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

Objectives. This study was designed to examine the societal cost-effectiven ess and the impact on government payers of earlier initiation of antiretrov iral 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 t rials, and medical care cost estimates for all government payers and for Ma ssachusetts, New York, and Florida. Results, Quality-adjusted life expectancy increased from 7.64 years with th erapy initiated at 200 CD4 cells/muL to 8.21 years with therapy initiated a t 500 CD4 cells/muL. Initiating therapy at 500 CD4/muL was a more efficient use of resources than initiating therapy at 200 CD4/muL and had an increme ntal cost-effectiveness ratio of $17 300 per quality-adjusted life-year gai ned, compared with no therapy. Costs to state payers in the first 5 years r anged from $5 500 to $24 900 because of differences among the states in the availability of federal funds for AIDS drug assistance programs. Conclusions. Antiretroviral therapy initiated at 500 CD4 cells/mul. is cost -effective from a societal perspective compared with therapy initiated late r. States should consider Medicaid waivers to expand access to early therap y.