title: Clinical impact and cost-effectiveness of making third-line antiretroviral therapy available in sub-Saharan Africa: a model-based analysis in Côte d'Ivoire.
abstract: OBJECTIVE
  In sub-Saharan Africa, HIV-infected adults who fail second-line antiretroviral therapy (ART) often do not have access to third-line ART. We examined the clinical impact and cost-effectiveness of making third-line ART available in Côte d'Ivoire.
  
  
  METHODS
  We used a simulation model to compare 4 strategies after second-line ART failure: continue second-line ART (C-ART2), continue second-line ART with an adherence reinforcement intervention (AR-ART2), immediate switch to third-line ART (IS-ART3), and continue second-line ART with adherence reinforcement, switching patients with persistent failure to third-line ART (AR-ART3). Third-line ART consisted of a boosted-darunavir plus raltegravir-based regimen. Primary outcomes were 10-year survival and lifetime incremental cost-effectiveness ratios (ICERs), in $/year of life saved (YLS). ICERs below $3585 (3 times the country per capita gross domestic product) were considered cost-effective.
  
  
  RESULTS
  Ten-year survival was 6.0% with C-ART2, 17.0% with AR-ART2, 35.4% with IS-ART3, and 37.2% with AR-ART3. AR-ART2 was cost-effective ($1100/YLS). AR-ART3 had an ICER of $3600/YLS and became cost-effective if the cost of third-line ART decreased by <1%. IS-ART3 was less effective and more costly than AR-ART3. Results were robust to wide variations in the efficacy of third-line ART and of the adherence reinforcement, as well as in the cost of second-line ART.
  
  
  CONCLUSIONS
  Access to third-line ART combined with an intense adherence reinforcement phase, used as a tool to distinguish between patients who can still benefit from their current second-line regimen and those who truly need third-line ART would provide substantial survival benefits. With minor decreases in drug costs, this strategy would be cost-effective.
authors.affiliation: *Centre Inserm 897, University of Bordeaux, Bordeaux, France; †ISPED, University of Bordeaux, Bordeaux, France; ‡Programme PAC-CI/ANRS Research Site, CHU de Treichville, Abidjan, Côte d'Ivoire; §Division of General Medicine and the Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA; ‖Department of Infectious and Tropical Diseases, Bichat-Claude Bernard University Hospital, Paris, France; ¶Equipe Atip/Avenir Inserm U738, University Paris Diderot, Paris, France; #Department of Orthopedics, Brigham and Women's Hospital, Boston, MA; **Center for AIDS Research, Harvard University, Boston, MA; ††Harvard Medical School, Boston, MA; ‡‡Departments of Biostatistics, Boston University School of Public Health, Boston, MA; §§Department of Infectious and Tropical Diseases, Treichville University Hospital, Abidjan, Côte d'Ivoire; ‖‖Divisions of Infectious Disease and the Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA; ¶¶Division of Infectious Disease, Brigham and Women's Hospital, Boston, MA; ##Department of Epidemiology and Public Health, Yale School of Public Health, New Haven, CT; ***Department of Epidemiology, Boston University School of Public Health, Boston, MA; and †††Department of Health Policy and Management, Harvard School of Public Health, Boston, MA.
authors.forename: Eric N
authors.initials: EN
authors.lastname: Ouattara
authors.forename: Eric L
authors.initials: EL
authors.lastname: Ross
authors.forename: Yazdan
authors.initials: Y
authors.lastname: Yazdanpanah
authors.forename: Angela Y
authors.initials: AY
authors.lastname: Wong
authors.forename: Marion
authors.initials: M
authors.lastname: Robine
authors.forename: Elena
authors.initials: E
authors.lastname: Losina
authors.forename: Raoul
authors.initials: R
authors.lastname: Moh
authors.forename: Rochelle P
authors.initials: RP
authors.lastname: Walensky
authors.forename: Christine
authors.initials: C
authors.lastname: Danel
authors.forename: A David
authors.initials: AD
authors.lastname: Paltiel
authors.forename: Serge P
authors.initials: SP
authors.lastname: Eholié
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Freedberg
authors.forename: Xavier
authors.initials: X
authors.lastname: Anglaret
mesh_terms: D000328:Adult; D017954:Africa South of the Sahara; D023241:Antiretroviral Therapy, Highly Active; D003362:Cost-Benefit Analysis; D000069454:Darunavir; D016527:Drug Costs; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000191:economics; D006295:Health Resources / Q000191:economics; D006801:Humans; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D008962:Models, Theoretical; D011760:Pyrrolidinones / Q000191:economics / Q000627:therapeutic use*; D000068898:Raltegravir Potassium; D013449:Sulfonamides / Q000191:economics / Q000627:therapeutic use*; D016019:Survival Analysis; D017211:Treatment Failure
chemical_list: D011760:Pyrrolidinones; D013449:Sulfonamides; D000068898:Raltegravir Potassium; D000069454:Darunavir
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