Cost-effectiveness of easy-access, risk-informed oral pre-exposure prophylaxis in HIV epidemics in sub-Saharan Africa: a modelling study.
Cost-effectiveness of easy-access, risk-informed oral pre-exposure prophylaxis in HIV epidemics in sub-Saharan Africa: a modelling study.
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DOI：
10.1016/s2352-3018(22)00029-7
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发表时间：
2022-05
期刊：
影响因子：
16.1
通讯作者：
Cambiano, Valentina
中科院分区：
文献类型：
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作者：
Phillips, Andrew N.;Bershteyn, Anna;Revill, Paul;Bansi-Matharu, Loveleen;Kripke, Katharine;Boily, Marie-Claude;Martin-Hughes, Rowan;Johnson, Leigh F.;Mukandavire, Zindoga;Jamieson, Lise;Meyer-Rath, Gesine;Hallett, Timothy B.;ten Brink, Debra;Kelly, Sherrie L.;Nichols, Brooke E.;Bendavid, Eran;Mudimu, Edinah;Taramusi, Isaac;Smith, Jennifer;Dalal, Shona;Baggaley, Rachel;Crowley, Siobhan;Terris-Prestholt, Fern;Godfrey-Faussett, Peter;Mukui, Irene;Jahn, Andreas;Case, Kelsey K.;Havlir, Diane;Petersen, Maya;Kamya, Moses;Koss, Catherine A.;Balzer, Laura B.;Apollo, Tsitsi;Chidarikire, Thato;Mellors, John W.;Parikh, Urvi M.;Godfrey, Catherine;Cambiano, Valentina
允许轻松获得暴露前预防 (PrEP) 的方法，例如药房的非处方药，可以促进风险知情的 PrEP 使用并降低艾滋病毒发病率，但其成本效益尚不清楚。我们的目的是评估在何种条件下使用基于风险的 PrEP 具有成本效益。我们应用艾滋病毒传播的数学模型来模拟 3000 个场景，反映撒哈拉以南非洲社区的一系列流行病学特征。所有成年人（HIV 阳性和阴性）中 HIV 病毒载量超过 1000 拷贝/mL 的患病率从 1·1% 到 7·4%（90% 范围）不等。我们假设，如果 PrEP 很容易获得，不受限制，并进行有关其使用的教育，那么女性和男性将在所谓的风险季节（即个人有感染风险的时期）使用 PrEP，并每天坚持足够的坚持。我们将此称为风险知情 PrEP。对于每个场景，我们考虑了 2021 年中期的情况，并对两种政策的结果进行了两两比较：立即扩大 PrEP 规模，然后持续 50 年，以及不实施 PrEP。我们估计了流行病与计划特征之间的关系以及在风险季节向所有人提供 PrEP 的成本效益。对于我们的基本案例分析，我们假设 3 个月的 PrEP 费用为 29 美元（药物 11 美元，HIV 检测 4 美元，以及促进教育和获取所需的额外费用 14 美元），每个避免残疾调整生命年 (DALY) 的成本效益阈值为 500 美元，年度贴现率为 3%，时间范围为 50 年。在敏感性分析中，我们考虑了每避免 DALY 100 美元的成本效益阈值、每年 7% 的贴现率、在风险季节之外使用 PrEP 以及减少风险告知 PrEP 的使用。在 PrEP 规模扩大的背景下，66%（场景 46-81 中的 90%）有至少一名非主要无安全套性伴侣的 HIV 阴性人群在任何特定时期都采取 PrEP，导致所有 HIV 阴性成年人中有 2·6% (0·9–6·0) 在任何特定时间采取 PrEP，预计风险告知的 PrEP 将使 HIV 发病率降低 49% (23–78)与无 PrEP 相比 50 年。 PrEP 在 71% 的所有环境情景中具有成本效益，在所有成人中 HIV 病毒载量超过 1000 拷贝/毫升的流行率高于 2% 的环境情景中，PrEP 在 76% 的环境情景中具有成本效益。在敏感性分析中，每 DALY 避免的成本效益阈值为 100 美元，每年折扣率为 7%，或者 PrEP 的使用风险信息不如我们的基本案例，PrEP 不太可能具有成本效益，但如果所有成年人中 HIV 病毒载量超过 1000 拷贝/mL 的流行率高于 3%，则通常仍然具有成本效益。在基于风险告知 PrEP 较少广泛使用的其他场景的敏感性分析中，艾滋病毒发病率降低幅度较小，但风险告知 PrEP 的成本效益并未降低。假设在社区教育的背景下，让撒哈拉以南非洲地区的所有成年人都能轻松获得 PrEP，从而能够在风险知情的情况下使用，那么在所有成年人中 HIV 病毒载量超过 1000 拷贝/毫升的情况下，PrEP 可能具有成本效益，且所有成年人中的感染率高于 2%，这表明需要实施此类方法并进行持续评估。美国国际开发署、美国总统艾滋病紧急救援计划以及比尔及梅琳达·盖茨基金会。
Approaches that allow easy access to pre-exposure prophylaxis (PrEP), such as over-the-counter provision at pharmacies, could facilitate risk-informed PrEP use and lead to lower HIV incidence, but their cost-effectiveness is unknown. We aimed to evaluate conditions under which risk-informed PrEP use is cost-effective. We applied a mathematical model of HIV transmission to simulate 3000 setting-scenarios reflecting a range of epidemiological characteristics of communities in sub-Saharan Africa. The prevalence of HIV viral load greater than 1000 copies per mL among all adults (HIV positive and negative) varied from 1·1% to 7·4% (90% range). We hypothesised that if PrEP was made easily available without restriction and with education regarding its use, women and men would use PrEP, with sufficient daily adherence, during so-called seasons of risk (ie, periods in which individuals are at risk of acquiring infection). We refer to this as risk-informed PrEP. For each setting-scenario, we considered the situation in mid-2021 and performed a pairwise comparison of the outcomes of two policies: immediate PrEP scale-up and then continuation for 50 years, and no PrEP. We estimated the relationship between epidemic and programme characteristics and cost-effectiveness of PrEP availability to all during seasons of risk. For our base-case analysis, we assumed a 3-monthly PrEP cost of US$29 (drug $11, HIV test $4, and $14 for additional costs necessary to facilitate education and access), a cost-effectiveness threshold of $500 per disability-adjusted life-year (DALY) averted, an annual discount rate of 3%, and a time horizon of 50 years. In sensitivity analyses, we considered a cost-effectiveness threshold of $100 per DALY averted, a discount rate of 7% per annum, the use of PrEP outside of seasons of risk, and reduced uptake of risk-informed PrEP. In the context of PrEP scale-up such that 66% (90% range across setting-scenarios 46–81) of HIV-negative people with at least one non-primary condomless sex partner take PrEP in any given period, resulting in 2·6% (0·9–6·0) of all HIV negative adults taking PrEP at any given time, risk-informed PrEP was predicted to reduce HIV incidence by 49% (23–78) over 50 years compared with no PrEP. PrEP was cost-effective in 71% of all setting-scenarios, and cost-effective in 76% of setting-scenarios with prevalence of HIV viral load greater than 1000 copies per mL among all adults higher than 2%. In sensitivity analyses with a $100 per DALY averted cost-effectiveness threshold, a 7% per year discount rate, or with PrEP use that was less well risk-informed than in our base case, PrEP was less likely to be cost-effective, but generally remained cost-effective if the prevalence of HIV viral load greater than 1000 copies per mL among all adults was higher than 3%. In sensitivity analyses based on additional setting-scenarios in which risk-informed PrEP was less extensively used, the HIV incidence reduction was smaller, but the cost-effectiveness of risk-informed PrEP was undiminished. Under the assumption that making PrEP easily accessible for all adults in sub-Saharan Africa in the context of community education leads to risk-informed use, PrEP is likely to be cost-effective in settings with prevalence of HIV viral load greater than 1000 copies per mL among all adults higher than 2%, suggesting the need for implementation of such approaches, with ongoing evaluation. US Agency for International Development, US President's Emergency Plan for AIDS Relief, and Bill & Melinda Gates Foundation.