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Cost-effectiveness Implications of the Timing of Antiretroviral Therapy in HIV-Infected Adults
Bruce R. Schackman, PhD;
Kenneth A. Freedberg, MD,MSc;
Milton C. Weinstein, PhD;
Paul E. Sax, MD;
Elena Losina, PhD;
Hong Zhang, SM;
Sue J. Goldie, MD,MPH
Arch Intern Med. 2002;162:2478-2486.
Background The appropriate time to initiate antiretroviral therapy is controversial for human immunodeficiency virus (HIV)–infected patients with CD4 cell counts between 200/µL and 350/µL and low levels of HIV RNA, potentially leading to barriers to treatment access.
Objective To examine the effect of cholesterol changes and fat redistribution symptoms on the clinical benefits and cost-effectiveness of early antiretroviral therapy in these patients.
Methods We used a state-transition model to compare initiating antiretroviral therapy at CD4 cell counts of 350/µL (early therapy) with initiating therapy at CD4 cell counts of 200/µL (deferred therapy) in patients with HIV RNA levels of 10 000 to 30 000 copies/mL. Data were from randomized clinical trials, cohort studies, and other published literature.
Results If cholesterol changes associated with antiretroviral therapy resulted in a permanent increase in coronary heart disease risk, life expectancy with early therapy was 16.54 years (vs 16.66 years without this risk) and with deferred therapy was 13.73 years (vs 13.80 years without this risk). Early therapy was a more efficient use of resources (ie, dominated) compared with deferred therapy. Early therapy cost $13 000 per quality-adjusted life-year compared with no therapy with or without increased coronary heart disease risk, and $17 000 to $24 000 per quality-adjusted life-year taking into account the quality-of-life reduction in patients with fat distribution symptoms. Early therapy had a higher quality-adjusted life expectancy than deferred therapy as long as this quality-of-life reduction was 70% or less.
Conclusions Changes in cholesterol or quality of life associated with antiretroviral therapy do not justify limiting access to early HIV treatment. The effect of fat redistribution symptoms on quality of life will determine the optimal choice of early vs deferred therapy for an individual patient.
From the Center for Risk Analysis, Department of Health Policy and Management, Harvard School of Public Health (Drs Schackman, Freedberg, Weinstein, and Goldie); Infectious Disease Division, Brigham and Women's Hospital and Harvard Medical School (Dr Sax); Department of Epidemiology and Biostatistics, Boston University School of Public Health (Drs Freedberg and Losina); and Division of General Medicine and Partners AIDS Research Center, Massachusetts General Hospital and Harvard Medical School (Dr Freedberg and Mr Zhang); Boston, Mass. Dr Schackman is now affiliated with the Division of Outcomes and Effectiveness Research, Department of Public Health, Weill Medical College of Cornell University, New York, NY.
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