title: Cost-effectiveness of tenofovir as first-line antiretroviral therapy in India.
abstract: BACKGROUND
  World Health Organization guidelines for antiretroviral treatment (ART) in resource-limited settings recommend either stavudine or tenofovir as part of initial therapy. We evaluated the clinical outcomes and cost-effectiveness of first-line ART using tenofovir in India, compared with current practice using stavudine or zidovudine.
  
  
  METHODS
  We used a state-transition model of human immunodeficiency virus (HIV) disease to examine strategies using different nucleoside reverse-transcriptase inhibitors, combined with lamivudine and nevirapine, compared with no ART: (1) stavudine, (2) stavudine with substitution by zidovudine after 6 months, (3) zidovudine, and (4) tenofovir. Data were from the Y. R. Gaitonde Centre for AIDS Research and Education in Chennai, India, and published studies. Results. Discounted mean per person survival was 36.9 months (40.2 months undiscounted) with no ART, 115.5 months (145.3) with stavudine-containing ART, 115.7 months (145.6) with stavudine and 6-month zidovudine substitution, 115.8 months (145.6) with zidovudine-containing ART, and 125.8 months (162.0) with initial tenofovir. Discounted lifetime medical costs were $610 with no ART and ranged from $5580 with stavudine-containing ART to $5720 with zidovudine-containing ART. Initial tenofovir had an incremental cost-effectiveness ratio of $670 per year of life saved, compared with no ART, and was more economically efficient than the other regimens.
  
  
  RESULTS
  were most sensitive to variations in the costs of first-line tenofovir, access to additional ART after treatment failure, and quality of life adjustment.
  
  
  CONCLUSIONS
  Using tenofovir as part of first-line ART in India will improve survival, is cost-effective by international standards, and should be considered for initial therapy for HIV-infected patients in India.
authors.affiliation: Divisions of General Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA. melissa.bender@nyumc.org
authors.forename: Melissa A
authors.initials: MA
authors.lastname: Bender
authors.forename: Nagalingeswaran
authors.initials: N
authors.lastname: Kumarasamy
authors.forename: Kenneth H
authors.initials: KH
authors.lastname: Mayer
authors.forename: Bingxia
authors.initials: B
authors.lastname: Wang
authors.forename: Rochelle P
authors.initials: RP
authors.lastname: Walensky
authors.forename: Timothy
authors.initials: T
authors.lastname: Flanigan
authors.forename: Bruce R
authors.initials: BR
authors.lastname: Schackman
authors.forename: Callie A
authors.initials: CA
authors.lastname: Scott
authors.forename: Zhigang
authors.initials: Z
authors.lastname: Lu
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Freedberg
mesh_terms: D000225:Adenine / Q000031:analogs & derivatives* / Q000191:economics / Q000627:therapeutic use; D000328:Adult; D000935:Antifungal Agents / Q000191:economics / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000191:economics* / Q000379:methods*; D003362:Cost-Benefit Analysis; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000191:economics / Q000453:epidemiology*; D006801:Humans; D007194:India / Q000453:epidemiology; D008297:Male; D063065:Organophosphonates / Q000191:economics / Q000627:therapeutic use*; D018119:Stavudine / Q000191:economics / Q000627:therapeutic use; D016019:Survival Analysis; D000068698:Tenofovir; D016896:Treatment Outcome; D015215:Zidovudine / Q000191:economics / Q000627:therapeutic use
chemical_list: D000935:Antifungal Agents; D063065:Organophosphonates; D015215:Zidovudine; D000068698:Tenofovir; D018119:Stavudine; D000225:Adenine