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Laboratory Monitoring to Guide Switching Antiretroviral Therapy in Resource-Limited Settings: Clinical Benefits and Cost-Effectiveness

Kimmel, April D PhD, MSc*†; Weinstein, Milton C PhD†‡; Anglaret, Xavier MD, PhD§‖; Goldie, Sue J MD, MPH; Losina, Elena PhD‡¶#; Yazdanpanah, Yazdan MD, PhD**††; Messou, Eugène MD, MPH; Cotich, Kara L BS; Walensky, Rochelle P MD, MPH‡#‡‡; Freedberg, Kenneth A MD†‡¶‡‡for the CEPAC-International Investigators

JAIDS Journal of Acquired Immune Deficiency Syndromes: July 1st, 2010 - Volume 54 - Issue 3 - p 258-268
doi: 10.1097/QAI.0b013e3181d0db97
Clinical Science

Background: As second-line antiretroviral therapy (ART) availability increases in resource-limited settings, questions about the value of laboratory monitoring remain. We assessed the outcomes and cost-effectiveness (CE) of laboratory monitoring to guide switching ART.

Methods: We used a computer model to project life expectancy and costs of different strategies to guide ART switching in patients in Côte d'Ivoire. Strategies included clinical assessment, CD4 count, and HIV RNA testing. Data were from clinical trials and cohort studies from Côte d'Ivoire and the literature. Outcomes were compared using the incremental CE ratio. We conducted multiple sensitivity analyses to assess uncertainty in model parameters.

Results: Compared with first-line ART only, second-line ART increased life expectancy by 24% with clinical monitoring only, 46% with CD4 monitoring, and 61% with HIV RNA monitoring. The incremental CE ratio of switching based on clinical monitoring was $1670 per year of life gained (YLS) compared with first-line ART only; biannual CD4 monitoring was $2120 per YLS. The CE ratio of biannual HIV RNA testing ranged from $2920 ($87/test) to $1990 per YLS ($25/test). If second-line ART costs were reduced, the CE of HIV RNA monitoring improved.

Conclusions: In resource-limited settings, CD4 count and HIV RNA monitoring to guide switching to second-line ART improve survival and, under most conditions, are cost-effective.

From the *Weill Cornell Medical College, New York, NY; †Harvard School of Public Health, Boston, MA; ‡Harvard Medical School, Boston, MA; §INSERM Unité 897, Bordeaux, France; ‖Programme PAC-CI, Abidjan, Côte d'Ivoire; ¶Boston University School of Public Health, Boston, MA; #Brigham and Women's Hospital, Boston, MA; **Service Universitaire des Maladies Infectieuses et du Voyageur, Centre Hospitalier de Tourcoing, Lille, France; ††EA 2694, Faculté de Médecine de Lille, Lille, France; and ‡‡Massachusetts General Hospital, Boston, MA.

Received for publication June 16, 2009; accepted December 18, 2009.

Supported in part by the National Institute of Allergy and Infectious Diseases (T32 AI007433, R01 AI058736, K24 AI062476, K25 AI50436, and CFAR P30 AI42851), the French Agence National de Recherches sur le SIDA (ANRS 1286), the Agency for Healthcare Research and Quality (T32 HS000055), the Doris Duke Charitable Foundation (CSDA 2005075), the Project on Justice, Welfare and Economics, Weatherhead Center for International Affairs, Harvard University, and the Graduate Society Summer Fellowship, Graduate School of Arts and Sciences, Harvard University.

Preliminary results for this article were presented in part at the XVII International AIDS Conference, August 3-8, 2008, Mexico City, Mexico, as well as at the 31st Annual Meeting of the Society for Medical Decision Making, October 18-21, 2009, Hollywood, CA.

§§Members of the CEPAC-International team are listed in Appendix 1 (also available online at www.jaids.com).

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions this article on the journal's Web site (www.jaids.com).

Correspondence to: April D. Kimmel, PhD, MSc, Department of Public Health, Weill Cornell Medical College, 402 E. 67th Street, New York, NY 10065 (e-mail: adk2010@med.cornell.edu).

© 2010 Lippincott Williams & Wilkins, Inc.