Background: In 2000, WHO/UNAIDS recommended co-trimoxazole prophylaxis for persons at early stages of HIV infection (WHO stage ≥ 2) in sub-Saharan Africa.
Objective: To assess the cost-effectiveness of alternative strategies for initiation of co-trimoxazole in Côte d’Ivoire.
Design: Cost-effectiveness analysis with an HIV simulation model using clinical and cost data from a randomized trial of co-trimoxazole in HIV-infected adults.
Methods: The study included HIV-infected patients in Côte d’Ivoire, with median age 33 years. Thirty-four percent were classified as WHO stage 2, 59% as stage 3, and 7% as stage 4. The mean CD4 cell count was 331 × 106 cells/l. The interventions were no prophylaxis, clinical criteria-based co-trimoxazole initiation (early: WHO stage ≥ 2; late: WHO stage ≥ 3), CD4-based co-trimoxazole initiation (< 500, < 200, < 50 × 106 CD4 cells/l). The outcome measures were life expectancy, lifetime costs, and incremental cost-effectiveness.
Results: The most effective strategy, initiation of co-trimoxazole prophylaxis at WHO stage ≥ 2, increased undiscounted life expectancy by 5.2 months, discounted life expectancy by 4.4 months, and lifetime costs by US$ 60, compared with no prophylaxis. Delaying prophylaxis initiation until WHO stage ≥ 3 was less costly and less effective. All CD4-based strategies were dominated. The incremental cost-effectiveness of early versus late co-trimoxazole prophylaxis initiation was US$ 200/year of life gained. Results were stable despite wide variations in plausible assumptions about bacterial resistance and the prophylaxis efficacy on co-trimoxazole-resistant strains.
Conclusions: For HIV-infected adults in Côte d’Ivoire, co-trimoxazole prophylaxis is reasonably cost-effective and most effective if initiated when WHO stage ≥ 2. Early co-trimoxazole prophylaxis will prevent complications prior to antiretroviral therapy initiation and should be considered an essential component of care for early HIV in sub-Saharan Africa.
From the aService Universitaire des Maladies Infectieuses et du Voyageur, Centre Hospitalier de Tourcoing, Faculté de Médecine de Lille
bLaboratoire de Recherches Économiques et Sociales, CNRS URA 362, Lille, France
cBoston University School of Public Health, Boston, Massachusetts
dMassachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
eINSERM U593, Bordeaux, France
fProgramme PAC-CI, Abidjan, Côte d’Ivoire
gHarvard School of Public Health, Boston, Massachusetts
hCenters for Disease Control and Prevention, Atlanta, GA, USA.
Received 17 August, 2004
Revised 22 March, 2005
Accepted 17 April, 2005
Correspondence to Yazdan Yazdanpanah, MD, PhD, Service Universitaire des Maladies Infectieuses et du Voyageur, Centre Hospitalier de Tourcoing (Faculté de Médecine de Lille), 135, rue du Président Coty – B.P.619, F 59208 Tourcoing, France. E-mail: firstname.lastname@example.org