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Does a significant reduction in malaria risk make lopinavir/ritonavir-based ART cost-effective for children with HIV
Bilaal S Ahmed1, B Ryan Phelps, Elan B Reuben
1United States Agency for International Development, Office of HIV/AIDS, 1300 Pennsylvania Ave., Washington, DC 20523, USA.
Insights
Lopinavir/ritonavir (LPV/r)-based ART regimens offer improved cost-effectiveness for pediatric HIV patients in malaria-endemic areas. These regimens reduce malaria incidence, increasing disability-adjusted life years (DALYs) gained compared to non-nucleoside reverse transcriptase inhibitor (NNRTI)-based treatments.
Area of Science:
- Global Health
- Infectious Diseases
- Health Economics
Background:
- HIV and malaria co-infection is prevalent in children in co-endemic regions.
- HIV increases the risk of severe malaria in children.
- Some HIV protease inhibitors (PIs) show activity against Plasmodium falciparum, with lopinavir/ritonavir (LPV/r) reducing malaria incidence by over 40% in pediatric HIV patients compared to non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens.
Purpose of the Study:
- To assess the cost-effectiveness of LPV/r-based antiretroviral therapy (ART) regimens compared to NNRTI-based regimens in co-endemic, low-resource settings for HIV-positive children under five.
- To determine if the reduction in malaria risk associated with LPV/r regimens improves their cost-effectiveness.
Main Methods:
- A cost-effectiveness model was developed comparing two groups of HIV-positive children under five receiving ART in a resource-limited, malaria-endemic setting.
- Group 1 received standard NNRTI-based ART; Group 2 received a standard regimen containing LPV/r.
- Disability-adjusted life years (DALYs) for HIV and malaria were sourced from WHO estimates, and drug costs were based on the 2011 Clinton Health Access Initiative ARV ceiling price list.
Main Results:
- The model estimated a unit cost of US$147 per DALY gained for the LPV/r-based ART group.
- The unit cost for the NNRTI-based ART group was estimated at US$37 per DALY gained.
Conclusions:
- Considering reduced malaria mortality, PI-based ART regimens show a nominal increase in DALYs gained compared to NNRTI-based regimens for pediatric HIV patients in co-endemic settings.
- The analysis relies on assumptions due to limited data on DALY attribution for pediatric malaria and HIV co-infection.
- Further research is needed to validate these findings and improve data accuracy.
Background:
HIV infection and malaria co-infection is not uncommon among children in co-endemic regions, and evidence suggests that HIV is a risk factor for severe malaria among children. HIV protease inhibitors (PIs) are highly effective in pediatric HIV treatment regimens, however, their effectiveness against malaria has been mixed, with some PIs demonstrating in vitro activity against Plasmodium falciparum. Recent findings suggest lopinavir/ritonavir (LPV/r)-based treatment regimens reduce the incidence of malaria infection by over 40% in pediatric HIV patients compared to non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens.
Methods:
We assessed whether a significant reduction in malaria risk makes LPV/r-based ART regimens cost-effective compared to NNRTI-based regimens in co-endemic, low-resource settings. We modeled the difference in unit cost per disability adjusted life year (DALY) gained among two theoretical groups of HIV+ children under 5 years old receiving ART in a resource-limited setting co-endemic for malaria. The first group received standard NNRTI-based antiretrovirals, the second group received a standard regimen containing LPV/r. We used recent cohort data for the incidence reduction for malaria. Drug costs were taken from the 2011 Clinton Health Access Initiative Antiretroviral (ARV) ceiling price list. DALYs for HIV and malaria were derived from WHO estimates.
Results:
Our model suggests a unit cost of US$147 per DALY gained for the LPV/r-based group compared to US$37 per DALY gained for the NNRTI-based group.
Conclusion:
In HIV and malaria co-endemic settings, considerations of PI cost effectiveness incorporating known reductions in malaria mortality suggest a nominal increase in DALYs gained for PIs over NNRTI-based regimens for HIV positive children under five on ART. Our analysis was based on several assumptions due to lack of sound data on malaria and HIV DALY attribution among pediatric populations. Further study in this area is required.
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