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.
Design/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
