CROI 2017 Abstract e-Book

Abstract eBook

Poster and Themed Discussion Abstracts

Methods: From September 2014 through July 2016, we collected comprehensive data on facility-level ART costs from 7 facilities prior to and after transitioning to EAAA as part of a large-scale randomized stepped-wedge health systems trial of EAAA. We used a “bottom-up costing” approach extracting data from facility budgets, expenditure reports, and patient records. SOC ART eligibility threshold was ≤350 cells/ml until December 2015, when it changed to ≤500 cells/ml. We used an activity-based allocation method for costs shared with non-ART patients. The costs include medications, laboratory services, direct and indirect personnel, equipment and administrative services. Total costs were divided by the total number of ART patient-years over the period the facility experienced SOC and EAAA to derive ART cost per patient per year (PPPY). Results: The average facility-level cost for ART patients was $277 PPPY (95%CI: 184-371) in SOC compared to $254 PPPY (95%CI: 209-298) in EAAA (p=0.66). The cost of ARVs was $113 PPPY (95%CI: 111-116) in SOC and $110 PPPY (95%CI: 108-112) in EAAA (p=0.04). The personnel costs were $130 PPPY (95%CI: 43-217) in SOC and $96 PPPY (95%CI: 51-141) in EAAA (p=0.51). Laboratory costs were $22 PPPY (95%CI: 11-33) in SOC and $37 PPPY (95%CI: 29-44) in EAAA (p=0.05). Conclusion: We present the first direct comparison of public-sector patient costs under EAAA and SOC. Even though we would expect ART patients under EAAA to be on average healthier than patients under SOC, average public-sector costs per ART patient are essentially the same under the two treatment policies. Differences in funding requirements for SOC vs. EAAA will thus be largely driven by the number of patients receiving treatment. The larger average laboratory costs in EAAA were explained by increased uptake of viral load monitoring.

Poster and Themed Discussion Abstracts

476 COST-EFFECTIVENESS AND BUDGET IMPACT OF IMMEDIATE ART INITIATION IN CÔTE D’IVOIRE Eric N. Ouattara 1 , Rachel L. MacLean 2 , Christine DANEL 3 , Ethan D. Borre 2 , DELPHINE GABILLARD 3 , Mingshu Huang 2 , A. David Paltiel 4 , xavier anglaret 3 , Serge EHOLIE 5 , Kenneth Freedberg 2 1 Prog PAC-CI, ANRS Rsr site, Abidjan, Cote d’Ivoire, 2 Massachusetts General Hosp, Boston, MA, USA, 3 INSERM, Bordeaux, France, 4 Yale Univ, New Haven, CT, USA, 5 Service des Maladies Infectieuses et Tropes, Abidjan, Côte d’Ivoire Background: In 2015, the Temprano and START trials provided evidence supporting early ART initiation, prompting the WHO to recommend ART at diagnosis for HIV-infected persons. Our objective was to project the clinical and economic outcomes, cost-effectiveness, and 5yr budget impact of immediate ART initiation in Côte d’Ivoire, the setting of Temprano. Methods: We used a mathematical model of HIV (CEPAC-I), informed by the Temprano trial, to assess three ART initiation criteria in Côte d’Ivoire: 1) CD4 count <350/μL; 2) CD4 count <500/μL; and 3) Immediate ART. We reported outcomes from the payor perspective for the entire HIV-infected population currently in care in Côte d’Ivoire (All-in-care, mean CD4 259/μL; 170,000 persons) and for only those in care with CD4 counts >500 cells/µL (>500/µL-in-care, mean CD4: 666/uL; 22,000 persons). We assumed viral load-dependent transmission rates (0.16-9.03/100PY). ART 48-week efficacy was 80% and adherence-dependent loss to follow-up rates were 1.9-13%/month. 1st- and 2nd-line ART costs were $122 and $391/year. Outcomes included transmitted HIV cases, life expectancy in life-years (LY), 10yr incremental cost-effectiveness ratios (ICERs), and 5yr budget impact. We labeled a strategy “cost-effective” if its ICER, in $/year of life saved (YLS), was less than the annual per capita GDP in Côte d’Ivoire ($1,530). We conducted extensive sensitivity analyses to assess the impact of parameter uncertainty on our findings. Results: For All-in-care, Immediate ART decreased 10-year transmissions from 93,900 to 84,800 (-9.7%) compared to ART<350/µL and increased life expectancy by 17,000 LYs over 10 years, yielding an ICER of $300/YLS (<0.25x per capita GDP). Immediate ART increased total 5yr costs from $515.5M to $523.4M (+1.4%) compared to ART<350/µL. Increasing mean CD4 at linkage to care to 500/µl and varying transmission rates over their 95% confidence interval, the 5yr cost difference for Immediate ART compared to ART<350/µL ranged from -11.1% to +3.1%. For the >500/µL-in-care, Immediate ART was cost-saving over 10yr, with small increases in 5yr costs (+2.3%). Cost-effectiveness and budget impact findings were most sensitive to 1st-line ART cost. Conclusion: In Côte d’Ivoire, Immediate ART compared to later initiation reduces HIV transmissions, increases survival, and is very cost-effective, all with modest increase in program costs. Immediate ART initiation should be the standard of care in Côte d’Ivoire and similar settings.

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