Seeking realistic gains within tight budgetary constraints: Is changing HIV drug regimen the next step in India’s struggle against HIV/AIDS?

The case of India has been seen as a model of an intelligent and integrated use of data for an evidence-based response to the HIV/AIDS epidemic (Sgaier & Chandramouli (STI)). Avahan, the India HIV/AIDS initiative, can claim considerable success in reducing incidence among ‘bridging’ populations – by 21-45% among female sex-workers, and among their clients by proportionately more (between 2 and 8 times) (Vickerman & Boily (STI)).

It remains the case that India remains home to the world’s third-largest population of people living with HIV/AIDS with an estimated 2.1 million infected. Reported new infections per year have decreased by 66% from 130,000 in 2000 to 86,000 in 2015. However, a shocking 60% of people living with HIV in India remain untreated (Zheng & Freedberg).

Here as elsewhere, hopes of a swift elimination of HIV/AIDS seem to have receded, despite the early promise of treatment as prevention. And, in addition, health services are finding themselves having to operate under renewed financial constraint, with the recent political challenges to the funding of international programmes ((Modelling the scale-down of HIV services (STI/blog); How should PEPFAR be evaluated? (STI/blog)).

Zheng & Freedberg, a recent cost-effectiveness study, very much inhabits this landscape of realistic ambition and tight budgetary constraint, modelling as it does the impact of changing the recommended first-line anti-retroviral therapy from an Efavirenz-based regimen to dolutegravir – now increasingly seen as the standard recommended first-line treatment, even in sub-Saharan Africa. The predicted medical gains include 13,000 HIV transmissions averted over 5 years.  This will not solve the problem of HIV/AIDS in India, but will give the rate of new infections a further nudge in the downward direction. In addition, it will improve five-year survival from 76.7% to 83%, and increase life expectancy for HIV infected by three years. A worthwhile gain; but cost-effectiveness is, of course, crucial. Cost-effectiveness is shown to be very sensitive to the cost of the medication itself. Currently, the cost of the present regime is estimated at $98 USD per year, and that of dolutegravir at $102 USD. Authors show that the change to dolutegravir would be cost-neutral where cost of the drug is ≤$105 USD. Above that, change of regimen would still be cost-effective, with incremental cost effectiveness ratio (ICER) at below 50% of India’s per capita GDP so long the drug cost remains under $180 USD. Small but significant gains then for little if any added cost!

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