Antiretroviral treatment switch strategies for lowering the costs of antiretroviral therapy in subjects with suppressed HIV-1 viremia in Spain

Figures & data

Table 1 Main types of antiretroviral treatment regimens initiated in switches to a more economical regimen in individuals with suppressed plasma HIV-1 RNA (<50 copies/mL)

Treatment strategy
Tenofovir/emtricitabine → abacavir/lamivudine
Darunavir/ritonavir monotherapy
Lopinavir/ritonavir monotherapy
Nevirapine substituting a more expensive drug
Substitution of raltegravir
Withdrawal of raltegravir*
Darunavir/ritonavir dose reduction**
Generic lamivudine
Atazanavir/ritonavir (300/100 mg) → atazanavir 400 mg
Withdrawal* or substitution of etravirine
Switches to efavirenz/tenofovir/emtricitabine
Reduction of dose or withdrawal of maraviroc*
Withdrawal of inactive NRTI
Switching tipranavir to other drugs
Other

Notes:

* In subjects receiving more than three active antiretroviral drugs, generally patients from clinical trials or advanced salvage regimens;

** usually from 600 mg/100 mg twice daily to 800 mg/100 mg once daily.

Abbreviation: NRTI, nucleoside reverse transcriptase inhibitor.

Table 2 Different categories of switches in antiretroviral treatment undertaken in a cohort of 2401 HIV-1-infected patients during the study period

Treatment change goal	Monthly cost (€)	N	Percentage
Cost-saving measures	−87,409.80	378	56.17%
Toxicity	12,022.50	76	11.29%
Treatment-naïve patients initiating ART, patients receiving treatment in the center for the first time, or reinitiation of ART >1 year after withdrawal#	52,995.60	64	9.51%
Inclusion in clinical trials*	−2712.00	47	6.83%
Virological failure	17,657.85	44	6.54%
Others	8100.00	31	4.61%
Postexposure prophylaxis	16,710.00	22	3.27%
Ends a clinical trial*	3826.80	9	1.34%
Toxicity plus adherence or pharmacokinetic issues	1406.70	2	0.30%
Total	30,962.85	673	100.00%

Notes:

# Reinitiation <1 year after withdrawal was not included because it was not considered a change in treatment;

* only clinical trials in which the sponsor paid for any part of the antiretroviral treatment are included.

Abbreviation: ART, antiretroviral treatment.

Figure 1 Correlation between the number of switches identified as cost-saving measures and the costs saved with them (shown as percentages).

Abbreviations: ABC/3TC, abacavir/lamivudine; ATV, atazanavir; DRV/r, darunavir/ritonavir; EFV, efavirenz; ETR, etravirine; FDC, fixed-dose combinations; FPV, fosamprenavir; LPV/r, lopinavir/ritonavir; MVC, maraviroc; NRTI, nucleoside reverse transcriptase inhibitor; NVP, nevirapine; RAL, raltegravir; TDF/FTC, tenofovir/emtricitabine; TPV, tipranavir; 3TC gen, generic lamivudine.

Table 3 Comparison of the number of cost-reduction measures undertaken (shown as categories) and costs saved with each one

Category of antiretroviral cost-reduction measure	N changes	Percentage of changes	€/month saved	Percentage of costs saved
Darunavir/ritonavir monotherapy	63	14.96%	19,845.15	22.70%
Lopinavir/ritonavir monotherapy	41	9.74%	13,122.00	15.01%
Withdrawal of raltegravir	23	5.46%	12,718.50	14.55%
TDF/FTC to ABC/3TC	129	30.64%	10,977.15	12.56%
Substitution of raltegravir	32	7.60%	7582.95	8.68%
Switch to nevirapine	33	7.84%	4135.50	4.73%
Withdrawal of etravirine	9	2.14%	3518.40	4.03%
Reduction of dose of darunavir	20	4.75%	3355.50	3.84%
Withdrawal of maraviroc	4	0.95%	2486.70	2.84%
Withdrawal of inactive NRTI	5	1.19%	1947.90	2.23%
Switch to EFV/TDF/FTC	10	2.38%	1878.00	2.15%
Reduction of dose of maraviroc	7	1.66%	1518.15	1.74%
Other	6	1.43%	1324.20	1.51%
Lamivudine generic (break FDC)	15	3.56%	1111.20	1.27%
Withdrawal of tipranavir	4	0.95%	639.90	0.73%
Reduction of dose of fosamprenavir	4	0.95%	559.80	0.64%
ATV/ritonavir to unboosted ATV	14	3.33%	451.80	0.52%
Substitution of etravirine	2	0.47%	237.00	0.27%
Total	421	100.00%	87,409.80	100.00%

Abbreviations: ABC/3TC, abacavir/lamivudine; ATV, atazanavir; EFV/TDF/FTC, efavirenz/tenofovir disoproxil fumarate/emtricitabine; FDC, fixed-dose combinations; NRTI, nucleoside reverse transcriptase inhibitors; TDF/FTC, tenofovir/emtricitabine.

Figure 2 Final savings achieved during the study period with the three main cost-saving strategies: cost-effective treatment changes, inclusion in antiretroviral treatment trials (with antiretroviral medication totally or partially paid for by the sponsor of the clinical trial), and discount arrangements (shown as € per month saved).