Expanded HIV screening in the United States: Effect on clinical outcomes, HIV transmission, and costs
Expanded HIV screening in the United States: Effect on clinical outcomes, HIV transmission, and costs
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DOI：
10.7326/0003-4819-145-11-200612050-00004
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发表时间：
2006-12-05
影响因子：
39.2
通讯作者：
Freedberg, Kenneth A.
中科院分区：
文献类型：
--
作者：
Paltiel, A. David;Walensky, Rochelle P.;Freedberg, Kenneth A.
背景：大量文献支持在美国扩大艾滋病毒筛查。然而，测试谁以及测试频率的问题仍然存在争议。目的：通过确定筛查频率和艾滋病毒患病率和发病率的组合，在艾滋病毒筛查项目的设计中提供成本效益。设计：成本效益分析，将艾滋病毒筛查模拟模型与已发表的艾滋病毒传播风险报告（无论是否接受抗逆转录病毒治疗）联系起来。数据来源：已发表的随机试验、观察队列、国家成本和服务利用调查、红皮书和之前的建模结果。目标人群：美国社区的 HIV 感染率从低到中度（0.05% 至 1.0%），年发病率（0.0084% 至 0.12%）。时间范围：终生。视角：社会。干预措施：使用当天快速检测对所有成年人进行一次性且越来越频繁的自愿 HIV 筛查。结果衡量标准：检测到 HIV 感染、避免二次传播、质量调整生存期、终生医疗费用和社会效益成本效益，以每个质量调整生命年 (QALY) 的折现 2004 美元报告。 基本案例分析结果：在关于 HIV 患者护理对二次传播的影响的适度有利假设下，在 HIV 患病率 1.0%、年发病率为 0.12% 的人群中进行常规 HIV 筛查的增量成本效益比为 30800 美元/QALY（一次性筛查）、32300 美元/QALY（每5 年），以及 55500 美元/QALY（每 3 年筛查一次）。在艾滋病毒流行率为 0.10%、年发病率为 0.014% 的环境中，一次性筛查的成本效益比为 60700 美元/QALY。 敏感性分析结果：由于关于筛查对二次传播影响的假设从有利到不利，筛查政策的成本效益在一个狭窄的范围内变化。假设抗逆转录病毒治疗对传播有适度有利的影响，在艾滋病毒流行率低至 0.20% 的环境中进行一次性常规艾滋病毒筛查，以及在流行率低至 0.45% 和年发病率低至 0.0075% 的情况下每 5 年筛查一次，成本效益比保持在 50000 美元/QALY 以下。 局限性：该分析没有解决确定艾滋病毒感染率和发病率的困难。结论：建议对所有成年人进行常规快速 HIV 检测，但有证据表明未确诊 HIV 感染率低于 0.2% 的地区除外。
Background: An extensive literature supports expanded HIV screening in the United States. However, the question of whom to test and how frequently remains controversial.Objective: To inform the design of HIV screening programs by identifying combinations of screening frequency and HIV prevalence and incidence at which screening is cost-effective.Design: Cost-effectiveness analysis linking simulation models of HIV screening to published reports of HIV transmission risk, with and without antiretroviral therapy.Data Sources: Published randomized trials, observational cohorts, national cost and service utilization surveys, the Red Book, and previous modeling results.Target Population: U.S. communities with low to moderate HIV prevalence (0.05% to 1.0%) and annual incidence (0.0084% to 0.12%).Time Horizon: Lifetime.Perspective: Societal.Interventions: One-time and increasingly frequent voluntary HIV screening of all adults using a same-day rapid test.Outcome Measures: HIV infections detected, secondary transmissions averted, quality-adjusted survival, lifetime medical costs, and societal cost-effectiveness, reported in discounted 2004 dollars per quality-adjusted life-year (QALY) gained.Results of Base-Case Analysis: Under moderately favorable assumptions regarding the effect of HIV patient care on secondary transmission, routine HIV screening in a population with HIV prevalence of 1.0% and annual incidence of 0.12% had incremental cost-effectiveness ratios of $30800/QALY (one-time screening), $32300/QALY (screening every 5 years), and $55500/QALY (screening every 3 years). In settings with HIV prevalence of 0.10% and annual incidence of 0.014%, one-time screening produced cost-effectiveness ratios of $60700/QALY.Results of Sensitivity Analysis: The cost-effectiveness of screening policies varied within a narrow range as assumptions about the effect of screening on secondary transmission varied from favorable to unfavorable. Assuming moderately favorable effects of antiretroviral therapy on transmission, cost-effectiveness ratios remained below $50000/QALY in settings with HIV prevalence as low as 0.20% for routine HIV screening on a one-time basis and at prevalences as low as 0.45% and annual incidences as low as 0.0075% for screening every 5 years.Limitations: This analysis does not address the difficulty of determining the prevalence and incidence of undetected HIV infection in a given patient population.Conclusions: Routine, rapid HIV testing is recommended for all adults except in settings where there is evidence that the prevalence of undiagnosed HIV infection is below 0.2%.