Partnership for Health Analytic Research, Beverly Hills, CA, USA.
J Med Econ. 2011;14(2):167-78. doi: 10.3111/13696998.2011.554932. Epub 2011 Feb 2.
To evaluate lifetime cost effectiveness of atazanavir-ritonavir (ATV + r) versus lopinavir-ritonavir (LPV/r), both with tenofovir-emtricitabine, in US HIV-infected patients initiating first-line antiretroviral therapy.
A Markov microsimulation model was developed to calculate quality-adjusted life-years (QALYs) based on CD4 and HIV RNA levels, coronary heart disease (CHD), AIDS, opportunistic infections (OIs), diarrhea, and hyperbilirubinemia. A million-member cohort of HIV-1-infected, treatment-naïve adults progressed at 3-month intervals through eight health states. Baseline characteristics, virologic suppression, cholesterol changes, and diarrhea and hyperbilirubinemia rates were based on 96-week CASTLE trial results. HIV mortality, OI rates, adherence, costs, utilities, and CHD risk were from literature and experts.
The incremental cost-effectiveness ratio (ICER) may be overestimated because the ATV + r treatment effect was based on an intention-to-treat analysis. The QALY weights used for diarrhea, hyperbilirubinemia, and CHD events are uncertain; however, the ICER remained < $50,000/QALY when these values were varied in sensitivity analyses.
ATV + r patients received first-line therapy longer than LPV/r patients (97.3 vs. 70.7 months), had longer quality-adjusted survival (11.02 vs. 10.76 years), similar overall survival (18.52 vs. 18.51 years), and higher costs ($275,986 vs. 269,160). ATV+r [corrected] patients had lower rates of AIDS (19.08 vs. 20.05 cases/1000 patient-years), OIs (0.44 vs.0.52), diarrhea (1.27 vs. 6.26), and CHD events(5.44 vs. 5.51), but higher hyperbilirubinemia rates (6.99 vs. 0.25. ATV + r added 0.26 QALYs at a cost of $6826, for $26,421/QALY.
By more effectively reducing viral load with less gastrointestinal toxicity and a better lipid profile, ATV + r lowered rates of AIDS and CHD, increased quality-adjusted survival, and was cost effective (< $50,000/QALY) compared with LPV/r.
评估阿扎那韦-利托那韦（ATV+r）与洛匹那韦-利托那韦（LPV/r）联合替诺福韦-恩曲他滨用于美国初治 HIV 感染患者的终生成本效果。
采用马尔可夫微模拟模型，根据 CD4 和 HIV RNA 水平、冠心病（CHD）、艾滋病、机会性感染（OIs）、腹泻和高胆红素血症计算质量调整生命年（QALYs）。基于 96 周 CASTLE 试验结果，对 100 万例 HIV-1 感染、未经治疗的成年人进行了每 3 个月一次的进展，通过 8 种健康状态。基线特征、病毒学抑制、胆固醇变化以及腹泻和高胆红素血症的发生率基于 96 周 CASTLE 试验结果。HIV 死亡率、OIs 发生率、依从性、成本、效用和 CHD 风险来自文献和专家。
由于 ATV+r 治疗效果基于意向治疗分析，因此增量成本效果比（ICER）可能被高估。腹泻、高胆红素血症和 CHD 事件的 QALY 权重不确定；然而，当在敏感性分析中改变这些值时，ICER 仍保持在 <50000 美元/QALY 以下。
与 LPV/r 患者相比，ATV+r 患者接受一线治疗的时间更长（97.3 个月 vs. 70.7 个月），质量调整生存时间更长（11.02 年 vs. 10.76 年），总生存时间相似（18.52 年 vs. 18.51 年），成本更高（275986 美元 vs. 269160 美元）。ATV+r 患者的艾滋病（19.08 例/1000 患者年 vs. 20.05 例/1000 患者年）、机会性感染（0.44 例/1000 患者年 vs. 0.52 例/1000 患者年）、腹泻（1.27 例/1000 患者年 vs. 6.26 例/1000 患者年）和 CHD 事件（5.44 例/1000 患者年 vs. 5.51 例/1000 患者年）发生率较低，但高胆红素血症发生率较高（6.99 例/1000 患者年 vs. 0.25 例/1000 患者年）。ATV+r 增加了 0.26 QALYs，成本为 6826 美元，每 QALY 成本为 26421 美元。
与 LPV/r 相比，阿扎那韦-利托那韦通过更有效地降低病毒载量、减少胃肠道毒性和改善血脂谱，降低了艾滋病和 CHD 的发生率，提高了质量调整后的生存率，且具有成本效果（<50000 美元/QALY）。
