Patient- and population-level health consequences of discontinuing antiretroviral therapy in settings with inadequate HIV treatment availability
<p>Abstract</p> <p>Background</p> <p>In resource-limited settings, HIV budgets are flattening or decreasing. A policy of discontinuing antiretroviral therapy (ART) after HIV treatment failure was modeled to highlight trade-offs among competing policy goals of optimizing...
| Main Authors: | , , , , , , , , |
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| Format: | Article |
| Language: | English |
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BMC
2012-09-01
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| Series: | Cost Effectiveness and Resource Allocation |
| Subjects: | |
| Online Access: | http://www.resource-allocation.com/content/10/1/12 |
| _version_ | 1819034694501531648 |
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| author | Kimmel April D Resch Stephen C Anglaret Xavier Daniels Norman Goldie Sue J Danel Christine Wong Angela Y Freedberg Kenneth A Weinstein Milton C |
| author_facet | Kimmel April D Resch Stephen C Anglaret Xavier Daniels Norman Goldie Sue J Danel Christine Wong Angela Y Freedberg Kenneth A Weinstein Milton C |
| author_sort | Kimmel April D |
| collection | DOAJ |
| description | <p>Abstract</p> <p>Background</p> <p>In resource-limited settings, HIV budgets are flattening or decreasing. A policy of discontinuing antiretroviral therapy (ART) after HIV treatment failure was modeled to highlight trade-offs among competing policy goals of optimizing individual and population health outcomes.</p> <p>Methods</p> <p>In settings with two available ART regimens, we assessed two strategies: (1) continue ART after second-line failure (Status Quo) and (2) discontinue ART after second-line failure (Alternative). A computer model simulated outcomes for a single cohort of newly detected, HIV-infected individuals. Projections were fed into a population-level model allowing multiple cohorts to compete for ART with constraints on treatment capacity. In the Alternative strategy, discontinuation of second-line ART occurred upon detection of antiretroviral failure, specified by WHO guidelines. Those discontinuing failed ART experienced an increased risk of AIDS-related mortality compared to those continuing ART.</p> <p>Results</p> <p>At the population level, the Alternative strategy increased the mean number initiating ART annually by 1,100 individuals (+18.7%) to 6,980 compared to the Status Quo. More individuals initiating ART under the Alternative strategy increased total life-years by 15,000 (+2.8%) to 555,000, compared to the Status Quo. Although more individuals received treatment under the Alternative strategy, life expectancy for those treated decreased by 0.7 years (−8.0%) to 8.1 years compared to the Status Quo. In a cohort of treated patients only, 600 more individuals (+27.1%) died by 5 years under the Alternative strategy compared to the Status Quo. Results were sensitive to the timing of detection of ART failure, number of ART regimens, and treatment capacity. Although we believe the results robust in the short-term, this analysis reflects settings where HIV case detection occurs late in the disease course and treatment capacity and the incidence of newly detected patients are stable.</p> <p>Conclusions</p> <p>In settings with inadequate HIV treatment availability, trade-offs emerge between maximizing outcomes for individual patients already on treatment and ensuring access to treatment for all people who may benefit. While individuals may derive some benefit from ART even after virologic failure, the aggregate public health benefit is maximized by providing effective therapy to the greatest number of people. These trade-offs should be explicit and transparent in antiretroviral policy decisions.</p> |
| first_indexed | 2024-12-21T07:37:48Z |
| format | Article |
| id | doaj.art-d2a4b278966f41699dd02dc10220363e |
| institution | Directory Open Access Journal |
| issn | 1478-7547 |
| language | English |
| last_indexed | 2024-12-21T07:37:48Z |
| publishDate | 2012-09-01 |
| publisher | BMC |
| record_format | Article |
| series | Cost Effectiveness and Resource Allocation |
| spelling | doaj.art-d2a4b278966f41699dd02dc10220363e2022-12-21T19:11:25ZengBMCCost Effectiveness and Resource Allocation1478-75472012-09-011011210.1186/1478-7547-10-12Patient- and population-level health consequences of discontinuing antiretroviral therapy in settings with inadequate HIV treatment availabilityKimmel April DResch Stephen CAnglaret XavierDaniels NormanGoldie Sue JDanel ChristineWong Angela YFreedberg Kenneth AWeinstein Milton C<p>Abstract</p> <p>Background</p> <p>In resource-limited settings, HIV budgets are flattening or decreasing. A policy of discontinuing antiretroviral therapy (ART) after HIV treatment failure was modeled to highlight trade-offs among competing policy goals of optimizing individual and population health outcomes.</p> <p>Methods</p> <p>In settings with two available ART regimens, we assessed two strategies: (1) continue ART after second-line failure (Status Quo) and (2) discontinue ART after second-line failure (Alternative). A computer model simulated outcomes for a single cohort of newly detected, HIV-infected individuals. Projections were fed into a population-level model allowing multiple cohorts to compete for ART with constraints on treatment capacity. In the Alternative strategy, discontinuation of second-line ART occurred upon detection of antiretroviral failure, specified by WHO guidelines. Those discontinuing failed ART experienced an increased risk of AIDS-related mortality compared to those continuing ART.</p> <p>Results</p> <p>At the population level, the Alternative strategy increased the mean number initiating ART annually by 1,100 individuals (+18.7%) to 6,980 compared to the Status Quo. More individuals initiating ART under the Alternative strategy increased total life-years by 15,000 (+2.8%) to 555,000, compared to the Status Quo. Although more individuals received treatment under the Alternative strategy, life expectancy for those treated decreased by 0.7 years (−8.0%) to 8.1 years compared to the Status Quo. In a cohort of treated patients only, 600 more individuals (+27.1%) died by 5 years under the Alternative strategy compared to the Status Quo. Results were sensitive to the timing of detection of ART failure, number of ART regimens, and treatment capacity. Although we believe the results robust in the short-term, this analysis reflects settings where HIV case detection occurs late in the disease course and treatment capacity and the incidence of newly detected patients are stable.</p> <p>Conclusions</p> <p>In settings with inadequate HIV treatment availability, trade-offs emerge between maximizing outcomes for individual patients already on treatment and ensuring access to treatment for all people who may benefit. While individuals may derive some benefit from ART even after virologic failure, the aggregate public health benefit is maximized by providing effective therapy to the greatest number of people. These trade-offs should be explicit and transparent in antiretroviral policy decisions.</p>http://www.resource-allocation.com/content/10/1/12HIVAIDSAntiretroviral therapyARTDiscontinuationPopulation healthEthicsLimited resources |
| spellingShingle | Kimmel April D Resch Stephen C Anglaret Xavier Daniels Norman Goldie Sue J Danel Christine Wong Angela Y Freedberg Kenneth A Weinstein Milton C Patient- and population-level health consequences of discontinuing antiretroviral therapy in settings with inadequate HIV treatment availability Cost Effectiveness and Resource Allocation HIV AIDS Antiretroviral therapy ART Discontinuation Population health Ethics Limited resources |
| title | Patient- and population-level health consequences of discontinuing antiretroviral therapy in settings with inadequate HIV treatment availability |
| title_full | Patient- and population-level health consequences of discontinuing antiretroviral therapy in settings with inadequate HIV treatment availability |
| title_fullStr | Patient- and population-level health consequences of discontinuing antiretroviral therapy in settings with inadequate HIV treatment availability |
| title_full_unstemmed | Patient- and population-level health consequences of discontinuing antiretroviral therapy in settings with inadequate HIV treatment availability |
| title_short | Patient- and population-level health consequences of discontinuing antiretroviral therapy in settings with inadequate HIV treatment availability |
| title_sort | patient and population level health consequences of discontinuing antiretroviral therapy in settings with inadequate hiv treatment availability |
| topic | HIV AIDS Antiretroviral therapy ART Discontinuation Population health Ethics Limited resources |
| url | http://www.resource-allocation.com/content/10/1/12 |
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