When to start antiretroviral therapy in resource-limited settings.
Ann Intern Med
; 151(3): 157-66, 2009 Aug 04.
Article
em En
| MEDLINE
| ID: mdl-19620143
ABSTRACT
BACKGROUND:
The results of international clinical trials that are assessing when to initiate antiretroviral therapy (ART) will not be available for several years.OBJECTIVE:
To inform HIV treatment decisions about the optimal CD4 threshold at which to initiate ART in South Africa while awaiting the results of these trials.DESIGN:
Cost-effectiveness analysis by using a computer simulation model of HIV disease. DATA SOURCES Published data from randomized trials and observational cohorts in South Africa. TARGET POPULATION HIV-infected patients in South Africa. TIME HORIZON 5-year and lifetime. PERSPECTIVE Modified societal. INTERVENTION No treatment, ART initiated at a CD4 count less than 0.250 x 10(9) cells/L, and ART initiated at a CD4 count less than 0.350 x 10(9) cells/L. OUTCOMEMEASURES:
Morbidity, mortality, life expectancy, medical costs, and cost-effectiveness. RESULTS OF BASE-CASEANALYSIS:
If 10% to 100% of HIV-infected patients are identified and linked to care, a CD4 count threshold for ART initiation of 0.350 x 10(9) cells/L would reduce severe opportunistic diseases by 22,000 to 221,000 and deaths by 25,000 to 253,000 during the next 5 years compared with ART initiation at 0.250 x 10(9) cells/L; cost increases would range from $142 million (10%) to $1.4 billion (100%). Either ART initiation strategy would increase long-term survival by at least 7.9 years, with a mean per-person life expectancy of 3.8 years with no ART and 12.5 years with an initiation threshold of 0.350 x 10(9) cells/L. Compared with an initiation threshold of 0.250 x 10(9) cells/L, a threshold of 0.350 x 10(9) cells/L has an incremental cost-effectiveness ratio of $1200 per year of life saved. RESULTS OF SENSITIVITYANALYSIS:
Initiating ART at a CD4 count less than 0.350 x 10(9) cells/L would remain cost-effective over the next 5 years even if the probability that the trial would demonstrate the superiority of earlier therapy is as low as 17%.LIMITATION:
This model does not consider the possible benefits of initiating ART at a CD4 count greater than 0.350 x 10(9) cells/L or of reduced HIV transmission.CONCLUSION:
Earlier initiation of ART in South Africa will probably reduce morbidity and mortality, improve long-term survival, and be cost-effective. While awaiting trial results, treatment guidelines should be liberalized to allow initiation at CD4 counts less than 0.350 x 10(9) cells/L, earlier than is currently recommended. PRIMARY FUNDING SOURCE National Institute of Allergy and Infectious Diseases and the Doris Duke Charitable Foundation.
Texto completo:
1
Coleções:
01-internacional
Base de dados:
MEDLINE
Assunto principal:
Infecções por HIV
/
Infecções Oportunistas Relacionadas com a AIDS
/
Fármacos Anti-HIV
Tipo de estudo:
Clinical_trials
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Diagnostic_studies
/
Etiology_studies
/
Guideline
/
Incidence_studies
/
Observational_studies
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Prognostic_studies
/
Risk_factors_studies
Limite:
Adult
/
Humans
País/Região como assunto:
Africa
Idioma:
En
Revista:
Ann Intern Med
Ano de publicação:
2009
Tipo de documento:
Article
País de afiliação:
Estados Unidos