Kirby Institute, UNSW Sydney, Sydney, NSW, Australia.
Institute for Health Policy Studies, University of California, San Francisco, CA, USA.
J Int AIDS Soc. 2020 Jun;23 Suppl 1(Suppl 1):e25494. doi: 10.1002/jia2.25494.
People living with HIV (PLHIV) have an elevated risk of atherosclerotic cardiovascular disease (CVD) compared to their HIV-negative peers. Expanding statin use may help alleviate this burden. However, the choice of statin in the context of antiretroviral therapy is challenging. Pravastatin and pitavastatin improve cholesterol levels in PLHIV without interacting substantially with antiretroviral therapy. They are also more expensive than most statins. We evaluated the cost-effectiveness of pravastatin and pitavastatin for the primary prevention of CVD among PLHIV in Thailand who are not currently using lipid-lowering therapy.
We developed a discrete-state microsimulation model that randomly selected (with replacement) individuals from the TREAT Asia HIV Observational Database cohort who were aged 40 to 75 years, receiving antiretroviral therapy in Thailand, and not using lipid-lowering therapy. The model simulated each individual's probability of experiencing CVD. We evaluated: (1) treating no one with statins; (2) treating everyone with pravastatin 20mg/day (drug cost 7568 Thai Baht ($US243)/year) and (3) treating everyone with pitavastatin 2 mg/day (drug cost 8182 Baht ($US263)/year). Direct medical costs and quality-adjusted life-years (QALYs) were assigned in annual cycles over a 20-year time horizon and discounted at 3% per year. We assumed the Thai healthcare sector perspective.
Pravastatin was estimated to be less effective and less cost-effective than pitavastatin and was therefore dominated (extended) by pitavastatin. Patients receiving pitavastatin accumulated 0.042 additional QALYs compared with those not using a statin, at an extra cost of 96,442 Baht ($US3095), giving an incremental cost-effectiveness ratio of 2,300,000 Baht ($US73,812)/QALY gained. These findings were sensitive to statin costs and statin efficacy, pill burden, and targeting of PLHIV based on CVD risk. At a willingness-to-pay threshold of 160,000 Baht ($US5135)/QALY gained, we estimated that pravastatin would become cost-effective at an annual cost of 415 Baht ($US13.30)/year and pitavastatin would become cost-effective at an annual cost of 600 Baht ($US19.30)/year.
Neither pravastatin nor pitavastatin were projected to be cost-effective for the primary prevention of CVD among PLHIV in Thailand who are not currently using lipid-lowering therapy. We do not recommend expanding current use of these drugs among PLHIV in Thailand without substantial price reduction.
与 HIV 阴性同龄人相比，HIV 感染者（PLHIV）患动脉粥样硬化性心血管疾病（CVD）的风险更高。扩大他汀类药物的使用可能有助于减轻这一负担。然而，在抗逆转录病毒治疗的背景下选择他汀类药物具有挑战性。普伐他汀和匹伐他汀可改善 PLHIV 的胆固醇水平，且与抗逆转录病毒治疗的相互作用不大。它们也比大多数他汀类药物更昂贵。我们评估了普伐他汀和匹伐他汀在泰国未接受降脂治疗的 PLHIV 中的 CVD 一级预防中的成本效益。
我们开发了一个离散状态的微观模拟模型，该模型从 TREAT Asia HIV 观察性数据库队列中随机选择（替换）年龄在 40 至 75 岁、在泰国接受抗逆转录病毒治疗且未接受降脂治疗的个体。该模型模拟了每个人患 CVD 的概率。我们评估了以下三种方案：（1）不使用他汀类药物治疗任何人；（2）使用普伐他汀 20mg/天（药物成本 7568 泰铢（243 美元）/年）治疗所有人；（3）使用匹伐他汀 2mg/天（药物成本 8182 泰铢（263 美元）/年）治疗所有人。直接医疗成本和质量调整生命年（QALY）在 20 年的时间范围内按年度分配，并按每年 3%贴现。我们假设泰国医疗保健部门的观点。
普伐他汀的疗效和成本效益均低于匹伐他汀，因此被匹伐他汀所主导（延长）。与不使用他汀类药物的患者相比，接受匹伐他汀治疗的患者获得了 0.042 个额外的 QALY，额外花费为 96442 泰铢（3095 美元），增量成本效益比为 2300000 泰铢（73812 美元）/获得的 QALY。这些发现对他汀类药物的成本、他汀类药物的疗效、药丸负担以及基于 CVD 风险的 PLHIV 靶向治疗敏感。在支付意愿阈值为 160000 泰铢（5135 美元）/获得的 QALY 时，我们估计普伐他汀的年成本为 415 泰铢（13.30 美元）/年，匹伐他汀的年成本为 600 泰铢（19.30 美元）/年时，普伐他汀将具有成本效益，匹伐他汀将具有成本效益。
普伐他汀和匹伐他汀都不被预测为在泰国未接受降脂治疗的 PLHIV 中用于 CVD 的一级预防具有成本效益。我们不建议在没有大幅降价的情况下，在泰国扩大这些药物在 PLHIV 中的使用。
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