CSHOR In Progress PMTCT Modeling, JYC wrap-up

Report
Determining the opportunity costs of using more expensive
first line regimens with regard to treatment access in
resource limited settings: A look at tenofovir and stavudine
Jennifer Campbell, Erin Koehler, Shaffiq Essajee, Elya Tagar, Megan O’Brien
Vienna – July 2010
1
Background
+
HIV Treatment funding
Will treatment costs outpace available resources?
=
Flatlining
budgets
Year
Number of
patients
requiring
treatment
Cost of 1L
treatment with
AZT or TDF
instead of d4T
Total HIV
treatment
program
costs
2
Background: Key questions
a. What are the benefits of a more expensive first line
regimen with better toxicity and durability profile?
b. What is the opportunity cost in terms of patients not
treated, given a set budget?
3
Methodology: Calculator design
a.
b.
c.
d.
10 year forecast of costs, based on 2013 ARV prices
MS Excel-based “closed cohort” analysis of 100,000 patients
Costs include 1st and 2nd line ARVs and toxicity costs
Permits modeling of scenarios where inputs such as estimated
improvements in toxicity rates, toxicity treatment costs and
migration to 2nd line can be compared with ARV treatment
costs
e. Also permits modeling of reduction in loss to follow-up and
mortality associated with “better” regimens
4
Methodology: Input screen shot
Patient combined outcomes calculator
* cells for entry are white
Inputs
Starting number
100,000
Year (drug cost)
2013
Regimen 1
D4T+3TC+NVP
$ 84.00
Regimen 2
TDF+3TC+EFV
$ 165.00
% reduction loss
0%
% reduction mortality
0%
% reduction toxcity rate
75%
% reduction toxicity cost
75%
% reduction migration rate
50%
D4T+3TC+NVP
Toxicity rate
Toxicity cost per toxicity
Annual migration rate
15%
154
4.0%
4000%
$30.00
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Results: Screen shot
Results
Outputs
D4T+3TC+NVP
TDF+3TC+EFV
Difference
568,826
431,174
568,826
431,174
toxicity cost
Cost of 2L
$ 2,627,976
$ 37,229,133
$ 164,248
$ 18,956,454
$ (2,463,727)
$ (18,272,679)
Cost of 1L
Total cost (10 years)
$ 39,576,069
$ 79,433,178
$ 85,797,490
$ 104,918,193
$ 46,221,421
$ 25,485,015
cost per person-year
$ 140
$ 184
$ 45
person years treated
person years loss/died
Opportunity cost
Total patients who could start treatment on D4T+3TC+NVP with $25,485,015
32,084
Person-years gained at $139.64 per person year
Total patient years on D4T+3TC+NVP with $104,918,193
182,500
751,326
Difference in person years treated
Cost per gained person year
32%
$ 140
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Results: opportunity cost for selecting
a TDF-based regimen
Results: opportunity cost for selecting
a TDF-based regimen
Cost for 100K
patients for 10 years
Patient years treated
182K
25M
104M
79M
569K
* Cost includes toxicity, 1L and 2L ARVs
569K
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Conclusions
• In addition to the break-even analysis, the calculator
can estimate the likely net cost of more expensive
regimens with the joint savings from reduced toxicity
and improved durability.
• This additional cost is translated into the patient-years
of treatment that could be purchased with a cheaper
regimen.
• Tools like this one allow us to better understand the
impact of more expensive, more effective regimen on
access to treatment.
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Conclusions
• Scenarios like this suggest that a one-size-fits-all
change to more expensive regimens may not be
advisable.
• Countries with constrained budgets and/or low
coverage may want to consider starting subsets
of patients on more expensive regimens, but
leaving others on D4T to maintain scale-up
10
Thank you
Meg O’Brien
Jennifer Campbell
Elya Tagar
Erin Koehler
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