1
|
Indirect comparison of 48-week efficacy and safety of long-acting cabotegravir and rilpivirine maintenance every 8 weeks with daily oral standard of care antiretroviral therapy in participants with virologically suppressed HIV-1-infection. BMC Infect Dis 2022; 22:428. [PMID: 35508986 PMCID: PMC9066757 DOI: 10.1186/s12879-022-07243-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 03/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background Efficacy and safety of long-acting cabotegravir (CAB) + rilpivirine (RPV) every 8 weeks (Q8W) versus daily oral standard of care (SoC) maintenance in treatment-experienced individuals with virologically suppressed human immunodeficiency virus type 1 (HIV-1) has not been directly compared in randomized clinical trials. This analysis aimed to indirectly compare these regimens. Methods An adjusted indirect treatment comparison of CAB + RPV Q8W with daily oral SoC was performed, using Phase 3 data from studies of CAB + RPV every 4 weeks (Q4W) vs SoC (ATLAS/FLAIR, n = 591 per group) and a Phase 3b trial of CAB + RPV Q8W vs Q4W (ATLAS-2M [excluding participants with prior CAB + RPV exposure]; n = 327 per group). Eligible participants were virologically suppressed (viral load < 50 HIV-1 ribonucleic acid (RNA) copies/mL), treatment-experienced individuals with HIV-1-infection. Treatment efficacy and safety assessments at Week 48 included virologic suppression and lack of virologic suppression (proportion of participants with plasma HIV-1 RNA < 50 copies/mL or ≥ 50 copies/mL, respectively; both as per FDA snapshot algorithm), CD4-cell count change from baseline, no virologic data, discontinuations due to adverse events (AEs), and overall AEs, serious AEs and Grade 3–5 AEs excluding injection-site reactions. A subgroup analysis stratified by baseline third active drug class was performed. Results Baseline characteristics between the Q4W arms of ATLAS/FLAIR and ATLAS-2M showed no significant differences or differences were not judged to be clinically relevant, apart from participants switching from a baseline third active drug class; more participants switched from integrase strand inhibitors in ATLAS/FLAIR, and from non-nucleoside reverse transcriptase inhibitors in ATLAS-2M. Injections of CAB + RPV Q8W showed no significant differences across efficacy and safety outcomes versus daily oral SoC. Univariate subgroup analysis found there were no significant differences on virologic suppression or lack of virologic suppression for any baseline third active drug class subgroup. These results suggest that CAB + RPV Q8W is non-inferior to daily oral SoC. Conclusions This analysis supports the therapeutic potential of CAB + RPV Q8W for virologically suppressed people living with HIV-1 infection seeking an alternative maintenance treatment option to daily oral SoC. Trial registration: NCT02938520, NCT02951052, NCT03299049. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07243-3.
Collapse
|
2
|
Naturally Derived Anti-HIV Polysaccharide Peptide (PSP) Triggers a Toll-Like Receptor 4-Dependent Antiviral Immune Response. J Immunol Res 2018; 2018:8741698. [PMID: 30116757 PMCID: PMC6079438 DOI: 10.1155/2018/8741698] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 04/17/2018] [Accepted: 05/27/2018] [Indexed: 12/26/2022] Open
Abstract
Aim Intense interest remains in the identification of compounds to reduce human immunodeficiency virus type 1 (HIV-1) replication. Coriolus versicolor's polysaccharide peptide (PSP) has been demonstrated to possess immunomodulatory properties with the ability to activate an innate immune response through Toll-like receptor 4 (TLR4) showing insignificant toxicity. This study sought to determine the potential use of PSP as an anti-HIV agent and whether its antiviral immune response was TLR4 dependent. Materials and Methods HIV-1 p24 and anti-HIV chemokine release was assessed in HIV-positive (HIV+) THP1 cells and validated in HIV+ peripheral blood mononuclear cells (PBMCs), to determine PSP antiviral activity. The involvement of TLR4 activation in PSP anti-HIV activity was evaluated by inhibition. Results PSP showed a promising potential as an anti-HIV agent, by downregulating viral replication and promoting the upregulation of specific antiviral chemokines (RANTES, MIP-1α/β, and SDF-1α) known to block HIV-1 coreceptors in THP1 cells and human PBMCs. PSP produced a 61% viral inhibition after PSP treatment in HIV-1-infected THP1 cells. Additionally, PSP upregulated the expression of TLR4 and TLR4 inhibition led to countereffects in chemokine expression and HIV-1 replication. Conclusion Taken together, these findings put forward the first evidence that PSP exerts an anti-HIV activity mediated by TLR4 and key antiviral chemokines. Elucidating these new molecular mediators may reveal additional drug targets and open novel therapeutic avenues for HIV-1 infection.
Collapse
|
3
|
Kazooba P, Mayanja BN, Levin J, Masiira B, Kaleebu P. Virological failure on first-line antiretroviral therapy; associated factors and a pragmatic approach for switching to second line therapy-evidence from a prospective cohort study in rural South-Western Uganda, 2004-2011. Pan Afr Med J 2018; 29:191. [PMID: 30061969 PMCID: PMC6061817 DOI: 10.11604/pamj.2018.29.191.11940] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 12/03/2017] [Indexed: 11/11/2022] Open
Abstract
Introduction We investigated factors affecting Virological failure (VF) on first line Antiretroviral Therapy (ART) and evaluated a pragmatic approach to switching to second line ART. Methods Between 2004 and 2011, we assessed adults taking ART. After 6 months or more on ART, participants with VL >1000 copies/ml or two successive VL > 400 copies/ml (Conventional VF) received intensified adherence counselling and continued on first-line ART for 6 more months, after which participants who still had VL > 1000 copies/ml (Pragmatic VF) were switched to second line ART. VF rates were calculated and predictors of failure were found by fitting logistic regression and Cox proportional hazards models. Results The 316 participants accrued 1036 person years at risk (pyar), 84 (26.6%) had conventional VF (rate 8.6 per 100 pyar) of whom 28 (33.3%) had pragmatic VF (rate 2.7 per 100 pyar). Independent predictors of conventional VF were; alcohol consumption, (adjusted Hazard Ratio; aHR = 1.71, 95% CI 1.05-2.79, P = 0.03) and ART adherence: per 10% decrease in proportion of adherent visits, (aHR = 1.83, 95% CI 1.50-2.23; P < 0.001). Using reference age group < 30 years, among conventional failures, the adjusted odds ratio (aOR) of pragmatic failure for age group 30-39 years were 0.12, 95% CI 0.03-0.57, P = 0.02 and for age group > 40 years were 0.14, 95%CI 0.03-0.71, P = 0.02. Alcohol consumers had a threefold odds of pragmatic failure than non-alcohol consumers (aOR = 3.14, 95%CI 0.95-10.34, P = 0.06). Conclusion A pragmatic VF approach is essential to guide switching to second line ART. Patient tailored ART adherence counselling among young patients and alcohol users is recommended.
Collapse
Affiliation(s)
| | | | | | - Ben Masiira
- MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
| | - Pontiano Kaleebu
- MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda.,Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London
| |
Collapse
|
4
|
Rosenblatt L, Buikema AR, Seare J, Bengtson LGS, Johnson J, Cao F, Villasis-Keever A. Economic Outcomes of First-Line Regimen Switching Among Stable Patients with HIV. J Manag Care Spec Pharm 2017. [PMID: 28650246 PMCID: PMC10397957 DOI: 10.18553/jmcp.2017.16403] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Although switching of antiretroviral therapy (ART) is a valid approach for addressing treatment failure in patients with human immunodeficiency virus (HIV), ART changes among those who are well maintained on their current regimens may lead to the development of new side effects or resistance. OBJECTIVE To examine the effect of first-line regimen switching on subsequent health care utilization and cost among stable HIV patients. METHODS This was a retrospective claims data study of adult patients with HIV who initiated ART between 2007 and 2013 and had been treated with their initial regimens for at least 6 continuous months. Those with evidence of pregnancy or HIV-2 were excluded. Patients who underwent an ART change were assigned to a switcher cohort; a nonswitcher cohort was then generated by matching up to 20 nonswitchers for each switcher, with replacement. The index date was the date of the first ART change for switchers and was the claim date closest to the corresponding switcher's switch date for nonswitchers. Patient characteristics at baseline and post-index annualized health care utilization and costs were analyzed descriptively and with multivariable models. Analyses were performed in the full population and among patients designated as virologically stable (had undetectable viral ribonucleic acid [RNA] for 90 days pre-index) and virologically and clinically stable (had undetectable viral RNA and no apparent clinical reason for switching ART). RESULTS The study population consisted of 6,983 individuals, which included 927 switchers (168 virologically stable; 55 virologically+clinically stable), who were matched with replacement with 18,511 nonswitcher comparators. The switcher cohort was 88.8% male (mean age 43.8 years). Mean preindex and follow-up treatment durations for switchers and nonswitchers were 1.8 years and 1.5 years, respectively; demographic characteristics, pre-index treatment duration, and follow-up duration were similar between cohorts. Significantly more nonswitchers than switchers had a first-line efavirenz-based regimen (67.2% vs. 47.8%, P < 0.001). In the virologically stable subset, follow-up annualized health care utilization for switchers versus nonswitchers, respectively, was 14.8 versus 12.3 ambulatory visits (P < 0.05), 0.8 versus 0.9 emergency department visits (P = 0.652), and 0.05 versus 0.05 inpatient hospitalizations (P = 0.915). Follow-up annualized health care costs were $37,120 for switchers versus $31,771 for nonswitchers (P < 0.05), with the difference driven largely by pharmacy costs. Multivariable-adjusted follow-up annualized health care costs were 8.9% higher among switchers versus nonswitchers (P < 0.01), and switchers also had a shorter time to subsequent ART regimen change (P < 0.001). Results were similar for the virologically+clinically stable subset. CONCLUSIONS In this large, real-world population, stable patients with HIV who switched from their first-line ART regimens had significantly higher health care costs than those who did not change therapies, suggesting that ART regimen changes may be costly and should be undertaken only when clinically warranted. DISCLOSURES This work was funded by Bristol-Myers Squibb (BMS), which participated in the design of the study, interpretation of the data, revision of the manuscript, and the decision to submit the manuscript for publication. Rosenblatt is an employee and stock owner of BMS; Villasis-Keever was an employee of BMS at the time this study was conducted and is currently an employee of Janssen. Buikema is an employee and stock owner of Optum, and Seare, Bengston, Johnson, and Cao are employees of Optum, which was contracted by BMS to conduct the study. Optum contracts with pharmaceutical companies, such as Janssen, Merck, EMD Serano, GlaxoSmithKline, and Gilead, to conduct research in HIV. Optum is also a subsidiary of a health plan that has interest in managing the health and associated costs of patients with HIV. Study concept and design were contributed by Rosenblatt and Buikema, along with the other authors. Cao and Johnson took the lead in data collection, along with Buikema, Seare, and Bengston. Data interpretation was performed by Buikema, Seare, Bengston, and Villasis-Keever. The manuscript was written by Buikema and Bengston, along with Rosenblatt, Seare, Johnson and Villasis-Keever, and revised by Rosenblatt, Villasis-Keever, and Johnson, along with the other authors.
Collapse
Affiliation(s)
| | | | | | | | | | - Feng Cao
- 2 Optum, Eden Prairie, Minnesota
| | | |
Collapse
|
5
|
Restelli U, Fabbiani M, Di Giambenedetto S, Nappi C, Croce D. Budget impact analysis of the simplification to atazanavir + ritonavir + lamivudine dual therapy of HIV-positive patients receiving atazanavir-based triple therapies in Italy starting from data of the Atlas-M trial. CLINICOECONOMICS AND OUTCOMES RESEARCH 2017; 9:173-179. [PMID: 28280375 PMCID: PMC5338853 DOI: 10.2147/ceor.s127097] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background This analysis aimed at evaluating the impact of a therapeutic strategy of treatment simplification of atazanavir (ATV)+ ritonavir (r) + lamivudine (3TC) in virologically suppressed patients receiving ATV+r+2 nucleoside reverse transcriptase inhibitors (NRTIs) on the budget of the Italian National Health Service (NHS). Methods A budget impact model with a 5-year time horizon was developed based on the clinical data of Atlas-M trial at 48 weeks (in terms of percentage of patients experiencing virologic failure and adverse events), from the Italian NHS perspective. A scenario in which the simplification strategy was not considered was compared with three scenarios in which, among a target population of 1,892 patients, different simplification strategies were taken into consideration in terms of percentage of patients simplified on a yearly basis among those eligible for simplification. The costs considered were direct medical costs related to antiretroviral drugs, adverse events management, and monitoring activities. Results The percentage of patients of the target population receiving ATV+r+3TC varies among the scenarios and is between 18.7% and 46.9% in year 1, increasing up to 56.3% and 84.4% in year 5. The antiretroviral treatment simplification strategy considered would lead to lower costs for the Italian NHS in a 5-year time horizon between −28.7 million € and −16.0 million €, with a reduction of costs between −22.1% (−3.6 million €) and −8.8% (−1.4 million €) in year 1 and up to −39.9% (−6.9 million €) and −26.6% (−4.6 million €) in year 5. Conclusion The therapy simplification for patients receiving ATV+r+2 NRTIs to ATV+r+3TC at a national level would lead to a reduction of direct medical costs over a 5-year period for the Italian NHS.
Collapse
Affiliation(s)
- Umberto Restelli
- Centre for Research on Health Economics, Social and Health Care Management (CREMS), LIUC - Università Cattaneo, Castellanza, Italy; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Carmela Nappi
- Health Economics, Bristol-Myers Squibb S.r.l., Rome, Italy
| | - Davide Croce
- Centre for Research on Health Economics, Social and Health Care Management (CREMS), LIUC - Università Cattaneo, Castellanza, Italy; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
6
|
Ribera E, Martínez-Sesmero JM, Sánchez-Rubio J, Rubio R, Pasquau J, Poveda JL, Pérez-Mitru A, Roldán C, Hernández-Novoa B. Economic impact of optimising antiretroviral treatment in human immunodeficiency virus-infected adults with suppressed viral load in Spain, by implementing the grade A-1 evidence recommendations of the 2015 GESIDA/National AIDS Plan. Enferm Infecc Microbiol Clin 2017; 36:157-164. [PMID: 28109551 DOI: 10.1016/j.eimc.2016.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 11/05/2016] [Accepted: 11/27/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The objective of this study is to estimate the economic impact associated with the optimisation of triple antiretroviral treatment (ART) in patients with undetectable viral load according to the recommendations from the GeSIDA/PNS (2015) Consensus and their applicability in the Spanish clinical practice. METHODS A pharmacoeconomic model was developed based on data from a National Hospital Prescription Survey on ART (2014) and the A-I evidence recommendations for the optimisation of ART from the GeSIDA/PNS (2015) consensus. The optimisation model took into account the willingness to optimise a particular regimen and other assumptions, and the results were validated by an expert panel in HIV infection (Infectious Disease Specialists and Hospital Pharmacists). The analysis was conducted from the NHS perspective, considering the annual wholesale price and accounting for deductions stated in the RD-Law 8/2010 and the VAT. RESULTS The expert panel selected six optimisation strategies, and estimated that 10,863 (13.4%) of the 80,859 patients in Spain currently on triple ART, would be candidates to optimise their ART, leading to savings of €15.9M/year (2.4% of total triple ART drug cost). The most feasible strategies (>40% of patients candidates for optimisation, n=4,556) would be optimisations to ATV/r+3TC therapy. These would produce savings between €653 and €4,797 per patient per year depending on baseline triple ART. CONCLUSION Implementation of the main optimisation strategies recommended in the GeSIDA/PNS (2015) Consensus into Spanish clinical practice would lead to considerable savings, especially those based in dual therapy with ATV/r+3TC, thus contributing to the control of pharmaceutical expenditure and NHS sustainability.
Collapse
Affiliation(s)
- Esteban Ribera
- Servicio de Enfermedades Infecciosas, Hospital Universitari Vall d'Hebron, Barcelona, España.
| | | | | | - Rafael Rubio
- Unidad de Infección VIH, Hospital Universitario 12 de Octubre, Madrid, España
| | - Juan Pasquau
- Sección de Enfermedades Infecciosas, Hospital Universitario Virgen de las Nieves, Granada, España
| | - José Luis Poveda
- Servicio de Farmacia, Hospital Universitari i Politècnic La Fe de Valencia, Valencia, España
| | | | - Celia Roldán
- Departamento Médico, Bristol-Myers Squibb, Madrid, España
| | | |
Collapse
|
7
|
Croce D, Lazzarin A, Rizzardini G, Gianotti N, Scolari F, Foglia E, Garagiola E, Ricci E, Bini T, Quirino T, Viganò P, Re T, D’Arminio Monforte A, Bonfanti P. HIV Clinical Pathway: A New Approach to Combine Guidelines and Sustainability of Anti-Retroviral Treatment in Italy. PLoS One 2016; 11:e0168399. [PMID: 28030621 PMCID: PMC5193418 DOI: 10.1371/journal.pone.0168399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 11/29/2016] [Indexed: 11/18/2022] Open
Abstract
The present article describes the case study of a “real world” HIV practice within the debate concerning the strategic role of Clinical Governance (CG) tools in the management of a National Healthcare System’s sustainability. The study aimed at assessing the impact of a Clinical Pathway (CP) implementation, required by the Regional Healthcare Service, in terms of effectiveness (virological and immunological conditions) and efficiency (economic resources absorption), from the budget holder perspective. Data derived from a multi-centre cohort of patients treated in 6 Hospitals that provided care to approximately 42% of the total HIV+ patients, in Lombardy Region, Italy. Two phases were compared: Pre-CP (2009–2010) vs. Post-CP implementation (2011–2012). All HIV infected adults, observed in the participating hospitals during the study periods, were enrolled and stratified into the 3 categories defined by the Regional CP: first-line, switch for toxicity/other, and switch for failure. The study population was composed of 1,284 patients (Pre-CP phase) and 1,135 patients (Post-CP phase). The results showed that the same level of virological and immunological effectiveness was guaranteed to HIV+ patients: 81.2% of Pre-CP phase population and 83.2% of Post-CP phase population had undetectable HIV-RNA (defined as <50 copies/mL) at 12-month follow up. CD4+ cell counts increased by 28 ± 4 cells/mm3 in Pre-CP Phase and 39 ± 5 cells/mm3 in Post-CP Phase. From an economic point of view, the CP implementation led to a substantial advantage: the mean total costs related to the management of the HIV disease (ART, hospital admission and laboratory tests) decreased (-8.60%) in the Post-CP phase (p-value < 0.0001). Results confirmed that the CP provided appropriateness and quality of care, with a cost reduction for the budget holder.
Collapse
Affiliation(s)
- Davide Croce
- Centre for Research in Health Economics, Social and Health Care Management, LIUC-Università Cattaneo, Varese, Italy
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Adriano Lazzarin
- Clinic of Infectious Diseases, San Raffaele Scientific Institute, Milan, Italy
| | - Giuliano Rizzardini
- Department of Infectious Diseases, Fatebebefratelli Sacco Hospital, Milan, Italy
- School of Clinical Medicine, Faculty of Health Science, University of the Witwatersrand, Johannesburg, South Africa
| | - Nicola Gianotti
- Clinic of Infectious Diseases, San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Scolari
- Centre for Research in Health Economics, Social and Health Care Management, LIUC-Università Cattaneo, Varese, Italy
| | - Emanuela Foglia
- Centre for Research in Health Economics, Social and Health Care Management, LIUC-Università Cattaneo, Varese, Italy
| | - Elisabetta Garagiola
- Centre for Research in Health Economics, Social and Health Care Management, LIUC-Università Cattaneo, Varese, Italy
- * E-mail:
| | - Elena Ricci
- Department of Infectious Diseases, Fatebebefratelli Sacco Hospital, Milan, Italy
| | - Teresa Bini
- Unit of Infectious Diseases, Santi Paolo e Carlo Hospital, Milan, Italy
| | - Tiziana Quirino
- Department of Infectious Diseases, Valle Olona Hospital, Busto Arsizio, Italy
| | - Paolo Viganò
- Department of Infectious Diseases, Ovest Milanese Hospital, Legnano, Italy
| | - Tiziana Re
- Department of Infectious Diseases, Ovest Milanese Hospital, Legnano, Italy
| | | | - Paolo Bonfanti
- Department of Infectious Diseases, Lecco Hospital, Lecco, Italy
| |
Collapse
|
8
|
Paton NI, Stöhr W, Oddershede L, Arenas-Pinto A, Walker S, Sculpher M, Dunn DT. The Protease Inhibitor Monotherapy Versus Ongoing Triple Therapy (PIVOT) trial: a randomised controlled trial of a protease inhibitor monotherapy strategy for long-term management of human immunodeficiency virus infection. Health Technol Assess 2016; 20:1-158. [PMID: 26986803 DOI: 10.3310/hta20210] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Standard-of-care antiretroviral therapy (ART) for human immunodeficiency virus (HIV) infection uses a combination of drugs, until now considered essential to minimise treatment failure and development of drug resistance. Protease inhibitors (PIs) are potent with a high genetic barrier to resistance and have the potential for use as monotherapy after viral load (VL) suppression achieved on combination therapy. However, longer-term resistance and toxicity risks are uncertain. OBJECTIVE To compare the effectiveness, toxicity profile and cost-effectiveness of PI monotherapy with those of standard-of-care triple therapy in a pragmatic long-term clinical trial. DESIGN Open-label, parallel-group, randomised controlled trial. SETTING Forty-three HIV clinical centres in the UK NHS. PARTICIPANTS HIV-positive adults taking standard combination ART with a suppressed VL for ≥ 6 months. INTERVENTIONS Patients were randomised to maintain ongoing triple therapy (OT) or switch to a strategy of physician-selected ritonavir-boosted PI monotherapy (PI-mono), with prompt return to combination therapy in the event of VL rebound. MAIN OUTCOME MEASURES The primary outcome was reduction of future drug options, defined as new intermediate-/high-level resistance to one or more drugs to which the patient's virus was considered to be sensitive at trial entry (non-inferiority comparison, 10% margin). Secondary outcomes included confirmed virological rebound, serious drug- or disease-related complications, total grade 3 or 4 adverse events (AEs), neurocognitive function change, cluster of differentiation 4 (CD4) cell count change, change in health-related quality of life, cardiovascular risk change, health-care costs and health economic analysis. RESULTS In total, 587 participants were randomised (77% male, 68% white) to OT (n = 291) or PI-mono (n = 296) and followed for a median of 44 months, of whom 2.7% withdrew/were lost to follow-up. One or more episodes of confirmed VL rebound were observed in eight patients (Kaplan-Meier estimate 3.2%) in the OT group and 95 patients (35.0%) in the PI-mono group [absolute risk difference 31.8%, 95% confidence interval (CI) 24.6% to 39.0%; p < 0.001]. PI-mono patients who changed to ART after VL rebound all resuppressed (median 3.5 weeks). The proportions with loss of a future drug option at 3 years were 0.7% in the OT group and 2.1% in the PI-mono group (difference 1.4%, (95% CI -0.4% to 3.4%); non-inferiority demonstrated). There were no significant differences in serious disease complications between groups or in the frequency of grade 3 or 4 clinical AEs (16.8% OT group vs. 22% PI-mono group; absolute risk difference 5.1%, 95% CI -1.3% to 11.5%; p = 0.12). Overall, the PI-mono strategy was shown to be cost-effective compared with OT under most scenarios explored. PI-mono was cost saving because of the large savings in ART drug costs while being no less effective in terms of quality-adjusted life-years in the within-trial analysis and only marginally less effective when extrapolated to lifetime outcomes. CONCLUSIONS PI monotherapy, with prompt reintroduction of combination therapy for VL rebound, was non-inferior to combination therapy in preserving future treatment options and is an acceptable and cost-effective alternative for long-term management of HIV infection. TRIAL REGISTRATION Current Controlled Trials ISRCTN04857074. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 21. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Nicholas I Paton
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, University College London, London, UK.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wolfgang Stöhr
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Lars Oddershede
- Danish Centre for Healthcare Improvements, Faculty of Social Sciences and Faculty of Health Sciences, Aalborg University, Aalborg, Denmark
| | - Alejandro Arenas-Pinto
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Simon Walker
- Centre for Health Economics, University of York, York, UK
| | - Mark Sculpher
- Centre for Health Economics, University of York, York, UK
| | - David T Dunn
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, University College London, London, UK
| |
Collapse
|
9
|
Di Biagio A, Cozzi-Lepri A, Prinapori R, Angarano G, Gori A, Quirino T, De Luca A, Costantini A, Mussini C, Rizzardini G, Castagna A, Antinori A, dʼArminio Monforte A. Discontinuation of Initial Antiretroviral Therapy in Clinical Practice: Moving Toward Individualized Therapy. J Acquir Immune Defic Syndr 2016; 71:263-71. [PMID: 26871881 PMCID: PMC4770376 DOI: 10.1097/qai.0000000000000849] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is Available in the Text. Background: Study aim was to estimate the rate and identify predictors of discontinuation of first combination antiretroviral therapy (cART) in recent years. Methods: Patients who initiated first cART between January 2008 and October 2014 were included. Discontinuation was defined as stop of at least 1 drug of the regimen, regardless of the reason. All causes of discontinuation were evaluated and 3 main endpoints were considered: toxicity, intolerance, and simplification. Predictors of discontinuation were examined separately for all 3 endpoints. Kaplan–Meier analysis was used for the outcome discontinuation of ≥1 drug regardless of the reason. Cox regression analysis was used to identify factors associated with treatment discontinuation because of the 3 reasons considered. Results: A total of 4052 patients were included. Main reason for stopping at least 1 drug were simplification (29%), intolerance (21%), toxicity (19%), other causes (18%), failure (8%), planned discontinuation (4%), and nonadherence (2%). In a multivariable Cox model, predictors of discontinuation for simplification were heterosexual transmission (P = 0.007), being immigrant (P = 0.017), higher nadir lymphocyte T CD4+ cell (P = 0.011), and higher lymphocyte T CD8+ cell count (P = 0.025); for discontinuation due to intolerance: the use of statins (P = 0.029), higher blood glucose levels (P = 0.050). About toxicity: higher blood glucose levels (P = 0.010) and the use of zidovudine/lamivudine as backbone (P = 0.044). Conclusions: In the late cART era, the main reason for stopping the initial regimen is simplification. This scenario reflects the changes in recommendations aimed to enhance adherence and quality of life, and minimize drug toxicity.
Collapse
Affiliation(s)
- Antonio Di Biagio
- *Infectious Diseases Unit, IRCCS AOU S. Martino-IST, National Institute for Cancer Research, Genoa, Italy;†Department of Infection and Population Health, Division of Population Health, UCL Medical School, Royal Free Campus, London, United Kingdom;‡Department of Biomedical Science and Human Oncology, University of Bari, Bari, Italy;§Clinic of Infectious Diseases, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy;‖Infectious Diseases Unit, Busto Arsizio Hospital, Busto Arsizio (VA), Italy;¶Infectious Diseases Unit, Siena University Hospital, Siena, Italy;#Department of Health Sciences, University of Ancona, Ancona, Italy;**Infectious Diseases Clinic, Policlinico of Modena, University of Modena and Reggio Emilia, Modena, Italy;††Infectious Diseases Unit, Sacco Hospital, Milan, Italy;‡‡Infectious Diseases Unit, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy;§§National Institute for Infectious Diseases IRCCS L. Spallanzani, Rome, Italy; and‖‖Clinic of Infectious and Tropical Diseases, Department of Health Sciences, S Paolo Hospital, University of Milan, Milan, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Mikkelsen CM, Andersen SE. A Regional Drug and Therapeutics Committee-led Intervention to Reduce the Hospital Costs of Expensive HIV Drugs. Basic Clin Pharmacol Toxicol 2016; 119:278-83. [PMID: 27009401 DOI: 10.1111/bcpt.12585] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 03/10/2016] [Indexed: 12/24/2022]
Abstract
In 2009, the regional Drug and Therapeutics Committee (DTC) began a series of meetings with lead specialists in infectious diseases. The role of the DTC was to engage clinicians and ensure commitment to prescribing the least expensive drugs among the clinically equivalent HAARTs (highly active antiretroviral therapy). DTC also led implementation of a national guideline. This study analyses the impact of this process on HAART consumption and expenditure. The HAART consumption and expenditure (2009-2013) was compared to forecasts produced by exponential smoothing (2004-2009). Abrupt switches between drug regimens coincided with the DTC-led meetings. Overall, HAART consumption rose 16%, while price per defined daily dose (DDD) fell 11% and the 2013 expenditure decreased 23%. The consumption of drugs addressed by the guideline rose 48%. Still, the 2013 expenditure was 41.5 million DKK (5.5 million €) (27%) lower than expected, reflecting a fall in price per DDD that coincided with the intervention. The consumption of drugs not addressed by the guideline rose 8.3%, while price per DDD fell 8.5% and the 2013 expenditure was 26.8 million DKK (3.6 million €) (19%) lower than expected. Despite a steadily increasing consumption, significant cost savings followed this DTC-led intervention. This multifaceted approach might be applicable to changing the prescribing of other expensive drug classes.
Collapse
Affiliation(s)
- Camilla Munk Mikkelsen
- The Hospital Pharmacy, The Capital Region of Denmark, Bispebjerg Hospital, Copenhagen, Denmark
| | | |
Collapse
|
11
|
Yazdanpanah Y, Schwarzinger M. Generic antiretroviral drugs and HIV care: An economic review. Med Mal Infect 2016; 46:67-71. [PMID: 26905394 DOI: 10.1016/j.medmal.2016.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 11/30/2015] [Accepted: 01/15/2016] [Indexed: 11/16/2022]
Abstract
The cost of HIV care in European countries is high. Direct medical costs, in France, have been estimated at 500,000 Euros per patient's lifetime (20,000 Euros/year/patient). Overall, 73% of these costs are related to antiretroviral treatments. In the current financial crisis context, some European countries are beginning to make economic decisions on the drugs to be used. These approaches are likely to become more frequent. It is obviously essential to prescribe the most effective, appropriate, best tolerated, and easy-to-use antiretroviral treatments to patients. However, while taking the above into consideration, and if various treatment options or combinations are available, cost should also be considered in the treatment choice. One may thus reflect on the use of generic antiretroviral agents as they have just been launched in France. We aimed to review the cost and cost-effectiveness of generic antiretroviral drugs and to review treatment strategies other than generic drugs that could help reduce HIV-related costs. HIV clinicians should consider treatment costs to avoid any future coercive measures.
Collapse
Affiliation(s)
- Y Yazdanpanah
- UMR 1137, Inserm, IAME, 75018 Paris, France; Université Paris Diderot, Sorbonne Paris Cité, 75018 Paris, France; Service des maladies infectieuses et tropicales, hôpital Bichat, AP-HP, 75018 Paris, France.
| | - M Schwarzinger
- UMR 1137, Inserm, IAME, 75018 Paris, France; Université Paris Diderot, Sorbonne Paris Cité, 75018 Paris, France
| |
Collapse
|
12
|
Protease inhibitor monotherapy is associated with a higher level of monocyte activation, bacterial translocation and inflammation. J Int AIDS Soc 2014; 17:19246. [PMID: 25280865 PMCID: PMC4185085 DOI: 10.7448/ias.17.1.19246] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 08/25/2014] [Accepted: 08/29/2014] [Indexed: 12/24/2022] Open
Abstract
Introduction Monotherapy with protease-inhibitors (MPI) may be an alternative to cART for HIV treatment. We assessed the impact of this strategy on immune activation, bacterial translocation and inflammation. Methods We performed a cross-sectional study comparing patients on successful MPI (n=40) with patients on cART (n=20). Activation, senescence, exhaustion and differentiation stage in CD4+ and CD8+ T lymphocyte subsets, markers of monocyte activation, microbial translocation, inflammation, coagulation and low-level viremia were assessed. Results CD4+ or CD8+ T lymphocyte subset parameters were not significantly different between both groups. Conversely, as compared with triple cART, MPI patients showed a higher proportion of activated monocytes (CD14+ CD16−CD163+ cells, p=0.031), soluble markers of monocyte activation (sCD14 p=0.004, sCD163 p=0.002), microbial translocation (lipopolysaccharide (LPS)-binding protein; LBP p=0.07), inflammation (IL-6 p=0.04) and low-level viremia (p=0.035). In a multivariate model, a higher level of CD14+ CD16−CD163+ cells and sCD14, and presence of very low-level viremia were independently associated with MPI. Monocyte activation was independently associated with markers of inflammation (IL-6, p=0.006), microbial translocation (LBP, p=0.01) and low-level viremia (p=0.01). Conclusions Patients on MPI showed a higher level of monocyte activation than patients on standard therapy. Microbial translocation and low-level viremia were associated with the high level of monocyte activation observed in patients on MPI. The long-term clinical consequences of these findings should be assessed.
Collapse
|
13
|
Restelli U, Andreoni M, Antinori A, Bonfanti M, Di Perri G, Galli M, Lazzarin A, Rizzardini G, Croce D. Budget impact analysis of antiretroviral less drug regimen simplification in HIV-positive patients on the Italian National Health Service. CLINICOECONOMICS AND OUTCOMES RESEARCH 2014; 6:409-14. [PMID: 25285019 PMCID: PMC4181445 DOI: 10.2147/ceor.s68101] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Deintensification and less drug regimen (LDR) antiretroviral therapy (ART) strategies have proved to be effective in terms of maintaining viral suppression in human immunodeficiency virus (HIV)-positive patients, increasing tolerability, and reducing toxicity of antiretroviral drugs administered to patients. However, the economic impact of these strategies have not been widely investigated. The aim of the study is to evaluate the economic impact that ART LDR could have on the Italian National Health Service (INHS) budget. Methods A budget impact model was structured to assess the potential savings for the INHS by the use of ART LDR for HIV-positive patients with a 3 year perspective. Data concerning ART cost, patient distribution within different ARTs, and probabilities for patients to change ART on a yearly basis were collected within four Italian infectious diseases departments, providing ART to 13.7% of the total number of patients receiving ART in Italy. Results The LDR investigated (protease inhibitor-based dual and monotherapies) led to savings for the hospitals involved when compared to the “do nothing” scenario on a 3 year basis, between 6.7% (23.11 million €) and 12.8% (44.32 million €) of the total ART expenditures. The mean yearly cost per patient is reduced from 9,875 € in the do nothing scenario to a range between 9,218 € and 8,615 €. The use of these strategies within the four departments involved would have led to a reduction of ART expenditures for the INHS of between 1.1% and 2.1% in 3 years. Conclusion ART LDR simplification would have a significant impact in the reduction of ART-related costs within the hospitals involved in the study. These strategies could therefore be addressed as a sustainable answer to the public financing reduction observed within the INHS in the last year, allowing therapies to be dispensed without affecting the quality of the services provided.
Collapse
Affiliation(s)
- Umberto Restelli
- Department of Community Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa ; Centro di Ricerca in Economia e Management in Sanità e nel Sociale (CREMS), Università Carlo Cattaneo - LIUC, Castellanza (VA), Italy
| | - Massimo Andreoni
- Clinical Infectious Diseases, Tor Vergata University (PTV), Rome, Italy
| | - Andrea Antinori
- Clinical Department, National Institute for Infectious Diseases "L. Spallanzani," Rome, Italy
| | - Marzia Bonfanti
- Centro di Ricerca in Economia e Management in Sanità e nel Sociale (CREMS), Università Carlo Cattaneo - LIUC, Castellanza (VA), Italy
| | - Giovanni Di Perri
- Department of Medical Sciences, Infectious Diseases, Amedeo di Savoia Hospital, Turin, Italy
| | - Massimo Galli
- Third Division of Infectious Diseases, "Luigi Sacco" Hospital, Milan, Italy
| | - Adriano Lazzarin
- Department of Infectious Diseases, San Raffaele Scientific Institute, Milan, Italy
| | - Giuliano Rizzardini
- First and Second Divisions of Infectious Diseases, "Luigi Sacco" Hospital, Milan, Italy ; School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Davide Croce
- Department of Community Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa ; Centro di Ricerca in Economia e Management in Sanità e nel Sociale (CREMS), Università Carlo Cattaneo - LIUC, Castellanza (VA), Italy
| |
Collapse
|
14
|
Van den Eynde E, Podzamczer D. Switch strategies in antiretroviral therapy regimens. Expert Rev Anti Infect Ther 2014; 12:1055-74. [PMID: 25075752 DOI: 10.1586/14787210.2014.944506] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Despite great advances in antiretroviral therapy in the last decade, several limitations still remain such as adverse effects, lack of adherence and drug-drug interactions. Switching antiretroviral therapy in stable, virologically suppressed patients with the aim of improving tolerability and convenience is an expanding strategy in clinical practice. Several factors need to be taken into consideration when switching a suppressive regimen, such as previous virologic failure, genetic barrier of the new regimen, prior duration of virologic suppression and expected level of adherence. The most frequently used strategies include reductions in the number of pills, drugs or doses. Although switching strategies may be useful, not all the regimens used in clinical practice are based on data from randomized clinical trials and some may not be the best option for certain patients; therefore, therapy should be individualized taking into consideration available information as well as patient and drug characteristics.
Collapse
Affiliation(s)
- Eva Van den Eynde
- HIV Unit, Infectious Disease Service, Hospital Universitari de Bellvitge, c/Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907 Barcelona, Spain
| | | |
Collapse
|
15
|
|