Browsing by Author "Kyomugisha, Irene"
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- ItemModelling early iInitiation of HAART to forestall AIDS-related lymphoma in South Africa: a cost-effectiveness analysis.(Stellenbosch : Stellenbosch University, 2017-03) Kyomugisha, Irene; Nyabadza, Farai; Hui, Cang; Stellenbosch University. Faculty of Science. Dept. of Mathematical Sciences.ENGLISH SUMMARY: The burden of cancer in low and middle income countries has been projected to shift from 59% (in 2012) to 65% (by 2030) of all cancer cases globally. Since the introduction of highly active antiretroviral therapy (HAART) in South Africa, there has been a marked decline in AIDS-related illnesses and premature death. However, this has not been the case with AIDS-related lymphoma which was observed to be on the rise despite the large HAART roll-out programme. It was discovered that 37% of all lymphoma cases diagnosed in 2009 in the Western Cape province, were HIV-related, indicating a remarkable increase from 5% in 2002. The ineffectiveness of HAART in reducing the incidence of lymphoma is largely attributed to late commencement of treatment. However, increasing HAART coverage is still a major challenge to many developing countries in Africa as well as South Africa due to limited resources. Therefore, increasing early HAART initiation has a cost implication that needs to be investigated in resource limited settings. In this study we used a deterministic compartmental model to investigate the potential impact of initiating HAART at different CD4 cell count levels on the incidence of lymphoma in HIV-infected individuals. We also developed a linked transmission and health state transition (Markov) model in TreeAge Pro to determine the cost-effectiveness of early HAART initiation from the public healthcare payer perspective. The CD4 count driven transmission model predicted lymphoma incidence in HIV-infected adults (aged 15 to 80 years) over a period of ten years. The Markov model predicted the health outcomes and costs. Data on transmission, transition probabilities, CD4 count thresholds, life expectancy, effectiveness and costs were obtained from literature. We compared early initiation of HAART at a CD4 cell count of greater than 500 cells= L to initiation at less than 500 cells= L, the current standard of care. Our primary outcomes were Quality-adjusted life years (QALYs), expected costs, net monetary benefit and the incremental cost-effectiveness ratio (ICER). Health outcomes and costs were discounted at a rate of 5% per annum as recommended in Southern Africa. We also performed deterministic sensitivity analyses to assess parameter uncertainty. Results indicated that early HAART initiation prevents lymphoma cases and related deaths, translating to 3.76 QALYs gained over the 10-year time horizon (6.47 vs. 2.71 expected QALYs with HAART initiation at greater than 500 cells= L and less than 500 cells= L, respectively). The incremental cost of early initiation was $14,613 compared to the alternative. The net monetary benefit (NMB) of early initiation was $90,581 and $30,063 for the alternative. HAART initiation at greater than 500 cells= L was therefore cost-effective with an ICER of $3,890/QALY gained. Sensitivity analysis showed outcomes were sensitive to the effectiveness of HAART in preventing lymphoma, with early initiation being more sensitive than the base case. Therefore, early HAART initiation at CD4 greater than 500 cells= L would not only be effective in forestalling AIDS-related lymphoma but also cost-effective in resource limited settings.