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

长效药物能否促进南部非洲“到 2030 年终结艾滋病”？

• 批准号: 10663840
• 负责人: Ronald Scott Braithwaite
• 金额: $ 66.69万
• 依托单位: NEW YORK UNIVERSITY SCHOOL OF MEDICINE
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-09-25 至 2024-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10663840
• 关键词: AIDS prevention; Acceleration; Acquired Immunodeficiency Syndrome; Adherence; Appointment; Budgets; Caring; Collaborations; Computer Simulation; Continuity of Patient Care; Cost Effectiveness Analysis; Country; Data; Decision Making; Epidemic; Formulation; Funding; Goals; HIV; Health; Health Benefit; Incidence; Individual; Inequality; Infrastructure; Intervention; Link; Male Circumcision; Medical; Mental disorders; Modeling; Morbidity - disease rate; Operations Research; Persons; Pharmaceutical Preparations; Policies; Population; Prevention strategy; Preventive; Prophylactic treatment; Province; Published Comment; Publishing; Randomized, Controlled Trials; Recording of previous events; Resource Allocation; Resource-limited setting; Resources; Role; South Africa; Southern Africa; Swaziland; Text; Viral; Viral Load result; Zimbabwe; alcohol use disorder; antiretroviral therapy; cost effective; demographics; financial incentive; high risk population; improved; incremental cost; intervention cost; mathematical model; medication compliance; mortality; phase III trial; pre-exposure prophylaxis; surveillance data; tool

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).

摘要/总结 在 2018 年《柳叶刀》艾滋病毒评论中（“到 2030 年终结艾滋病：朗朗上口的口号还是真诚的目标？”），我们注意到 公布的监测数据与数学模型明确表明，联合国艾滋病规划署 2030 年目标（90% 当前的支出和资源分配无法满足艾滋病毒发病率的降低，并且 联合国艾滋病规划署 2020 年目标（90% 的感染者被检测到，90% 的检测者与护理相关，90% 的感染者与护理相关） 到 2020 年，这一目标还无法实现。现有模型表明，艾滋病毒感染人数将增加两倍 为了实现这些目标，需要支出（从每年 128 亿美元到 400 亿美元），同时还需要 优化该支出。事实上，如果没有优化，实现该目标所需的支出可能会超过 每年 520 亿美元。 为了实现联合国艾滋病规划署 2030 年目标，有必要严格评估所有可用工具的作用并进行调整 最大限度地发挥其影响力的战略。然而，当前的数学模型忽略了三个重要的工具： 在资源有限地区实现 2030 年目标的武器库： (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字提醒 [包括加速药物启动、基于短信的文本提醒、护理/信息包 +/- 非现金 经济激励]），（2）针对高风险人群（如酗酒人群）进行干预 与某个地区的具体相关的精神障碍 [AUD] 和常见精神障碍 [CMD]） 人口统计和政策限制，以及 (3) 艾滋病毒支出高峰的交替时间（越早越好） 因为它会导致“领先于流行病”，但可能不太可行）。 因此，重点关注津巴布韦、斯威士兰（前称斯威士兰）和南非等国家 （特别是夸祖鲁纳塔尔省 [KZN]），因为该省的艾滋病毒发病率负担过重 和死亡率，我们的建议使用数学模型来评估广泛的分配效率 艾滋病毒预防组合策略的范围，以确定： 干预措施的成本效益如何 需要增强 ART 连接-依从性-保留（例如长效 ART），以便有效地 艾滋病毒综合预防战略（目标 1）；增强 PrEP 联系的干预措施的成本效益如何？ 需要坚持-保留（例如长效 PrEP）才能有效地构成 HIV 组合 预防策略（目标 2）；以及增强 PrEP 和 ART 联系的干预措施如何具有成本效益- 为了有效地制定艾滋病毒预防组合策略（目标 3），需要坚持-保留。