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Cost-effectiveness of different starting criteria of antiretroviral therapy in Mexico.

Cost-effectiveness of different starting criteria of antiretroviral therapy in Mexico. Caro Y., Colchero A. , Valencia A. , Bautista-Arredondo S. , Sierra J., Bertozzi S. Background.

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Cost-effectiveness of different starting criteria of antiretroviral therapy in Mexico.

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  1. Cost-effectiveness of different starting criteria of antiretroviral therapy in Mexico. Caro Y., Colchero A. , Valencia A. , Bautista-Arredondo S. , Sierra J., Bertozzi S.

  2. Background • Optimal time for antiretroviral (ARV) therapy initiation for asymptomatic HIV infected individuals remains controversial, especially in developing countries. • Previous studies agree on initiation of ARV in CD4 counts<200 cells/mm3. Few of them focus on asymptomatic patients. • Results indicate higher survival in early initiation, however this decision implies higher financial burden. • In Mexico there are no cost effectiveness studies on this topic. Studies to assess the costs and effects of different criteria to start ARV in Mexico are needed to guide optimal resource allocation.

  3. Mexican Guidelines (currently under revision)

  4. Initiating ARV with CD4>350 *DHHS. Guidelines for the use of ARV agents in HIV-1 infected adults and adolescents, Dec 2007

  5. Objective To develop a cost-effectiveness model to compare different CD4 counts levels for treatment initiation in asymptomatic HIV infected patients in Mexico.

  6. Methods • A Markov model was developed to simulate a cohort of HIV positive patients with starting CD4 points of therapy between 200 and 500cells/mm3. • Disease progression for treated individual was modeled as a function of time on therapy. • We assumed different probabilities of viral suppression by adherence level and time on treatment.

  7. acute survive survive die survive Natural History chronic survive suppressed die die die acute (*) survive non suppressed survive die ARV (*) chronic ARV die survive No ARV die Model

  8. Main assumptions • Only first line treatment is available. • Viral suppression is defined as VL<50copies/ml • CD4 reaches a plateau according CD4 count at ARV initiation. • High adherence (>95%) in 77% of patients. • Non suppressed patients continue treatment but disease progression is 50% lower for 5 years.

  9. Data modeling • CD4 and VL distributions from cohorts of asymptomatic patients without prior treatment in INCMNSZ. (National Institute of Medical Sciences and Nutrition) • Changes in CD4 and VL, supression by adherence, probabilities of OD and mortality from previous studies. • Costs data were extracted from local sources. • We estimated the cost per year lived for each simulated alternative.

  10. Mean: 292.2cel/mm3 (sd:188.38) n=195 Source:National Institute of Medical Sciences and Nutrition

  11. Treatment initiation criteria • CD4 count for treatment initiation is randomly selected from a uniform distribution Unif(200,500). • Each patient has a random CD4 count for treatment initiation. • Treat if AIDS defining condition is present regardless of CD4 cell count.

  12. Base case results *All costs are in 2007 US dollars. Discounted costs

  13. Mean Mean Scenario Strategy ICER Effectiveness Cost No ARV 3.21 4,431 - 200-300 11.21* 52,011 5,948 Base Case Weakly 300-400 11.43 57,166 dominated 400-500 11.53** 57,601 17,467 No ARV 4.81 6,418 - CD4 at 200-300 9.96* 40,076 6,535 baseline 11.92*** 300-400 53,518 6,858 3 500cell/mm 400-500 12.99** 63,823 9,631 No ARV 3.22 4,430 - 50% of 200-300 10.89* 49,711 5,904 patients with Weakly high 300-400 10.66 49,844 dominated adherence 400-500 11.25** 55,403 15,443 Sensitivity analysis * p-value<0.01 CD4 200-300 vs No ARV ** p-value<0.01 CD4 200-300 vs CD4 400-500 *** p-value<0.01 CD4 300-400 vs CD4 400-500

  14. Comparisonwith other studies

  15. Conclusions • In Mexico, starting therapy early may lead better survival benefits but at a higher cost. • Results could be overestimated due to uncertainty in the parameters used. However, sensitivity analysis showed similar conclusions.

  16. Discussion • Improvement in VCT services with earlier detection could lead to higher benefits from ARVs. • Costs could be overestimated. Using median costs could lead to lower ICERs. • Including second-line therapy could increase benefits but at a higher cost. • Future models should incorporate adverse effects to treatment, drug resistance and disease transmission to fully assess all risk and benefits of early versus late treatment initiation. • Results of this study can help decision makers select cost effective strategies for treatment initiation.

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