Finding New Strategies for Achieving the UNAIDS 90-90-90 Targets: Cost-Effectiveness of a "Test and Treat" Intervention in Peru

联合国艾滋病规划署最近发布的90-90-90指南为扩大艾滋病毒治疗设定了雄心勃勃的目标：“到2020年，90%的 所有艾滋病毒携带者都将知道他们的艾滋病毒状态…，90%的被诊断为艾滋病毒感染的人将 接受持续抗逆转录病毒治疗(ART)…，所有接受抗逆转录病毒治疗的人中将有90% [1]实现这些目标将需要扩大现有方案和实施 新战略。这项拟议的成本效益分析将审查一种新的检测和治疗策略 通过早期艾滋病毒诊断和与艾滋病毒护理的快速联系，包括抗逆转录病毒治疗，实现第一个和第二个90年代。 这种方法通过频繁使用检测急性和非传染性疾病的测试来改进艾滋病毒检测 已确定的艾滋病毒感染以及通过使用同伴健康导航员与艾滋病毒护理的快速联系。我们的 假设是早期干预(抗逆转录病毒治疗和降低风险服务)，特别是在急性艾滋病毒感染期间 (Ahi)当病毒载量较高时，由于降低了医疗保健成本和减少了艾滋病毒，将具有成本效益 在高危人群中传播，例如男男性行为者(MSM)。我们对此进行测试 在秘鲁利马的男男性接触者中存在假说，那里是艾滋病毒高感染率的集中流行病。我们的 利马的研究表明，用AHI识别MSM是可行的，MSM中存在需求 为这样一个测试程序。干预效果和成本数据可从最近完成的 对2000多名男男性接触者进行了为期4年的Sabes研究，每月检测HIV RNA和抗体以检测 收购后不久发生艾滋病毒感染事件。Sabes的研究使用了同行导航器来确保快速链接 艾滋病毒+参与者的护理和当天的艺术启蒙。我们的假设是，增加对 急性/早期艾滋病毒感染和与艾滋病毒护理和抗逆转录病毒疗法的快速联系总体上减少了成本，并改善了健康 比目前半年一次的艾滋病毒血清检测和患者转诊到治疗中心的做法更多。 此外，这些差异将由避免的艾滋病毒护理费用以及更长和更好的生命质量推动。 目的1.模拟艾滋病毒在秘鲁利马男男性接触者人群中的传播，并估计 通过增加检测和与男男性接触者护理的快速联系避免了新的艾滋病毒感染人数 最近感染了艾滋病病毒。建立男男性接触者中HIV传播的详细数学模型， 使用Sabes的数据进行参数化，将使我们能够探索人口水平的有效性 对未来扩大抗逆转录病毒药物治疗和可能引入暴露前预防措施的情景进行干预。 目的2.评估增加检测和快速联系治疗男男性接触者的成本效益 最近从卫生系统和患者那里检测到的在急性艾滋病毒感染期间检测到的艾滋病毒 透视。目标2 A。估计10年的个人和医疗系统成本，增加检测和 与男男性行为者急性艾滋病毒携带者的护理快速联系。目标2B。调整目标1中节省的预测寿命年数，以提高 寿命和估计每残疾调整后的费用--与国家护理标准相比--避免的寿命年。

The recent UNAIDS 90-90-90 guidelines set ambitious targets for scale-up of HIV treatment: “By 2020, 90% of all people living with HIV will know their HIV status…, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy (ART)…, 90% of all people receiving antiretroviral therapy will have viral suppression”.[1] Reaching these goals will require expansion of existing programs and implementation of new strategies. This proposed cost-effectiveness analysis will examine a novel test and treat strategy for achieving the first and second `90s' through early HIV diagnosis and rapid linkage to HIV care, including ART. This approach improves HIV detection through frequent testing using tests that detect both acute and established HIV infection as well as rapid linkage to HIV care through the use of peer health navigators. Our hypothesis is that early intervention (ART and risk reduction services), especially during acute HIV infection (AHI) when viral load is high, will be cost-effective due to lower health care costs and reduced HIV transmission among high-risk populations such as men who have sex with men (MSM). We test this hypothesis among MSM in Lima, Peru, where there is a concentrated epidemic with high rates of HIV. Our research in Lima indicates that identifying MSM with AHI is feasible and that there is a demand among MSM for such a testing program. Intervention effectiveness and cost data are available from the recently completed 4-year SABES study which followed over 2000 MSM with monthly testing for HIV RNA and antibodies to detect incident HIV infections shortly after acquisition. The SABES study used peer navigators to assure rapid linkage of HIV+ participants to care and same-day ART initiation. Our hypothesis is that increased detection of acute/early HIV infection and rapid linkage to HIV care and ART incurs fewer costs overall and improves health more than the current practice of semi-annual serologic HIV testing and patient referral to treatment centers. Moreover, the differences will be driven by HIV care costs avoided as well as longer and better quality lives. Aim 1. Model the transmission of HIV within the MSM population in Lima, Peru and estimate the number of new HIV infections averted through increased detection and rapid linkage to care of MSM with recently acquired HIV. Developing a detailed mathematical model of HIV transmission among MSM, parameterized with the data from SABES, will allow us to explore the population-level effectiveness of the intervention in scenarios of future expansion of ART and possible introduction of pre-exposure prophylaxis. Aim 2. Estimate the cost-effectiveness of increased detection and rapid linkage to care of MSM with recently acquired HIV, detected during acute HIV infection, from the health system and patient perspectives. Aim 2A. Estimate the 10-year individual and health system costs with increased detection and rapid linkage to care of MSM with acute HIV. Aim 2B. Adjust predicted life years saved in Aim 1 for quality of life and estimate the cost per disability adjusted life-year averted compared to the national standard of care.