Johns Hopkins University School of Medicine, Baltimore, USA.
Indian J Med Res. 2013 Jun;137(6):1145-53.
BACKGROUND & OBJECTIVES: Sustainability of free antiretroviral therapy (ART) roll out programmes in resource-limited settings is challenging given the need for lifelong therapy and lack of effective vaccine. This study was undertaken to compare treatment outcomes among HIV-infected patients enrolled in a graduated cost-recovery programme of ART delivery in Chennai, India.
Financial status of patients accessing care at a tertiary care centre, YRGCARE, Chennai, was assessed using an economic survey; patients were distributed into tiers 1- 4 requiring them to pay 0, 50, 75 or 100 per cent of their medication costs, respectively. A total of 1754 participants (ART naοve = 244) were enrolled from February 2005-January 2008 with the following distribution: tier 1=371; tier 2=338; tier 3=693; tier 4=352. Linear regression models with generalized estimating equations were used to examine immunological response among patients across the four tiers.
Median age was 34; 73 per cent were male, and the majority were on nevirapine-based regimens. Median follow up was 11.1 months. The mean increase in CD4 cell count within the 1 st three months of HAART was 50.3 cells/μl per month in tier 1. Compared to those in tier 1, persons in tiers 2, 3 and 4 had comparable increases (49.7, 57.0, and 50.9 cells/μl per month, respectively). Increases in subsequent periods (3-18 and >18 months) were also comparable across tiers. No differential CD4 gains across tiers were observed when the analysis was restricted to patients initiating ART under the GCR programme.
INTERPRETATION & CONCLUSIONS: This ART delivery model was associated with significant CD4 gains with no observable difference by how much patients paid. Importantly, gains were comparable to those in other free rollout programmes. Additional cost-effectiveness analyses and mathematical modelling would be needed to determine whether such a delivery programme is a sustainable alternative to free ART programmes.
在资源有限的环境中，由于需要终身治疗且缺乏有效的疫苗，免费抗逆转录病毒治疗（ART）推广计划的可持续性具有挑战性。本研究旨在比较在印度钦奈的一个逐步成本回收 ART 提供计划中接受治疗的 HIV 感染患者的治疗结果。
使用经济调查评估在 YRGCARE 三级护理中心接受护理的患者的财务状况；将患者分为 1-4 层，分别需要支付其药物费用的 0%、50%、75%或 100%。共有 1754 名参与者（ART 初治=244 名）于 2005 年 2 月至 2008 年 1 月入组，分布如下：1 层=371 名；2 层=338 名；3 层=693 名；4 层=352 名。使用广义估计方程的线性回归模型来检查四个层次的患者之间的免疫反应。
中位年龄为 34 岁；73%为男性，大多数人接受基于奈韦拉平的方案治疗。中位随访时间为 11.1 个月。在 HAART 的头三个月内，CD4 细胞计数的平均每月增加量为第一层中的 50.3 个/μl。与第一层相比，第二层、第三层和第四层的人的增加量相当（分别为 49.7、57.0 和 50.9 个/μl/月）。在随后的时期（3-18 个月和>18 个月），各层之间的增加也相当。在将分析仅限于根据 GCR 计划开始接受 ART 的患者时，未观察到各层之间的 CD4 差异。
这种 ART 提供模式与显著的 CD4 增益相关，而患者支付的费用没有明显差异。重要的是，增益与其他免费推广计划相当。需要进行额外的成本效益分析和数学建模，以确定这种提供方案是否是免费 ART 方案的可持续替代方案。
