*Centre Inserm 897, University of Bordeaux, Bordeaux, France; †ISPED, University of Bordeaux, Bordeaux, France; ‡Programme PAC-CI/ANRS Research Site, CHU de Treichville, Abidjan, Côte d'Ivoire; §Division of General Medicine and the Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA; ‖Department of Infectious and Tropical Diseases, Bichat-Claude Bernard University Hospital, Paris, France; ¶Equipe Atip/Avenir Inserm U738, University Paris Diderot, Paris, France; #Department of Orthopedics, Brigham and Women's Hospital, Boston, MA; **Center for AIDS Research, Harvard University, Boston, MA; ††Harvard Medical School, Boston, MA; ‡‡Departments of Biostatistics, Boston University School of Public Health, Boston, MA; §§Department of Infectious and Tropical Diseases, Treichville University Hospital, Abidjan, Côte d'Ivoire; ‖‖Divisions of Infectious Disease and the Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA; ¶¶Division of Infectious Disease, Brigham and Women's Hospital, Boston, MA; ##Department of Epidemiology and Public Health, Yale School of Public Health, New Haven, CT; ***Department of Epidemiology, Boston University School of Public Health, Boston, MA; and †††Department of Health Policy and Management, Harvard School of Public Health, Boston, MA.
J Acquir Immune Defic Syndr. 2014 Jul 1;66(3):294-302. doi: 10.1097/QAI.0000000000000166.
In sub-Saharan Africa, HIV-infected adults who fail second-line antiretroviral therapy (ART) often do not have access to third-line ART. We examined the clinical impact and cost-effectiveness of making third-line ART available in Côte d'Ivoire.
We used a simulation model to compare 4 strategies after second-line ART failure: continue second-line ART (C-ART2), continue second-line ART with an adherence reinforcement intervention (AR-ART2), immediate switch to third-line ART (IS-ART3), and continue second-line ART with adherence reinforcement, switching patients with persistent failure to third-line ART (AR-ART3). Third-line ART consisted of a boosted-darunavir plus raltegravir-based regimen. Primary outcomes were 10-year survival and lifetime incremental cost-effectiveness ratios (ICERs), in $/year of life saved (YLS). ICERs below $3585 (3 times the country per capita gross domestic product) were considered cost-effective.
Ten-year survival was 6.0% with C-ART2, 17.0% with AR-ART2, 35.4% with IS-ART3, and 37.2% with AR-ART3. AR-ART2 was cost-effective ($1100/YLS). AR-ART3 had an ICER of $3600/YLS and became cost-effective if the cost of third-line ART decreased by <1%. IS-ART3 was less effective and more costly than AR-ART3. Results were robust to wide variations in the efficacy of third-line ART and of the adherence reinforcement, as well as in the cost of second-line ART.
Access to third-line ART combined with an intense adherence reinforcement phase, used as a tool to distinguish between patients who can still benefit from their current second-line regimen and those who truly need third-line ART would provide substantial survival benefits. With minor decreases in drug costs, this strategy would be cost-effective.
在撒哈拉以南非洲，二线抗逆转录病毒疗法（ART）失败的 HIV 感染者通常无法获得三线 ART。我们研究了在科特迪瓦提供三线 ART 的临床影响和成本效益。
我们使用模拟模型比较了二线 ART 失败后的 4 种策略：继续二线 ART（C-ART2）、继续二线 ART 并加强依从性干预（AR-ART2）、立即转为三线 ART（IS-ART3）和继续二线 ART 并加强依从性，将持续失败的患者转为三线 ART（AR-ART3）。三线 ART 包括一种增效达芦那韦/利托那韦联合拉替拉韦方案。主要结局是 10 年生存率和终生增量成本效益比（ICER），以每挽救 1 年生命的成本（YLS）表示。ICER 低于 3585 美元（是该国人均国内生产总值的 3 倍）被认为具有成本效益。
C-ART2 的 10 年生存率为 6.0%，AR-ART2 为 17.0%，IS-ART3 为 35.4%，AR-ART3 为 37.2%。AR-ART2 具有成本效益（1100 美元/YLS）。AR-ART3 的 ICER 为 3600 美元/YLS，如果三线 ART 的成本降低不到 1%，则具有成本效益。IS-ART3 比 AR-ART3 效果差且成本高。结果在三线 ART 和依从性强化的疗效以及二线 ART 的成本方面存在广泛变化时仍然稳健。
获得三线 ART 并结合强化依从性阶段，作为区分仍能从当前二线方案中获益和真正需要三线 ART 的患者的工具，可以显著提高生存率。随着药物成本的微小下降，这种策略将具有成本效益。
