title: Cost-Effectiveness of Initiating Antiretroviral Therapy at Different Points in TB Treatment in HIV-TB Coinfected Ambulatory Patients in South Africa.
abstract: OBJECTIVE
  Initiation of antiretroviral therapy (ART) during tuberculosis (TB) treatment improves survival in TB-HIV coinfected patients. In patients with CD4 counts <50 cells per cubic millimeter, there is a substantial clinical and survival benefit of early ART initiation. The purpose of this study was to assess the costs and cost-effectiveness of starting ART at various time points during TB treatment in patients with CD4 counts ≥50 cells per cubic millimeter.
  
  
  METHODS
  In the SAPiT trial, 642 HIV-TB coinfected patients were randomized to 3 arms: receiving ART within 4 weeks of starting TB treatment (early treatment arm; Arm-1), after the intensive phase of TB treatment (late treatment arm; Arm-2), or after completing TB treatment (sequential arm; Arm-3). Direct health care costs were measured from a provider perspective using a micro-costing approach. The incremental cost per death averted was calculated using the trial outcomes.
  
  
  RESULTS
  For patients with CD4 count ≥50 cells per cubic millimeter, median monthly variable costs per patient were US $116, US $113, and US $102 in Arm-1, Arm-2 and Arm-3, respectively. There were 12 deaths in 177 patients in Arm-1, 8 deaths in 180 patients in the Arm-2, and 19 deaths in 172 patients in Arm-3. Although the costs were lower in Arm-3, it had a substantially higher mortality rate. The incremental cost per death averted associated with moving from Arm-3 to Arm-2 was US $4199. There was no difference in mortality between Arm-1 and Arm-2, but Arm-1 was slightly more expensive.
  
  
  CONCLUSIONS
  Initiation of ART after the completion of the intensive phase of TB treatment is cost-effective for patients with CD4 counts ≥50 cells per cubic millimeter.
authors.affiliation: *Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa; †Health Economics and HIV & AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa; ‡Biostatistics Unit, Medical Research Council, Durban, South Africa; §Discipline of Pharmaceutical Sciences, University of KwaZulu-Natal, Durban, South Africa; and ‖Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY.
authors.forename: Kogieleum
authors.initials: K
authors.lastname: Naidoo
authors.forename: Anneke C
authors.initials: AC
authors.lastname: Grobler
authors.forename: Nicola
authors.initials: N
authors.lastname: Deghaye
authors.forename: Tarylee
authors.initials: T
authors.lastname: Reddy
authors.forename: Santhanalakshmi
authors.initials: S
authors.lastname: Gengiah
authors.forename: Andrew
authors.initials: A
authors.lastname: Gray
authors.forename: Salim
authors.initials: S
authors.lastname: Abdool Karim
mesh_terms: D019380:Anti-HIV Agents / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use*; D000995:Antitubercular Agents / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D004334:Drug Administration Schedule; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy / Q000191:economics* / Q000453:epidemiology; D017048:Health Care Costs; D006801:Humans; D013019:South Africa / Q000453:epidemiology; D014376:Tuberculosis / Q000150:complications* / Q000188:drug therapy / Q000191:economics* / Q000453:epidemiology
chemical_list: D019380:Anti-HIV Agents; D000995:Antitubercular Agents