Desmonde Sophie, Frank Simone C, Coovadia Ashraf, Dahourou Désiré L, Hou Taige, Abrams Elaine J, Amorissani-Folquet Madeleine, Walensky Rochelle P, Strehlau Renate, Penazzato Martina, Freedberg Kenneth A, Kuhn Louise, Leroy Valeriane, Ciaranello Andrea L
UMR 1027 Inserm, Université Paul Sabatier, Toulouse.
Bordeaux School of Public Health, France.
Open Forum Infect Dis. 2019 Jun 11;6(7):ofz276. doi: 10.1093/ofid/ofz276. eCollection 2019 Jul.
The NEVEREST-3 (South Africa) and MONOD-ANRS-12206 (Côte d'Ivoire, Burkina Faso) randomized trials found that switching to efavirenz (EFV) in human immunodeficiency virus-infected children >3 years old who were virologically suppressed by ritonavir-boosted lopinavir (LPV/r) was noninferior to continuing o LPV/r. We evaluated the cost-effectiveness of this strategy using the Cost-Effectiveness of Preventing AIDS Complications-Pediatric model.
We examined 3 strategies in South African children aged ≥3 years who were virologically suppressed by LPV/r: (1) continued LPV/r, even in case of virologic failure, without second-line regimens; continued on LPV/r with second-line option after observed virologic failure; and preemptive switch to EFV-based antiretroviral therapy (ART), with return to LPV/r after observed virologic failure. We derived data on 24-week suppression (<1000 copies/mL) after a switch to EFV (98.4%) and the subsequent risk of virologic failure (LPV/r, 0.23%/mo; EFV, 0.15%/mo) from NEVEREST-3 data; we obtained ART costs (LPV/r, $6-$20/mo; EFV, $3-$6/mo) from published sources. We projected discounted life expectancy (LE) and lifetime costs per person. A secondary analysis used data from MONOD-ANRS-12206 in Côte d'Ivoire.
Continued LPV/r led to the shortest LE (18.2 years) and the highest per-person lifetime cost ($19 470). LPV/r with second-line option increased LE (19.9 years) and decreased per-person lifetime costs($16 070). Switching led to the longest LE (20.4 years) and the lowest per-person lifetime cost ($15 240); this strategy was cost saving under plausible variations in key parameters. Using MONOD-ANRS-12206 data in Côte d'Ivoire, the Switch strategy remained cost saving only compared with continued LPV/r, but the LPV/r with second-line option strategy was cost-effective compared with switching.
For children ≥3 years old and virologically suppressed by LPV/r-based ART, preemptive switching to EFV can improve long-term clinical outcomes and be cost saving.
NCT01127204.
NEVEREST - 3（南非）和MONOD - ANRS - 12206（科特迪瓦、布基纳法索）随机试验发现，对于接受洛匹那韦利托那韦（LPV/r）治疗且病毒学得到抑制的3岁以上人类免疫缺陷病毒感染儿童，换用依非韦伦（EFV）并不劣于继续使用LPV/r。我们使用预防艾滋病并发症 - 儿科模型评估了该策略的成本效益。
我们研究了南非≥3岁且被LPV/r抑制病毒学的儿童的3种策略：（1）即使出现病毒学失败也继续使用LPV/r，不使用二线治疗方案；在观察到病毒学失败后继续使用LPV/r并选择二线治疗方案；以及抢先换用基于EFV的抗逆转录病毒疗法（ART），在观察到病毒学失败后再换回LPV/r。我们从NEVEREST - 3数据中得出换用EFV后24周病毒抑制（<1000拷贝/毫升）的数据（98.4%）以及随后病毒学失败的风险（LPV/r，0.23%/月；EFV，0.15%/月）；我们从已发表的资料中获取ART成本（LPV/r，6 - 20美元/月；EFV，3 - 6美元/月）。我们预测了贴现预期寿命（LE）和人均终身成本。二次分析使用了科特迪瓦MONOD - ANRS - 12206的数据。
继续使用LPV/r导致最短的预期寿命（18.2年）和最高的人均终身成本（19470美元）。使用二线治疗方案的LPV/r增加了预期寿命（19.9年）并降低了人均终身成本（16070美元）。换用治疗导致最长的预期寿命（20.4年）和最低的人均终身成本（15240美元）；在关键参数的合理变化下，该策略具有成本节约效益。使用科特迪瓦MONOD - ANRS - 12206的数据，换用策略仅与继续使用LPV/r相比具有成本节约效益，但使用二线治疗方案的LPV/r策略与换用策略相比具有成本效益。
对于3岁以上且被基于LPV/r的ART抑制病毒学的儿童，抢先换用EFV可改善长期临床结局并具有成本节约效益。
NCT01127204
