Scaling up the 2010 World Health Organization HIV Treatment Guidelines in resource-limited settings: a model-based analysis |
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Authors: | Walensky Rochelle P Wood Robin Ciaranello Andrea L Paltiel A David Lorenzana Sarah B Anglaret Xavier Stoler Adam W Freedberg Kenneth A;CEPAC-International Investigators |
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Institution: | Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA. rwalensky@partners.org |
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Abstract: | BackgroundThe 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.Methods and FindingsWe 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).ConclusionsIn 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.
Please see later in the article for the Editors'' Summary |
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