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Scaling Up the 2010 World Health Organization HIV Treatment Guidelines in Resource-Limited Settings: A Model-Based Analysis
PLoS Medicine
December 21, 2010

Since 1981, acquired immunodeficiency syndrome (AIDS) has killed more than 25 million people, and about 33 million people (30 million of them in low- and middle-income countries) are now infected with the human immunodeficiency virus (HIV), which causes AIDS. HIV destroys immune system cells (including CD4 cells, a type of lymphocyte), leaving infected individuals susceptible to other infections (so-called opportunistic infections). Early in the AIDS epidemic, most people with HIV died within 10 years of infection. Then, in 1996, highly active antiretroviral therapy (ART)—a combination of several powerful antiretroviral drugs—was developed. Now, in resource-rich countries, clinicians care for people with HIV by prescribing ART regimens tailored to each individual's needs. They also regularly measure the amount of virus in their patients' blood, test for antiretroviral-resistant viruses, and monitor the health of their patients' immune systems through regular CD4 cell counts. As a result, the life expectancy of patients with HIV in developed countries has dramatically improved.

Initially, resource-limited countries could not afford to provide ART for their populations, and the life expectancy of HIV-positive people remained low. Now, through the concerted efforts of governments, the World Health Organization (WHO), and other international agencies, more than a third of the people in low- and middle-income countries who need ART are receiving it. However, many without access are still in need of ART, and ART programs in developing countries follow a public-health approach rather than an individualized approach. That is, drug regimens, clinical decision-making, and disease monitoring are all standardized and follow recommendations in the 2006 WHO ART guidelines. This year (2010), these guidelines were revised. The guidelines now recommend the following: earlier ART initiation—when the CD4 count falls below 350/µl of blood, instead of below 200/µl as in the 2006 guidelines; the provision of sequential ART regimens instead of a single regimen; and the replacement of the antiretroviral drug stavudine with tenofovir, a less toxic but more expensive drug, in first-line ART regimens. However, many resource-limited countries are still struggling to implement the 2006 guidelines, so which of these new recommendations should be prioritized? Here, the researchers use a mathematical model to address this question.

The Cost Effectiveness of AIDS Complications (CEPAC)–International model simulates the natural history and treatment of HIV disease. The researchers entered South African clinical and cost data for HIV treatment into this model and then used it to project survival and costs in a hypothetical group of South African HIV-positive patients under alternative guideline prioritization scenarios. The reference strategy for the simulations (denoted as “stavudine/WHO/one-line”) assumed that patients (with a mean CD4 count of 375/µl) began a single stavudine-based ART regimen when they developed WHO stage III/IV HIV disease (i.e., when patients develop multiple opportunistic infections such as tuberculosis and pneumonia). When the new guideline recommendations were considered separately, ART initiation at CD4<350/µl (stavudine/<350/µl/one-line) maximized five-year survival. Stepwise adjustment from the reference strategy (which had a life expectancy 99.0 months) through strategies of stavudine/<350/µl/one-line (a projected life expectancy of 124.3 months), stavudine/<350/µl/two-lines (177.6 months), and tenofovir/<350/µl/two-lines (193.6 months) produced the greatest improvements in life expectancy. Finally, strategies of stavudine/<350/µl/one-line, tenofovir/<350/µl/one-line, and tenofovir/<350µl/two-lines produced incremental cost-effectiveness ratios of US$610, US$1,140, and US$2,370 per year of life saved, respectively.

As with all mathematical models, the accuracy of these findings are dependent on the assumptions included in the model and on the data populating it. Nevertheless, these findings suggest that, where resources are limited and immediate implementation of all the new WHO recommendations is impossible, ART initiation at a CD4 count of less than 350/µl would provide the greatest survival advantage and would be very cost-effective. In countries that are already initiating ART at this threshold and that have access to CD4 monitoring, a switch from stavudine to tenofovir would further increase survival and would also be cost-effective. Finally, although access to second-line ART regimen would provide more clinical benefits than access to tenofovir, the cost of this change in strategy would be substantially greater. Importantly, these findings should help to avoid the complete dismissal of the revised WHO guidelines on the basis of cost and should help policy makers adjust their ART program strategies to maximize their clinical benefits and cost effectiveness.

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