Médecins Sans Frontières, Morija, Lesotho.
J Acquir Immune Defic Syndr. 2011 Nov 1;58(3):e68-74. doi: 10.1097/QAI.0b013e31822a9f8d.
Latest World Health Organization guidelines recommend shifting away from Stavudine (d4T)-based regimens due to severe side effects. However, widespread replacement of d4T by Tenofovir (TDF) or Zidovudine (AZT) is hampered by cost concerns.
We established the cost-effectiveness of alternative first-line regimens using primary utilization, cost, and outcome data from a program in a rural district in Lesotho. We calculated cost per patient-year, incremental costs, and incremental cost-effectiveness ratios per life year, and per Quality Adjusted Life Year gained. Uncertainty was assessed using multiway and probabilistic sensitivity analyses.
Our study included 1260 patients representing 1635 patient-years on antiretroviral therapy (ART). Six hundred eight patients were on TDF, 290 were on AZT, and 362 were on d4T. Patients on d4T experienced more toxicities; toxicities with the biggest impact on quality of life were moderate neuropathy and severe lipodystrophy. The cost per patient-year ranged from US $266 on d4T to US $353 on TDF. Inpatient care and essential drug costs were higher for patients on d4T than on AZT or TDF. Incremental cost-effectiveness ratio results suggest that AZT-based ART is weakly dominated by a combination of d4T- and TDF-based ART.
This is one of the first analyses to investigate the cost-effectiveness of TDF using primary data in a resource-poor setting. Although TDF-based first-line ART is more costly than d4T, it is also more effective. Political pressure should be exerted to encourage further price reductions and additional generic manufacturing for TDF and partner drugs such as Efavirenz. This should be met by a commitment from donors and implementers to ensure that supply is met by a clear demand.
世界卫生组织最新指南建议避免使用司他夫定（d4T）为基础的治疗方案，因为其存在严重的副作用。然而，由于成本问题，广泛用替诺福韦（TDF）或齐多夫定（AZT）替代 d4T 受到阻碍。
我们利用莱索托一个农村地区项目的初级利用、成本和结果数据，建立了替代一线治疗方案的成本效益。我们计算了每位患者每年的成本、增量成本和每获得 1 个生命年、1 个质量调整生命年的增量成本效益比。使用多向和概率敏感性分析评估了不确定性。
我们的研究包括 1260 名患者，他们在抗逆转录病毒治疗（ART）中代表了 1635 个患者年。608 名患者使用 TDF，290 名患者使用 AZT，362 名患者使用 d4T。使用 d4T 的患者出现更多毒性反应；对生活质量影响最大的毒性反应是中度神经病和严重脂肪营养不良。每位患者每年的成本从 d4T 的 266 美元到 TDF 的 353 美元不等。与使用 AZT 或 TDF 的患者相比，使用 d4T 的患者的住院护理和基本药物成本更高。增量成本效益比的结果表明，基于 AZT 的 ART 比基于 d4T 和 TDF 的 ART 略差。
这是首次使用资源匮乏环境中的原始数据调查 TDF 的成本效益的分析之一。尽管基于 TDF 的一线 ART 比 d4T 更昂贵，但它也更有效。应该施加政治压力，鼓励进一步降低 TDF 和依非韦伦等伙伴药物的价格，并增加其通用制造。这应该得到捐助者和实施者的承诺，以确保通过明确的需求来满足供应。
