Early ART Cost Effective in HIV Patients With Acute Opportunistic Infections

Emma Hitt, PhD

July 23, 2009

July 23, 2009 (Cape Town, South Africa) — An analysis of data from the AIDS Clinical Trial Group (ACTG) 5164 study indicates that early initiation of antiretroviral therapy (ART) in patients with acute opportunistic infections is less costly than deferring treatment, according to American standards of cost-effectiveness.

Dr. Paul Sax

Paul E. Sax, MD, from the Brigham and Women's Hospital and Harvard Medical School in Boston, Massachusetts, presented the findings here at the 5th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention.

The ACTG 5164 investigators found that early ART, compared with ART deferred by 5 weeks, significantly reduced the progression of AIDS and death at 48 weeks (14% vs 24%; P = 0.035) in patients presenting with advanced disease and opportunistic infections. The researchers evaluated the long-term cost-effectiveness of initiating early ART using data from this study.

The researchers used a simulation model of cost efficacy, called Cost-Effectiveness of Preventing AIDS Complications (CEPAC), to determine the relative cost-efficacy of the 2 different strategies for treating HIV.

Early ART initiation decreased projected mortality from 2.8% to 1.5% at 30 days, and from 10.4% to 8.0% at 1 year. Projected life expectancy as a result of early intervention increased from 11.1 quality-adjusted life-years (QALYs) for deferred ART to 11.5 QALYs for early ART.

These differences mean an increase in lifetime costs from $434,890 to $447,180, translating into an incremental cost-effectiveness ratio of $38,000 per QALY with early ART.

According to Dr. Sax, “a cost of anything less than $50,000 per QALY is considered to be a very cost-effective intervention in the United States.” He added that the results were robust through a wide range of sensitivity analyses.

“The cost-effectiveness held up pretty well, even when we diminished the number of cases that were eligible, when we included patients with immune reconstitution inflammatory syndrome, and when there was a very poor linkage to outpatient care,” he told Medscape HIV/AIDS after the meeting.

“The only way this intervention would not be cost-effective would be if it were to reduce the efficacy of first-line therapy, and there are no data in ACTG 5164 to suggest that this is the case,” he added.

Dr. Sax recommended that this practice be “implemented widely, even in institutions with low caseloads.”

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Dr. Paul Sax discusses the ACTG 5164 study

Dr. Glenda Gray

Glenda Gray, MBBCH, FCPaeds (SA), from the University of the Witwatersrand in Johannesburg, South Africa, who moderated the session, said that this study shows that starting early in well-resourced settings appears to be cost effective. “These are important data, especially since early ART is associated with efficacy benefits,” she told Medscape HIV/AIDS.

According to Dr. Gray, it is important to determine whether these cost-benefits persist beyond the study duration of 48 weeks, not just in the short term. “Obviously, what needs to be investigated further is the cost of future treatment after second- and third-line therapy and salvage regimens when initial ART is started early,” she said.

The study was funded by the National Institute for Allergy and Infectious Diseases and the ACTG. Dr. Sax and Dr. Gray have disclosed no relevant financial relationships.

5th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention: Abstract WELBD102. Presented July 22, 2009.