減害防治藥癮者愛滋病毒感染的成本效性

Cost-effectiveness of Harm Reduction for Prevention of Human Immunodeficiency Virus Infection in Intravenous Drug Users

朱芳瑩(Fang-Ying Chu)

指導教授 ： 方啟泰

國立臺灣大學/公共衛生學院/流行病學與預防醫學研究所/碩士(2012年)

https://doi.org/10.6342/NTU.2012.01797

摘要

背景
2003年起在台灣的靜脈藥癮注射者中爆發一波人類免疫缺陷病毒感染的流行。台灣為了因應此狀況在2006年開始實施全國減害計畫，感染人類免疫缺陷病毒的靜脈藥癮者數目也隨之急遽下降。不過關於減害計畫的成本效性卻從未被評估過。
目的
1.評估新診斷出感染人類免疫缺陷病毒的靜脈藥癮注射者的平均餘命與生活品質調整平均餘命。
2.評估這些感染人類免疫缺陷病毒的靜脈藥癮注射者與一般健康族群相較之下損失的生活品質調整人年。評估一個感染人類免疫缺陷病毒的靜脈藥癮注射者個案所需要的平均終生可歸因醫療費用。
3.評估台灣減害計畫的成本效性
方法
追蹤資料來自疾病管制局，裡面包含從1984到2010年通報有感染人類免疫缺陷病毒的個案發病時間及存活狀況。本研究使用半母數存活外插方式去推估診斷出人類免疫缺陷病毒後生活品質調整平均餘命與損失的生活品質調整人年。生活品質的資料來自245份於2009-2010年橫斷性收集來的EuroQol-5D (EQ-5D)問卷。減害計畫費用與藥物費用的相關資料則來自疾病管制局公開資料。
結果
診斷出感染人類免疫缺陷病毒後的平均餘命（±標準差）在診斷時即發病的組別與診斷時未發病的組別分別為18.99 ± 4.14和31.16 ± 6.73年。生活品質調整平均餘命在診斷時即發病的組別與診斷時未發病的組別分別為17.09和28.04個生活品質調整人年。在利用兩組人數比例做權重平均之後，生活品質調整平均餘命為27.88個生活品質調整人年，與一般健康族群對照後損失11.88個生活品質調整人年。每一個感染人類免疫缺陷病毒的靜脈藥癮注射者個案所需的終生可歸因醫療費用為新台幣$3,713,279元。最保守估計下，每增加一個生活品質調整人年的成本效益增量比率為新台幣$173,161元（美金$5,791元，每新台幣$29.90元兌換一美元）。最樂觀估計下，每投資一元可節省1.2-8.4元。
結論
台灣實施的減害計畫是一個具有高度成本效性的公共衛生介入措施，在最樂觀的情境下甚至可以節省費用，所以我們支持繼續實施減害計畫以控制靜脈注射藥癮者中愛滋病毒感染疫情。

關鍵字

成本效性 ； 靜脈注射藥癮者 ； 人類免疫缺陷病毒 ； 存活外插 ； EQ-5D ； iSQoL ； 減害

並列摘要

Background
Taiwan has experienced a large human immunodeficiency virus (HIV) outbreak among intravenous drug users (IDUs) since 2003. In response, the Taiwanese government launched a national harm reduction program in 2006, which was followed by a rapid decline in new IDU-HIV cases. Nevertheless, the cost-effectiveness of harm reduction programs has not yet been evaluated.
Objectives
1. To estimate the life expectancy (LE) and quality-adjusted life expectancy (QALE) of newly diagnosed HIV-infected IDUs
2. To estimate the quality-adjusted life year (QALY) losses of HIV-infected IDUs and the mean lifetime attributable medical expenditure per new IDU-HIV case
3. To evaluate the cost-effectiveness of the harm reduction program in Taiwan
Methods
The follow-up data from all HIV-infected patients from 1984 to 2010 were obtained from the Taiwan Centers for Disease Control (CDC) (Taipei, Taiwan). We used a semi-parametric survival extrapolation method to estimate QALE and QALY loss. The data on the quality of life of IDU-HIV patients were obtained from a cross-sectional survey of 245 IDU-HIV patients using the EuroQol-5D (EQ-5D) questionnaire during 2009-2010. Information on the cost of the harm reduction program and the cost of medicine expenditure was obtained from the CDC.
Results
The life expectancy (±SE) after a diagnosis of HIV was 18.99 ± 4.14 years and 31.16 ± 6.73 years in the initially acquired immunodeficiency syndrome (AIDS) group and the non-AIDS group, respectively. The QALE after a diagnosis of HIV was 17.09 and 28.04 QALYs in the AIDS group and the non-AIDS group, respectively. The QALE was 27.88 QALYs and the QALY loss was 11.88 (QALYs) after weighting according to the numbers of people in both groups. The lifetime attributable medical expenditure was NT$3,713,279 per new IDU-HIV case. Under the most conservative estimation, the incremental cost-effectiveness ratio (ICER) was NT$173,161 (US$5,791 at an exchange rate of 29.90 NT$/US$) per QALY gained. Under the most optimistic estimation, the harm reduction program could save 1.2-8.4 dollar per one dollar of investment.
Conclusion
The national harm reduction program in Taiwan is a highly cost-effective public health intervention and would be cost-saving under the most optimistic estimation. Therefore, we endorse the continuation of the harm reduction policy to control the spread of HIV infection in IDUs.

並列關鍵字

cost-effectiveness ； intravenous drug users ； human immunodeficiency virus ； survival extrapolation ； EQ-5D ； iSQoL ； harm reduction

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