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Early Treatment of Serodiscordant Couples Is Cost-Effective

Summary and Comment |
October 30, 2013

Early Treatment of Serodiscordant Couples Is Cost-Effective

  1. Carlos del Rio, MD and
  2. Wendy S. Armstrong, MD

In a model based on HPTN 052 data, early ART initiation for the HIV-infected partner was very cost-effective over a lifetime in both South Africa and India.

  1. Carlos del Rio, MD and
  2. Wendy S. Armstrong, MD

In the HIV Prevention Trials Network (HPTN) 052 study, early antiretroviral therapy (ART) initiation (i.e., at CD4 counts 350–500 cells/mm3) for the HIV-infected partner in a serodiscordant couple was associated with a 96% decrease in HIV transmission compared with delayed ART initiation. Patients in the early-ART group also showed clear clinical benefits.

Now, using HPTN 052 data and a microsimulation model of HIV disease, progression, and treatment, investigators have projected the cost-effectiveness of early ART, compared with delayed ART, in serodiscordant couples in South Africa and India. These countries were chosen in part because they have high numbers of HIV-infected people but differ in economic conditions: South Africa is classified as middle-income, and India as low-income (per capita gross domestic products [GDPs] in 2011, US$8,100 and $1,500, respectively). Outcomes were defined as cost-saving if costs were decreased and life-years increased, and cost-effective or very cost-effective based on cost as a multiple of the country's GDP.

Overall, early ART increased the survival of the HIV-infected partners, prevented opportunistic infections (e.g., tuberculosis), and decreased the number of projected transmissions. Short-term decreased utilization of the relatively more expensive medical care in South Africa led early ART to be cost-saving over 5 years. In India, the cost of ART outweighed the relatively less expensive medical care costs; early ART — although not cost-saving — was cost-effective over 5 years. In both countries, early ART was very cost-effective over a lifetime. Importantly, in both countries, early ART's clinical benefit to the individual HIV-infected person was much larger than the clinical benefit associated with preventing new infections.

Comment

Evidence supporting early antiretroviral therapy initiation continues to accumulate, with benefits both to the individual patient and to society. The major barrier to global implementation of early ART is economic.

The study findings suggest that in both South Africa and India, early ART provides an excellent return on investment. Because of cost-of-care and gross domestic product differences between the two countries, early ART was found to be cost-saving in South Africa and cost-effective in India over 5 years. Over the long term, it was very cost-effective in both countries, underlining the generalizability of these results to countries with different abilities to pay. These findings strongly support early ART for serodiscordant couples in resource-limited settings.

Dr. Armstrong is Medical Director of the Infectious Diseases Program at Grady Health System and Associate Professor of Infectious Diseases at Emory University School of Medicine, Atlanta. She reports no conflicts of interest.

  • Disclosures for Carlos del Rio, MD at time of publication Consultant / Advisory board Gilead Sciences; Pfizer Grant / research support CDC; NIH Editorial boards AIDS Research and Human Retroviruses; Journal of AIDS Leadership positions in professional societies HIV Medicine Association (Board of Directors); Infectious Diseases Society of America (Board of Directors); International AIDS Society-USA (Board of Directors)

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