Linas Benjamin P, Barter Devra M, Leff Jared A, DiLorenzo Madeline, Schackman Bruce R, Horsburgh Charles R, Assoumou Sabrina A, Salomon Joshua A, Weinstein Milton C, Kim Arthur Y, Freedberg Kenneth A
aSection of Infectious Diseases, Department of Medicine, Boston Medical Center bDepartment of Epidemiology, Boston University School of Public Health, Boston, Massachusetts cDepartment of Public Health, Weill Cornell Medical College, New York, New York dDivision of General Medicine, Massachusetts General Hospital eDivision of Infectious Diseases, Massachusetts General Hospital fDepartment of Global Health and Population gDepartment of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA.
AIDS. 2014 Jan 28;28(3):365-76. doi: 10.1097/QAD.0000000000000093.
To evaluate the effectiveness and cost-effectiveness of strategies to treat hepatitis C virus (HCV) in HIV/HCV coinfected patients in the United States.
Simulated cohort of HIV/HCV genotype 1 coinfected, noncirrhotic, HCV treatment-naive individuals enrolled in US HIV guideline-concordant care.
DESIGN/INTERVENTIONS: Monte Carlo simulation comparing five strategies: no treatment; dual therapy with pegylated-interferon (PEG) and ribavirin (RBV); 'PEG/RBV trial' in which all patients initiate dual therapy and switch to triple therapy upon failure; 'IL28B triage' in which patients initiate either dual therapy or triple therapy based on their IL28B allele type; and PEG/RBV and telaprevir (TPV) triple therapy. Sensitivity analyses varied efficacies and costs and included a scenario with interferon (IFN)-free therapy.
Sustained virologic response (SVR), life expectancy, discounted quality-adjusted life expectancy (QALE), lifetime medical costs, and incremental cost-effectiveness ratios (ICERs) in $/quality-adjusted life years (QALY) gained.
'PEG/RBV trial,' 'IL28B triage,' and 'triple therapy' each provided 72% SVR and extended QALE compared with 'dual therapy' by 1.12, 1.14, and 1.15 QALY, respectively. The ICER of 'PEG/RBV trial' compared with 'dual therapy' was $37 500/QALY. 'IL28B triage' and 'triple therapy' provided little benefit compared with 'PEG/RBV trial,' and both had ICERs exceeding $300 000/QALY. In sensitivity analyses, IFN-free treatment attaining 90% SVR had an ICER less than $100 000/QALY compared with 'PEG/RBV trial' when its cost was $109 000 or less (125% of the cost of PEG/RBV/TVR).
HCV protease inhibitors are most efficiently used in HIV/HCV coinfection after a trial of PEG/RBV, sparing protease inhibitors for those who attain rapid virologic response and SVR. The cost-effectiveness of IFN-free regimens for HIV/HCV coinfection will depend on the cost of these therapies.
评估美国艾滋病毒/丙型肝炎病毒（HCV）合并感染患者丙型肝炎病毒治疗策略的有效性和成本效益。
模拟队列，为参与美国艾滋病毒指南一致护理的艾滋病毒/HCV基因1型合并感染、无肝硬化、未接受过HCV治疗的个体。
设计/干预措施：蒙特卡洛模拟，比较五种策略：不治疗；聚乙二醇化干扰素（PEG）和利巴韦林（RBV）联合治疗；“PEG/RBV试验”，即所有患者开始联合治疗，失败后转为三联治疗；“IL28B分类”，即患者根据其IL28B等位基因类型开始联合治疗或三联治疗；PEG/RBV和特拉匹韦（TPV）三联治疗。敏感性分析改变了疗效和成本，并纳入了无干扰素（IFN）治疗的情景。
持续病毒学应答（SVR）、预期寿命、贴现质量调整预期寿命（QALE）、终身医疗成本以及每获得一个质量调整生命年（QALY）的增量成本效益比（ICER）。
与“联合治疗”相比，“PEG/RBV试验”、“IL28B分类”和“三联治疗”的SVR均为72%，QALE分别延长了1.12、1.14和1.15个QALY。“PEG/RBV试验”与“联合治疗”相比的ICER为37500美元/QALY。与“PEG/RBV试验”相比，“IL28B分类”和“三联治疗”获益不大，两者的ICER均超过300000美元/QALY。在敏感性分析中，与“PEG/RBV试验”相比，当无干扰素治疗的成本为109000美元或更低（PEG/RBV/TVR成本的125%）且SVR达到90%时，其ICER低于100000美元/QALY。
在进行PEG/RBV试验后，HCV蛋白酶抑制剂在艾滋病毒/HCV合并感染中使用最为有效，将蛋白酶抑制剂留给那些能实现快速病毒学应答和SVR的患者。艾滋病毒/HCV合并感染的无干扰素治疗方案的成本效益将取决于这些疗法的成本。
