The cost effectiveness of antiretroviral treatment strategies in resource-limited settings

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Abstract
Background: Optimal resource allocation for antiretroviral treatment (ART) in developing countries requires assessment of different strategies for drug treatment and laboratory monitoring. Objectives: To compare costs and outcomes for 10 000 simulated HIV-infected patients followed every 6 months for 10 years in a limited-resource setting. Method: Five nested strategies, with and without the availability of a second-line treatment regimen, were simulated: (a) no ART (NO ART); (b) with ART but without any laboratory markers of HIV other than positive serology (ART ONLY); (c) ART plus total lymphocyte count (TLC); (d) ART plus CD4 cell counts (CD4); and (e) ART plus CD4 cell count plus viral load measurement (VL). Baseline prices of CD4 cell count and viral load measurements were $5.00 and $25.00 per test, respectively. Results: With no second-line treatment available, treating 10 000 patients with ART ONLY compared with NO ART would cost $14.49 million [95% confidence interval (CI), 14.45–14.52] and would generate an additional 23 060 quality-adjusted life years (QALYS) (95% CI, 22 770–23 360) for a median incremental cost effectiveness ratio (ICER) of $628/QALY. Median ICER values per QALY for CD4 and VL strategies are $238 and $16 139, respectively, when second-line treatment is unavailable. With second-line ART available, the corresponding median ICER values are $8636, and $14 670. Conclusions: In the absence of second-line ART, the CD4 strategy is a more cost-effective laboratory testing strategy for managing HIV infection than either TLC or VL. Availability of second-line ART plus CD4 cell count and/or viral load measurement would save additional lives, but at high incremental cost.