Antiretroviral switching strategies to treat HIV improve survival and are cost-effective in resource-limited countries
Treatment for HIV/AIDS consists of multiple regimens containing antiretroviral drugs. As a result of increased international funding efforts and marked decreases in the cost of antiretroviral therapy, initial treatment with first-line antiretroviral regimens is now more widely available in resource-limited countries. When these regimens fail, second-line regimens are then selected. However, the availability of laboratory monitoring to guide the selection of these second-line regimens is often limited in these countries. A new study finds that the use of these tests improves survival and can be cost-effective.
Researchers assessed the outcomes and cost-effectiveness of two types of laboratory tests to guide switching to second-line treatment in Côte d'Ivoire. One test monitors CD4 immune system cells, which decrease after treatment failure. Another test measures how much HIV RNA is in the blood, another indication of HIV disease progression after treatment failure. The researchers also looked at the effectiveness of simple clinical monitoring. A computer model was used to project life expectancy and the costs of each of the three approaches to guiding antiretroviral regimen switching strategies.
Several advantages were found for using CD4 cell counts and HIV RNA levels to guide switching to second-line regimens. First, they identified failing first-line regimens earlier. This resulted in shorter times on failing regimens, earlier switching to second-line regimens, and higher CD4 counts at switching. Compared with first-line therapy, second-line therapy increased life expectancy by 24.3 percent with clinical monitoring only. CD4 cell count monitoring increased survival by 46 percent, and HIV RNA monitoring increased survival by 61.3 percent compared with first-line therapy alone.
The incremental cost-effectiveness ratio of switching to second-line therapy compared with first-line therapy based on clinical monitoring alone was $1,670 per year-of-life gained. This figure was $2,120 for twice-a-year CD4 monitoring and from $1,990 to $2,920 for twice-a-year HIV RNA testing, depending on the cost of individual tests (ranging from $25 to $87). The researchers call for more efforts to provide low-cost HIV RNA tests, while at the same time reducing the cost of second-line antiretroviral regimens. The study was supported in part by the Agency for Healthcare Research and Quality (T32 HS00055).
See "Laboratory monitoring to guide switching antiretroviral therapy in resource-limited settings: Clinical benefits and cost-effectiveness," by April D. Kimmel, Ph.D., M.Sc., Milton C. Weinstein, Ph.D., Xavier Anglaret, M.D., Ph.D., and others in the July 1, 2010, Journal of Acquired Immune Deficiency Syndrome 54(3), pp. 258-268.
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