Early antiretroviral therapy for patients with acute aids-related opportunistic infections: a cost-effectiveness analysis of ACTG A5164.
OBJECTIVE
ACTG A5164 demonstrated that early antiretroviral therapy (ART) in HIV-infected patients with acute opportunistic infections (OIs) reduced death and AIDS progression compared to ART initiation 1 month later. We project the life expectancies, costs, and incremental cost-effectiveness ratios (ICERs) of these strategies.


METHODS
using an HIV simulation model, we compared 2 strategies for patients with acute OIs: (1) an intervention to deliver early ART, and (2) deferred ART. Parameters from ACTG A5164 included initial mean CD4 count (47/microL), linkage to outpatient care (87%), and immune reconstitution inflammatory syndrome 1 month after ART initiation (7%). The estimated intervention cost was $1,650/patient.


RESULTS
early ART lowered projected 1-year mortality from 10.4% to 8.2% and increased life expectancy from 10.07 to 10.39 quality-adjusted life-years (QALYs). Lifetime costs increased from $385,220 with deferred ART to $397,500 with early ART, primarily because life expectancy increased, producing an ICER of $38,600/QALY. Results were most sensitive to increased intervention cost and decreased virologic efficacy in the early ART strategy.


CONCLUSIONS
an intervention to initiate ART early in patients with acute OIs improves survival and meets US cost-effectiveness thresholds. Programs should be developed to implement this strategy at sites where HIV-infected patients present with OIs.
Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA. psax@partners.org
Paul E
PE
Sax
Caroline E
CE
Sloan
Bruce R
BR
Schackman
Philip M
PM
Grant
Jian
J
Rong
Andrew R
AR
Zolopa
William
W
Powderly
Elena
E
Losina
Kenneth A
KA
Freedberg
D017088:AIDS-Related Opportunistic Infections / Q000188:drug therapy* / Q000191:economics* / Q000276:immunology / Q000382:microbiology; D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage* / Q000191:economics; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D018450:Disease Progression; D005260:Female; D006678:HIV / Q000302:isolation & purification*; D015658:HIV Infections / Q000188:drug therapy* / Q000191:economics* / Q000276:immunology / Q000382:microbiology; D006801:Humans; D008017:Life Expectancy; D008297:Male; D018803:Models, Economic; D018448:Models, Immunological; D019057:Quality-Adjusted Life Years
D019380:Anti-HIV Agents