Journal
AIDS
Volume 29, Issue 10, Pages 1247-1259Publisher
LIPPINCOTT WILLIAMS & WILKINS
DOI: 10.1097/QAD.0000000000000672
Keywords
Africa; cost-effectiveness; first-line antiretroviral therapy; IMPAACT; P1060 trial; pediatric HIV
Categories
Funding
- WHO
- National Institutes of Health through International Maternal Pediatric Adolescent AIDS Clinical Trials Group (IMPAACT)
- International Database to Evaluate AIDS (IeDEA)
- National Institute of Allergy and Infectious Diseases [K01 AI078754, R01 HD079214, K24 AI062476, R01 AI058736, R01 AI093269, U01 AI069911, U01AI09919]
- Harvard Center for AIDS Research
- March of Dimes Foundation
- Massachusetts General Hospital Executive Committee on Research
- National Institute of Allergy and Infectious Diseases (NIAID) of the National Institutes of Health (NIH) (IMPAACT LOC) [UM1AI068632]
- National Institute of Allergy and Infectious Diseases (NIAID) of the National Institutes of Health (NIH) (IMPAACT SDMC) [UM1AI068616]
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)
- National Institute of Mental Health (NIMH)
- National Institute of Allergy and Infectious Diseases (NIAID)
- NICHD [N01-DK-9-001/HHSN 267200800001C]
- National Cancer Institute
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Background:The International Maternal, Pediatric, and Adolescent Clinical Trials P1060 trial demonstrated superior outcomes for HIV-infected children less than 3 years old initiating antiretroviral therapy (ART) with lopinavir/ritonavir compared to nevirapine, but lopinavir/ritonavir is four-fold costlier.Design/methods:We used the Cost-Effectiveness of Preventing AIDS Complications (CEPAC)-Pediatric model, with published and P1060 data, to project outcomes under three strategies: no ART; first-line nevirapine (with second-line lopinavir/ritonavir); and first-line lopinavir/ritonavir (second-line nevirapine). The base-case examined South African children initiating ART at age 12 months; sensitivity analyses varied all key model parameters. Outcomes included life expectancy, lifetime costs, and incremental cost-effectiveness ratios [ICERs; dollars/year of life saved ($/YLS)]. We considered interventions with ICERs less than 1x per-capita gross domestic product (South Africa: $7500)/YLS as very cost-effective,' interventions with ICERs below 3x gross domestic product/YLS as cost-effective,' and interventions leading to longer life expectancy and lower lifetime costs as cost-saving'.Results:Projected life expectancy was 2.8 years with no ART. Both ART regimens markedly improved life expectancy and were very cost-effective, compared to no ART. First-line lopinavir/ritonavir led to longer life expectancy (28.8 years) and lower lifetime costs ($41350/person, from lower second-line costs) than first-line nevirapine (27.6 years, $44030). First-line lopinavir/ritonavir remained cost-saving or very cost-effective compared to first-line nevirapine unless: liquid lopinavir/ritonavir led to two-fold higher virologic failure rates or 15-fold greater costs than in the base-case, or second-line ART following first-line lopinavir/ritonavir was very ineffective.Conclusions:On the basis of P1060 data, first-line lopinavir/ritonavir leads to longer life expectancy and is cost-saving or very cost-effective compared to first-line nevirapine. This supports WHO guidelines, but increasing access to pediatric ART is critical regardless of the regimen used.
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