Cost-effectiveness Implications of the Timing of Antiretroviral Therapy in HIV-Infected Adults

Schackman, Bruce R.; Freedberg, Kenneth A.; Weinstein, Milton C.; Sax, Paul E.; Losina, Elena; Zhang, Hong; Goldie, Sue J.

doi:10.1001/archinte.162.21.2478

Cited by 64 publications

(46 citation statements)

References 56 publications

(75 reference statements)

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“…This association was shown in the overall population as well as in a subset of patients aged between 35 and 65 years. Although the effect of PI treatment on CVD risk was evident in this analysis, the demonstrated benefits of HAART therapy still outweigh the risk of subsequent cardiovascular events [30]. However, a combination of several factors, such as longer life expectancy, higher smoking rates among HIV-infected persons and prolonged exposure to PI-based HAART regimens, may lead to greater CVD event rates, especially as this population continues to age.…”

Section: Hazards Ratiomentioning

confidence: 81%

Protease inhibitor exposure and increased risk of cardiovascular disease in HIV‐infected patients

et al. 2005

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ObjectivesTo study the relationship between exposure to protease inhibitor (PI) therapy and increased risk of cardiovascular events in HIV-infected patients. MethodsWe estimated the risk of cardiovascular disease (CVD) events with PI exposure in a cohort of HIVinfected patients using a time-dependent Cox proportional hazards model adjusting for the major CVD risk factors. Only the first CVD event for each subject was counted. ResultsOf a total of 7542 patients, 77% were exposed to PIs. CVD event rates were 9.8/1000 and 6.5/1000 person-years of follow-up (PYFU) in the PI-exposed and nonexposed groups, respectively (P 5 0.0008). PI exposure 60 days was associated with an increased risk of CVD event [adjusted hazards ratio (HR adj ) 1.71; 95% confidence interval (CI) 1.08-2.74; P 5 0.03]. Results from a subgroup of patients aged between 35 and 65 years were similar (HR adj 1.90; 95% CI 1.13-3.20; P 5 0.02). Other significant risk factors included smoking status, age, hypertension, diabetes mellitus and pre-existing CVD. ConclusionsPatients exposed to PI therapy had an increased risk of CVD events. Clinicians should evaluate the risk of CVD when making treatment decisions for HIV-infected patients.Keywords: antiretroviral therapy, cardiovascular disease, HAART, protease inhibitors, treatment complications IntroductionHighly active antiretroviral therapy (HAART) has resulted in dramatic declines in progression to AIDS and AIDS mortality in HIV-infected persons [1][2][3][4][5][6]. In some reports, death from nonAIDS-related causes exceed those attributed to AIDS in this patient population [2,[7][8][9], and cardiovascular deaths are increasing in these patients [1,2]. Recent reports suggest a shift in the relative cause of death among HIV-infected individuals, with cardiovascular deaths accounting for fewer than 4% of all deaths pre-1997 [1,10], and for 7-10% in more recent years [8,10,11].Reports from large observational studies demonstrate that considerable controversy exists over the association of HAART, particularly protease inhibitor (PI) therapies, with increased cardiovascular disease (CVD) risk [12][13][14][15][16][17]. PIs have been associated with alterations in surrogate markers of CVD, including coronary calcium scores and endothelial function [18,19], as well as with metabolic complications such as hyperlipidaemia, fat redistribution, insulin resistance, hypertension and diabetes mellitus [19][20][21][22][23][24]. Also, HIV-infected patients may have a higher prevalence of traditional CVD risk factors such as smoking than the general population [20,21]. In addition, as the mean age of the HIV-infected patient population has increased as a result of longer life expectancy with the disease, the consequent cardiovascular risk has also increased. 37These changes in patient demographics and the increasing prevalence of traditional CVD risk factors such as smoking, along with the increasing prevalence of PIassociated metabolic complications, have clearly increased the risk of CVD in HIV-infected individuals. ...

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Section: Hazards Ratiomentioning

confidence: 81%

Protease inhibitor exposure and increased risk of cardiovascular disease in HIV‐infected patients

et al. 2005

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“…Although the relative risk of cardiac disease may be increased as a result of ART, this increase is greatly outweighed by the absolute reduction in the risk of AIDS-related complications from ART [47]. Previous work estimating HIV treatment-induced changes in lipid levels suggests that hyperlipidemia reduces overall life expectancy by ∼1 month [48].…”

Section: Discussionmentioning

confidence: 99%

The Survival Benefits of AIDS Treatment in the United States

Walensky¹,

Paltiel²,

Losina³

et al. 2006

J INFECT DIS

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514

341

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“…Increased HIV-related morbidity and mortality [9], poorer response to treatment [10] and increased healthcare costs are the consequences of late HIV diagnosis [11]. Moreover, delayed diagnosis is one the most important determinants of increased rates of HIV transmission; based on US modelling data, half of new infections are derived from HIV-positive persons that are not yet diagnosed and therefore unaware of the possible risk of transmitting the virus [12].…”

mentioning

confidence: 99%

Indicator condition-guided HIV testing in Europe: a step forward to HIV control:

Blasi

Matteelli

2013

Eur Respir J

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Cost-effectiveness Implications of the Timing of Antiretroviral Therapy in HIV-Infected Adults

Abstract: Changes in cholesterol or quality of life associated with antiretroviral therapy do not justify limiting access to early HIV treatment. The effect of fat redistribution symptoms on quality of life will determine the optimal choice of early vs deferred therapy for an individual patient.

Cited by 64 publications

References 56 publications

Protease inhibitor exposure and increased risk of cardiovascular disease in HIV‐infected patients

Protease inhibitor exposure and increased risk of cardiovascular disease in HIV‐infected patients

The Survival Benefits of AIDS Treatment in the United States

Indicator condition-guided HIV testing in Europe: a step forward to HIV control:

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