Walensky Rochelle P, Weinstein Milton C, Yazdanpanah Yazdan, Losina Elena, Mercincavage Lauren M, Touré Siaka, Divi Nomita, Anglaret Xavier, Goldie Sue J, Freedberg Kenneth A
Division of Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
AIDS. 2007 May 11;21(8):973-82. doi: 10.1097/QAD.0b013e328011ec53.
Sentinel testing programs for HIV drug resistance in resource-limited settings can inform policy on antiretroviral therapy (ART) and drug sequencing.
: To examine the value of resistance surveillance in influencing recommendations toward effective and cost-effective sequencing of ART regimens.
A state-transition model of HIV infection was adapted to simulate clinical care in Côte d'Ivoire and evaluate the incremental cost-effectiveness of (1) no ART; (2) ART beginning with a non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen followed by a boosted protease inhibitor (PI)-based regimen; and (3) ART beginning with a boosted PI-based regimen followed by an NNRTI-based regimen.
At a 5% prevalence of NNRTI resistance, a strategy that started with a PI-based regimen had a smaller health benefit and higher cost-effectiveness ratio than a strategy that started with an NNRTI-based regimen (cost-effectiveness ratio $910/year of life saved). Results consistently favored initiation with an NNRTI-based regimen, regardless of the population prevalence of NNRTI resistance (up to 76%) and the efficacy of an NNRTI-based regimen in the setting of resistance. The most influential parameters on the cost-effectiveness of sequencing strategies were boosted PI-based regimen costs and the efficacy of this regimen when used as second-line therapy.
Drug costs and treatment efficacies, but not NNRTI resistance levels, were most influential in determining optimal HIV drug sequencing in Côte d'Ivoire. Results of surveillance for NNRTI resistance should not be used as a major guide to treatment policy in resource-limited settings.
在资源有限的环境中开展的艾滋病病毒耐药性哨点检测项目可为抗逆转录病毒疗法（ART）及药物序贯治疗政策提供依据。
探讨耐药性监测在影响有效且具成本效益的ART方案序贯治疗建议方面的价值。
采用艾滋病病毒感染的状态转换模型来模拟科特迪瓦的临床护理情况，并评估以下三种情况的增量成本效益：（1）不进行ART治疗；（2）ART治疗从基于非核苷类逆转录酶抑制剂（NNRTI）的方案开始，随后采用增强型蛋白酶抑制剂（PI）方案；（3）ART治疗从基于增强型PI的方案开始，随后采用基于NNRTI的方案。
在NNRTI耐药率为5%的情况下，与从基于NNRTI的方案开始的策略相比，从基于PI的方案开始的策略健康效益较小且成本效益比更高（成本效益比为每挽救一年生命910美元）。无论NNRTI耐药的人群患病率（高达76%）以及基于NNRTI的方案在耐药情况下的疗效如何，结果始终支持从基于NNRTI的方案开始治疗。对序贯治疗策略成本效益影响最大的参数是基于增强型PI的方案成本以及该方案作为二线治疗时的疗效。
药物成本和治疗效果而非NNRTI耐药水平，在确定科特迪瓦最佳艾滋病病毒药物序贯治疗中影响最大。NNRTI耐药性监测结果不应作为资源有限环境下治疗政策的主要指导依据。
