Scaling Up the 2010 World Health Organization HIV Treatment Guidelines in Resource-Limited Settings: A Model-Based Analysis
Paltiel, A. David
Lorenzana, Sarah B.
Stoler, Adam W.
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CitationWalensky, Rochelle P., Robin Wood, Andrea L. Ciaranello, A. David Paltiel, Sarah B. Lorenzana, Xavier Anglaret, Adam W. Stoler, and Kenneth A. Freedberg. 2010. Scaling Up the 2010 World Health Organization HIV Treatment Guidelines in Resource-Limited Settings: A Model-Based Analysis. PLoS Medicine 7(12): e1000382.
AbstractBackground: The new 2010 World Health Organization (WHO) HIV treatment guidelines recommend earlier antiretroviral
therapy (ART) initiation (CD4,350 cells/ml instead of CD4,200 cells/ml), multiple sequential ART regimens, and replacement
of first-line stavudine with tenofovir. This paper considers what to do first in resource-limited settings where immediate
implementation of all of the WHO recommendations is not feasible.
Methods and Findings: We use a mathematical model and local input data to project clinical and economic outcomes in a
South African HIV-infected cohort (mean age = 32.8 y, mean CD4 = 375/ml). For the reference strategy, we assume that all
patients initiate stavudine-based ART with WHO stage III/IV disease and receive one line of ART (stavudine/WHO/one-line).
We rank—in survival, cost-effectiveness, and equity terms—all 12 possible combinations of the following: (1) stavudine
replacement with tenofovir, (2) ART initiation (by WHO stage, CD4,200 cells/ml, or CD4,350 cells/ml), and (3) one or two
regimens, or lines, of available ART. Projected life expectancy for the reference strategy is 99.0 mo. Considering each of the
guideline components separately, 5-y survival is maximized with ART initiation at CD4,350 cells/ml (stavudine/,350/ml/
one-line, 87% survival) compared with stavudine/WHO/two-lines (66%) and tenofovir/WHO/one-line (66%). The greatest life
expectancies are achieved via the following stepwise programmatic additions: stavudine/,350/ml/one-line (124.3 mo),
stavudine/,350/ml/two-lines (177.6 mo), and tenofovir/,350/ml/two-lines (193.6 mo). Three program combinations are
economically efficient: stavudine/,350/ml/one-line (cost-effectiveness ratio, US$610/years of life saved [YLS]), tenofovir/
,350/ml/one-line (US$1,140/YLS), and tenofovir/,350/ml/two-lines (US$2,370/YLS).
Conclusions: In settings where immediate implementation of all of the new WHO treatment guidelines is not feasible, ART
initiation at CD4,350 cells/ml provides the greatest short- and long-term survival advantage and is highly cost-effective.
Citable link to this pagehttp://nrs.harvard.edu/urn-3:HUL.InstRepos:4891671