削减南非总统艾滋病紧急救援计划所带来的潜在临床和经济影响：一项建模分析。

Potential Clinical and Economic Impacts of Cutbacks in the President's Emergency Plan for AIDS Relief Program in South Africa : A Modeling Analysis.

作者信息

Gandhi Aditya R, Bekker Linda-Gail, Paltiel A David, Hyle Emily P, Ciaranello Andrea L, Pillay Yogan, Freedberg Kenneth A, Neilan Anne M

机构信息

Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, and Department of Medicine, NYU Grossman School of Medicine, New York, New York (A.R.G.).

Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa (L.G.B.).

出版信息

Ann Intern Med. 2025 Apr;178(4):457-467. doi: 10.7326/ANNALS-24-01104. Epub 2025 Feb 11.

BACKGROUND

Future U.S. congressional funding for the President's Emergency Plan for AIDS Relief (PEPFAR) program is uncertain.

OBJECTIVE

To evaluate the clinical and economic impacts of abruptly scaling back PEPFAR funding ($460 million) from South Africa's total HIV budget ($2.56 billion) in 2024.

DESIGN

Model-based analysis of 100%, 50%, and 0% PEPFAR funding with proportional decreases in HIV diagnosis rates (26.0, 24.3, 22.6 per 100 person-years [PY]), 1-year treatment engagement (people with HIV [PWH] receiving/initiating antiretroviral therapy: 92.2%/80.4%, 87.1%/76.0%, 82.0%/71.5%), and primary prevention (4.0%, 2.2%, 0.5% reduction in incidence with no programming [1.24 per 100 PY]).

DATA SOURCES

Published HIV care continuum; PEPFAR funding estimates.

TARGET POPULATION

South African adults (HIV prevalence, 16.2%; incidence, 0.32 per 100 PY).

TIME HORIZON

Lifetime.

PERSPECTIVE

Health care sector.

INTERVENTION

PEPFAR funded 100% (PEPFAR_100%), 50% (PEPFAR_50%), or 0% (PEPFAR_0%).

OUTCOME MEASURES

HIV infections, life expectancy, and lifetime costs (2023 U.S. dollars).

RESULTS OF BASE-CASE ANALYSIS: With current HIV programming (PEPFAR_100%), 1 190 000 new infections are projected over 10 years; life expectancy would be 61.42 years for PWH, with lifetime costs of $11 180 per PWH. Reduced PEPFAR funding (PEPFAR_50% and PEPFAR_0%) would add 286 000 and 565 000 new infections, respectively. PWH would lose 2.02 and 3.71 life-years with nominal lifetime cost reductions of $620 per PWH and $1140 per PWH that would be offset at the population level by more PWH requiring treatment for infection.

RESULTS OF SENSITIVITY ANALYSIS

Countries with similar HIV prevalence and greater reliance on PEPFAR funding could experience disproportionately higher incremental infections and survival losses.

LIMITATION

Budget fungibility and exact programmatic implications of reducing PEPFAR funding are unknown.

CONCLUSION

Abrupt PEPFAR cutbacks would have immediate and long-term detrimental effects on epidemiologic and clinical HIV outcomes in South Africa.

PRIMARY FUNDING SOURCE

National Institutes of Health.

背景

美国国会未来对总统艾滋病紧急救援计划（PEPFAR）项目的资金投入尚不确定。

目的

评估2024年将南非艾滋病毒总预算（25.6亿美元）中的PEPFAR资金（4.6亿美元）突然削减所产生的临床和经济影响。

设计

基于模型的分析，分别设定PEPFAR资金投入为100%、50%和0%，同时按比例降低艾滋病毒诊断率（每100人年分别为26.0、24.3、22.6例）、1年治疗参与率（艾滋病毒感染者接受/开始抗逆转录病毒治疗的比例：92.2%/80.4%、87.1%/76.0%、82.0%/71.5%）以及一级预防效果（发病率分别降低4.0%、2.2%、0.5%，无相关项目时发病率为每100人年1.24例）。

数据来源

已发表的艾滋病毒治疗连续过程数据；PEPFAR资金估计数。

目标人群

南非成年人（艾滋病毒感染率为16.2%；发病率为每100人年0.32例）。

时间范围

终生。

视角

卫生保健部门。

干预措施

PEPFAR资金投入100%（PEPFAR_100%）、50%（PEPFAR_50%）或0%（PEPFAR_0%）。

结局指标

艾滋病毒感染数、预期寿命和终生成本（2023年美元）。

基础病例分析结果

按照当前的艾滋病毒防治方案（PEPFAR_100%），预计10年内将有119万例新感染病例；艾滋病毒感染者的预期寿命为61.42岁，每位感染者的终生成本为11180美元。PEPFAR资金削减（PEPFAR_50%和PEPFAR_0%）将分别新增28.6万例和56.5万例感染病例。艾滋病毒感染者将分别损失2.02年和3.71年的预期寿命，每位感染者的终生成本名义上分别降低了620美元和1140美元，但在人群层面，更多感染者需要接受感染治疗将抵消这一成本降低。

敏感性分析结果

艾滋病毒感染率相似且对PEPFAR资金依赖程度更高的国家可能会出现不成比例的更高增量感染病例和生存损失。

局限性

预算的可替代性以及削减PEPFAR资金的确切项目影响尚不清楚。

结论

突然削减PEPFAR资金将对南非艾滋病毒的流行病学和临床结局产生即时和长期的不利影响。

主要资金来源

美国国立卫生研究院。