Date of download: 6/27/2016 From: Influence of Alternative Thresholds for Initiating HIV Treatment on Quality-Adjusted Life Expectancy: A Decision Model.

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Date of download: 6/27/2016 From: Influence of Alternative Thresholds for Initiating HIV Treatment on Quality-Adjusted Life Expectancy: A Decision Model Ann Intern Med. 2008;148(3): doi: / Selected constructs in computer simulation.Constructs fall into 2 broad categories: genetic characteristics of the HIV strain and clinical characteristics of the patient. Genetic characteristics reflect the acquisition of mutations and affect clinical characteristics by altering the effectiveness of combination antiretroviral therapy (CART). Clinical characteristics affect the probability of dying of HIV-related or non–HIV-related causes. With time, combination antiretroviral therapy may give rise to HIV mutations through selection pressures on viral replication. As resistance accrues, the viral replication rate increases, and this in turn increases the probability that subsequent mutations will develop. Adherence, viral resistance, and other patient characteristics together determine the level of effectiveness of combination therapies, as manifested by changes in CD4 count and viral load. The simulation does not merely extrapolate long-term mortality risks based on short-term mortality data but rather predicts long-term mortality risks on the basis of the duration of the effectiveness of CART and other factors, including toxicity. Although determinants of the effectiveness of combination antiretroviral therapy may be unobserved or rarely observed, they may have a profound effect on survival and quality of life. Figure Legend: Copyright © American College of Physicians. All rights reserved.American College of Physicians

Date of download: 6/27/2016 From: Influence of Alternative Thresholds for Initiating HIV Treatment on Quality-Adjusted Life Expectancy: A Decision Model Ann Intern Med. 2008;148(3): doi: / Cumulative incidence of resistance mutations (top) and combination antiretroviral therapy (CART) regimens (bottom) after 5 years, by treatment initiation threshold and viral load.Earlier therapy leads to more resistance mutations and to more regimens being used. Resistance mutations are defined as any mutation that may give rise to antiretroviral resistance in any drug class. A change in regimen is defined as a change in 2 or more antiretroviral drugs. We show results for age 40 years; results for other age groups did not differ greatly. Figure Legend: Copyright © American College of Physicians. All rights reserved.American College of Physicians

Date of download: 6/27/2016 From: Influence of Alternative Thresholds for Initiating HIV Treatment on Quality-Adjusted Life Expectancy: A Decision Model Ann Intern Med. 2008;148(3): doi: / Quantity of therapy-related toxicity required to favor earlier rather than later initiation of combination antiretroviral therapy (CART).In each bar, as the hazard ratio of therapy-related toxicities increases, the different fills indicate the preferred treatment strategy, stratified by age and viral load. Therapy-related toxicity is manifested by greater non–HIV-related mortality. The upper bound used in our base-case analyses (3.8 × non–HIV- related mortality) favors starting therapy at a CD4 count of 500 cells/mm 3 at age 30 years and at age 40 years if the viral load is greater than copies/mL. If toxicity were below 2.4 × non–HIV-related mortality, starting therapy at a CD4 count of 500 cells/mm 3 would be preferred for all ages and viral loads examined. Figure Legend: Copyright © American College of Physicians. All rights reserved.American College of Physicians

Date of download: 6/27/2016 From: Influence of Alternative Thresholds for Initiating HIV Treatment on Quality-Adjusted Life Expectancy: A Decision Model Ann Intern Med. 2008;148(3): doi: / Sensitivity analysis of how preferred treatment strategies vary with different parameter assumptions.The 3 graphs correspond to distinct assumptions about toxicity related to combination antiretroviral treatment (CART): high toxicity, as in our upper-bound base-case analysis (top); moderate toxicity (middle); and low toxicity (bottom). Within each graph, other model parameters are varied across plausible ranges. We analyzed only scenarios in which base-case results favored earlier treatment (age 30 years, all viral loads; age 40 years, viral loads of and copies/mL) because results favoring later treatment were unlikely to be robust. These analyses suggest that findings in favor of earlier treatment were generally stable, varying little with parameter assumptions. Numbers in parentheses are reference citations. *Reference refers to base-case estimate. Figure Legend: Copyright © American College of Physicians. All rights reserved.American College of Physicians

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