HIV This Week

Micheloud D, Berenguer J, Bellón JM, Miralles P, Cosin J, de Quiros JC, Conde MS,Muñoz-Fernández MA, Resino S. Negative influence of age on CD4+ cell recovery after highly active antiretroviral therapy in naive HIV-1-infected patients with severe immunodeficiency. J Infect. 2008 ;56(2):130-6.

Micheloud and colleagues aimed to study the effect of age on several outcomes among 187 antiretroviral-naive infected patients who started highly active antiretroviral therapy (HAART) with <or=200 CD4(+)/microl. The authors carried out a retrospective study to determine the hazard ratio (HR) to reach an outcome in patients who experienced a change from the baseline in CD4(+) counts of at least +100, +200, +300, +400 and +500 cells/microl at any moment during the follow-up and the odds ratio (OR) of achieving and maintaining a CD4(+) value above a certain setpoint during at least 6, 12 or 18 months. The adjusted HR for an increase of +400 CD4(+)/microl and +500 CD4(+)/microl were 1.3 (95% CI: 1.1; 1.5) and 1.3 (95% CI: 1.1; 1.6) times slower for each additional 5 years of age at baseline. In addition, for every 5 years of extra age, the adjusted OR to achieve an absolute CD4(+) cell count >500/microl at 6, 12 and 18 months after the initiation of HAART were 2.2 (95% CI: 1.5; 3.2), 1.8 (95% CI: 1.2; 2.6), and 1.8 (95% CI: 1.2; 2.9) times less likely, respectively. The authors also found that patients >or=45 years old had worse complete CD4(+) recovery (CD4(+)>500 cells/microl) than patients <45 years old. in conclusion, the CD4(+) recovery after HAART is a prolonged and continuous process which extends for several years. Age at baseline is inversely correlated with the magnitude and speed of CD4(+) recovery among HIV-1 infected patients.

Editors’ note: Older age at the time of HIV acquisition is associated with faster disease progression. This study found that increasing age was associated with slower CD4 count recovery after initiation of antiretroviral treatment and a lower likelihood of reaching an absolute CD4 count of 500. This suggests that older people may benefit from earlier initiation of antiretroviral treatment before CD4 counts reach 200.

The aim of this study was to estimate the outcome and cost-effectiveness per life-year-gained (LYG) of first-, second- and third-line non-nucleoside reverse transcriptase inhibitors (NNRTI) versus protease inhibitor (PI) containing highly active antiretroviral therapy regimens. Hospital care costs (2002 US dollars discounted 3.5% per annum) were linked to treatment failure times. Results show that the median time-to-treatment failure for first-line (nucleoside reverse transcriptase inhibitors) 2NRTIs + NNRTI was substantially longer than that for 2NRTIs + PI (boosted), 2NRTIs + PI and 2NRTIs + 2PIs, whereas for second- and third-line they were similar. Comparing first-line 2NRTIs + NNRTI with 2NRTIs + PI (boosted) cost per LYG was US$ 12,375; US$ 12,139 per LYG when compared with 2NRTIs + PI and US$ 2948 per LYG when compared with 2NRTIs + 2PIs. For second-line cost per LYG comparing 2NRTIs + NNRTI with 2NRTIs + PI (boosted) was US$ 19,501; US$ 18,364 per LYG when compared with 2NRTIs + PI and cost-saving when compared with 2NRTIs + 2PIs. For third-line cost per LYG comparing 2NRTIs + NNRTI with 2NRTIs + PI(boosted) was US$ 2708; US$ 11,559 per LYG when compared with 2NRTIs + PI and cost-saving when compared with 2NRTIs + 2PIs. In conclusion, first-line 2NRTIs + NNRTI was cost-effective or cost-saving when compared with PI-containing regimens for all lines of therapy. Such information is required by clinicians and managers of HIV services to make appropriate treatment decisions based on clinical and financial grounds, and given the increasing number of people living with HIV, such information will become more important over time.

Editors’ note: In low- and middle–income countries, the standard first-line therapy recommended by the WHO public health approach contains a backbone of two nucleoside reverse transcriptase inhibitors (NRTI) and one non-nucleoside reverse transcriptase inhibitor (2 nukes and 1 non-nuke). Until now, the outcome and cost-effectiveness of such regimens compared to protease inhibitor (PI) containing regimens have not been studied. Although the setting for this study is a high-income country, the 2 nukes-1 non-nuke first-line, second-line, and third-line regimens were either cost-effective or cost-saving. Of note is the much longer median time to treatment failure for people on these first-line regimens compared to those containing protease inhibitors, a finding of direct relevance for low- and middle-income countries.