Cost-effectiveness of viral load testing for transitioning antiretroviral therapy-experienced children to dolutegravir in South Africa: a modelling analysis

被引:0
作者
Brenner, Isaac Ravi [1 ]
Flanagan, Clare F. [1 ]
Penazzato, Martina [4 ]
Webb, Karen A. [5 ,6 ]
Horsfall, Stephanie B. [1 ]
Hyle, Emily P. [1 ,7 ,8 ,9 ]
Abrams, Elaine [10 ,11 ]
Bacha, Jason [12 ,13 ,14 ]
Neilan, Anne M. [1 ,2 ,7 ,8 ]
Collins, Intira Jeannie [15 ]
Desmonde, Sophie [1 ,16 ]
Crichton, Siobhan [15 ]
Davies, Mary-Ann [17 ,18 ]
Freedberg, Kenneth A. [1 ,3 ,7 ,8 ,9 ,18 ,19 ]
Ciaranello, Andrea L. [1 ,7 ,8 ,9 ]
机构
[1] Massachusetts Gen Hosp, Med Practice Evaluat Ctr, Boston, MA USA
[2] Massachusetts Gen Hosp, Div Gen Acad Pediat, Boston, MA 02114 USA
[3] Massachusetts Gen Hosp, Div Gen Internal Med, Boston, MA USA
[4] WHO, Res Hlth Dept, Sci Div, Geneva, Switzerland
[5] Org Publ Hlth Intervent & Dev, Harare, Zimbabwe
[6] London Sch Hyg & Trop Med, London, England
[7] Massachusetts Gen Hosp, Dept Med, Div Infect Dis, Boston, MA USA
[8] Harvard Med Sch, Boston, MA USA
[9] Boston Univ, Pulm Ctr, Boston, MA 02215 USA
[10] ICAP Columbia Univ, Mailman Sch Publ Hlth, New York, NY USA
[11] Columbia Univ, Dept Pediat, Coll Phys & Surg, New York, NY USA
[12] Baylor Coll Med, Childrens Fdn Tanzania, Dept Pediat, Mbeya, Tanzania
[13] Baylor Coll Med Pediat AIDS Initiat, Texas Childrens Hosp, Houston, TX 77030 USA
[14] Baylor Coll Med, Dept Pediat, Houston, TX USA
[15] Univ Coll London UCL, UCL, MRC Clin Trials Unit, London, England
[16] Univ Toulouse III, Inserm U1027, Toulouse, France
[17] Univ Cape Town, Ctr Infect Dis Epidemiol & Res, Sch Publ Hlth, Cape Town, South Africa
[18] Western Cape Govt, Dept Hlth & Wellness, Cape Town, South Africa
[19] HarvardT H Chan Sch Publ Hlth, Dept Hlth Policy & Management, 677 Huntington Ave, Boston, MA 02115 USA
来源
LANCET GLOBAL HEALTH | 2024年 / 12卷 / 12期
基金
英国医学研究理事会;
关键词
2ND-LINE TREATMENT; HIV-1; INFECTION; OPEN-LABEL; MULTICENTER; MONOTHERAPY; MUTATIONS; COUNTRIES; SAFETY; PLUS;
D O I
10.1016/S2214-109X(24)00381-4
中图分类号
R1 [预防医学、卫生学];
学科分类号
1004 ; 120402 ;
摘要
Background For children with HIV on antiretroviral therapy (ART), transitioning to dolutegravir-containing regimens is recommended. The aim of this study was to assess whether introducing viral load testing to inform new nucleoside or nucleotide reverse transcriptase inhibitors (NRTIs) for children with HIV and viraemia alongside dolutegravirbased ART is beneficial and of good economic value. Methods We used the Cost-Effectiveness of Preventing AIDS Complications-Pediatric model to project clinical and cost implications of three strategies among a simulated cohort of South African children aged 8 years with HIV receiving abacavir-lamivudine-efavirenz: (1) continue current ART (no dolutegravir; abacavir-lamivudine-efavirenz); (2) transition all children with HIV to dolutegravir, keeping current NRTIs (dolutegravir; abacavir-lamivudine- dolutegravir); or (3) transition to dolutegravir based on viral load testing (viral load plus dolutegravir), keeping current NRTIs if virologically suppressed (abacavir-lamivudine-dolutegravir, 70% of cohort) or switching abacavir to zidovudine (zidovudine) if viraemic (zidovudine-lamivudine-dolutegravir, 30%). We assumed 50% of children who had viraemia after abacavir-lamivudine exposure had NRTI resistance; with resistance, we assumed zidovudine- lamivudine-dolutegravir was more effective than abacavir-lamivudine-dolutegravir. We designated a strategy as preferred if it was most effective and least costly or had an incremental cost-effectiveness ratio less than half the South African 2020 gross domestic product per capita. Findings Under base-case assumptions, the viral load plus dolutegravir strategy would be the most effective (projected undiscounted life expectancy of 39<middle dot>72 life-years) and least costly strategy (US$24600 per person); the no dolutegravir strategy was the least effective (34<middle dot>49 life-years) and most expensive ($26 480 per person). In sensitivity analyses, the 24-week virological suppression probability and subsequent monthly virological failure risks (ie, late failure) were most influential on cost-effectiveness. Only with a high late-failure risk for zidovudine-lamivudine-dolutegravir (ie, >= 0<middle dot>3% per month in the base case or >0<middle dot>5% per month if abacavir also confers low virological suppression probability in the presence of NRTI resistance [65%]) would the dolutegravir strategy become preferred above the viral load plus dolutegravir strategy. Interpretation For programmes transitioning to dolutegravir-based regimens, our model predicted that doing so would be more effective and less costly than continuing current ART regimens, regardless of NRTI choice. Whether viral load testing for children with HIV is necessary to inform NRTI choice depends substantially on the comparative outcomes of abacavir and zidovudine after switching to dolutegravir-containing ART.
引用
收藏
页码:e2068 / e2079
页数:12
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