Addressing Pediatric HIV Pretreatment Drug Resistance and Virologic Failure in Sub-Saharan Africa: A Cost-Effectiveness Analysis of Diagnostic-Based Strategies in Children ≥3 Years Old

Abstract

Improvement of antiretroviral therapy (ART) regimen switching practices and implementation of pretreatment drug resistance (PDR) testing are two potential approaches to improve health outcomes for children living with HIV. We developed a microsimulation model of disease progression and treatment focused on children with perinatally acquired HIV in sub-Saharan Africa who initiate ART at 3 years of age. We evaluated the cost-effectiveness of diagnostic-based strategies (improved switching and PDR testing), over a 10-year time horizon, in settings without and with pediatric dolutegravir (DTG) availability as first-line ART. The improved switching strategy increases the probability of switching to second-line ART when virologic failure is diagnosed through viral load testing. The PDR testing strategy involves a one-time PDR test prior to ART initiation to guide choice of initial regimen. When DTG is not available, PDR testing is dominated by the improved switching strategy, which has an incremental cost-effectiveness ratio (ICER) of USD 579/life-year gained (LY), relative to the status quo. If DTG is available, improved switching has a similar ICER (USD 591/LY) relative to the DTGstatus quo. Even when substantial financial investment is needed to achieve improved regimen switching practices, the improved switching strategy still has the potential to be cost-effective in a wide range of sub-Saharan African countries. Our analysis highlights the importance of strengthening existing laboratory monitoring systems to improve the health of children living with HIV.

Realizing the Promise of Dolutegravir in Effectively Treating Children and Adolescents Living With HIV in Real-world Settings in 6 Countries in Eastern and Southern Africa

“…It also compared favorably to multiple HIC settings where VLS rates among CALHIV on DTG varied from 66% 27 to 74% 22 to 88%. 21 The treatment success of DTG experienced by our cohort was encouraging as all too often CALHIV in LMICs have limited access to new, optimal ART formulations, 28 missed opportunities for regimen switching, 29 and remain disproportionally disadvantaged compared with adult or HIC counterparts. Our cohort is a strong reminder of the treatment success that can be achieved in CALHIV with timely, widespread, and sustained use of DTG in CALHIV in LMICs.…”

“…32 Our findings offer support for programmatic switching to DTG in settings where pre-switch VL or HIV resistance testing is not feasible as part of ART optimization strategies for CAL-HIV. 14,29,33 Despite our sites not having routine access to HIV resistance, post-DTG VLS rates were impressive at more than 90%. Similar VLS rates were observed in our SDS cohort and 83% (73/88) of unsuppressed CALHIV were able to achieve VLS with an SDS using DTG.…”