[论文解读] Ending AIDS in South Africa: How long will it take? How much will it cost?

Brian Williams, Eleanor Gouws|arXiv (Cornell University)|Nov 7, 2013

HIV/AIDS Research and Interventions参考文献 21被引用 5

一句话总结

本文通过建模南非普遍检测与早期抗逆转录病毒治疗（ART）的影响，表明扩大ART可使未接受ART的成年人群中HIV感染率降至0.06%，并在2023年消除艾滋病相关死亡，额外成本仅为6.92亿美元。若自1998年起更早实施，可挽救250万条生命，每挽救一条生命成本为7,200美元，具有成本效益。

ABSTRACT

South Africa has more people infected with HIV but, by providing access to anti-retroviral therapy (ART), has kept more people alive than any other country. The effectiveness, availability and affordability of potent anti-retroviral therapy (ART) make it possible to contemplate ending the epidemic of HIV/AIDS. We consider what would have happened without ART, the impact of the current roll-out of ART, what might be possible if early treatment becomes available to all, and what could have happened if ART had been provided much earlier in the epidemic. In 2013 the provision of ART has reduced the prevalence of HIV from an estimated 15% to 9% among adults not on ART, the annual incidence from 2% to 0.9%, and the AIDS related deaths from 0.9% to 0.3% p.a. saving 1.5 million lives and USD727M. Regular testing and universal access to ART could reduce the prevalence among adults not on ART in 2023 to 0.06%, annual incidence to 0.05%, and eliminate AIDS deaths. Cumulative costs between 2013 ands 2023 would increase by USD692M only 4% of the total cost of USD17Bn. If a universal testing and early treatment had started in 1998 the prevalence of HIV among adults not on ART in 2013 would have fallen to 0.03%, annual incidence to 0.03%, and saved 2.5 million lives. The cost up to 2013 would have increased by USD18Bn but this would have been cost effective at US$7,200 per life saved. Future surveys of HIV among women attending ante-natal clinics should include testing women for the presence of anti-retroviral drugs, measuring their viral loads, and using appropriate assays for estimating HIV incidence. These data would make it possible to develop better and more reliable estimates of the current state of the epidemic, the success of the current ART programme, levels of viral load suppression for those on ART and the incidence of infection.

研究动机与目标

• 估算通过扩大抗逆转录病毒治疗（ART）在南非终结艾滋病疫情所需的时间和成本。
• 评估当前ART推广对HIV感染率、发病率和艾滋病相关死亡率的影响。
• 评估普遍检测与早期治疗的潜在收益与成本。
• 模拟若自1998年起更早实施ART，长期结果将如何。
• 提出通过在产科诊所中整合抗逆转录病毒药物检测与病毒载量监测，改进监测方法。

提出的方法

• 使用数学传播模型，预测不同ART推广情景下的HIV传播动态。
• 利用南非历史HIV感染率、发病率和死亡率数据校准模型。
• 模拟四种情景：无ART、当前ART推广、自2013年起普遍检测与早期治疗、自1998年起普遍ART。
• 估算每种情景下的累计成本与挽救的生命数，包括增量成本效益分析。
• 提出将ART药物检测与病毒载量检测整合至常规产科诊所调查中，以提升疫情监测能力。
• 应用统计方法，利用血清学检测与监测样本中的病毒载量数据估算HIV发病率。

实验结果

研究问题

• RQ1 若自2013年起实施普遍检测与早期ART，南非需要多长时间才能终结艾滋病疫情？
• RQ2 若到2023年实现疫情控制，通过普遍检测与早期治疗的额外成本是多少？
• RQ3 若自1998年起实施普遍ART，可挽救多少条生命？
• RQ4 若更早推广ART，到2013年HIV感染率、发病率和艾滋病相关死亡率将受到何种影响？
• RQ5 如何通过改进产科诊所的监测方法，提升HIV发病率与治疗成功率监测的准确性？

主要发现

• 至2013年，ART已使未接受ART的成年人群中HIV感染率从15%降至9%，艾滋病相关死亡率从每年0.9%降至0.3%。
• 当前ART推广在2013至2023年间挽救了150万条生命，并避免了7.27亿美元的成本。
• 若自2013年起实施普遍检测与早期ART，未接受ART的成年人群中HIV感染率可降至0.06%，并有望在2023年消除艾滋病相关死亡。
• 自2013年起实施普遍检测与早期治疗的额外成本为6.92亿美元，占预计总成本170亿美元的4%。
• 若自1998年起实施普遍ART，至2013年未接受ART的成年人群中HIV感染率将降至0.03%，并可挽救250万条生命。
• 更早实施ART的增量成本效益为每挽救一条生命7,200美元，表明其为具有成本效益的公共卫生干预措施。