Search

IntroductionSince 2015, the World Health Organization (WHO) has recommended that all people living with HIV (PLHIV) initiate antiretroviral treatment (ART), irrespective of CD4+ count or clinical stage. National adoption of universal treatment has accelerated since WHO's 2015 "Treat All" recommendation; however, little is known about the translation of this guidance into practice. This study aimed to assess the status of Treat All implementation across regions, countries, and levels of the health care delivery system.MethodsBetween June and December 2017, 201/221 (91%) adult HIV treatment sites that participate in the global IeDEA research consortium completed a survey on capacity and practices related to HIV care. Located in 41 countries across seven geographic regions, sites provided information on the status and timing of site-level introduction of Treat All, as well as site-level practices related to ART initiation.ResultsAlmost all sites (93%) reported that they had begun implementing Treat All, and there were no statistically significant differences in site-level Treat All introduction by health facility type, urban/rural location, sector (public/private) or country income level. The median time between national policy adoption and site-level introduction was one month. In countries where Treat All was not yet adopted in national guidelines, 69% of sites reported initiating all patients on ART, regardless of clinical criteria, and these sites had been implementing Treat All for a median period of seven months at the time of the survey. The majority of sites (77%) reported typically initiating patients on ART within 14 days of confirming diagnosis, with 60% to 62% of sites implementing Treat All in East, Southern and West Africa reporting same-day ART initiation for most patients.ConclusionsBy mid- to late-2017, the Treat All strategy was the standard of care at almost all IeDEA sites, including rural, primary-level health facilities in low-resource settings. While further assessments of site-level capacity to provide high-quality HIV care under Treat All and to support sustained viral suppression after ART initiation are needed, the widespread introduction of Treat All at the service delivery level is a critical step towards global targets for ending the HIV epidemic as a public health threat.

ObjectiveTo test the impact of a nationwide Long-Lasting Insecticidal Nets [LLINs] distribution program in the Democratic Republic of Congo [DRC] on all-cause under-five child mortality exploiting subnational variation in malaria endemicity and the timing in the scale-up of the program across provinces.DesignGeospatial Impact Evaluation using a difference-in-differences approach.SettingDemocratic Republic of the Congo.Participants52,656 children sampled in the 2007 and 2013/2014 DRC Demographic and Health Surveys.InterventionsThe analysis provides plausibly causal estimates of both average treatment effects of the LLIN distribution campaign and geospatial heterogeneity in these effects based on malaria endemicity. It compares the under-five, all-cause mortality for children pre- and post-LLIN campaign relative to children in those areas that had not yet been exposed to the campaign using a difference-in-differences model and controlling for year- and province-fixed effects, and province-level trends in mortality.ResultsWe find that the campaign led to a 41% decline [3.7 percentage points, 95% CI 1.3 to 6.0] in under-5 mortality risk among children living in rural areas with malaria ecology above the sample median. Results were robust to controlling for household assets and the presence of other health aid programs. No effect was detected in children living in areas with malaria ecology below the median.ConclusionThe findings of this paper make important contributions to the evidence base for the effectiveness of large scale-national LLIN campaigns against malaria. We found that the program was effective in areas of the DRC with the highest underlying risk of malaria. Targeting bednets to areas with greatest underlying risk for malaria may help to increase the efficiency of increasingly limited malaria resources but should be balanced against other malaria control concerns.

Introduction"Treat All" - the treatment of all people with HIV, irrespective of disease stage or CD4 cell count - represents a paradigm shift in HIV care that has the potential to end AIDS as a public health threat. With accelerating implementation of Treat All in sub-Saharan Africa (SSA), there is a need for a focused agenda and research to identify and inform strategies for promoting timely uptake of HIV treatment, retention in care, and sustained viral suppression and addressing bottlenecks impeding implementation.MethodsThe Delphi approach was used to develop consensus around research priorities for Treat All implementation in SSA. Through an iterative process (June 2017 to March 2018), a set of research priorities was collectively formulated and refined by a technical working group and shared for review, deliberation and prioritization by more than 200 researchers, implementation experts, policy/decision-makers, and HIV community representatives in East, Central, Southern and West Africa.Results and discussionThe process resulted in a list of nine research priorities for generating evidence to guide Treat All policies, implementation strategies and monitoring efforts. These priorities highlight the need for increased focus on adolescents, men, and those with mental health and substance use disorders - groups that remain underserved in SSA and for whom more effective testing, linkage and care strategies need to be identified. The priorities also reflect consensus on the need to: (1) generate accurate national and sub-national estimates of the size of key populations and describe those who remain underserved along the HIV-care continuum; (2) characterize the timeliness of HIV care and short- and long-term HIV care continuum outcomes, as well as factors influencing timely achievement of these outcomes; (3) estimate the incidence and prevalence of HIV-drug resistance and regimen switching; and (4) identify cost-effective and affordable service delivery models and strategies to optimize uptake and minimize gaps, disparities, and losses along the HIV-care continuum, particularly among underserved populations.ConclusionsReflecting consensus among a broad group of experts, researchers, policy- and decision-makers, PLWH, and other stakeholders, the resulting research priorities highlight important evidence gaps that are relevant for ministries of health, funders, normative bodies and research networks.

Awareness of the impact of education on health remains relatively low among the public, professionals, and policy makers. Virginia Commonwealth University's Center on Society and Health sought to raise awareness among key decision makers about the impact of education on health outcomes through its Education and Health Initiative (EHI). EHI utilized four key strategies to raise awareness: user-oriented research, strategic communication, local and national stakeholder engagement, and policy outreach to decision makers. We review the research highlighted in four stages of EHI product releases, as well as the development, process, products, and key outcomes associated with this initiative.

Achieving US state and municipal benchmarks to end the HIV epidemic and promote health equity requires access to comprehensive HIV care. However, this care may not be geographically accessible for all people living with HIV (PLHIV). We estimated county-level drive time and suboptimal geographic accessibility to HIV care across the contiguous US, assessing regional and urban--rural differences. We integrated publicly available data from four federal databases to identify and geocode sites providing comprehensive HIV care in 2015, defined as the co-located provision of core HIV medical care and support services. Leveraging street network, US Census and HIV surveillande data (2014), we used geographic analysis to estimate the fastest one-way drive time between the population-weighted county centroid and the nearest site providing HIV care for counties reporting at least five diagnosed HIV cases. We summarized HIV care sites, county-level drive time, population-weighted drive time and suboptimal geographic accessibility to HIV care, by US region and county rurality (2013). Geographic accessibility to HIV care was suboptimal if drive time was >30 min, a common threshold for primary care accessibility in the general US population. Tests of statistical significande were not performed, since the analysis is population-based. We identified 671 HIV care sites across the US, with 95% in urban counties. Nationwide, the median county-level drive time to HIV care is 69 min (interquartile range (IQR) 66 min). The median county-level drive time to HIV care for rural counties (90 min, IQR 61) is over twice that of urban counties (40 min, IQR 48), with the greatest urban-rural differences in the West. Nationally, population-weighted drive time, an approximation of individual-level drive time, is over five times longer in rural counties than in urban counties. Geographic access to HIV care is suboptimal for over 170,000 people diagnosed with HIV (19%), with over half of these individuals from the South and disproportionately the rural South. Nationally, approximately 80,000 (9%) drive over an hour to receive HIV care. Suboptimal geographic accessibility to HIV care is an important structural barrier in the US, particularly for rural residents living with HIV in the South and West. Targeted policies and interventions to address this challenge should become a priority. Keywords: HIV/AIDS; geography; travel time; access to care; rural; disparities, 1 | INTRODUCTION Many United States (US) municipalities and states are implementing strategic plans to end HIV as an epidemic [1]. In addition to meeting benchmarks such as percent virally [...]

U.S. HIV diagnoses disproportionately affect Non-Hispanic Black (NHB) and Hispanic gay and bisexual men. Using data from the National Health Interview Survey (2013-2018), we examined race and ethnicity and primary care access, an HIV prevention resource, among gay and bisexual men. The explanatory variable was NHB, Hispanic or Non-Hispanic White (NHW). Outcomes were primary care-specific usual place of care (potential access) and saw general doctor <12 months (realized access). We used multivariable logistic regression, adjusting for individual sociodemographic characteristics, health status, and care barriers. In sensitivity analysis, we examined general access (any place/doctor) and subgroups (1) NHB (2) has usual place of care. The sample included 1,858 adult, gay and bisexual men (unweighted). Nearly one-third self-identified as NHB or Hispanic. Compared to NHW men, NHB and Hispanic men were younger, with lower household income, and more care barriers (p < 0.05). NHB and Hispanic men had lower realized access (aOR 0.7058, p = 0.030) than NHW men. Potential access was lower for NHB only (versus NHW) and, among those with any usual place of care, NHB and Hispanic men versus NHW men. Lower primary care access for NHB or Hispanic, rather than NHW, gay and bisexual men, may reduce HIV prevention access. [ABSTRACT FROM AUTHOR]

In the United States, people living with HIV (PLWH) in rural areas fare worse along the HIV care continuum than their urban counterparts; this may be due in part to limited geographic access to care. We estimated drive time to care for PLWH, focusing on urban-rural differences. Adult Medicaid enrollees living with HIV and their usual care clinicians were identified using administrative claims data from 14 states (Medicaid Analytic eXtract, 2009–2012). We used geographic network analysis to calculate one-way drive time from the enrollee's ZIP code tabulation area centroid to their clinician's practice address, then examined urban-rural differences using bivariate statistics. Additional analyses included altering the definition of rurality; examining subsamples based on the state of residence, services received, and clinician specialty; and adjusting for individual and county characteristics. Across n = 49,596 PLWH, median drive time to care was 12.8 min (interquartile range 26.3). Median drive time for rural enrollees (43.6 (82.0)) was nearly four times longer than for urban enrollees (11.9 (20.6) minutes, p < 0.0001), and drive times exceeded one hour for 38% of rural enrollees (versus 12% of urban, p < 0.0001). Urban-rural disparities remained in all additional analyses. Sustained efforts to circumvent limited geographic access to care are critical for rural areas. [ABSTRACT FROM AUTHOR]

We conducted a systematic review on the performance of diagnostic tests for clinical and laboratory monitoring of HIV-infected adults in developing countries. Diagnostic test information collected from computerized databases, bibliographies and the Internet were categorized as clinical (non-laboratory patient information), immunologic (information from immunologic laboratory tests), or virologic (information from virologic laboratory tests). Of the 51 studies selected for the review 28 assessed immunologic tests, 12 virologic tests and seven clinical and immunologic tests. Methods of performance evaluation were primarily sensitivity and specificity for the clinical category and correlation coefficients for immunologic and virologic categories. In the clinical category, the majority of test performance measures was reported as >70% sensitive and >65% specific. In the immunologic category, correlation coefficients ranged from r = 0.54 to r = 0.99 for different CD4 count enumeration techniques, while correlation for CD4 and total lymphocyte counts was between r = 0.23 and r = 0.74. In the virologic category, correlation coefficients for different human immunodeficiency virus (HIV) ribonucleic acid (RNA) quantification techniques ranged from r = 0.54 to r = 0.90. Future research requires consensus on designing studies, and collecting and reporting data useful for decision-makers. We recommend classifying information into clinically relevant categories, using a consistent definition of disease across studies and providing measures of both association and accuracy. Bulletin of the World Health Organization 2006;84:581-588. Resume Tests diagnostiques et prise en charge des infections a VIH : revue des methodes cliniques et analytiques permettant le suivi des personnes contaminees dans les pays en developpement Nous avons realise une revue systematique des performances des tests diagnostiques utilises pour le suivi clinique et biologique des adultes contamines par le VIH dans les pays en developpement. Les resultats de tests diagnostiques recueillis a partir des bases de donnees informatisees, les donnees bibliographiques et les informations obtenues sur Internet ont ete classes en trois categories :donnees cliniques (informations au sujet des malades ne provenant pas des examens en laboratoire), immunologiques (informations fournies par les tests immunologiques en laboratoire) et virologiques (informations fournies par les tests virologiques en laboratoire). Parmi les 51 etudes selectionnees pour la revue, 28 evaluaient des tests immunologiques, 12 des tests virologiques et 7 des tests cliniques et immunologiques. L&apos;evaluation des performances methodologiques se fondait principalement sur la sensibilite et la specificite pour les donnees de la categorie clinique et sur les coefficients de correlation pour les donnees appartenant aux categories immunologique et virologique. Pour la categorie clinique, d&apos;apres la mesure des performances, la majorite des tests presentaient une sensibilite > 70 % et une specificite > 65 %. Pour la categorie immunologique, les coefficients de correlation allaient de r = 0,54 a r = 0,99 pour les differentes techniques de numeration des CD4, tandis qu&apos;entre la numeration des CD4 et celle des lymphocytes totaux, ces coefficients se situaient entre r = 0,23 et r = 0,74. Pour la categorie virologique, les coefficients de correlation entre les differentes techniques de quantification de I&apos;ARN du VIH allaient de r = 0,54 a r = 0,90. Pour les travaux de recherche a venir, il serait necessaire de parvenir a un consensus sur les modalites de conception des etudes et, de collecte et de rapport des donnees utiles aux decideurs. L&apos;article recommande de classer les informations selon des categories cliniques pertinentes, en utilisant une definition identique de la maladie dans l&apos;ensemble des etudes et en fournissant une evaluation de la correlation et de la precision. Resumen Pruebas diagnosticas en el manejo de la infeccion por VIH: estudio de las estrategias clinicas y de laboratorio empleadas para controlar a las personas infectadas por el VIH en los paises en desarrollo Realizamos una revision sistematica de la eficacia de las pruebas diagnosticas como medio de seguimiento clinico y de laboratorio de las personas infectadas por el VIH en los paises en desarrollo. La informacion sobre pruebas diagnosticas reunida a partir de bases de datos computadorizadas, de las publicaciones y de Internet se clasifico como clinica (informacion sobre los pacientes distinta de los datos de laboratofio), inmunologica (informacion sobre pruebas inmunologicas) o virologica (informacion sobre pruebas virologicas). De los 51 estudios seleccionados para la revision, 28 evaluaron pruebas inmunologicas, 12 pruebas virologicas, y 7 pruebas clinicas e inmunologicas. Los metodos de evaluacion de la eficacia fueron principalmente la sensibilidad y la especificidad en el caso de las pruebas clinicas, y los coeficientes de correlacion en el caso de las pruebas inmunologicas y virologicas. Entre las primeras, la mayoria de las medidas de eficacia de las pruebas revelaron una sensibilidad superior al 70% y una especificidad superior al 65%. En la categoria de pruebas inmunologicas, los coeficientes de correlacion oscilaron entre 0,54 y 0,99 para diferentes tecnicas de recuento de CD4, mientras que la correlacion (r) entre los recuentos de CD4 y de linfocitos totales se situo entre 0,23 y 0,74. En cuanto a las pruebas virologicas, los coeficientes de correlacion para diferentes tecnicas de cuantificacion del ARN del VIH fueron de entre 0,54 y 0,90. A la hora de realizar nuevas investigaciones en el futuro, sera necesario consensuar el diseno de los estudios, y reunir y notificar datos de utilidad para las instancias decisorias. Recomendamos clasificar la informacion en categorias clinicamente pertinentes, utilizar una definicion coherente de enfermedad en todos los estudios, y proporcionar medidas tanto de asociacion como de exactitud. [TEXT NOT REPRODUCIBLE IN ASCII], Introduction In developed countries, immunologic and virologic status of human immunodeficiency virus (HIV)-infected patients is monitored using laboratory markers. Cluster designation 4 (CD4) cell count and human immunodeficiency virus (HIV) [...]

The potential long-term clinical impact and cost-effective of enfuvirtide (ENF) in HIV patients is determined. The results revealed that in highly treatment-experienced patient, ENF plus an optimized background regimen (OBR) provides substantial gains in quality-adjusted life expectancy compared with an OBR alone.

A computer simulation model of Human immune-deficiency virus (HIV) screening and treatment to compare routine, voluntary HIV counseling, testing, and referrals (HIVCTR) with recent practice in 'high-risk', 'CDC threshold' and 'US general' is developed. In all but lowest-risk populations, routine, voluntary screening for HIV once every three to five years is justified on both clinical and cost-effectiveness grounds.

Research has been conducted on the primary HIV infection treatment strategies. The clinical outcome and life expectance projections for these strategies have been evaluated via the simulation model developed by the authors in order to assist decision makers in HIV infection treatment.

Preventable opportunistic infections have been found to cause not only short-term mortality in HIV-1 disease, but also seem to have a major impact on chronic mortality. The relationship of the opportunistic infections, HIV-1 RNA, and CD4 cell counts to chronic mortality was studied. Statistically significant effect modification was seen between preventable opportunistic infections and CD4 cell count.

Combination antiretroviral therapy for HIV infection is cost-effective, according to a mathematical simulation. Although the lifetime costs of treatment per patient increased from $45,460 to $77,300, life expectancy also increased. Consequently, the cost per quality-adjusted year of life gained was between $13,000 and $23,000.

Background Human immunodeficiency virus (HIV)–experienced clinicians are critical for positive outcomes along the HIV care continuum. However, access to HIV-experienced clinicians may be limited, particularly in nonmetropolitan areas, where HIV is increasing. We examined HIV clinician workforce capacity, focusing on HIV experience and urban–rural differences, in the Southern United States. Methods We used Medicaid claims and clinician characteristics (Medicaid Analytic eXtract [MAX] and MAX Provider Characteristics, 2009–2011), county-level rurality (National Center for Health Statistics, 2013), and diagnosed HIV cases (AIDSVu, 2014) to assess HIV clinician capacity in 14 states. We assumed that clinicians accepting Medicaid approximated the region's HIV workforce, since three-quarters of clinicians accept Medicaid insurance. HIV-experienced clinicians were defined as those providing care to ≥ 10 Medicaid enrollees over 3 years. We assessed HIV workforce capacity with county-level clinician-to-population ratios, using Wilcoxon-Mann-Whitney tests to compare urban–rural differences. Results We identified 5012 clinicians providing routine HIV management, of whom 28% were HIV-experienced. HIV-experienced clinicians were more likely to specialize in infectious diseases (48% vs 6%, P  < .001) and practice in urban areas (96% vs 83%, P  < .001) compared to non–HIV-experienced clinicians. The median clinician-to-population ratio for all HIV clinicians was 13.3 (interquartile range, 38.0), with no significant urban–rural differences. When considering HIV experience, 81% of counties had no HIV-experienced clinicians, and rural counties generally had fewer HIV-experienced clinicians per 1000 diagnosed HIV cases (P  < .001). Conclusions Significant urban–rural disparities exist in HIV-experienced workforce capacity for communities in the Southern United States. Policies to improve equity in access to HIV-experienced clinical care for both urban and rural communities are urgently needed. [ABSTRACT FROM AUTHOR]

Abstract Background In resource-limited settings, HIV budgets are flattening or decreasing. A policy of discontinuing antiretroviral therapy (ART) after HIV treatment failure was modeled to highlight trade-offs among competing policy goals of optimizing individual and population health outcomes. Methods In settings with two available ART regimens, we assessed two strategies: (1) continue ART after second-line failure (Status Quo) and (2) discontinue ART after second-line failure (Alternative). A computer model simulated outcomes for a single cohort of newly detected, HIV-infected individuals. Projections were fed into a population-level model allowing multiple cohorts to compete for ART with constraints on treatment capacity. In the Alternative strategy, discontinuation of second-line ART occurred upon detection of antiretroviral failure, specified by WHO guidelines. Those discontinuing failed ART experienced an increased risk of AIDS-related mortality compared to those continuing ART. Results At the population level, the Alternative strategy increased the mean number initiating ART annually by 1,100 individuals (+18.7%) to 6,980 compared to the Status Quo. More individuals initiating ART under the Alternative strategy increased total life-years by 15,000 (+2.8%) to 555,000, compared to the Status Quo. Although more individuals received treatment under the Alternative strategy, life expectancy for those treated decreased by 0.7 years (−8.0%) to 8.1 years compared to the Status Quo. In a cohort of treated patients only, 600 more individuals (+27.1%) died by 5 years under the Alternative strategy compared to the Status Quo. Results were sensitive to the timing of detection of ART failure, number of ART regimens, and treatment capacity. Although we believe the results robust in the short-term, this analysis reflects settings where HIV case detection occurs late in the disease course and treatment capacity and the incidence of newly detected patients are stable. Conclusions In settings with inadequate HIV treatment availability, trade-offs emerge between maximizing outcomes for individual patients already on treatment and ensuring access to treatment for all people who may benefit. While individuals may derive some benefit from ART even after virologic failure, the aggregate public health benefit is maximized by providing effective therapy to the greatest number of people. These trade-offs should be explicit and transparent in antiretroviral policy decisions.

Structural barriers to HIV care are particularly challenging in the US South, which has higher HIV diagnosis rates, poverty, uninsurance, HIV stigma, and rurality, and fewer comprehensive public health programs versus other US regions. Focusing on one structural barrier, we examined geographic accessibility to comprehensive, coordinated HIV care (HIVCCC) in the US South. We integrated publicly available data to study travel time to HIVCCC in 16 Southern states and District of Columbia. We geocoded HIVCCC service locations and estimated drive time between the population-weighted county centroid and closest HIVCCC facility. We evaluated drive time in aggregate, and by county-level HIV prevalence quintile, urbanicity, and race/ethnicity. Optimal drive time was ≤30 min, a common primary care accessibility threshold. We identified 228 service locations providing HIVCCC across 1422 Southern counties, with median drive time to care of 70 min (IQR 64 min). For 368 counties in the top HIV prevalence quintile, median drive time is 50 min (IQR 61 min), exceeding 60 min in over one-third of these counties. Among counties in the top HIV prevalence quintile, drive time to care is six-folder higher for rural versus super-urban counties. Counties in the top HIV prevalence quintiles for non-Hispanic Blacks and for Hispanics have >50% longer drive time to care versus for non-Hispanic Whites. Including another potential care source—publicly-funded health centers serving low-income populations—could double the number of high-HIV burden counties with drive time ≤30 min, representing nearly 35,000 additional people living with HIV with accessible HIVCCC. Geographic accessibility to HIVCCC is inadequate in the US South, even in high HIV burden areas, and geographic and racial/ethnic disparities exist. Structural factors, such as geographic accessibility to care, may drive disparities in health outcomes. Further research on programmatic policies, and evidence-based alternative HIV care delivery models improving access to care, is critical. [ABSTRACT FROM AUTHOR]

Structural barriers to HIV care are particularly challenging in the US South, which has higher HIV diagnosis rates, poverty, uninsurance, HIV stigma, and rurality, and fewer comprehensive public health programs versus other US regions. Focusing on one structural barrier, we examined geographic accessibility to comprehensive, coordinated HIV care (HIVCCC) in the US South. We integrated publicly available data to study travel time to HIVCCC in 16 Southern states and District of Columbia. We geocoded HIVCCC service locations and estimated drive time between the population-weighted county centroid and closest HIVCCC facility. We evaluated drive time in aggregate, and by county-level HIV prevalence quintile, urbanicity, and race/ethnicity. Optimal drive time was ≤30 min, a common primary care accessibility threshold. We identified 228 service locations providing HIVCCC across 1422 Southern counties, with median drive time to care of 70 min (IQR 64 min). For 368 counties in the top HIV prevalence quintile, median drive time is 50 min (IQR 61 min), exceeding 60 min in over one-third of these counties. Among counties in the top HIV prevalence quintile, drive time to care is six-folder higher for rural versus super-urban counties. Counties in the top HIV prevalence quintiles for non-Hispanic Blacks and for Hispanics have >50% longer drive time to care versus for non-Hispanic Whites. Including another potential care source—publicly-funded health centers serving low-income populations—could double the number of high-HIV burden counties with drive time ≤30 min, representing nearly 35,000 additional people living with HIV with accessible HIVCCC. Geographic accessibility to HIVCCC is inadequate in the US South, even in high HIV burden areas, and geographic and racial/ethnic disparities exist. Structural factors, such as geographic accessibility to care, may drive disparities in health outcomes. Further research on programmatic policies, and evidence-based alternative HIV care delivery models improving access to care, is critical. [ABSTRACT FROM AUTHOR]

Awareness of the impact of education on health remains relatively low among the public, professionals, and policy makers. Virginia Commonwealth University’s Center on Society and Health sought to raise awareness among key decision makers about the impact of education on health outcomes through its Education and Health Initiative (EHI). EHI utilized four key strategies to raise awareness: user-oriented research, strategic communication, local and national stakeholder engagement, and policy outreach to decision makers. We review the research highlighted in four stages of EHI product releases, as well as the development, process, products, and key outcomes associated with this initiative. [ABSTRACT FROM AUTHOR]

Background: Human immunodeficiency virus (HIV)infected patients receiving highly active antiretroviral therapy (HAART) have experienced a dramatic decrease in Pneumocystis carinii pneumonia (PCP), necessitating reassessment of clinical guidelines for prophylaxis. Methods: A simulation model of HIV infection was used to estimate the lifetime costs and quality-adjusted life expectancy (QALE) for alternative CD4 cell count criteria for stopping primary PCP prophylaxis in patients with CD4 cell count increases receiving HAART and alternative agents for second-line PCP prophylaxis in those intolerant of trimethoprim-sulfamethoxazole (TMP/SMX). The target population was a cohort of HIV-infected patients in the United States with initial CD4 cell counts of 350/µL who began PCP prophylaxis after their first measured CD4 lymphocyte count less than 200/µL. Data were from randomized controlled trials and other published literature. Results: For patients with CD4 cell count increases during HAART, waiting to stop prophylaxis until the first observed CD4 cell count was greater than 300/µL prevented 9 additional cases per 1000 patients and cost $9400 per quality-adjusted life year (QALY) gained compared with stopping prophylaxis at 200/µL. For patients intolerant of TMP/SMX, using dapsone increased QALE by 2.7 months and cost $4500 per QALY compared with no prophylaxis. Using atovaquone rather than dapsone provided only 3 days of additional QALE and cost more than $1.5 million per QALY. Conclusions: Delaying discontinuation of PCP prophylaxis until the first observed CD4 cell count greater than 300/µL is cost-effective and provides an explicit "PCP prophylaxis stopping criterion." In TMP/SMX-intolerant patients, dapsone is more cost-effective than atovaquone. [ABSTRACT FROM AUTHOR]