HIV cure strategies: how good must they be to improve on current antiretroviral therapy?
BACKGROUND
We examined efficacy, toxicity, relapse, cost, and quality-of-life thresholds of hypothetical HIV cure interventions that would make them cost-effective compared to life-long antiretroviral therapy (ART).


METHODS
We used a computer simulation model to assess three HIV cure strategies: Gene Therapy, Chemotherapy, and Stem Cell Transplantation (SCT), each compared to ART. Efficacy and cost parameters were varied widely in sensitivity analysis. Outcomes included quality-adjusted life expectancy, lifetime cost, and cost-effectiveness in dollars/quality-adjusted life year ($/QALY) gained. Strategies were deemed cost-effective with incremental cost-effectiveness ratios <$100,000/QALY.


RESULTS
For patients on ART, discounted quality-adjusted life expectancy was 16.4 years and lifetime costs were $591,400. Gene Therapy was cost-effective with efficacy of 10%, relapse rate 0.5%/month, and cost $54,000. Chemotherapy was cost-effective with efficacy of 88%, relapse rate 0.5%/month, and cost $12,400/month for 24 months. At $150,000/procedure, SCT was cost-effective with efficacy of 79% and relapse rate 0.5%/month. Moderate efficacy increases and cost reductions made Gene Therapy cost-saving, but substantial efficacy/cost changes were needed to make Chemotherapy or SCT cost-saving.


CONCLUSIONS
Depending on efficacy, relapse rate, and cost, cure strategies could be cost-effective compared to current ART and potentially cost-saving. These results may help provide performance targets for developing cure strategies for HIV.
Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, United States of America; Harvard University Center for AIDS Research, Harvard University, Boston, Massachusetts, United States of America.
Paul E
PE
Sax
Division of General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America.
Alexis
A
Sypek
Division of General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America.
Bethany K
BK
Berkowitz
Division of General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America.
Bethany L
BL
Morris
Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States of America; Harvard University Center for AIDS Research, Harvard University, Boston, Massachusetts, United States of America; Division of General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America.
Elena
E
Losina
Yale School of Public Health, New Haven, Connecticut, United States of America.
A David
AD
Paltiel
Division of General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America.
Kathleen A
KA
Kelly
Harvard School of Public Health, Harvard University, Boston, Massachusetts, United States of America.
George R
GR
Seage
Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, United States of America; Harvard University Center for AIDS Research, Harvard University, Boston, Massachusetts, United States of America; Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America.
Rochelle P
RP
Walensky
Harvard School of Public Health, Harvard University, Boston, Massachusetts, United States of America.
Milton C
MC
Weinstein
Division of Infectious Disease, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.
Joseph
J
Eron
Harvard University Center for AIDS Research, Harvard University, Boston, Massachusetts, United States of America; Harvard School of Public Health, Harvard University, Boston, Massachusetts, United States of America; Division of General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America.
Kenneth A
KA
Freedberg
D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D005260:Female; D015316:Genetic Therapy; D015658:HIV Infections / Q000188:drug therapy* / Q000191:economics; D006801:Humans; D008017:Life Expectancy; D008297:Male; D008875:Middle Aged; D019057:Quality-Adjusted Life Years; D012008:Recurrence; D033581:Stem Cell Transplantation
D019380:Anti-HIV Agents