The price of change Replacing Stavudine with Tenofovir in firstline ART in scalingup settings

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• The price of change Replacing Stavudine with
  Tenofovir in first-line ART in scaling-up
  settings
• XVII International AIDS Conference
• Mexico City, 7th August 2008
• Jari Kivela
• Health Economist
• jari.kivela_at_qalys.eu

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Background

• WHO recommendation to replace d4T
• Scaling-up
• Problem How much will it cost?
• Tool Health economic model

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Objectives

• Develop a model to
• Support decision making
• Demonstrate budget impacts
• Compare timing of introdcution
• Forecast ART budget 2008 - 2014

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Tenofovir vs. Stavudine

• Tenofovir (TDF)
• WHO recommendation
• Better toxicity profile
• Once a day dosing
• TDF 128 PPY

• Stavudine (d4T)
• d4T 19 PPY
• Significant toxicitìes
• Fixed dose combinationd4T / 3TC / NVP 30mg /
  150mg / 200mg

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Current first-line regimen
d4T
NVP
3TC
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New improved first-line regimen
d4T
NVP
3TC
TDF
EFV
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Price of d4T/3TC/NVP
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Price of TDF/3TC/EFV
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ART survival and 2nd-line switch rate

• Global Cohort MSF57.000 ART patients
• Extrapolated after 48 months
• ART survival 9.7 years
• 2nd-line switching rate

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Epworth Program

• Epworth, Harare township
• Population 400.000
• 20 infected with HIV
• MSF program
• 6.000 HIV patients
• 1.400 on ART
• First ARTs April 2007
• 150 new patients / month

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150 new ART patients / month
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Methods

• Patient volumeNr of patients, speed of
  scaling-up
• Medical dataART regimens, ART survival, rate of
  switch to 2nd-line, CD4 baselines
• Financial informationForecasted ART prices,
  actual expenditures, annual budget
• Sensitivity analyses

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Base case All patients on d4T/3TC/NVP
1.8M
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All patients on TDF/3TC/EFV 2008
8.8M
1.8M
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Only new patients on TDF/3TC/EFV 2008
8.8M
8.8M
7.6M
1.8M
1.8M
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Only new patients on TDF/3TC/EFV 2009
8.8M
6.1M
1.8M
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Only new patients on TDF/3TC/EFV 2010
8.8M
4.7M
1.8M
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Limitations

• Potential cost savingsFrom better toxicity
  profile of TDF
• ART price development
• Inadequate TDF survival data

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Summary

• Useful tool to forecast costs
• High cost of TDF and EFV
• Major barrier in resource poor settings

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d4T
NVP
3TC
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d4T
NVP
3TC
TDF
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All patients on TDF/3TC/NVP 2008
6.6M
1.8M
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ART Prices