Abstract
BackgroundUgandan national guidelines recommend initiation of combination antiretroviral therapy (cART) at CD4+ T cell (CD4) count below 350 cell/μl, but the implementation of this is limited due to availability of medication. However, cART initiation at higher CD4 count increases survival, albeit at higher lifetime treatment cost. This analysis evaluates the cost-effectiveness of initiating cART at a CD4 count between 250–350 cell/μl (early) versus <250 cell/μl (delayed).MethodsLife expectancy of cART-treated patients, conditional on baseline CD4 count, was modeled based on published literature. First-line cART costs $192 annually, with an additional $113 for patient monitoring. Delaying initiation of cART until the CD4 count falls below 250 cells/μl would incur the cost of the bi-annual CD4 count tests and routine maintenance care at $85 annually. We compared lifetime treatment costs and disability adjusted life-expectancy between early vs. delayed cART for ten baseline CD4 count ranges from 250-350 cell/μl. All costs and benefits were discounted at 3% annually.ResultsTreatment delay varied from 6–18 months. Early cART initiation increased life expectancy from 1.5-3.5 years and averted 1.33–3.10 disability adjusted life years (DALY’s) per patient. Lifetime treatment costs were $4,300–$5,248 for early initiation and $3,940–$4,435 for delayed initiation. The cost/DALY averted of the early versus delayed start ranged from $260–$270.ConclusionsIn HIV-positive patients presenting with CD4 count between 250-350 cells/μl, immediate initiation of cART is a highly cost-effective strategy using the recommended one-time per capita GDP threshold of $490 reported for Uganda. This would constitute an efficient use of scarce health care funds.
Highlights
Ugandan national guidelines recommend initiation of combination antiretroviral therapy at CD4+ T cell (CD4) count below 350 cell/μl, but the implementation of this is limited due to availability of medication
Despite the evidence of the benefits of early initiation of ART [7,8]in sub-Saharan Africa, where the HIV pandemic is most severe, combination antiretroviral therapy (cART) is usually commenced at later stages of the disease and often after the onset of Acquired Immune Deficiency Syndrome (AIDS) [9] when the risk of death is much higher [10]
Patients who initiated treatment immediately (Scenario A) were assigned a life expectancy [19]; patients who initiated cART after their CD4 count fell below 250 cells/μL (Scenario B) were assigned another lower life expectancy which we defined as the sum of the waiting time plus the life expectancy associated with the lower baseline CD4 count at initiation of therapy [19]
Summary
Ugandan national guidelines recommend initiation of combination antiretroviral therapy (cART) at CD4+ T cell (CD4) count below 350 cell/μl, but the implementation of this is limited due to availability of medication. CART initiation at higher CD4 count increases survival, albeit at higher lifetime treatment cost. This analysis evaluates the cost-effectiveness of initiating cART at a CD4 count between 250–350 cell/μl (early) versus
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