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Publication Details
AFRICAN RESEARCH NEXUS
SHINING A SPOTLIGHT ON AFRICAN RESEARCH
medicine
The cost-effectiveness of prophylaxis strategies for individuals with advanced HIV starting treatment in Africa
Journal of the International AIDS Society, Volume 23, No. 3, Article e25469, Year 2020
Notification
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Description
Introduction: Many HIV-positive individuals in Africa have advanced disease when initiating antiretroviral therapy (ART) so have high risks of opportunistic infections and death. The REALITY trial found that an enhanced-prophylaxis package including fluconazole reduced mortality by 27% in individuals starting ART with CD4 <100 cells/mm3. We investigated the cost-effectiveness of this enhanced-prophylaxis package versus other strategies, including using cryptococcal antigen (CrAg) testing, in individuals with CD4 <200 cells/mm3 or <100 cells/mm3 at ART initiation and all individuals regardless of CD4 count. Methods: The REALITY trial enrolled from June 2013 to April 2015. A decision-analytic model was developed to estimate the cost-effectiveness of six management strategies in individuals initiating ART in the REALITY trial countries. Strategies included standard-prophylaxis, enhanced-prophylaxis, standard-prophylaxis with fluconazole; and three CrAg testing strategies, the first stratifying individuals to enhanced-prophylaxis (CrAg-positive) or standard-prophylaxis (CrAg-negative), the second to enhanced-prophylaxis (CrAg-positive) or enhanced-prophylaxis without fluconazole (CrAg-negative) and the third to standard-prophylaxis with fluconazole (CrAg-positive) or without fluconazole (CrAg-negative). The model estimated costs, life-years and quality-adjusted life-years (QALY) over 48 weeks using three competing mortality risks: cryptococcal meningitis; tuberculosis, serious bacterial infection or other known cause; and unknown cause. Results: Enhanced-prophylaxis was cost-effective at cost-effectiveness thresholds of US$300 and US$500 per QALY with an incremental cost-effectiveness ratio (ICER) of US$157 per QALY in the CD4 <200 cells/mm3 population providing enhanced-prophylaxis components are sourced at lowest available prices. The ICER reduced in more severely immunosuppressed individuals (US$113 per QALY in the CD4 <100 cells/mm3 population) and increased in all individuals regardless of CD4 count (US$722 per QALY). Results were sensitive to prices of the enhanced-prophylaxis components. Enhanced-prophylaxis was more effective and less costly than all CrAg testing strategies as enhanced-prophylaxis still conveyed health gains in CrAg-negative patients and savings from targeting prophylaxis based on CrAg status did not compensate for costs of CrAg testing. CrAg testing strategies did not become cost-effective unless the price of CrAg testing fell below US$2.30. Conclusions: The REALITY enhanced-prophylaxis package in individuals with advanced HIV starting ART reduces morbidity and mortality, is practical to administer and is cost-effective. Efforts should continue to ensure that components are accessed at lowest available prices. © 2020 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.
Authors & Co-Authors
Walker, Simon M.
United Kingdom, York
University of York
Cox, Edward
United Kingdom, York
University of York
Revill, Paul A.
United Kingdom, York
University of York
Musiime, Victor
Uganda, Kampala
Joint Clinical Research Center Uganda
Bwakura-Dangarembizi, Mutsa F.
Zimbabwe, Harare
University of Zimbabwe
Mallewa, Jane E.
Malawi, Blantyre
Kamuzu University of Health Sciences
Cheruiyot, Priscilla Chepkorir
Kenya, Eldoret
Moi University
Maitland, Kathryn M.
Kenya, Nairobi
Wellcome Trust Research Laboratories Nairobi
United Kingdom, London
Imperial College London
Ford, Nathan P.
Switzerland, Geneva
Unaids
Gibb, Diana M.
United Kingdom, London
Mrc Clinical Trials Unit
Walker, Anne Sarah
United Kingdom, London
Mrc Clinical Trials Unit
Soares, Marta O.
United Kingdom, York
University of York
Mugyenyi, Peter N.
Unknown Affiliation
Kityo, Cissy Mutuluuza
Unknown Affiliation
Wavamunno, Priscilla
Unknown Affiliation
Nambi, Esther
Unknown Affiliation
Ocitti, Paul
Unknown Affiliation
Ndigendawani, Milly
Unknown Affiliation
Kabahenda, Sheila
Unknown Affiliation
Kemigisa, Mable
Unknown Affiliation
Acen, Juliet
Unknown Affiliation
Olebo, David Francis
Unknown Affiliation
Mpamize, Gordon
Unknown Affiliation
Amone, Alexander
Unknown Affiliation
Okweny, David
Unknown Affiliation
Mbonye, Andrew
Unknown Affiliation
Nambaziira, Florence
Unknown Affiliation
Rweyora, Angela K.
Unknown Affiliation
Kangah, Mary Goretti
Unknown Affiliation
Kabaswahili, V.
Unknown Affiliation
Abach, James
Unknown Affiliation
Abongomera, George
Unknown Affiliation
Omongin, Joseph
Unknown Affiliation
Aciro, Irene Claren
Unknown Affiliation
Philliam, Aleti
Unknown Affiliation
Arach, Beatrice
Unknown Affiliation
Ocung, Emmanuel
Unknown Affiliation
Amone, Geoffrey
Unknown Affiliation
Miles, Peter
Unknown Affiliation
Adong, Claudia
Unknown Affiliation
Tumsuiime, Constance
Unknown Affiliation
Kidega, Patrick
Unknown Affiliation
Otto, Benjamin
Unknown Affiliation
Apio, Florence
Unknown Affiliation
Baleeta, Keith
Unknown Affiliation
Mukuye, Andrew
Unknown Affiliation
Abwola, Mary C.
Unknown Affiliation
Ssennono, Fred
Unknown Affiliation
Baliruno, David
Unknown Affiliation
Tuhirwe, Stephen
Unknown Affiliation
Namisi, Ronald
Unknown Affiliation
Kigongo, Fredrick
Unknown Affiliation
Kikyonkyo, Dickson
Unknown Affiliation
Mushahara, Furaha
Unknown Affiliation
Tusiime, Julian
Unknown Affiliation
Musiime, Alex V.
Unknown Affiliation
Nankya, Agnes
Unknown Affiliation
Atwongyeire, Dickens
Unknown Affiliation
Sirikye, Sowal
Unknown Affiliation
Mula, S.
Unknown Affiliation
Noowe, Nelson
Unknown Affiliation
Lugemwa, Abbas
Unknown Affiliation
Kasozi, Miriam
Unknown Affiliation
Mwebe, Sandra Z.
Unknown Affiliation
Atwine, Lorna
Unknown Affiliation
Senkindu, Tapson
Unknown Affiliation
Natuhurira, T.
Unknown Affiliation
Katemba, Chrispus
Unknown Affiliation
Ninsiima, Emily
Unknown Affiliation
Acaku, Moses
Unknown Affiliation
Kyomuhangi, Joy
Unknown Affiliation
Ankunda, Rogers
Unknown Affiliation
Tukwasibwe, Deogratiuos
Unknown Affiliation
Ayesiga, Lillian
Unknown Affiliation
Hakim, James Gita
Unknown Affiliation
Nathoo, Kusum Jackison
Unknown Affiliation
Reid, Andrew
Unknown Affiliation
Chidziva, Ennie
Unknown Affiliation
Mhute, Tawanda
Unknown Affiliation
Tinago, Gloria C.
Unknown Affiliation
Bhiri, Joyline
Unknown Affiliation
Mudzingwa, Shepherd
Unknown Affiliation
Phiri, Misheck Nkalo
Unknown Affiliation
Steamer, John
Unknown Affiliation
Nhema, Ruth
Unknown Affiliation
Warambwa, Colin
Unknown Affiliation
Musoro, Godfrey
Unknown Affiliation
Mutsai, Shirley
Unknown Affiliation
Nemasango, Beauty
Unknown Affiliation
Moyo, Columbus
Unknown Affiliation
Chitongo, Stuart
Unknown Affiliation
Rashirai, Kennias M.
Unknown Affiliation
Vhembo, Sydney
Unknown Affiliation
Mlambo, Brian
Unknown Affiliation
Nkomani, Sanele
Unknown Affiliation
Ndemera, Buxton
Unknown Affiliation
Willard, Marko
Unknown Affiliation
Berejena, Chipo
Unknown Affiliation
Musodza, Yeukai
Unknown Affiliation
Matiza, Patience
Unknown Affiliation
Mudenge, Boniface
Unknown Affiliation
Etyang, Anthony O.
Unknown Affiliation
Agutu, Clara A.
Unknown Affiliation
Berkley, James Alexander
Unknown Affiliation
Njuguna, Patricia
Unknown Affiliation
Mwaringa, Shalton Lwambi
Unknown Affiliation
Etyang, Timothy Juma
Unknown Affiliation
Awuondo, Ken O.
Unknown Affiliation
Shangala, Jimmy
Unknown Affiliation
Mwarumba, Salim
Unknown Affiliation
Mwambingu, Gabriel
Unknown Affiliation
Mwanzu, Alfred
Unknown Affiliation
Shikuku, Joyce
Unknown Affiliation
Njogu, Anne
Unknown Affiliation
Siika, Abraham Mosigisi
Unknown Affiliation
Wools-Kaloustian, Kara K.
Unknown Affiliation
Nyandiko, Winstone Mokaya
Unknown Affiliation
Sudoi, Allan
Unknown Affiliation
Wachira, Simon
Unknown Affiliation
Karoney, Mercy Jelagat
Unknown Affiliation
Mokaya, Martha Mokeira Bisieri
Unknown Affiliation
Mboya, Chris Sande
Unknown Affiliation
Injera, Wilfred Emonyi
Unknown Affiliation
Cherutich, Salinah
Unknown Affiliation
Kutto, Irene
Unknown Affiliation
Kaunda, Symon
Unknown Affiliation
van Oosterhout, Joep J.G.
Unknown Affiliation
O'Hare, Bernadette A.M.
Unknown Affiliation
Heydermann, Robert
Unknown Affiliation
Dzabala, Nettie
Unknown Affiliation
Kelly, Christine M.
Unknown Affiliation
Denis, Brigitte B.
Unknown Affiliation
Selemani, George
Unknown Affiliation
Nyondo-Mipando, Linda Alinane
Unknown Affiliation
Banda, Peter K.
Unknown Affiliation
Msuku, Harrison
Unknown Affiliation
Masesa, Clemens
Unknown Affiliation
Mwalukomo, Thandie S.
Unknown Affiliation
Makhaza, Lumbani
Unknown Affiliation
Sheha, Irene
Unknown Affiliation
Bwanali, Joseph
Unknown Affiliation
Thomason, Margaret J.
Unknown Affiliation
Pett, Sarah Lilian
Unknown Affiliation
Szubert, Alexander J.
Unknown Affiliation
Griffiths, Anna L.
Unknown Affiliation
Wilkes, Helen C.
Unknown Affiliation
Rajapakse, Chathurika
Unknown Affiliation
Spyer, Moira J.
Unknown Affiliation
Prendergast, Andrew J.
Unknown Affiliation
Klein, Nigel J.
Unknown Affiliation
Rauchenberger, Mary
Unknown Affiliation
Van-Looy, Nadine
Unknown Affiliation
Little, Emma
Unknown Affiliation
Fairbrother, Keith
Unknown Affiliation
Cowan, Frances Mary
Unknown Affiliation
Seeley, Janet
Unknown Affiliation
Bernays, Sarah
Unknown Affiliation
Kawuma, Rachel
Unknown Affiliation
Mupambireyi, Zivai
Unknown Affiliation
Kyomuhendo, Flavia
Unknown Affiliation
Nakalanzi, Sarah
Unknown Affiliation
Peshu, Judy
Unknown Affiliation
Chabuka, John
Unknown Affiliation
Mkandawire, Nkhafwire
Unknown Affiliation
Weller, Ian V.D.
Unknown Affiliation
Malianga, E.
Unknown Affiliation
Mwansambo, Charles C.V.
Unknown Affiliation
Miiro, F.
Unknown Affiliation
Elyanu, Peter J.
Unknown Affiliation
Bukusi, Elizabeth Anne
Unknown Affiliation
Katabira, Elly Tebasoboke
Unknown Affiliation
Mugurungi, Owen M.
Unknown Affiliation
Peto, Timothy E.A.
Unknown Affiliation
Musoke, Philippa Martha
Unknown Affiliation
Matenga, Jonathan Arthur
Unknown Affiliation
Phiri, Sam John Peter
Unknown Affiliation
Lyall, Hermione
Unknown Affiliation
Johnston, Victoria J.
Unknown Affiliation
Fitzgerald, Felicity C.
Unknown Affiliation
Post, Frank A.
Unknown Affiliation
Ssali, Francis N.
Unknown Affiliation
Prendergast, Andrew J.
Unknown Affiliation
Arenas-Pinto, Alejandro
Unknown Affiliation
Turkova, Anna
Unknown Affiliation
Bamford, A. R.J.
Unknown Affiliation
Statistics
Authors: 185
Affiliations: 9
Identifiers
Doi:
10.1002/jia2.25469
ISSN:
17582652
Research Areas
Infectious Diseases
Study Design
Cross Sectional Study