Cost-effectiveness and budget impact of immediate antiretroviral therapy initiation for treatment of HIV infection in Cote d'Ivoire: A model-based analysis

Introduction The Temprano and START trials provided evidence to support early ART initiation recommendations. We projected long-term clinical and economic outcomes of immediate ART initiation in Cote d'Ivoire. Methods We used a mathematical model to compare three potential ART initiation criteria: 1) CD4 <350/mu L (ART<350/mu L); 2) CD4 <500/mu L (ART<500/mu L); and 3) ART at presentation (Immediate ART). Outcomes from the model included life expectancy, 10-year medical resource use, incremental cost-effectiveness ratios (ICERs) in $/year of life saved (YLS), and 5-year budget impact. We simulated people with HIV (PWH) in care (mean CD4: 259/mu L, SD 198/mu L) and transmitted cases. Key input parameters to the analysis included first-line ART efficacy (80% suppression at 6 months) and ART cost ($90/person-year). We assessed cost-effectiveness relative to Cote d'Ivoire's 2017 per capita annual gross domestic product ($1,600). Results Immediate ART increased life expectancy by 0.34 years compared to ART<350/mu L and 0.17 years compared to ART<500/mu L. Immediate ART resulted in 4,500 fewer 10-year transmissions per 170,000 PWH compared to ART<350/mu L. In cost-effectiveness analysis, Immediate ART had a 10-year ICER of $680/YLS compared to ART<350/mu L, ranging from cost-saving to an ICER of $1,440/YLS as transmission rates varied. ART<500/mu L was dominated (an inefficient use of resources), compared with Immediate ART. Immediate ART increased the 5-year HIV care budget from $801.9M to $812.6M compared to ART<350/mu L. Conclusions In Cote d'Ivoire, immediate compared to later ART initiation will increase life expectancy, decrease HIV transmission, and be cost-effective over the long-term, with modest budget impact. Immediate ART initiation is an appropriate, high-value standard of care in Cote d'Ivoire and similar settings.