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Prophylaxis for Human Immunodeficiency Virus–Related Pneumocystis carinii Pneumonia
Using Simulation Modeling to Inform Clinical Guidelines
Sue J. Goldie, MD, MPH;
Jonathan E. Kaplan, MD;
Elena Losina, PhD;
Milton C. Weinstein, PhD;
A. David Paltiel, PhD;
George R. Seage III, ScD, MPH;
Donald E. Craven, MD;
April D. Kimmel;
Hong Zhang;
Calvin J. Cohen, MD, MSc;
Kenneth A. Freedberg, MD, MSc
Arch Intern Med. 2002;162:921-928.
Background Human immunodeficiency virus (HIV)-infected patients receiving highly
active antiretroviral therapy (HAART) have experienced a dramatic decrease
in Pneumocystis carinii pneumonia (PCP), necessitating
reassessment of clinical guidelines for prophylaxis.
Methods A simulation model of HIV infection was used to estimate the lifetime
costs and quality-adjusted life expectancy (QALE) for alternative CD4 cell
count criteria for stopping primary PCP prophylaxis in patients with CD4 cell
count increases receiving HAART and alternative agents for second-line PCP
prophylaxis in those intolerant of trimethoprim-sulfamethoxazole (TMP/SMX).
The target population was a cohort of HIV-infected patients in the United
States with initial CD4 cell counts of 350/µL who began PCP prophylaxis
after their first measured CD4 lymphocyte count less than 200/µL. Data
were from randomized controlled trials and other published literature.
Results For patients with CD4 cell count increases during HAART, waiting to
stop prophylaxis until the first observed CD4 cell count was greater than
300/µL prevented 9 additional cases per 1000 patients and cost $9400
per quality-adjusted life year (QALY) gained compared with stopping prophylaxis
at 200/µL. For patients intolerant of TMP/SMX, using dapsone increased
QALE by 2.7 months and cost $4500 per QALY compared with no prophylaxis. Using
atovaquone rather than dapsone provided only 3 days of additional QALE and
cost more than $1.5 million per QALY.
Conclusions Delaying discontinuation of PCP prophylaxis until the first observed
CD4 cell count greater than 300/µL is cost-effective and provides an
explicit "PCP prophylaxis stopping criterion." In TMP/SMX-intolerant patients,
dapsone is more cost-effective than atovaquone.
From the Center for Risk Analysis, the Departments of Health Policy
and Management (Drs Goldie, Weinstein, and Freedberg) and Epidemiology (Dr
Seage), Harvard School of Public Health, Boston, Mass; the Division of HIV/AIDS
Prevention, Centers for Disease Control and Prevention, Atlanta, Ga (Dr Kaplan);
the Department of Epidemiology and Biostatistics, Boston University School
of Public Health (Drs Losina, Craven, and Freedberg); the Department of Epidemiology
and Public Health, Yale University School of Medicine, New Haven, Conn (Dr
Paltiel); the Division of General Medicine and Partners AIDS Research Center,
Massachusetts General Hospital, Harvard Medical School, Boston (Drs Losina
and Freedberg, Ms Kimmel, and Mr Zhang); and the Community Research Initiative
New England, Brookline, Mass (Dr Cohen).
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