Abstract
The new 2010 World Health Organization (WHO) HIV treatment guidelines recommend earlier antiretroviral therapy (ART) initiation (CD4<350 cells/µl instead of CD4<200 cells/µl), multiple sequential ART regimens, and replacement of first-line stavudine with tenofovir. This paper considers what to do first in resource-limited settings where immediate implementation of all of the WHO recommendations is not feasible. We use a mathematical model and local input data to project clinical and economic outcomes in a South African HIV-infected cohort (mean age = 32.8 y, mean CD4 = 375/µl). For the reference strategy, we assume that all patients initiate stavudine-based ART with WHO stage III/IV disease and receive one line of ART (stavudine/WHO/one-line). We rank-in survival, cost-effectiveness, and equity terms-all 12 possible combinations of the following: (1) stavudine replacement with tenofovir, (2) ART initiation (by WHO stage, CD4<200 cells/µl, or CD4<350 cells/µl), and (3) one or two regimens, or lines, of available ART. Projected life expectancy for the reference strategy is 99.0 mo. Considering each of the guideline components separately, 5-y survival is maximized with ART initiation at CD4<350 cells/µl (stavudine/<350/µl/one-line, 87% survival) compared with stavudine/WHO/two-lines (66%) and tenofovir/WHO/one-line (66%). The greatest life expectancies are achieved via the following stepwise programmatic additions: stavudine/<350/µl/one-line (124.3 mo), stavudine/<350/µl/two-lines (177.6 mo), and tenofovir/<350/µl/two-lines (193.6 mo). Three program combinations are economically efficient: stavudine/<350/µl/one-line (cost-effectiveness ratio, US$610/years of life saved [YLS]), tenofovir/<350/µl/one-line (US$1,140/YLS), and tenofovir/<350/µl/two-lines (US$2,370/YLS). In settings where immediate implementation of all of the new WHO treatment guidelines is not feasible, ART initiation at CD4<350 cells/µl provides the greatest short- and long-term survival advantage and is highly cost-effective.
Highlights
The 2006 World Health Organization (WHO) guidelines on antiretroviral therapy (ART) established a worldwide standard of care for patients with human immunodeficiency virus (HIV) infection [1]
New evidence has emerged on how to treat patients infected with HIV, and this evidence formed the basis for the WHO 2010 ART guidelines update [2]
In settings confronted with numerous new recommendations, not all of which are immediately feasible, the relevant policy question is: What to do first? Should countries begin by replacing stavudine with tenofovir or by making CD4 count monitoring universally available? To assist policy makers in this prioritization process, we use a modelbased analysis with data from South Africa to project the clinical and economic outcomes of alternative stepwise implementation scenarios toward the 2010 WHO ART guidelines
Summary
The 2006 World Health Organization (WHO) guidelines on antiretroviral therapy (ART) established a worldwide standard of care for patients with HIV infection [1]. New evidence has emerged on how to treat patients infected with HIV, and this evidence formed the basis for the WHO 2010 ART guidelines update [2] These revisions aim to better align global standards with those already adopted in well-resourced countries [3,4]. The new 2010 World Health Organization (WHO) HIV treatment guidelines recommend earlier antiretroviral therapy (ART) initiation (CD4,350 cells/ml instead of CD4,200 cells/ml), multiple sequential ART regimens, and replacement of first-line stavudine with tenofovir. In resource-rich countries, clinicians care for people with HIV by prescribing ART regimens tailored to each individual’s needs They regularly measure the amount of virus in their patients’ blood, test for antiretroviral-resistant viruses, and monitor the health of their patients’ immune systems through regular CD4 cell counts. The life expectancy of patients with HIV in developed countries has dramatically improved
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