title: The potential cost and benefits of raltegravir in simplified second-line therapy among HIV infected patients in Nigeria and South Africa.
abstract: BACKGROUND
  There is an urgent need to improve the evidence base for provision of second-line antiretroviral therapy (ART) following first-line virological failure. This is particularly the case in Sub-Saharan Africa where 70% of all people living with HIV/AIDS (PHA) reside. The aim of this study was to simulate the potential risks and benefits of treatment simplification in second-line therapy compared to the current standard of care (SOC) in a lower-middle income and an upper-middle income country in Sub-Saharan Africa.
  
  
  METHODS
  We developed a microsimulation model to compare outcomes associated with reducing treatment discontinuations between current SOC for second-line therapy in South Africa and Nigeria and an alternative regimen: ritonavir-boosted lopinavir (LPV/r) combined with raltegravir (RAL). We used published studies and collaborating sites to estimate efficacy, adverse effect and cost. Model outcomes were reported as incremental cost effectiveness ratios (ICERs) in 2011 USD per quality adjusted life year ($/QALY) gained.
  
  
  RESULTS
  Reducing treatment discontinuations with LPV/r+RAL resulted in an additional 0.4 discounted QALYs and increased the undiscounted life expectancy by 0.8 years per person compared to the current SOC. The average incremental cost was $6,525 per treated patient in Nigeria and $4,409 per treated patient in South Africa. The cost-effectiveness ratios were $16,302/QALY gained and $11,085/QALY gained for Nigeria and South Africa, respectively. Our results were sensitive to the probability of ART discontinuation and the unit cost for RAL.
  
  
  CONCLUSIONS
  The combination of raltegravir and ritonavir-boosted lopinavir was projected to be cost-effective in South Africa. However, at its current price, it is unlikely to be cost-effective in Nigeria.
authors: The Kirby Institute for Infection and Immunity in Society, University of New South Wales, Sydney, New South Wales, Australia. KSchneider@kirby.unsw.edu.au
authors: Karen
authors: K
authors: Schneider
authors: Chidi
authors: C
authors: Nwizu
authors: Richard
authors: R
authors: Kaplan
authors: Jonathan
authors: J
authors: Anderson
authors: David P
authors: DP
authors: Wilson
authors: Sean
authors: S
authors: Emery
authors: David A
authors: DA
authors: Cooper
authors: Mark A
authors: MA
authors: Boyd
mesh_terms: D023241:Antiretroviral Therapy, Highly Active / Q000009:adverse effects / Q000191:economics / Q000379:methods; D003362:Cost-Benefit Analysis; D015658:HIV Infections / Q000188:drug therapy* / Q000191:economics*; D017320:HIV Protease Inhibitors / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D006801:Humans; D061466:Lopinavir / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use; D008954:Models, Biological; D018803:Models, Economic; D009549:Nigeria; D011760:Pyrrolidinones / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use; D019057:Quality-Adjusted Life Years; D000068898:Raltegravir Potassium; D019438:Ritonavir / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D013019:South Africa
chemical_list: D017320:HIV Protease Inhibitors; D011760:Pyrrolidinones; D061466:Lopinavir; D000068898:Raltegravir Potassium; D019438:Ritonavir