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Effectiveness and cost-effectiveness of potential responses to future high levels of transmitted HIV drug resistance in antiretroviral drug-naive populations beginning treatment: modelling study and economic analysis

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  • Andrew Phillips
  • Valentina Cambiano
  • Alec Miners
  • Paul Revill
  • Deenan Pillay
  • Jens Lundgren
  • Diane Bennett
  • Elliott Raizes
  • Fumiyo Nakagawa
  • Andrea De Luca
  • Marco Vitoria
  • Jhoney Barcarolo
  • Joseph Perriens
  • Michael Jordan
  • Silvia Bertagnolio


Publication details

JournalThe Lancet HIV
DateE-pub ahead of print - 13 Oct 2014
DatePublished (current) - Nov 2014
Issue number2
Pages (from-to)e85–e93
Early online date13/10/14
Original languageEnglish


Background With continued roll-out of antiretroviral therapy (ART) in resource-limited settings, evidence is emerging of increasing levels of transmitted drug-resistant HIV. We aimed to compare the effectiveness and cost-effectiveness of different potential public health responses to substantial levels of transmitted drug resistance.Methods We created a model of HIV transmission, progression, and the effects of ART, which accounted for resistance generation, transmission, and disappearance of resistance from majority virus in the absence of drug pressure. We simulated 5000 ART programmatic scenarios with different prevalence levels of detectable resistance in people starting ART in 2017 (t0) who had not previously been exposed to antiretroviral drugs. We used the model to predict cost-effectiveness of various potential changes in policy triggered by different prevalence levels of resistance to nonnucleoside reverse transcriptase inhibitors (NNRTIs) measured in the population starting ART.Findings Individual-level resistance testing before ART initiation was not generally a cost-effective option, irrespective of the cost-effectiveness threshold. At a cost-effectiveness threshold of US$500 per quality-adjusted life-year (QALY),no change in policy was cost effective (ie, no change in policy would involve paying less than $500 per QALY gained), irrespective of the prevalence of pretreatment NNRTI resistance, because of the increased cost of the policyalternatives. At thresholds of $1000 or higher, and with the prevalence of pretreatment NNRTI resistance greater than 10%, a policy to measure viral load 6 months after ART initiation became cost effective. The policy option to changethe standard first-line treatment to a boosted protease inhibitor regimen became cost effective at a prevalence of NNRTI resistance higher than 15%, for cost-eff ectiveness thresholds greater than $2000.Interpretation Cost-effectiveness of potential policies to adopt in response to diff erent levels of pretreatment HIV drug resistance depends on competing budgetary claims, reflected in the cost-effectiveness threshold. Results from our model will help inform WHO recommendations on monitoring of HIV drug resistance in people starting ART.Funding WHO (with funds provided by the Bill & Melinda Gates Foundation), CHAIN (European Commission).

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