Revill Paul A, Walker Simon, Mabugu Travor, Nathoo Kusum J, Mugyenyi Peter, Kekitinwa Adeodata, Munderi Paula, Bwakura-Dangarembizi Mutsawashe, Musiime Victor, Bakeera-Kitaka Sabrina, Nahirya-Ntege Patricia, Walker A Sarah, Sculpher Mark J, Gibb Diana M
aCentre for Health Economics, University of York, York, UK bClinical Research Centre, University of Zimbabwe cUniversity of Zimbabwe, College of Health Sciences, Harare, Zimbabwe dJoint Clinical Research Centre, Kampala ePaediatric Infectious Diseases Clinic/Baylor - Uganda, Mulago Hospital, Mulago fMedical Research Council/Uganda Research Unit on AIDS, Uganda Virus Research Institute, Entebbe, Uganda gMedical Research Council (MRC) Clinical Trials Unit at University College London, London, UK.
AIDS. 2015 Jan 14;29(2):201-10. doi: 10.1097/QAD.0000000000000518.
To conduct two economic analyses addressing whether to: routinely monitor HIV-infected children on antiretroviral therapy (ART) clinically or with laboratory tests; continue or stop cotrimoxazole prophylaxis when children become stabilized on ART.
The ARROW randomized trial investigated alternative strategies to deliver paediatric ART and cotrimoxazole prophylaxis in 1206 Ugandan/Zimbabwean children. Incremental cost-effectiveness and value of implementation analyses were undertaken. Scenario analyses investigated whether laboratory monitoring (CD4 tests for efficacy monitoring; haematology/biochemistry for toxicity) could be tailored and targeted to be delivered cost-effectively. Cotrimoxazole use was examined in malaria-endemic and non-endemic settings.
Using all trial data, clinical monitoring delivered similar health outcomes to routine laboratory monitoring, but at a reduced cost, so was cost-effective. Continuing cotrimoxazole improved health outcomes at reduced costs. Restricting routine CD4 monitoring to after 52 weeks following ART initiation and removing toxicity testing was associated with an incremental cost-effectiveness ratio of $6084 per quality-adjusted life-year (QALY) across all age groups, but was much lower for older children (12+ years at initiation; incremental cost-effectiveness ratio = $769/QALY). Committing resources to improve cotrimoxazole implementation appears cost-effective. A healthcare system that could pay $600/QALY should be willing to spend up to $12.0 per patient-year to ensure continued provision of cotrimoxazole.
Clinically driven monitoring of ART is cost-effective in most circumstances. Routine laboratory monitoring is generally not cost-effective at current prices, except possibly CD4 testing amongst adolescents initiating ART. Committing resources to ensure continued provision of cotrimoxazole in health facilities is more likely to represent an efficient use of resources.
进行两项经济分析，以探讨是否：对接受抗逆转录病毒治疗（ART）的HIV感染儿童进行常规临床监测或实验室检测；当儿童在ART治疗中病情稳定后，继续或停止复方新诺明预防治疗。
ARROW随机试验在1206名乌干达/津巴布韦儿童中研究了提供儿科ART和复方新诺明预防治疗的替代策略。进行了增量成本效益分析和实施价值分析。情景分析调查了实验室监测（用于疗效监测的CD4检测；用于毒性监测的血液学/生物化学检测）是否可以进行调整和靶向，以实现成本效益。在疟疾流行和非流行地区对复方新诺明的使用情况进行了研究。
使用所有试验数据，临床监测与常规实验室监测产生的健康结果相似，但成本更低，因此具有成本效益。继续使用复方新诺明可在降低成本的情况下改善健康结果。将常规CD4监测限制在ART开始后52周之后，并取消毒性检测，在所有年龄组中，每质量调整生命年（QALY）的增量成本效益比为6084美元，但对年龄较大的儿童（开始治疗时12岁及以上；增量成本效益比=769美元/QALY）要低得多。投入资源改善复方新诺明的实施似乎具有成本效益。一个能够支付600美元/QALY的医疗保健系统应该愿意为确保持续提供复方新诺明而每人每年花费高达12.0美元。
在大多数情况下，由临床驱动的ART监测具有成本效益。按照当前价格，常规实验室监测通常不具有成本效益，可能ART起始阶段的青少年进行CD4检测除外。投入资源确保在医疗机构持续提供复方新诺明更有可能是对资源的有效利用。
