背景:在晚期HIV患者中进行隐球菌抗原(CrAg)筛查可减少隐球菌性脑膜炎(CM)的病例和死亡。世界卫生组织最近建议将筛查阈值从CD4≤100细胞/μL增加到≤200细胞/μL。CD4≤100个细胞/μL的CrAg筛查具有成本效益;然而,需要评估筛查CD4101-200细胞/µL患者的成本效益.方法:使用具有博茨瓦纳特定成本和临床估计的决策分析模型,我们评估了CD4计数为101-200细胞/µL的个体中的CrAg筛查和治疗。我们估计了全国CM病例和死亡人数以及未经筛查的治疗费用。为了进行筛选,我们对进行的CrAg测试的数量进行了建模,确定的CrAg阳性患者数量,比例从先发制人的氟康唑开始,CM病例和死亡。与未筛查相比,评估了筛查和治疗费用,并节省了每个死亡避免或残疾调整生命年(DALY)的费用。结果:未经筛查,我们估计,CD4101-200细胞/μL的个体每年有142例CM病例和85例死亡,治疗费用为368,982美元。与CrAg筛选,估计进行了33,036次CrAg测试,避免了48例死亡(节省了1,017例DALYs)。虽然CrAg筛查费用额外增加了$155,601,但总体治疗费用下降了$39,600(先发制人和基于医院的CM治疗),净增加116,001美元。与没有筛查相比,在该人群中,CrAg筛查和对CrAg阳性个体的抢先治疗的高覆盖率避免了1例死亡,每节省2440美元和114美元。在敏感性分析中,假设抗逆转录病毒治疗(ART)初治患者比例较高(75%对15%),避免的每次死亡费用为1472美元;节省的每次死亡费用为69美元。结论:对CD4101-200细胞/μL的个体进行CrAg筛查估计具有适度的影响,涉及额外费用,与CD4计数≤100细胞/µL的筛查人群相比,成本效益较低。额外的CrAg筛查费用必须与其他卫生系统优先事项相比较。
Background: Cryptococcal antigen (
CrAg) screening in individuals with advanced HIV reduces cryptococcal meningitis (CM) cases and deaths. The World Health Organization recently recommended increasing screening thresholds from CD4 ≤100 cells/µL to ≤200 cells/µL. CrAg screening at CD4 ≤100 cells/µL is cost-effective; however, the cost-effectiveness of screening patients with CD4 101-200 cells/µL requires evaluation. Methods: Using a decision analytic model with Botswana-specific cost and clinical estimates, we evaluated CrAg screening and treatment among individuals with CD4 counts of 101-200 cells/µL. We estimated the number of CM cases and deaths nationally and treatment costs without screening. For screening we modeled the number of
CrAg tests performed, number of
CrAg-positive patients identified, proportion started on pre-emptive fluconazole, CM cases and deaths. Screening and treatment costs were estimated and cost per death averted or disability-adjusted life year (DALY) saved compared with no screening. Results: Without screening, we estimated 142 CM cases and 85 deaths annually among individuals with CD4 101-200 cells/µL, with treatment costs of $368,982. With
CrAg screening, an estimated 33,036
CrAg tests are performed, and 48 deaths avoided (1,017 DALYs saved). While CrAg screening costs an additional $155,601, overall treatment costs fall by $39,600 (preemptive and hospital-based CM treatment), yielding a net increase of $116,001. Compared to no screening, high coverage of
CrAg screening and pre-emptive treatment for
CrAg-positive individuals in this population avoids one death for $2440 and $114 per DALY saved. In sensitivity analyses assuming a higher proportion of antiretroviral therapy (ART)-naïve patients (75% versus 15%), cost per death averted was $1472; $69 per DALY saved. Conclusions: CrAg screening for individuals with CD4 101-200 cells/µL was estimated to have a modest impact, involve additional costs, and be less cost-effective than screening populations with CD4 counts ≤100 cells/µL. Additional
CrAg screening costs must be considered against other health system priorities.