Journal Article

Optimizing Treatment for HIV-Infected South African Women Exposed to Single-Dose Nevirapine: Balancing Efficacy and Cost

Charles B. Holmes, Hui Zheng, Neil A. Martinson, Kenneth A. Freedberg and Rochelle P. Walensky

in Clinical Infectious Diseases

Published on behalf of Infectious Diseases Society of America

Volume 42, issue 12, pages 1772-1780
Published in print June 2006 | ISSN: 1058-4838
Published online June 2006 | e-ISSN: 1537-6591 | DOI: https://dx.doi.org/10.1086/504382
Optimizing Treatment for HIV-Infected South African Women Exposed to Single-Dose Nevirapine: Balancing Efficacy and Cost

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Introduction. Nevirapine (NVP) resistance may decrease the effectiveness of viral suppression with NVP-based antiretroviral therapy (ART) in women infected with human immunodeficiency virus (HIV) with previous exposure to single-dose NVP. However, the alternative lopinavir-ritonavir—based ART regimen is more expensive. Our objectives were to project the tradeoffs regarding life expectancy, cost, and cost-effectiveness of these ART regimens for NVP-exposed, HIV-infected women in South Africa.

Methods. We developed a simulation model in which NVP-exposed, HIV-infected South African women received 1 of 5 treatment strategies: HIV care without ART, NVP-based ART, lopinavir-ritonavir—based ART, NVP-based ART followed by lopinavir-ritonavir—based ART, or lopinavir-ritonavir—based ART followed by NVP-based ART. The prevalence of NVP resistance was 39%; other data were obtained from the published literature.

Results. Projected life expectancy was 43.7 months for women who did not receive ART, 77.4 months for women who received a single NVP-based regimen, and 84.5 months for women who received a single lopinavir-ritonavir—based regimen. NVP resistance reduced survival time by up to 11.6 months among women who received NVP-based ART. The cost-effectiveness of NVP-based ART was $800 (US dollars) per year of life saved, compared with no ART, and the cost-effectiveness of lopinavir-ritonavir—based therapy was $4400 per year of life saved, compared with NVP-based ART. Lopinavir-ritonavir followed by NVP-based ART yielded the greatest life expectancy (105.4 months), had a cost-effectiveness of $2300 per year of life saved, and, if the efficacy of NVP-based regimens improved >6 months postpartum, further increased survival.

Conclusions. NVP resistance substantially decreased the projected survival time associated with NVP-based ART, and lopinavir-ritonavir—based ART resulted in a superior survival time but at higher cost. A sequential regimen starting with lopinavir-ritonavir—based ART followed by NVP-based ART maximized projected survival and was cost effective in South Africa.

Journal Article.  4861 words.  Illustrated.

Subjects: Infectious Diseases ; Immunology ; Public Health and Epidemiology ; Microbiology

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