PLOS ONE2013-11-06 7:05 PM

Elimination of HIV in South Africa through Expanded Access to Antiretroviral Therapy: A Model Comparison Study 通过增加抗逆转录病毒疗法的应用途径消除南非艾滋病的比较研究模型

Abstract Background Expanded access to antiretroviral therapy (ART) using universal test and treat (UTT) has been suggested as a strategy to eliminate HIV in South Africa within 7 y based on an influential mathematical modeling study. However, the underlying deterministic model was criticized widely, and other modeling studies did not always confirm the study's finding. The objective of our study is to better understand the implications of different model structures and assumptions, so as to arrive at the best possible predictions of the long-term impact of UTT and the possibility of elimination of HIV. 背景 经过一个影响重大的数学模型研究,扩大获得抗逆转录病毒疗法(ART),使用通用的测试和治疗(UTT)已被建议作为一项战略在7年内消除南非地区的艾滋病毒。但是,这项起决定作用的模型却广受争议,其他建模研究也曾得出过和该模型研究结论不一致的结果。本研究的目的是为了更好地了解不同的模型结构和假设的情况,希望由此获得UTT的长期影响以及消除HIV的最佳预测。 Methods and Findings We developed nine structurally different mathematical models of the South African HIV epidemic in a stepwise approach of increasing complexity and realism. The simplest model resembles the initial deterministic model, while the most comprehensive model is the stochastic microsimulation model STDSIM, which includes sexual networks and HIV stages with different degrees of infectiousness. We defined UTT as annual screening and immediate ART for all HIV-infected adults, starting at 13% in January 2012 and scaled up to 90% coverage by January 2019. All models predict elimination, yet those that capture more processes underlying the HIV transmission dynamics predict elimination at a later point in time, after 20 to 25 y. Importantly, the most comprehensive model predicts that the current strategy of ART at CD4 count ≤350 cells/µl will also lead to elimination, albeit 10 y later compared to UTT. Still, UTT remains cost-effective, as many additional life-years would be saved. The study's major limitations are that elimination was defined as incidence below 1/1,000 person-years rather than 0% prevalence, and drug resistance was not modeled. 研究方法和结果 针对南非流行的且日渐复杂和严峻的艾滋病现实,我们开发了9个结构不同的数学模型,其中最简单的模型和最初那个决定性模型类似,而最全面的模型是随机微观仿真模型STDSIM,它包括性关系网络和传染程度不同的HIV各阶段。我们规定所有感染HIV病毒的成年人使用UTT做年度筛查,并立即进行抗逆转录病毒疗法,覆盖率从2012年1月开始的13%扩大到2019年1月的90%。所有模型都能对病毒消除的结果做出预测,但那些能够反映更多潜在的HIV传播过程的预测时间上靠后,要20至25年后才有。重要的是,最全面的模型显示,ART目前的战略在CD4细胞计数≤ 350个/μl时最终也能消除病毒,尽管和UTT相比时间上要晚10年。尽管如此,UTT不仅更经济划算,还能节约很多时间。这项研究的主要限制在于,消除病毒的标准是发病率低于1‰/年,而不是0%,耐药性因素也没有算在内。 Conclusions Our results confirm previous predictions that the HIV epidemic in South Africa can be eliminated through universal testing and immediate treatment at 90% coverage. However, more realistic models show that elimination is likely to occur at a much later point in time than the initial model suggested. Also, UTT is a cost-effective intervention, but less cost-effective than previously predicted because the current South African ART treatment policy alone could already drive HIV into elimination. 结论 我们的研究结果证实了先前的预测,南非流行的艾滋病疫情通过广泛的检测和及时的治疗,90%的病毒都可以消除。然而,更现实的模型显示,和初始模型认为的消除时间相比,结果出现地可能会晚一些。此外,UTT应用起来成本较低,但现在的成本和最初相比也要略为高一些,因为目前南非的抗逆转录病毒疗法政策已经可以消除艾滋病毒了。

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