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Abstract
Scaling up
WHO recommendations for HIV therapy in resource-limited settings: what to do
first
R. Walensky1,2,3,4, R. Wood5, A. Ciaranello1,2, A. Paltiel6, S. Lorenzana1, X. Anglaret7, A. Stoler1, K. Freedberg1,4,8
Background:
The 2009 WHO HIV treatment guidelines recommend
earlier ART initiation (CD4< 350/µl vs. < 200/µl), multiple sequential ART regimens,
and replacement of first-line stavudine with tenofovir. We consider what to do first in settings
where immediate implementation of all WHO recommendations is infeasible.
Methods:
We use a mathematical model and regional input
data to project clinical and economic outcomes in a South African HIV-infected
cohort (mean age 32.8y, mean CD4 375/µl). We rank - in survival and
cost-effectiveness terms - all 12 possible combinations of: 1) stavudine
replacement with tenofovir; 2) ART initiation criterion (WHO stage;
CD4< 200/µl; or CD4< 350/µl); and 3) number of ART regimens available (1 or
2). Clinical results are undiscounted; cost-effectiveness results discount life
expectancy (LE) and costs at 3%/year. The
baseline assumption is that patients receive a single, stavudine-based ART
regimen, initiatied at WHO Stage III/IV (“stavudine/WHO/one-line”).
Results:
Projected baseline
survival is 99.1m. Five-year survival is maximized by initiating ART at CD4< 350/µl
(stavudine/< 350/µl/one-line; 87% survival) compared with adding 2nd-line
ART (stavudine/WHO/two-lines; 66%) or substituting tenofovir (tenofovir/WHO/one-line;
67%). Incremental life expectancy gains
are maximized via the following stepwise programmatic additions:
stavudine/< 350/µl/one-line (124.4m); stavudine/< 350/µl/two-lines (177.7m);
and tenofovir/< 350/µl/two-lines (191.5m).
Three programs are economically efficient: stavudine/< 350/µl/one-line
(cost-effectiveness ratio $610/year of life saved [YLS]),
tenofovir/< 350/µl/one-line ($1,410/YLS), and tenofovir/< 350/µl/two-lines
($2,230/YLS). These results persist in
the face of plausible variation in efficacy and cost assumptions.
Conclusions:
While full and immediate implementation of the WHO
recommendations is cost-effective by widely accepted international standards,
nations with very limited resources should focus first on access to CD4
count monitoring and ART initiation at CD4< 350/µl. The optimal
second step is to switch from stavudine to tenofovir. In countries with
sufficient budgets to provide second-line ART, it is neither effective nor
cost-effective to maintain stavudine in first-line regimens.
AIDS 2010 - XVIII International AIDS Conference
Abstract no.
WEAE0204
Suggested Citation
"R.Walensky, et al.
Scaling up
WHO recommendations for HIV therapy in resource-limited settings: what to do
first.
:
AIDS 2010 - XVIII International AIDS Conference:
Abstract no.
WEAE0204 "
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