Effectiveness and cost-effectiveness of potential responses to future high levels of transmitted HIV drug resistance in antiretroviral drug-naive populations beginning treatment: modelling study and economic analysis

Abstract

Summary Background With continued roll-out of antiretroviral therapy (ART) in resource-limited settings, evidence is emerging of increasing levels of transmitted drug-resistant HIV. We aimed to compare the effectiveness and cost-effectiveness of different potential public health responses to substantial levels of transmitted drug resistance. Methods We created a model of HIV transmission, progression, and the effects of ART, which accounted for resistance generation, transmission, and disappearance of resistance from majority virus in the absence of drug pressure. We simulated 5000 ART programmatic scenarios with different prevalence levels of detectable resistance in people starting ART in 2017 (t0) who had not previously been exposed to antiretroviral drugs. We used the model to predict cost-effectiveness of various potential changes in policy triggered by different prevalence levels of resistance to non-nucleoside reverse transcriptase inhibitors (NNRTIs) measured in the population starting ART. Findings Individual-level resistance testing before ART initiation was not generally a cost-effective option, irrespective of the cost-effectiveness threshold. At a cost-effectiveness threshold of US$500 per quality-adjusted life-year (QALY), no change in policy was cost effective (ie, no change in policy would involve paying less than $500 per QALY gained), irrespective of the prevalence of pretreatment NNRTI resistance, because of the increased cost of the policy alternatives. At thresholds of $1000 or higher, and with the prevalence of pretreatment NNRTI resistance greater than 10%, a policy to measure viral load 6 months after ART initiation became cost effective. The policy option to change the standard first-line treatment to a boosted protease inhibitor regimen became cost effective at a prevalence of NNRTI resistance higher than 15%, for cost-effectiveness thresholds greater than $2000. Interpretation Cost-effectiveness of potential policies to adopt in response to different levels of pretreatment HIV drug resistance depends on competing budgetary claims, reflected in the cost-effectiveness threshold. Results from our model will help inform WHO recommendations on monitoring of HIV drug resistance in people starting ART. Funding WHO (with funds provided by the Bill & Melinda Gates Foundation), CHAIN (European Commission).

Antiretroviral therapy supply chain quality control and assurance in improving people living with HIV therapeutic outcomes in Cameroon

“…Good quality of antiretroviral drugs found in our study was consistent with other studies [29–31]. However, other relevant issues that rose from previous findings in other studies such as storage conditions and their impact on quality of medications were not documented [2–5, 32–34]. …”

The burden of chronic diseases and cost-of-care in subjects with HIV infection in a Health District of Northern Italy over a 12-year period compared to that of the general population

“…The main reasons for this is that cheaper drugs are more commonly used in the first-line regimen than in the following ART lines [18]. Indeed, various authors [6, 19] have shown that the most powerful determinant of ART cost was the line of ART.…”

HIV-1 drug resistance and resistance testing

“…However, in LMIC settings, models have produced conflicting results regarding the cost-effectiveness of SGRT (Levison et al, 2013; Phillips et al, 2014a; Phillips et al, 2014b; Rosen et al, 2011). Platforms that are more economical than SGRT may play a role in expanding access to genotypic drug resistance testing, which is currently limited or non-existent in most LMICs.…”

“…To help achieve these goals, the World Health Organization (WHO) in 2016 recommended that all HIV-infected individuals should begin ART as soon after diagnosis as possible (Treat All) and that pre-exposure prophylaxis (PrEP) should be considered for persons at high risk of HIV infection (World Health Organization, 2016b). While the successful implementation of these recommendations will reduce the number of new HIV infections, the dramatic increase in ARV use will likely increase the prevalence of acquired drug resistance (ADR) in treated individuals and transmitted drug resistance (TDR) in newly infected individuals (Phillips et al, 2014b). …”