title: Cost-effectiveness of first-line antiretroviral therapy for HIV-infected African children less than 3 years of age.
abstract: BACKGROUND
  The International Maternal, Pediatric, and Adolescent Clinical Trials P1060 trial demonstrated superior outcomes for HIV-infected children less than 3 years old initiating antiretroviral therapy (ART) with lopinavir/ritonavir compared to nevirapine, but lopinavir/ritonavir is four-fold costlier.
  
  
  METHODS
  We used the Cost-Effectiveness of Preventing AIDS Complications (CEPAC)-Pediatric model, with published and P1060 data, to project outcomes under three strategies: no ART; first-line nevirapine (with second-line lopinavir/ritonavir); and first-line lopinavir/ritonavir (second-line nevirapine). The base-case examined South African children initiating ART at age 12 months; sensitivity analyses varied all key model parameters. Outcomes included life expectancy, lifetime costs, and incremental cost-effectiveness ratios [ICERs; dollars/year of life saved ($/YLS)]. We considered interventions with ICERs less than 1× per-capita gross domestic product (South Africa: $7500)/YLS as 'very cost-effective,' interventions with ICERs below 3× gross domestic product/YLS as 'cost-effective,' and interventions leading to longer life expectancy and lower lifetime costs as 'cost-saving'.
  
  
  RESULTS
  Projected life expectancy was 2.8 years with no ART. Both ART regimens markedly improved life expectancy and were very cost-effective, compared to no ART. First-line lopinavir/ritonavir led to longer life expectancy (28.8 years) and lower lifetime costs ($41 350/person, from lower second-line costs) than first-line nevirapine (27.6 years, $44 030). First-line lopinavir/ritonavir remained cost-saving or very cost-effective compared to first-line nevirapine unless: liquid lopinavir/ritonavir led to two-fold higher virologic failure rates or 15-fold greater costs than in the base-case, or second-line ART following first-line lopinavir/ritonavir was very ineffective.
  
  
  CONCLUSIONS
  On the basis of P1060 data, first-line lopinavir/ritonavir leads to longer life expectancy and is cost-saving or very cost-effective compared to first-line nevirapine. This supports WHO guidelines, but increasing access to pediatric ART is critical regardless of the regimen used.
authors: aDivision of Infectious Diseases bDivision of General Medicine cMedical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA dThe Medical Research Council Clinical Trials Unit, London, UK eWorld Health Organization, Geneva, Switzerland fCenter for Biostatistics in AIDS Research gDepartment of Health Policy and Management, Harvard School of Public Health hDivision of Infectious Diseases, Department of Medicine iDepartment of Orthopedic Surgery, Brigham and Women's Hospital, Boston jCenter for AIDS Research, Harvard University, Cambridge, Massachusetts kClinton Health Access Initiative, New York lDepartments of Biostatistics and Epidemiology, Boston University School of Public Health, Boston, Massachusetts mDivision of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA nDepartment of Child Health and Pediatrics, Moi University, Eldoret, Kenya oDepartment of Medicine and Department of Pediatrics16, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.
authors: Andrea L
authors: AL
authors: Ciaranello
authors: Kathleen
authors: K
authors: Doherty
authors: Martina
authors: M
authors: Penazzato
authors: Jane C
authors: JC
authors: Lindsey
authors: Linda
authors: L
authors: Harrison
authors: Kathleen
authors: K
authors: Kelly
authors: Rochelle P
authors: RP
authors: Walensky
authors: Shaffiq
authors: S
authors: Essajee
authors: Elena
authors: E
authors: Losina
authors: Lulu
authors: L
authors: Muhe
authors: Kara
authors: K
authors: Wools-Kaloustian
authors: Samuel
authors: S
authors: Ayaya
authors: Milton C
authors: MC
authors: Weinstein
authors: Paul
authors: P
authors: Palumbo
authors: Kenneth A
authors: KA
authors: Freedberg
mesh_terms: D044966:Anti-Retroviral Agents / Q000191:economics* / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000191:economics* / Q000379:methods*; D002675:Child, Preschool; D002986:Clinical Trials as Topic; D003362:Cost-Benefit Analysis; D015658:HIV Infections / Q000188:drug therapy* / Q000191:economics*; D017048:Health Care Costs; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008017:Life Expectancy; D061466:Lopinavir / Q000191:economics / Q000627:therapeutic use; D008297:Male; D019829:Nevirapine / Q000191:economics / Q000627:therapeutic use; D019438:Ritonavir / Q000191:economics / Q000627:therapeutic use; D013019:South Africa
chemical_list: D044966:Anti-Retroviral Agents; D061466:Lopinavir; D019829:Nevirapine; D019438:Ritonavir