Alternative antiretroviral monitoring strategies for HIV-infected patients in east Africa: opportunities to save more lives?

Braithwaite, R Scott; Nucifora, Kimberly A; Yiannoutsos, Constantin T; Musick, Beverly; Kimaiyo, Sylvester; Diero, Lameck; Bacon, Melanie C; Wools-Kaloustian, Kara

doi:10.1186/1758-2652-14-38

Journal of the International AIDS Society

Table 2 Value of alternative laboratory monitoring strategies compared with earlier treatment initiation, assuming two antiretroviral regimens are available

From: Alternative antiretroviral monitoring strategies for HIV-infected patients in east Africa: opportunities to save more lives?

Monitoring strategy	Freq-uency (mo.)	Viral load threshold for switching ARV (copies/ ml)	5-year outcomes				Cost ($2008)	QALY	ICER ($/QALY)	Value com-pared with earlier treatment initiation*
			Mean # ARV rounds used	Mean new mut-ations	Median CD4 (cells/mm ³ )	Median HIV (log units)
Clinical	3	N/A	1.26	1.02	270	2.66	11,490	10.681	N/A	N/A
Viral load only if CD4 meets WHO criteria†	12	10,000	1.23	1.09	270	2.70	11,691	10.890	1,000	Same or better
Viral load only if CD4 meets WHO criteria†‡	12	500	1.27	1.06	270	2.66	12,060	10.948	6,400	Worse
Viral load¶	12	10,000	1.33	1.02	277	2.69	13,308	11.125	7,100	Worse
Viral load	12	500	1.67	0.82	285	2.42	16,035	11.412	9,500	Worse
Viral load	6	500	1.69	0.81	286	2.40	17,087	11.446	30,900	Worse
Viral load	3	500	1.70	0.79	286	2.39	18,901	11.461	121,000	Worse

Mo.: months; QALY: quality-adjusted life year; ICER: incremental cost-effectiveness ratio.
* Earlier treatment initiation at CD4 of 350 cells/mm³ compared with CD4 of 200 cells/mm³. "Better" value is indicated by a numerically lower ICER, and suggests that health benefits would be increased if resources were allocated away from earlier treatment initiation towards this monitoring strategy. "Worse" value is indicated by a numerically higher ICER, and suggests that health benefits would be increased if resources were allocated towards earlier ARV initiation away from this monitoring strategy.
† WHO (World Health Organization) criteria for changing ARV regimen based on CD4 count
‡ Four strategies had ICERs that were not on the frontier but were sufficiently close to the frontier so that they were difficult to distinguish statistically. Three employed the conditional strategy "viral load only if CD4 meets WHO criteria" for: (1) frequency of 6 months and ARV switching threshold of 10,000 copies/mL [ICER > = $2200/QALY]; (2) frequency of 6 months and ARV switching threshold of 500 copies/mL [ICER > = $4900/QALY]; and (3) frequency of 3 months and ARV switching threshold of 10,000 copies/mL [ICER > = $6100/QALY. The fourth strategy was a CD4 alone strategy at a frequency of 12 months [ICER > = $5200/QALY).
¶ One strategy had an ICER that was not on the frontier but was sufficiently close to the frontier so that it was difficult to distinguish statistically: a CD4 alone strategy with a frequency of 6 months [ICER > = $6,500/QALY].
Results are only shown for strategies that maximized health benefits for some budget scenarios or willingness to pay for health benefits.

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