Abstract | BACKGROUND: METHODS: We used an existing individual-based model of HIV to predict the effects of introducing monthly injections of cabotegravir- rilpivirine for people with HIV in low-income settings in sub-Saharan Africa. We evaluated policies in the context of 1000 setting scenarios that reflected characteristics of HIV epidemics and programmes in sub-Saharan Africa. We compared three policies for introduction of injectable cabotegravir- rilpivirine with continued use of dolutegravir-based oral regimens for: all individuals on antiretroviral therapy (ART); individuals with a recently measured viral load of more than 1000 copies per mL (signifying poor adherence to oral drugs, and often associated with drug resistance); and individuals with a recently measured viral load of less than 1000 copies per mL (a group with a lower prevalence of pre-existing drug resistance). We also did cost-effectiveness analysis, taking a health system perspective over a 10 year period, with 3% discounting of disability-adjusted life-years (DALYs) and costs. A cost-effectiveness threshold of US$500 per DALY averted was used to establish if a policy was cost-effective. FINDINGS: In our model, all policies involving the introduction of injectable cabotegravir- rilpivirine were predicted to lead to an increased proportion of people with HIV on ART, increased viral load suppression, and decreased AIDS-related mortality, with lesser benefits in people with a recently measured viral load of less than 1000 copies per mL. Its introduction is also predicted to lead to increases in resistance to integrase inhibitors and non- nucleoside reverse transcriptase inhibitors if introduced in all people with HIV on ART or in those with a recently measured viral load of less than 1000 copies per mL, but to a lesser extent if introduced in people with more than 1000 copies per mL due to concentration of its use in people less adherent to oral therapy. Consistent with the effect on AIDS-related mortality, all approaches to the introduction of injectable cabotegravir- rilpivirine are predicted to avert DALYs. Assuming a cost of $120 per person per year, use of this regimen in people with a recently measured viral load of more than 1000 copies per mL was borderline cost-effective (median cost per DALY averted across setting scenarios $404). The other approaches considered for its use are unlikely to be cost-effective unless the cost per year of injectable cabotegravir- rilpivirine is considerably reduced. INTERPRETATION: Our modelling suggests that injectable cabotegravir- rilpivirine offers potential benefits; however, to be a cost-effective option, its introduction might need to be carefully targeted to individuals with HIV who might otherwise have suboptimal adherence to ART. As data accumulate from trials and implementation studies, such findings can be incorporated into the model to better inform on the full consequences of policy alternatives. FUNDING: Bill & Melinda Gates Foundation, including through the HIV Modelling Consortium (OPP1191655).
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Authors | Andrew N Phillips, Loveleen Bansi-Matharu, Valentina Cambiano, Peter Ehrenkranz, Celicia Serenata, Francois Venter, Sarah Pett, Charles Flexner, Andreas Jahn, Paul Revill, Geoff P Garnett |
Journal | The Lancet. Global health
(Lancet Glob Health)
Vol. 9
Issue 5
Pg. e620-e627
(05 2021)
ISSN: 2214-109X [Electronic] England |
PMID | 33770513
(Publication Type: Journal Article, Research Support, Non-U.S. Gov't)
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Copyright | Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved. |
Chemical References |
- Anti-HIV Agents
- HIV Integrase Inhibitors
- Pyridones
- Rilpivirine
- cabotegravir
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Topics |
- Adolescent
- Adult
- Africa South of the Sahara
- Anti-HIV Agents
(administration & dosage, therapeutic use)
- Cost-Benefit Analysis
(economics, statistics & numerical data)
- Drug Therapy, Combination
(methods)
- Female
- HIV Infections
(drug therapy, economics)
- HIV Integrase Inhibitors
(therapeutic use)
- Humans
- Injections, Intravenous
- Male
- Middle Aged
- Pyridones
(administration & dosage, economics, therapeutic use)
- Rilpivirine
(administration & dosage, economics, therapeutic use)
- Time
- Young Adult
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