Lindsey L. Wolf

When to Start Antiretroviral Therapy in Resource-Limited Settings

BACKGROUND The results of international clinical trials that are assessing when to initiate antiretroviral therapy (ART) will not be available for several years. OBJECTIVE To inform HIV treatment decisions about the optimal CD4 threshold at which to initiate ART in South Africa while awaiting the results of these trials. DESIGN Cost-effectiveness analysis by using a computer simulation model of HIV disease. DATA SOURCES Published data from randomized trials and observational cohorts in South Africa. TARGET POPULATION HIV-infected patients in South Africa. TIME HORIZON 5-year and lifetime. PERSPECTIVE Modified societal. INTERVENTION No treatment, ART initiated at a CD4 count less than 0.250 x 10(9) cells/L, and ART initiated at a CD4 count less than 0.350 x 10(9) cells/L. OUTCOME MEASURES Morbidity, mortality, life expectancy, medical costs, and cost-effectiveness. RESULTS OF BASE-CASE ANALYSIS If 10% to 100% of HIV-infected patients are identified and linked to care, a CD4 count threshold for ART initiation of 0.350 x 10(9) cells/L would reduce severe opportunistic diseases by 22,000 to 221,000 and deaths by 25,000 to 253,000 during the next 5 years compared with ART initiation at 0.250 x 10(9) cells/L; cost increases would range from

Cost-effectiveness of an intervention to improve adherence to antiretroviral therapy in HIV-infected patients.

142 million (10%) to

The cost-effectiveness of antiretroviral therapy for treating HIV disease in the Caribbean.

1.4 billion (100%). Either ART initiation strategy would increase long-term survival by at least 7.9 years, with a mean per-person life expectancy of 3.8 years with no ART and 12.5 years with an initiation threshold of 0.350 x 10(9) cells/L. Compared with an initiation threshold of 0.250 x 10(9) cells/L, a threshold of 0.350 x 10(9) cells/L has an incremental cost-effectiveness ratio of

Subtyping sub-Saharan esophageal squamous cell carcinoma by comprehensive molecular analysis

1200 per year of life saved. RESULTS OF SENSITIVITY ANALYSIS Initiating ART at a CD4 count less than 0.350 x 10(9) cells/L would remain cost-effective over the next 5 years even if the probability that the trial would demonstrate the superiority of earlier therapy is as low as 17%. LIMITATION This model does not consider the possible benefits of initiating ART at a CD4 count greater than 0.350 x 10(9) cells/L or of reduced HIV transmission. CONCLUSION Earlier initiation of ART in South Africa will probably reduce morbidity and mortality, improve long-term survival, and be cost-effective. While awaiting trial results, treatment guidelines should be liberalized to allow initiation at CD4 counts less than 0.350 x 10(9) cells/L, earlier than is currently recommended. PRIMARY FUNDING SOURCE National Institute of Allergy and Infectious Diseases and the Doris Duke Charitable Foundation.

Esophagogastroduodenoscopy in a Public Referral Hospital in Lilongwe, Malawi: Spectrum of Disease and Associated Risk Factors

Summary:Adherence to antiretroviral medications has been shown to be an important factor in predicting viral suppression and clinical outcomes. The objective of this analysis was to assess the cost-effectiveness of a nursing intervention on antiretroviral adherence using data from a randomized controlled clinical trial as input to a computer-based simulation model of HIV disease. For a cohort of HIV-infected patients similar to those in the clinical trial (mean initial CD4 count of 319 cells/mm3), implementing the nursing intervention in addition to standard care yielded a 63% increase in virologic suppression at 48 weeks. This produced increases in expected survival (from 94.5 to 100.9 quality-adjusted life months) and estimated discounted direct lifetime medical costs (

Implications of the patient protection and affordable care act on insurance coverage and rehabilitation use among young adult trauma patients

253,800 to

Insurance status is associated with complex presentation among emergency general surgery patients

261,300). The incremental cost-effectiveness ratio for the intervention was

CD4+ T-cell-guided structured treatment interruptions of antiretroviral therapy in HIV disease: projecting beyond clinical trials.

14,100 per quality-adjusted life year gained compared with standard care. Adherence interventions with modest effectiveness are likely to provide long-term survival benefit to patients and to be cost-effective compared with other uses of HIV care funds.

Factors associated with pediatric mortality from motor vehicle crashes in the United States: a state-based analysis

Background:Antiretroviral therapy (ART) recently became available in the Organization of Eastern Caribbean States (OECS). Survival benefits and budgetary implications associated with universal access to ART have not been examined in the Caribbean. Methods:Using a state-transition simulation model of HIV with regional data, we projected survival, cost, and cost-effectiveness of treating an HIV-infected cohort. We examined 1 or 2 ART regimens and cotrimoxazole. In sensitivity analysis, we varied HIV natural history and ART efficacy, cost, and switching criteria. Results:Without treatment, mean survival was 2.30 years (mean baseline CD4 count = 288 cells/μL). One ART regimen with cotrimoxazole when the CD4 count was <350 cells/μL provided an additional 5.86 years of survival benefit compared with no treatment; the incremental cost-effectiveness ratio was

Hernia recurrence following inguinal hernia repair in children

690 per year of life saved (YLS). A second regimen added 1.04 years of survival benefit; the incremental cost-effectiveness ratio was