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Patient- and population-level health consequences of discontinuing antiretroviral therapy in settings with inadequate HIV treatment availability.
Kimmel A., Resch S., Anglaret X., Daniels N., Goldie S., Danel C., Wong A., Freedberg K., Weinstein M.
Cost Effectiveness and Resource Allocation 10, 1 (2012) 12 - http://www.hal.inserm.fr/inserm-00753866
 (22992315) 
Patient- and population-level health consequences of discontinuing antiretroviral therapy in settings with inadequate HIV treatment availability.
April Kimmel () 1, 2, 3, Stephen Resch3, Xavier Anglaret4, 5, Norman Daniels3, Sue Goldie3, Christine Danel4, Angela Wong6, Kenneth Freedberg3, 6, 7, Milton Weinstein3, 7
1 :  Department of Healthcare Policy and Research
Virginia Commonwealth University School of Medicine
Richmond, VA, 23298
États-Unis
2 :  Weill Cornell Medical College
Weill Cornell Medical College
New York
États-Unis
3 :  Harvard School of Public Health
Harvard School of Public Health
Boston
États-Unis
4 :  Programme PAC-CI
ANRS
Côte D'Ivoire
5 :  Epidémiologie et Biostatistique
INSERM : U897 – Université Victor Segalen - Bordeaux II – Institut de Santé Publique, d'Épidémiologie et de Développement (ISPED)
146, rue Léo-Saignat 33076 Bordeaux
France
6 :  MGH - Massachusetts General Hospital
http://www.massgeneral.org/
Massachusetts General Hospital
Massachusetts General Hospital 55 Fruit Street Boston, MA 02114
États-Unis
7 :  HMS - Harvard Medical School
http://www.hms.harvard.edu
Harvard University
25 Shattuck Street Boston, MA 02115
États-Unis
ABSTRACT: BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.
Sciences du Vivant/Santé publique et épidémiologie
Anglais
1478-7547

Articles dans des revues avec comité de lecture
10.1186/1478-7547-10-12
Cost Effectiveness and Resource Allocation
Publisher BioMed Central
ISSN 1478-7547 
internationale
19/09/2012
19/09/2012
10
1
12

HIV – AIDS – Antiretroviral therapy – ART – Discontinuation – Population health – Ethics – Limited resources
This work was supported in part by the Fogarty International Center (D43TW000018); National Institute of Allergy and Infectious Diseases (T32 AI007433 and R01 AI058736); National Institute on Drug Abuse (DA15162); and Graduate Society Merit Award and Graduate Society Summer Fellowship, Graduate School of Arts and Sciences, Harvard University; and Project on Justice, Welfare and Economics, Weatherhead Center for International Affairs, Harvard University.
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