title: The clinical role and cost-effectiveness of long-acting antiretroviral therapy.
abstract: BACKGROUND
  Long-acting antiretroviral therapy (LA-ART) is currently under development and could improve outcomes for human immunodeficiency virus (HIV)-infected individuals with poor daily ART adherence.
  
  
  METHODS
  We used a computer simulation model to evaluate the cost-effectiveness of 3 LA-ART strategies vs daily oral ART for all: (1) LA-ART for patients with multiple ART failures; (2) second-line LA-ART for those failing first-line therapy; and (3) first-line LA-ART for ART-naive patients. We calculated the maximum annual cost of LA-ART at which each strategy would be cost-effective at a willingness to pay of $100 000 per quality-adjusted life-year. We assumed HIV RNA suppression on daily ART ranged from 0% to 91% depending on adherence, vs 91% suppression on LA-ART regardless of daily ART adherence. In sensitivity analyses, we varied adherence, efficacy of LA-ART and daily ART, and loss to follow-up.
  
  
  RESULTS
  Relative to daily ART, LA-ART increased overall life expectancy by 0.15-0.24 years, and by 0.51-0.89 years among poorly adherent patients, depending on the LA-ART strategy. LA-ART after multiple failures became cost-effective at an annual drug cost of $48 000; in sensitivity analysis, this threshold varied from $40 000-$70 000. Second-line LA-ART and first-line LA-ART became cost-effective at an annual drug cost of $26 000-$31 000 and $24 000-$27 000, vs $28 000 and $25 000 for current second-line and first-line regimens.
  
  
  CONCLUSIONS
  LA-ART could improve survival of HIV patients, especially those with poor daily ART adherence. At an annual cost of $40 000-$70 000, LA-ART will offer good value for patients with multiple prior failures. To be a viable option for first- or second-line therapy, however, its cost must approach that of currently available regimens.
authors.affiliation: Division of General Internal Medicine Division of Medical Practice Evaluation Center, Massachusetts General Hospital, Boston.
authors.forename: Eric L
authors.initials: EL
authors.lastname: Ross
authors.affiliation: Department of Health Policy and Management Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts.
authors.forename: Milton C
authors.initials: MC
authors.lastname: Weinstein
authors.affiliation: Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York.
authors.forename: Bruce R
authors.initials: BR
authors.lastname: Schackman
authors.affiliation: Division of AIDS and Center for AIDS Research, Harvard Medical School Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Paul E
authors.initials: PE
authors.lastname: Sax
authors.affiliation: Yale School of Public Health, New Haven, Connecticut.
authors.forename: A David
authors.initials: AD
authors.lastname: Paltiel
authors.affiliation: Division of General Internal Medicine Division of Infectious Disease Division of Medical Practice Evaluation Center, Massachusetts General Hospital, Boston Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Rochelle P
authors.initials: RP
authors.lastname: Walensky
authors.affiliation: Division of General Internal Medicine Division of Infectious Disease Division of Medical Practice Evaluation Center, Massachusetts General Hospital, Boston Department of Health Policy and Management Division of AIDS and Center for AIDS Research, Harvard Medical School Department of Epidemiology.
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Freedberg
authors.affiliation: Division of Medical Practice Evaluation Center, Massachusetts General Hospital, Boston Department of Biostatistics, Boston University School of Public Health Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Elena
authors.initials: E
authors.lastname: Losina
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000008:administration & dosage* / Q000191:economics*; D023241:Antiretroviral Therapy, Highly Active / Q000191:economics* / Q000379:methods*; D015331:Cohort Studies; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D003692:Delayed-Action Preparations / Q000008:administration & dosage* / Q000191:economics*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016019:Survival Analysis; D016896:Treatment Outcome
chemical_list: D044966:Anti-Retroviral Agents; D003692:Delayed-Action Preparations
keywords: HIV/AIDS; cost-effectiveness; long-acting antiretroviral therapy; modeling