Early ART for HIV 'Very Cost-Effective,' Researchers Find

Larry Hand

October 30, 2013

Early antiretroviral therapy (ART) is "very cost-effective" over a lifetime for couples with mixed HIV status, according to an article published in the October 31 issue of the New England Journal of Medicine.

Rochelle P. Walensky, MD, MPH, from the Medical Practice Evaluation Center at Massachusetts General Hospital, Boston, and colleagues used a computer simulation of data from 2 of 9 countries involved in the HIV Prevention Trials Network 052 (HPTN) study to project cost-effectiveness of early ART in serodiscordant couples.

The researchers selected South Africa and India for the analysis because the countries have different care and cost structures, which enhances the generalizability of any findings to low-resource settings.

The authors classified cost-effectiveness in 3 categories: very cost-effective (incremental ratio less than annual per capita gross domestic product [GDP] of $8100 in South Africa and $1500 in India), cost-effective (ratio less than 3 times GDP), and cost-saving (decrease in total costs and increase in life years compared with delayed ART).

In South Africa, early ART was very cost-effective, at $590 per life-year saved over a lifetime. In India, early ART also was very cost-effective, at $530 per life-year saved over a lifetime and $1800 per life-year during a 5-year period.

"We've known for a while now that ART saves and improves lives. It has substantial prevention impact, and this article adds another piece to the puzzle, showing the powerful economic impact of earlier initiation of treatment," Chris Collins, MPP, vice president and director of public policy at amfAR, the Foundation for AIDS Research in New York City, told Medscape Medical News. "The study makes the economic case for what we know we need to do on a public health level anyway. In a time of budget pressures, these kinds of studies are important for lawmakers to see the economic benefits of investment."

Modeling Impact

In their model, the CEPAC International model, the researchers simulated HIV disease, treatment, and transmission comparing early ART with delayed ART in serodiscordant couples. They evaluated clinical outcomes, transmission outcomes, and economic outcome but did not look at time and productivity costs. They simulated the 24-month HPTN trial period and projected results over the course of 5 years and a lifetime. The model simulates CD4+ count and HIV RNA levels.

The researchers calculated costs of treatment by multiplying factors such as inpatient days, outpatient visits, and laboratory tests by country-specific unit costs. They determined ART costs from the World Health Organization Global Price Reporting Mechanism database, converting all figures to 2011 US dollars.

In South Africa, life expectancies with early ART amounted to 189.4 months compared with 165.2 months for delayed ART. Early ART, compared with delayed ART, resulted in a relative reduction of 69% in transmissions over the course of 5 years and 13% over a lifetime in South Africa.

The results were similar in India, in terms of both life-expectancy and transmission.

"[W]e found that early ART substantially improved the rate of survival of infected patients, greatly decreased the rate of early HIV transmissions, and provided an excellent return on investment," the researchers write.

South Africa and India are useful models, according to the authors, because the countries had the highest number of HIV-infected persons of any countries in the HPTN study and because they are representative of middle- and lower-income countries.

A model for studying the economic effect of early ART in the United States would be different because of higher GDP and higher healthcare costs, as well as a different type of epidemic, according to Collins.

"That said, I think the core findings of this model are highly relevant in the United States. That includes earlier initiation of ART leading to significantly lower transmission rates, lower rates of opportunistic infection, and a variety of cost benefits," Collins said. "In this study they did not look into productivity and other nonmedical economic benefits. If you did that in either South Africa or India, or in the United States, you would find an even greater positive economic impact of earlier initiation of ART."

Another dimension also applies to this study, he added: "Given what we know about the life-saving nature of ART, and its prevention impact, I think there is an ethical imperative to be getting ART to people who are eligible. The economic model is valuable in making the case to lawmakers…[W]e really have an ethical imperative to take advantage of the great opportunity to begin to end the AIDS epidemic globally, but also in the United States. Early ART is certainly part of that effort."

This research was supported by the National Institute of Allergy and Infectious Diseases, the National Institute of Mental Health, the HIV Prevention Trials Network, and the AIDS Clinical Trials Network. Dr. Walensky reports receiving grants from Gilead, Merck, and Bristol Myers Squibb and consulting fees from LeClair Ryan. A number of authors report receiving funding for them or their institutions from the National Institutes of Health and its institutes, and others report receiving funding for them or their institution from the Clinton Foundation, French National Research Agency, FHI 360, Wits Health Consortium, and Harvard University. One coauthor reports receiving consulting and lecture fees from Gilead, Abbott, Johnson & Johnson, Merck, and Mylan and a pending grant from GlaxoSmithKline. One coauthor reports receiving travel funding from several entities. The other authors and Collins have disclosed no relevant financial relationships.

N Engl J Med. 2013;369:1715-1725.

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