalizable and provides some useful information for public-health planners that can now be tested in other, more resource-limited patient populations. In particular, the findings of this study suggest that the high early costs of ART programs could be reduced by starting ART at higher CD4 cell counts or by providing longer pre-ART care. In addition, the findings suggest that monitoring ART adherence and introducing interventions to improve ART adherence could reduce the later direct costs of ART programs. Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000189. Information is available from the US National Institute of Allergy and infectious diseases on HIV infection and AIDS HIV InSite has comprehensive information on all aspects of HIV/AIDS Information is available from Avert, an international AIDS charity on many aspects of HIV/AIDS, including information on the HIV and AIDS in Africa, and on universal access to AIDS treatment (in English and Spanish) The World Health Organization provides information about universal access to AIDS treatment, including the September 2009 progress report (in English and French) The US Centers for Disease Control and Prevention also provides information on global efforts to deal with the HIV/AIDS epidemic
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影响因子：
2.8
作者：
Harling, Guy;Orrell, Catherine;Wood, Robin
通讯作者：
Wood, Robin
影响因子：
3.3
作者：
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通讯作者：
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DOI：
10.2471/blt.07.044248
发表时间：
2008-07-01
期刊：
Bulletin of the World Health Organization: International Journal of Public Health
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作者：
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通讯作者：
Anglaret, Xavier
影响因子：
168.9
作者：
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通讯作者：
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DOI：
10.1097/01.qai.0000225015.43266.46
发表时间：
2006-09-01
影响因子：
3.6
作者：
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通讯作者：
Maartens, Gary