Bendavid Eran, Wood Robin, Katzenstein David A, Bayoumi Ahmed M, Owens Douglas K
Department of Medicine, Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University, Stanford, CA 94305, USA.
J Acquir Immune Defic Syndr. 2009 Sep 1;52(1):106-13. doi: 10.1097/QAI.0b013e3181a4f9c4.
Current World Health Organization (WHO) guidelines for treatment of HIV in resource-limited settings call for 2 antiretroviral regimens. The effectiveness and cost-effectiveness of increasing the number of antiretroviral regimens is unknown.
Using a simulation model, we compared the survival and costs of current WHO regimens with two 3-regimen strategies: an initial regimen of 3 nucleoside reverse transcriptase inhibitors followed by the WHO regimens and the WHO regimens followed by a regimen with a second-generation boosted protease inhibitor (2bPI). We evaluated monitoring with CD4 counts only and with both CD4 counts and viral load. We used cost and effectiveness data from Cape Town and tested all assumptions in sensitivity analyses.
Over the lifetime of the cohort, 25.6% of individuals failed both WHO regimens by virologic criteria. However, when patients were monitored using CD4 counts alone, only 6.5% were prescribed additional highly active antiretroviral therapy due to missed and delayed detection of failure. The life expectancy gain for individuals who took a 2bPI was 6.7-8.9 months, depending on the monitoring strategy. When CD4 alone was available, adding a regimen with a 2bPI was associated with an incremental cost-effectiveness ratio of $2581 per year of life gained, and when viral load was available, the ratio was $6519 per year of life gained. Strategies with triple-nucleoside reverse transcriptase inhibitor regimens in initial therapy were dominated. Results were sensitive to the price of 2bPIs.
About 1 in 4 individuals who start highly active antiretroviral therapy in sub-Saharan Africa will fail currently recommended regimens. At current prices, adding a regimen with a 2bPI is cost effective for South Africa and other middle-income countries by WHO standards.
世界卫生组织（WHO）目前关于在资源有限地区治疗艾滋病病毒的指南要求采用两种抗逆转录病毒治疗方案。增加抗逆转录病毒治疗方案数量的有效性和成本效益尚不清楚。
我们使用模拟模型，将当前WHO方案的生存率和成本与两种三方案策略进行比较：一种是初始采用3种核苷类逆转录酶抑制剂方案，随后采用WHO方案；另一种是先采用WHO方案，随后采用含第二代增强型蛋白酶抑制剂（2bPI）的方案。我们评估了仅用CD4细胞计数监测以及同时用CD4细胞计数和病毒载量监测的情况。我们使用了开普敦的成本和有效性数据，并在敏感性分析中检验了所有假设。
在队列的整个生命周期中，25.6%的个体按病毒学标准两种WHO方案均治疗失败。然而，当仅用CD4细胞计数监测患者时，因治疗失败漏诊和延迟诊断而接受额外高效抗逆转录病毒治疗的患者仅为6.5%。服用2bPI的个体预期寿命增加6.7 - 8.9个月，具体取决于监测策略。当仅可获得CD4细胞计数时，添加含2bPI的方案每获得一年生命的增量成本效益比为2581美元；当可获得病毒载量时，该比值为每获得一年生命6519美元。初始治疗采用三联核苷类逆转录酶抑制剂方案的策略不占优势。结果对2bPI的价格敏感。
在撒哈拉以南非洲开始接受高效抗逆转录病毒治疗的个体中，约四分之一会使目前推荐的治疗方案失败。按目前价格，根据WHO标准为南非和其他中等收入国家添加含2bPI的方案具有成本效益。
