viernes, 1 de noviembre de 2013

Cost-Effectiveness of HIV Treatment as Prevention in Serodiscordant Couples — NEJM

Cost-Effectiveness of HIV Treatment as Prevention in Serodiscordant Couples — NEJM

Cost-Effectiveness of HIV Treatment as Prevention in Serodiscordant Couples

Rochelle P. Walensky, M.D., M.P.H., Eric L. Ross, B.A., Nagalingeswaran Kumarasamy, M.B., B.S., Ph.D., Robin Wood, D.Sc., Farzad Noubary, Ph.D., A. David Paltiel, Ph.D., M.B.A., Yoriko M. Nakamura, B.A., Sheela V. Godbole, M.D., Ravindre Panchia, M.B., B.Ch., Ian Sanne, M.B., B.Ch., D.T.M.&H., Milton C. Weinstein, Ph.D., Elena Losina, Ph.D., Kenneth H. Mayer, M.D., Ying Q. Chen, Ph.D., Lei Wang, Ph.D., Marybeth McCauley, M.P.H., Theresa Gamble, Ph.D., George R. Seage, III, D.Sc., M.P.H., Myron S. Cohen, M.D., and Kenneth A. Freedberg, M.D.
N Engl J Med 2013; 369:1715-1725October 31, 2013DOI: 10.1056/NEJMsa1214720


The cost-effectiveness of early antiretroviral therapy (ART) in persons infected with human immunodeficiency virus (HIV) in serodiscordant couples is not known. Using a computer simulation of the progression of HIV infection and data from the HIV Prevention Trials Network 052 study, we projected the cost-effectiveness of early ART for such persons.


For HIV-infected partners in serodiscordant couples in South Africa and India, we compared the early initiation of ART with delayed ART. Five-year and lifetime outcomes included cumulative HIV transmissions, life-years, costs, and cost-effectiveness. We classified early ART as very cost-effective if its incremental cost-effectiveness ratio was less than the annual per capita gross domestic product (GDP; $8,100 in South Africa and $1,500 in India), as cost-effective if the ratio was less than three times the GDP, and as cost-saving if it resulted in a decrease in total costs and an increase in life-years, as compared with delayed ART.


In South Africa, early ART prevented opportunistic diseases and was cost-saving over a 5-year period; over a lifetime, it was very cost-effective ($590 per life-year saved). In India, early ART was cost-effective ($1,800 per life-year saved) over a 5-year period and very cost-effective ($530 per life-year saved) over a lifetime. In both countries, early ART prevented HIV transmission over short periods, but longer survival attenuated this effect; the main driver of life-years saved was a clinical benefit for treated patients. Early ART remained very cost-effective over a lifetime under most modeled assumptions in the two countries.


In South Africa, early ART was cost-saving over a 5-year period. In both South Africa and India, early ART was projected to be very cost-effective over a lifetime. With individual, public health, and economic benefits, there is a compelling case for early ART for serodiscordant couples in resource-limited settings. (Funded by the National Institute of Allergy and Infectious Diseases and others.)

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