BACKGROUND The cost-effectiveness of early antiretroviral therapy (ART) in persons infected with human immunodeficiency virus (HIV) in serodiscordant couples is not known. Using a computer simulation of the progression of HIV infection and data from the HIV Prevention Trials Network 052 study, we projected the cost-effectiveness of early ART for such persons. METHODS For HIV-infected partners in serodiscordant couples in South Africa and India, we compared the early initiation of ART with delayed ART. Five-year and lifetime outcomes included cumulative HIV transmissions, life-years, costs, and cost-effectiveness. We classified early ART as very cost-effective if its incremental cost-effectiveness ratio was less than the annual per capita gross domestic product (GDP; $8,100 in South Africa and $1,500 in India), as cost-effective if the ratio was less than three times the GDP, and as cost-saving if it resulted in a decrease in total costs and an increase in life-years, as compared with delayed ART. RESULTS In South Africa, early ART prevented opportunistic diseases and was cost-saving over a 5-year period; over a lifetime, it was very cost-effective ($590 per life-year saved). In India, early ART was cost-effective ($1,800 per life-year saved) over a 5-year period and very cost-effective ($530 per life-year saved) over a lifetime. In both countries, early ART prevented HIV transmission over short periods, but longer survival attenuated this effect; the main driver of life-years saved was a clinical benefit for treated patients. Early ART remained very cost-effective over a lifetime under most modeled assumptions in the two countries. CONCLUSIONS In South Africa, early ART was cost-saving over a 5-year period. In both South Africa and India, early ART was projected to be very cost-effective over a lifetime. With individual, public health, and economic benefits, there is a compelling case for early ART for serodiscordant couples in resource-limited settings. (Funded by the National Institute of Allergy and Infectious Diseases and others.)

Importance: Anti-vascular endothelial growth factor (anti-VEGF) medicines have revolutionized diabetic macular edema (DME) treatment. A recent randomized clinical trial comparing anti-VEGF agents for patients with decreased vision from DME found that at one year aflibercept (2.0-mg) achieved better visual outcomes than repackaged (compounded) bevacizumab (1.25-mg) or ranibizumab (0.3-mg); the worse the starting vision, the greater the treatment benefit with aflibercept. However, aflibercept and ranibizumab, respectively, are approximately 31 and 20 times more expensive than bevacizumab. Objective: To determine the incremental cost-effectiveness ratios (ICERs) of each of these agents for DME. Design, Setting, Participants: Post-hoc analysis of efficacy, safety, and resource utilization data at 1 one year follow-up from a Diabetic Retinopathy Clinical Research Network randomized clinical trial. Main Outcomes and Measures: ICERs for all trial participants and subgroups with baseline vision of approximate Snellen equivalent 20/32 to 20/40 (“better vision”) and baseline vision of approximate Snellen equivalent 20/50 or worse (“worse vision”). One-year trial data were used to calculate cost-effectiveness over one year for the 3 anti-VEGF agents; mathematical modeling then was used to project 10-year cost-effectiveness results. Results: For all participants, over one year, the ICERs of aflibercept and ranibizumab compared with bevacizumab were $1,110,000 per quality-adjusted life-year (QALY) and $1,730,000/QALY. Over 10 years, they were $349,000/QALY and $603,000/QALY, respectively. Compared with ranibizumab, aflibercept’s ICER was $648,000/QALY at one year and $203,000/QALY at ten years. For the subgroup with worse baseline vision, the 10-year ICERs of aflibercept and ranibizumab compared with bevacizumab were $287,000/QALY and $817,000/QALY, respectively. In eyes with decreased vision from DME, treatment costs of aflibercept and ranibizumab would need to decline by 69% and 80%, respectively, to reach a cost-effectiveness threshold of $100,000/QALY compared with bevacizumab over a 10-year horizon; for the subgroup with worse baseline vision, the costs would need to decline by 62% and 84%, respectively. Conclusions and Relevance: Aflibercept 2.0-mg and ranibizumab 0.3-mg are not cost-effective relative to bevacizumab for treatment of DME unless their prices decline substantially. These results highlight the challenges that clinicians, patients, and policy-makers face when safety and efficacy results are at odds with cost-effectiveness results.

For US patients with treatment-resistant depression, ECT may be an effective and cost-effective treatment option. Although many factors influence the decision to proceed with ECT, these data suggest that, from a health-economic standpoint, ECT should be considered after failure of 2 or more lines of pharmacotherapy/psychotherapy.

These results suggest that correlates of personality are important, although frequently ignored, predictors of compliance with antidepressant medication. Identifying predictors of medication compliance may help in the development of individualized treatment regimens and lead to improved therapeutic outcome in the treatment of MDD.