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 3 Value of alternative laboratory monitoring strategies compared to earlier treatment initiation, assuming three antiretroviral (ARV) 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 compared 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	1.32	1.02	271	2.65	16,017	10.814	N/A	N/A
Viral load only if CD4 meets WHO criteria†	12	10,000	1.3	1.1	270	2.70	17,050	11.281	2200	Similar
Viral load only if CD4 meets WHO criteria†‡	6	10,000	1.32	1.12	270	2.70	17,571	11.361	6500	Worse
Viral load	12	10,000	1.45	1.03	280	2.68	19,900	11.652	8000	Worse
Viral load¶	12	500	2.06	0.81	290	2.38	25,527	11.941	19,500	Worse
Viral load	6	500	2.12	0.77	290	2.36	26,927	11.988	29,800	Worse
Viral load	3	500	2.16	0.76	290	2.34	29,063	12.018	71,200	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, all employing the conditional strategy, "viral load only if CD4 meets WHO criteria", for: (1) frequency of 12 months and ARV switching threshold of 500 copies/mL [ICER > = $3600/QALY]; (2) frequency of 6 months and ARV switching threshold of 500 copies/mL [ICER > = $5600/QALY]; (3) frequency of 3 months and ARV switching threshold of 10,000 copies/mL [ICER > = $5100/QALY; (4) frequency of 3 months and ARV switching threshold of 500 copies/mL [ICER > = $5100/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: viral load alone with a frequency of 6 months and switching threshold of 10,000 copies/mL [ICER > = $11,200/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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