The cost‐effectiveness of prophylaxis strategies for individuals with advanced HIV starting treatment in Africa
Introduction Many HIV‐positive individuals in Africa have advanced disease when initiating antiretroviral therapy (ART) so have high risks of opportunistic infections and death. The REALITY trial found that an enhanced‐prophylaxis package including fluconazole reduced mortality by 27% in individuals...
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| Veröffentlicht in: | Journal of the International AIDS Society 2020-03, Vol.23 (3), p.e25469-n/a |
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| creator | Cox, Edward Revill, Paul Bwakura‐Dangarembizi, Mutsa Mallewa, Jane Cheruiyot, Priscilla Gibb, Diana M Walker, A Sarah Kityo, C Wavamunno, P Nambi, E Ocitti, P Ndigendawani, M Kabahenda, S Acen, J Nambaziira, F Kabaswahili, V Abach, J Omongin, J Philliam, A Ocung, E Miles, P Adong, C Kidega, P Mukuye, A Baliruno, D Kigongo, F Kikyonkyo, D Mushahara, F Okweny, D Atwongyeire, D Mula, S Noowe, N Lugemwa, A Kyomuhangi, J Ankunda, R Ayesiga, L Nathoo, K Reid, A Tinago, GC Mudzingwa, S Phiri, M Musoro, G Nemasango, B Moyo, C Chitongo, S Mlambo, B Ndemera, B Agutu, C Berkley, J Maitland, K Wale, S Shangala, J Kithunga, J Mutai, R Mwanzu, A Latham, H Shikuku, J Mwakisha, B Siika, A Wools‐Kaloustian, K Nyandiko, W Meli, B Mokaya, M Mboya, C Mengich, C Choge, J Injera, W Njenga, K Cherutich, S Anyango Orido, M Kutto, I Shali, A Pierre, M Van Oosterhout, J Heydermann, R Dzabala, N Ziwoya, M Masesa, C Mwalukomo, T Bwanali, J Thomason, M Pett, S Little, E Cowan, F Bernays, S Mupambireyi, Z Kyomuhendo, F Nakalanzi, S Mkandawire, N Matandika, L Kapuya, C Malianga, E Gibb, D Etyang, A Phiri, S Lyall, H Fitzgerald, F Prendergast, A Arenas‐Pinto, A Turkova, A |
| description | Introduction
Many HIV‐positive individuals in Africa have advanced disease when initiating antiretroviral therapy (ART) so have high risks of opportunistic infections and death. The REALITY trial found that an enhanced‐prophylaxis package including fluconazole reduced mortality by 27% in individuals starting ART with CD4 |
| doi_str_mv | 10.1002/jia2.25469 |
| format | Article |
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Many HIV‐positive individuals in Africa have advanced disease when initiating antiretroviral therapy (ART) so have high risks of opportunistic infections and death. The REALITY trial found that an enhanced‐prophylaxis package including fluconazole reduced mortality by 27% in individuals starting ART with CD4 <100 cells/mm3. We investigated the cost‐effectiveness of this enhanced‐prophylaxis package versus other strategies, including using cryptococcal antigen (CrAg) testing, in individuals with CD4 <200 cells/mm3 or <100 cells/mm3 at ART initiation and all individuals regardless of CD4 count.
Methods
The REALITY trial enrolled from June 2013 to April 2015. A decision‐analytic model was developed to estimate the cost‐effectiveness of six management strategies in individuals initiating ART in the REALITY trial countries. Strategies included standard‐prophylaxis, enhanced‐prophylaxis, standard‐prophylaxis with fluconazole; and three CrAg testing strategies, the first stratifying individuals to enhanced‐prophylaxis (CrAg‐positive) or standard‐prophylaxis (CrAg‐negative), the second to enhanced‐prophylaxis (CrAg‐positive) or enhanced‐prophylaxis without fluconazole (CrAg‐negative) and the third to standard‐prophylaxis with fluconazole (CrAg‐positive) or without fluconazole (CrAg‐negative). The model estimated costs, life‐years and quality‐adjusted life‐years (QALY) over 48 weeks using three competing mortality risks: cryptococcal meningitis; tuberculosis, serious bacterial infection or other known cause; and unknown cause.
Results
Enhanced‐prophylaxis was cost‐effective at cost‐effectiveness thresholds of US$300 and US$500 per QALY with an incremental cost‐effectiveness ratio (ICER) of US$157 per QALY in the CD4 <200 cells/mm3 population providing enhanced‐prophylaxis components are sourced at lowest available prices. The ICER reduced in more severely immunosuppressed individuals (US$113 per QALY in the CD4 <100 cells/mm3 population) and increased in all individuals regardless of CD4 count (US$722 per QALY). Results were sensitive to prices of the enhanced‐prophylaxis components. Enhanced‐prophylaxis was more effective and less costly than all CrAg testing strategies as enhanced‐prophylaxis still conveyed health gains in CrAg‐negative patients and savings from targeting prophylaxis based on CrAg status did not compensate for costs of CrAg testing. CrAg testing strategies did not become cost‐effective unless the price of CrAg testing fell below US$2.30.
Conclusions
The REALITY enhanced‐prophylaxis package in individuals with advanced HIV starting ART reduces morbidity and mortality, is practical to administer and is cost‐effective. Efforts should continue to ensure that components are accessed at lowest available prices.</description><identifier>ISSN: 1758-2652</identifier><identifier>EISSN: 1758-2652</identifier><identifier>DOI: 10.1002/jia2.25469</identifier><identifier>PMID: 32219991</identifier><language>eng</language><publisher>Switzerland: International AIDS Society</publisher><subject>Acquired immune deficiency syndrome ; Adolescent ; Adult ; Africa ; AIDS ; AIDS-Related Opportunistic Infections - economics ; AIDS-Related Opportunistic Infections - prevention & control ; Analysis ; Anti-HIV Agents - administration & dosage ; Anti-HIV Agents - economics ; Anti-HIV Agents - therapeutic use ; Antifungal agents ; Antifungal Agents - administration & dosage ; Antifungal Agents - therapeutic use ; Antigens, Fungal - analysis ; Antiretroviral agents ; Bacterial infections ; Care and treatment ; CD4 Lymphocyte Count ; Child ; Child, Preschool ; Cohort Studies ; Cost benefit analysis ; Costs ; cost‐effectiveness ; Cryptococcus - immunology ; Diagnosis ; Drug dosages ; Drug therapy ; Economic aspects ; Evaluation ; Female ; Fluconazole ; Fluconazole - therapeutic use ; Health aspects ; Highly active antiretroviral therapy ; HIV ; HIV infection ; HIV Infections - drug therapy ; HIV Infections - economics ; HIV Infections - mortality ; HIV Infections - prevention & control ; Human immunodeficiency virus ; Humans ; Infections ; Kenya ; late‐presenters ; Malawi ; Male ; Meningitis ; Mortality ; Post-Exposure Prophylaxis - economics ; Practice guidelines (Medicine) ; Prophylaxis ; Quality-Adjusted Life Years ; Strategic planning (Business) ; Sub-Saharan Africa ; Tuberculosis ; Uganda ; United Kingdom ; Zimbabwe</subject><ispartof>Journal of the International AIDS Society, 2020-03, Vol.23 (3), p.e25469-n/a</ispartof><rights>2020 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.</rights><rights>COPYRIGHT 2020 International AIDS Society</rights><rights>COPYRIGHT 2020 John Wiley & Sons, Inc.</rights><rights>2020. This work is published under http://creativecommons.org/licenses/by/4.0/ (the “License”). Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><cites>FETCH-LOGICAL-c6799-e2810e86da2c1b68947a239c8bcc96e8d4a2759c1cda4c9c4933b75a9ef27903</cites><orcidid>0000-0003-1482-3967 ; 0000-0002-5750-3691</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7099175/pdf/$$EPDF$$P50$$Gpubmedcentral$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7099175/$$EHTML$$P50$$Gpubmedcentral$$Hfree_for_read</linktohtml><link.rule.ids>230,314,727,780,784,864,885,1417,11562,27924,27925,45574,45575,46052,46476,53791,53793</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/32219991$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Cox, Edward</creatorcontrib><creatorcontrib>Revill, Paul</creatorcontrib><creatorcontrib>Bwakura‐Dangarembizi, Mutsa</creatorcontrib><creatorcontrib>Mallewa, Jane</creatorcontrib><creatorcontrib>Cheruiyot, Priscilla</creatorcontrib><creatorcontrib>Gibb, Diana M</creatorcontrib><creatorcontrib>Walker, A Sarah</creatorcontrib><creatorcontrib>Kityo, C</creatorcontrib><creatorcontrib>Wavamunno, P</creatorcontrib><creatorcontrib>Nambi, E</creatorcontrib><creatorcontrib>Ocitti, P</creatorcontrib><creatorcontrib>Ndigendawani, M</creatorcontrib><creatorcontrib>Kabahenda, S</creatorcontrib><creatorcontrib>Acen, J</creatorcontrib><creatorcontrib>Nambaziira, F</creatorcontrib><creatorcontrib>Kabaswahili, V</creatorcontrib><creatorcontrib>Abach, J</creatorcontrib><creatorcontrib>Omongin, J</creatorcontrib><creatorcontrib>Philliam, A</creatorcontrib><creatorcontrib>Ocung, E</creatorcontrib><creatorcontrib>Miles, P</creatorcontrib><creatorcontrib>Adong, C</creatorcontrib><creatorcontrib>Kidega, P</creatorcontrib><creatorcontrib>Mukuye, A</creatorcontrib><creatorcontrib>Baliruno, D</creatorcontrib><creatorcontrib>Kigongo, F</creatorcontrib><creatorcontrib>Kikyonkyo, D</creatorcontrib><creatorcontrib>Mushahara, F</creatorcontrib><creatorcontrib>Okweny, D</creatorcontrib><creatorcontrib>Atwongyeire, D</creatorcontrib><creatorcontrib>Mula, S</creatorcontrib><creatorcontrib>Noowe, N</creatorcontrib><creatorcontrib>Lugemwa, A</creatorcontrib><creatorcontrib>Kyomuhangi, J</creatorcontrib><creatorcontrib>Ankunda, R</creatorcontrib><creatorcontrib>Ayesiga, L</creatorcontrib><creatorcontrib>Nathoo, K</creatorcontrib><creatorcontrib>Reid, A</creatorcontrib><creatorcontrib>Tinago, GC</creatorcontrib><creatorcontrib>Mudzingwa, S</creatorcontrib><creatorcontrib>Phiri, M</creatorcontrib><creatorcontrib>Musoro, G</creatorcontrib><creatorcontrib>Nemasango, B</creatorcontrib><creatorcontrib>Moyo, C</creatorcontrib><creatorcontrib>Chitongo, S</creatorcontrib><creatorcontrib>Mlambo, B</creatorcontrib><creatorcontrib>Ndemera, B</creatorcontrib><creatorcontrib>Agutu, C</creatorcontrib><creatorcontrib>Berkley, J</creatorcontrib><creatorcontrib>Maitland, K</creatorcontrib><creatorcontrib>Wale, S</creatorcontrib><creatorcontrib>Shangala, J</creatorcontrib><creatorcontrib>Kithunga, J</creatorcontrib><creatorcontrib>Mutai, R</creatorcontrib><creatorcontrib>Mwanzu, A</creatorcontrib><creatorcontrib>Latham, H</creatorcontrib><creatorcontrib>Shikuku, J</creatorcontrib><creatorcontrib>Mwakisha, B</creatorcontrib><creatorcontrib>Siika, A</creatorcontrib><creatorcontrib>Wools‐Kaloustian, K</creatorcontrib><creatorcontrib>Nyandiko, W</creatorcontrib><creatorcontrib>Meli, B</creatorcontrib><creatorcontrib>Mokaya, M</creatorcontrib><creatorcontrib>Mboya, C</creatorcontrib><creatorcontrib>Mengich, C</creatorcontrib><creatorcontrib>Choge, J</creatorcontrib><creatorcontrib>Injera, W</creatorcontrib><creatorcontrib>Njenga, K</creatorcontrib><creatorcontrib>Cherutich, S</creatorcontrib><creatorcontrib>Anyango Orido, M</creatorcontrib><creatorcontrib>Kutto, I</creatorcontrib><creatorcontrib>Shali, A</creatorcontrib><creatorcontrib>Pierre, M</creatorcontrib><creatorcontrib>Van Oosterhout, J</creatorcontrib><creatorcontrib>Heydermann, R</creatorcontrib><creatorcontrib>Dzabala, N</creatorcontrib><creatorcontrib>Ziwoya, M</creatorcontrib><creatorcontrib>Masesa, C</creatorcontrib><creatorcontrib>Mwalukomo, T</creatorcontrib><creatorcontrib>Bwanali, J</creatorcontrib><creatorcontrib>Thomason, M</creatorcontrib><creatorcontrib>Pett, S</creatorcontrib><creatorcontrib>Little, E</creatorcontrib><creatorcontrib>Cowan, F</creatorcontrib><creatorcontrib>Bernays, S</creatorcontrib><creatorcontrib>Mupambireyi, Z</creatorcontrib><creatorcontrib>Kyomuhendo, F</creatorcontrib><creatorcontrib>Nakalanzi, S</creatorcontrib><creatorcontrib>Mkandawire, N</creatorcontrib><creatorcontrib>Matandika, L</creatorcontrib><creatorcontrib>Kapuya, C</creatorcontrib><creatorcontrib>Malianga, E</creatorcontrib><creatorcontrib>Gibb, D</creatorcontrib><creatorcontrib>Etyang, A</creatorcontrib><creatorcontrib>Phiri, S</creatorcontrib><creatorcontrib>Lyall, H</creatorcontrib><creatorcontrib>Fitzgerald, F</creatorcontrib><creatorcontrib>Prendergast, A</creatorcontrib><creatorcontrib>Arenas‐Pinto, A</creatorcontrib><creatorcontrib>Turkova, A</creatorcontrib><creatorcontrib>REALITY trial team</creatorcontrib><creatorcontrib>the REALITY trial team</creatorcontrib><title>The cost‐effectiveness of prophylaxis strategies for individuals with advanced HIV starting treatment in Africa</title><title>Journal of the International AIDS Society</title><addtitle>J Int AIDS Soc</addtitle><description>Introduction
Many HIV‐positive individuals in Africa have advanced disease when initiating antiretroviral therapy (ART) so have high risks of opportunistic infections and death. The REALITY trial found that an enhanced‐prophylaxis package including fluconazole reduced mortality by 27% in individuals starting ART with CD4 <100 cells/mm3. We investigated the cost‐effectiveness of this enhanced‐prophylaxis package versus other strategies, including using cryptococcal antigen (CrAg) testing, in individuals with CD4 <200 cells/mm3 or <100 cells/mm3 at ART initiation and all individuals regardless of CD4 count.
Methods
The REALITY trial enrolled from June 2013 to April 2015. A decision‐analytic model was developed to estimate the cost‐effectiveness of six management strategies in individuals initiating ART in the REALITY trial countries. Strategies included standard‐prophylaxis, enhanced‐prophylaxis, standard‐prophylaxis with fluconazole; and three CrAg testing strategies, the first stratifying individuals to enhanced‐prophylaxis (CrAg‐positive) or standard‐prophylaxis (CrAg‐negative), the second to enhanced‐prophylaxis (CrAg‐positive) or enhanced‐prophylaxis without fluconazole (CrAg‐negative) and the third to standard‐prophylaxis with fluconazole (CrAg‐positive) or without fluconazole (CrAg‐negative). The model estimated costs, life‐years and quality‐adjusted life‐years (QALY) over 48 weeks using three competing mortality risks: cryptococcal meningitis; tuberculosis, serious bacterial infection or other known cause; and unknown cause.
Results
Enhanced‐prophylaxis was cost‐effective at cost‐effectiveness thresholds of US$300 and US$500 per QALY with an incremental cost‐effectiveness ratio (ICER) of US$157 per QALY in the CD4 <200 cells/mm3 population providing enhanced‐prophylaxis components are sourced at lowest available prices. The ICER reduced in more severely immunosuppressed individuals (US$113 per QALY in the CD4 <100 cells/mm3 population) and increased in all individuals regardless of CD4 count (US$722 per QALY). Results were sensitive to prices of the enhanced‐prophylaxis components. Enhanced‐prophylaxis was more effective and less costly than all CrAg testing strategies as enhanced‐prophylaxis still conveyed health gains in CrAg‐negative patients and savings from targeting prophylaxis based on CrAg status did not compensate for costs of CrAg testing. CrAg testing strategies did not become cost‐effective unless the price of CrAg testing fell below US$2.30.
Conclusions
The REALITY enhanced‐prophylaxis package in individuals with advanced HIV starting ART reduces morbidity and mortality, is practical to administer and is cost‐effective. Efforts should continue to ensure that components are accessed at lowest available prices.</description><subject>Acquired immune deficiency syndrome</subject><subject>Adolescent</subject><subject>Adult</subject><subject>Africa</subject><subject>AIDS</subject><subject>AIDS-Related Opportunistic Infections - economics</subject><subject>AIDS-Related Opportunistic Infections - prevention & control</subject><subject>Analysis</subject><subject>Anti-HIV Agents - administration & dosage</subject><subject>Anti-HIV Agents - economics</subject><subject>Anti-HIV Agents - therapeutic use</subject><subject>Antifungal agents</subject><subject>Antifungal Agents - administration & dosage</subject><subject>Antifungal Agents - therapeutic use</subject><subject>Antigens, Fungal - analysis</subject><subject>Antiretroviral agents</subject><subject>Bacterial infections</subject><subject>Care and treatment</subject><subject>CD4 Lymphocyte Count</subject><subject>Child</subject><subject>Child, Preschool</subject><subject>Cohort Studies</subject><subject>Cost benefit analysis</subject><subject>Costs</subject><subject>cost‐effectiveness</subject><subject>Cryptococcus - immunology</subject><subject>Diagnosis</subject><subject>Drug dosages</subject><subject>Drug therapy</subject><subject>Economic aspects</subject><subject>Evaluation</subject><subject>Female</subject><subject>Fluconazole</subject><subject>Fluconazole - therapeutic use</subject><subject>Health aspects</subject><subject>Highly active antiretroviral therapy</subject><subject>HIV</subject><subject>HIV infection</subject><subject>HIV Infections - drug therapy</subject><subject>HIV Infections - economics</subject><subject>HIV Infections - mortality</subject><subject>HIV Infections - prevention & control</subject><subject>Human immunodeficiency virus</subject><subject>Humans</subject><subject>Infections</subject><subject>Kenya</subject><subject>late‐presenters</subject><subject>Malawi</subject><subject>Male</subject><subject>Meningitis</subject><subject>Mortality</subject><subject>Post-Exposure Prophylaxis - economics</subject><subject>Practice guidelines (Medicine)</subject><subject>Prophylaxis</subject><subject>Quality-Adjusted Life Years</subject><subject>Strategic planning (Business)</subject><subject>Sub-Saharan Africa</subject><subject>Tuberculosis</subject><subject>Uganda</subject><subject>United Kingdom</subject><subject>Zimbabwe</subject><issn>1758-2652</issn><issn>1758-2652</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2020</creationdate><recordtype>article</recordtype><sourceid>24P</sourceid><sourceid>WIN</sourceid><sourceid>EIF</sourceid><sourceid>ABUWG</sourceid><sourceid>AFKRA</sourceid><sourceid>AZQEC</sourceid><sourceid>BENPR</sourceid><sourceid>CCPQU</sourceid><sourceid>DWQXO</sourceid><recordid>eNqNk82O0zAQgCMEYpeFCw-ALCEhhJRiOz-OL0jVCtiilbhUXC3XmSSuUrtrO1164xF4Rp4Ely5Liqpq5UMs55tvxplMkrwkeEIwpu-XWtIJLfKSP0rOCSuqlJYFfTzanyXPvF9iXNIq50-Ts4xSwjkn58nNvAOkrA-_fvyEpgEV9AYMeI9sg9bOrrttL79rj3xwMkCrwaPGOqRNrTe6HmTv0a0OHZL1RhoFNbqafYuwdEGbFgUHMqzAhBiApo3TSj5PnjQxCl7cPS-S-aeP88ur9Prr59nl9DpVJeM8BVoRDFVZS6rIoqx4ziTNuKoWSvESqjqXlBVcEVXLXHGV8yxbsEJyaCjjOLtIPuy162GxglrFGpzsxdrplXRbYaUWh2-M7kRrN4Lh-GFYEQVv7wTO3gzgg1hpr6DvpQE7eEGzKqeYVQWL6Ov_0KUdnIm3ixTHFGNOqn9UK3sQ2jQ25lU7qZgyiimPSelJqoxtK3CZ7VzpEaqNnYtXsQYaHY8PrA_hx_7JET6uGlZaHU3woIBxhjejgA5kHzpv-yFoa_yh-SQ4Nr7bg8pZ7x00980mWOwGRewGRfwZlAi_Gv8e9-jfyYgA2QO3sfDtCZX4MpvSvfQ396wanA</recordid><startdate>202003</startdate><enddate>202003</enddate><creator>Cox, 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A</creator><creator>Kyomuhangi, J</creator><creator>Ankunda, R</creator><creator>Ayesiga, L</creator><creator>Nathoo, K</creator><creator>Reid, A</creator><creator>Tinago, GC</creator><creator>Mudzingwa, S</creator><creator>Phiri, M</creator><creator>Musoro, G</creator><creator>Nemasango, B</creator><creator>Moyo, C</creator><creator>Chitongo, S</creator><creator>Mlambo, B</creator><creator>Ndemera, B</creator><creator>Agutu, C</creator><creator>Berkley, J</creator><creator>Maitland, K</creator><creator>Wale, S</creator><creator>Shangala, J</creator><creator>Kithunga, J</creator><creator>Mutai, R</creator><creator>Mwanzu, A</creator><creator>Latham, H</creator><creator>Shikuku, J</creator><creator>Mwakisha, B</creator><creator>Siika, A</creator><creator>Wools‐Kaloustian, K</creator><creator>Nyandiko, W</creator><creator>Meli, B</creator><creator>Mokaya, M</creator><creator>Mboya, C</creator><creator>Mengich, C</creator><creator>Choge, J</creator><creator>Injera, 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A</creator><general>International AIDS Society</general><general>John Wiley & Sons, Inc</general><general>John Wiley and Sons Inc</general><scope>24P</scope><scope>WIN</scope><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>3V.</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>AZQEC</scope><scope>BENPR</scope><scope>CCPQU</scope><scope>DWQXO</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>K9.</scope><scope>M0S</scope><scope>M1P</scope><scope>PIMPY</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>PRINS</scope><scope>7X8</scope><scope>5PM</scope><orcidid>https://orcid.org/0000-0003-1482-3967</orcidid><orcidid>https://orcid.org/0000-0002-5750-3691</orcidid></search><sort><creationdate>202003</creationdate><title>The cost‐effectiveness of prophylaxis strategies for individuals with advanced HIV starting treatment in Africa</title><author>Cox, Edward ; Revill, Paul ; Bwakura‐Dangarembizi, Mutsa ; Mallewa, Jane ; Cheruiyot, Priscilla ; Gibb, Diana M ; Walker, A Sarah ; Kityo, C ; Wavamunno, P ; Nambi, E ; Ocitti, P ; Ndigendawani, M ; Kabahenda, S ; Acen, J ; Nambaziira, F ; Kabaswahili, V ; Abach, J ; Omongin, J ; Philliam, A ; Ocung, E ; Miles, P ; Adong, C ; Kidega, P ; Mukuye, A ; Baliruno, D ; Kigongo, F ; Kikyonkyo, D ; Mushahara, F ; Okweny, D ; Atwongyeire, D ; Mula, S ; Noowe, N ; Lugemwa, A ; Kyomuhangi, J ; Ankunda, R ; Ayesiga, L ; Nathoo, K ; Reid, A ; Tinago, GC ; Mudzingwa, S ; Phiri, M ; Musoro, G ; Nemasango, B ; Moyo, C ; Chitongo, S ; Mlambo, B ; Ndemera, B ; Agutu, C ; Berkley, J ; Maitland, K ; Wale, S ; Shangala, J ; Kithunga, J ; Mutai, R ; Mwanzu, A ; Latham, H ; Shikuku, J ; Mwakisha, B ; Siika, A ; Wools‐Kaloustian, K ; Nyandiko, W ; Meli, B ; Mokaya, M ; Mboya, C ; Mengich, C ; Choge, J ; Injera, W ; Njenga, K ; Cherutich, S ; Anyango Orido, M ; Kutto, I ; Shali, A ; Pierre, M ; Van Oosterhout, J ; Heydermann, R ; Dzabala, N ; Ziwoya, M ; Masesa, C ; Mwalukomo, T ; Bwanali, J ; Thomason, M ; Pett, S ; Little, E ; Cowan, F ; Bernays, S ; Mupambireyi, Z ; Kyomuhendo, F ; Nakalanzi, S ; Mkandawire, N ; Matandika, L ; Kapuya, C ; Malianga, E ; Gibb, D ; Etyang, A ; Phiri, S ; Lyall, H ; Fitzgerald, F ; Prendergast, A ; Arenas‐Pinto, A ; Turkova, A</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c6799-e2810e86da2c1b68947a239c8bcc96e8d4a2759c1cda4c9c4933b75a9ef27903</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2020</creationdate><topic>Acquired immune deficiency syndrome</topic><topic>Adolescent</topic><topic>Adult</topic><topic>Africa</topic><topic>AIDS</topic><topic>AIDS-Related Opportunistic Infections - economics</topic><topic>AIDS-Related Opportunistic Infections - prevention & control</topic><topic>Analysis</topic><topic>Anti-HIV Agents - administration & dosage</topic><topic>Anti-HIV Agents - economics</topic><topic>Anti-HIV Agents - therapeutic use</topic><topic>Antifungal agents</topic><topic>Antifungal Agents - administration & dosage</topic><topic>Antifungal Agents - therapeutic use</topic><topic>Antigens, Fungal - analysis</topic><topic>Antiretroviral agents</topic><topic>Bacterial infections</topic><topic>Care and treatment</topic><topic>CD4 Lymphocyte Count</topic><topic>Child</topic><topic>Child, Preschool</topic><topic>Cohort Studies</topic><topic>Cost benefit analysis</topic><topic>Costs</topic><topic>cost‐effectiveness</topic><topic>Cryptococcus - immunology</topic><topic>Diagnosis</topic><topic>Drug dosages</topic><topic>Drug therapy</topic><topic>Economic aspects</topic><topic>Evaluation</topic><topic>Female</topic><topic>Fluconazole</topic><topic>Fluconazole - therapeutic use</topic><topic>Health aspects</topic><topic>Highly active antiretroviral therapy</topic><topic>HIV</topic><topic>HIV infection</topic><topic>HIV Infections - drug therapy</topic><topic>HIV Infections - economics</topic><topic>HIV Infections - mortality</topic><topic>HIV Infections - prevention & control</topic><topic>Human immunodeficiency virus</topic><topic>Humans</topic><topic>Infections</topic><topic>Kenya</topic><topic>late‐presenters</topic><topic>Malawi</topic><topic>Male</topic><topic>Meningitis</topic><topic>Mortality</topic><topic>Post-Exposure Prophylaxis - economics</topic><topic>Practice guidelines (Medicine)</topic><topic>Prophylaxis</topic><topic>Quality-Adjusted Life Years</topic><topic>Strategic planning (Business)</topic><topic>Sub-Saharan Africa</topic><topic>Tuberculosis</topic><topic>Uganda</topic><topic>United Kingdom</topic><topic>Zimbabwe</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Cox, Edward</creatorcontrib><creatorcontrib>Revill, Paul</creatorcontrib><creatorcontrib>Bwakura‐Dangarembizi, Mutsa</creatorcontrib><creatorcontrib>Mallewa, Jane</creatorcontrib><creatorcontrib>Cheruiyot, Priscilla</creatorcontrib><creatorcontrib>Gibb, Diana M</creatorcontrib><creatorcontrib>Walker, A Sarah</creatorcontrib><creatorcontrib>Kityo, C</creatorcontrib><creatorcontrib>Wavamunno, P</creatorcontrib><creatorcontrib>Nambi, E</creatorcontrib><creatorcontrib>Ocitti, P</creatorcontrib><creatorcontrib>Ndigendawani, M</creatorcontrib><creatorcontrib>Kabahenda, S</creatorcontrib><creatorcontrib>Acen, J</creatorcontrib><creatorcontrib>Nambaziira, F</creatorcontrib><creatorcontrib>Kabaswahili, V</creatorcontrib><creatorcontrib>Abach, J</creatorcontrib><creatorcontrib>Omongin, J</creatorcontrib><creatorcontrib>Philliam, A</creatorcontrib><creatorcontrib>Ocung, E</creatorcontrib><creatorcontrib>Miles, P</creatorcontrib><creatorcontrib>Adong, C</creatorcontrib><creatorcontrib>Kidega, P</creatorcontrib><creatorcontrib>Mukuye, 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B</creatorcontrib><creatorcontrib>Agutu, C</creatorcontrib><creatorcontrib>Berkley, J</creatorcontrib><creatorcontrib>Maitland, K</creatorcontrib><creatorcontrib>Wale, S</creatorcontrib><creatorcontrib>Shangala, J</creatorcontrib><creatorcontrib>Kithunga, J</creatorcontrib><creatorcontrib>Mutai, R</creatorcontrib><creatorcontrib>Mwanzu, A</creatorcontrib><creatorcontrib>Latham, H</creatorcontrib><creatorcontrib>Shikuku, J</creatorcontrib><creatorcontrib>Mwakisha, B</creatorcontrib><creatorcontrib>Siika, A</creatorcontrib><creatorcontrib>Wools‐Kaloustian, K</creatorcontrib><creatorcontrib>Nyandiko, W</creatorcontrib><creatorcontrib>Meli, B</creatorcontrib><creatorcontrib>Mokaya, M</creatorcontrib><creatorcontrib>Mboya, C</creatorcontrib><creatorcontrib>Mengich, C</creatorcontrib><creatorcontrib>Choge, J</creatorcontrib><creatorcontrib>Injera, W</creatorcontrib><creatorcontrib>Njenga, K</creatorcontrib><creatorcontrib>Cherutich, S</creatorcontrib><creatorcontrib>Anyango Orido, M</creatorcontrib><creatorcontrib>Kutto, I</creatorcontrib><creatorcontrib>Shali, A</creatorcontrib><creatorcontrib>Pierre, M</creatorcontrib><creatorcontrib>Van Oosterhout, J</creatorcontrib><creatorcontrib>Heydermann, R</creatorcontrib><creatorcontrib>Dzabala, N</creatorcontrib><creatorcontrib>Ziwoya, M</creatorcontrib><creatorcontrib>Masesa, C</creatorcontrib><creatorcontrib>Mwalukomo, T</creatorcontrib><creatorcontrib>Bwanali, J</creatorcontrib><creatorcontrib>Thomason, M</creatorcontrib><creatorcontrib>Pett, S</creatorcontrib><creatorcontrib>Little, E</creatorcontrib><creatorcontrib>Cowan, F</creatorcontrib><creatorcontrib>Bernays, S</creatorcontrib><creatorcontrib>Mupambireyi, Z</creatorcontrib><creatorcontrib>Kyomuhendo, F</creatorcontrib><creatorcontrib>Nakalanzi, S</creatorcontrib><creatorcontrib>Mkandawire, N</creatorcontrib><creatorcontrib>Matandika, L</creatorcontrib><creatorcontrib>Kapuya, C</creatorcontrib><creatorcontrib>Malianga, E</creatorcontrib><creatorcontrib>Gibb, D</creatorcontrib><creatorcontrib>Etyang, A</creatorcontrib><creatorcontrib>Phiri, S</creatorcontrib><creatorcontrib>Lyall, H</creatorcontrib><creatorcontrib>Fitzgerald, F</creatorcontrib><creatorcontrib>Prendergast, A</creatorcontrib><creatorcontrib>Arenas‐Pinto, A</creatorcontrib><creatorcontrib>Turkova, A</creatorcontrib><creatorcontrib>REALITY trial team</creatorcontrib><creatorcontrib>the REALITY trial team</creatorcontrib><collection>Wiley Online Library (Open Access Collection)</collection><collection>Wiley Online Library (Open Access Collection)</collection><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Medical 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One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>ProQuest Central China</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><jtitle>Journal of the International AIDS Society</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Cox, Edward</au><au>Revill, Paul</au><au>Bwakura‐Dangarembizi, Mutsa</au><au>Mallewa, Jane</au><au>Cheruiyot, Priscilla</au><au>Gibb, Diana M</au><au>Walker, A Sarah</au><au>Kityo, C</au><au>Wavamunno, P</au><au>Nambi, E</au><au>Ocitti, P</au><au>Ndigendawani, M</au><au>Kabahenda, S</au><au>Acen, J</au><au>Nambaziira, F</au><au>Kabaswahili, V</au><au>Abach, J</au><au>Omongin, J</au><au>Philliam, A</au><au>Ocung, E</au><au>Miles, P</au><au>Adong, C</au><au>Kidega, P</au><au>Mukuye, A</au><au>Baliruno, D</au><au>Kigongo, F</au><au>Kikyonkyo, D</au><au>Mushahara, F</au><au>Okweny, D</au><au>Atwongyeire, D</au><au>Mula, S</au><au>Noowe, N</au><au>Lugemwa, A</au><au>Kyomuhangi, J</au><au>Ankunda, R</au><au>Ayesiga, L</au><au>Nathoo, K</au><au>Reid, A</au><au>Tinago, GC</au><au>Mudzingwa, S</au><au>Phiri, M</au><au>Musoro, G</au><au>Nemasango, B</au><au>Moyo, C</au><au>Chitongo, S</au><au>Mlambo, B</au><au>Ndemera, B</au><au>Agutu, C</au><au>Berkley, J</au><au>Maitland, K</au><au>Wale, S</au><au>Shangala, J</au><au>Kithunga, J</au><au>Mutai, R</au><au>Mwanzu, A</au><au>Latham, H</au><au>Shikuku, J</au><au>Mwakisha, B</au><au>Siika, A</au><au>Wools‐Kaloustian, K</au><au>Nyandiko, W</au><au>Meli, B</au><au>Mokaya, M</au><au>Mboya, C</au><au>Mengich, C</au><au>Choge, J</au><au>Injera, W</au><au>Njenga, K</au><au>Cherutich, S</au><au>Anyango Orido, M</au><au>Kutto, I</au><au>Shali, A</au><au>Pierre, M</au><au>Van Oosterhout, J</au><au>Heydermann, R</au><au>Dzabala, N</au><au>Ziwoya, M</au><au>Masesa, C</au><au>Mwalukomo, T</au><au>Bwanali, J</au><au>Thomason, M</au><au>Pett, S</au><au>Little, E</au><au>Cowan, F</au><au>Bernays, S</au><au>Mupambireyi, Z</au><au>Kyomuhendo, F</au><au>Nakalanzi, S</au><au>Mkandawire, N</au><au>Matandika, L</au><au>Kapuya, C</au><au>Malianga, E</au><au>Gibb, D</au><au>Etyang, A</au><au>Phiri, S</au><au>Lyall, H</au><au>Fitzgerald, F</au><au>Prendergast, A</au><au>Arenas‐Pinto, A</au><au>Turkova, A</au><aucorp>REALITY trial team</aucorp><aucorp>the REALITY trial team</aucorp><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>The cost‐effectiveness of prophylaxis strategies for individuals with advanced HIV starting treatment in Africa</atitle><jtitle>Journal of the International AIDS Society</jtitle><addtitle>J Int AIDS Soc</addtitle><date>2020-03</date><risdate>2020</risdate><volume>23</volume><issue>3</issue><spage>e25469</spage><epage>n/a</epage><pages>e25469-n/a</pages><issn>1758-2652</issn><eissn>1758-2652</eissn><abstract>Introduction
Many HIV‐positive individuals in Africa have advanced disease when initiating antiretroviral therapy (ART) so have high risks of opportunistic infections and death. The REALITY trial found that an enhanced‐prophylaxis package including fluconazole reduced mortality by 27% in individuals starting ART with CD4 <100 cells/mm3. We investigated the cost‐effectiveness of this enhanced‐prophylaxis package versus other strategies, including using cryptococcal antigen (CrAg) testing, in individuals with CD4 <200 cells/mm3 or <100 cells/mm3 at ART initiation and all individuals regardless of CD4 count.
Methods
The REALITY trial enrolled from June 2013 to April 2015. A decision‐analytic model was developed to estimate the cost‐effectiveness of six management strategies in individuals initiating ART in the REALITY trial countries. Strategies included standard‐prophylaxis, enhanced‐prophylaxis, standard‐prophylaxis with fluconazole; and three CrAg testing strategies, the first stratifying individuals to enhanced‐prophylaxis (CrAg‐positive) or standard‐prophylaxis (CrAg‐negative), the second to enhanced‐prophylaxis (CrAg‐positive) or enhanced‐prophylaxis without fluconazole (CrAg‐negative) and the third to standard‐prophylaxis with fluconazole (CrAg‐positive) or without fluconazole (CrAg‐negative). The model estimated costs, life‐years and quality‐adjusted life‐years (QALY) over 48 weeks using three competing mortality risks: cryptococcal meningitis; tuberculosis, serious bacterial infection or other known cause; and unknown cause.
Results
Enhanced‐prophylaxis was cost‐effective at cost‐effectiveness thresholds of US$300 and US$500 per QALY with an incremental cost‐effectiveness ratio (ICER) of US$157 per QALY in the CD4 <200 cells/mm3 population providing enhanced‐prophylaxis components are sourced at lowest available prices. The ICER reduced in more severely immunosuppressed individuals (US$113 per QALY in the CD4 <100 cells/mm3 population) and increased in all individuals regardless of CD4 count (US$722 per QALY). Results were sensitive to prices of the enhanced‐prophylaxis components. Enhanced‐prophylaxis was more effective and less costly than all CrAg testing strategies as enhanced‐prophylaxis still conveyed health gains in CrAg‐negative patients and savings from targeting prophylaxis based on CrAg status did not compensate for costs of CrAg testing. CrAg testing strategies did not become cost‐effective unless the price of CrAg testing fell below US$2.30.
Conclusions
The REALITY enhanced‐prophylaxis package in individuals with advanced HIV starting ART reduces morbidity and mortality, is practical to administer and is cost‐effective. Efforts should continue to ensure that components are accessed at lowest available prices.</abstract><cop>Switzerland</cop><pub>International AIDS Society</pub><pmid>32219991</pmid><doi>10.1002/jia2.25469</doi><tpages>12</tpages><orcidid>https://orcid.org/0000-0003-1482-3967</orcidid><orcidid>https://orcid.org/0000-0002-5750-3691</orcidid><oa>free_for_read</oa></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 1758-2652 |
| ispartof | Journal of the International AIDS Society, 2020-03, Vol.23 (3), p.e25469-n/a |
| issn | 1758-2652 1758-2652 |
| language | eng |
| recordid | cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_7099175 |
| source | MEDLINE; DOAJ Directory of Open Access Journals; Access via Wiley Online Library; EZB-FREE-00999 freely available EZB journals; Wiley Online Library (Open Access Collection); PubMed Central |
| subjects | Acquired immune deficiency syndrome Adolescent Adult Africa AIDS AIDS-Related Opportunistic Infections - economics AIDS-Related Opportunistic Infections - prevention & control Analysis Anti-HIV Agents - administration & dosage Anti-HIV Agents - economics Anti-HIV Agents - therapeutic use Antifungal agents Antifungal Agents - administration & dosage Antifungal Agents - therapeutic use Antigens, Fungal - analysis Antiretroviral agents Bacterial infections Care and treatment CD4 Lymphocyte Count Child Child, Preschool Cohort Studies Cost benefit analysis Costs cost‐effectiveness Cryptococcus - immunology Diagnosis Drug dosages Drug therapy Economic aspects Evaluation Female Fluconazole Fluconazole - therapeutic use Health aspects Highly active antiretroviral therapy HIV HIV infection HIV Infections - drug therapy HIV Infections - economics HIV Infections - mortality HIV Infections - prevention & control Human immunodeficiency virus Humans Infections Kenya late‐presenters Malawi Male Meningitis Mortality Post-Exposure Prophylaxis - economics Practice guidelines (Medicine) Prophylaxis Quality-Adjusted Life Years Strategic planning (Business) Sub-Saharan Africa Tuberculosis Uganda United Kingdom Zimbabwe |
| title | The cost‐effectiveness of prophylaxis strategies for individuals with advanced HIV starting treatment in Africa |
| url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2024-12-26T11%3A13%3A18IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-gale_pubme&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=The%20cost%E2%80%90effectiveness%20of%20prophylaxis%20strategies%20for%20individuals%20with%20advanced%20HIV%20starting%20treatment%20in%20Africa&rft.jtitle=Journal%20of%20the%20International%20AIDS%20Society&rft.au=Cox,%20Edward&rft.aucorp=REALITY%20trial%20team&rft.date=2020-03&rft.volume=23&rft.issue=3&rft.spage=e25469&rft.epage=n/a&rft.pages=e25469-n/a&rft.issn=1758-2652&rft.eissn=1758-2652&rft_id=info:doi/10.1002/jia2.25469&rft_dat=%3Cgale_pubme%3EA622150638%3C/gale_pubme%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=2390200918&rft_id=info:pmid/32219991&rft_galeid=A622150638&rfr_iscdi=true |