Freedberg Kenneth A, Kumarasamy Nagalingeswaran, Borre Ethan D, Ross Eric L, Mayer Kenneth H, Losina Elena, Swaminathan Soumya, Flanigan Timothy P, Walensky Rochelle P
1 Division of General Internal Medicine, Massachusetts General Hospital , Boston, Massachusetts.
2 Division of Infectious Diseases, Massachusetts General Hospital , Boston, Massachusetts.
AIDS Res Hum Retroviruses. 2018 Jun;34(6):486-497. doi: 10.1089/AID.2017.0258. Epub 2018 May 3.
Current Indian guidelines recommend twice-annual CD4 testing to monitor first-line antiretroviral therapy (ART), with a plasma HIV RNA test to confirm failure if CD4 declines, which would prompt a switch to second-line ART. We used a mathematical model to assess the clinical benefits and cost-effectiveness of alternative laboratory monitoring strategies in India. We simulated a cohort of HIV-infected patients initiating first-line ART and compared 11 strategies with combinations of CD4 and HIV RNA testing at varying frequencies. We included adaptive strategies that reduce the frequency of tests after 1 year from 6 to 12 months for virologically suppressed patients. We projected life expectancy, time on failed first-line ART, cumulative 10-year HIV transmissions, lifetime cost (2014 US dollars), and incremental cost-effectiveness ratios (ICERs). We defined strategies as cost-effective if their ICER was <1 × the Indian per capita gross domestic product (GDP, $1,600). We found that the current Indian guidelines resulted in a per person life expectancy (from mean age 37) of 150.2 months and a per person cost of $2,680. Adding annual HIV RNA testing increased survival by ∼8 months; adaptive strategies were less expensive than similar nonadaptive strategies with similar life expectancy. The most effective strategy with an ICER <1 × GDP was the adaptive HIV RNA strategy (ICER $840/year). Cumulative 10-year transmissions decreased from 27.2/1,000 person-years with standard-of-care to 20.9/1,000 person-years with adaptive HIV RNA testing. In India, routine HIV RNA monitoring of patients on first-line ART would increase life expectancy, decrease transmissions, be cost-effective, and should be implemented.
印度现行指南建议每半年进行一次CD4检测，以监测一线抗逆转录病毒疗法（ART），若CD4下降，则进行血浆HIV RNA检测以确认治疗失败，这将促使转而采用二线ART。我们使用数学模型评估了印度替代实验室监测策略的临床益处和成本效益。我们模拟了一组开始接受一线ART的HIV感染患者，并比较了11种不同频率的CD4和HIV RNA检测组合策略。我们纳入了适应性策略，即对于病毒学抑制的患者，将1年后的检测频率从每6个月一次降至每12个月一次。我们预测了预期寿命、一线ART失败时间、10年累计HIV传播数、终生成本（2014年美元）以及增量成本效益比（ICER）。如果ICER<1×印度人均国内生产总值（GDP，1600美元），我们将策略定义为具有成本效益。我们发现，印度现行指南导致人均预期寿命（从平均年龄37岁起）为150.2个月，人均成本为2680美元。增加年度HIV RNA检测可使生存期延长约8个月；适应性策略比具有相似预期寿命的非适应性策略成本更低。ICER<1×GDP的最有效策略是适应性HIV RNA策略（ICER为每年840美元）。10年累计传播率从标准治疗的每1000人年27.2例降至适应性HIV RNA检测的每1000人年20.9例。在印度，对接受一线ART的患者进行常规HIV RNA监测将延长预期寿命、减少传播、具有成本效益，应予以实施。
