Limits...
Opportunities for improving the efficiency of paediatric HIV treatment programmes.

Revill PA, Walker S, Mabugu T, Nathoo KJ, Mugyenyi P, Kekitinwa A, Munderi P, Bwakura-Dangarembizi M, Musiime V, Bakeera-Kitaka S, Nahirya-Ntege P, Walker AS, Sculpher MJ, Gibb DM - AIDS (2015)

Bottom Line: Committing resources to improve cotrimoxazole implementation appears cost-effective.Clinically driven monitoring of ART is cost-effective in most circumstances.Routine laboratory monitoring is generally not cost-effective at current prices, except possibly CD4 testing amongst adolescents initiating ART.

View Article: PubMed Central - PubMed

Affiliation: aCentre for Health Economics, University of York, York, UK bClinical Research Centre, University of Zimbabwe cUniversity of Zimbabwe, College of Health Sciences, Harare, Zimbabwe dJoint Clinical Research Centre, Kampala ePaediatric Infectious Diseases Clinic/Baylor - Uganda, Mulago Hospital, Mulago fMedical Research Council/Uganda Research Unit on AIDS, Uganda Virus Research Institute, Entebbe, Uganda gMedical Research Council (MRC) Clinical Trials Unit at University College London, London, UK.

ABSTRACT

Objectives: To conduct two economic analyses addressing whether to: routinely monitor HIV-infected children on antiretroviral therapy (ART) clinically or with laboratory tests; continue or stop cotrimoxazole prophylaxis when children become stabilized on ART.

Design and methods: The ARROW randomized trial investigated alternative strategies to deliver paediatric ART and cotrimoxazole prophylaxis in 1206 Ugandan/Zimbabwean children. Incremental cost-effectiveness and value of implementation analyses were undertaken. Scenario analyses investigated whether laboratory monitoring (CD4 tests for efficacy monitoring; haematology/biochemistry for toxicity) could be tailored and targeted to be delivered cost-effectively. Cotrimoxazole use was examined in malaria-endemic and non-endemic settings.

Results: Using all trial data, clinical monitoring delivered similar health outcomes to routine laboratory monitoring, but at a reduced cost, so was cost-effective. Continuing cotrimoxazole improved health outcomes at reduced costs. Restricting routine CD4 monitoring to after 52 weeks following ART initiation and removing toxicity testing was associated with an incremental cost-effectiveness ratio of $6084 per quality-adjusted life-year (QALY) across all age groups, but was much lower for older children (12+ years at initiation; incremental cost-effectiveness ratio = $769/QALY). Committing resources to improve cotrimoxazole implementation appears cost-effective. A healthcare system that could pay $600/QALY should be willing to spend up to $12.0 per patient-year to ensure continued provision of cotrimoxazole.

Conclusion: Clinically driven monitoring of ART is cost-effective in most circumstances. Routine laboratory monitoring is generally not cost-effective at current prices, except possibly CD4 testing amongst adolescents initiating ART. Committing resources to ensure continued provision of cotrimoxazole in health facilities is more likely to represent an efficient use of resources.

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Related in: MedlinePlus

Cost-effectiveness acceptability curves of alternative approaches to monitoring.
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Figure 1: Cost-effectiveness acceptability curves of alternative approaches to monitoring.

Mentions: Cost-effectiveness acceptability curves, based on costs and health outcomes in weeks 52–228, are presented in Fig. 1, for the two selected scenarios for which routine laboratory monitoring is more likely to be cost-effective for some healthcare systems: removing costs of toxicity testing, for all trial participants; removing costs of toxicity testing and reducing costs of CD4+ testing by 50%, for all trial participants and by age sub-groups. These show that LCM is very unlikely to be cost-effective at thresholds below $2000, overall and within sub-groups, with the exception of CD4+ testing alone for adolescents (aged 12+), especially when testing costs are reduced.


Opportunities for improving the efficiency of paediatric HIV treatment programmes.

Revill PA, Walker S, Mabugu T, Nathoo KJ, Mugyenyi P, Kekitinwa A, Munderi P, Bwakura-Dangarembizi M, Musiime V, Bakeera-Kitaka S, Nahirya-Ntege P, Walker AS, Sculpher MJ, Gibb DM - AIDS (2015)

Cost-effectiveness acceptability curves of alternative approaches to monitoring.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4318642&req=5

Figure 1: Cost-effectiveness acceptability curves of alternative approaches to monitoring.
Mentions: Cost-effectiveness acceptability curves, based on costs and health outcomes in weeks 52–228, are presented in Fig. 1, for the two selected scenarios for which routine laboratory monitoring is more likely to be cost-effective for some healthcare systems: removing costs of toxicity testing, for all trial participants; removing costs of toxicity testing and reducing costs of CD4+ testing by 50%, for all trial participants and by age sub-groups. These show that LCM is very unlikely to be cost-effective at thresholds below $2000, overall and within sub-groups, with the exception of CD4+ testing alone for adolescents (aged 12+), especially when testing costs are reduced.

Bottom Line: Committing resources to improve cotrimoxazole implementation appears cost-effective.Clinically driven monitoring of ART is cost-effective in most circumstances.Routine laboratory monitoring is generally not cost-effective at current prices, except possibly CD4 testing amongst adolescents initiating ART.

View Article: PubMed Central - PubMed

Affiliation: aCentre for Health Economics, University of York, York, UK bClinical Research Centre, University of Zimbabwe cUniversity of Zimbabwe, College of Health Sciences, Harare, Zimbabwe dJoint Clinical Research Centre, Kampala ePaediatric Infectious Diseases Clinic/Baylor - Uganda, Mulago Hospital, Mulago fMedical Research Council/Uganda Research Unit on AIDS, Uganda Virus Research Institute, Entebbe, Uganda gMedical Research Council (MRC) Clinical Trials Unit at University College London, London, UK.

ABSTRACT

Objectives: To conduct two economic analyses addressing whether to: routinely monitor HIV-infected children on antiretroviral therapy (ART) clinically or with laboratory tests; continue or stop cotrimoxazole prophylaxis when children become stabilized on ART.

Design and methods: The ARROW randomized trial investigated alternative strategies to deliver paediatric ART and cotrimoxazole prophylaxis in 1206 Ugandan/Zimbabwean children. Incremental cost-effectiveness and value of implementation analyses were undertaken. Scenario analyses investigated whether laboratory monitoring (CD4 tests for efficacy monitoring; haematology/biochemistry for toxicity) could be tailored and targeted to be delivered cost-effectively. Cotrimoxazole use was examined in malaria-endemic and non-endemic settings.

Results: Using all trial data, clinical monitoring delivered similar health outcomes to routine laboratory monitoring, but at a reduced cost, so was cost-effective. Continuing cotrimoxazole improved health outcomes at reduced costs. Restricting routine CD4 monitoring to after 52 weeks following ART initiation and removing toxicity testing was associated with an incremental cost-effectiveness ratio of $6084 per quality-adjusted life-year (QALY) across all age groups, but was much lower for older children (12+ years at initiation; incremental cost-effectiveness ratio = $769/QALY). Committing resources to improve cotrimoxazole implementation appears cost-effective. A healthcare system that could pay $600/QALY should be willing to spend up to $12.0 per patient-year to ensure continued provision of cotrimoxazole.

Conclusion: Clinically driven monitoring of ART is cost-effective in most circumstances. Routine laboratory monitoring is generally not cost-effective at current prices, except possibly CD4 testing amongst adolescents initiating ART. Committing resources to ensure continued provision of cotrimoxazole in health facilities is more likely to represent an efficient use of resources.

Show MeSH
Related in: MedlinePlus