艾滋病单阳家庭不同抗病毒治疗策略成本、效果及效用研究
发布时间：2018-08-14 13:33
【摘要】：背景：自2003年,为响应国家“四免一关怀”的号召,各地积极推进艾滋病抗病毒治疗(Antiretroviral Treatment ART)工作,并逐年扩大覆盖面。随着国家免费ART起始治疗标准的逐步提高,不同ART策略的HIV单阳家庭HIV/AIDS患者的生命质量,抗病毒治疗的效果,以及成本-效果和成本-效用情况,国内尚未见有关的研究和报导。目的：通过了解调查地区HIV单阳家庭HIV/AIDS患者生命质量、艾滋病ART情况及影响因素,评价HIV单阳家庭HIV/AIDS生命质量和接受艾滋病ART的效果；探讨调查地区HIV单阳家庭不同ART策略的成本,成本效果,成本-效用,为下一步扩大艾滋病ART预防HIV传播的策略提供依据,为决策部门今后因地制宜地实施和调整该策略提供科学依据。方法：第一部分以现场调查为基础,选择河南省周口市HIV单阳家庭HIV/AIDS患者为研究对象,通过2015年1-5月现场问卷调查,并与调查地区艾滋病疫情数据库回顾性分析相结合的方法收集HIV单阳家庭HIV/AIDS患者的基本特征、生命质量、艾滋病ART直接医疗成本和直接非医疗成本、调查地区配偶转阳率、不同ART策略研究期间的累计生存时间、病毒载量(VL)完全抑制率和CD4+T淋巴细胞(简称CD4细胞)增长率效果指标,开展不同ART策略成本-效果分析；第二部分为通过构建Markov模型并模拟计算获得质量调整生命年,对HIV单阳家庭HIV/AIDS患者早期和常规接受艾滋病ART策略进行成本-效用分析。结果：根据调查地区接受ART治疗后各类直接医疗费用和直接非医疗费用年人均单价,结合当地CPI各年涨跌比率,测算出调查地区2,271例HIV单阳家庭HIV/AIDS患者接受ART治疗2004-2015年总成本为30,832.91万。不同CD4细胞起始ART的总成本分别为：CD4细胞≤200个/mm3组12,177.87万,201～350个/mm3组10,470.85万,351～500个/mm3组4,680.31万,500个/mm3组3,503.88万；各组每人年费用分别为2.13万元、2.42万元、2.14万元及1.96万元,其中,CD4细胞500个/mm3组每人年费用最低。通过方差分析,4组HIV单阳家庭HIV/AIDS患者除二线药物费用外,其它类别抗病毒治疗相关成本差异均有统计学意义(P0.01)。对调查地区HIV单阳家庭HIV/AIDS患者不同ART策略成本-效果分析,以不同ART策略累计生存时间作为效果指标,成本-效果比最低的为CD4细胞≤200个/mm3策略的2.13万元/生命年,而CD4细胞500个/mm3组成本-效果比仅高于CD4细胞≤200个/mm3策略为2.20万元/生命年,且与CD4细胞≤200个/mm3策略比,CD4细胞500个/mm3策略增量成本效果比(ICER)最小,每多获得1个生存年的花费2.25万元；以配偶未阳转率作为效果指标,成本-效果比最低为CD4细胞≤200个/mm3策略122.34万元,而成本-效果比最高的为CD4细胞500个/mm3策略309.54万元,与CD4细胞≤200个/mm3策略相比,CD4细胞500个/mm3策略ICER最小,表示每多获得1/100人年配偶未阳转率比CD4细胞≤200个/mm3策略少花费3.33万元；以各年VL完全抑制率作为效果指标,不同ART策略VL完全抑制率存在波动,各检测时段CD4细胞≤200个/mm3策略成本-效果比最低,CD4细胞500个/mm3策略成本-效果比仅高于CD4细胞≤200个/mm3策略,且在接受ART第1、2、6年均低于CD4细胞≤350个/mm3和CD4细胞≤500个/mm3策略；以每年CD4细胞增长率作为效果指标,CD4细胞≤200个/mm3策略成本-效果比各检测时段均最低,CD4500个/mm3策略在接受ART第1年成本-效果比最高,随后均为CD4细胞≤500个/mm3策略成本-效果比最高。与CD4细胞≤200个/mm3策略相比,CD4细胞≤350个/mm3策略ICER最小。对调查地区HIV单阳家庭HIV/AIDS患者艾滋病ART策略成本-效果分析,首先开展了现场生命质量调查,结果为河南周口市单阳家庭HIV/AIDS在生理领域、心理领域、社会关系领域和环境领域的得分分别为(12.00±2.02)、(12.07±2.07)、(11.87±1.99)和(11.09±1.84)分。周口市艾滋病患者生理、心理、社会关系和环境4个领域得分与常模(15.10±2.30)、(13.89±1.89)、(13.93±2.06)和(12.14±2.08)分比较,各领域得分与常模差异均有统计学意义(P0.01)。浙江台州市HIV/AIDS在生理领域、心理领域、社会关系领域和环境领域的得分分别为(14.99±2.25)、(14.25±2.12)、(13.22±2.37)、(13.31±1.99)。4个领域得分与常模比较,除环境领域得分与常模存在显著性差异外(P0.05),其它领域均无统计学意义。周口市单阳家庭在生理领域、心理领域、社会关系领域和环境领域的得分均低于台州市单阳家庭在生理领域、心理领域、社会关系领域和环境领域的得分(14.76±2.43)、(14.07±2.16)、(13.07±2.24)和(13.07±1.97),差异均有统计学意义(P0.01)。成本-效用分析结果发现：调查地区常规艾滋病ART策略(CD4细胞≤350个/mm3),则每获得一个QALY需花费2.96万元,早期艾滋病ART策略(CD4细胞350个/mm3),则每获得一个QALY需花费3.18万元,且相对于常规ART策略,早期ART策略的ICUR为6.48,即每多获得1个QALY需多花费6.48万元。按WHO标准,早期和常规艾滋病ART策略均符合成本效益原则。结论：调查地区针对HIV单阳家庭HIV/AIDS患者实施早期艾滋病ART策略,不仅扩大了艾滋病ART服务覆盖面,延长HIV/AIDS患者寿命,并且降低了配偶HIV阳转比例,成本-效果明显：按WHO标准,成本-效用分析结果符合成本效益原则。
[Abstract]:BACKGROUND: Since 2003, in response to the call of "four exemptions and one care" of the state, anti-retroviral treatment (ART) has been actively promoted and expanded year by year. Objective: To evaluate the quality of life (QOL) of HIV / AIDS patients in single-positive families and the effect of HIV / AIDS ART on their acceptance of AIDS ART by demodulating the quality of life (QOL), AIDS ART and influencing factors of HIV / AIDS patients in single-positive families. The cost, cost-effectiveness and cost-effectiveness of different ART strategies for HIV single-positive families provide the basis for further expanding the strategy of AIDS ART to prevent HIV transmission, and provide scientific basis for decision-making departments to implement and adjust the strategy in accordance with local conditions in the future. The basic characteristics, quality of life, ART direct medical costs and direct non-medical costs of HIV/AIDS patients in single-positive families were collected through on-the-spot questionnaires conducted from January to May 2015 and retrospective analysis of the AIDS epidemic database in the investigated areas. The cumulative survival time, viral load (VL) complete inhibition rate and CD4 + T lymphocyte (CD4 cell) growth rate during the strategy study were used to analyze the cost-effectiveness of different ART strategies. The second part was to construct Markov model and simulate the quality-adjusted life year for HIV/AIDS patients in single-positive families. Results: According to the annual per capita price of direct medical expenses and direct non-medical expenses after ART treatment in the survey area, combined with the local CPI rate of rise and fall in each year, the total cost of ART treatment for 2,271 HIV/AIDS patients in single-positive families in the survey area was estimated to be 30,832 in 2004-2015. The total cost of ART initiation for different CD4 cells was 127.787 million in the group of <200/mm 3, 1047.85million in the group of 201-350/mm 3, 46.8031 million in the group of 351-500/mm 3 and 35.038 million in the group of 500/mm 3, respectively; the annual cost for each group was 21.13 million yuan, 24.2 million yuan, 21.14 million yuan and 19.96 million yuan, respectively. Cost-effectiveness analysis of different ART strategies for HIV/AIDS patients in single-positive families was conducted. The cumulative survival time of different ART strategies was taken as the effect index. The lowest cost-effectiveness ratio was 21.3 million yuan per life year for CD4 cells (< 200 / mm3) strategy, whereas the cost-effectiveness ratio of CD4 cells (< 200 / mm3) strategy was only higher than that of CD4 cells (< 200 / mm3) strategy. Compared with CD4 cells (< 200 / mm3) strategy, the incremental cost-effectiveness ratio (ICER) of CD4 cells (< 500 / mm3) strategy was the smallest. The lowest cost-effectiveness ratio was CD4 cells (< 200 / mm3) strategy 1.2234 million yuan, and the highest cost-effectiveness ratio was CD4 cells (< 500 / mm3) strategy 3.0954 million yuan. Compared with CD4 cells (< 200 / mm3) strategy, CD4 cells (< 500 / mm3) strategy ICER was the smallest, indicating that every additional gain was 1/10. The total inhibition rate of VL by different ART strategies fluctuated, and the cost-effectiveness ratio of CD4 cells less than 200/mm3 strategies was the lowest in each detection period, and that of CD4 cells less than 500/mm3 strategies was only higher than that of CD4 cells less than 200 cells less than that of CD4 cells less than that of CD4 cells less than 200/mm3 strategies. The cost-effectiveness ratio of CD4 cells < 200/mm3 strategy was the lowest in each test period, and the cost-effectiveness ratio of CD4 500/mm3 strategy was the highest in the first year of ART, followed by CD4 fine. Compared with CD4 cell < 200 cell / mm3 strategy, CD4 cell < 350 cell / mm3 strategy ICER is the smallest. To analyze the cost - effectiveness of HIV / AIDS ART strategy in HIV / AIDS single-positive families in the investigation area, the field quality of life survey was carried out, and the results showed that HIV / AIDS in single-positive families in Zhoukou City, Henan Province was in physiology. Scores in physical, psychological, social and environmental fields of AIDS patients in Zhoukou were (15.10 [2.30], (13.89 [1.89], (13.93 [2.06] and (12.14 [2.08], respectively. The scores of HIV/AIDS in physiological, psychological, social and environmental fields were (14.99 2.25), (14.25 2.12), (13.22 2.37), (13.31 1.99). Compared with the norm, the scores of HIV/AIDS in four fields were (14.99 2.25), (14.25 2.12, (13.22 2.37), (13.31 1.99). Except for the The scores in physiological, psychological, social and environmental fields of single-yang families in Zhoukou City were lower than those in physiological, psychological, social and environmental fields of Taizhou City (14.76 + 2.43), 14.07 + 2.16, 13.07 + 2.24 and 13.07 + 1.97). Cost-utility analysis showed that the cost of acquiring a QALY was 29.6 million yuan for the conventional ART strategy (CD4 cells < 350/mm3) and 31.8 million yuan for the early ART strategy (CD4 cells 350/mm3). According to WHO standards, early and conventional ART strategies for HIV/AIDS patients in single-positive families in the survey area are cost-effective. Conclusion: The implementation of early AIDS ART strategy for HIV/AIDS patients in single-positive families not only enlarges the coverage of AIDS ART services, prolongs the life span of HIV/AIDS patients, but also reduces the cost-effectiveness. According to WHO standard, the cost-effectiveness analysis results accord with the cost-benefit principle.
【学位授予单位】：中国疾病预防控制中心
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R512.91
本文编号：2183017
[Abstract]:BACKGROUND: Since 2003, in response to the call of "four exemptions and one care" of the state, anti-retroviral treatment (ART) has been actively promoted and expanded year by year. Objective: To evaluate the quality of life (QOL) of HIV / AIDS patients in single-positive families and the effect of HIV / AIDS ART on their acceptance of AIDS ART by demodulating the quality of life (QOL), AIDS ART and influencing factors of HIV / AIDS patients in single-positive families. The cost, cost-effectiveness and cost-effectiveness of different ART strategies for HIV single-positive families provide the basis for further expanding the strategy of AIDS ART to prevent HIV transmission, and provide scientific basis for decision-making departments to implement and adjust the strategy in accordance with local conditions in the future. The basic characteristics, quality of life, ART direct medical costs and direct non-medical costs of HIV/AIDS patients in single-positive families were collected through on-the-spot questionnaires conducted from January to May 2015 and retrospective analysis of the AIDS epidemic database in the investigated areas. The cumulative survival time, viral load (VL) complete inhibition rate and CD4 + T lymphocyte (CD4 cell) growth rate during the strategy study were used to analyze the cost-effectiveness of different ART strategies. The second part was to construct Markov model and simulate the quality-adjusted life year for HIV/AIDS patients in single-positive families. Results: According to the annual per capita price of direct medical expenses and direct non-medical expenses after ART treatment in the survey area, combined with the local CPI rate of rise and fall in each year, the total cost of ART treatment for 2,271 HIV/AIDS patients in single-positive families in the survey area was estimated to be 30,832 in 2004-2015. The total cost of ART initiation for different CD4 cells was 127.787 million in the group of <200/mm 3, 1047.85million in the group of 201-350/mm 3, 46.8031 million in the group of 351-500/mm 3 and 35.038 million in the group of 500/mm 3, respectively; the annual cost for each group was 21.13 million yuan, 24.2 million yuan, 21.14 million yuan and 19.96 million yuan, respectively. Cost-effectiveness analysis of different ART strategies for HIV/AIDS patients in single-positive families was conducted. The cumulative survival time of different ART strategies was taken as the effect index. The lowest cost-effectiveness ratio was 21.3 million yuan per life year for CD4 cells (< 200 / mm3) strategy, whereas the cost-effectiveness ratio of CD4 cells (< 200 / mm3) strategy was only higher than that of CD4 cells (< 200 / mm3) strategy. Compared with CD4 cells (< 200 / mm3) strategy, the incremental cost-effectiveness ratio (ICER) of CD4 cells (< 500 / mm3) strategy was the smallest. The lowest cost-effectiveness ratio was CD4 cells (< 200 / mm3) strategy 1.2234 million yuan, and the highest cost-effectiveness ratio was CD4 cells (< 500 / mm3) strategy 3.0954 million yuan. Compared with CD4 cells (< 200 / mm3) strategy, CD4 cells (< 500 / mm3) strategy ICER was the smallest, indicating that every additional gain was 1/10. The total inhibition rate of VL by different ART strategies fluctuated, and the cost-effectiveness ratio of CD4 cells less than 200/mm3 strategies was the lowest in each detection period, and that of CD4 cells less than 500/mm3 strategies was only higher than that of CD4 cells less than 200 cells less than that of CD4 cells less than that of CD4 cells less than 200/mm3 strategies. The cost-effectiveness ratio of CD4 cells < 200/mm3 strategy was the lowest in each test period, and the cost-effectiveness ratio of CD4 500/mm3 strategy was the highest in the first year of ART, followed by CD4 fine. Compared with CD4 cell < 200 cell / mm3 strategy, CD4 cell < 350 cell / mm3 strategy ICER is the smallest. To analyze the cost - effectiveness of HIV / AIDS ART strategy in HIV / AIDS single-positive families in the investigation area, the field quality of life survey was carried out, and the results showed that HIV / AIDS in single-positive families in Zhoukou City, Henan Province was in physiology. Scores in physical, psychological, social and environmental fields of AIDS patients in Zhoukou were (15.10 [2.30], (13.89 [1.89], (13.93 [2.06] and (12.14 [2.08], respectively. The scores of HIV/AIDS in physiological, psychological, social and environmental fields were (14.99 2.25), (14.25 2.12), (13.22 2.37), (13.31 1.99). Compared with the norm, the scores of HIV/AIDS in four fields were (14.99 2.25), (14.25 2.12, (13.22 2.37), (13.31 1.99). Except for the The scores in physiological, psychological, social and environmental fields of single-yang families in Zhoukou City were lower than those in physiological, psychological, social and environmental fields of Taizhou City (14.76 + 2.43), 14.07 + 2.16, 13.07 + 2.24 and 13.07 + 1.97). Cost-utility analysis showed that the cost of acquiring a QALY was 29.6 million yuan for the conventional ART strategy (CD4 cells < 350/mm3) and 31.8 million yuan for the early ART strategy (CD4 cells 350/mm3). According to WHO standards, early and conventional ART strategies for HIV/AIDS patients in single-positive families in the survey area are cost-effective. Conclusion: The implementation of early AIDS ART strategy for HIV/AIDS patients in single-positive families not only enlarges the coverage of AIDS ART services, prolongs the life span of HIV/AIDS patients, but also reduces the cost-effectiveness. According to WHO standard, the cost-effectiveness analysis results accord with the cost-benefit principle.
【学位授予单位】：中国疾病预防控制中心
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R512.91
【参考文献】
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1 王倩,金丕焕;Markov模型在卫生经济评价的应用[J];中国卫生统计;2000年02期
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