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Abstract
Cost-effectiveness of initiating and monitoring HAART based on WHO versus US DHHS guidelines in the developing world
A. Vijayaraghavan1, M. Efrusy1, P. Mazonson1, O. Ebrahim2, I. Sanne3, C. Santas1, G. Sanders4
1Mosaic Health Care Consultants, Larkspur, United States, 2Brenthurst Clinic, HIV/Clinical Pharmacology & Therapeutics, Johannesburg, South Africa, 3University of the Witwatersrand, Clinical HIV Research Unit, Johannesburg, South Africa, 4Duke University, Duke Clinical Research Institute, Durham, United States
Background: World Heath Organization (WHO) 3 by 5 guidelines recommend initiating HIV treatment fairly late in the disease process. No studies have compared the cost-effectiveness of this strategy to more inclusive developed world guidelines.
Methods: We developed a lifetime Markov model of costs (direct and indirect), quality of life, survival, and transmission to sexual contacts, associated with treating HIV patients according to US Department of Health and Human Services (US DHHS) guidelines (initiate treatment at CD4<350 or viral load>100,000 and monitor with CD4 counts and viral load every three months) versus WHO 3 by 5 guidelines (initiate treatment at CD4<200 or for patients with AIDS and monitor using CD4 counts every 6 months). Costs and prevalence data came from South Africa.
Results: Treating HIV patients according to US DHHS versus WHO guidelines increased life expectancy by 2.09 quality-adjusted life years (QALYs), at an estimated lifetime direct cost of US$10,323 per patient, for an incremental cost-effectiveness ratio (ICER) of $4,939 per QALY. Incorporating the costs and benefits of transmission lowered the ICER to $3,869 per QALY, while including indirect costs (without transmission) lowered the ICER further to $1,305 per QALY. Results were sensitive to the cost of second-line HAART regimens and rates of transmission to sexual contacts.
Conclusions: Including the effects on decreased transmission, treating HIV patients in some developing world countries according to US versus WHO guidelines is highly cost effective, at 79% of South African per capita GDP. Adding indirect costs (without transmission) makes implementing US DHHS guidelines even more cost-effective at 27% of South African GDP. Over a five-year period, treating all HIV patients in South Africa according to US DHHS versus WHO guidelines would increase direct medical costs by US$14.5 billion but would result in approximately 400,000 fewer deaths and 1.1 million fewer new AIDS cases.
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