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Economic and epidemiological impact of early antiretroviral therapy initiation in India

INTRODUCTION: Recent WHO guidance advocates for early antiretroviral therapy (ART) initiation at higher CD4 counts to improve survival and reduce HIV transmission. We sought to quantify how the cost-effectiveness and epidemiological impact of early ART strategies in India are affected by attrition t...

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Autores principales: Maddali, Manoj V, Dowdy, David W, Gupta, Amita, Shah, Maunank
Formato: Online Artículo Texto
Lenguaje:English
Publicado: International AIDS Society 2015
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4592848/
https://www.ncbi.nlm.nih.gov/pubmed/26434780
http://dx.doi.org/10.7448/IAS.18.1.20217
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author Maddali, Manoj V
Dowdy, David W
Gupta, Amita
Shah, Maunank
author_facet Maddali, Manoj V
Dowdy, David W
Gupta, Amita
Shah, Maunank
author_sort Maddali, Manoj V
collection PubMed
description INTRODUCTION: Recent WHO guidance advocates for early antiretroviral therapy (ART) initiation at higher CD4 counts to improve survival and reduce HIV transmission. We sought to quantify how the cost-effectiveness and epidemiological impact of early ART strategies in India are affected by attrition throughout the HIV care continuum. METHODS: We constructed a dynamic compartmental model replicating HIV transmission, disease progression and health system engagement among Indian adults. Our model of the Indian HIV epidemic compared implementation of early ART initiation (i.e. initiation above CD4 ≥350 cells/mm(3)) with delayed initiation at CD4 ≤350 cells/mm(3); primary outcomes were incident cases, deaths, quality-adjusted-life-years (QALYs) and costs over 20 years. We assessed how costs and effects of early ART initiation were impacted by suboptimal engagement at each stage in the HIV care continuum. RESULTS: Assuming “idealistic” engagement in HIV care, early ART initiation is highly cost-effective ($442/QALY-gained) compared to delayed initiation at CD4 ≤350 cells/mm(3) and could reduce new HIV infections to <15,000 per year within 20 years. However, when accounting for realistic gaps in care, early ART initiation loses nearly half of potential epidemiological benefits and is less cost-effective ($530/QALY-gained). We project 1,285,000 new HIV infections and 973,000 AIDS-related deaths with deferred ART initiation with current levels of care-engagement in India. Early ART initiation in this continuum resulted in 1,050,000 new HIV infections and 883,000 AIDS-related deaths, or 18% and 9% reductions (respectively), compared to current guidelines. Strengthening HIV screening increases benefits of earlier treatment modestly (1,001,000 new infections; 22% reduction), while improving retention in care has a larger modulatory impact (676,000 new infections; 47% reduction). CONCLUSIONS: Early ART initiation is highly cost-effective in India but only has modest epidemiological benefits at current levels of care-engagement. Improved retention in care is needed to realize the full potential of earlier treatment.
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spelling pubmed-45928482015-10-13 Economic and epidemiological impact of early antiretroviral therapy initiation in India Maddali, Manoj V Dowdy, David W Gupta, Amita Shah, Maunank J Int AIDS Soc Research Article INTRODUCTION: Recent WHO guidance advocates for early antiretroviral therapy (ART) initiation at higher CD4 counts to improve survival and reduce HIV transmission. We sought to quantify how the cost-effectiveness and epidemiological impact of early ART strategies in India are affected by attrition throughout the HIV care continuum. METHODS: We constructed a dynamic compartmental model replicating HIV transmission, disease progression and health system engagement among Indian adults. Our model of the Indian HIV epidemic compared implementation of early ART initiation (i.e. initiation above CD4 ≥350 cells/mm(3)) with delayed initiation at CD4 ≤350 cells/mm(3); primary outcomes were incident cases, deaths, quality-adjusted-life-years (QALYs) and costs over 20 years. We assessed how costs and effects of early ART initiation were impacted by suboptimal engagement at each stage in the HIV care continuum. RESULTS: Assuming “idealistic” engagement in HIV care, early ART initiation is highly cost-effective ($442/QALY-gained) compared to delayed initiation at CD4 ≤350 cells/mm(3) and could reduce new HIV infections to <15,000 per year within 20 years. However, when accounting for realistic gaps in care, early ART initiation loses nearly half of potential epidemiological benefits and is less cost-effective ($530/QALY-gained). We project 1,285,000 new HIV infections and 973,000 AIDS-related deaths with deferred ART initiation with current levels of care-engagement in India. Early ART initiation in this continuum resulted in 1,050,000 new HIV infections and 883,000 AIDS-related deaths, or 18% and 9% reductions (respectively), compared to current guidelines. Strengthening HIV screening increases benefits of earlier treatment modestly (1,001,000 new infections; 22% reduction), while improving retention in care has a larger modulatory impact (676,000 new infections; 47% reduction). CONCLUSIONS: Early ART initiation is highly cost-effective in India but only has modest epidemiological benefits at current levels of care-engagement. Improved retention in care is needed to realize the full potential of earlier treatment. International AIDS Society 2015-10-01 /pmc/articles/PMC4592848/ /pubmed/26434780 http://dx.doi.org/10.7448/IAS.18.1.20217 Text en © 2015 Maddali MV et al; licensee International AIDS Society http://creativecommons.org/licenses/by/3.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
spellingShingle Research Article
Maddali, Manoj V
Dowdy, David W
Gupta, Amita
Shah, Maunank
Economic and epidemiological impact of early antiretroviral therapy initiation in India
title Economic and epidemiological impact of early antiretroviral therapy initiation in India
title_full Economic and epidemiological impact of early antiretroviral therapy initiation in India
title_fullStr Economic and epidemiological impact of early antiretroviral therapy initiation in India
title_full_unstemmed Economic and epidemiological impact of early antiretroviral therapy initiation in India
title_short Economic and epidemiological impact of early antiretroviral therapy initiation in India
title_sort economic and epidemiological impact of early antiretroviral therapy initiation in india
topic Research Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4592848/
https://www.ncbi.nlm.nih.gov/pubmed/26434780
http://dx.doi.org/10.7448/IAS.18.1.20217
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