title: Cost-effectiveness of early initiation of first-line combination antiretroviral therapy in Uganda.
abstract: BACKGROUND
  Ugandan national guidelines recommend initiation of combination antiretroviral therapy (cART) at CD4+ T cell (CD4) count below 350 cell/μl, but the implementation of this is limited due to availability of medication. However, cART initiation at higher CD4 count increases survival, albeit at higher lifetime treatment cost. This analysis evaluates the cost-effectiveness of initiating cART at a CD4 count between 250-350 cell/μl (early) versus <250 cell/μl (delayed).
  
  
  METHODS
  Life expectancy of cART-treated patients, conditional on baseline CD4 count, was modeled based on published literature. First-line cART costs $192 annually, with an additional $113 for patient monitoring. Delaying initiation of cART until the CD4 count falls below 250 cells/μl would incur the cost of the bi-annual CD4 count tests and routine maintenance care at $85 annually. We compared lifetime treatment costs and disability adjusted life-expectancy between early vs. delayed cART for ten baseline CD4 count ranges from 250-350 cell/μl. All costs and benefits were discounted at 3% annually.
  
  
  RESULTS
  Treatment delay varied from 6-18 months. Early cART initiation increased life expectancy from 1.5-3.5 years and averted 1.33-3.10 disability adjusted life years (DALY's) per patient. Lifetime treatment costs were $4,300-$5,248 for early initiation and $3,940-$4,435 for delayed initiation. The cost/DALY averted of the early versus delayed start ranged from $260-$270.
  
  
  CONCLUSIONS
  In HIV-positive patients presenting with CD4 count between 250-350 cells/μl, immediate initiation of cART is a highly cost-effective strategy using the recommended one-time per capita GDP threshold of $490 reported for Uganda. This would constitute an efficient use of scarce health care funds.
authors.affiliation: Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda. jsempa@idi.co.ug
authors.forename: Joseph
authors.initials: J
authors.lastname: Sempa
authors.forename: Mark
authors.initials: M
authors.lastname: Ssennono
authors.forename: Andreas
authors.initials: A
authors.lastname: Kuznik
authors.forename: Mohammed
authors.initials: M
authors.lastname: Lamorde
authors.forename: Stefanie
authors.initials: S
authors.lastname: Sowinski
authors.forename: Aggrey
authors.initials: A
authors.lastname: Semeere
authors.forename: Sabine
authors.initials: S
authors.lastname: Hermans
authors.forename: Barbara
authors.initials: B
authors.lastname: Castelnuovo
authors.forename: Yukari C
authors.initials: YC
authors.lastname: Manabe
mesh_terms: D044966:Anti-Retroviral Agents / Q000191:economics / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D003362:Cost-Benefit Analysis; D004359:Drug Therapy, Combination / Q000191:economics*; D042241:Early Diagnosis; D015658:HIV Infections / Q000188:drug therapy / Q000401:mortality; D006801:Humans; D019057:Quality-Adjusted Life Years; D014454:Uganda / Q000453:epidemiology
chemical_list: D044966:Anti-Retroviral Agents