JOHANNESBURG, 26 September 2011 (PlusNews) – Modelling has demonstrated the benefits and now data has provided the proof as researchers in Haiti have found that earlier HIV treatment is cost-effective, reducing the risk of death by 75 percent among HIV patients for just US$6.25 more a month.
In 2009, researchers released the results of a then unpublished Haitian clinical trial. Conducted among 800 HIV patients, the study showed that those who received antiretrovirals (ARVs) when their immune systems were stronger – at higher CD4 counts of 200 to 350 – were less likely to die than their peers who waited until their CD4 counts fell to 200.
About five months later, the World Health Organization (WHO) issued new HIV treatment guidelines that advised countries to start HIV patients on treatment at a new higher CD4 count of 350 instead of 200.
Now those researchers have released the world’s first and possibly only cost-effectiveness study on earlier HIV treatment tied to a randomized clinical trial. Published in the September 2011 edition of the medical journal, PLoS Medicine, the study is based on data from the original Haitian study that allowed researchers to calculate costs associated with the first three years of earlier treatment – including everything from drug and family caregiver costs to subsidies for patient transport to and from the clinic.
Bruce Schackman, associate professor of public health at the US Weill Cornell Medical College and a co-author of the study, said this was probably the first and last research of its kind. Given the overwhelming evidence for early treatment, duplicating the study now would be unethical, he said.
“This was a unique opportunity to do this kind of research,” Schackman told IRIN/PlusNews. “I don’t think we’d be able to do a similar comparison [study] given the compelling mortality gain we’ve seen with early treatment.”
And although cost effectiveness is relative, Schackman said he believed the findings were applicable to other countries.
“The patterns of care that occurred in the early treatment versus the standard treatment group are generalizable,” he told IRIN/PlusNews.
“Among the standard treatment group, you see higher costs for lab tests and more costs for outpatient care because patients were not yet receiving drugs and got sicker.”
He added that some countries with higher healthcare costs than Haiti might see an even greater degree of cost-effectiveness.
With an HIV prevalence of about 2 percent, Haiti has the second highest prevalence rate in the Caribbean. The country moved to earlier treatment at CD4 counts of 350 soon after the WHO revised its guidelines, informed in part by the Haiti study. More than half of all HIV patients in the country are under the care of the health organizations that undertook the research – the Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO) and Partners in Health.
“This study is so important because the US government pays a lot of money for HIV treatment and… right now there’s a committee in Congress that is trying to cut millions in foreign aid,” said lead author Serena Koenig. “Our ability to treat people in resource-poor settings depends greatly on how much it costs.”
Koenig is also the medical director for Partners in Health’s Haiti programmes.
Up until now, the cost-effectiveness of early treatment had only been shown through modelling studies. These have demonstrated that while earlier treatment involves more money for drugs initially, it becomes more cost-effective the longer patients are on ARVs as they stay healthier for longer, decreasing the burden on national health systems.
The median follow-up time for patients enrolled in the Haiti study was only 21 months and while 18 lives were saved by access to early treatment during this time, Koenig said she expected her research team to find early ARVs even more cost-effective as they continue to track patients for the next 10 years.
After the trial was stopped in 2009, all patients with CD4 counts of 350 or below in the study were offered HIV treatment and uptake was high, according to Koenig. However, those patients who started treatment later may never recover as much of their immune system as their early-treatment peers.
“There are indications that patients who start treatment late never develop the immune system that they would have with early treatment,” she told IRIN/PlusNews. “For the rest of their lives they are going to have more infections.
“For the price of two Starbuck’s lattes a month, you could preserve someone’s immune system,” Koenig added. “In the US, if we had an intervention that reduced mortality by 75 percent that only cost a few dollars a month? Sure, we’d do it.”
Both authors said they hoped their findings would help more developing countries move towards adopting earlier treatment – and donors commit to supporting this.
“It’s important to highlight the findings of this study but also to continue the funding for early treatment, which also has HIV prevention benefits that were not part of the economic analysis, as well as direct life expectancy benefits,” Schackman said. “In this environment it’s challenging to do that but we’re hoping this will provide the additional economic [rationale] to pursue this.”