The cost-effectiveness of antiretroviral therapy for treating HIV disease in the Caribbean.

The Organization of Eastern Caribbean States (OECS) includes 9 territories—Anguilla, Antigua and Barbuda, the British Virgin Islands, Dominica, Grenada, Montserrat, St. Kitts and Nevis, St. Lucia, and St. Vincent and the Grenadines—with a total regional population of 609,000; 5000 are estimated to be HIV-infected.1 In 2006, fewer than 800 people were aware of their infection.1 With substantial mobility between OECS nations, the rest of the Caribbean, and Europe and the Americas and economies dependent on tourism, the AIDS epidemic in the OECS may have an inordinate impact regionally. Funding has been awarded to 6 of the OECS territories (Antigua and Barbuda, Dominica, Grenada, St. Lucia, St. Kitts and Nevis, and St. Vincent and the Grenadines) by the Global Fund to Fight AIDS, Tuberculosis, and Malaria to work toward several HIV control measures in the region. Top priorities include the provision of universal access to care and treatment, voluntary counseling and testing services, locally available laboratory monitoring, and antiretroviral therapy (ART) at low cost.1 Beginning in 2004, ART became available through national programs in the OECS. Although first-line ART is currently available at discounted negotiated prices, second-line regimens remain much more expensive. Because ART became available only recently, and the number of patients receiving ART is relatively small (an estimated 266 persons in the OECS in August 2006), there has not yet been a large demand for second-line drugs.2 With an estimated 250,000 persons currently living with HIV/AIDS in the Caribbean and nearly 3000 HIV-infected persons identified since the beginning of the epidemic in the OECS, however, this is likely to change in the near future.2,3 Provision of HIV care in the OECS is largely governed by recommendations from the Caribbean HIV/AIDS Regional Training Network. These recommendations, consistent with those from the World Health Organization (WHO), suggest that ART should be offered to all symptomatic patients and asymptomatic patients with CD4 counts <200 cells/μL.4,5 They also suggest that ART should “generally be offered” to patients who are asymptomatic or have minor symptoms and a CD4 count between 200 and 350 cells/μL. Our objectives were to model the HIV care currently available in the OECS to evaluate clinical outcomes and cost-effectiveness and to assess the budgetary impact of providing universal access to HIV treatment in this region of the Caribbean.