The price of change – Replacing Stavudine with Tenofovir in first-line ART in scaling-up settings
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The price of change – Replacing Stavudine with Tenofovir in first-line ART in scaling-up settings XVII International AIDS Conference Mexico City, 7th August 2008 Jari Kivela Health Economist [email protected] Background. WHO recommendation to replace d4T Scaling-up

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The price of change – Replacing Stavudine with Tenofovir in first-line ART in scaling-up settings

XVII International AIDS Conference

Mexico City, 7th August 2008

Jari Kivela

Health Economist

[email protected]


Background
Background in first-line ART in scaling-up settings

  • WHO recommendation to replace d4T

  • Scaling-up

  • Problem: How much will it cost?

  • Tool: Health economic model


Objectives
Objectives in first-line ART in scaling-up settings

Develop a model to:

  • Support decision making

  • Demonstrate budget impacts

  • Compare timing of introdcution

  • Forecast ART budget 2008 - 2014


Tenofovir vs stavudine

Tenofovir (TDF) in first-line ART in scaling-up settings

WHO recommendation

Better toxicity profile

Once a day dosing

TDF $128 PPY

Stavudine (d4T)

d4T $19 PPY

Significant toxicitìes

Fixed dose combination:d4T / 3TC / NVP30mg / 150mg / 200mg

Tenofovir vs. Stavudine


Current first line regimen
Current first-line regimen in first-line ART in scaling-up settings

d4T

NVP

3TC


New improved first line regimen
New improved first-line regimen in first-line ART in scaling-up settings

d4T

NVP

3TC

TDF

EFV


Price of d4t 3tc nvp
Price of d4T/3TC/NVP in first-line ART in scaling-up settings


Price of tdf 3tc efv
Price of TDF/3TC/EFV in first-line ART in scaling-up settings


Art survival and 2nd line switch rate
ART survival and 2nd-line switch rate in first-line ART in scaling-up settings

  • Global Cohort MSF57.000 ART patients

  • Extrapolated after 48 months

  • ART survival 9.7 years

  • 2nd-line switching rate


Epworth program
Epworth Program in first-line ART in scaling-up settings

Epworth, Harare township

  • Population 400.000

  • 20% infected with HIV

    MSF program

  • 6.000 HIV+ patients

  • 1.400 on ART

  • First ARTs April 2007

  • 150 new patients / month


150 new art patients month
150 new ART patients / month in first-line ART in scaling-up settings


Methods
Methods in first-line ART in scaling-up settings

  • Patient volumeNr of patients, speed of scaling-up

  • Medical dataART regimens, ART survival, rate of switch to 2nd-line, CD4 baselines

  • Financial informationForecasted ART prices, actual expenditures, annual budget

  • Sensitivity analyses


Base case all patients on d4t 3tc nvp
Base case: All patients on d4T/3TC/NVP in first-line ART in scaling-up settings

$1.8M


All patients on tdf 3tc efv 2008
All patients on TDF/3TC/EFV 2008 in first-line ART in scaling-up settings

$8.8M

$1.8M


Only new patients on tdf 3tc efv 2008
Only new patients on TDF/3TC/EFV 2008 in first-line ART in scaling-up settings

$8.8M

$8.8M

$7.6M

$1.8M

$1.8M


Only new patients on tdf 3tc efv 2009
Only new patients on TDF/3TC/EFV 2009 in first-line ART in scaling-up settings

$8.8M

$6.1M

$1.8M


Only new patients on tdf 3tc efv 2010
Only new patients on TDF/3TC/EFV 2010 in first-line ART in scaling-up settings

$8.8M

$4.7M

$1.8M


Limitations
Limitations in first-line ART in scaling-up settings

  • Potential cost savings:From better toxicity profile of TDF

  • ART price development

  • Inadequate TDF survival data


Summary
Summary in first-line ART in scaling-up settings

  • Useful tool to forecast costs

  • High cost of TDF and EFV

  • Major barrier in resource poor settings


d4T in first-line ART in scaling-up settings

NVP

3TC


d4T in first-line ART in scaling-up settings

NVP

3TC

TDF


All patients on tdf 3tc nvp 2008
All patients on TDF/3TC/NVP 2008 in first-line ART in scaling-up settings

$6.6M

$1.8M


Art prices
ART Prices in first-line ART in scaling-up settings


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