Alternative antiretroviral monitoring strategies for HIV-infected patients in east Africa: opportunities to save more lives?
Alternative antiretroviral monitoring strategies for HIV-infected patients in east Africa: opportunities to save more lives?
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DOI：
10.1186/1758-2652-14-38
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发表时间：
2011-07-30
影响因子：
6
通讯作者：
Wools-Kaloustian, Kara
中科院分区：
文献类型：
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作者：
Braithwaite, R. Scott;Nucifora, Kimberly A.;Wools-Kaloustian, Kara
工作背景：世界卫生组织的最新准则扩大了关于资源限制应如何影响艾滋病毒感染者接受抗逆转录病毒综合疗法的监测战略的辩论。我们估计的增量效益和成本效益的替代监测策略东非人已知的HIV infection.Methods：使用一个有效的艾滋病毒计算机模拟资源有限的数据（美国国际开发署和AMPATH）和情况（东非）的基础上，我们比较了新开始的cART艾滋病毒感染者的替代监测策略。我们评估了临床，免疫学和病毒学监测策略，包括组合和条件逻辑（e。例如，在一个实施例中，仅在免疫学检测为阳性时进行病毒学检测）。我们计算了增量成本效益比（ICER）的单位成本每质量调整生命年（QALY），使用社会的角度和终身的视野。成本以2008年美元计算，成本和收益按3%贴现。我们比较了监测策略与其他资源受限决策的ICER，特别是早期cART启动（CD 4计数为350个细胞/mm 3而不是200个细胞/mm 3）。结果：采用常规CD 4检测而不进行病毒学检测的监测策略从未最大化健康益处，无论预算或社会是否愿意支付额外的健康益处。监测策略采用病毒学检测条件下，特定的CD 4结果提供了最大的好处，在支付意愿水平类似的成本较早的cART启动（约2600美元/QALY）。监测策略采用常规病毒学检测单独只有最大限度地提高健康效益的意愿支付水平（> 4400美元/QALY），大大超过了早期cART initiation.Conclusions ICER：CD 4检测单独从来没有最大限度地提高健康效益，无论资源的限制。常规进行病毒学检测但推迟启动cART的项目可能会通过将监测资源重新分配给早期启动cART来增加健康益处。
Background: Updated World Health Organization guidelines have amplified debate about how resource constraints should impact monitoring strategies for HIV-infected persons on combination antiretroviral therapy (cART). We estimated the incremental benefit and cost effectiveness of alternative monitoring strategies for east Africans with known HIV infection.Methods: Using a validated HIV computer simulation based on resource-limited data (USAID and AMPATH) and circumstances (east Africa), we compared alternative monitoring strategies for HIV-infected persons newly started on cART. We evaluated clinical, immunologic and virologic monitoring strategies, including combinations and conditional logic (e. g., only perform virologic testing if immunologic testing is positive). We calculated incremental cost-effectiveness ratios (ICER) in units of cost per quality-adjusted life year (QALY), using a societal perspective and a lifetime horizon. Costs were measured in 2008 US dollars, and costs and benefits were discounted at 3%. We compared the ICER of monitoring strategies with those of other resource-constrained decisions, in particular earlier cART initiation (at CD4 counts of 350 cells/mm(3) rather than 200 cells/mm3).Results: Monitoring strategies employing routine CD4 testing without virologic testing never maximized health benefits, regardless of budget or societal willingness to pay for additional health benefits. Monitoring strategies employing virologic testing conditional upon particular CD4 results delivered the most benefit at willingness-to-pay levels similar to the cost of earlier cART initiation (approximately $2600/QALY). Monitoring strategies employing routine virologic testing alone only maximized health benefits at willingness-to-pay levels (> $4400/QALY) that greatly exceeded the ICER of earlier cART initiation.Conclusions: CD4 testing alone never maximized health benefits regardless of resource limitations. Programmes routinely performing virologic testing but deferring cART initiation may increase health benefits by reallocating monitoring resources towards earlier cART initiation.