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A Southern African Analysis

Eran Bendavid, MD; Sean D. Young, MS; David A. Katzenstein, MD; Ahmed M. Bayoumi, MD, MSc; Gillian D. Sanders, PhD; Douglas K. Owens, MD, MS

Arch Intern Med. 2008;168(17):1910-1918.

Background  Although the number of infected persons receiving highly active antiretroviral therapy (HAART) in low- and middle-income countries has increased dramatically, optimal disease management is not well defined.

Methods  We developed a model to compare the costs and benefits of 3 types of human immunodeficiency virus monitoring strategies: symptom-based strategies, CD4-based strategies, and CD4 counts plus viral load strategies for starting, switching, and stopping HAART. We used clinical and cost data from southern Africa and performed a cost-effectiveness analysis. All assumptions were tested in sensitivity analyses.

Results  Compared with the symptom-based approaches, monitoring CD4 counts every 6 months and starting treatment at a threshold of 200/µL was associated with a gain in life expectancy of 6.5 months (61.9 months vs 68.4 months) and a discounted lifetime cost savings of US $464 per person (US $4069 vs US $3605, discounted 2007 dollars). The CD4-based strategies in which treatment was started at the higher threshold of 350/µL provided an additional gain in life expectancy of 5.3 months at a cost-effectiveness of US $107 per life-year gained compared with a threshold of 200/µL. Monitoring viral load with CD4 was more expensive than monitoring CD4 counts alone, added 2.0 months of life, and had an incremental cost-effectiveness ratio of US $5414 per life-year gained relative to monitoring of CD4 counts. In sensitivity analyses, the cost savings from CD4 count monitoring compared with the symptom-based approaches was sensitive to cost of inpatient care, and the cost-effectiveness of viral load monitoring was influenced by the per test costs and rates of virologic failure.

Conclusions  Use of CD4 monitoring and early initiation of HAART in southern Africa provides large health benefits relative to symptom-based approaches for HAART management. In southern African countries with relatively high costs of hospitalization, CD4 monitoring would likely reduce total health care expenditures. The cost-effectiveness of viral load monitoring depends on test prices and rates of virologic failure.

Author Affiliations: Center for Health Policy and the Center for Primary Care and Outcomes Research (Drs Bendavid and Owens) and Departments of Psychology and Health Research and Policy (Mr Young), School of Medicine, Stanford University; and Division of Infectious Diseases and Geographic Medicine, Stanford University Medical Center (Drs Bendavid and Katzenstein), Stanford, California; Centre for Research on Inner City Health, The Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, and Departments of Medicine and of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada (Dr Bayoumi); Duke Clinical Research Institute, Duke University, Durham, North Carolina (Dr Sanders); and Veterans Affairs Palo Alto Health Care System, Palo Alto, California (Dr Owens).

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