Opportunities for improving the efficiency of paediatric HIV treatment programmes.
OBJECTIVE
To conduct two economic analyses addressing whether to: routinely monitor HIV-infected children on antiretroviral therapy (ART) clinically or with laboratory tests; continue or stop cotrimoxazole prophylaxis when children become stabilized on ART.


METHODS
The ARROW randomized trial investigated alternative strategies to deliver paediatric ART and cotrimoxazole prophylaxis in 1206 Ugandan/Zimbabwean children. Incremental cost-effectiveness and value of implementation analyses were undertaken. Scenario analyses investigated whether laboratory monitoring (CD4 tests for efficacy monitoring; haematology/biochemistry for toxicity) could be tailored and targeted to be delivered cost-effectively. Cotrimoxazole use was examined in malaria-endemic and non-endemic settings.


RESULTS
Using all trial data, clinical monitoring delivered similar health outcomes to routine laboratory monitoring, but at a reduced cost, so was cost-effective. Continuing cotrimoxazole improved health outcomes at reduced costs. Restricting routine CD4 monitoring to after 52 weeks following ART initiation and removing toxicity testing was associated with an incremental cost-effectiveness ratio of $6084 per quality-adjusted life-year (QALY) across all age groups, but was much lower for older children (12+ years at initiation; incremental cost-effectiveness ratio = $769/QALY). Committing resources to improve cotrimoxazole implementation appears cost-effective. A healthcare system that could pay $600/QALY should be willing to spend up to $12.0 per patient-year to ensure continued provision of cotrimoxazole.


CONCLUSIONS
Clinically driven monitoring of ART is cost-effective in most circumstances. Routine laboratory monitoring is generally not cost-effective at current prices, except possibly CD4 testing amongst adolescents initiating ART. Committing resources to ensure continued provision of cotrimoxazole in health facilities is more likely to represent an efficient use of resources.
aCentre for Health Economics, University of York, York, UK bClinical Research Centre, University of Zimbabwe cUniversity of Zimbabwe, College of Health Sciences, Harare, Zimbabwe dJoint Clinical Research Centre, Kampala ePaediatric Infectious Diseases Clinic/Baylor - Uganda, Mulago Hospital, Mulago fMedical Research Council/Uganda Research Unit on AIDS, Uganda Virus Research Institute, Entebbe, Uganda gMedical Research Council (MRC) Clinical Trials Unit at University College London, London, UK.
Paul A
PA
Revill
Simon
S
Walker
Travor
T
Mabugu
Kusum J
KJ
Nathoo
Peter
P
Mugyenyi
Adeodata
A
Kekitinwa
Paula
P
Munderi
Mutsawashe
M
Bwakura-Dangarembizi
Victor
V
Musiime
Sabrina
S
Bakeera-Kitaka
Patricia
P
Nahirya-Ntege
A Sarah
AS
Walker
Mark J
MJ
Sculpher
Diana M
DM
Gibb
D023241:Antiretroviral Therapy, Highly Active / Q000191:economics; D018791:CD4 Lymphocyte Count; D002648:Child; D002675:Child, Preschool; D003362:Cost-Benefit Analysis; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000191:economics; D017048:Health Care Costs; D006801:Humans; D008297:Male; D019057:Quality-Adjusted Life Years; D016896:Treatment Outcome; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000191:economics* / Q000627:therapeutic use*; D014454:Uganda; D015030:Zimbabwe
D015662:Trimethoprim, Sulfamethoxazole Drug Combination