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Sunday, October 21, 2007
P1-49

COST-EFFECTIVENESS OF HIV MONITORING STRATEGIES IN RESOURCE-LIMITED SETTINGS

Eran Bendavid, MD, Stanford University, Stanford, CA, Am Bayoumi, MD, MSc, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada, David A. Katzenstein, MD, Stanford University, Stanford, CA, Gillian D. Sanders, PhD, Duke, Durham, NC, and Douglas K. Owens, MD, MS, VA Palo Alto Health Care System & Stanford University, Palo Alto, CA.

Background: Although the number of HIV infected people receiving highly active anti-retroviral therapy (HAART) in low- and middle- income countries has increased dramatically, optimal disease management in these settings is not well defined. Methods: We developed a model to compare the lifetime costs and benefits of three different strategies for managing HAART: a symptom-based strategy, a CD4-based strategy, and a CD4 & viral load strategy for starting, switching, and stopping HAART. Patients were followed from the time of presentation to care, and were eligible for first- and second-line regimens. We used published data from Cape Town cohorts and performed a cost-effectiveness analysis. Results: Compared to a symptom-based approach, monitoring CD4 every 6 months and starting treatment at a threshold of 200 cells/μl was associated with a gain of 10.8 months of life (57.6 vs. 68.4 discounted months) and lifetime cost savings of $689 per person ($3,752 vs. $4,441). CD4-based strategies where treatment was started at 350 cells/μl were more costly but yielded an additional gain of 5.7 months compared to a threshold of 200 cells/μl. Using viral load in addition to CD4 was substantially more expensive than monitoring CD4 alone, produced a gain of 1.4 months of life, and had an incremental cost-effectiveness ratio of $6,050 per life-year gained. In sensitivity analysis, the price of viral load testing and the rates of virologic failure had a significant effect on the cost-effectiveness of viral load monitoring. Conclusion: Expanding access to CD4 monitoring in resource-limited regions is cost-saving and provides substantial health benefits. The cost-effectiveness of viral load monitoring depends on the price per test and rates of virologic failure.