Differentiated Human Immunodeficiency Virus RNA Monitoring in Resource-Limited Settings: An Economic Analysis.
Differentiated Human Immunodeficiency Virus RNA Monitoring in Resource-Limited Settings: An Economic Analysis.
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DOI：
10.1093/cid/cix177
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发表时间：
2017-06-15
期刊：
影响因子：
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通讯作者：
Swiss HIV Cohort Study
中科院分区：
文献类型：
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作者：
Negoescu DM;Zhang Z;Bucher HC;Bendavid E;Swiss HIV Cohort Study
将重点放在病毒学失败风险最大的患者身上可以提高病毒载量监测的效率，尤其是在资源丰富的环境中。在乌干达，如果没有适应性政策，每12个月监测一次是下一个最有效的监测政策。全球推荐对接受抗逆转录病毒治疗(ART)的患者进行病毒载量(VL)监测。然而，频繁监测的费用是在资源有限的情况下实施的障碍。个性化监测频率在多大程度上可能具有成本效益尚不得而知。我们使用人员级别的纵向数据创建了一个参数化的模拟模型，以评估灵活的监测频率的好处。我们的数据驱动模型在ART启动后对人类免疫缺陷病毒(HIV)感染者进行了长达10年的跟踪。我们根据患者的年龄、性别、教育程度、自抗逆转录病毒治疗开始以来的时间长短、依从性行为和成本效益阈值来优化病毒载量测试之间的间隔。我们比较了个性化监测策略与每隔1、3、6、12和24个月的固定监测间隔的成本效益。更短的固定VL监测间隔产生了更多的好处(每个患者在10年中每24至1个月监测一次的折扣质量调整生命年分别为6.034至6.221个QALY，标准误差=0.005 QALY)，平均成本增加：每个患者每年监测3,445美元至每月监测5,393美元(标准误差=3.7美元)。针对低收入情况优化的适应性政策实现了6.142个平均QALY，成本为3,524美元，与固定的12个月保单(6.135 QALY，3,518美元)类似。针对中等收入资源设置优化的自适应策略可使人均QALY减少0.008，但与每3个月监测一次相比，可节省204万美元。实施自适应VL监控策略与固定VL监控策略的好处随着资源的可用性而增加。在低收入和中等收入国家，适应性政策与更简单的固定间隔政策取得了类似的结果。
Focusing on patients most at risk of virologic failure improves the efficiency of viral load monitoring, most prominently in high-resource settings. In Uganda, monitoring every 12 months is the next most efficient monitoring policy if an adaptive policy is unavailable. Viral load (VL) monitoring for patients receiving antiretroviral therapy (ART) is recommended worldwide. However, the costs of frequent monitoring are a barrier to implementation in resource-limited settings. The extent to which personalized monitoring frequencies may be cost-effective is unknown. We created a simulation model parameterized using person-level longitudinal data to assess the benefits of flexible monitoring frequencies. Our data-driven model tracked human immunodeficiency virus (HIV)–infected individuals for 10 years following ART initiation. We optimized the interval between viral load tests as a function of patients’ age, gender, education, duration since ART initiation, adherence behavior, and the cost-effectiveness threshold. We compared the cost-effectiveness of the personalized monitoring strategies to fixed monitoring intervals every 1, 3, 6, 12, and 24 months. Shorter fixed VL monitoring intervals yielded increasing benefits (6.034 to 6.221 discounted quality-adjusted life-years [QALYs] per patient with monitoring every 24 to 1 month over 10 years, respectively, standard error = 0.005 QALY), at increasing average costs: US$3445 (annual monitoring) to US$5393 (monthly monitoring) per patient, respectively (standard error = US$3.7). The adaptive policy optimized for low-income contexts achieved 6.142 average QALYs at a cost of US$3524, similar to the fixed 12-month policy (6.135 QALYs, US$3518). The adaptive policy optimized for middle-income resource settings yields 0.008 fewer QALYs per person, but saves US$204 compared to monitoring every 3 months. The benefits from implementing adaptive vs fixed VL monitoring policies increase with the availability of resources. In low- and middle-income countries, adaptive policies achieve similar outcomes to simpler, fixed-interval policies.