Cost-effectiveness of cytomegalovirus (CMV) disease prevention in patients with AIDS: Oral ganciclovir and CMV polymerase chain reaction testing

Objective: To perform a cost-effectiveness analysis of strategies to prevent cytomegalovirus (CMV) disease. Method: Markov model and published data. Patients: Hypothetical HIV-infected patients with CD4 cell counts ≤ 50 x 10⁶/l and positive CMV serologies. Interventions: Oral ganciclovir daily versus plasma CMV DNA polymerase chain reaction (PCR) testing every 3 months with oral ganciclovir for patients with positive tests. Outcome measures: The number of CMV disease cases prevented by the interventions, life expectancy, disease-free life expectancy, and the cost to extend life by 1 year. Results: Oral ganciclovir preventive therapy reduces the lifetime number of CMV disease cases by 50 per 1000 cohort, extends life expectancy by 5 days and disease-free life expectancy by 18 days, and costs US$ 1,762,517 per year of life extended. Periodic PCR testing reduces the lifetime number of CMV disease cases by eight per 1000 cohort, extends life expectancy by 1 day and disease-free life expectancy by 3 days, and costs US$ 495,158 per year of life extended. The prevention strategies could be acceptably cost effective only under a combination of optimistic assumptions and reduced costs. Conclusions: Oral ganciclovir preventive therapy and periodic plasma testing for CMV PCR with oral ganciclovir for those with positive tests result in small benefits at great cost. They are not cost-effective prevention strategies for persons with advanced HIV infection and positive CMV serologies.