Abstract
BackgroundThere is an urgent need to improve the evidence base for provision of second-line antiretroviral therapy (ART) following first-line virological failure. This is particularly the case in Sub-Saharan Africa where 70% of all people living with HIV/AIDS (PHA) reside. The aim of this study was to simulate the potential risks and benefits of treatment simplification in second-line therapy compared to the current standard of care (SOC) in a lower-middle income and an upper-middle income country in Sub-Saharan Africa.MethodsWe developed a microsimulation model to compare outcomes associated with reducing treatment discontinuations between current SOC for second-line therapy in South Africa and Nigeria and an alternative regimen: ritonavir-boosted lopinavir (LPV/r) combined with raltegravir (RAL). We used published studies and collaborating sites to estimate efficacy, adverse effect and cost. Model outcomes were reported as incremental cost effectiveness ratios (ICERs) in 2011 USD per quality adjusted life year ($/QALY) gained.ResultsReducing treatment discontinuations with LPV/r+RAL resulted in an additional 0.4 discounted QALYs and increased the undiscounted life expectancy by 0.8 years per person compared to the current SOC. The average incremental cost was $6,525 per treated patient in Nigeria and $4,409 per treated patient in South Africa. The cost-effectiveness ratios were $16,302/QALY gained and $11,085/QALY gained for Nigeria and South Africa, respectively. Our results were sensitive to the probability of ART discontinuation and the unit cost for RAL.ConclusionsThe combination of raltegravir and ritonavir-boosted lopinavir was projected to be cost-effective in South Africa. However, at its current price, it is unlikely to be cost-effective in Nigeria.
Highlights
In June 2001 the United Nations issued a Declaration of Commitment to facilitate and support a global effort to combat the HIV/AIDS pandemic through a combination of prevention and treatment initiatives made universally available to all people living with HIV/AIDS (PHA)
Nigeria In the base case analysis, the reduction in treatment discontinuations estimated with LPV/r+RAL increased the undiscounted life expectancy by 0.79 years and the discounted quality-adjusted life years by 0.4 for an incremental cost of approximately $6,525 USD per person compared with the standard of care
We found the incremental cost effectiveness ratios (ICERs) to be most sensitive to the probability of antiretroviral therapy (ART) discontinuation and the cost of RAL
Summary
In June 2001 the United Nations issued a Declaration of Commitment to facilitate and support a global effort to combat the HIV/AIDS pandemic through a combination of prevention and treatment initiatives made universally available to all people living with HIV/AIDS (PHA). UNAIDS reported that more than 6.5 million people (of a UN agreed target of 15 million by 2015) had access to combination antiretroviral therapy (ART) by the end of 2010 [1] The majority of these individuals are receiving standard first-line ART combinations comprising of one drug selected from the nonnucleoside reverse transcriptase inhibitor (NNRTI) class with two drugs from the nucleoside/nucleotide reverse transcriptase inhibitor (N(t)RTI) class. There is an urgent need to improve the evidence base for provision of second-line antiretroviral therapy (ART) following first-line virological failure. This is the case in Sub-Saharan Africa where 70% of all people living with HIV/AIDS (PHA) reside. The aim of this study was to simulate the potential risks and benefits of treatment simplification in second-line therapy compared to the current standard of care (SOC) in a lower-middle income and an upper-middle income country in Sub-Saharan Africa
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