title: Clinical impact and cost-effectiveness of co-trimoxazole prophylaxis in patients with HIV/AIDS in Côte d'Ivoire: a trial-based analysis.
abstract: BACKGROUND
  In 2000, WHO/UNAIDS recommended co-trimoxazole prophylaxis for persons at early stages of HIV infection (WHO stage > or = 2) in sub-Saharan Africa.
  
  
  OBJECTIVE
  To assess the cost-effectiveness of alternative strategies for initiation of co-trimoxazole in Côte d'Ivoire.
  
  
  METHODS
  Cost-effectiveness analysis with an HIV simulation model using clinical and cost data from a randomized trial of co-trimoxazole in HIV-infected adults.
  
  
  METHODS
  The study included HIV-infected patients in Côte d'Ivoire, with median age 33 years. Thirty-four percent were classified as WHO stage 2, 59% as stage 3, and 7% as stage 4. The mean CD4 cell count was 331 x 10(6) cells/l. The interventions were no prophylaxis, clinical criteria-based co-trimoxazole initiation (early: WHO stage > or = 2; late: WHO stage > or = 3), CD4-based co-trimoxazole initiation (< 500, < 200, < 50 x 10(6) CD4 cells/l). The outcome measures were life expectancy, lifetime costs, and incremental cost-effectiveness.
  
  
  RESULTS
  The most effective strategy, initiation of co-trimoxazole prophylaxis at WHO stage > or = 2, increased undiscounted life expectancy by 5.2 months, discounted life expectancy by 4.4 months, and lifetime costs by US dollars 60, compared with no prophylaxis. Delaying prophylaxis initiation until WHO stage >or = 3 was less costly and less effective. All CD4-based strategies were dominated. The incremental cost-effectiveness of early versus late co-trimoxazole prophylaxis initiation was US dollars 200/year of life gained. Results were stable despite wide variations in plausible assumptions about bacterial resistance and the prophylaxis efficacy on co-trimoxazole-resistant strains.
  
  
  CONCLUSIONS
  For HIV-infected adults in Côte d'Ivoire, co-trimoxazole prophylaxis is reasonably cost-effective and most effective if initiated when WHO stage > or = 2. Early co-trimoxazole prophylaxis will prevent complications prior to antiretroviral therapy initiation and should be considered an essential component of care for early HIV in sub-Saharan Africa.
authors.affiliation: Service Universitaire des Maladies Infectieuses et du Voyageur, Centre Hospitalier de Tourcoing, Faculté de Médecine de Lille, France. yyazdan@yahoo.com
authors.forename: Yazdan
authors.initials: Y
authors.lastname: Yazdanpanah
authors.forename: Elena
authors.initials: E
authors.lastname: Losina
authors.forename: Xavier
authors.initials: X
authors.lastname: Anglaret
authors.forename: Sue J
authors.initials: SJ
authors.lastname: Goldie
authors.forename: Rochelle P
authors.initials: RP
authors.lastname: Walensky
authors.forename: Milton C
authors.initials: MC
authors.lastname: Weinstein
authors.forename: Siaka
authors.initials: S
authors.lastname: Toure
authors.forename: Heather E
authors.initials: HE
authors.lastname: Smith
authors.forename: Jonathan E
authors.initials: JE
authors.lastname: Kaplan
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Freedberg
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000191:economics / Q000517:prevention & control*; D000328:Adult; D000890:Anti-Infective Agents / Q000191:economics / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D024882:Drug Resistance, Viral; D005260:Female; D006801:Humans; D007902:Length of Stay; D008017:Life Expectancy; D008297:Male; D012307:Risk Factors; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000191:economics / Q000627:therapeutic use*
chemical_list: D000890:Anti-Infective Agents; D015662:Trimethoprim, Sulfamethoxazole Drug Combination