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J Acquir Immune Defic Syndr. 2013 Dec 1;64(4):382-91. doi: 10.1097/QAI.0000000000000002.

Cost-effectiveness of newer antiretroviral drugs in treatment-experienced patients with multidrug-resistant HIV disease.

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*Center for Research on Inner City Health, The Keenan Research Center in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; †Department of Medicine, University of Toronto, Toronto, Ontario, Canada; ‡Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; §Division of General Internal Medicine, St. Michael's Hospital, Toronto, Ontario, Canada; ‖VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, CA; ¶Center for Health Economics, University of York, York, United Kingdom; #Center for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada **CIHR Canadian HIV Trials Network, Vancouver, British Columbia, Canada; ††School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada; ‡‡VA Palo Alto Health Care System, Palo Alto, CA; §§Department of Medicine, Stanford University, Stanford, CA; ‖‖Duke Clinical Research Institute, Duke University, Durham, NC; ¶¶James J. Peters VA Medical Center, Bronx, NY; ##Department of Medicine, Mt. Sinai School of Medicine, New York, NY; ***VA Cooperative Studies Program Coordinating Center, West Haven, CT; †††MRC Clinical Trials Unit, London, United Kingdom; ‡‡‡Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom; §§§The University of Ottawa at The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; and ‖‖‖Center for Primary Care and Outcomes Research and Center for Health Policy, Stanford University, Stanford, CA.



Newer antiretroviral drugs provide substantial benefits but are expensive. The cost-effectiveness of using antiretroviral drugs in combination for patients with multidrug-resistant HIV disease was determined.


A cohort state-transition model was built representing treatment-experienced patients with low CD4 counts, high viral load levels, and multidrug-resistant virus. The effectiveness of newer drugs (those approved in 2005 or later) was estimated from published randomized trials. Other parameters were estimated from a randomized trial and from the literature. The model had a lifetime time horizon and used the perspective of an ideal insurer in the United States. The interventions were combination antiretroviral therapy, consisting of 2 newer drugs and 1 conventional drug, compared with 3 conventional drugs. Outcome measures were life-years, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness.


Substituting newer antiretroviral drugs increased expected survival by 3.9 years in advanced HIV disease. The incremental cost-effectiveness ratio of newer, compared with conventional, antiretroviral drugs was $75,556/QALY gained. Sensitivity analyses showed that substituting only one newer antiretroviral drug cost $54,559 to $68,732/QALY, depending on assumptions about efficacy. Substituting 3 newer drugs cost $105,956 to $117,477/QALY. Cost-effectiveness ratios were higher if conventional drugs were not discontinued.


In treatment-experienced patients with advanced HIV disease, use of newer antiretroviral agents can be cost-effective, given a cost-effectiveness threshold in the range of $50,000 to $75,000 per QALY gained. Newer antiretroviral agents should be used in carefully selected patients for whom less expensive options are clearly inferior.

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