Improving access to antiretrovirals in China: economic analyses of dolutegravir in HIV-1 patients

Cost-effectiveness analysis of antiretroviral drugs for treatment-naive HIV infection in China

INTRODUCTION

Dolutegravir (DTG)-based regimen was included in the expanded formulary of China's National Free Antiretroviral Treatment Program at the end of 2021. Yet high price of DTG and lack of health economic evaluation in China present barriers for implementation of the regimen. The study aims to investigate the lifetime cost-effectiveness of DTG-based regimen for treatment-naive HIV infection in China.

METHODS

A decision-analytic Markov model was used to obtain the costs and effectiveness of four regimens: Arm A, efavirenz (EFV)-based regimen; Arm B, DTG-based regimen; Arm C, elvitegravir/cobicistat/tenofovir alafenamide/emtricitabine (EVG/c/FTC/TAF) regimen; Arm D, abacavir/lamivudine/dolutegravir (ABC/3TC/DTG) regimen. The potential impact of national centralized drug procurement policy was assessed in scenario analysis. The results were further validated through sensitivity analysis.

RESULTS

Compared with other three regimens, DTG-based regimen led to the fewest cumulative adverse reactions, opportunistic infections and deaths. Compared with EFV-based regimen, the base-case ICERs for DTG-based regimen were 13,357 (USD/QALY) and 13,424 (USD/QALY) from the healthcare system and societal perspective respectively. In the policy scenario analysis with the procurement price of DTG equal to that of LPV/r, DTG-based regimen would be dominant. The model results remained robust in sensitivity analyses.

CONCLUSIONS

DTG-based regimen for treatment-naive patients is likely to be cost-effective and deserve wider implementation in China. This study strongly suggests the centralized procurement of DTG to minimize cost and maximize cost-effectiveness.

Cost-effectiveness of dolutegravir vs. efavirenz-based combined antiretroviral therapies in HIV-infected treatment-naive patients in a Nigerian treatment centre

BACKGROUND

Dolutegravir (DTG) based antiretroviral therapy (ART) has largely replaced Efavirenz (EFV) based therapy as the preferred first-line regimen in the treatment of adults with HIV. This study was carried out to evaluate the comparative cost-effectiveness of DTG and EFV-based ART in HIV-infected treatment-naïve patients in a treatment centre in Nigeria.

METHODS

This was a retrospective case-control study of patients initiated on DTG vs. EFV-based regimens from January 2018 to December 2019 at the APIN/HAVARD clinic of Nigeria's Jos University Teaching Hospital. The current viral load result was used to determine treatment effectiveness using a benchmark of ≤200 copies/mL. Sensitivity analysis was carried out to ensure the robustness of the benchmark. The total cost of treatment was obtained by summing up the relevant cost components. Appropriate descriptive and inferential statistics were employed in data analysis using Statistical Product and Services Solutions (SPSS) V.25. The incremental cost-effectiveness ratio of DTG compared to EFV was presented as cost/effectiveness.

RESULTS

Treatment was effective in 42(51.9%) and 58(71.6%) patients initiated on DTG and EFV-based regimen, respectively. The incremental cost-effective ratio (ICER) of patients on DTG compared to those on EFV was $10.5076 per effectiveness, which was less than 1% of the Nigerian 2019 per capita Gross Domestic Product. Sensitivity analysis showed the robustness of the result.

CONCLUSION

Efavirenz based regimen had higher treatment effectiveness than DTG-based regimen in treatment-naive patients after initiating treatment in a short term. Compared to EFV, DTG-based regimen is cost-effective in the management of treatment naïve HIV patients.

Health utility measurement for people living with HIV/AIDS under combined antiretroviral therapy: A comparison of EQ-5D-5L and SF-6D

We compared the discriminative validity, agreement and sensitivity of EQ-5D-5L and SF-6D utility scores in people living with HIV/AIDS (PLWHIV). We conducted a cross-sectional survey among PLWHIV aged more than 18 years old in 9 municipalities in Yunnan Province, China. A convenience sample was enrolled. We administered the SF-12 and EQ-5D-5L to measure health-related quality of life. The utility index of the SF-6D was derived from the SF-12. We calculate correlation coefficients to evaluate the relationship and agreement of 2 instruments. To evaluate the homogeneity of the EQ-5D-5L and SF-6D, intraclass correlation coefficients, scatter plots, and Bland-Altman plots were computed and drawn. We also used receiver operating characteristic curves to compare the discriminative properties and sensitivity of the econometric index. A total of 1797 respondents, with a mean age of 45.6 ± 11.7 years, was interviewed. The distribution of EQ-5D-5L scores skewed towards full health with a skewness of -3.316. The overall correlation between EQ-5D-5L and SF-6D index scores was 0.46 (P < .001). The association of the 2 scales appeared stronger at the upper end. An intraclass correlation coefficient of 0.59 between the EQ-5D-5L and SF-6D meant a moderate correlation and indicated general agreement. The Bland-Altman plot displayed the same results as the scatter plot. The receiver operating characteristic curve showed that the AUC for the SF-6D was 0.776 (95% CI: 0.757, 0.796) and that for the EQ-5D-5L was 0.732 (95% CI: 0.712, 0.752) by the PCS-12, and it was 0.782 (95% CI: 0.763, 0.802) for the SF-6D and 0.690 (95% CI: 0.669, 0.711) for the EQ-5D-5L by the MCS-12. Our study demonstrated evidence of the performance of EQ-5D-5L and SF-6D index scores to measure health utility in people living with HIV/AIDS. There were significant differences in their performance. We preferred to apply the SF-6D to measure the health utility of PLWHIV during the combined antiretroviral therapy period. Our study has demonstrated evidence for instrument choice and preference measurements in PLWHIV under combined antiretroviral therapy.

Cost and cost-effectiveness of dolutegravir-based antiretroviral regimens: an economic evaluation of a clinical trial

BACKGROUND

HIV programmes world-wide currently make decisions regarding new antiretroviral therapy (ART) regimens with less side-effects and higher resistance barriers, which may improve adherence and viral suppression. Economic evaluation helps inform these decisions.

METHODS

We conducted an economic evaluation of three ART regimens included in the ADVANCE trial from the provider's perspective: tenofovir alafenamide (TAF)/emtricitabine (FTC)+dolutegravir (DTG) and tenofovir disoproxil fumarate (TDF)/FTC+DTG, compared with TDF/FTC/efavirenz (EFV). We used top-down and bottom-up cost analysis with resource utilization based on trial data and adjusted to emulate routine care. We estimated the cost-effectiveness of each regimen as cost per person virally suppressed or retained and per life-year saved, at 48 and 96 weeks.

RESULTS

Though the DTG-based trial arms were 2% more costly than TDF/FTC/EFV, both had slightly lower cost-per-outcome ($9783 and $9929/patient virally suppressed for TDF/FTC+DTG and TAF/FTC+DTG, respectively) than TDF/FTC/EFV ($10 365). The trial cost per additional virally suppressed patient, compared with TDF/FTC/EFV, was lower in the TDF/FTC+DTG arm ($2967) compared with TAF/FTC+DTG ($3430). In routine care, cost per virally suppressed patient was estimated as similar between TDF/FTC+DTG ($426) and TDF/FTC/EFV ($424) but more costly under TAF/FTC+DTG. Similar results were seen in the cost per additional person retained across scenarios. When modelled over 20 years, TDF/FTC+DTG was more cost-effective than TAF/FTC+DTG ($10 341 vs $41 958/life-year saved).

CONCLUSION

TDF/FTC+DTG had similar costs per outcome as TDF/FTC/EFV in the routine care scenario but TDF/FTC+DTG was more cost-effective when modelled over 20 years.