Estimating the cost-effectiveness of HIV pre-exposure prophylaxis delivery through maternal and child health clinics in Kenya

摘要 艾滋病毒对年轻妇女的影响尤为严重，撒哈拉以南非洲有近20万年轻妇女感染艾滋病毒。 每年感染艾滋病毒。暴露前预防（PrEP）是预防HIV感染的有效方法 并提供了作为女性控制的干预措施的承诺。然而，有效识别 尚未建立艾滋病毒感染高风险妇女的预防措施，并让她们参与预防措施。孕妇和 产后妇女感染艾滋病毒的风险增加，怀孕期间获得的艾滋病毒感染可能是 在围产期或哺乳期间传播给婴儿。因此，将PrEP纳入现有的孕产妇和 儿童保健诊所可能是预防新的艾滋病毒感染的有效战略。国家卫生 在有限资源下运行的计划需要指导，以确定在何处推出PrEP， 冲击拟议的项目将使用数学建模结合数据从两个实施 研究，以评估通过肯尼亚西部妇幼保健诊所提供PrEP的成本效益。目标1： 作为PrEP示范项目的一部分，将进行微成本研究，以估计 将PrEP纳入常规妇幼保健服务。在目标2中，我们将开发一个基于个人的数学模型 根据肯尼亚西部的艾滋病病毒动态进行校准，模拟艾滋病病毒的自然历史， 人口统计学，性关系的形成，并明确模拟通过艾滋病毒和妇幼保健的个人流动 服务使用这个模型，我们将评估孕妇和孕妇摄取PrEP的人群水平影响， 在妇幼保健诊所就诊的产后妇女。结合目标1的成本估算，我们将计算 与标准阈值和其他阈值相比，该PrEP交付策略的成本效益和预算影响 艾滋病毒预防干预措施。计划成功的一个关键基准是PrEP使用的优先程度 艾滋病高危人群中。在目标3中，我们将评估风险评分指导与 为孕妇提供PrEP。该分析将纳入随机试验的结果 将两种策略之间的PrEP吸收、保留和坚持情况与Aim开发的模型进行比较 2.这些目标的结果将有助于指导政策制定者决定如何最有效地扩大规模 在撒哈拉以南非洲提供PrEP。除了这些目标外，该提案还描述了一项严格的培训计划 在数学建模，卫生经济学和临床护理以及指导从领先的艾滋病毒预防 研究人员结合起来，这一建议将提供一个坚实的基础，职业生涯作为一个传染病临床医生 和公共卫生研究人员为控制艾滋病毒流行做出贡献。

ABSTRACT HIV disproportionately affects young women, and nearly 200,000 young women in sub-Saharan Africa are infected with HIV each year. Pre-exposure prophylaxis (PrEP) is an effective method for preventing HIV infection and offers promise as a female-controlled intervention. However, effective strategies for efficiently identifying women at high risk of HIV infection and engaging them in PrEP have not been established. Pregnant and postpartum women have elevated risk of HIV infection, and HIV infection acquired during pregnancy can be transmitted to infants perinatally or during breastfeeding. Therefore, integrating PrEP into existing maternal and child health (MCH) clinics could be an efficient strategy for preventing new HIV infections. National health programs operating under limited resources need guidance to determine where to roll out PrEP to maximize impact. The proposed project will use mathematical modeling combined with data from two implementation studies to evaluate the cost-effectiveness of PrEP delivery through MCH clinics in western Kenya. In Aim 1, we will conduct a microcosting study as part of a PrEP demonstration project to estimate the incremental cost of integrating PrEP into routine MCH services. In Aim 2, we will develop an individual-based mathematical model of HIV transmission calibrated to HIV dynamics in western Kenya that simulates HIV natural history, demography, sexual relationship formation, and explicitly models the flow of individuals through HIV and MCH services. Using this model, we will evaluate the population-level impact of PrEP uptake by pregnant and postpartum women attending MCH clinics. Combined with the cost estimates from Aim 1, we will calculate the cost-effectiveness and budget impact of this PrEP delivery strategy compared to standard thresholds and other HIV prevention interventions. A key benchmark of program success is the extent to which PrEP use is prioritized among individuals with high HIV risk. In Aim 3, we will estimate the cost-effectiveness of risk score-guided vs. universal PrEP delivery to pregnant women. This analysis will incorporate results from a randomized trial comparing PrEP uptake, retention, and adherence between the two strategies into the model developed in Aim 2. Together, the results from these Aims will help guide policymakers decide how to most effectively scale up PrEP delivery in sub-Saharan Africa. In addition to these Aims, the proposal describes a rigorous training plan in mathematical modeling, health economics, and clinical care as well as mentorship from leading HIV prevention researchers. Combined, this proposal will provide a solid foundation for a career as an infectious disease clinician and public health researcher contributing to efforts to control the HIV epidemic.