The cost-effectiveness of fluconazole prophylaxis against primary systemic fungal infections in AIDS patients

Objective. To project the cost-effectiveness of fluconazole for prophylaxis against AIDS-related primary systemic fungal infections. Design. A Markov model with data from the literature. Patients. Hypothetical cohort of 100,000 AIDS patients. Intervention. No prophylaxis, and fluconazole prophylaxis beginning when a patient's CD4 count declined to below 200/mm(3), below 100/mm(3), or below 50/mm(3). Results. The no-prophylaxis policy was associated with a discounted life expectancy of 28.20 months and direct medical costs of $36,100 per person. The <200/mm(3) strategy increased costs to $40,500 and life expectancy to 28.42 months, producing a ratio of $240,000 per year of life saved (YLS). Compared with the no-prophylaxis and <200/mm(3) policies, the intermediate alternatives were less economically efficient. A reduction in fluconazole's cost from $206 to $80 decreased the ratio to $50,000 for the <200/mm(3) strategy. Doubling fungal infection incidence lowered this ratio to $96,000/YLS. Conclusions. Fluconazole prophylaxis is unlikely to be cost-effective unless its cost is lowered, dr it is focused on patients in regions endemic for fungal infections.