Optimal Medication Dispensing for People Living with HIV with and without Other Chronic Diseases in Zambia: A Mathematical Model

项目摘要 在当前普及抗逆转录病毒治疗的时代，卫生系统面临着优化 照顾越来越多的艾滋病毒感染者和接受抗逆转录病毒治疗的慢性病患者， 非传染性疾病的终身治疗。差异化服务交付（DSD）是 开发作为一种手段，以打击次优的长期保留对艺术和提高效率， 通过简化和调整护理沿着级联，以患者偏好为指导， 同时减少个人和卫生系统的不必要负担。仍有许多工作要 然而，我了解DSD模型是否适用于多个 条件以及如何为特定人群和卫生系统找到最佳的DSD模型。使用大 患者数据集的常规收集的医疗记录在赞比亚，我建议创建一个动态微观模拟 疾病和服务提供模式-侧重于艾滋病毒，包括和不包括其他慢性疾病， 糖尿病-确定最佳药物分配策略的潜在效益和成本。我预计 替代药物分配策略的成本效益将是服务量、患者 结果、单位成本和诊所内拥挤的概率。这项研究将直接为政策提供信息 有关应如何实施DSD模式以改善人口健康结果的问题，以及 方案的成本效益。目标1和2将建立艾滋病毒服务提供的强度、能力、 密度和频率，评估患者/设施组的分布，并评估药物的规模经济 分发艾滋病毒的策略，并与其他慢性疾病，如糖尿病。我将建立一个模型， 量化的程度，服务能力和利用率增加使用综合和多个月的药物 基于稳定/共病患者比例、单位时间/成本的HIV和糖尿病的配药策略 和诊所的能力。目标3将预测一个综合的 艾滋病毒/艾滋病合并或不合并其他慢性病的药物分发战略。我的模型将估计 服务整合和多月药物分发在多大程度上可以改变总的治疗开始， 在诊所的保留，以及如何反过来改变诊所拥挤的概率，单位成本，治疗 保留/服务质量和成本效益。主要研究环境，波士顿大学医学院 校园，将有助于拟议项目的成功，因为它提供了丰富的，多学科的机构 资源，包括对研究和培训的坚定承诺以及充足的部门设施， 资源我可以获得必要的资源和数据来完成拟议的研究。通过 这个指导研究培训奖，我将获得传染病传播建模的专业知识， 成本效益，以及成功撰写赠款的经验。

PROJECT SUMMARY In the current era of universal antiretroviral treatment (ART), health systems have the challenge of optimizing care for a growing number of diverse groups of people living with HIV and on ART who are also on chronic, life-long treatment for non-communicable diseases (NCDs). Differentiated service delivery (DSD) was developed as a means to combat suboptimal long-term retention on ART and increase the efficiency of resource utilization by simplifying and adapting care along the cascade, guided by patient preferences and needs, while reducing unnecessary burdens on individuals and the health system. Much remains to be understood, however, about whether DSD models will work for integrated service delivery for multiple conditions and how to find the optimal DSD model for specific populations and health systems. Using a large patient dataset of routinely collected medical records in Zambia, I propose to create a dynamic microsimulation model of disease and service delivery – focusing on HIV with and without other chronic diseases such as diabetes – to identify the potential benefits and costs of an optimal medication dispensing strategy. I expect that the cost-effectiveness of alternative drug dispensing strategies will be a function of service volume, patient outcomes, unit costs, and probability of congestion within clinics. This research will directly inform policy questions relating to how DSD models should be implemented to improve population health outcomes and program cost-effectiveness. Aims 1 and 2 will construct HIV service delivery indices of intensity, capacity, density, and frequency, assess distributions by patient/facility groups, and evaluate economies of scale of drug dispensing strategies for HIV with and without other chronic diseases such as diabetes. I will build a model to quantify the extent of service capacity and utilization increase using an integrated and multi-month drug dispensing strategy for HIV and diabetes, based on the proportion of stable/comorbid patients, unit time/cost per service, and clinic capacity. Aim 3 will project the long-term impact and cost-effectiveness of an integrated drug dispensing strategy for HIV with and without other chronic diseases. My model will estimate whether and to what extent service integration and multi-month drug dispensing can change total treatment initiation and retention in a clinic and how that may in turn change the probability of clinic congestion, unit costs, treatment retention/service quality, and cost effectiveness. The primary research environment, Boston University Medical Campus, will contribute to the success of the proposed project, as it provides rich, multidisciplinary institutional resources, including a strong commitment to research and training and ample departmental facilities and resources. I have access to the necessary resources and data to complete the proposed research. Through this mentored research training award, I will gain expertise in infectious diseases transmission modeling and cost-effectiveness, and experience of successful grant writing.