title: Cost-effectiveness of genotype testing for primary resistance in Brazil.
abstract: OBJECTIVE
  HIV genotype-resistance testing can help identify more effective antiretroviral treatment (ART) regimens for patients, substantially increasing the likelihood of viral suppression and immune recovery. We sought to evaluate the cost-effectiveness of genotype-resistance testing before first-line ART initiation in Brazil.
  
  
  METHODS
  We used a previously published microsimulation model of HIV disease (CEPAC-International) and data from Brazil to compare the clinical impact, costs, and cost-effectiveness of initial genotype testing (Genotype) with no initial genotype testing (No genotype).
  
  
  METHODS
  Model parameters were derived from the HIV Clinical Cohort at the Evandro Chagas Clinical Research Institute and from published data, using Brazilian sources whenever possible. Baseline patient characteristics included 69% male, mean age of 36 years (SD, 10 years), mean CD4 count of 347 per microliter (SD, 300/µL) at ART initiation, annual ART costs from 2012 US $1400 to US $13,400, genotype test cost of US $230, and primary resistance prevalence of 4.4%. Life expectancy and costs were discounted 3% per year. Genotype was defined as "cost-effective" compared with No Genotype if its incremental cost-effectiveness ratio was less than 3 times the 2012 Brazilian per capita GDP of US $12,300.
  
  
  RESULTS
  Compared with No genotype, Genotype increased life expectancy from 18.45 to 18.47 years and reduced lifetime cost from US $45,000 to $44,770; thus, in the base case, Genotype was cost saving. Genotype was cost-effective at primary resistance prevalence as low as 1.4% and remained cost-effective when subsequent-line ART costs decreased to 30% of baseline value. Cost-inefficient results were observed only when simultaneously holding multiple parameters to extremes of their plausible ranges.
  
  
  CONCLUSIONS
  Genotype-resistance testing in ART-naive individuals in Brazil will improve survival and decrease costs and should be incorporated into HIV treatment guidelines in Brazil.
authors.affiliation: *Instituto de Pesquisa Clinica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil; †Division of General Medicine, ‡The Medical Practice Evaluation Center, and the §Division of Infectious Disease, Massachusetts General Hospital, Boston, MA; ‖Harvard University Center for AIDS Research, Harvard Medical School, Boston, MA; ¶Department of Epidemiology, Boston University School of Public Health, Boston, MA; #Department of Health Policy and Management, Harvard School of Public Health, Boston, MA; **Division of Infectious Disease, Department of Medicine, Brigham and Women's Hospital, Boston, MA; ††Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA; ‡‡Department of Biostatistics, Boston University School of Public Health, Boston, MA; and §§Yale School of Public Health, New Haven, CT.
authors.forename: Paula M
authors.initials: PM
authors.lastname: Luz
authors.forename: Bethany L
authors.initials: BL
authors.lastname: Morris
authors.forename: Beatriz
authors.initials: B
authors.lastname: Grinsztejn
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Freedberg
authors.forename: Valdilea G
authors.initials: VG
authors.lastname: Veloso
authors.forename: Rochelle P
authors.initials: RP
authors.lastname: Walensky
authors.forename: Elena
authors.initials: E
authors.lastname: Losina
authors.forename: Yoriko M
authors.initials: YM
authors.lastname: Nakamura
authors.forename: Michael P
authors.initials: MP
authors.lastname: Girouard
authors.forename: Paul E
authors.initials: PE
authors.lastname: Sax
authors.forename: Claudio J
authors.initials: CJ
authors.lastname: Struchiner
authors.forename: A David
authors.initials: AD
authors.lastname: Paltiel
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D001938:Brazil; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D024882:Drug Resistance, Viral; D005260:Female; D060005:Genotyping Techniques / Q000191:economics* / Q000379:methods*; D006678:HIV / Q000187:drug effects* / Q000235:genetics / Q000302:isolation & purification; D015658:HIV Infections / Q000188:drug therapy* / Q000821:virology*; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008826:Microbial Sensitivity Tests / Q000379:methods; D008875:Middle Aged; D016019:Survival Analysis
chemical_list: D044966:Anti-Retroviral Agents