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Cost-Effectiveness of Newer Antiretroviral Drugs in Treatment-Experienced Patients With Multidrug-Resistant HIV Disease

Bayoumi, Ahmed M. MD, MSc*,†,‡,§; Barnett, Paul G. PhD; Joyce, Vilija R. MS; Griffin, Susan C. MSc, BSc; Sun, Huiying PhD#,**; Bansback, Nick J. PhD††; Holodniy, Mark MD‡‡,§§; Sanders, Gillian PhD‖‖; Brown, Sheldon T. MD¶¶,##; Kyriakides, Tassos C. PhD***; Angus, Brian MD, PhD†††,‡‡‡; Cameron, D. William MD§§§; Anis, Aslam H. PhD**,††; Sculpher, Mark PhD; Owens, Douglas K. MD, MS‡‡,§§,‖‖‖

JAIDS Journal of Acquired Immune Deficiency Syndromes: December 1st, 2013 - Volume 64 - Issue 4 - p 382–391
doi: 10.1097/QAI.0000000000000002
Clinical Science

Objective: Newer antiretroviral drugs provide substantial benefits but are expensive. The cost-effectiveness of using antiretroviral drugs in combination for patients with multidrug-resistant HIV disease was determined.

Design: A cohort state-transition model was built representing treatment-experienced patients with low CD4 counts, high viral load levels, and multidrug-resistant virus. The effectiveness of newer drugs (those approved in 2005 or later) was estimated from published randomized trials. Other parameters were estimated from a randomized trial and from the literature. The model had a lifetime time horizon and used the perspective of an ideal insurer in the United States. The interventions were combination antiretroviral therapy, consisting of 2 newer drugs and 1 conventional drug, compared with 3 conventional drugs. Outcome measures were life-years, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness.

Results: Substituting newer antiretroviral drugs increased expected survival by 3.9 years in advanced HIV disease. The incremental cost-effectiveness ratio of newer, compared with conventional, antiretroviral drugs was $75,556/QALY gained. Sensitivity analyses showed that substituting only one newer antiretroviral drug cost $54,559 to $68,732/QALY, depending on assumptions about efficacy. Substituting 3 newer drugs cost $105,956 to $117,477/QALY. Cost-effectiveness ratios were higher if conventional drugs were not discontinued.

Conclusions: In treatment-experienced patients with advanced HIV disease, use of newer antiretroviral agents can be cost-effective, given a cost-effectiveness threshold in the range of $50,000 to $75,000 per QALY gained. Newer antiretroviral agents should be used in carefully selected patients for whom less expensive options are clearly inferior.

Supplemental Digital Content is Available in the Text.

*Center for Research on Inner City Health, The Keenan Research Center in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada;

Department of Medicine, University of Toronto, Toronto, Ontario, Canada;

Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada;

§Division of General Internal Medicine, St. Michael's Hospital, Toronto, Ontario, Canada;

VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, CA;

Center for Health Economics, University of York, York, United Kingdom;

#Center for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada

**CIHR Canadian HIV Trials Network, Vancouver, British Columbia, Canada;

††School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada;

‡‡VA Palo Alto Health Care System, Palo Alto, CA;

§§Department of Medicine, Stanford University, Stanford, CA;

‖‖Duke Clinical Research Institute, Duke University, Durham, NC;

¶¶James J. Peters VA Medical Center, Bronx, NY;

##Department of Medicine, Mt. Sinai School of Medicine, New York, NY;

***VA Cooperative Studies Program Coordinating Center, West Haven, CT;

†††MRC Clinical Trials Unit, London, United Kingdom;

‡‡‡Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom;

§§§The University of Ottawa at The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; and

‖‖‖Center for Primary Care and Outcomes Research and Center for Health Policy, Stanford University, Stanford, CA.

Correspondence to: Ahmed M. Bayoumi, MD, MSc, Center for Research on Inner City Health, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, Canada M5B 1W8 (e-mail:

A.M.B is supported by a Canadian Institutes of Health Research/Ontario Ministry of Health & Long-Term Care Applied Chair in Health Services and Policy Research. The Center for Research on Inner City Health is supported in part by a grant from the Ontario Ministry of Health and Long-Term Care. The US Department of Veterans Affairs Cooperative Studies Program, the UK Medical Research Council, and the Canadian Institutes of Health Research funded the OPTIMA trial for Health Research. This work was supported in part by Grants 1RC1AI086927-01 and 2 R01 DA15612-016 from the National Institutes of Health. D.K.O., P.G.B., M.H., S.T.B., and T.C.K. are supported by the Department of Veterans Affairs.

The authors have no conflicts of interest to disclose.

Preliminary results were presented at the 32nd Annual Meeting of the Society for Medical Decision Making, October 23–27, 2010, Toronto, Ontario, Canada.

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, the US government, or the Ontario Ministry of Health and Long-Term Care; no official endorsement by other supporting agencies is intended or should be inferred.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Received April 19, 2013

Accepted September 09, 2013

© 2013 by Lippincott Williams & Wilkins