title: Does a significant reduction in malaria risk make lopinavir/ritonavir-based ART cost-effective for children with HIV in co-endemic, low-resource settings?
abstract: BACKGROUND
  HIV infection and malaria co-infection is not uncommon among children in co-endemic regions, and evidence suggests that HIV is a risk factor for severe malaria among children. HIV protease inhibitors (PIs) are highly effective in pediatric HIV treatment regimens, however, their effectiveness against malaria has been mixed, with some PIs demonstrating in vitro activity against Plasmodium falciparum. Recent findings suggest lopinavir/ritonavir (LPV/r)-based treatment regimens reduce the incidence of malaria infection by over 40% in pediatric HIV patients compared to non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens.
  
  
  METHODS
  We assessed whether a significant reduction in malaria risk makes LPV/r-based ART regimens cost-effective compared to NNRTI-based regimens in co-endemic, low-resource settings. We modeled the difference in unit cost per disability adjusted life year (DALY) gained among two theoretical groups of HIV+ children under 5 years old receiving ART in a resource-limited setting co-endemic for malaria. The first group received standard NNRTI-based antiretrovirals, the second group received a standard regimen containing LPV/r. We used recent cohort data for the incidence reduction for malaria. Drug costs were taken from the 2011 Clinton Health Access Initiative Antiretroviral (ARV) ceiling price list. DALYs for HIV and malaria were derived from WHO estimates.
  
  
  RESULTS
  Our model suggests a unit cost of US$147 per DALY gained for the LPV/r-based group compared to US$37 per DALY gained for the NNRTI-based group.
  
  
  CONCLUSIONS
  In HIV and malaria co-endemic settings, considerations of PI cost effectiveness incorporating known reductions in malaria mortality suggest a nominal increase in DALYs gained for PIs over NNRTI-based regimens for HIV positive children under five on ART. Our analysis was based on several assumptions due to lack of sound data on malaria and HIV DALY attribution among pediatric populations. Further study in this area is required.
authors.affiliation: United States Agency for International Development, Office of HIV/AIDS, 1300 Pennsylvania Ave., Washington, DC 20523, USA.
authors.forename: Bilaal S
authors.initials: BS
authors.lastname: Ahmed
authors.forename: B Ryan
authors.initials: BR
authors.lastname: Phelps
authors.forename: Elan B
authors.initials: EB
authors.lastname: Reuben
authors.forename: Robert E
authors.initials: RE
authors.lastname: Ferris
mesh_terms: D044966:Anti-Retroviral Agents / Q000191:economics* / Q000627:therapeutic use; D002675:Child, Preschool; D015331:Cohort Studies; D060085:Coinfection; D003362:Cost-Benefit Analysis; D004359:Drug Therapy, Combination; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy*; D017320:HIV Protease Inhibitors / Q000191:economics* / Q000627:therapeutic use; D006801:Humans; D015994:Incidence; D007223:Infant; D061466:Lopinavir / Q000191:economics* / Q000627:therapeutic use; D008288:Malaria / Q000191:economics / Q000453:epidemiology* / Q000517:prevention & control; D008297:Male; D019057:Quality-Adjusted Life Years; D019438:Ritonavir / Q000191:economics* / Q000627:therapeutic use; D014454:Uganda / Q000453:epidemiology
chemical_list: D044966:Anti-Retroviral Agents; D017320:HIV Protease Inhibitors; D061466:Lopinavir; D019438:Ritonavir
keywords: Children; Cost-effectiveness; HIV; Malaria; NNRTI; Protease inhibitor