Division of General Internal Medicine, Stanford University, Stanford, USA.
AIDS. 2011 Jan 14;25(2):211-20. doi: 10.1097/QAD.0b013e328340fdf8.
the World Health Organization (WHO) recently changed its first-line antiretroviral treatment guidelines in resource-limited settings. The cost-effectiveness of the new guidelines is unknown.
comparative effectiveness and cost-effectiveness analysis using a model of HIV disease progression and treatment.
using a simulation of HIV disease and treatment in South Africa, we compared the life expectancy, quality-adjusted life expectancy, lifetime costs, and cost-effectiveness of five initial regimens. Four are currently recommended by the WHO: tenofovir/lamivudine/efavirenz; tenofovir/lamivudine/nevirapine; zidovudine/lamivudine/efavirenz; and zidovudine/lamivudine/nevirapine. The fifth is the most common regimen in current use: stavudine/lamivudine/nevirapine. Virologic suppression and toxicities determine regimen effectiveness and cost-effectiveness.
choice of first-line regimen is associated with a difference of nearly 12 months of quality-adjusted life expectancy, from 135.2 months (tenofovir/lamivudine/efavirenz) to 123.7 months (stavudine/lamivudine/nevirapine). Stavudine/lamivudine/nevirapine is more costly and less effective than zidovudine/lamivudine/nevirapine. Initiating treatment with a regimen containing tenofovir/lamivudine/nevirapine is associated with an incremental cost-effectiveness ratio of $1045 per quality-adjusted life year compared with zidovudine/lamivudine/nevirapine. Using tenofovir/lamivudine/efavirenz was associated with the highest survival, fewest opportunistic diseases, lowest rate of regimen substitution, and an incremental cost-effectiveness ratio of $5949 per quality-adjusted life year gained compared with tenofovir/lamivudine/nevirapine. Zidovudine/lamivudine/efavirenz was more costly and less effective than tenofovir/lamivudine/nevirapine. Results were sensitive to the rates of toxicities and the disutility associated with each toxicity.
among the options recommended by WHO, we estimate only three should be considered under normal circumstances. Choice among those depends on available resources and willingness to pay. Stavudine/lamivudine/nevirapine is associated with the poorest quality-adjusted survival and higher costs than zidovudine/lamivudine/nevirapine.
世界卫生组织（WHO）最近改变了资源有限环境下的一线抗逆转录病毒治疗指南。新指南的成本效益尚不清楚。
使用 HIV 疾病进展和治疗模型进行的比较有效性和成本效益分析。
使用南非 HIV 疾病和治疗的模拟，我们比较了五种初始方案的预期寿命、质量调整预期寿命、终生成本和成本效益。目前 WHO 推荐使用四种方案：替诺福韦/拉米夫定/依非韦伦；替诺福韦/拉米夫定/奈韦拉平；齐多夫定/拉米夫定/依非韦伦；齐多夫定/拉米夫定/奈韦拉平。第五种是目前最常用的方案：司他夫定/拉米夫定/奈韦拉平。病毒学抑制和毒性决定了方案的有效性和成本效益。
一线方案的选择与质量调整预期寿命相差近 12 个月，从 135.2 个月（替诺福韦/拉米夫定/依非韦伦）到 123.7 个月（司他夫定/拉米夫定/奈韦拉平）。司他夫定/拉米夫定/奈韦拉平比齐多夫定/拉米夫定/奈韦拉平成本更高，效果更差。与齐多夫定/拉米夫定/奈韦拉平相比，起始治疗时使用包含替诺福韦/拉米夫定/奈韦拉平的方案会导致每增加一个质量调整生命年的增量成本效益比为 1045 美元。与替诺福韦/拉米夫定/依非韦伦相比，使用替诺福韦/拉米夫定/依非韦伦治疗的患者生存时间最长，机会性疾病最少，方案替代率最低，每增加一个质量调整生命年的增量成本效益比为 5949 美元。齐多夫定/拉米夫定/依非韦伦比替诺福韦/拉米夫定/依非韦伦成本更高，效果更差。结果对毒性发生率和每种毒性相关的不适效用敏感。
在 WHO 推荐的方案中，我们估计只有三种方案在正常情况下可以考虑。在这些方案中进行选择取决于可用资源和支付意愿。司他夫定/拉米夫定/奈韦拉平与齐多夫定/拉米夫定/奈韦拉平相比，生存质量调整最差，成本最高。
