The cost-effectiveness of prophylaxis strategies for individuals with advanced HIV starting treatment in Africa
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Date
2020
Authors
Walker, Simon M.
Cox, Edward
Revill, Paul
Musiime, Victor
Bwakura-Dangarembizi, Mutsa
Mallewa, Jane
Cheruiyot, Priscilla
Maitland, Kathryn
Ford, Nathan
Gibb, Diana M
Journal Title
Journal ISSN
Volume Title
Publisher
John Wiley & Sons Ltd
Abstract
Many HIV-positive individuals in Africa have advanced disease when initiating antiretroviral therapy (ART) so
have high risks of opportunistic infections and death. The REALITY trial found that an enhanced-prophylaxis package including
fluconazole reduced mortality by 27% in individuals starting ART with CD4 <100 cells/mm3. We investigated the cost-effectiveness of this enhanced-prophylaxis package versus other strategies, including using cryptococcal antigen (CrAg) testing, in individuals with CD4 <200 cells/mm3 or <100 cells/mm3 at ART initiation and all individuals regardless of CD4 count.
Methods: The REALITY trial enrolled from June 2013 to April 2015. A decision-analytic model was developed to estimate
the cost-effectiveness of six management strategies in individuals initiating ART in the REALITY trial countries. Strategies
included standard-prophylaxis, enhanced-prophylaxis, standard-prophylaxis with fluconazole; and three CrAg testing strategies,
the first stratifying individuals to enhanced-prophylaxis (CrAg-positive) or standard-prophylaxis (CrAg-negative), the second to
enhanced-prophylaxis (CrAg-positive) or enhanced-prophylaxis without fluconazole (CrAg-negative) and the third to standardprophylaxis
with fluconazole (CrAg-positive) or without fluconazole (CrAg-negative). The model estimated costs, life-years and
quality-adjusted life-years (QALY) over 48 weeks using three competing mortality risks: cryptococcal meningitis; tuberculosis,
serious bacterial infection or other known cause; and unknown cause.
Results: Enhanced-prophylaxis was cost-effective at cost-effectiveness thresholds of US$300 and US$500 per QALY with an
incremental cost-effectiveness ratio (ICER) of US$157 per QALY in the CD4 <200 cells/mm3 population providing enhancedprophylaxis components are sourced at lowest available prices. The ICER reduced in more severely immunosuppressed individuals
(US$113 per QALY in the CD4 <100 cells/mm3 population) and increased in all individuals regardless of CD4 count (US
$722 per QALY). Results were sensitive to prices of the enhanced-prophylaxis components. Enhanced-prophylaxis was more
effective and less costly than all CrAg testing strategies as enhanced-prophylaxis still conveyed health gains in CrAg-negative
patients and savings from targeting prophylaxis based on CrAg status did not compensate for costs of CrAg testing. CrAg testing
strategies did not become cost-effective unless the price of CrAg testing fell below US$2.30.
Conclusions: The REALITY enhanced-prophylaxis package in individuals with advanced HIV starting ART reduces morbidity
and mortality, is practical to administer and is cost-effective. Efforts should continue to ensure that components are accessed
at lowest available prices.
Description
Keywords
HIV, prophylaxis, fluconazole, late-presenters, cost-effectiveness
Citation
Walker, S. M., Cox, E., Revill, P., Musiime, V., Bwakura‐Dangarembizi, M., Mallewa, J., ... & Anyango Orido, M. (2020). The cost‐effectiveness of prophylaxis strategies for individuals with advanced HIV starting treatment in Africa. Journal of the International AIDS Society, 23(3), e25469.doi:10.1002