title: Primary prophylaxis for Pneumocystis carinii pneumonia in HIV-infected people with CD4 counts below 200/mm3: a cost-effectiveness analysis.
abstract: We developed a decision-analytic model to assess the effectiveness and costs of dapsone, trimethoprim-sulfamethoxazole, or aerosolized pentamidine as initial prophylaxis for Pneumocystis carinii pneumonia in human immunodeficiency virus-infected people without prior symptoms AIDS and with CD4 counts less than 200/mm3. Each strategy increased life expectancy by about 18% compared with no prophylaxis; annual per-person costs were $440, $700, and $1,680 for dapsone, trimethoprim-sulfamethoxazole, and aerosolized pentamidine, respectively. These cost differences make a strategy beginning with dapsone most cost effective, with an incremental cost-effectiveness ratio of $13,400 per life year saved compared with no prophylaxis. Aerosolized pentamidine was substantially less cost effective, but the incremental cost effectiveness ratios were highly dependent on estimates for quality of life, efficacy, toxicity, and compliance. We conclude that, based on currently available data, initial prophylaxis with either dapsone or trimethoprim-sulfamethoxazole is most cost effective. For every 100,000 people treated, starting prophylaxis with trimethoprim-sulfamethoxazole or dapsone--with crossover to aerosolized pentamidine if oral therapy is not tolerated--may save between $98 million and $124 million per year.
authors.affiliation: Department of Medicine, Boston City Hospital, Boston University School of Medicine, MA 02118.
authors.forename: K A
authors.initials: KA
authors.lastname: Freedberg
authors.forename: A N
authors.initials: AN
authors.lastname: Tosteson
authors.forename: C J
authors.initials: CJ
authors.lastname: Cohen
authors.forename: D J
authors.initials: DJ
authors.lastname: Cotton
mesh_terms: D000163:Acquired Immunodeficiency Syndrome / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy; D000336:Aerosols; D000998:Antiviral Agents / Q000627:therapeutic use*; D015496:CD4-Positive T-Lymphocytes / Q000187:drug effects / Q000382:microbiology*; D003362:Cost-Benefit Analysis; D003622:Dapsone / Q000627:therapeutic use; D004361:Drug Tolerance; D006291:Health Policy / Q000191:economics; D006801:Humans; D007958:Leukocyte Count; D008017:Life Expectancy; D008954:Models, Biological; D010349:Patient Compliance; D010419:Pentamidine / Q000627:therapeutic use; D011020:Pneumonia, Pneumocystis / Q000175:diagnosis / Q000188:drug therapy / Q000517:prevention & control*; D011788:Quality of Life; D012680:Sensitivity and Specificity; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000627:therapeutic use
chemical_list: D000336:Aerosols; D000998:Antiviral Agents; D010419:Pentamidine; D015662:Trimethoprim, Sulfamethoxazole Drug Combination; D003622:Dapsone