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The Temprano and START trials provided evidence to support early ART initiation recommendations. We projected long-term clinical and economic outcomes of immediate ART initiation in Côte d’Ivoire.    Methods  We used a mathematical model to compare three potential ART initiation criteria: 1) CD4 <350/μL ( ART<350/μL ); 2) CD4 <500/ μ L ( ART<500/μL ); and 3) ART at presentation ( Immediate ART ). Outcomes from the model included life expectancy, 10-year medical resource use, incremental cost-effectiveness ratios (ICERs) in $/year of life saved (YLS), and 5-year budget impact. We simulated people with HIV (PWH) in care (mean CD4: 259/ μ L, SD 198/ μ L) and transmitted cases. Key input parameters to the analysis included first-line ART efficacy (80% suppression at 6 months) and ART cost ($90/person-year). We assessed cost-effectiveness relative to Côte d’Ivoire’s 2017  per capita  annual gross domestic product ($1,600).    Results   Immediate ART  increased life expectancy by 0.34 years compared to  ART<350/μL  and 0.17 years compared to  ART<500/μL .  Immediate ART  resulted in 4,500 fewer 10-year transmissions per 170,000 PWH compared to  ART<350/μL . In cost-effectiveness analysis,  Immediate ART  had a 10-year ICER of $680/YLS compared to  ART<350/μL , ranging from cost-saving to an ICER of $1,440/YLS as transmission rates varied.  ART<500/μL  was “dominated” (an inefficient use of resources), compared with  Immediate ART .  Immediate ART  increased the 5-year HIV care budget from $801.9M to $812.6M compared to  ART<350/μL .    Conclusions  In Côte d’Ivoire, immediate compared to later ART initiation will increase life expectancy, decrease HIV transmission, and be cost-effective over the long-term, with modest budget impact. Immediate ART initiation is an appropriate, high-value standard of care in Côte d’Ivoire and similar settings.

plos one

Cost-effectiveness and budget impact of immediate antiretroviral therapy initiation for treatment of HIV infection in Côte d’Ivoire: A model-based analysis