Abstract:
INTRODUCTION:Recent WHO guidance advocates for early antiretroviral therapy (ART) initiation at higher CD4 counts to improve survival and reduce HIV transmission. We sought to quantify how the cost-effectiveness and epidemiological impact of early ART strategies in India are affected by attrition throughout the HIV care continuum. METHODS:We constructed a dynamic compartmental model replicating HIV transmission, disease progression and health system engagement among Indian adults. Our model of the Indian HIV epidemic compared implementation of early ART initiation (i.e. initiation above CD4 ≥350 cells/mm(3)) with delayed initiation at CD4 ≤350 cells/mm(3); primary outcomes were incident cases, deaths, quality-adjusted-life-years (QALYs) and costs over 20 years. We assessed how costs and effects of early ART initiation were impacted by suboptimal engagement at each stage in the HIV care continuum. RESULTS:Assuming "idealistic" engagement in HIV care, early ART initiation is highly cost-effective ($442/QALY-gained) compared to delayed initiation at CD4 ≤350 cells/mm(3) and could reduce new HIV infections to <15,000 per year within 20 years. However, when accounting for realistic gaps in care, early ART initiation loses nearly half of potential epidemiological benefits and is less cost-effective ($530/QALY-gained). We project 1,285,000 new HIV infections and 973,000 AIDS-related deaths with deferred ART initiation with current levels of care-engagement in India. Early ART initiation in this continuum resulted in 1,050,000 new HIV infections and 883,000 AIDS-related deaths, or 18% and 9% reductions (respectively), compared to current guidelines. Strengthening HIV screening increases benefits of earlier treatment modestly (1,001,000 new infections; 22% reduction), while improving retention in care has a larger modulatory impact (676,000 new infections; 47% reduction). CONCLUSIONS:Early ART initiation is highly cost-effective in India but only has modest epidemiological benefits at current levels of care-engagement. Improved retention in care is needed to realize the full potential of earlier treatment.
journal_name
J Int AIDS Socjournal_title
Journal of the International AIDS Societyauthors
Maddali MV,Dowdy DW,Gupta A,Shah Mdoi
10.7448/IAS.18.1.20217subject
Has Abstractpub_date
2015-10-01 00:00:00pages
20217issn
1758-2652pii
20217journal_volume
18pub_type
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journal_title:Journal of the International AIDS Society
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journal_title:Journal of the International AIDS Society
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journal_title:Journal of the International AIDS Society
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journal_title:Journal of the International AIDS Society
pub_type: 杂志文章
doi:10.7448/IAS.17.4.19542
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journal_title:Journal of the International AIDS Society
pub_type: 杂志文章,评审
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pub_type: 杂志文章
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pub_type: 杂志文章,随机对照试验
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journal_title:Journal of the International AIDS Society
pub_type: 杂志文章,随机对照试验
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journal_title:Journal of the International AIDS Society
pub_type: 杂志文章
doi:10.7448/IAS.15.2.17422
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journal_title:Journal of the International AIDS Society
pub_type: 杂志文章,随机对照试验
doi:10.7448/IAS.17.3.19146
更新日期:2014-09-08 00:00:00
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journal_title:Journal of the International AIDS Society
pub_type: 杂志文章
doi:10.7448/IAS.18.1.19247
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journal_title:Journal of the International AIDS Society
pub_type: 杂志文章
doi:10.1186/1758-2652-13-8
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journal_title:Journal of the International AIDS Society
pub_type: 杂志文章,评审
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journal_title:Journal of the International AIDS Society
pub_type: 杂志文章
doi:10.7448/IAS.18.1.20499
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journal_title:Journal of the International AIDS Society
pub_type: 杂志文章
doi:10.7448/IAS.17.4.19680
更新日期:2014-11-02 00:00:00
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journal_title:Journal of the International AIDS Society
pub_type: 杂志文章
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journal_title:Journal of the International AIDS Society
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journal_title:Journal of the International AIDS Society
pub_type: 杂志文章
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journal_title:Journal of the International AIDS Society
pub_type: 杂志文章
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journal_title:Journal of the International AIDS Society
pub_type: 杂志文章
doi:10.1002/jia2.25518
更新日期:2020-06-01 00:00:00
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journal_title:Journal of the International AIDS Society
pub_type: 杂志文章
doi:10.7448/IAS.18.1.20221
更新日期:2015-08-27 00:00:00
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journal_title:Journal of the International AIDS Society
pub_type: 杂志文章
doi:10.1186/1758-2652-14-29
更新日期:2011-06-09 00:00:00
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journal_title:Journal of the International AIDS Society
pub_type: 杂志文章
doi:10.7448/IAS.17.1.18790
更新日期:2014-02-14 00:00:00
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journal_title:Journal of the International AIDS Society
pub_type: 杂志文章
doi:10.7448/IAS.17.4.19786
更新日期:2014-11-02 00:00:00
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journal_title:Journal of the International AIDS Society
pub_type: 杂志文章,随机对照试验
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更新日期:2017-10-01 00:00:00
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journal_title:Journal of the International AIDS Society
pub_type: 杂志文章,评审
doi:10.1002/jia2.25354
更新日期:2019-08-01 00:00:00
abstract:INTRODUCTION:Despite significant gains in access to early infant diagnosis (EID) over the past decade, most HIV-exposed infants still do not get tested for HIV in the first two months of life. For those who are tested, the long turnaround time between when the sample is drawn and when the results are returned leads to ...
journal_title:Journal of the International AIDS Society
pub_type: 杂志文章,评审
doi:10.7448/IAS.18.7.20299
更新日期:2015-12-02 00:00:00