title: First-line antiretroviral therapy after single-dose nevirapine exposure in South Africa: a cost-effectiveness analysis of the OCTANE trial.
abstract: BACKGROUND
  The OCTANE trial reports superior outcomes of lopinavir/ritonavir vs. nevirapine-based antiretroviral therapy (ART) among women previously exposed to single-dose nevirapine to prevent mother-to-child HIV transmission. However, lopinavir/ritonavir is 12 times costlier than nevirapine.
  
  
  METHODS
  We used a computer model, with OCTANE and local data, to simulate HIV-infected, single-dose nevirapine-exposed women in South Africa. Outcomes of three alternative ART sequences were projected: no ART (for comparison), first-line nevirapine, and first-line lopinavir/ritonavir. OCTANE data included mean age (31 years) and CD4 cell count (135/μl); median time since single-dose nevirapine (17 months); and 24-week viral suppression efficacy for first-line ART (nevirapine: 85%, lopinavir/ritonavir: 97%). Outcomes included life expectancy, per-person costs (2008 US$), and incremental cost-effectiveness ratios.
  
  
  RESULTS
  With no ART, projected life expectancy was 1.6 years and per-person cost was $2980. First-line nevirapine increased life expectancy (15.2 years) and cost ($13 990; cost-effectiveness ratio: $810/year of life saved versus no ART). First-line lopinavir/ritonavir further increased life expectancy to 16.3 years and cost to $15 630 (cost-effectiveness ratio: $1520/year of life saved versus first-line nevirapine). First-line lopinavir/ritonavir cost-effectiveness was sensitive to prevalence of nevirapine-resistant virus at ART initiation, time from single-dose nevirapine exposure to ART initiation (6-12, 12-24, or >24 months), second-line ART efficacies, and outcomes after 24 weeks on ART.
  
  
  CONCLUSIONS
  First-line lopinavir/ritonavir-based ART is very cost-effective in single-dose nevirapine-exposed, South African women similar to OCTANE participants. Lopinavir/ritonavir should be initiated in women with known nevirapine resistance or single-dose nevirapine exposure less than 12 months prior, or in whom such information is unknown.
authors.affiliation: Division of Infectious Disease, Massachusetts General Hospital, Boston, 02114, USA. aciaranello@partners.org
authors.forename: Andrea L
authors.initials: AL
authors.lastname: Ciaranello
authors.forename: Shahin
authors.initials: S
authors.lastname: Lockman
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Freedberg
authors.forename: Michael
authors.initials: M
authors.lastname: Hughes
authors.forename: Jennifer
authors.initials: J
authors.lastname: Chu
authors.forename: Judith
authors.initials: J
authors.lastname: Currier
authors.forename: Robin
authors.initials: R
authors.lastname: Wood
authors.forename: Charles B
authors.initials: CB
authors.lastname: Holmes
authors.forename: Sandy
authors.initials: S
authors.lastname: Pillay
authors.forename: Francesca
authors.initials: F
authors.lastname: Conradie
authors.forename: James
authors.initials: J
authors.lastname: McIntyre
authors.forename: Elena
authors.initials: E
authors.lastname: Losina
authors.forename: Rochelle P
authors.initials: RP
authors.lastname: Walensky
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000191:economics* / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000191:economics* / Q000453:epidemiology; D006801:Humans; D007231:Infant, Newborn; D018445:Infectious Disease Transmission, Vertical / Q000191:economics* / Q000517:prevention & control; D008017:Life Expectancy; D061466:Lopinavir; D008297:Male; D019829:Nevirapine / Q000191:economics* / Q000627:therapeutic use; D011247:Pregnancy; D011744:Pyrimidinones / Q000191:economics* / Q000627:therapeutic use; D019438:Ritonavir / Q000191:economics* / Q000627:therapeutic use; D013019:South Africa / Q000453:epidemiology; D016896:Treatment Outcome
chemical_list: D019380:Anti-HIV Agents; D011744:Pyrimidinones; D061466:Lopinavir; D019829:Nevirapine; D019438:Ritonavir