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Ann Intern Med. 2009 Aug 4;151(3):157-66. Epub 2009 Jul 20.

When to start antiretroviral therapy in resource-limited settings.

Author information

  • 1Massachusetts General Hospital, Brigham and Women's Hospital, Harvard University Medical School, Harvard School of Public Health, and Boston University School of Public Health, Boston, Massachusetts 02114, USA.

Abstract

BACKGROUND:

The results of international clinical trials that are assessing when to initiate antiretroviral therapy (ART) will not be available for several years.

OBJECTIVE:

To inform HIV treatment decisions about the optimal CD4 threshold at which to initiate ART in South Africa while awaiting the results of these trials.

DESIGN:

Cost-effectiveness analysis by using a computer simulation model of HIV disease.

DATA SOURCES:

Published data from randomized trials and observational cohorts in South Africa.

TARGET POPULATION:

HIV-infected patients in South Africa.

TIME HORIZON:

5-year and lifetime.

PERSPECTIVE:

Modified societal.

INTERVENTION:

No treatment, ART initiated at a CD4 count less than 0.250 x 10(9) cells/L, and ART initiated at a CD4 count less than 0.350 x 10(9) cells/L.

OUTCOME MEASURES:

Morbidity, mortality, life expectancy, medical costs, and cost-effectiveness.

RESULTS OF BASE-CASE ANALYSIS:

If 10% to 100% of HIV-infected patients are identified and linked to care, a CD4 count threshold for ART initiation of 0.350 x 10(9) cells/L would reduce severe opportunistic diseases by 22,000 to 221,000 and deaths by 25,000 to 253,000 during the next 5 years compared with ART initiation at 0.250 x 10(9) cells/L; cost increases would range from $142 million (10%) to $1.4 billion (100%). Either ART initiation strategy would increase long-term survival by at least 7.9 years, with a mean per-person life expectancy of 3.8 years with no ART and 12.5 years with an initiation threshold of 0.350 x 10(9) cells/L. Compared with an initiation threshold of 0.250 x 10(9) cells/L, a threshold of 0.350 x 10(9) cells/L has an incremental cost-effectiveness ratio of $1200 per year of life saved.

RESULTS OF SENSITIVITY ANALYSIS:

Initiating ART at a CD4 count less than 0.350 x 10(9) cells/L would remain cost-effective over the next 5 years even if the probability that the trial would demonstrate the superiority of earlier therapy is as low as 17%.

LIMITATION:

This model does not consider the possible benefits of initiating ART at a CD4 count greater than 0.350 x 10(9) cells/L or of reduced HIV transmission.

CONCLUSION:

Earlier initiation of ART in South Africa will probably reduce morbidity and mortality, improve long-term survival, and be cost-effective. While awaiting trial results, treatment guidelines should be liberalized to allow initiation at CD4 counts less than 0.350 x 10(9) cells/L, earlier than is currently recommended.

PRIMARY FUNDING SOURCE:

National Institute of Allergy and Infectious Diseases and the Doris Duke Charitable Foundation.

Comment in

PMID:
19620143
[PubMed - indexed for MEDLINE]
PMCID:
PMC3092478
Free PMC Article

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