A Cost-effectiveness Analysis of Preexposure Prophylaxis for the Prevention of HIV Among Los Angeles County Men Who Have Sex With Men
A Cost-effectiveness Analysis of Preexposure Prophylaxis for the Prevention of HIV Among Los Angeles County Men Who Have Sex With Men
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DOI：
10.1093/cid/ciw578
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发表时间：
2016-12-01
影响因子：
11.8
通讯作者：
Sood, Neeraj
中科院分区：
文献类型：
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作者：
Drabo, Emmanuel F.;Hay, Joel W.;Sood, Neeraj
背景资料。在理解选择替代人类免疫缺陷病毒(HIV)预防策略的成本和收益之间的权衡方面仍然存在很大差距，这些策略包括检测和治疗(扩大艾滋病毒检测与立即治疗相结合)和PrEP(由高危非感染者启动暴露前预防)策略。我们开发了一个数学流行病学模型来模拟居住在加利福尼亚州洛杉矶县的15-65岁与男性发生性行为的男性中艾滋病毒的发病率。我们将这些发病率数据与经济模型结合起来，使用社会视角和终生视野来估计各种艾滋病毒预防策略的贴现成本、有效性(质量调整寿命年)和增量成本-效果比。与现状相比，与现状相比，准备和测试和治疗产生了最大程度的艾滋病毒发病率下降，而且成本效益很高(分别为27863美元/QALY和19302美元/QALY)，美国愿意支付的门槛为15万美元/QALY。现状和12项检测和治疗以及PrEP战略决定了有效决策的前沿。更激进的策略成本更高，但更有效，尽管回报越来越小。PrEP的相对有效性对初始HIV感染率、PrEP和抗逆转录病毒治疗(ART)依从率和启动率、HIV传播概率和性伴侣交配率敏感。准备和测试和治疗为现状提供了具有成本效益的替代方案。这些策略的成功取决于ART和PrEP的依从率和启动率。因此，缺乏关于PrEP依从性行为的证据，值得进一步研究。
Background. Substantial gaps remain in understanding the trade-offs between the costs and benefits of choosing alternative human immunodeficiency virus (HIV) prevention strategies, including test-and-treat (expanded HIV testing combined with immediate treatment) and PrEP (initiation of preexposure prophylaxis by high-risk uninfected individuals) strategies.Methods. We develop a mathematical epidemiological model to simulate HIV incidence among men residing in Los Angeles County, California, aged 15-65 years, who have sex with men. We combine these incidence data with an economic model to estimate the discounted cost, effectiveness (quality-adjusted life-years [QALYs]), and incremental cost-effectiveness ratios of various HIV prevention strategies using a societal perspective and a lifetime horizon.Results. PrEP and test-and-treat yield the largest reductions in HIV incidence, and are highly cost-effective ($27 863/QALY and $19 302/QALY, respectively) relative to status quo and at a US willingness-to-pay threshold of $150 000/QALY saved. Status quo and 12 test-and-treat and PrEP strategies determine the frontier for efficient decisions. More aggressive strategies are costlier, but more effective, albeit with diminishing returns. The relative effectiveness of PrEP is sensitive to the initial HIV prevalence rate, PrEP and antiretroviral therapy (ART) adherence and initiation rates, the probabilities of HIV transmission, and the rates of sexual partner mixing.Conclusions. PrEP and test-and-treat offer cost-effective alternatives to the status quo. The success of these strategies depends on ART and PrEP adherence and initiation rates. The lack of evidence on adherence behaviors toward PrEP, therefore, warrants further studies.