First-line antiretroviral therapy after single-dose nevirapine exposure in South Africa: a cost-effectiveness analysis of the OCTANE trial.

TitleFirst-line antiretroviral therapy after single-dose nevirapine exposure in South Africa: a cost-effectiveness analysis of the OCTANE trial.
Publication TypeJournal Article
Year of Publication2011
AuthorsCiaranello AL, Lockman S, Freedberg KA, Hughes M, Chu J, Currier J, Wood R, Holmes CB, Pillay S, Conradie F, McIntyre J, Losina E, Walensky RP
Corporate AuthorsCEPAC-International and OCTANE Investigators
JournalAIDS
Volume25
Issue4
Pagination479-92
Date Published2011 Feb 20
ISSN1473-5571
KeywordsAdult, Anti-HIV Agents, Cost-Benefit Analysis, Female, HIV Infections, Humans, Infant, Newborn, Infectious Disease Transmission, Vertical, Life Expectancy, Lopinavir, Male, Nevirapine, Pregnancy, Pyrimidinones, Ritonavir, South Africa, Treatment Outcome
Abstract

BACKGROUND: The OCTANE trial reports superior outcomes of lopinavir/ritonavir vs. nevirapine-based antiretroviral therapy (ART) among women previously exposed to single-dose nevirapine to prevent mother-to-child HIV transmission. However, lopinavir/ritonavir is 12 times costlier than nevirapine.

METHODS: We used a computer model, with OCTANE and local data, to simulate HIV-infected, single-dose nevirapine-exposed women in South Africa. Outcomes of three alternative ART sequences were projected: no ART (for comparison), first-line nevirapine, and first-line lopinavir/ritonavir. OCTANE data included mean age (31 years) and CD4 cell count (135/μl); median time since single-dose nevirapine (17 months); and 24-week viral suppression efficacy for first-line ART (nevirapine: 85%, lopinavir/ritonavir: 97%). Outcomes included life expectancy, per-person costs (2008 US$), and incremental cost-effectiveness ratios.

RESULTS: With no ART, projected life expectancy was 1.6 years and per-person cost was $2980. First-line nevirapine increased life expectancy (15.2 years) and cost ($13 990; cost-effectiveness ratio: $810/year of life saved versus no ART). First-line lopinavir/ritonavir further increased life expectancy to 16.3 years and cost to $15 630 (cost-effectiveness ratio: $1520/year of life saved versus first-line nevirapine). First-line lopinavir/ritonavir cost-effectiveness was sensitive to prevalence of nevirapine-resistant virus at ART initiation, time from single-dose nevirapine exposure to ART initiation (6-12, 12-24, or >24 months), second-line ART efficacies, and outcomes after 24 weeks on ART.

CONCLUSIONS: First-line lopinavir/ritonavir-based ART is very cost-effective in single-dose nevirapine-exposed, South African women similar to OCTANE participants. Lopinavir/ritonavir should be initiated in women with known nevirapine resistance or single-dose nevirapine exposure less than 12 months prior, or in whom such information is unknown.

DOI10.1097/QAD.0b013e3283428cbe
Alternate JournalAIDS
PubMed ID21293199
PubMed Central IDPMC3068908
Grant List3U01AI32775-13S5 / AI / NIAID NIH HHS / United States
5 U01 AI069518 / AI / NIAID NIH HHS / United States
5U01AI069455-03 / AI / NIAID NIH HHS / United States
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K24 AI56933 / AI / NIAID NIH HHS / United States
P30 AI 60354 / AI / NIAID NIH HHS / United States
P30 AI060354 / AI / NIAID NIH HHS / United States
R01 AI 69453 / AI / NIAID NIH HHS / United States
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R01 HD044391 / HD / NICHD NIH HHS / United States
R01 HD044391 / HD / NICHD NIH HHS / United States
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U01 AI069424 / AI / NIAID NIH HHS / United States
U01 AI069436 / AI / NIAID NIH HHS / United States
U01 AI069453 / AI / NIAID NIH HHS / United States
U01 AI069455 / AI / NIAID NIH HHS / United States
U01 AI069456 / AI / NIAID NIH HHS / United States
U01 AI069501 / AI / NIAID NIH HHS / United States
U01 AI069518 / AI / NIAID NIH HHS / United States
U01 AI68634 / AI / NIAID NIH HHS / United States
U01 AI69463-03 / AI / NIAID NIH HHS / United States
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