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Background

Can better toxicity and durability profiles of more expensive first line treatment antiretrovirals offset their costs in resource limited settings? A cost-outcome calculator to compare first-line regimens Jennifer Campbell , Erin Koehler, Shaffiq Essajee, Elya Tagar, Megan O’Brien

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  1. Can better toxicity and durability profiles of more expensive first line treatment antiretrovirals offset their costs in resource limited settings? A cost-outcome calculator to compare first-line regimens Jennifer Campbell, Erin Koehler, Shaffiq Essajee, Elya Tagar, Megan O’Brien Vienna – July 2010

  2. Background 2010 WHO recommendations to discontinue use of d4T in favor of AZT or TDF

  3. Background Difference in regimen treatment cost persists

  4. Methodology: Key questions a. Safety - How much better does the toxicity profile of a more expensive regimen have to be to offset the higher drug costs? b. Durability - How much less failure must there be for a more expensive regimen to offset the higher drug costs?

  5. Methodology Key inputs for a toxicity cost break-even analysis - Regimen A – base (cheaper drug option) ARV cost per patient year 1L Annual toxicity rate Cost to treat toxicity Regimen B – comparator (more expensive drug option) ARV cost per patient year 1L ????? Cost to treat toxicity

  6. Methodology Relationship for toxicity rates and costs to treat – Given Regimen A toxicity rate and cost to treat (hypothetical) As difference in regimen costs grow or the toxicity rate of Regimen A decreases

  7. Methodology Snap shot of the calculator

  8. Results – toxicity break even example comparison: d4T/3TC/NVP - $84 vs. TDF/3TC/EFV - $165 (2013 price forecast) $81 difference $325 toxicity costs 25% annual toxicity rate 93% reduction in toxicity incidence 95% reduction in cost to treat toxicity Any lower toxicity rate or cost to treat d4T and TDF regimen cannot be cost neutral

  9. Methodology Key inputs for a failure break-even analysis - Regimen A – base (cheaper option) Number of years of analysis ARV cost per patient year on 1L ARV cost per patient year on 2L Annual migration to 2L rate Regimen B – comparator (more expensive option) Number of years of analysis ARV cost per patient year on 1L ARV cost per patient year on 2L ?????

  10. Results – durability break-even example Comparison: Annual migration from d4T/3TC/NVP – 7.3% 2L for d4T/3TC/NVP – TDF/3TC/ATV/r ($381ppy); for TDF/3TC/EFV – AZT/3TC/ATV/r ($388 ppy) At 5 years, costs cannot be offset with lower migration At 10 years regimen B must be 66% more effective than Regimen A. This is 29 more months on first line for regimen B; any higher migration rate for Regimen B will not be cost neutral

  11. Conclusions Simple tools can help gain insights to costing and policy questions using minimal input assumptions It is unlikely that costs of more expensive first line regimens will be offset by savings in either toxicity treatment or second line in most LMIC settings Change to better 1L regimens may be warranted, but will require increases in budgets to avoid compromising access

  12. Thank you Jennifer Campbell - jcampbell@clintonfoundation.org Center for Strategic Health Operations Research

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