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

摘要 艾滋病毒对年轻女性的影响不成比例，撒哈拉以南非洲地区近20万名年轻女性 每年都会感染艾滋病毒。暴露前预防是预防HIV感染的有效方法 并提供了作为女性控制的干预的希望。然而，高效识别的有效策略 尚未确定感染艾滋病毒的高危妇女和让她们参与预防接种计划的情况。怀孕了， 产后妇女感染艾滋病毒的风险增加，怀孕期间感染艾滋病毒可能是 在围产期或哺乳期间传染给婴儿。因此，将PrEP整合到现有的孕产妇和 儿童保健诊所可能是预防新的艾滋病毒感染的有效战略。国民健康 在有限资源下运行的计划需要指导，以确定在哪里部署PrEP以最大限度地提高 冲击力。拟议的项目将使用数学建模，并结合来自两个实施的数据 评估通过肯尼亚西部妇幼保健诊所提供PrEP的成本效益的研究。在目标1中，我们 将进行微观成本计算研究，作为PrEP示范项目的一部分，以估算 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体的数学模型 根据模拟艾滋病毒自然历史的艾滋病毒在肯尼亚西部的动态传播， 人口学、性关系的形成，并明确地模拟个人通过艾滋病毒和妇幼保健的流动 服务。使用这个模型，我们将评估孕期和孕期PrEP摄取对人群水平的影响 去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 此PrEP交付战略与标准阈值和其他 艾滋病毒预防干预措施。项目成功的一个关键基准是PrEP使用的优先程度 在艾滋病毒高危人群中。在目标3中，我们将评估以风险分数为导向的与 为孕妇提供普遍的PrEP分娩。这项分析将纳入随机试验的结果。 在AIM开发的模型中比较两种策略之间的PrEP摄取、保留和依从性 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 准备在撒哈拉以南非洲地区分娩。除了这些目标，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领导艾滋病毒预防的指导下 研究人员。综合起来，这项提议将为传染病临床医生的职业生涯奠定坚实的基础。 和公共卫生研究人员，为控制艾滋病毒流行的努力做出贡献。

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.