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 4 Value of alternative laboratory monitoring strategies compared with earlier treatment initiation without any fixed assumption about numbers of available antiretroviral (ARV) regimens

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

# ARV regimens	Monitoring strategy	Freq-uency (mo.)	Viral load thres-hold	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)
0	Nothing	NA	NA	0	0	0	0	807	1.966	NA	NA
1	Clinical	3	NA	1	1.05	265	2.79	5713	9.901	600	Better
2	Viral load only if CD4 meets WHO criteria†‡	12	10,000	1.23	1.09	270	2.7	11,691	10.890	6000	Worse
2	Viral load only if CD4 meets WHO criteria†¶	12	500	1.27	1.06	270	2.66	12,060	10.948	6400	Worse
2	Viral load	12	10,000	1.33	1.02	277	2.69	13,308	11.125	7100	Worse
2	Viral load§	12	500	1.67	0.82	285	2.42	16,035	11.412	9500	Worse
3	Viral load	12	10,000	1.45	1.03	280	2.68	19,900	11.652	16,100	Worse
3	Viral load	12	500	2.06	0.81	290	2.38	25,527	11.941	19,500	Worse
3	Viral load	6	500	2.12	0.77	290	2.36	26,927	11.988	29,800	Worse
3	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
‡ Three 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 allowing 2 ARV regimens. Two 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]. The third employed a CD4 alone strategy with a frequency of 12 months [ICER > = $5200/QALY].
¶ Two strategies had an ICER that was not on the frontier but was sufficiently close to the frontier so that it was difficult to distinguish statistically, both allowing 2 ARV regimens. One employed the strategy, "viral load only if CD4 meets WHO criteria", with frequency of 3 months and ARV switching threshold of 10,000 copies/mL [ICER > = $6100/QALY] and the other was a CD4 alone strategy with a frequency of 6 months [ICER > = $6400/QALY],
§ Two strategies had an ICER that was not on the frontier but was sufficiently close to the frontier so that it was difficult to distinguish statistically, both employing viral loads alone with 6 month frequency, the first using an ARV switching threshold of 500 copies/mL and allowing 2 ARV regimens [ICER > = $13,900/QALY] and the second using an ARV switching threshold of 10,000 copies/mL and allowing 3 ARV regimens [ICER > = $14,900/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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