Wednesday, 28th of September 2011 |
Full text is at http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001095
Serena P. Koenig1, Heejung Bang2, Patrice Severe3, Marc Antoine Jean Juste3, Alex Ambroise3, Alison
Edwards2, Jessica Hippolyte3, Daniel W. Fitzgerald4, Jolion McGreevy3, Cynthia Riviere3, Serge
Marcelin3, Rode Secours3, Warren D. Johnson4, Jean W. Pape3,4, Bruce R. Schackman2*
1 Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America, 2 Department of Public Health, Weill Cornell Medical
College, New York, New York, United States of America, 3 Groupe Haitien d’Etude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO), Port au Prince, Haiti,
4 Department of Medicine, Weill Cornell Medical College, New York, New York, United States of America
Abstract
Background: In a randomized clinical trial of early versus standard antiretroviral therapy (ART) in HIV-infected adults with a CD4 cell count between 200 and 350 cells/mm3 in Haiti, early ART decreased mortality by 75%. We assessed the costeffectiveness
of early versus standard ART in this trial.
Methods and Findings: Trial data included use of ART and other medications, laboratory tests, outpatient visits, radiographic studies, procedures, and hospital services. Medication, laboratory, radiograph, labor, and overhead costs were from the study clinic, and hospital and procedure costs were from local providers. We evaluated cost per year of life saved (YLS), including patient and caregiver costs, with a median of 21 months and maximum of 36 months of follow-up, and with costs and life expectancy discounted at 3% per annum. Between 2005 and 2008, 816 participants were enrolled and followed for a median of 21 months. Mean total costs per patient during the trial were US$1,381 for early ART and US$1,033 for standard ART. After excluding research-related laboratory tests without clinical benefit, costs were US$1,158 (early ART) and US$979 (standard ART). Early ART patients had higher mean costs for ART (US$398 versus US$81) but lower costs for non-ART medications, CD4 cell counts, clinically indicated tests, and radiographs (US$275 versus US$384). The costeffectiveness ratio after a maximum of 3 years for early versus standard ART was US$3,975/YLS (95% CI US$2,129/YLS–US$9,979/YLS) including research-related tests, and US$2,050/YLS excluding research-related tests (95% CI US$722/YLS–
US$5,537/YLS).
Conclusions: Initiating ART in HIV-infected adults with a CD4 cell count between 200 and 350 cells/mm3 in Haiti, consistent with World Health Organization advice, was cost-effective (US$/YLS ,3 times gross domestic product per capita) after a maximum of 3 years, after excluding research-related laboratory tests.
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