Use of Genotypic Resistance Testing To Guide HIV Therapy: Clinical Impact and Cost-Effectiveness
- Milton C. Weinstein, PhD;
- Sue J. Goldie, MD, MPH;
- Elena Losina, PhD;
- Calvin J. Cohen, MD, MSc;
- John D. Baxter, MD;
- Hong Zhang, BA;
- April D. Kimmel, AB; and
- Kenneth A. Freedberg, MD, MSc
- From Harvard School of Public Health, Boston University School of Public Health, Harvard Medical School, and Massachusetts General Hospital, Boston, Massachusetts; Community Research Initiative of New England, Brookline, Massachusetts; and Cooper Hospital/University of Medicine and Dentistry of New Jersey and Robert Wood Johnson Medical School, Camden, New Jersey.
Abstract
Background: Genotypic sequencing for drug-resistant strains of HIV can guide the choice of antiretroviral therapy.
Objective: To assess the cost-effectiveness of genotypic resistance testing for patients acquiring drug resistance through failed treatment (secondary resistance) and those infected with resistant virus (primary resistance).
Design: Cost-effectiveness analysis with an HIV simulation model incorporating CD4 cell count and HIV RNA level as predictors of disease progression.
Data Sources: Published randomized trials and data from the Multicenter AIDS Cohort Study, the national AIDS Cost and Services Utilization Survey, the Red Book, and an institutional cost-accounting system.
Target Population: HIV-infected patients in the United States with baseline CD4 counts of 0.250 × 109 cells/L.
Time Horizon: Lifetime.
Perspective: Societal.
Interventions: Genotypic resistance testing and clinical judgment, compared with clinical judgment alone, in two contexts: after initial treatment failure (secondary resistance testing) and before initiation of antiretroviral therapy (primary resistance testing).
Outcome Measures: Life expectancy, quality-adjusted life expectancy, and cost-effectiveness in dollars per quality-adjusted life-year (QALY) gained.
Results of Base-Case Analysis: Secondary resistance testing increased life expectancy by 3 months, at a cost of $17 900 per QALY gained. The cost-effectiveness of primary resistance testing was $22 300 per QALY gained with a 20% prevalence of primary resistance but increased to $69 000 per QALY gained with 4% prevalence.
Results of Sensitivity Analysis: The cost-effectiveness ratio for secondary resistance testing remained under $25 000 per QALY gained, even when effectiveness and cost of testing and antiretroviral therapy, quality-of-life weights, and discount rate were varied.
Conclusions: Genotypic antiretroviral resistance testing following antiretroviral failure is cost-effective. Primary resistance testing also seems to be reasonably cost-effective and will become more so as the prevalence of primary resistance increases.
- Genotype
- Anti-HIV agents
- Cost-benefit analysis
- Drug resistance, microbial
- Human immunodeficiency virus infections
Article and Author Information
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Acknowledgments: The authors thank members of the research group on Cost-Effectiveness of Preventing AIDS Complications for valuable guidance: Donald E. Craven, MD; Runa Islam; A. David Paltiel, PhD; and George R. Seage, ScD, MPH. They also thank Karen Kuntz, PhD, and Lisa Sullivan, PhD, for helpful advice.
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Grant Support: By the National Institute of Allergy and Infectious Diseases (R01-AI42006) and the Centers for Disease Control and Prevention (U64/CCU 114927).
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Requests for Single Reprints: Milton C. Weinstein, PhD, Center for Risk Analysis, Harvard School of Public Health, 718 Huntington Avenue, Boston, MA 02115-5924.
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Current Author Addresses: Drs. Weinstein and Goldie: Center for Risk Analysis, Harvard School of Public Health, 718 Huntington Avenue, Boston, MA 02115-5924.
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Drs. Losina and Freedberg, Mr. Zhang, and Ms. Kimmel: Division of General Internal Medicine, Massachusetts General Hospital, 50 Staniford Street, Ninth Floor, Boston, MA 02114.
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Dr. Cohen: Community Research Initiative of New England, 320 Washington Street, Third Floor, Brookline, MA 02445.
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Dr. Baxter: Department of Medicine, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Education and Research Building, 401 Haddon Avenue, Second Floor, Camden, NJ 08103.
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Author Contributions: Conception and design: M.C. Weinstein, S.J. Goldie, C.J. Cohen, K.A. Freedberg.
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Analysis and interpretation of the data: M.C. Weinstein, S.J. Goldie, C.J. Cohen, J.D. Baxter, K.A. Freedberg.
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Drafting of the article: M.C. Weinstein.
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Critical revision of the article for important intellectual content: M.C. Weinstein, S.J. Goldie, E. Losina, C.J. Cohen, J.D. Baxter, K.A. Freedberg.
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Final approval of the article: M.C. Weinstein, S.J. Goldie, E. Losina, C.J. Cohen, J.D. Baxter, H. Zhang, A.D. Kimmel, K.A. Freedberg.
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Provision of study materials or patients: J.D. Baxter.
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Statistical expertise: E. Losina.
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Obtaining of funding: K.A. Freedberg.
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Administrative, technical, or logistic support: A.D. Kimmel, K.A. Freedberg.
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Collection and assembly of data: E. Losina, C.J. Cohen.
- Copyright ©2004 by the American College of Physicians
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