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

Wednesday, October 22, 2014
Poster Board # PS4-4

S. Maria E. Finnell, MD, MS1, Jason Kessler, M.D., M.P.H2, Lingfeng Li, PhD2, Winstone Nyandiko, MD, MS3, Rachel Vreeman, MD, MS1, Kim Nucifora, MS2, Christopher Toohey, MS2 and R. Scott Braithwaite, MD, MSc, FACP2, (1)Children's Health Services Research, Indiana University School of Medicine, Indianapolis, IN, (2)New York University School of Medicine, New York, NY, (3)Moi University School of Medicine, Eldoret, 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.