Estimation of the cost-effectiveness of HIV prevention portfolios for people who inject drugs in the United States: A model-based analysis
Estimation of the cost-effectiveness of HIV prevention portfolios for people who inject drugs in the United States: A model-based analysis
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DOI：
10.1371/journal.pmed.1002312
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发表时间：
2017-05-01
期刊：
影响因子：
15.8
通讯作者：
Brandeau, Margaret L.
中科院分区：
文献类型：
--
作者：
Bernard, Cora L.;Owens, Douglas K.;Brandeau, Margaret L.
背景与阿片类药物流行相关的艾滋病毒传播风险使为注射毒品者(PWID)提供成本效益高的计划成为公共卫生的优先事项。其中一些方案的好处不仅仅是预防艾滋病毒--考虑到注射毒品在美国大多数人口群体中的使用正在增加，这是一个关键的考虑因素。为了确定美国PWID的高价值HIV预防计划组合，我们考虑了四种已证明有效的干预措施的组合：阿片类激动剂治疗(OAT)、针头和注射器计划(NSP)、HIV检测和治疗(测试和治疗)和口服HIV暴露前预防(PrEP)。方法和发现我们采用了一个经验校准的动态分区模型，并使用它来评估四个预防计划的贴现成本(以2015美元计)、健康结果(避免了HIV感染、HIV流行率的变化和贴现的质量调整生命年[QALY])以及增量成本-效果比(ICER在20年的时间范围内单独和组合考虑。我们从文献、先前发表的模型和专家意见中获得了流行病学、经济学和卫生效用的参数估计。我们估计，与下一个最高的覆盖水平(分别为40%、45%和50%)相比，单独实施高达50%的覆盖水平的OAT、NSP和测试和治疗的扩展可能是具有成本效益的，并且我们认为对个人具有直接和直接的健康益处的OAT具有潜在的最高价值投资，即使在它防止感染比其他计划更少的情况下也是如此。虽然基于模型的分析只能提供对健康结果的估计，但我们预计，在20年以上，OAT的50%覆盖率可以避免多达22,000(95%CI：5,200，46,000)的感染，每个QALY的成本为18,000美元(95%CI：14,000美元，24,000美元)，50%的NSP覆盖率可以避免多达35,000(95%CI：8,900，43,000)的感染，每个QALY的成本为25,000美元(95%CI：7,000美元，76,000美元)，50%的检测和治疗覆盖范围可以避免多达6,700(95%CI：1,200，16,000)的感染，每个QALY的成本27,000美元(95%CI：15,000美元，48,000美元)50%的PrEP覆盖率可以避免多达37,000(22,000，58,000)例感染，每获得一次QALY成本为300,000美元(95%CI：162,000美元，667,000美元)。如果允许覆盖范围扩展包括与其他计划的组合投资，并将其与次佳干预措施进行比较，则将OAT覆盖范围扩大到50%，然后将NSP覆盖范围扩大到50%，然后将测试和治疗覆盖范围扩大到50%的模型项目可能具有成本效益，每次覆盖范围扩展的成本可能低于与次佳投资组合相比获得的每个QALY成本低于50,000美元。在概率敏感性分析中，59%的投资组合优先增加OAT，41%优先增加NSP，而PrEP不太可能是优先事项，也不是具有成本效益的增加。我们的调查结果旨在起到说明性作用，因为关于可实现覆盖范围的数据有限，而且在实践中，所考虑的扩展方案可能超过可行的水平。我们假设干预是独立的，规模回报是恒定的。广泛的敏感性分析使我们能够评估参数敏感性，但动态分区模型的使用限制了对结构敏感性的探索。结论我们估计，OAT、NSP和测试与治疗单独或联合实施，有可能在美国PWID中有效和低成本地预防HIV。根据我们评估的场景，PREP在这一人群中不太可能具有成本效益。虽然地方预算或政策可能会限制各种干预措施的可行覆盖水平，但我们的研究结果表明，对联合预防计划的投资可以显著减少艾滋病毒的传播，并改善PWID的健康结果。
BackgroundThe risks of HIV transmission associated with the opioid epidemic make cost-effective programs for people who inject drugs (PWID) a public health priority. Some of these programs have benefits beyond prevention of HIV-a critical consideration given that injection drug use is increasing across most United States demographic groups. To identify high-value HIV prevention program portfolios for US PWID, we consider combinations of four interventions with demonstrated efficacy: opioid agonist therapy (OAT), needle and syringe programs (NSPs), HIV testing and treatment (Test & Treat), and oral HIV pre-exposure prophylaxis (PrEP).Methods and findingsWe adapted an empirically calibrated dynamic compartmental model and used it to assess the discounted costs (in 2015 US dollars), health outcomes (HIV infections averted, change in HIV prevalence, and discounted quality-adjusted life years [QALYs]), and incremental cost-effectiveness ratios (ICERs) of the four prevention programs, considered singly and in combination over a 20-y time horizon. We obtained epidemiologic, economic, and health utility parameter estimates from the literature, previously published models, and expert opinion. We estimate that expansions of OAT, NSPs, and Test & Treat implemented singly up to 50% coverage levels can be cost-effective relative to the next highest coverage level (low, medium, and high at 40%, 45%, and 50%, respectively) and that OAT, which we assume to have immediate and direct health benefits for the individual, has the potential to be the highest value investment, even under scenarios where it prevents fewer infections than other programs. Although a model-based analysis can provide only estimates of health outcomes, we project that, over 20 y, 50% coverage with OAT could avert up to 22,000 (95% CI: 5,200, 46,000) infections and cost US$18,000 (95% CI: US$14,000, US$24,000) per QALY gained, 50% NSP coverage could avert up to 35,000 (95% CI: 8,900, 43,000) infections and cost US$25,000 (95% CI: US$7,000, US$76,000) per QALY gained, 50% Test & Treat coverage could avert up to 6,700 (95% CI: 1,200, 16,000) infections and cost US$27,000 (95% CI: US$15,000, US$48,000) per QALY gained, and 50% PrEP coverage could avert up to 37,000 (22,000, 58,000) infections and cost US$300,000 (95% CI: US$162,000, US $667,000) per QALY gained. When coverage expansions are allowed to include combined investment with other programs and are compared to the next best intervention, the model projects that scaling OAT coverage up to 50%, then scaling NSP coverage to 50%, then scaling Test & Treat coverage to 50% can be cost-effective, with each coverage expansion having the potential to cost less than US$50,000 per QALY gained relative to the next best portfolio. In probabilistic sensitivity analyses, 59% of portfolios prioritized the addition of OAT and 41% prioritized the addition of NSPs, while PrEP was not likely to be a priority nor a cost-effective addition. Our findings are intended to be illustrative, as data on achievable coverage are limited and, in practice, the expansion scenarios considered may exceed feasible levels. We assumed independence of interventions and constant returns to scale. Extensive sensitivity analyses allowed us to assess parameter sensitivity, but the use of a dynamic compartmental model limited the exploration of structural sensitivities.ConclusionsWe estimate that OAT, NSPs, and Test & Treat, implemented singly or in combination, have the potential to effectively and cost-effectively prevent HIV in US PWID. PrEP is not likely to be cost-effective in this population, based on the scenarios we evaluated. While local budgets or policy may constrain feasible coverage levels for the various interventions, our findings suggest that investments in combined prevention programs can substantially reduce HIV transmission and improve health outcomes among PWID.