Designing an optimal HIV programme for South Africa: Does the optimal package change when diminishing returns are considered?
Designing an optimal HIV programme for South Africa: Does the optimal package change when diminishing returns are considered?
复制标题
为南非设计最佳的艾滋病毒计划：考虑回报率降低时，最佳包装是否会改变？
DOI：
10.1186/s12889-017-4023-3
复制
发表时间：
2017-01-31
影响因子：
4.5
通讯作者：
Meyer-Rath G
中科院分区：
文献类型：
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作者：
Chiu C;Johnson LF;Jamieson L;Larson BA;Meyer-Rath G
南非有一个由国内供资的大规模艾滋病毒方案，大多数预防和治疗干预措施的覆盖面高度饱和。为了进一步优化其配置效率，我们设计了一种新的优化方法，并检查是否最佳的干预措施包的变化时，相互作用和非线性规模效应纳入成本效益分析。传统的成本-效果分析排行榜方法依赖于干预措施之间独立性的假设。我们增加了一种方法，允许同时考虑大量艾滋病毒干预措施及其潜在的规模边际收益递减。我们分析了增量成本效益比（ICER）的16艾滋病毒干预措施的基础上，一个良好的校准的流行病学模型，占互动和非线性规模效应，自定义成本模型和优化程序，迭代添加最具成本效益的干预滚动基线之前，评估所有剩余的选项。我们将我们的结果与基于排名表的结果进行了比较。两种方法之间的干预措施的等级顺序没有实质性差异-在每一种方法中，增加避孕套的供应和男性医疗包皮环切术被认为是最具成本效益的，其次是按照目前的准则进行的抗逆转录病毒治疗。然而，在优化方法下进行评估时，干预措施的成本效益较低，表明边际收益大幅递减，在我们的优化程序下，ICER平均高出437%。在大规模实施方案时，传统的排名表可能会夸大干预措施的成本效益。考虑到相互作用和非线性放大效应，在高度饱和的现实世界环境中提供了更现实的估计。本文的在线版本（doi：10.1186/s12889-017-4023-3）包含补充材料，可供授权用户使用。
South Africa has a large domestically funded HIV programme with highly saturated coverage levels for most prevention and treatment interventions. To further optimise its allocative efficiency, we designed a novel optimisation method and examined whether the optimal package of interventions changes when interaction and non-linear scale-up effects are incorporated into cost-effectiveness analysis. The conventional league table method in cost-effectiveness analysis relies on the assumption of independence between interventions. We added methodology that allowed the simultaneous consideration of a large number of HIV interventions and their potentially diminishing marginal returns to scale. We analysed the incremental cost effectiveness ratio (ICER) of 16 HIV interventions based on a well-calibrated epidemiological model that accounted for interaction and non-linear scale-up effects, a custom cost model, and an optimisation routine that iteratively added the most cost-effective intervention onto a rolling baseline before evaluating all remaining options. We compared our results with those based on a league table. The rank order of interventions did not differ substantially between the two methods- in each, increasing condom availability and male medical circumcision were found to be most cost-effective, followed by anti-retroviral therapy at current guidelines. However, interventions were less cost-effective throughout when evaluated under the optimisation method, indicating substantial diminishing marginal returns, with ICERs being on average 437% higher under our optimisation routine. Conventional league tables may exaggerate the cost-effectiveness of interventions when programmes are implemented at scale. Accounting for interaction and non-linear scale-up effects provides more realistic estimates in highly saturated real-world settings. The online version of this article (doi:10.1186/s12889-017-4023-3) contains supplementary material, which is available to authorized users.