Could long-acting medications facilitate "ending AIDS by 2030" in southern Africa? An allocative efficiency analysis

摘要/摘要 在我们2018年的《柳叶刀》艾滋病评论(《到2030年消灭艾滋病：朗朗上口的口号还是真诚的目标？》)中，我们注意到 公布的监测数据与数学模型一起清楚地表明，联合国艾滋病规划署2030年的目标(90% (艾滋病毒发病率的减少)将无法满足目前的支出和资源分配，以及 联合国艾滋病规划署2020年的目标(90%的感染者被检测到，90%的被检测到的人与护理有关，90%的人与 医疗保健受到病毒抑制)到2020年将不会得到满足。现有的模型表明艾滋病病毒的感染率增加了两倍 支出(每年128亿至400亿美元)将是实现这些目标所必需的，以及 优化这一支出。事实上，如果没有优化，实现这一目标的必要支出可能会超过 每年520亿美元。 为实现联合国艾滋病规划署2030年目标，必须严格评估所有可用工具的作用，并为其量身定制 最大限度地发挥其影响的战略。然而，当前的数学模型忽略了三个重要的工具 阿森纳在资源有限的地区实现2030年目标：(1)针对艾滋病毒护理的具体干预措施 连续体(特别是具有随机对照试验证据的具体干预措施包括基于短信的 类似于Link4Health的预约和/或药物和组合干预的文本提醒 [包括加速用药、短信短信提醒、护理/信息包+/-非现金 财政奖励])，(2)针对高危人群(如饮酒者)的干预措施 精神障碍[AUD]和常见精神障碍[CMD])与某个地区的 人口结构和政策限制，以及(3)艾滋病毒支出高峰的交替时间(越早越好 因为这会导致“赶在疫情之前”，但可能不太可行)。 因此，重点关注津巴布韦、埃斯瓦蒂尼(前身为斯威士兰)和南非等国 (特别是夸祖鲁纳塔尔省[KZN])，因为他们的艾滋病毒发病率负担不成比例 和死亡率，我们的建议使用数学模型来评估广泛的配置效率 确定组合艾滋病毒预防战略的范围：干预措施的成本效益如何 加强艺术联系-坚持-保留(例如，长效艺术)需要有效地构成 艾滋病毒综合预防战略(目标1)；加强预防前预防工作联系的干预措施成本效益如何-- 依从性-滞留(例如，长效PrEP)需要有效地构成组合HIV 预防战略(目标2)；加强预防接种和抗逆转录病毒治疗联系的干预措施的成本效益如何-- 需要坚持-保留，以便有效地制定组合艾滋病毒预防战略(目标3)。

ABSTRACT/SUMMARY In our 2018 Lancet HIV commentary (“Ending AIDS by 2030: Catchy slogan or sincere goal?"), we note that published surveillance data together with mathematical modeling make it clear that UNAIDS 2030 goals (90% reduction in HIV incidence) are not going to be met with current spending and resource allocation, and UNAIDS 2020 goals (90% of infected are detected, 90% of detected are linked to care, and 90% of linked to care are virally suppressed) are not going to be met by 2020. Existing models suggest a tripling in HIV spending (from $12.8 billion to $40 billion per year) would be necessary to meet these goals, together with an optimizing of that spending. Indeed, without optimization, the necessary spending for that goal would likely top $52 billion per year. To achieve UNAIDS 2030 goals it will be necessary to critically assess the role of all available tools and tailor strategies to maximize their impact. However, current mathematical models omit three important tools in the arsenal for achieving 2030 goals in resource-limited regions: (1) Specific interventions that target the HIV care continuum (in particular specific interventions with randomized controlled-trial evidence include SMS-based text reminders for appointments and/or medications and combination interventions similar to Link4Health [including accelerated medication initiation, SMS-based text reminders, care/information package +/- noncash financial incentive]), (2) targeting interventions to high risk populations (such as those with alcohol use disorders [AUDs] and common mental disorders [CMDs]) that are specifically relevant to a region’s demographics and policy constraints, and (3) alternate timing of the peak of HIV spending (earlier is better because it leads to “getting ahead of the epidemic” but may be less feasible). Accordingly, focusing on the countries of Zimbabwe, eSwatini (formerly known as Swaziland), and South Africa (in particular, the province of KwaZulu Natal [KZN]) because of their disproportionate burden of HIV morbidity and mortality, our proposal uses mathematical modeling to evaluate the allocative efficiency of a wide spectrum of combination HIV prevention strategies to determine: How cost-effective would interventions enhancing ART linkage-adherence-retention (e.g., long acting ART) need to be in order to efficiently constitute combination HIV prevention strategy (Aim 1); How cost-effective would interventions enhancing PrEP linkage- adherence-retention (e.g., long-acting PrEP) need to be in order to efficiently constitute combination HIV prevention strategy (Aim 2); and how cost-effective would interventions enhancing PrEP and ART linkage- adherence-retention need to be in order to efficiently constitute combination HIV prevention strategy (Aim 3).