78. The Clinical Role and Cost-effectiveness of Long-acting Antiretroviral Formulations
Session: Oral Abstract Session: HIV: Treatment, Complications, and Outcomes
Thursday, October 3, 2013: 9:30 AM
Room: The Moscone Center: 250-262

Background:

Long-acting antiretroviral formulations (LA-ART), currently in development, aim to achieve monthly or quarterly ART dosing; this could improve health benefits of ART for HIV-infected individuals who have difficulty maintaining daily adherence. We sought to identify the clinical and economic circumstances under which differing clinical roles of LA-ART might be cost-effective in the US.

Methods:

We used a microsimulation model of HIV disease progression (CEPAC-US) to project the impact of 3 potential roles of LA-ART (compared to daily ART only): 1) initial therapy for all ART-naïve patients, 2) 2nd-line therapy for those failing 1st-line, and 3) use for patients with multiple prior failures on NNRTI- and PI-based regimens. Model outcomes include quality-adjusted life-years (QALYs), lifetime cost, and incremental cost-effectiveness ratio (ICER); strategies with ICER < $100,000/QALY are designated “cost-effective”. We simulate a cohort with mean adherence (medication possession ratio) of 89% (SD = 22%). Depending on adherence, HIV RNA < 400c/mL at 48 weeks on daily ART ranges from 0 to 91%, and loss to follow-up ranges from 41 to 4/100PY. We assume LA-ART's efficacy is 91% regardless of adherence to daily ART, and that LA-ART costs $60,000/patient-year (vs. $28,000 for daily PI-based regimens). In sensitivity analysis, we vary LA-ART's cost, efficacy, and quality of life (QOL) impact (due to benefits of reduced pill burden or detrimental side effects).

Results:

In the base case, LA-ART increases overall life expectancy (LE) compared to daily ART by 0.5-0.6 years, and LE of patients with the lowest adherence by 2.3-3.0 years, depending on clinical role; only LA-ART for patients with multiple failures is cost-effective ($86,000/QALY, Table). With a cost of $30,000/year and a favorable QOL impact, 2nd-line LA-ART is cost-effective ($94,000/QALY); varying efficacy of LA-ART has minimal impact on cost-effectiveness results.

Conclusion:

LA-ART could improve survival of US HIV patients, especially those with barriers to adherence and poor outcomes on daily ART. With a high cost, it will be a good value for use in patients with multiple prior failures; a cost close to current regimens combined with demonstrable QOL benefit would support broader use.

Eric Ross, AB1, Milton Weinstein, PhD2, Bruce Schackman, PhD3, Paul Sax, MD, FIDSA4,5, A. David Paltiel, PhD6, Rochelle Walensky, MD, MPH, FIDSA1,4,7,8,9,10, Kenneth Freedberg, MD, MSc1,2,4,7,10,11 and Elena Losina, PhD1,10,12,13, (1)Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, (2)Harvard School of Public Health, Boston, MA, (3)Weill Cornell Medical College, New York, NY, (4)Harvard Medical School, Boston, MA, (5)Division Of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, (6)Yale School of Public Health, New Haven, CT, (7)General Medicine Division, Massachusetts General Hospital, Boston, MA, (8)Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, (9)Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, (10)Harvard University Center for AIDS Research, Boston, MA, (11)Department of Epidemiology, Boston University School of Public Health, Boston, MA, (12)Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, (13)Department of Biostatistics, Boston University School of Public Health, Boston, MA

Disclosures:

E. Ross, None

M. Weinstein, None

B. Schackman, None

P. Sax, BMS: Investigator and Scientific Advisor, Grant recipient and Salary
Gilead: Investigator and Scientific Advisor, Research grant and Salary
Janssen: Scientific Advisor, Salary
Merck: Scientific Advisor, Salary
GSK: Investigator and Scientific Advisor, Grant recipient and Salary

A. D. Paltiel, None

R. Walensky, None

K. Freedberg, None

E. Losina, None

<< Previous Abstract | Next Abstract

Findings in the abstracts are embargoed until 12:01 a.m. PST, Oct. 2nd with the exception of research findings presented at the IDWeek press conferences.