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Economic and epidemiological impact of early antiretroviral therapy initiation in India.

Maddali MV, Dowdy DW, Gupta A, Shah M - J Int AIDS Soc (2015)

Bottom Line: 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.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.Early ART initiation is highly cost-effective in India but only has modest epidemiological benefits at current levels of care-engagement.

View Article: PubMed Central - PubMed

Affiliation: Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.

ABSTRACT

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.

No MeSH data available.


Related in: MedlinePlus

Epidemiological impact of delayed ART initiation (CD4 ≤350 cells/mm3), early ART initiation and early ART initiation in combination with various interventions in the HIV care continuum. “Delayed ART initiation” represents current practice and incorporates the current HIV care continuum with suboptimal screening, linkage and retention in care. “Early ART initiation” represents increased rates of ART initiation at CD4 >350 cells/mm3, but assumes continuation of current levels of care-engagement. “Expanded screening” involves annual screening of high-risk groups, with 95% linkage to care. “Improved detection of virological failure” involves detecting ART failure and modifying treatment promptly (within six months of virological failure). “Improved retention in care” is defined as optimal retention of PLWH in care (annual disengagement rate of 2.5% and reengagement within one year of disengagement).
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Figure 0003: Epidemiological impact of delayed ART initiation (CD4 ≤350 cells/mm3), early ART initiation and early ART initiation in combination with various interventions in the HIV care continuum. “Delayed ART initiation” represents current practice and incorporates the current HIV care continuum with suboptimal screening, linkage and retention in care. “Early ART initiation” represents increased rates of ART initiation at CD4 >350 cells/mm3, but assumes continuation of current levels of care-engagement. “Expanded screening” involves annual screening of high-risk groups, with 95% linkage to care. “Improved detection of virological failure” involves detecting ART failure and modifying treatment promptly (within six months of virological failure). “Improved retention in care” is defined as optimal retention of PLWH in care (annual disengagement rate of 2.5% and reengagement within one year of disengagement).

Mentions: We found that the degree to which each stage of the care continuum modifies the epidemiological impact of early HIV treatment in India can vary greatly (Figure 3). For example, if early treatment was combined with rapid identification of ART failure (with prompt changes to alternative effective regimens, i.e. second-line therapy), our model projects 992,000 new infections (23% reduction) and 821,000 AIDS-related deaths (16% reduction) over 20 years, despite other gaps in care (e.g. poor linkage and retention).


Economic and epidemiological impact of early antiretroviral therapy initiation in India.

Maddali MV, Dowdy DW, Gupta A, Shah M - J Int AIDS Soc (2015)

Epidemiological impact of delayed ART initiation (CD4 ≤350 cells/mm3), early ART initiation and early ART initiation in combination with various interventions in the HIV care continuum. “Delayed ART initiation” represents current practice and incorporates the current HIV care continuum with suboptimal screening, linkage and retention in care. “Early ART initiation” represents increased rates of ART initiation at CD4 >350 cells/mm3, but assumes continuation of current levels of care-engagement. “Expanded screening” involves annual screening of high-risk groups, with 95% linkage to care. “Improved detection of virological failure” involves detecting ART failure and modifying treatment promptly (within six months of virological failure). “Improved retention in care” is defined as optimal retention of PLWH in care (annual disengagement rate of 2.5% and reengagement within one year of disengagement).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4592848&req=5

Figure 0003: Epidemiological impact of delayed ART initiation (CD4 ≤350 cells/mm3), early ART initiation and early ART initiation in combination with various interventions in the HIV care continuum. “Delayed ART initiation” represents current practice and incorporates the current HIV care continuum with suboptimal screening, linkage and retention in care. “Early ART initiation” represents increased rates of ART initiation at CD4 >350 cells/mm3, but assumes continuation of current levels of care-engagement. “Expanded screening” involves annual screening of high-risk groups, with 95% linkage to care. “Improved detection of virological failure” involves detecting ART failure and modifying treatment promptly (within six months of virological failure). “Improved retention in care” is defined as optimal retention of PLWH in care (annual disengagement rate of 2.5% and reengagement within one year of disengagement).
Mentions: We found that the degree to which each stage of the care continuum modifies the epidemiological impact of early HIV treatment in India can vary greatly (Figure 3). For example, if early treatment was combined with rapid identification of ART failure (with prompt changes to alternative effective regimens, i.e. second-line therapy), our model projects 992,000 new infections (23% reduction) and 821,000 AIDS-related deaths (16% reduction) over 20 years, despite other gaps in care (e.g. poor linkage and retention).

Bottom Line: 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.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.Early ART initiation is highly cost-effective in India but only has modest epidemiological benefits at current levels of care-engagement.

View Article: PubMed Central - PubMed

Affiliation: Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.

ABSTRACT

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.

No MeSH data available.


Related in: MedlinePlus