Statins for atherosclerotic cardiovascular disease prevention in people living with HIV in Thailand: a cost‐effectiveness analysis

Abstract

Introduction: 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 lipidlowering therapy. Methods: 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. Results: 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. Conclusions: 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.

Cost‐effectiveness of statins for primary prevention of atherosclerotic cardiovascular disease among people living with HIV in the United States

“…Probability of non-CVD death by age [12,13] Table S7. Annual probability of recurrent T1MI [17,24] Table S8. Annual probability of recurrent ischemic stroke [25][26][27] Table S9.…”

Atherosclerotic cardiovascular disease thresholds for statin initiation among people living with HIV in Thailand: A cost-effectiveness analysis

“…Background mortality rates were based on those of the Asian population on ART [ 12 ]. Recurrent event rates were modelled as per our earlier analysis evaluating pravastatin and pitavastatin expansion [ 8 ]. Further detail on the model is provided in the Supplementary Material, including S1 Fig in S1 File which presents a schematic of the model structure.…”

“…We recently reported that it would not be cost-effective to expand pravastatin or pitavastatin use to PLHIV in Thailand not currently on lipid-lowering therapy [ 8 ]. Pravastatin and pitavastatin are preferred statins in the context of HIV due to their lack of interaction with ART.…”

Towards evidence‐based integration of services for HIV, non‐communicable diseases and substance use: insights from modelling

“…While integrated HIV/NCD programmes may be cost-effective in some settings, the costs of treatment for PLHIV on ART may be high due to contraindications between common medications for NCDs and ART. A third analysis, by Boettiger et al [14], presents such a counterexample. These authors use data from the TREAT Asia HIV Observational Database to inform a 20-year simulation of adults receiving ART in Thailand.…”

“…A third analysis, by Boettiger et al . [14], presents such a counterexample. These authors use data from the TREAT Asia HIV Observational Database to inform a 20‐year simulation of adults receiving ART in Thailand.…”