title: Cost effectiveness of atazanavir-ritonavir versus lopinavir-ritonavir in treatment-naïve human immunodeficiency virus-infected patients in the United States.
abstract: OBJECTIVE
  To evaluate lifetime cost effectiveness of atazanavir-ritonavir (ATV + r) versus lopinavir-ritonavir (LPV/r), both with tenofovir-emtricitabine, in US HIV-infected patients initiating first-line antiretroviral therapy.
  
  
  METHODS
  A Markov microsimulation model was developed to calculate quality-adjusted life-years (QALYs) based on CD4 and HIV RNA levels, coronary heart disease (CHD), AIDS, opportunistic infections (OIs), diarrhea, and hyperbilirubinemia. A million-member cohort of HIV-1-infected, treatment-naïve adults progressed at 3-month intervals through eight health states. Baseline characteristics, virologic suppression, cholesterol changes, and diarrhea and hyperbilirubinemia rates were based on 96-week CASTLE trial results. HIV mortality, OI rates, adherence, costs, utilities, and CHD risk were from literature and experts.
  
  
  CONCLUSIONS
  The incremental cost-effectiveness ratio (ICER) may be overestimated because the ATV + r treatment effect was based on an intention-to-treat analysis. The QALY weights used for diarrhea, hyperbilirubinemia, and CHD events are uncertain; however, the ICER remained < $50,000/QALY when these values were varied in sensitivity analyses.
  
  
  RESULTS
  ATV + r patients received first-line therapy longer than LPV/r patients (97.3 vs. 70.7 months), had longer quality-adjusted survival (11.02 vs. 10.76 years), similar overall survival (18.52 vs. 18.51 years), and higher costs ($275,986 vs. 269,160). ATV+r [corrected] patients had lower rates of AIDS (19.08 vs. 20.05 cases/1000 patient-years), OIs (0.44 vs.0.52), diarrhea (1.27 vs. 6.26), and CHD events(5.44 vs. 5.51), but higher hyperbilirubinemia rates (6.99 vs. 0.25. ATV + r added 0.26 QALYs at a cost of $6826, for $26,421/QALY.
  
  
  CONCLUSIONS
  By more effectively reducing viral load with less gastrointestinal toxicity and a better lipid profile, ATV + r lowered rates of AIDS and CHD, increased quality-adjusted survival, and was cost effective (< $50,000/QALY) compared with LPV/r.
authors.affiliation: Partnership for Health Analytic Research, Beverly Hills, CA, USA. mbroder@pharllc.com
authors.forename: Michael S
authors.initials: MS
authors.lastname: Broder
authors.forename: Eunice Y
authors.initials: EY
authors.lastname: Chang
authors.forename: Tanya G K
authors.initials: TG
authors.lastname: Bentley
authors.forename: Timothy
authors.initials: T
authors.lastname: Juday
authors.forename: Jonathan
authors.initials: J
authors.lastname: Uy
mesh_terms: D000225:Adenine / Q000031:analogs & derivatives / Q000191:economics / Q000627:therapeutic use; D000328:Adult; D019380:Anti-HIV Agents / Q000191:economics / Q000627:therapeutic use*; D000069446:Atazanavir Sulfate; D018791:CD4 Lymphocyte Count; D003362:Cost-Benefit Analysis / Q000706:statistics & numerical data; D003841:Deoxycytidine / Q000031:analogs & derivatives / Q000191:economics / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D000068679:Emtricitabine; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000191:economics; D017320:HIV Protease Inhibitors / Q000191:economics / Q000627:therapeutic use*; D015497:HIV-1; D006801:Humans; D061466:Lopinavir; D008297:Male; D008390:Markov Chains; D009842:Oligopeptides / Q000191:economics / Q000627:therapeutic use*; D063065:Organophosphonates / Q000191:economics / Q000627:therapeutic use; D011725:Pyridines / Q000191:economics / Q000627:therapeutic use*; D011744:Pyrimidinones / Q000191:economics / Q000627:therapeutic use*; D019057:Quality-Adjusted Life Years; D018894:Reverse Transcriptase Inhibitors / Q000191:economics / Q000627:therapeutic use; D018570:Risk Assessment / Q000379:methods; D019438:Ritonavir / Q000191:economics / Q000627:therapeutic use*; D000068698:Tenofovir; D014481:United States
chemical_list: D019380:Anti-HIV Agents; D017320:HIV Protease Inhibitors; D009842:Oligopeptides; D063065:Organophosphonates; D011725:Pyridines; D011744:Pyrimidinones; D018894:Reverse Transcriptase Inhibitors; D003841:Deoxycytidine; D061466:Lopinavir; D000069446:Atazanavir Sulfate; D000068698:Tenofovir; D000068679:Emtricitabine; D000225:Adenine; D019438:Ritonavir