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Azithromycin is the most cost-effective option for preventing a common, serious infection among AIDS patients

Azithromycin is the most cost-effective medication to prevent the common, serious disseminated infection, Mycobacterium avium complex (MAC), among AIDS patients if begun when their CD4 cell count has declined to 50/ul, concludes a new study. This is the point at which so-called opportunistic infections like MAC and cytomegalovirus (CMV) attack these patients' weakened immune systems and reduce their survival chances.

Researchers from Johns Hopkins School of Public Health, Yale School of Medicine, Harvard School of Public Health, and Boston University's Schools of Medicine and Public Health developed a simulation model in which one hypothetical patient at a time was followed from a CD4 lymphocyte cell count between 201 and 300/ul to death. Using several AIDS databases and clinical trial results, they projected costs, life expectancy, and cost-effectiveness of five different drug regimens to prevent MAC in patients with AIDS: initial therapy with azithromycin, rifabutin, clarithromycin, azithromycin/ rifabutin combination therapy, and clarithromycin/rifabutin combination therapy.

Initiating azithromycin prophylaxis (and changing to clarithromycin and then rifabutin if needed because of drug toxicity) after a patient's CD4 count had fallen to 50/ul was the best option. It had a cost-effectiveness ratio of $25,000 per quality-adjusted life year (QALY) saved compared with only using prophylaxis for Pneumocystis carinii pneumonia (PCP) and decreased to $21,000 per QALY if the risk of MAC was lower, as appears to be the case with currently used combination antiretroviral therapy. Overall, baseline results suggest that it would cost $4.3 billion to care for 100,000 patients with AIDS from a CD4 count of 300/ul to death, if PCP prophylaxis were the only prophylaxis used. An additional $89 million would buy azithromycin prophylaxis for MAC, which would increase survival by about 3,600 years for the entire group. This research was supported by the Agency for Healthcare Research and Quality (HS07317).

Details are in "The cost-effectiveness of prophylaxis for Mycobacterium avium complex in AIDS," by Julie A. Scharfstein, A. David Paltiel, Milton C. Weinstein, Elena Losina, Kenneth A. Freedberg, and others, in the International Journal of Technology Assessment in Health Care 15(3), pp. 531-547, 1999.

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