title: The cost effectiveness of antiretroviral treatment strategies in resource-limited settings.
abstract: BACKGROUND
  Optimal resource allocation for antiretroviral treatment (ART) in developing countries requires assessment of different strategies for drug treatment and laboratory monitoring.
  
  
  OBJECTIVE
  To compare costs and outcomes for 10 000 simulated HIV-infected patients followed every 6 months for 10 years in a limited-resource setting.
  
  
  METHODS
  Five nested strategies, with and without the availability of a second-line treatment regimen, were simulated: (a) no ART (NO ART); (b) with ART but without any laboratory markers of HIV other than positive serology (ART ONLY); (c) ART plus total lymphocyte count (TLC); (d) ART plus CD4 cell counts (CD4); and (e) ART plus CD4 cell count plus viral load measurement (VL). Baseline prices of CD4 cell count and viral load measurements were $5.00 and $25.00 per test, respectively.
  
  
  RESULTS
  With no second-line treatment available, treating 10 000 patients with ART ONLY compared with NO ART would cost $14.49 million [95% confidence interval (CI), 14.45-14.52] and would generate an additional 23 060 quality-adjusted life years (QALYS) (95% CI, 22 770-23 360) for a median incremental cost effectiveness ratio (ICER) of $628/QALY. Median ICER values per QALY for CD4 and VL strategies are $238 and $16 139, respectively, when second-line treatment is unavailable. With second-line ART available, the corresponding median ICER values are $8636, and $14 670.
  
  
  CONCLUSIONS
  In the absence of second-line ART, the CD4 strategy is a more cost-effective laboratory testing strategy for managing HIV infection than either TLC or VL. Availability of second-line ART plus CD4 cell count and/or viral load measurement would save additional lives, but at high incremental cost.
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA.
authors.forename: David
authors.initials: D
authors.lastname: Bishai
authors.forename: Arantxa
authors.initials: A
authors.lastname: Colchero
authors.forename: David T
authors.initials: DT
authors.lastname: Durack
mesh_terms: D000465:Algorithms; D044966:Anti-Retroviral Agents / Q000191:economics / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D003198:Computer Simulation; D003362:Cost-Benefit Analysis / Q000379:methods; D003906:Developing Countries; D015658:HIV Infections / Q000188:drug therapy* / Q000191:economics; D017048:Health Care Costs; D006801:Humans; D018655:Lymphocyte Count; D019057:Quality-Adjusted Life Years; D019562:Viral Load
chemical_list: D044966:Anti-Retroviral Agents