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Initiation of antiretroviral therapy based on the 2015 WHO guidelines: A cost-effectiveness analysis in Nigeria, South Africa, Uganda and India.

Initiation of antiretroviral therapy based on the 2015 WHO guidelines: A cost-effectiveness analysis in Nigeria, South Africa, Uganda and India.
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Kuznik A, Iliyasu G, Habib AG, Musa BM, Kambugu A, Lamorde M,


Kuznik A, Iliyasu G, Habib AG, Musa BM, Kambugu A, Lamorde M, (click to view)

Kuznik A, Iliyasu G, Habib AG, Musa BM, Kambugu A, Lamorde M,

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AIDS (London, England) 2016 9 20()

Abstract
OBJECTIVE
In 2015, the World Health Organization (WHO) recommended initiation of antiretroviral therapy (ART) in all HIV-positive patients regardless of CD4 cell count. We evaluated the cost-effectiveness of immediate versus deferred ART initiation among patients with CD4 counts exceeding 500 cells/mm in four resource-limited countries (South Africa, Nigeria, Uganda, and India).

DESIGN
A 5-year Markov model with annual cycles including patients at CD4>500 cells/mm initiating ART or deferring therapy until historic ART initiation criteria of CD < 350 cells/mm were met. METHODS
The incidence of opportunistic infections, malignancies, cardiovascular disease, unscheduled hospitalizations, and death, were informed by the START trial results. Risk of HIV transmission was obtained from a systematic review. Disability weights were based on published literature. Cost inputs were inflated to 2014 US Dollars and based on local sources. Results were expressed in cost per disability-adjusted life years (DALYs) averted and measured against WHO cost-effectiveness thresholds.

RESULTS
Immediate initiation of ART is associated with a cost per DALY averted of -$275 (95% CI: -$717 to $787) in South Africa, -$353 (95% CI: -$613 to $234) in Nigeria, -$126 (95% CI: -$367 to $445) in Uganda and -$68 (95% CI: -$232 to 366) in India. The results are largely driven by the impact of ART on reducing the risk of new HIV transmissions.

CONCLUSIONS
In HIV-positive patients with CD4 counts above 500 cells/mm in the 4 studied countries, immediate initiation of ART versus deferred therapy until historic eligibility criteria are met is cost-effective and likely even cost-saving over time.

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