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Modeling the cost–effectiveness of HIV treatment: how to buy the most ‘health’ when resources are limited

Kessler, Jason; Braithwaite, R. Scott

doi: 10.1097/COH.0000000000000005
TREATMENT OPTIMISATION: Edited by David H. Brown Ripin, Charles W. Flexner and Ben Plumley

Purpose of review: To summarize recent cost–effectiveness analyses (CEAs) that evaluate optimal treatment strategies for persons living with HIV/AIDS (PLWHA).

Recent findings: Efforts to attain universal coverage of current treatment guidelines (e.g., initiation at CD4+ cell count <350 cells/μl) are generally very costeffective. Expansion of access beyond current guidelines will additionally improve clinical outcomes and aversion of new HIV infections; however, cost–effectiveness is more uncertain. Increasing access to antiretroviral therapy (ART) offers greater health benefit than investing the same funds in intensive laboratory monitoring for those on ART, particularly in those settings in which universal coverage has not yet been attained. Recommended ART regimens (e.g., tenofovir) have favorable cost–effectiveness when compared with substitution of newer, more expensive agents (e.g., rilpivirine, darunavir) or substitution of older, cheaper alternatives that are more toxic (e.g., stavudine).

Summary: There is increasing use of CEA to evaluate decisions regarding HIV treatment in order to buy the most ‘health’ with limited resources. Expansion of ART access provides substantial clinical and preventive benefit and offers favorable cost–effectiveness. Intensive laboratory monitoring may not be the highest priority in settings in which resources are constrained. Further work on the economic impact, clinical effectiveness, and feasibility of ART treatment for all (e.g., no CD4+ cell initiation criteria) is needed.

Division of Comparative Effectiveness and Decision Science, Department of Population Health, New York University School of Medicine, New York, New York, USA

Correspondence to Jason Kessler, Department of Population Health, NYU School of Medicine, 227 East 30th Street, Room 650, New York, NY 10016, USA. Tel: +1 212 263 4994; e-mail:

© 2013 Lippincott Williams & Wilkins, Inc.