Initiation of antiretroviral therapy based on the 2015 WHO guidelines.
In 2015, the WHO recommended initiation of antiretroviral therapy (ART) in all HIV-positive patients regardless of CD4 cell count. We evaluated the cost-effectiveness of immediate versus deferred ART initiation among patients with CD4 cell counts exceeding 500cells/μl in four resource-limited countries (South Africa, Nigeria, Uganda, and India).



A 5-year Markov model with annual cycles, including patients at CD4 cell counts more than 500 cells/μl initiating ART or deferring therapy until historic ART initiation criteria of CD4 cell counts more than 350 cells/μl were met.



The incidence of opportunistic infections, malignancies, cardiovascular disease, unscheduled hospitalizations, and death, were informed by the START trial results. Risk of HIV transmission was obtained from a systematic review. Disability weights were based on published literature. Cost inputs were inflated to 2014 US dollars and based on local sources. Results were expressed in cost per disability-adjusted life years averted and measured against WHO cost-effectiveness thresholds.



Immediate initiation of ART is associated with a cost per disability-adjusted life years averted of -$317 [95% confidence interval (CI): -$796-$817] in South Africa; -$507 (95% CI: -$765-$837) in Nigeria; -$136 (-$382-$459) in Uganda; and -$78 (-$256-$374) in India. The results are largely driven by the impact of ART on reducing the risk of new HIV transmissions.



In HIV-positive patients with CD4 counts above 500 cells/μl in the four studied countries, immediate initiation of ART versus deferred therapy until historic eligibility criteria are met is cost-effective and likely even cost-saving over time.
aHealth Economics and Outcomes Research, Regeneron Pharmaceuticals, Tarrytown, New York, USA bInfectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda cInfectious and Tropical Diseases Unit, College of Health Sciences, Bayero University Kano dDepartment of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria.
Andreas
A
Kuznik
Garba
G
Iliyasu
Abdulrazaq G
AG
Habib
Baba M
BM
Musa
Andrew
A
Kambugu
Mohammed
M
Lamorde
D000328:Adult; D000349:Africa; D044966:Anti-Retroviral Agents / Q000191:economics* / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000191:economics* / Q000379:methods*; D018791:CD4 Lymphocyte Count; D003362:Cost-Benefit Analysis; D005260:Female; D017408:Guidelines as Topic; D015658:HIV Infections / Q000188:drug therapy* / Q000191:economics*; D006801:Humans; D007194:India; D008297:Male; D014944:World Health Organization
D044966:Anti-Retroviral Agents