Abstract
Background:The most challenging issue physicians are facing is the appropriate timing of introducing antiretroviral therapy (ART) along with ongoing tuberculosis (TB) therapy in HIV and TB co-infected patients. This study examined the cost-effectiveness of early versus delayed ART initiation in TB patients, infected with HIV (co-infected patients) in a sub-Saharan Africa setting. Methods:A decision analytic model based on previously published and real-world evidence was applied to evaluate clinical and economic outcomes associated with early versus delayed ART in TB and HIV co-infection. Incremental cost-effectiveness ratio (ICER) was calculated with both costs and quality-adjusted life years (QALYs). Different assumptions of treatment benefits and costs were taken to address uncertainties and were tested with sensitivity analyses. Results:In base case analysis, the expected cost of giving early ART to TB patients infected with HIV was $1372, with a QALY gain of 0.68, while the cost of delayed ART was $955, with a QALY gain of 0.62. The ICER shows $6775 per QALYs, which suggests that it is not as cost-effective, since it is greater than 3 x GDP per capita ($5,086) for sub-Saharan Africa willingness to pay (WTP) threshold. At $10,000 WTP, the probability that early ART is cost effective compared to delayed ART is 0.9933. At cost-effectiveness threshold of $5086, the population expected value of perfect information becomes substantial (≈US$5 million), and is likely to exceed the cost of additional investigation. This suggests that further research will be potentially cost-effective. Conclusions:From the perspective of the health-care payer in sub-Saharan Africa, early initiation of ART in HIV and TB co-infection cannot be regarded as cost-effective based on current information. The analysis shows that further research will be worthwhile and potentially cost-effective in resolving uncertainty about whether or not to start ART early in HIV and TB co-infection.
Highlights
Co-infected patients with HIV and tuberculosis (TB) has been a serious concern to healthcare sectors in many countries, commonly countries with resource constrained settings (Blanc et al, 2011; Manosuthi et al, 2012; Sinha et al, 2012)
The expected cost of providing early antiretroviral therapy (ART) to TB patients infected with HIV was $1372, with a quality-adjusted life years (QALYs) gain of 0.68, while the cost of delayed ART was $955, with a QALY gain of 0.62
The results demonstrate that early ART provides a higher QALY value than delayed ART, but with a higher cost
Summary
Co-infected patients with HIV and tuberculosis (TB) has been a serious concern to healthcare sectors in many countries, commonly countries with resource constrained settings (Blanc et al, 2011; Manosuthi et al, 2012; Sinha et al, 2012). Delaying the introduction of ART for co-infected patients, and prescribing antibiotics only to these patients, has been proven to increase the risk of reactivation and reinfection of TB among patients, as a result of the HIV infection (Daley et al, 1992; De Cock et al, 1992; Sinha et al, 2012; Wilkinson & Moore, 1996). This study examined the cost-effectiveness of early versus delayed ART initiation in TB patients, infected with HIV (co-infected patients) in a sub-Saharan Africa setting. Conclusions: From the perspective of the health-care payer in sub-Saharan Africa, early initiation of ART in HIV and TB co-infection cannot be regarded as cost-effective based on current information. The analysis shows that further research will be worthwhile and potentially cost-effective in resolving uncertainty about whether or not to start ART early in HIV and TB co-infection
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