Cost impact of an HIV MDT for managing anti-retroviral switch
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- Barnaby Bryan
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1 Cost impact of an HIV MDT for managing anti-retroviral switch 2016 ST4 Farnaz Dave Infectious Diseases & General Internal Medicine Mr Ian Sayers Specialist Infectious Diseases Pharmacist Dr Fahar Niazi Foundation Year 2 Mrs Adele Torkington Lead Infectious Diseases Pharmacist Dr Katherine Ajdukiewicz Clinical Lead in Infectious Diseases Dr Edmund Wilkins Consultant in Infectious Diseases Northwest Infectious Diseases unit North Manchester General Hospital
2 Overview Background Aim Methods Results Patient demographics Cost effective changes in ART regimens Cost savings according to reason for switch Analysis of most costly ART combinations Conclusion Summary Acknowledgments & References
3 Background North West ART switch algorithm Managing patients on ART can present complex challenges HIV MDT meeting Forum for discussion and education Approval process for ART in context of agreed algorithms
4 Aim Model MDT arrangements for HIV drug prescribing: HIV CRG Jan 2016 Analysis of the cost impact of the MDT on ART switch decisions The MDT membership should include representation from, or access to, the following: Clinical Leads with a minimum requirement of: HIV physicians (3) Specialist HIV nurse (1) Specialist HIV pharmacist (1) Any of a range of other specialists involved in the care of persons with HIV
5 Methods February November 2015 Retrospective service evaluation 199 cases MDT records Demographic data Pharmacy data Case note review Patients primarily managed at other organisations were excluded due to insufficient information Data were analysed using SPSS
6 Results Demographics Gender Ethnicity Sexual orientation Age distribution
7 Results Cost change per month Mean decrease pp per month = 111 n=117 Mean increase pp per month = 120 n=82 Total cost decrease per month 13,006 Total cost increase per month 9,851 Total decrease in cost per month = 3155
8 Results ART regimens prior to and post MDT
9 Results Cost effective change in ART regimens 41/71 Truvada -> Lamivudine/Abacavir Mean saving 118 pp per month Mean saving 4873 per month 40 /71 - > Triumeq 1/71 - > Kivexa
10 Results Cost effective change in ART regimens 46/79 PI containing regimen -> regimens without PIs Mean saving 64 pp per month Mean saving 3305 per month n=7 9 n=4 6
11 Results Reasons for ART switch Reason for switch Total cost change per month Adherence 2043 Side effects 1340 DDIs 991 Resistance 1221 Key DDIs = Drug Drug Interactions
12 Results Reasons for ART switch Side effect Total change in cost per month GI 1136 Renal 745 Hepatic 44 CNS 356 Key GI = Gastrointestinal CNS = Central Nervous System Other 140
13 Results Cost change per month - excluding resistance Mean decrease pp per month = 95 n=105 Mean increase pp per month = 84 n=67 Total cost decrease per month 9,987 Total cost increase per month 5,612 Total saving per month = 4375
14 Results Costly regimens Patient no Summary of regimens costing > 1000 per month 9 patient s regimens cost > 1000 per month (mean cost 1298 pp) Reasons: 7 resistance 2 side effects 7 required Dolutegravir 5 required Maraviroc 1 Truvada Dolutegravir 2 Darunavir Dolutegravir Rilpivirine Maraviroc Ritonavir Ritonavir 3 Darunavir Dolutegravir Maraviroc Ritonavir 4 Atazanavir Dolutegravir Maraviroc Ritonavir 5 Darunavir Dolutegravir Truvada Ritonavir 6 Abacavir Dolutegravir Maraviroc Tenofovir Tripanivir 7 Darunavir Dolutegravir Maraviroc Ritonavir Etravirine 8 Darunavir Dolutegravir Maraviroc Ritonavir Tenofovir 9 Darunavir Dolutegravir Maraviroc Ritonavir
15 Summary Introduction of HIV MDT resulted in savings of > 4300 per month Most cost increases arose due to resistance Cost of resistance offset by switches to more cost-effective and better tolerated regimens
16 Conclusion The HIV MDT was highly effective in Providing a forum for discussion Allowing approval of ART switches Managing the cost of complex cases
17 Acknowledgments & References Model MDT arrangements for HIV drug prescribing: HIV CRG Jan of- care/bhivastandardsa4.pdf
18 Questions?
19 Truvada & Kivexa Pre MDT discussion Kivexa backbone & PI 16/39 (41%) NNRTI 10/39 (26%) Integrase 11/39 (28%) Truvada Backbone & PI 38/71 (54%) NNRTI 10/71 (14%) Integrase 17/71 (24%) >than 2 3 rd agents 2/39 (5%) >than two 3 rd agents 6/71 ( 8%)
20 PI containing regimen Pre MDT discussion PI & 33/79 Truvada (42%) 12/79 Kivexa (15%) 3/79 PI monotherapy (4%) Others E.g. nuc sparing regimens
21 Examples of other ART regimens 1. Darunavir600/Maraviroc/Raltegravir/Ritonavir- 1b/Tenofovir 2. Combivir/Darunavir600/Maraviroc/Ritonavir- 1b 3. Darunavir/Etravirine/Ritonavir 4. Atazanavir/Etravirine/Ritonavir 5. Darunavir/Raltegravir/Ritonavir/Tenofovir 6. Etravirine/Lamivudine- liq50/raltegravir 7. Abacavir, Lamivudine, Raltegravir 8. Darunavir/Ritonavir/Maraviroc/Tenofovir/Raltegravir 9. Darunavir/Ritonavir/Maraviroc- 150bd/raltegravir/tenofovir/entecavir 10. D/R/LAM 11. Abacavir/Emtricitabine/Efavirenz 12. Atazanavir/Ritonavir/Lamivudine 13. 3tC/D/R/RAL 14. Tenofovir/Zidovudine/Raltegravir 15. Tenofovir/Maraviroc/raltegravir 16. Darunavir/Ritonavir/Maraviroc- od 17. Darunavir600/Ritonavir- 1b/Maraviroc150bd/Dolutegravir- od 18. Tenofovir/Lamivudine/Etravirine 19. Darunavir/Ritonavir/Etravirine/Raltegravir 20. Darunavir/Ritonavir/Etravirine/Raltegravir 21. Tenofovir/Lamivudine/Raltegravir 22. Atazanavir/Ritonavir/Maraviroc/Raltegravir (total of 27, some repeated)
22 ART switches Truvada backbone Kivexa backbone Post MDT Atripla Eviplera Triumeq Other PI monotherapy Truvada backbone Kiveaxa backbone Atripla Total Prior to MDT Eviplera Stribild Triumeq Other PI monotherapy Total
23 Follow up 117 patients had follow up at 6 months Remained on original regimen 98/117 (83%) Reasons for changes to regimens: Didn t start discussed regimen 3/117 Deterioration in renal function due to other co- morbidities 2/117 Increases CVS risk 2/117 Intensified 2/117 Simplified 3/117 Side effects of regimen 7/117
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