Clinical Impact and Cost-Effectiveness of Making Third-Line Antiretroviral Therapy Available in Sub-Saharan Africa: A Model-Based Analysis in Côte d'Ivoire

Ouattara, Eric N. MD, PhD*,†,‡; Ross, Eric L. BA§; Yazdanpanah, Yazdan MD, PhD‖,¶; Wong, Angela Y. BS§; Robine, Marion BS§; Losina, Elena PhD§,#,**,††,‡‡; Moh, Raoul MD, PhD‡,§§; Walensky, Rochelle P. MD, MPH§,**,††,‖‖,¶¶; Danel, Christine MD, PhD*,†,‡; Paltiel, A. David PhD##; Eholié, Serge P. MD, MSc‡,§§; Freedberg, Kenneth A. MD, MSc§,**,††,‖‖,***,†††; Anglaret, Xavier MD, PhD*,†,‡

JAIDS Journal of Acquired Immune Deficiency Syndromes: 1 July 2014 - Volume 66 - Issue 3 - p 294–302
doi: 10.1097/QAI.0000000000000166
Clinical Science

Objective: In sub-Saharan Africa, HIV-infected adults who fail second-line antiretroviral therapy (ART) often do not have access to third-line ART. We examined the clinical impact and cost-effectiveness of making third-line ART available in Côte d'Ivoire.

Methods: We used a simulation model to compare 4 strategies after second-line ART failure: continue second-line ART (C-ART2), continue second-line ART with an adherence reinforcement intervention (AR-ART2), immediate switch to third-line ART (IS-ART3), and continue second-line ART with adherence reinforcement, switching patients with persistent failure to third-line ART (AR-ART3). Third-line ART consisted of a boosted-darunavir plus raltegravir-based regimen. Primary outcomes were 10-year survival and lifetime incremental cost-effectiveness ratios (ICERs), in $/year of life saved (YLS). ICERs below $3585 (3 times the country per capita gross domestic product) were considered cost-effective.

Results: Ten-year survival was 6.0% with C-ART2, 17.0% with AR-ART2, 35.4% with IS-ART3, and 37.2% with AR-ART3. AR-ART2 was cost-effective ($1100/YLS). AR-ART3 had an ICER of $3600/YLS and became cost-effective if the cost of third-line ART decreased by <1%. IS-ART3 was less effective and more costly than AR-ART3. Results were robust to wide variations in the efficacy of third-line ART and of the adherence reinforcement, as well as in the cost of second-line ART.

Conclusions: Access to third-line ART combined with an intense adherence reinforcement phase, used as a tool to distinguish between patients who can still benefit from their current second-line regimen and those who truly need third-line ART would provide substantial survival benefits. With minor decreases in drug costs, this strategy would be cost-effective.

*Centre Inserm 897, University of Bordeaux, Bordeaux, France;

ISPED, University of Bordeaux, Bordeaux, France;

Programme PAC-CI/ANRS Research Site, CHU de Treichville, Abidjan, Côte d'Ivoire;

§Division of General Medicine and the Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA;

Department of Infectious and Tropical Diseases, Bichat-Claude Bernard University Hospital, Paris, France;

Equipe Atip/Avenir Inserm U738, University Paris Diderot, Paris, France;

#Department of Orthopedics, Brigham and Women's Hospital, Boston, MA;

**Center for AIDS Research, Harvard University, Boston, MA;

††Harvard Medical School, Boston, MA;

‡‡Departments of Biostatistics, Boston University School of Public Health, Boston, MA;

§§Department of Infectious and Tropical Diseases, Treichville University Hospital, Abidjan, Côte d'Ivoire;

‖‖Divisions of Infectious Disease and the Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA;

¶¶Division of Infectious Disease, Brigham and Women's Hospital, Boston, MA;

##Department of Epidemiology and Public Health, Yale School of Public Health, New Haven, CT;

***Department of Epidemiology, Boston University School of Public Health, Boston, MA; and

†††Department of Health Policy and Management, Harvard School of Public Health, Boston, MA.

Correspondence to: Eric N. Ouattara, MD, PhD, Programme PACCI, CHU de Treichville, 18 BP 1954, Abidjan 18, Côte d'Ivoire (e-mail:

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Presented in part at the 12th Conference on Retroviruses and Opportunistic Infections (CROI), March 03–06, 2013, Atlanta, GA (Abstract Y-124).

X.A., E.N.O., E.L.R., Y.Y., and K.A.F. designed the study. E.N.O., E.L.R., M.R., and A.Y.W. performed the analysis. X.A., E.N.O., and K.A.F. interpreted the results and drafted the first report. E.N.O., E.L.R., M.R., Y.Y., E.L., R.P.W., C.D., A.D.P., S.P.E., K.A.F., and X.A. assisted with interpretation and revision of the report.

Supported by the Agence Nationale de Recherches sur le SIDA et les hépatites virales (ANRS, Paris, France), within the framework of the Thilao (Third-Line Antiretroviral Optimization) cohort study (grant: ANRS 12269); the National Institute of Allergy and Infectious Diseases (R01 AI058736); and the Doris Duke Charitable Foundation.

The authors have no conflicts of interest to disclose.

The article's contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

Received September 26, 2013

Accepted February 25, 2014

© 2014 by Lippincott Williams & Wilkins