Cost-effectiveness of WHO-endorsed Advanced HIV Care Package in Malawi
Assessment using the CEPAC model showed the cost-effectiveness of the WHO-endorsed advanced HIV care package in Malawi for adult ART initiation, with a cost of $360/QALY. Incorporating the AHD care package globally is crucial for improving clinical outcomes and reducing mortality.
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Cost-effectiveness of the WHO-endorsed Advanced HIV Care Package in Malawi Show me the money: The cost of epidemic control Emily P. Hyle, Thulani Maphosa, Ajay Rangaraj, Mary Feser, Krishna P. Reddy, C. Robert Horsburgh, Amir Shroufi, Prakriti Shrestha, Nathan Ford, Appolinaire Tiam, Andrew Phillips, Kenneth A. Freedberg With support from the World Health Organization, HIV Modelling Consortium (Bill & Melinda Gates Foundation), National Institute of Allergy and Infectious Diseases (R37AI058736, KAF), MGH Jerome and Celia Reich Endowed Scholar in HIV/AIDS Research Award (EPH), and Gorlin MGH Research Scholars Award (KAF) 23 26 July Brisbane and virtual ias2023.org
Disclosures I have no conflicts of interest in relation to the content of this presentation. 23 26 July Brisbane and virtual ias2023.org
Summary Goals. We used the Cost-effectiveness of Prevention AIDS Complications (CEPAC) simulation model to assess the cost-effectiveness of the WHO-endorsed advanced HIV (AHD) care package for adults initiating ART in Malawi as outpatients. Findings. We found that the AHD care package was cost-effective ($360/QALY) compared with strategies that include some or none of the AHD care package. Relevance. The AHD care package provides high value care to improve clinical outcomes and should be incorporated into HIV care programs globally. 23 26 July Brisbane and virtual ias2023.org
Background WHO defines advanced HIV disease (AHD) in adults and adolescents as having CD4 count <200/ L and/or WHO stage 3 or 4 disease. In sub-Saharan Africa, more than 20% of people living with HIV present with AHD at ART initiation, which is associated with high mortality. WHO and key partners support an AHD package of care to reduce mortality that includes a CD4 test to diagnose AHD, followed by rapid ART initiation and screening, treatment, and/or prophylaxis for severe bacterial infections, tuberculosis (TB), and cryptococcal disease. 23 26 July Brisbane and virtual ias2023.org
WHO-endorsed AHD package of care Serum CrAg test if CD4 <200/ L TB sputum Xpert Rapid ART initiation Co-trimoxazole Prophylaxis CD4 count Fluconazole pre-emptive treatment TB urine LAM TPT LAM, lipoarabinomannan; TPT, TB preventive therapy; CrAg, cryptococcal antigen. 23 26 July Brisbane and virtual ias2023.org
Objective To examine the clinical impact, costs, and cost-effectiveness of the WHO-endorsed AHD package of care for people living with HIV and presenting to care in Malawi. In addition to the full AHD package of care, we examined specific strategies where elements of the AHD package are included singly or in combination: 1. Co-trimoxazole prophylaxis 2. TB diagnosis with Xpert and/or LAM for people with TB symptoms 3. TB preventative therapy for people without active TB 4. Cryptococcal antigen (CrAg) screening and pre-emptive fluconazole 23 26 July Brisbane and virtual ias2023.org
Methods We used the Cost-effectiveness of Preventing AIDS Complications (CEPAC) model to simulate a population of people with HIV aged 18y who are initiating ART after a measured CD4 count in an outpatient setting in Malawi. The simulated population did not include people who are: Pregnant Younger than 18 years of age Hospitalized With severe symptoms (i.e., suspected cryptococcal or TB meningitis) 23 26 July Brisbane and virtual ias2023.org
Model-Projected Outcomes Quality-adjusted life years (QALYs) Costs Incremental cost-effectiveness ratios (ICERs) ICER = costs/ QALYs 3% discount rate We considered ICERs <$640/QALY (Malawi per capita GDP) to be cost-effective. 23 26 July Brisbane and virtual ias2023.org
Methods In strategies that include elements of the AHD package of care (singly or in combination), we used published data for: Test characteristics Uptake of testing, treatment, and prevention Treatment efficacy Costs 23 26 July Brisbane and virtual ias2023.org
Selected Clinical Input Parameters Input parameter Value Source Mean age, years Sex at birth, female/male, % Cohort distribution CD4<200/ L or WHO stage 3/4 disease Mean CD4 at model start, cells/ L CD4>=200/ L without WHO 3/4 disease Mean CD4 at model start, cells/ L CD4-stratified prevalence at model start, % Active TB Latent TB Asymptomatic cryptococcal disease 37 Hakim NEJM 2017 46/54 19% 90 81% 418 Nasuuna CID 2020 and Munthali JIAS 2014 Dodd Am J Epidemiol 2010; Henostroza Int J Tuberc Lung Dis 2016; Lawn PLoS Med 2011 Ford CID 2018 18-37 20-39 0-5 23 26 July Brisbane and virtual ias2023.org
Selected Cost Input Parameters Input parameter Value Source Cost per test, $ GeneXpert Urine LAM Serum CrAg screening Medication cost, monthly, $ Co-trimoxazole prophylaxis $13 $5 $3 Tagar PLoS One 2014; The Global Fund 2022; M decins Sans Fronti res Access Campaign 2019 Tagar PLoS One 2014; Management Sciences for Health (MSH) 2016 Kim Int J Tuberc Lung Dis 2018 $0.83 Fluconazole pre-emptive therapy $4 Isoniazid (TPT) $1 Costs are in 2021 USD 23 26 July Brisbane and virtual ias2023.org
Results Undisc. QALYs 12.81 Discounted QALYs* 9.00 Lifetime costs ($)* 1,010 ICER ($/QALY) - Strategy ART only 17.79 11.69 1,330 120 +Xpert 18.04 11.83 1,350 150 +Xpert+LAM 18.15 11.89 1,370 170 +Xpert+LAM+TPT 18.15 11.89 1,370 300 +Xpert+LAM+TPT+CrAg 18.42 12.05 1,420 360 Full AHD Care Package *Discounted at 3%/y; ICERs are calculated from unrounded estimates 23 26 July Brisbane and virtual ias2023.org
Results Undisc. QALYs 12.81 Discounted QALYs* 9.00 Lifetime costs ($)* 1,010 ICER ($/QALY) - Strategy ART only 17.79 11.69 1,330 120 +Xpert 18.04 11.83 1,350 150 +Xpert+LAM 18.15 11.89 1,370 170 +Xpert+LAM+TPT 18.15 11.89 1,370 300 +Xpert+LAM+TPT+CrAg 18.42 12.05 1,420 360 Full AHD Care Package *Discounted at 3%/y; ICERs are calculated from unrounded estimates 23 26 July Brisbane and virtual ias2023.org
Results Undisc. QALYs 12.81 Discounted QALYs* 9.00 Lifetime costs ($)* 1,010 ICER ($/QALY) - Strategy ART only 17.79 11.69 1,330 120 +Xpert 18.04 11.83 1,350 150 +Xpert+LAM 18.15 11.89 1,370 170 +Xpert+LAM+TPT 18.15 11.89 1,370 300 +Xpert+LAM+TPT+CrAg 18.42 12.05 1,420 360 Full AHD Care Package *Discounted at 3%/y; ICERs are calculated from unrounded estimates 23 26 July Brisbane and virtual ias2023.org
Results: Sensitivity Analyses We examined the results under a wide range of parameter estimates in one-way and multi-way sensitivity analyses for: Prevalence of opportunistic infections Diagnostic test characteristics Uptake of testing, treatment, and prevention interventions Treatment efficacy Costs 23 26 July Brisbane and virtual ias2023.org
Results: Sensitivity Analyses The full AHD package of care would remain cost-effective unless parameter estimates were far outside of published data, in particular: Efficacy of co-trimoxazole, fluconazole, and isoniazid is lower than reported Mortality from serious bacterial infections is lower than reported Prevalence of cryptococcal disease is lower than reported 23 26 July Brisbane and virtual ias2023.org
Limitations Although all published estimates have uncertainty, these model-based findings remained robust across extensive sensitivity analyses. We did not assess the AHD package of care when a CD4 count test is not available; that work is ongoing. This analysis did not examine the potential benefits of the AHD package of care for children, pregnant people, or people with severe symptoms requiring hospitalization. 23 26 July Brisbane and virtual ias2023.org
Conclusions Strategies that incorporate elements of the AHD package of care would improve clinical outcomes in Malawi. The full AHD package, including rapid ART initiation and CD4 count with Xpert and LAM for TB diagnosis, TB preventative therapy, co-trimoxazole, and CrAg testing with pre-emptive fluconazole, would result in the greatest life expectancy and would be cost-effective at $360/QALY. HIV care programs should invest in the AHD care package for adults living with HIV initiating ART in the outpatient setting. 23 26 July Brisbane and virtual ias2023.org
Thank You This work was funded by the World Health Organization, HIV Modelling Consortium (Bill & Melinda Gates Foundation), National Institute of Allergy and Infectious Diseases (R37AI058736, KAF), MGH Jerome and Celia Reich Endowed Scholar in HIV/AIDS Research award (EPH), and Steve and Deborah Gorlin MGH Research Scholars award (KAF) 23 26 July Brisbane and virtual ias2023.org
