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Earlier Initialization of Highly Active Antiretroviral Therapy Is Associated With Long-Term Survival and Is Cost-Effective: Findings From a Deterministic Model of a 10-Year Ugandan Cohort

Mills, Fergal P. BA*; Ford, Nathan PhD, MPH; Nachega, Jean B. MD, PhD, MPH‡,§; Bansback, Nicholas PhD, MSc; Nosyk, Bohdan PhD, MSc‖,¶; Yaya, Sanni PhD, MBA*; Mills, Edward J. PhD, MSc*

JAIDS Journal of Acquired Immune Deficiency Syndromes: November 1st, 2012 - Volume 61 - Issue 3 - p 364–369
doi: 10.1097/QAI.0b013e318265df06
Epidemiology and Prevention

Background: Raising the guidelines for the initiation of antiretroviral therapy in resource-limited settings at CD4+ T-cell counts of 350 cells per microliter raises concerns about feasibility and cost. We examined costs of this shift using data from Uganda for almost 10 years.

Methods: We projected total costs of earlier initiation with combined antiretroviral therapy, including inpatient and outpatient services, antiretroviral treatment and treatment for limited HIV-related opportunistic diseases, and benefits expressed in years-of-life-saved over 5- and 30-year time horizons using a deterministic economic model to examine the incremental cost-effectiveness ratio (ICER), expressed in cost per year-of-life-saved (YLS).

Results: The model generated ICERs for 5- and 30-year time horizons. Discounting both costs and benefits at 3% annually, for the 5-year analysis, the ICER was $695/YLS and $769 in the 30-year analysis. The results were most sensitive to program cost and the discount rate applied, but they were less sensitive to opportunistic infection treatment costs or the relative-risk reduction from earlier initiation. Program costs varied from 25% to 125%, and the ICER for the lower bound decreased to $491/YLS at 5-years and $574/YLS at 30 years. For the upper bound, the ICER increased to $899 for 5-years and $964 at 30-years. The budget impact of adoption, assuming the same level of program penetration in the community, is $261,651,942 for 5 years and $872,685,561 for 30 years.

Conclusions: Our model showed that earlier initiation of combined antiretroviral therapy in Uganda is associated with improved long-term survival and is highly cost-effective, as defined by WHO-CHOICE.

*Faculty of Health Sciences, University of Ottawa, Ottawa, Canada

Médecins Sans Frontiers, Geneva, Switzerland

Centre for Infectious Diseases, Faculty of Health Sciences, Stellenbosch University, Stellenbosch, South Africa

§Department of International Health and Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD

School of Population and Public Health; and

British Columbia Centre for Excellence in HIV/AIDS, University of British Columbia, Vancouver, Canada

Correspondence to: Edward J. Mills, PhD, MSc, Faculty of Health Sciences, University of Ottawa, 43 Templeton Street, Ottawa, Canada K1N6X1 (e-mail:

The authors have no funding or conflicts of interest to disclose.

Received February 13, 2012

Accepted June 01, 2012

© 2012 Lippincott Williams & Wilkins, Inc.