COST-EFFECTIVENESS OF FIRST LINE LPV/R-BASED REGIMEN FOR HIV INFECTED INFANTS IN WESTERN KENYA

Purpose: In 2013 the WHO recommended a LPV/r-based regimen as first-line ART for children less than three years of age. In this study we evaluated the recommendation’s cost-effectiveness (CE).

Method: We developed and calibrated a stochastic computer simulation model of HIV progression for children treated within the AMPATH program in western Kenya. The model explicitly represents ART failure through both resistance accumulation and non-adherence. Hypothetical patients are followed through disease state transition from program entry until age 14. Pediatric model features include CD4% trajectories, single-dose NVP exposure, and the possibility of non-adherence due to orphanhood and/or LPV/r-containing regimen. Cost-effectiveness analysis was performed for a cohort of 1 million children age 5 months for the following first-line treatment strategies; NNRTI (NVP) regimen (Strategy 1); LPV/r-based regimen (Strategy 2); and LPV/r-based regimen with a switch to a NNRTI (NVP)-based regimen if VL <400 (Strategy 3). Sensitivity analyses were performed to test the robustness of the results.  

Result: Strategy 2 (WHO-recommendation) resulted in the most optimal clinical outcomes (including highest median CD4% (33.99) and lowest viral load at age 5, fewest cumulative mutations, longest median survival time (12.92 years) and fewest HIV related deaths) followed by Strategy 3. Strategy 1 was the least costly strategy followed by Strategy 3. The incremental cost effectiveness ratio (ICER) was $23,250 going from Strategy 1 to Strategy 2,  $9,617 going from Strategy 1 to Strategy 3 and $33,687 going from Strategy 3 to Strategy 2 with all ICERs above the often-accepted CE threshold of x 3 per capita GDP. In comparison to Strategy 1 implementation of Strategy 3 would provide greater health benefits per dollar spent than Strategy 2. Strategy 3 would be more cost-effective with a lower cost of viral load testing ($30). The CE of Strategy 2 and 3 were sensitive to the possibility of non-adherence to the LPV/r-containing regimen. 

Conclusion: Computer simulation results suggest that a first line LPV/r-based regimen would result in increased health benefits for HIV-infected infants in western Kenya. However, such a first-line treatment strategy offers less favorable value than alternative options. Timely studies to determine the effect of adherence to LPV/r-containing regimens are needed.