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Starting HAART Early Rather Than Later Appears Cost Effective and
May Increase Quality Survival Time
Initiating
HAART
at a CD4+
T-cell count greater than 350 cells/microliter may
be cost-effective compared
with initiating HAART at a CD4+ T-cell count less than 350 cells/microliter
but greater than 200 cells/microliter and may result in longer quality-adjusted
survival,
according to study results that appear in the August 15, 2005 issue
of the Journal of Acquired Immune Deficiency Syndromes.
Cohort studies indicate that starting HAART when the CD4+ T-cell
count is less than 200 cells/microliter is associated with poor
outcomes. These studies have been unable to address how early HAART
should be initiated, however.
This
report uses a Markov modeling approach to compare starting HAART
at a mean CD4+ T-cell count greater than 350 cells/microliter (early)
versus less than 350 cells/microliter but greater than 200 cells/microliter
(later).
Results
· Starting
HAART earlier rather than later increases total lifetime costs by
$19,074, increases years of life by 1.21 years, increases discounted
quality-adjusted life-years by 0.61, and has an incremental cost-effectiveness
ratio of $31,266 per quality-adjusted life-year.
· Early
therapy is more cost-effective when the impact of HAART on well-being
is smaller.
The results of this analyses (which uses the Markov
cost-effectiveness model and real-world data from urban hospitals)
demonstrate that starting HAART earlier (at a CD4+
T-cell count greater than 350 cells/microliter) rather than later
(at a CD4+ T-cell count less than 350 cells/microliter
but greater than 200 cells/microliter) increases total lifetime
costs, increases life expectancy, and is a cost-effective strategy
when this is defined as a strategy with a cost per life-year gained
or cost per quality-adjusted life-year gained less than $50,000,
which is a generally accepted benchmark in the United States.
The
results also confirm the generally accepted view that starting HAART
at a CD4+ T-cell count less than 350 cells/ microliter
but greater than 200 cells/ microliter is cost-effective compared
with starting at a CD4+ T-cell count less than
200 cells/microliter . This modeling exercise indicates that further
life expectancy and quality-adjusted life expectancy gains can be
expected when starting HAART at a CD4+ T-cell
count greater than 350/microliter and that this early treatment
strategy is also likely to be cost-effective.
The
results of this study indicate that physicians and patients making
decisions about when to start HAART should balance the likely benefits
on life expectancy with the possible negative impact on overall
well-being associated with HAART. Clearly, drug regimens that have
more convenient dosing regimens and fewer adverse
effects can minimize the negative impact on overall
well-being and thus would be likely to have greater value, assuming
that their price was similar to the prices of drugs with less favorable
side-effect profiles.
For
the time being, say the study authors, there seems to be little
evidence to suggest that the initiation of HAART should be delayed
on the basis of cost-effectiveness. This would be especially true
if new drugs that have a more favorable side-effect profile become
available.
RTI Health Solutions, Research Triangle
Park, NC; Center for AIDS and STD Harborview Medical Center, University
of Washington, Seattle, WA; Duke Clinical Research Institute, Durham,
NC; and GlaxoSmithKline, Research Triangle Park, NC.
08/26/05
Reference
J Mauskopf and others. HIV Antiretroviral Treatment: Early
Versus Later. Journal of Acquired
Immune Deficiency Syndromes 39(5): 562-569. August 15, 2005.
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