Assessing the Benefits of Rapid Start Antiretroviral Therapy for Newly Diagnosed People with HIV in the United States.

Abstract

Introduction: International guidelines emphasize the need for earlier commencement of antiretroviral therapy (ART) among people with HIV (PWH). Reducing the time between HIV diagnosis and ART initiation can improve health outcomes, reduce healthcare utilization, and reduce HIV transmissions. This study evaluated the clinical and economic benefits associated with increasing uptake of rapid start ART among newly diagnosed PWH.

Methods: A state transition disease model was developed in the United States setting to evaluate the benefits from earlier initiation of ART. The base case analysis compared two cohorts of 1000 newly diagnosed PWH: one following current patterns of ART initiation, and a counterfactual cohort where those receiving rapid start ART was doubled. Individuals were classified by different CD4 states at diagnosis and over time with viral suppression rates also being tracked. ART and CD4 state-specific healthcare costs were estimated over a 3-year time horizon. Averted HIV transmissions were calculated and used to estimate lifetime healthcare cost savings while CD4-specific mortality was also calculated. Several scenario analyses explored alternate assumptions related to the time at which PWH started ART after diagnosis.

Results: Doubling the proportion of newly diagnosed PWH receiving rapid start ART averted 7 HIV transmissions and 0.3 deaths per 1000 people, corresponding to numbers needed to treat of 141 and 3502, respectively. This leads to cost savings resulting from reduced healthcare resource use and lifetime cost savings from preventing new HIV transmissions.

Conclusion: Reducing the time between HIV diagnosis and ART initiation can provide clinical and economic benefits by eliminating transmissions that might occur while individuals are viremic but not on treatment. The additional costs of providing ART required for this increase achieve high levels of return when considering the lifetime healthcare cost burden of onward HIV transmissions potentially averted by early ART start.