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Cost-effectiveness analysis of pre-ART HIV drug resistance testing in Kenyan women.
EClinicalMedicine. 2020 May; 22:100355.E

Abstract

Background

The prevalence of pre-treatment drug resistance (PDR) to non-nucleoside reverse-transcriptase inhibitor (NNRTI) agents is increasing in sub-Saharan Africa, which may decrease the effectiveness of efavirenz-based antiretroviral therapy (ART) programs. However, due to recent safety concerns, there has been hesitancy to replace efavirenz-based ART with dolutegravir in women of reproductive potential. Our objective was to evaluate whether PDR testing for women not initiating dolutegravir-based ART would be a cost-effective strategy to address the challenges posed by PDR.

Methods

We developed an HIV drug resistance model that simulates the emergence and transmission of resistance mutations, calibrated to the Kenyan epidemic. We modeled three care strategies for PDR testing among women not initiating dolutegravir-based ART: no PDR testing, PDR testing with a low-cost point mutation assay, known as oligonucleotide ligation assay (OLA), and PDR testing with consensus sequencing. Using a health sector perspective, this model was used to evaluate the health outcomes, lifetime costs, and cost-effectiveness under each strategy over a 15-year time horizon starting in 2019.

Findings

OLA and CS PDR testing were projected to have incremental cost-effectiveness ratios (ICER) of $10,741/QALY gained and $134,396/QALY gained, respectively, which are not cost-effective by national income standards. Viral suppression rates among women at 12 months after ART initiation were 87·8%, 89·0%, and 89·3% with no testing, OLA testing, and CS testing, respectively. PDR testing with OLA and CS were associated with a 0.5% and 0.6% reduction in incidence rate compared to no PDR testing. Initial PDR prevalence among women was 13.1% in 2019. By 2034, this prevalence was 17·6%, 17·4%, and 17·3% with no testing, OLA testing, and CS testing, respectively.

Interpretation

PDR testing for women is unlikely to be cost-effective in Kenya whether one uses a low-cost assay, such as OLA, or consensus sequencing.

Funding

National Institutes of Health, Gilead Sciences.

Authors+Show Affiliations

Department of Pediatrics, Division of Infectious Diseases, University of Washington, Seattle, WA, United States. Seattle Children's Research Institute, Seattle, WA, United States.Department of Global Health, University of Washington, Seattle, WA, United States.School of Public Health, Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, United States.Department of Pediatrics, Division of Infectious Diseases, University of Washington, Seattle, WA, United States.Department of Medicine, Stanford University, Stanford, CA, United States.Seattle Children's Research Institute, Seattle, WA, United States.The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA, United States.Department of Medicine, Aga Khan University, Nairobi, Kenya.Department of Pediatrics, Division of Infectious Diseases, University of Washington, Seattle, WA, United States. Seattle Children's Research Institute, Seattle, WA, United States. Department of Global Health, University of Washington, Seattle, WA, United States. Department of Laboratory Medicine, University of Washington, Seattle, WA, United States. Department of Medicine, University of Washington, Seattle, WA, United States.Department of Medicine, Stanford University, Stanford, CA, United States.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

32490370

Citation

Duarte, Horacio A., et al. "Cost-effectiveness Analysis of pre-ART HIV Drug Resistance Testing in Kenyan Women." EClinicalMedicine, vol. 22, 2020, p. 100355.
Duarte HA, Babigumira JB, Enns EA, et al. Cost-effectiveness analysis of pre-ART HIV drug resistance testing in Kenyan women. EClinicalMedicine. 2020;22:100355.
Duarte, H. A., Babigumira, J. B., Enns, E. A., Stauffer, D. C., Shafer, R. W., Beck, I. A., Garrison, L. P., Chung, M. H., Frenkel, L. M., & Bendavid, E. (2020). Cost-effectiveness analysis of pre-ART HIV drug resistance testing in Kenyan women. EClinicalMedicine, 22, 100355. https://doi.org/10.1016/j.eclinm.2020.100355
Duarte HA, et al. Cost-effectiveness Analysis of pre-ART HIV Drug Resistance Testing in Kenyan Women. EClinicalMedicine. 2020;22:100355. PubMed PMID: 32490370.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Cost-effectiveness analysis of pre-ART HIV drug resistance testing in Kenyan women. AU - Duarte,Horacio A, AU - Babigumira,Joseph B, AU - Enns,Eva A, AU - Stauffer,David C, AU - Shafer,Robert W, AU - Beck,Ingrid A, AU - Garrison,Louis P,Jr AU - Chung,Michael H, AU - Frenkel,Lisa M, AU - Bendavid,Eran, Y1 - 2020/05/22/ PY - 2020/01/01/received PY - 2020/04/13/revised PY - 2020/04/14/accepted PY - 2020/6/4/entrez PY - 2020/6/4/pubmed PY - 2020/6/4/medline KW - Africa KW - Cost-effectiveness analysis KW - Dolutegravir-based ART KW - Drug resistance testing KW - Efavirenz-based ART KW - HIV KW - Pretreatment drug resistance KW - Resource-limited setting SP - 100355 EP - 100355 JF - EClinicalMedicine JO - EClinicalMedicine VL - 22 N2 - Background: The prevalence of pre-treatment drug resistance (PDR) to non-nucleoside reverse-transcriptase inhibitor (NNRTI) agents is increasing in sub-Saharan Africa, which may decrease the effectiveness of efavirenz-based antiretroviral therapy (ART) programs. However, due to recent safety concerns, there has been hesitancy to replace efavirenz-based ART with dolutegravir in women of reproductive potential. Our objective was to evaluate whether PDR testing for women not initiating dolutegravir-based ART would be a cost-effective strategy to address the challenges posed by PDR. Methods: We developed an HIV drug resistance model that simulates the emergence and transmission of resistance mutations, calibrated to the Kenyan epidemic. We modeled three care strategies for PDR testing among women not initiating dolutegravir-based ART: no PDR testing, PDR testing with a low-cost point mutation assay, known as oligonucleotide ligation assay (OLA), and PDR testing with consensus sequencing. Using a health sector perspective, this model was used to evaluate the health outcomes, lifetime costs, and cost-effectiveness under each strategy over a 15-year time horizon starting in 2019. Findings: OLA and CS PDR testing were projected to have incremental cost-effectiveness ratios (ICER) of $10,741/QALY gained and $134,396/QALY gained, respectively, which are not cost-effective by national income standards. Viral suppression rates among women at 12 months after ART initiation were 87·8%, 89·0%, and 89·3% with no testing, OLA testing, and CS testing, respectively. PDR testing with OLA and CS were associated with a 0.5% and 0.6% reduction in incidence rate compared to no PDR testing. Initial PDR prevalence among women was 13.1% in 2019. By 2034, this prevalence was 17·6%, 17·4%, and 17·3% with no testing, OLA testing, and CS testing, respectively. Interpretation: PDR testing for women is unlikely to be cost-effective in Kenya whether one uses a low-cost assay, such as OLA, or consensus sequencing. Funding: National Institutes of Health, Gilead Sciences. SN - 2589-5370 UR - https://www.unboundmedicine.com/medline/citation/32490370/Cost-effectiveness_analysis_of_pre-ART_HIV_drug_resistance_testing_in_Kenyan_women L2 - https://linkinghub.elsevier.com/retrieve/pii/S2589-5370(20)30099-7 DB - PRIME DP - Unbound Medicine ER -
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