Improving health equity and ending the HIV epidemic in the USA: a distributional cost-effectiveness analysis in six cities.
Improving health equity and ending the HIV epidemic in the USA: a distributional cost-effectiveness analysis in six cities.
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DOI：
10.1016/s2352-3018(21)00147-8
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发表时间：
2021-09
期刊：
影响因子：
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通讯作者：
Localized HIV Economic Modeling Study Group
中科院分区：
文献类型：
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作者：
Quan AML;Mah C;Krebs E;Zang X;Chen S;Althoff K;Armstrong W;Behrends CN;Dombrowski JC;Enns E;Feaster DJ;Gebo KA;Goedel WC;Golden M;Marshall BDL;Mehta SH;Pandya A;Schackman BR;Strathdee SA;Sullivan P;Tookes H;Nosyk B;Localized HIV Economic Modeling Study Group
在美国，黑人和西班牙裔/拉丁裔人继续受到艾滋病毒的不成比例的影响。应用分配成本效益框架，我们估计了两种组合实施方法的成本效益和流行病学影响，以确定最能满足改善人口健康和减少种族/民族健康差距目标的方法。我们采用了一种动态的、区隔的艾滋病毒传播模型来描述美国六个城市的艾滋病毒微流行特征：亚特兰大、巴尔的摩、洛杉矶、迈阿密、纽约和西雅图。我们考虑了16种基于证据的干预措施的组合，以根据先前记录的规模水平来诊断、治疗和预防艾滋病毒传播。然后，我们求解每个城市的最佳组合策略，并根据1)现有服务水平（比例服务方法）和2)新诊断的种族/民族分布（黑人，西班牙裔/拉丁裔和白人/其他个人之间；公平方法）实施每种干预措施的分布。我们估计了从2020-2030年实施的战略的总成本、质量调整生命年（QALYs）和增量成本-效果比（卫生保健角度；20年时间范围；3%的年贴现率）。我们估计了三种健康不平等指标（组间方差、差异指数、泰尔指数）、发病率比和每种方法下所选策略的发病率差异。在所有城市中，公平方法下的最优组合策略比按比例服务产生更多的qaly，从纽约的3.1% （95%CrI:1.4%-5.3%）到亚特兰大的两倍多（101.9%[75.4%-134.6%]）。与比例服务相比，5/6的城市在20年内实现了更低的成本；较低的成本差异从西雅图的2290万美元（95%CrI: 530万美元- 5570万美元）到亚特兰大的5.798亿美元（95%CrI: 2.554亿美元- 9.4050亿美元）不等。在6个城市中，5个城市的公平做法还减少了发病率差距和卫生不平等措施。以公平为重点的艾滋病毒综合实施战略减少了黑人和西班牙裔/拉丁裔个人的差距，可以显着改善人口健康，降低成本，并推动在美国结束艾滋病毒流行的进展。
In the United States, Black and Hispanic/Latinx individuals continue to be disproportionately impacted by HIV. Applying a distributional cost-effectiveness framework, we estimated the cost-effectiveness and epidemiological impact of two combination implementation approaches to determine the approach that best meets objectives of improving population health and reducing racial/ethnic health disparities. We adapted a dynamic, compartmental HIV transmission model to characterize HIV microepidemics in six US cities: Atlanta, Baltimore, Los Angeles, Miami, New York, and Seattle. We considered combinations of 16 evidence-based interventions to diagnose, treat and prevent HIV transmission according to previously-documented levels of scale up. We then solved for optimal combination strategies for each city, with the distribution of each intervention implemented according to 1) existing service levels (proportional services approach) and 2) the racial/ethnic distribution of new diagnoses (between Black, Hispanic/Latinx, and white/other individuals; equity approach). We estimated total costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios of strategies implemented from 2020–2030 (health-care perspective; 20-year time horizon; 3% annual discount rate). We estimated three measures of health inequality (Between-Group Variance, Index of Disparity, Theil Index), incidence rate ratios, and rate differences for the selected strategies under each approach. In all cities, optimal combination strategies under the equity approach generated more QALYs than those with proportional services, ranging from a 3.1% increase (95%CrI:1.4%-5.3%) in New York to more than double (101.9% [75.4%-134.6%]) in Atlanta. Compared to proportional services, the equity approach delivered lower costs over 20 years in 5/6 cities; lower cost differences ranged from $22.9M (95%CrI: -$5.3M-$55.7M) in Seattle to $579.8M (95%CrI: $255.4M-940.5M) in Atlanta. The equity approach also reduced incidence disparities and health inequality measures in five of six cities. Equity-focused HIV combination implementation strategies that reduce disparities for Black and Hispanic/Latinx individuals can significantly improve population health, reduce costs, and drive progress toward Ending the HIV Epidemic in America.