Cost-effectiveness of earlier initiation of antiretroviral therapy for uninsured HIV-infected adults

OBJECTIVES: This study was designed to examine the societal cost-effectiveness and the impact on government payers of earlier initiation of antiretroviral therapy for uninsured HIV-infected adults. METHODS: A state-transition simulation model of HIV disease was used. Data were derived from the Multicenter AIDS Cohort Study, published randomized trials, and medical care cost estimates for all government payers and for Massachusetts, NewYork, and Florida. RESULTS: Quality-adjusted life expectancy increased from 7.64 years with therapy initiated at 200 CD4 cells/microL to 8.21 years with therapy initiated at 500 CD4 cells/microL. Initiating therapy at 500 CD4/microL was a more efficient use of resources than initiating therapy at 200 CD4/microL and had an incremental cost-effectiveness ratio of $17,300 per quality-adjusted life-year gained, compared with no therapy. Costs to state payers in the first 5 years ranged from $5,500 to $24,900 because of differences among the states in the availability of federal funds forAIDS drug assistance programs. CONCLUSIONS: Antiretroviral therapy initiated at 500 CD4 cells/microL is cost-effective from a societal: perspective compared with therapy initiated later. States should consider Medicaid waivers to expand access to early therapy.