Garay Osvaldo Ulises, Nishimwe Marie Libérée, Bousmah Marwân-Al-Qays, Janah Asmaa, Girard Pierre-Marie, Chêne Geneviève, Moinot Laetitia, Sagaon-Teyssier Luis, Meynard Jean-Luc, Spire Bruno, Boyer Sylvie
INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de La Santé & Traitement de l'Information Médicale, Aix Marseille University, Marseille, France.
ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France.
Pharmacoecon Open. 2019 Dec;3(4):505-515. doi: 10.1007/s41669-019-0130-7.
Protease inhibitor monotherapy is a simplified treatment strategy for virally suppressed HIV-positive patients that has the potential for cost savings, as fewer drugs are used than with combination therapy. However, evidence for its economic value is limited.
We assessed the cost-effectiveness of lopinavir/ritonavir monotherapy followed by treatment intensification in case of viral load rebound versus combination antiretroviral therapy (cART) with efavirenz/emtricitabine/tenofovir in HIV-1 infected patients with viral suppression in the ANRS 140 DREAM trial.
DREAM was conducted in 36 French Hospitals between 2009 and 2013. For each treatment strategy, we estimated the unadjusted and multivariate-adjusted mean costs (in €, year 2010 values) and quality-adjusted life-years (QALYs) per patient, as well as incremental costs and QALYs per patient. We then assessed uncertainty using the cost-effectiveness acceptability curve, scenario analyses and cost-effectiveness price-threshold (CEPT) analysis.
In the base-case analysis considering 2009-2013 antiretroviral drug (ARV) prices, adjusted incremental costs and QALYs were - €3296 (95% confidence interval [CI] - 5202 to - 1391) and 0.006 (95% CI - 0.021 to 0.033), respectively, over 2 years, suggesting that monotherapy was cost-effective with a probability of 100% at various cost-effectiveness thresholds. In scenario analyses considering 2018 ARV prices, monotherapy remained cost-effective but with a lower probability (94% vs. 100% in the base-case analysis). The current price of cART would have to decrease by 34% to be cost-effective with a probability of 95%.
Monotherapy appears to be cost-effective compared with cART for virologically suppressed HIV-positive patients in France. CEPT analysis is a useful tool to identify the preferred strategy to adopt given that ARV prices change rapidly.
Clinicaltrials.gov identifier: NCT00946595.
蛋白酶抑制剂单药治疗是一种针对病毒载量得到抑制的HIV阳性患者的简化治疗策略，由于使用的药物比联合治疗少，有可能节省成本。然而，其经济价值的证据有限。
在ANRS 140 DREAM试验中，我们评估了洛匹那韦/利托那韦单药治疗，继之以病毒载量反弹时强化治疗，相对于依非韦伦/恩曲他滨/替诺福韦联合抗逆转录病毒治疗（cART），在病毒载量得到抑制的HIV-1感染患者中的成本效益。
DREAM试验于2009年至2013年在36家法国医院进行。对于每种治疗策略，我们估计了每位患者未经调整和多变量调整的平均成本（以欧元计，2010年价值）和质量调整生命年（QALY），以及每位患者的增量成本和QALY。然后，我们使用成本效益可接受性曲线、情景分析和成本效益价格阈值（CEPT）分析来评估不确定性。
在考虑2009 - 2013年抗逆转录病毒药物（ARV）价格的基础病例分析中，2年期间调整后的增量成本和QALY分别为 - 3296欧元（95%置信区间[CI] - 5202至 - 1391）和0.006（95%CI - 0.021至0.033），这表明在各种成本效益阈值下，单药治疗具有100%的成本效益概率。在考虑2018年ARV价格的情景分析中，单药治疗仍然具有成本效益，但概率较低（基础病例分析中为94%对100%）。cART的当前价格必须降低34%才能具有95%概率的成本效益。
在法国，对于病毒学抑制的HIV阳性患者，单药治疗与cART相比似乎具有成本效益。鉴于ARV价格变化迅速，CEPT分析是确定首选治疗策略的有用工具。
Clinicaltrials.gov标识符：NCT00946595。
