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).
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.
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.
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.