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J Acquir Immune Defic Syndr. 2014 Jul 1;66(3):294-302. doi: 10.1097/QAI.0000000000000166.

Clinical impact and cost-effectiveness of making third-line antiretroviral therapy available in sub-Saharan Africa: a model-based analysis in Côte d'Ivoire.

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  • 1*Centre Inserm 897, University of Bordeaux, Bordeaux, France; †ISPED, University of Bordeaux, Bordeaux, France; ‡Programme PAC-CI/ANRS Research Site, CHU de Treichville, Abidjan, Côte d'Ivoire; §Division of General Medicine and the Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA; ‖Department of Infectious and Tropical Diseases, Bichat-Claude Bernard University Hospital, Paris, France; ¶Equipe Atip/Avenir Inserm U738, University Paris Diderot, Paris, France; #Department of Orthopedics, Brigham and Women's Hospital, Boston, MA; **Center for AIDS Research, Harvard University, Boston, MA; ††Harvard Medical School, Boston, MA; ‡‡Departments of Biostatistics, Boston University School of Public Health, Boston, MA; §§Department of Infectious and Tropical Diseases, Treichville University Hospital, Abidjan, Côte d'Ivoire; ‖‖Divisions of Infectious Disease and the Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA; ¶¶Division of Infectious Disease, Brigham and Women's Hospital, Boston, MA; ##Department of Epidemiology and Public Health, Yale School of Public Health, New Haven, CT; ***Department of Epidemiology, Boston University School of Public Health, Boston, MA; and †††Department of Health Policy and Management, Harvard School of Public Health, Boston, MA.

Abstract

OBJECTIVE:

In sub-Saharan Africa, HIV-infected adults who fail second-line antiretroviral therapy (ART) often do not have access to third-line ART. We examined the clinical impact and cost-effectiveness of making third-line ART available in Côte d'Ivoire.

METHODS:

We used a simulation model to compare 4 strategies after second-line ART failure: continue second-line ART (C-ART2), continue second-line ART with an adherence reinforcement intervention (AR-ART2), immediate switch to third-line ART (IS-ART3), and continue second-line ART with adherence reinforcement, switching patients with persistent failure to third-line ART (AR-ART3). Third-line ART consisted of a boosted-darunavir plus raltegravir-based regimen. Primary outcomes were 10-year survival and lifetime incremental cost-effectiveness ratios (ICERs), in $/year of life saved (YLS). ICERs below $3585 (3 times the country per capita gross domestic product) were considered cost-effective.

RESULTS:

Ten-year survival was 6.0% with C-ART2, 17.0% with AR-ART2, 35.4% with IS-ART3, and 37.2% with AR-ART3. AR-ART2 was cost-effective ($1100/YLS). AR-ART3 had an ICER of $3600/YLS and became cost-effective if the cost of third-line ART decreased by <1%. IS-ART3 was less effective and more costly than AR-ART3. Results were robust to wide variations in the efficacy of third-line ART and of the adherence reinforcement, as well as in the cost of second-line ART.

CONCLUSIONS:

Access to third-line ART combined with an intense adherence reinforcement phase, used as a tool to distinguish between patients who can still benefit from their current second-line regimen and those who truly need third-line ART would provide substantial survival benefits. With minor decreases in drug costs, this strategy would be cost-effective.

PMID:
24732870
[PubMed - indexed for MEDLINE]
PMCID:
PMC4146647
[Available on 2015-07-01]
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