Optimal frequency of CD4 cell count and HIV RNA monitoring prior to initiation of antiretroviral therapy in HIV-infected patients.
BACKGROUND
Guidelines regarding the frequency of CD4 cell count and HIV RNA monitoring in HIV-infected patients vary, with recommended strategies ranging from every 2 to every 6 months.


OBJECTIVE
To determine optimal CD4 cell count and HIV RNA monitoring frequency in HIV-infected patients prior to antiretroviral therapy initiation.


METHODS
Cost-effectiveness (CE) analysis using an HIV simulation model incorporating CD4 cell count and HIV RNA as immunological and virological predictors of clinical outcomes.


METHODS
Hypothetical clinical setting.


METHODS
Simulated cohort based on initial clinical presentation of HIV-infected patients in the US.


METHODS
CD4 cell count and HIV RNA monitoring at frequencies ranging from every 2 to 24 months prior to antiretroviral initiation, as well as accelerated monitoring frequencies as CD4 cell counts approach a specified treatment threshold.


METHODS
Life expectancy, quality-adjusted life expectancy and costs.


RESULTS
For patients presenting with median CD4 cell count 546/mm3 and median HIV RNA 4.8 log10 copies/ml, incremental CE ratios ranged from US$37800/quality-adjusted life year (QALY) gained for a constant testing frequency of every 18 months compared with every 24 months, to US$303300/QALY gained for a constant testing frequency of every 2 months compared with every 4 months when starting treatment at a CD4 cell count of 350/mm3. Monitoring every 12 months until a warning CD4 cell count threshold of 450/mm3 followed by every 3 months until 350/mm3 had an incremental CE ratio of US$74700/QALY gained. When starting antiretroviral therapy at CD4 cell count 200/mm3, monitoring every 12 months until 300/mm3 followed by every 2 months until treatment initiation yielded an incremental CE ratio of US$52200/QALY gained compared with the next best strategy. Increasing monitoring frequency as CD4 cell counts approached a treatment threshold yielded greater incremental clinical benefit for less cost than strategies using a constant frequency.


CONCLUSIONS
Monitoring HIV-infected patients every 12 months until 100 CD4 cells/mm3 prior to a specified treatment threshold followed by more frequent monitoring every 2 or 3 months until antiretroviral therapy initiation is both more effective and cost-effective than the current standard of care.
Kimmel
April D
AD
Division of General Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA. akimmel@partners.org
Goldie
Sue J
SJ
Walensky
Rochelle P
RP
Losina
Elena
E
Weinstein
Milton C
MC
Paltiel
A David
AD
Zhang
Hong
H
Freedberg
Kenneth A
KA
D019380:Anti-HIV Agents / Q000627:therapeutic use; D018791:CD4 Lymphocyte Count / Q000191:economics; D015331:Cohort Studies; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D015658:HIV Infections / Q000188:drug therapy / Q000191:economics / Q000276:immunology* / Q000821:virology*; D006801:Humans; D008954:Models, Biological; D018803:Models, Economic; D017063:Outcome Assessment, Health Care; D012367:RNA, Viral / Q000097:blood*; D012680:Sensitivity and Specificity; D013997:Time Factors; D014773:Virology / Q000191:economics / Q000379:methods
D019380:Anti-HIV Agents; D012367:RNA, Viral