Cost-Effectiveness of HIV Monitoring Strategies in Resource-Limited Settings
October 7, 2008
"Although the number of persons receiving highly active antiretroviral therapy (HAART) in low- and middle-income countries has increased dramatically, optimal disease management is not well-defined," wrote the authors of the current study.
A model was developed to compare the costs and benefits of three types of HIV monitoring strategies: symptom-based strategies, CD4-based strategies, and CD4 counts plus viral load strategies for initiating, switching and stopping HAART. A cost-effectiveness analysis was performed using clinical and cost data from southern Africa. All assumptions were tested in sensitivity analyses.
Compared with the symptom-based approaches, monitoring CD4 counts at six month intervals and initiating treatment at a threshold of 200/µL was associated with a gain in life expectancy of 6.5 months (61.9 months vs. 68.4 months) and a discounted lifetime cost savings of $464 per person ($4,069 vs. $3,605, discounted 2007 US dollars). CD4-based strategies that started treatment at the higher threshold of 350/µL provided an additional gain in life expectancy of 5.3 months at a cost-effectiveness of $107 per life-year gained compared with a threshold of 200/µL. Monitoring viral load with CD4 was more costly than monitoring CD4 counts alone, added 2.0 months of life, and had an incremental cost-effectiveness ratio of $5,414 per life-year gained relative to monitoring of CD4 counts. Sensitivity analyses showed the cost savings from CD4 count monitoring, compared with the symptom-based approaches, was sensitive to cost of inpatient care, and the cost-effectiveness of viral load monitoring was influenced by the per test costs and rates of virologic failure.
"Use of CD4 monitoring and early initiation of HAART in southern Africa provides large health benefits relative to symptom-based approaches for HAART management," the authors concluded. "In southern African countries with relatively high costs of hospitalization, CD4 monitoring would likely reduce total health care expenditures. The cost-effectiveness of viral load monitoring depends on test prices and rates of virologic failure."
Archives of Internal Medicine
09.22.2008; Eran Bendavid, M.D.; Sean D. Young, M.S.; David A. Katzenstein, M.D.; Ahmed M. Bayoumi, M.D., M.Sc.; Gillian D. Sanders, Ph.D.; Douglas K. Owens, M.D., M.S.