title: Cost-effectiveness of routine and low-cost CD4 T-cell count compared with WHO clinical staging of HIV to guide initiation of antiretroviral therapy in resource-limited settings.
abstract: BACKGROUND
  HIV is a major cause of disease and death in sub-Saharan Africa. Provision and scale-up of antiretroviral therapy (ART) in resource-limited settings is feasible and cost-effective. Initiation of ART is guided by WHO stage or CD4 cell count; the latter may not be available and up to 70% of eligible individuals are not identified. Low-cost CD4 cell count tests are comparable to conventional methods. We compared the direct healthcare costs and benefits using routine and low-cost CD4 cell count versus WHO staging to initiate ART.
  
  
  METHODS
  Using a Markov state transition model, we incorporated costs, survival and quality of life. We compared the direct healthcare costs and benefits in quality-adjusted life years gained using routine and low-cost CD4 cell count versus WHO staging to initiate ART. We estimated an incremental cost-effectiveness ratio in US$ per quality-adjusted life year gained and compared with threshold of gross domestic product per capita. Uncertainty was assessed by sensitivity analysis.
  
  
  RESULTS
  Routine and low-cost CD4 cell counts compared to WHO staging to guide initiation of ART improved quantity and quality of life and appears to be very cost-effective. The base case estimated an incremental cost-effectiveness ratio of US$939 and US$85 per quality-adjusted life years gained, respectively, and well below the cost effectiveness thresholds of gross domestic product per capita.
  
  
  CONCLUSIONS
  Routine or low-cost CD4 cell count compared to WHO staging, to guide initiation of ART, is a very cost-effective intervention for sub-Saharan Africa and should be an integral part of the scale-up of ART programs.
authors.affiliation: Department of Infectious Diseases, Barwon Health, Geelong, Australia. Eugene@barwonhealth.org.au
authors.forename: Eugene
authors.initials: E
authors.lastname: Athan
authors.forename: Daniel P
authors.initials: DP
authors.lastname: O'Brien
authors.forename: Rosa
authors.initials: R
authors.lastname: Legood
mesh_terms: D017954:Africa South of the Sahara / Q000453:epidemiology; D018791:CD4 Lymphocyte Count / Q000191:economics*; D003362:Cost-Benefit Analysis; D003695:Delivery of Health Care / Q000191:economics* / Q000706:statistics & numerical data; D004334:Drug Administration Schedule; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000191:economics* / Q000453:epidemiology; D006801:Humans; D008297:Male; D008390:Markov Chains; D011336:Probability; D019057:Quality-Adjusted Life Years