The cost-effectiveness of prophylaxis strategies for individuals with advanced HIV starting treatment in Africa

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dc.contributor.authorWalker, Simon M.
dc.contributor.authorCox, Edward
dc.contributor.authorRevill, Paul
dc.contributor.authorMusiime, Victor
dc.contributor.authorBwakura-Dangarembizi, Mutsa
dc.contributor.authorMallewa, Jane
dc.contributor.authorCheruiyot, Priscilla
dc.contributor.authorMaitland, Kathryn
dc.contributor.authorFord, Nathan
dc.contributor.authorGibb, Diana M
dc.contributor.authorWalker, Sarah A.
dc.contributor.authorSoares, Marta
dc.date.accessioned2021-12-10T13:19:31Z
dc.date.available2021-12-10T13:19:31Z
dc.date.issued2020
dc.description.abstractMany 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.en_US
dc.identifier.citationWalker, 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:10.1002en_US
dc.identifier.urihttps://doi.org/10.1002/jia2.25469
dc.identifier.urihttps://nru.uncst.go.ug/xmlui/handle/123456789/259
dc.language.isoenen_US
dc.publisherJohn Wiley & Sons Ltden_US
dc.subjectHIVen_US
dc.subjectprophylaxisen_US
dc.subjectfluconazoleen_US
dc.subjectlate-presentersen_US
dc.subjectcost-effectivenessen_US
dc.titleThe cost-effectiveness of prophylaxis strategies for individuals with advanced HIV starting treatment in Africaen_US
dc.typeArticleen_US
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