BACKGROUND:
The
possibility of incorporating generics into combination antiretroviral therapy
and breaking apart once-daily single-tablet regimens (STRs), may result in less
efficacious medications and/or more complex regimens with the expectation of
marked monetary savings. A modeling approach that assesses the merits of such
policies in terms of lifelong costs and health outcomes using adherence and
effectiveness data from real-world U.S. settings.
METHODS:
A
comprehensive computer-based microsimulation model was developed to assess the
lifetime health (life expectancy and quality adjusted life-years-QALYs) and
economic outcomes in HIV-1 infected patients initiating STRs compared with
multiple-table regimens including generic medications where possible (gMTRs).
The STRs considered included tenofovir disoproxil fumarate/emtricitabine and
efavirenz or rilpivirine or elvitegravir/cobicistat. gMTRs substitutions
included each counterpart to STRs, including generic lamivudine for
emtricitabine and generic versus branded efavirenz.
RESULTS:
Life
expectancy is estimated to be 1.301 years higher (discounted 0.619 QALY gain)
in HIV-1 patients initiating a single-tablet regimen in comparison to a
generic-based multiple-table regimen. STRs were associated with an average
increment of $26,547.43 per patient in medication and $1,824.09 in other
medical costs due to longer survival which were partially offset by higher
inpatients costs ($12,035.61) with gMTRs treatment. Overall, STRs presented
incremental lifetime costs of $16,335.91 compared with gMTRs, resulting in an
incremental cost-effectiveness ratio of $26,383.82 per QALY gained.
CONCLUSIONS:
STRs
continue to represent good value for money under contemporary
cost-effectiveness thresholds despite substantial price reductions of generic
medications in the U. S.
Below: Distribution of real-world average adherence levels,
stratified by first-line treatment strategy.
MTR, multiple-tablet regimen; STR, single-tablet regimen.
Below: Hazard ratios of virologic suppression and virologic failure
for different adherence classes.
VF, virological failure.
Below: Tornado diagram of univariate analyses showing the degree to
which uncertainty in individual variables affects ICER ($/QALY).
EFV, efavirenz; ICER, incremental cost-effectiveness ration;
MTR, multiple-tablet regimen; QALY, quality adjusted life years; STR,
single-tablet regimen.
- 1Internal Medicine, The University of Kansas School of Medicine-Wichita, Wichita, Kansas, United States of America.
- 2Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut, United States of America.
- 3CRI New England, Boston, Massachusetts, United States of America.
- 4Exigo Consultores, Lisbon, Portugal.
- PLoS One. 2016 Jan 25;11(1):e0147821. doi: 10.1371/journal.pone.0147821. eCollection 2016.
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