Cost-effectiveness of HIV treatment in resource-poor settings--the case of Côte d'Ivoire.
BACKGROUND
As antiretroviral therapy is increasingly used in settings with limited resources, key questions about the timing of treatment and use of diagnostic tests to guide clinical decisions must be addressed.


METHODS
We assessed the cost-effectiveness of treatment strategies for a cohort of adults in Côte d'Ivoire who were infected with the human immunodeficiency virus (HIV) (mean age, 33 years; CD4 cell count, 331 per cubic millimeter; HIV RNA level, 5.3 log copies per milliliter). Using a computer-based simulation model that incorporates the CD4 cell count and HIV RNA level as predictors of disease progression, we compared the long-term clinical and economic outcomes associated with no treatment, trimethoprim-sulfamethoxazole prophylaxis alone, antiretroviral therapy alone, and prophylaxis with antiretroviral therapy.


RESULTS
Undiscounted gains in life expectancy ranged from 10.7 months with antiretroviral therapy and prophylaxis initiated on the basis of clinical criteria to 45.9 months with antiretroviral therapy and prophylaxis initiated on the basis of CD4 testing and clinical criteria, as compared with trimethoprim-sulfamethoxazole prophylaxis alone. The incremental cost per year of life gained was 240 dollars (in 2002 U.S. dollars) for prophylaxis alone, 620 dollars for antiretroviral therapy and prophylaxis without CD4 testing, and 1,180 dollars for antiretroviral therapy and prophylaxis with CD4 testing, each compared with the next least expensive strategy. None of the strategies that used antiretroviral therapy alone were as cost-effective as those that also used trimethoprim-sulfamethoxazole prophylaxis. Life expectancy was increased by 30% with use of a second line of antiretroviral therapy after failure of the first-line regimen.


CONCLUSIONS
A strategy of trimethoprim-sulfamethoxazole prophylaxis and antiretroviral therapy, with the use of clinical criteria alone or in combination with CD4 testing to guide the timing of treatment, is an economically attractive health investment in settings with limited resources.
Goldie
Sue J
SJ
Department of Health Policy and Management, Program in Health Decision Science, Harvard School of Public Health, Boston, MA 02115, USA. sue_goldie@harvard.edu
Yazdanpanah
Yazdan
Y
Losina
Elena
E
Weinstein
Milton C
MC
Anglaret
Xavier
X
Walensky
Rochelle P
RP
Hsu
Heather E
HE
Kimmel
April
A
Holmes
Charles
C
Kaplan
Jonathan E
JE
Freedberg
Kenneth A
KA
D000328:Adult; D000890:Anti-Infective Agents / Q000191:economics* / Q000627:therapeutic use; D044966:Anti-Retroviral Agents / Q000191:economics* / Q000627:therapeutic use; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D007560:Cote d'Ivoire; D004180:Direct Service Costs / Q000706:statistics & numerical data; D018450:Disease Progression; D016527:Drug Costs / Q000706:statistics & numerical data; D006678:HIV / Q000235:genetics / Q000302:isolation & purification; D015658:HIV Infections / Q000188:drug therapy / Q000191:economics*; D006295:Health Resources; D006801:Humans; D008017:Life Expectancy; D008954:Models, Biological; D009010:Monte Carlo Method; D012367:RNA, Viral / Q000097:blood; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000191:economics* / Q000627:therapeutic use
D000890:Anti-Infective Agents; D044966:Anti-Retroviral Agents; D012367:RNA, Viral; D015662:Trimethoprim, Sulfamethoxazole Drug Combination