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Bruce R. Schackman, PhD, Sue J. Goldie, MD, MPH, Milton C. Weinstein, PhD, Elena Losina, PhD, Hong Zhang, SM and Kenneth A. Freedberg, MD, MSc

At the time of the study Bruce R. Schackman was, and Sue J. Goldie, Milton C. Weinstein, and Kenneth A. Freedberg are now, with the Center for Risk Analysis, Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass. Elena Losina and Dr. Freedberg are with the Department of Epidemiology and Biostatistics, Boston University School of Public Health, Boston. Dr. Losina, Hong Zhang, and Dr. Freedberg are with the Division of General Medicine and Partners AIDS Research Center, Massachusetts General Hospital and Harvard Medical School, Boston.

Correspondence: Requests for reprints should be sent to Bruce R. Schackman, PhD, Department of Public Health, Weill Medical College of Cornell University, 411 East 69th St, New York, NY 10021 (e-mail: brs2006{at}med.cornell.edu).

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, New York, and Florida.

Results. Quality-adjusted life expectancy increased from 7.64 years with therapy initiated at 200 CD4 cells/µL to 8.21 years with therapy initiated at 500 CD4 cells/µL. Initiating therapy at 500 CD4/µL was a more efficient use of resources than initiating therapy at 200 CD4/µL 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 $5500 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/µL is cost-effective from a societal perspective compared with therapy initiated later. States should consider Medicaid waivers to expand access to early therapy.

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