Patrikar Seema, Kachroo Kavita, Sharma Jitendar, Kotwal Atul, Basannar D R, Bhatti V K, Mukherji Sandip, Nair Velu
Statistician, Department of Community Medicine, Armed Forces Medical College, Pune 411040, India.
Consultant, NHSRC, Ministry of Health and Family Welfare, India.
Med J Armed Forces India. 2019 Jan;75(1):31-40. doi: 10.1016/j.mjafi.2018.08.012. Epub 2018 Nov 22.
The World Health Organization (WHO) in 2013 has revised its guidelines on antiretroviral therapy (ART) treatment for human immunodeficiency virus (HIV)-positive adults and further updated it in 2016. Based on the WHO recommendations, in May 2017, National AIDS Control Organisation, India recommended initiation of ART treatment for all people living with HIV, regardless of CD4 count, clinical stage, age, or population. This systematic review aims to assess the clinical effectiveness and cost implication of the new guidelines for India.
A systematic and comprehensive literature search on PubMed, OvidSP, Cochrane Library, and Google Scholar was carried out. Studies reporting either acquired immunodeficiency syndrome (AIDS) or mortality or both as outcome variables were selected. A meta-analysis of the available studies was carried out. The risk ratio was calculated to assess the reduction in AIDS or mortality or both. Cost-effectiveness analysis using health technology principles evaluating the lives saved in terms of incremental cost-effectiveness ratio and cost per quality-adjusted life years gained was carried out.
Nine eligible studies were included for the meta-analysis. For India, the pooled relative risk of AIDS or mortality or both being 0.84 (95% confidence interval [CI], 0.76-0.92) and 0.78 (95% CI, 0.68-0.89) for ART initiation at CD4 count of ≤350 vs CD4 count of ≤500 and at CD4 count of ≤500 vs CD4 count > 500 cells/mm, respectively. The incremental cost for per additional life saved is US$ 2592 and US$ 2357 for ART initiation at ≤500 and > 500 CD4 count, respectively.
The adoption of the new WHO guidelines is beneficial with substantial reduction in AIDS or mortality or both. This study suggests that adopting new WHO guidelines is cost-effective for India.
世界卫生组织（WHO）于2013年修订了针对人类免疫缺陷病毒（HIV）阳性成年人的抗逆转录病毒疗法（ART）治疗指南，并于2016年进一步更新。根据WHO的建议，2017年5月，印度国家艾滋病控制组织建议对所有HIV感染者启动ART治疗，无论其CD4细胞计数、临床分期、年龄或人群如何。本系统评价旨在评估新指南对印度的临床有效性和成本影响。
在PubMed、OvidSP、Cochrane图书馆和谷歌学术上进行了系统全面的文献检索。选择报告获得性免疫缺陷综合征（AIDS）或死亡率或两者作为结局变量的研究。对现有研究进行荟萃分析。计算风险比以评估AIDS或死亡率或两者的降低情况。使用卫生技术原则进行成本效益分析，根据增量成本效益比和每获得一个质量调整生命年的成本来评估挽救的生命。
纳入9项符合条件的研究进行荟萃分析。对于印度，在CD4细胞计数≤350时启动ART与CD4细胞计数≤500时启动ART相比，以及在CD4细胞计数≤500时启动ART与CD4细胞计数>500个细胞/mm时启动ART相比，AIDS或死亡率或两者的合并相对风险分别为0.84（95%置信区间[CI]，0.76 - 0.92）和0.78（95%CI，0.68 - 0.89）。在CD4细胞计数≤500和>500时启动ART，每多挽救一条生命的增量成本分别为2592美元和2357美元。
采用WHO新指南有益，可大幅降低AIDS或死亡率或两者。本研究表明，采用WHO新指南对印度具有成本效益。
