title: Lopinavir/ritonavir versus darunavir plus ritonavir for HIV infection: a cost-effectiveness analysis for the United States.
abstract: BACKGROUND
  The ARTEMIS trial compared first-line antiretroviral therapy (ART) with lopinavir/ritonavir (LPV/r) to darunavir plus ritonavir (DRV + RTV) for HIV-1-infected subjects. In order to fully assess the implications of this study, economic modelling extrapolating over a longer term is required.
  
  
  OBJECTIVE
  The aim of this study was to simulate the course of HIV and its management, including the multiple factors known to be of importance in ART.
  
  
  METHODS
  A comprehensive discrete event simulation was created to represent, as realistically as possible, ART management and HIV outcomes. The model was focused on patients for whom clinicians believed that LPV/r or DRV + RTV were good options as a first regimen. Prognosis was determined by the impact of initial treatment on baseline CD4+ T-cell count and viral load, adherence, virological suppression/failure/rebound, acquired resistance mutations, and ensuing treatment changes. Inputs were taken from trial data (ARTEMIS), literature and, where necessary, stated assumptions. Clinical measures included AIDS events, side effects, time on sequential therapies, cardiovascular events, and expected life-years lost as a result of HIV infection. The model underwent face, technical and partial predictive validation. Treatment-naive individuals similar to those in the ARTEMIS trial were modelled over a lifetime, and outcomes with first-line DRV + RTV were compared with those with LPV/r, both paired with tenofovir and emtricitabine. Up to three regimen changes were permitted. Drug prices were based on wholesale acquisition cost. Outcomes were lifetime healthcare costs (in 2011 US dollars) from the US healthcare system perspective and quality-adjusted life-years (QALYs) (discounted at 3 % per annum).
  
  
  RESULTS
  Choice of LPV/r over DRV + RTV as initial ART resulted in nearly identical clinical outcomes, but distinctly different economic consequences. Starting with an LPV/r regimen potentially results in approximately US$25,000 discounted lifetime savings. Accumulated QALYs for LPV/r and DRV + RTV were 12.130 and 12.083, respectively (a 19-day difference). In sensitivity analyses, net monetary benefit ranged from US$12,000 to US$31,000, favouring LPV/r (base case US$27,762).
  
  
  CONCLUSIONS
  A comprehensive simulation of lifetime course of HIV in the USA indicated that using LPV/r as first-line therapy compared with DRV + RTV may result in cost savings, with similar clinical outcomes.
authors.affiliation: Department of Health Leadership and Management, College of Health Professions, Medical University of South Carolina, 151B Rutledge Ave., Room 412, Charleston, SC 29425, USA. simpsonk@musc.edu
authors.forename: Kit N
authors.initials: KN
authors.lastname: Simpson
authors.forename: Pamela P
authors.initials: PP
authors.lastname: Pei
authors.forename: Jörgen
authors.initials: J
authors.lastname: Möller
authors.forename: Robert W
authors.initials: RW
authors.lastname: Baran
authors.forename: Birgitta
authors.initials: B
authors.lastname: Dietz
authors.forename: William
authors.initials: W
authors.lastname: Woodward
authors.forename: Kristen
authors.initials: K
authors.lastname: Migliaccio-Walle
authors.forename: J Jaime
authors.initials: JJ
authors.lastname: Caro
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D000069454:Darunavir; D004338:Drug Combinations; D004359:Drug Therapy, Combination; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000191:economics; D017048:Health Care Costs; D006801:Humans; D061466:Lopinavir / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D018803:Models, Economic; D011379:Prognosis; D019057:Quality-Adjusted Life Years; D019438:Ritonavir / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use*; D013449:Sulfonamides / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use*; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States
chemical_list: D019380:Anti-HIV Agents; D004338:Drug Combinations; D013449:Sulfonamides; C558899:lopinavir-ritonavir drug combination; D061466:Lopinavir; D019438:Ritonavir; D000069454:Darunavir